患者血液管理:超越最佳用血!

Ajay Gandhi
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引用次数: 1

摘要

输血是病人住院期间最常见的程序之一。然而,输血除了能挽救失血过多患者的生命外,还与输血传播感染、过敏反应、输血相关循环负荷过重、输血相关急性肺损伤、输血相关免疫调节引起的院内感染和癌症复发等不良事件有关。这些可能致命的并发症引起了医护人员对输血和患者预后的长期关注。因此,在过去的几十年里,血液制品的安全性一直是几乎所有利益相关者(无论是最终用户还是政策制定者)关注的焦点。优化使用血液是一项全球公认的推荐政策,可确保在正确的时间向正确的患者输注正确数量和类型的血液成分。从根本上说,它的重点是提高临床输血过程的安全性和有效性。然而,随着输血科学知识的不断发展,外科医生、麻醉师和其他专家越来越多地参与到输血服务和输血过程中来,而且有越来越多的证据表明,输血往往对患者的临床状态有害而无益,这促使人们认可并制定了优化用血的政策。患者血液管理(PBM)是近二十年前提出的一个概念,它不仅包括优化用血和尽可能减少输血的政策和程序,还包括更广泛的内容。PBM 通过 "三柱九场 "矩阵来推动和实施,其目标包括优化造血、减少出血和失血,以及在术前、术中和术后利用和优化贫血的生理耐受性。PBM 关注的是患者安全而非产品安全,因此确保采用定制方法,合理地临床使用血液这一宝贵资源。在过去几年中,尤其是在 COVID-19 大流行之后,世界卫生组织发布了一份关于紧急实施 PBM 的政策简报,PBM 的原则和实践获得了重要的现实意义和可接受性。通过这篇综述文章,我们不仅要确定实施 PBM 对改善患者预后的影响,还要确定 PBM 的相关性和手段远远超出血液的优化使用。
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Patient Blood Management: Moving Above and Beyond the Optimal Use of Blood!
Transfusion of blood components or products is among the most common procedures performed during a patient’s stay in the hospital. However, apart from being life-saving in exsanguination, blood transfusion is also associated with adverse events such as transfusion-transmitted infections, allergic reactions, transfusion-associated circulatory overload, transfusion-related acute lung injury, and transfusion-related immunomodulation with nosocomial infections and cancer recurrence. These potentially fatal complications have raised perennial concerns among healthcare professionals with regard to blood transfusion and patient outcomes. Thus, in the last few decades, the safety of the blood product has remained the key focus area for almost every stakeholder, whether end user or policy maker. Optimal use of blood is a globally recognized and recommended policy that ensures that the right amount and type of blood component is transfused to the right patient at the right time. Essentially, it focuses on improving the safety and effectiveness of the clinical transfusion process. However, with the evolving knowledge around transfusion science, increasing involvement of surgeons, anesthesiologists, and other specialists in transfusion offerings and proceedings, and the accumulating evidence on the fact that blood transfusion can, often, be more detrimental to a patient’s clinical status rather than benefiting it, has led to the endorsement and establishment of policy(ies) for optimal use of blood. Patient blood management (PBM), a concept coined and introduced almost two decades ago, encompasses, rather comprehensively, not just the policies and procedures of optimal use of blood and restricting transfusion to as minimum as possible but has a scope that spans much beyond that. PBM is driven and implemented through the three-pillar and nine-field matrix that incorporates the objectives of optimizing hematopoiesis, minimizing bleeding and blood loss, and harnessing and optimizing the physiological tolerance of anemia within the preoperative, intraoperative, and postoperative settings. PBM focuses on patient safety rather than product safety and, thus, ensures adopting a customized approach toward judicious and clinical use of the precious resource, blood. The principles and practices of PBM gained significant relevance and acceptability in the past few years, especially after the pandemic of COVID-19 when the World Health Organization issued a policy brief on its urgent implementation. Through this review article, we intend to establish not just the impact of PBM implementation towards improvement in patient outcomes but also the fact that the relevance and means of PBM extend far above and beyond just the optimal use of blood.
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