大量输血/出血方案与目标导向出血管理:科学变得阴森恐怖?

Klaus Görlinger, P. Kapoor
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引用次数: 1

摘要

出血管理的关键问题是 "病人为什么出血?"和 "如何止血?"要回答第一个问题,粘弹性测试的高阴性预测值可用于识别凝血病理出血。因此,以粘弹性测试为指导的目标导向性出血管理(GDBM)已被证明是患者血液管理(PBM)第二支柱的一个有效而重要的组成部分,其目的是改善患者的预后和安全性。患者的病史和用药史,尤其是口服抗凝药和抗血小板药物的用药史,对于急诊、紧急和择期手术都非常重要。此外,针对创伤性和产科出血开发并验证了风险评分,可作为预测严重出血和是否需要大量输血的有用工具。酸中毒、低钙血症、贫血和低体温("创伤死亡钻石")是止血的重要基本条件,也是凝血病的良好预测指标,出血患者应通过血气分析进行密切监测和纠正。在创伤研究中,止血时间越早,死亡率越低。因此,GDBM 的目的是尽快止血,避免输血中的主要杀手:输血相关循环负荷过重、输血相关急性肺损伤、输血相关免疫调节和血栓形成。血栓弹力仪指导下的出血管理遵循 "良好医疗规范 "和 "精准医学 "的理念。在这里,旋转式血栓弹力仪(ROTEM)指导下的出血管理算法采用了基于 "先治疗先致命的疾病 "顺序的渐进式方法:(1)纤维蛋白溶解管理;(2)血块牢固度管理;(3)凝血酶生成管理;以及(4)避免高凝状态和血栓形成。在这里,血栓弹力测定法不仅能识别高凝状态和血栓形成风险增加的患者,而且 ROTEM 指导下的出血管理也能避免血栓栓塞并发症。这可能支持术后在粘弹性测试指导下进行个性化抗血栓治疗的观点。最后,PBM 与输血无关:它关系到患者的治疗效果。因此,基于 20 多项随机对照试验对粘弹性测试指导下的围手术期出血管理效果进行的几项荟萃分析表明,粘弹性测试不仅显著减少了输血需求,还显著降低了死亡率和术后急性肾损伤。术后急性肾损伤的减少再次对长期生存产生了重大影响。因此,最近的 PBM 指南建议实施粘弹性测试指导下的出血管理算法,建议等级为 1B 或 1A。世界卫生组织的政策简报也提到了这一点,即迫切需要在所有成员国及时实施 PBM。然而,即使国家活动的数量在不断增加,但仍有很长的路要走。
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Massive Transfusion/Hemorrhage Protocols Versus Goal-Directed Bleeding Management: Science Gone Eerie?
Key questions in bleeding management are “Why does my patient bleed?” and “How to fix it?” To answer the first question, the high negative predictive value of viscoelastic testing can be used to identify coagulopathic bleeding. Accordingly, goal-directed bleeding management (GDBM) guided by viscoelastic testing has been shown to be an effective and essential part of the second pillar of patient blood management (PBM) with the aim to improve patients’ outcomes and safety. Patient’s medical and drug history – with a focus on medication with oral anticoagulants and antiplatelet drugs – are important in emergency, urgent, and elective surgery. Furthermore, risk scores have been developed and validated for traumatic and obstetric hemorrhage and can be helpful tools to predict severe hemorrhage and the need for massive transfusion. Acidosis, hypocalcemia, anemia, and hypothermia (“diamond of death in trauma”) are important basic conditions for hemostasis and good predictors of coagulopathy and should be closely monitored by blood gas analysis and corrected in bleeding patients. Earlier time to hemostasis was associated with decreased mortality in trauma studies. Therefore, GDBM aims to stop the bleeding as soon as possible and avoid the main killers in blood transfusion: Transfusion-associated circulatory overload, transfusion-related acute lung injury, transfusion-related immune modulation, and thrombosis. Thromboelastometry-guided bleeding management follows the concepts of Good Medical Practice and Precision Medicine. Here, rotational thromboelastometry (ROTEM)-guided bleeding management algorithms are using a stepwise approach based on the sequence “Treat first what kills first:” (1) Fibrinolysis management, (2) clot firmness management, (3) thrombin generation management, and (4) avoidance of hypercoagulability and thrombosis. Here, thromboelastometry can not only identify patients with hypercoagulability and increased risk of thrombosis but also ROTEM-guided bleeding management can avoid thromboembolic complications, too. This may support the idea of personalized antithrombotic therapy guided by viscoelastic testing in the postoperative period. Finally, PBM is not about blood transfusion: It is about patients’ outcomes. Accordingly, several meta-analyses based on more than 20 randomized controlled trials on the effect of viscoelastic testing-guided perioperative bleeding management did not only demonstrate a significant reduction in transfusion requirements but also a significant reduction in mortality and postoperative acute kidney injury. The reduction in postoperative acute kidney injury again has a significant impact on long-term survival. Accordingly, recent PBM guidelines recommend the implementation of viscoelastic testing-guided bleeding management algorithms with a 1B or 1A recommendation. This is also addressed in the World Health Organization policy brief about the urgent need to implement PBM in all member states in a timely manner. However, even if the number of national activities is increasing, there is still a long way to go.
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