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在心脏外科手术中限制性和宽松性输注红细胞的效果比较
Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery


C. David Mazer ... 心脑血管疾病 • 2017.11.30
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• 心脏手术限制性或宽松性输血后的6个月结局 • 用于急性上消化道出血患者的限制性输血得到更多数据支持 • 急性上消化道出血的输血策略

采用限制性或宽松性输血对心脏外科手术患者临床结局的影响

 

惠尚懿†,于春华†,麻浩波¶*,黄宇光†*

†中国医学科学院北京协和医院麻醉科;¶ Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA

*共同通信作者

 

接受心脏外科手术的患者常常需要输血:适量输血可以治疗贫血症状,改善器官的灌注;Koch等1和Morphy等2的观察性研究表明过量的输血会带来多种并发症甚至降低生存率。根据这些观察性研究,越来越多的医生采用限制性输血策略。

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摘要


背景

接受心脏外科手术的患者应用限制性或宽松性输注红细胞策略对临床结局的影响仍然不清楚。

 

方法

在此多中心、开放标签和非劣效性试验中,我们将5,243例接受心脏外科手术且欧洲心脏手术风险评估系统(European System for Cardiac Operative Risk Evaluation,EuroSCORE)Ⅰ评分≥6分(量表评分为0~47分,评分较高表明心脏外科手术后的死亡风险较高)的成人患者随机分配至限制性输注红细胞阈值组(如果血红蛋白水平<7.5 g/dL,则从诱导麻醉开始输注红细胞)或宽松性输注红细胞阈值组(在手术室或重症监护病房[ICU],如果血红蛋白水平<9.5 g/dL,则输注红细胞;在非ICU病房,如果血红蛋白水平<8.5 g/dL,则输注红细胞)。主要的复合结局是截至出院或第28日,任何原因死亡、心肌梗死、卒中或新发肾衰竭透析,以上两个时间以先达到的为准。次要结局包括输注红细胞和其他临床结局。

 

结果

与宽松性阈值组12.5%患者发生主要结局相比,限制性阈值组11.4%的患者发生主要结局(绝对风险差异,-1.11个百分点;95%置信区间[CI],-2.93~0.72;比值比,0.90;95% CI,0.76~1.07;非劣效性P<001)。限制性阈值组死亡率为3.0%,宽松性阈值组为3.6%(比值比,0.85;95% CI,0.62~1.16)。与宽松性阈值组72.6%患者接受输注红细胞相比,限制性阈值组为52.3%(比值比,0.41;95% CI,0.37~0.47)。两组间其他次要结局没有显著差异。

 

结论

在接受心脏手术且有中至高死亡风险的患者中,就全因死亡、心肌梗死、卒中或新发肾衰竭透析构成的复合结局而言,限制性输注红细胞策略不劣于宽松性策略,且前者输注红细胞较少(研究由加拿大卫生研究院[Canadian Institutes of Health Research]等资助;TRICS Ⅲ在ClinicalTrials.gov注册号为NCT02042898)。





作者信息

C. David Mazer, M.D., Richard P. Whitlock, M.D., Ph.D., Dean A. Fergusson, Ph.D., M.H.A., Judith Hall, M.Sc., Emilie Belley-Cote, M.D., Katherine Connolly, M.D., Boris Khanykin, M.D., Alexander J. Gregory, M.D., Étienne de Médicis, M.D., Shay McGuinness, M.B., Ch.B., Alistair Royse, M.B., B.S., M.D., François M. Carrier, M.D., Paul J. Young, F.C.I.C.M., Ph.D., Juan C. Villar, M.D., Ph.D., Hilary P. Grocott, M.D., Manfred D. Seeberger, M.D., Stephen Fremes, M.D., François Lellouche, M.D., Ph.D., Summer Syed, M.D., Kelly Byrne, M.B., Ch.B., Sean M. Bagshaw, M.D., Nian C. Hwang, M.B., B.S., G.D.Acu., Chirag Mehta, M.D., Thomas W. Painter, M.B., Ch.B., Colin Royse, M.B., B.S., M.D., Subodh Verma, M.D., Ph.D., Gregory M.T. Hare, M.D., Ph.D., Ashley Cohen, M.Sc., Kevin E. Thorpe, M.Math., Peter Jüni, M.D., and Nadine Shehata, M.D., for the TRICS Investigators and Perioperative Anesthesia Clinical Trials Group*
From the Department of Anesthesia (C.D.M., G.M.T.H.) and the Department of Surgery, Division of Cardiac Surgery (S.V.), Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Applied Health Research Centre (AHRC), Li Ka Shing Knowledge Institute of St. Michael’s Hospital (J.H., A.C.), Sunnybrook Health Sciences Center (S.F.), AHRC, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Dalla Lana School of Public Health (K.E.T.), and AHRC, Li Ka Shing Knowledge Institute of St. Michael’s Hospital, Department of Medicine and Institute of Health Policy, Management and Evaluation (P.J.), University of Toronto, and the Departments of Medicine, Laboratory Medicine, and Pathobiology, Institute of Health Policy, Management, and Evaluation, University of Toronto, and the Division of Hematology, Mount Sinai Hospital, Canadian Blood Services (N.S.), Toronto, Population Health Research Institute (R.P.W., E.B.-C.), Hamilton Health Sciences Centre (R.P.W., E.B.-C., K.C.), and McMaster University (R.P.W., E.B.-C., S.S.), Hamilton, ON, Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.A.F.), the Department of Anesthesia, Foothills Medical Centre, University of Calgary, Calgary, AB (A.J.G.), Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC (É.M.), the Departments of Anesthesia and Medicine, Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal (F.M.C.), the Departments of Anesthesia and Surgery, University of Manitoba, St. Boniface Hospital, Winnipeg (H.P.G.), the Department of Anesthesiology and Critical Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Laval, QC (F.L.), and the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (S.M.B.) — all in Canada; the Department of Cardiothoracic Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen (B.K.); Medical Research Institute of New Zealand, Wellington (S.M., P.J.Y.), and Waikato Hospital, Hamilton (K.B.) — both in New Zealand; the Department of Surgery, University of Melbourne (A.R., C.R.), and the Department of Anaesthesia and Pain Management, Royal Melbourne Hospital (C.R.), Melbourne, VIC, and the Department of Anaesthesia, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA (T.W.P.) — all in Australia; Fundación Cardioinfantil–Instituto de Cardiología, Bogota, and Universidad Autónoma de Bucaramanga, Bucaramanga — both in Colombia (J.C.V.); the University of Basel, Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, and Klinik Hirslanden, Zurich — both in Switzerland (M.D.S.); the Department of Cardiothoracic Anesthesia, National Heart Center, and the Department of Anesthesiology, Singapore General Hospital, Singapore (N.C.H.); and Heart Care Associates, Ahmedabad, India (C.M.). Address reprint requests to Dr. Mazer at the Department of Anesthesia, St. Michael’s Hospital, 30 Bond St., Toronto, ON, M5B 1W8, Canada, or at mazerd@smh.ca. *A complete list of the TRICS investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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