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心脏手术减少输血可能有益

Transfusions, Blood Conservation Yield Similar Outcomes After Cardiac Surgery
来源:EGMN 2012-07-04 10:29点击次数:153发表评论

据《内科学文献》7月2日在线发表的一项研究报告,接受心脏手术的耶和华见证会(一个拒绝输血的美国教派)信徒的术后结局,与接受相似心脏手术且输血的患者相当(Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.2449])。


克利夫兰医学中心心血管研究所的Gregory Pattakos博士及其同事报告称,在这项纳入49,000余例心脏手术患者的单中心研究中,拒绝接受输血的耶和华见证会信徒的院内并发症发生率相对更低,早期生存率更佳,长期生存率也与接受输血的手术患者相当。这提示避免输血或许也有益于其他心脏手术患者。


研究者介绍,医生通常在耶和华见证会信徒术前、术中或术后会采取一些血液保护措施以避免输血需求,包括术前给予促红细胞生成素、铁剂以及B族复合维生素,血液浓缩,尽可能减少晶体溶液使用;术中给予抗纤溶药物,对血液回收回输和使用小型体外循环机;术后维持低水平的红细胞压积。


研究者评估了1983~2011年期间术前输注红细胞的48,986例心脏手术患者和322例未输血的耶和华见证会信徒患者的结局。鉴于受试者非随机接受输血,研究者采用倾向匹配方法校正两组患者的基线差异。中位随访时间约7~9年。


结果显示,与输血患者相比,见证会信徒的院内死亡、卒中、房颤和肾衰发生率相似,但术后心梗、延长机械通气以及出血并发症导致再次手术发生率较低,并且ICU入住时间和住院时间均较短。见证会信徒术后5、10、15和20年生存率分别为86%、69%、51%和34%,输血患者分别为74%、53%、35%和23%,两者无显著差异。


研究者认为,见证会信徒所采用的某些血液保护策略或许也有益于其他患者。但遗憾的是,该项研究设计无法确定患者的受益主要来源于哪些措施。此外,该项研究的局限性还表现在,接受心脏手术的见证会信徒很可能是医生预期有良好结局的选定患者。


肯塔基大学钱德勒医学中心外科的Victor A. Ferraris博士在随刊评述中指出,该报告引发了有关耶和华见证会信徒所采取的减少血液制品输注的手术策略是否对其他患者有益的疑问。输血可引起不良免疫反应、增加疾病传播风险并导致循环负荷过重,基于在该项研究中见证会信徒术后结局与输血患者相当或甚至更佳,采取更加保守的输血策略或许对其他患者也有益处(Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.2458])。


Ferraris博士报告无相关利益冲突。


爱思唯尔  版权所有

By: MARY ANN MOON, Cardiology News Digital Network


Jehovah’s Witnesses, who do not accept transfusion of blood products, appear to fare at least as well as patients who do receive transfusions after undergoing similar cardiac surgery, according to a report published online July 2 in the Archives of Internal Medicine.


In a single-center study of more than 49,000 consecutive cardiac operations, Jehovah’s Witnesses who refused transfusions had fewer in-hospital complications, better early survival, and similar long-term survival as did transfusion recipients, said Dr. Gregory Pattakos of the Heart and Vascular Institute, Cleveland Clinic, and his associates.


The findings suggest that avoiding transfusions may be beneficial for other patients undergoing cardiac surgery, they noted.


Typically, physicians use a number of blood-conservation practices before, during, and after surgery in patients who are Witnesses, to avert the need for transfusions. These include preoperative erythropoietin, iron, and B-complex vitamins; hemoconcentration; minimal use of crystalloids; intraoperative antifibrinolytics; use of cell-saver and smaller cardiopulmonary bypass circuits; and postoperative tolerance of low hematocrit levels.


Dr. Pattakos and his colleagues assessed outcomes in 48,986 cardiac surgery patients who received red blood cell transfusions perioperatively in 1983-2011 and 322 Witnesses who did not. Since the study subjects could not be randomized for receiving transfusions, the investigators adjusted for baseline differences between the two study groups by using propensity matching.


Median follow-up was approximately 7-9 years.


Compared with transfusion recipients, Witnesses had similar rates of in-hospital mortality, stroke, atrial fibrillation, and renal failure. Witnesses had lower rates of postoperative MI, prolonged ventilation, and reoperation for bleeding complications, and they had shorter ICU stays and shorter hospitalizations than transfusion recipients, the researchers said (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.2449]).


Witnesses’ survival rates were 86% at 5 years, 69%at 10 years, 51% at 15 years, and 34% at 20 years after surgery. These were not significantly different from the transfusion recipients\' survival rates of 74%, 53%, 35%, and 23%, respectively.


Some of the blood-conservation strategies adopted for Witnesses may benefit other patients as well. Unfortunately, the design of this study did not allow for determination of which strategies contributed most to the beneficial outcomes, they said.


One limitation of this study is that Jehovah’s Witnesses who presented to the Cleveland Clinic and were accepted there by surgeons "likely represent a select group who might have been expected by their physicians to have better outcomes," Dr. Pattakos and his associates added.


Restricting Transfusions May Benefit Other Patients, Too


The article by Pattakos et al. raises the question of whether other patients might benefit from the same surgical strategies used for Jehovah’s Witnesses, which minimize the transfusion of blood products, said Victor A. Ferraris, M.D., Ph.D.


Blood transfusions can trigger adverse immune responses, raise the risk of disease transmission, and can cause circulatory overload. Given that the Witnesses in this study had similar or even better outcomes than patients who received transfusions, it may be that "more conservative use of blood transfusions would be in our patients’ interest."


Victor A. Ferraris, M.D., Ph.D., is in the department of surgery at the University of Kentucky Chandler Medical Center, Lexington. He reported no financial conflicts of interest. These remarks were taken from his invited commentary accompanying Dr. Pattakos’s report (Arch. Intern. Med. 2012 [doi:10.1001/archinternmed.2012.2458]).


学科代码:心血管病学 外科学 血液病学   关键词:心脏手术减少输血
来源: EGMN
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