| 词条 | Blood management |
| 释义 |
| name = Blood management | synonym = | image = | caption = | alt = | pronounce = | specialty = hematology | synonyms = | ICD10 = | ICD9 = | ICD9unlinked = | CPT = | MeshID = | LOINC = | other_codes = | MedlinePlus = | eMedicine = }}Patient Blood Management (PBM) is a multidisciplinary, evidence-based approach to optimizing the care of patients who might need a blood transfusion.[1][2] Patient blood management represents an international initiative in best practice for transfusion medicine that is supported by the World Health Organization (WHO).[1] Establishing a patient blood management strategy requires leadership and support from national and regional government policymakers and managers, healthcare professionals, and patients. Patients are an essential part of planning, implementing and evaluating PBM programs.[3] Examples of how to implement PBM are available from Australia,[4] the UK,[5] and the USA.[6] Three pillars of patient blood management
NecessityEvidence indicates that a great number of the patients who are being transfused today may not be seeing many tangible benefits from it, as the transfused blood fails to achieve its primary goals – prevention of ischemia and improving the clinical outcomes. The challenge lies in identifying those patients who are at risk of complications of severe anemia (ischemia) and transfusing them, without exposing other patients to unwarranted risks of inappropriate transfusions. Better transfusion practice should not be viewed as an option, but a necessity to ensure clinicians are doing good and not doing harm to their patients.[9][10][11] Cost issuesAnother significant reason to embrace the concept of patient blood management is cost. Allogeneic blood transfusion is extremely expensive. For example, some studies reported increased costs of $300–$1,000 per unit of allogeneic blood transfused.[12][13] The more blood that is transfused directly impacts hospital expenditures, and of course, it behoves administrators to search for ways to reduce this cost. This increasing cost of transfusions is the reason many hospital administrators are endeavoring to establish blood management programs. Patient outcomesPerhaps the single most important reason for implementing patient blood management is need to improve patient outcomes. Published in 2017, a retrospective observational study in four major adult tertiary-care hospitals concluded that implementation of a unique, jurisdiction-wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product-related cost savings.[14] Better outcomes are achieved with the reduction or avoidance of exposure to allogeneic blood. Numerous clinical studies have shown that allogeneic blood transfusions are associated with increased mortality and an increased level of serious complications, while potentially exposing the patient to viral, bacterial, or parasitic agents. Also, current medical literature shows that in most circumstances a restrictive threshold is as safe as a more liberal red cell transfusion threshold and in certain circumstances, for example gastrointestinal bleeding due to liver disease, a more liberal red cell transfusion strategy may be harmful.[11][9][15][16] MethodsThe cornerstone of patient blood management is a multidisciplinary approach, involving family physicians, nurses, anesthetists, surgeons, Transfusion Practitioners, hematologists, and hematology and blood transfusion laboratory staff.[3] Part of PBM is avoiding unnecessary treatments and procedures, and some of the PBM recommendations from around the world have been incorporated in to the "Choosing Wisely" campaigns that exist in Australia, Canada, the UK, and the USA.[17] Surgical PBMPatient blood management in the perioperative setting can be achieved by means of a variety of techniques and strategies. First, ensuring that the patient enters the operating room with a sufficient hematocrit level is essential. Preoperative anemia has been documented to range from 5% in female geriatric hip fracture patients to over 75% in colon cancer patients.[18] Patients who are anemic prior to surgery obviously receive more transfusions. Erythropoietin and iron therapy can be considered in cases of anemia. Accordingly, patients should be screened for anemia at least 30 days prior to an elective surgical procedure. Although either oral or parenteral iron could be given, increasingly clinicians are giving parenteral iron to ensure that the haemoglobin is increased the maximal amount before the elective surgery is undertaken. During surgery, techniques are utilized to reduce or eliminate exposure to allogeneic blood. For example, electrocautery, which is a technique utilized for surgical dissection, removal of soft tissue and sealing blood vessels, can be applied to a variety of procedures. During surgical procedures that are expected to have significant blood loss, blood that is lost during surgery can be collected, filtered, washed and given back to the patient.