Harvard Medical School, Beth Israel Deaconess Medical Center Internal Medicine Residency, Carl J. Shapiro Institute for Education and Research, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical Intensive Care Unit.
Harvard Medical School, Laboratory and Transfusion Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Curr Opin Hematol. 2018 Nov;25(6):468-472. doi: 10.1097/MOH.0000000000000460.
This review is a critical appraisal of the current data comparing restrictive vs. liberal transfusion strategies for patients who are critically ill in ICUs. We focus on four subsets of critically ill patients: pediatric patients, patients with gastrointestinal bleeds, septic patients and patients undergoing cardiac surgery.
Almost a decade after the TRICC trial, a randomized trial showing the safety of a restrictive transfusion threshold in critically ill patients, four large randomized controlled trials have shown that a restrictive transfusion strategy is safe in pediatric critically ill patients, patients with acute upper gastrointestinal bleeds, patients with septic shock and patients undergoing cardiac surgery. A large multicenter randomized trial is underway to determine the safety of a restrictive strategy in myocardial infarction.
A restrictive transfusion threshold is recommended in nearly all critically ill patients. This is at least noninferior to more liberal transfusion practice; in addition, a restrictive threshold has shown improved outcomes in some patients and decreased chances of adverse events in patients. Judicious use of red cells improves patient outcome and protects the blood supply, a limited resource. More data are needed to determine appropriate transfusion threshold recommendations for patients with traumatic brain injury and acute coronary syndrome.
本综述批判性地评估了目前比较 ICU 危重症患者限制性与宽松性输血策略的相关数据。我们重点关注了四个危重症亚组患者：儿科患者、胃肠道出血患者、脓毒症患者和心脏手术患者。
在 TRICC 试验近十年后，一项随机试验显示危重症患者采用限制性输血阈值是安全的，四项大型随机对照试验表明，对于儿科危重症患者、急性上消化道出血患者、脓毒性休克患者和心脏手术患者，限制性输血策略是安全的。一项大型多中心随机试验正在进行中，以确定心肌梗死患者采用限制性策略的安全性。
几乎所有危重症患者都推荐采用限制性输血阈值。这至少与更宽松的输血实践相当；此外，在某些患者中，限制性阈值已显示出更好的结果，并降低了患者发生不良事件的机会。合理使用红细胞可改善患者的预后并保护血液供应，这是一种有限的资源。需要更多的数据来确定创伤性脑损伤和急性冠状动脉综合征患者的适当输血阈值建议。