[19] This procedure is known as "Intraoperative Blood Salvage."[20] Pharmacologic agents, for example tranexamic acid, can also be utilized to minimize blood loss.[21] Another technique, acute normovolemic hemodilution" involves the collection of a selected calculated volume of autologous blood in collection bags prior to the start of surgery with the simultaneous replacement of an equal volume of asanguinous fluid. Since the patient's blood is now diluted, blood lost during the surgical procedure, i.e. by hemorrhage, contains smaller amounts of red blood cells. The collected autologous blood product, which contains red blood cells, platelets and coagulation factors, is reinfused at the end of the surgery.[22][23] When all of these therapies are combined, blood loss is greatly reduced which correspondingly reduces or averts the potential for allogeneic blood transfusion. Additional details on this question can be found in the journal, Transfusion.[24] Benefits of Information Technology in PBMInformation technology can be useful in implementing a patient blood management policy, this includes:
References1. ^1 {{cite web|url=http://hospital.blood.co.uk/patient-services/patient-blood-management/|title=Patient Blood Management|last=|first=|date=|website=NHS Blood and Transplant, UK|archive-url=|archive-date=|dead-url=|access-date=}} 2. ^{{cite journal | vauthors = Markowitz MA, Waters JH, Ness PM | title = Patient blood management: a primary theme in transfusion medicine | journal = Transfusion | volume = 54 | issue = 10 Pt 2 | pages = 2587 | date = October 2014 | pmid = 25308046 | doi = 10.1111/trf.12862 }} 3. ^1 {{Cite web|url=http://www.isbtweb.org/working-parties/clinical-transfusion/2-establishing-and-implementing-a-pbm-strategy/|title=Clinical Transfusion: 2 Establishing and Implementing a PBM strategy|last=|first=|date=|website=International Society of Blood Transfusion|archive-url=|archive-date=|dead-url=|access-date=}} 4. ^{{Cite web|url=http://www.blood.gov.au/patient-blood-management-pbm|title=Patient Blood Management|last=|first=|date=|website=www.blood.gov.au|archive-url=|archive-date=|dead-url=|access-date=22 August 2018}} 5. ^{{Cite web|url=https://www.transfusionguidelines.org/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management|title=Patient Blood Management|last=|first=|date=|website=JPAC|archive-url=|archive-date=|dead-url=|access-date=22 August 2018}} 6. ^{{Cite web|url=http://lp.aabb.org/pbm-whitepaper|title=Building a Better Patient Blood Management Program|last=|first=|date=|website=AABB|archive-url=|archive-date=|dead-url=|access-date=22 August 2018}} 7. ^{{cite journal | vauthors = Isbister JP | title = The three-pillar matrix of patient blood management--an overview | journal = Best Practice & Research. Clinical Anaesthesiology | volume = 27 | issue = 1 | pages = 69–84 | date = March 2013 | pmid = 23590917 | doi = 10.1016/j.bpa.2013.02.002 }} 8. ^{{Cite web|url=https://www.blood.gov.au/system/files/documents/pbm-3-pillars.pdf|title=Three Pillars of Patient Blood Management|last=|first=|date=|website=National Blood Authority, Australia|archive-url=|archive-date=|dead-url=|access-date=}} 9. ^1 {{cite journal | vauthors = Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, Hebert PC | title = Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion | journal = The Cochrane Database of Systematic Reviews | volume = 10 | pages = CD002042 | date = October 2016 | pmid = 27731885 | pmc = 4171966 | doi = 10.1002/14651858.cd002042.pub4 }} 10. ^{{cite journal | vauthors = Estcourt LJ, Malouf R, Trivella M, Fergusson DA, Hopewell S, Murphy MF | title = Restrictive versus liberal red blood cell transfusion strategies for people with haematological malignancies treated with intensive chemotherapy or radiotherapy, or both, with or without haematopoietic stem cell support | journal = The Cochrane Database of Systematic Reviews | volume = 1 | pages = CD011305 | date = January 2017 | pmid = 28128441 | pmc = 5298168 | doi = 10.1002/14651858.CD011305.pub2 }} 11. ^1 {{cite journal | vauthors = Desborough MJ, Colman KS, Prick BW, Duvekot JJ, Sweeney C, Odutayo A, Jairath V, Doree C, Trivella M, Hopewell S, Estcourt LJ, Stanworth SJ | title = Effect of restrictive versus liberal red cell transfusion strategies on haemostasis: systematic review and meta-analysis | journal = Thrombosis and Haemostasis | volume = 117 | issue = 5 | pages = 889–898 | date = May 2017 | pmid = 28251234 | doi = 10.1160/TH17-01-0015 }} 12. ^{{cite journal | vauthors = Crémieux PY, Barrett B, Anderson K, Slavin MB | title = Cost of outpatient blood transfusion in cancer patients | journal = Journal of Clinical Oncology | volume = 18 | issue = 14 | pages = 2755–61 | date = July 2000 | pmid = 10894876 | doi = 10.1200/jco.2000.18.14.2755 }} 13. ^{{cite journal | vauthors = Zilberberg MD, Shorr AF | title = Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation | journal = BMC Health Services Research | volume = 7 | pages = 138 | date = August 2007 | pmid = 17764560 | pmc = 2064919 | doi = 10.1186/1472-6963-7-138 }} 14. ^{{cite journal | vauthors = Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, Hamdorf J, Gallagher T, Koay A, Geelhoed GC, Farmer SL | title = Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals | journal = Transfusion | volume = 57 | issue = 6 | pages = 1347–1358 | date = June 2017 | pmid = 28150313 | doi = 10.1111/trf.14006 }} 15. ^{{cite journal | vauthors = Odutayo A, Desborough MJ, Trivella M, Stanley AJ, Dorée C, Collins GS, Hopewell S, Brunskill SJ, Kahan BC, Logan RF, Barkun AN, Murphy MF, Jairath V | title = Restrictive versus liberal blood transfusion for gastrointestinal bleeding: a systematic review and meta-analysis of randomised controlled trials | journal = The Lancet. Gastroenterology & Hepatology | volume = 2 | issue = 5 | pages = 354–360 | date = May 2017 | pmid = 28397699 | doi = 10.1016/s2468-1253(17)30054-7 }} 16. ^{{cite journal | vauthors = Shander A | title = Emerging risks and outcomes of blood transfusion in surgery | journal = Seminars in Hematology | volume = 41 | issue = 1 Suppl 1 | pages = 117–24 | date = January 2004 | pmid = 14872432 | doi = 10.1053/j.seminhematol.2003.11.023 }} 17. ^{{cite journal | vauthors = Estcourt LJ, Roberts DJ | title = Patient blood management - a renaissance of transfusion medicine | journal = Transfusion Medicine | volume = 28 | issue = 2 | pages = 85–88 | date = April 2018 | pmid = 29744975 | doi = 10.1111/tme.12530 }} 18. ^{{cite journal | vauthors = Shander A, Knight K, Thurer R, Adamson J, Spence R | title = Prevalence and outcomes of anemia in surgery: a systematic review of the literature | journal = The American Journal of Medicine | volume = 116 Suppl 7A | issue = 7 | pages = 58S–69S | date = April 2004 | pmid = 15050887 | doi = 10.1016/j.amjmed.2003.12.013 }} 19. ^{{Cite web|url=https://www.nice.org.uk/guidance/ng24|title=Blood transfusion {{!}} Guidance and guidelines {{!}} NICE|website=www.nice.org.uk|language=en-GB|access-date=2018-08-22}} 20. ^{{cite journal | vauthors = Waters JH | title = Indications and contraindications of cell salvage | journal = Transfusion | volume = 44 | issue = 12 Suppl | pages = 40S–4S | date = December 2004 | pmid = 15585004 | doi = 10.1111/j.0041-1132.2004.04176.x }} 21. ^{{cite journal | vauthors = Ker K, Edwards P, Perel P, Shakur H, Roberts I | title = Effect of tranexamic acid on surgical bleeding: systematic review and cumulative meta-analysis | journal = BMJ | volume = 344 | pages = e3054 | date = May 2012 | pmid = 22611164 | pmc = 3356857 | doi = 10.1136/bmj.e3054 | url = https://www.bmj.com/content/344/bmj.e3054 }} 22. ^{{cite journal | vauthors = Shander A, Rijhwani TS | title = Acute normovolemic hemodilution | journal = Transfusion | volume = 44 | issue = 12 Suppl | pages = 26S–34S | date = December 2004 | pmid = 15585002 | doi = 10.1111/j.0041-1132.2004.04293.x }} 23. ^{{cite journal | vauthors = Barile L, Fominskiy E, Di Tomasso N, Alpìzar Castro LE, Landoni G, De Luca M, Bignami E, Sala A, Zangrillo A, Monaco F | title = Acute Normovolemic Hemodilution Reduces Allogeneic Red Blood Cell Transfusion in Cardiac Surgery: A Systematic Review and Meta-analysis of Randomized Trials | journal = Anesthesia and Analgesia | volume = 124 | issue = 3 | pages = 743–752 | date = March 2017 | pmid = 27669554 | doi = 10.1213/ane.0000000000001609 }} 24. ^{{cite journal | vauthors = Goodnough LT, Shander A, Spence R | title = Bloodless medicine: clinical care without allogeneic blood transfusion | journal = Transfusion | volume = 43 | issue = 5 | pages = 668–76 | date = May 2003 | pmid = 12702192 | doi = 10.1046/j.1537-2995.2003.00367.x }} 25. ^1 {{Cite web|url=http://www.isbtweb.org/working-parties/clinical-transfusion/12-use-of-it-to-support-pbm/|title=Use of IT to support PBM|last=Yazer|first=Mark|date=|website=www.isbtweb.org|language=en|archive-url=|archive-date=|dead-url=|access-date=2018-08-22}} Further reading{{refbegin}}
4 : Blood|Hematology|Transfusion medicine|Surgery |
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