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心脏手术限制性或宽松性输血后的6个月结局
Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery


C. David Mazer ... 心脑血管疾病 • 2018.09.27
相关阅读
• 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

摘要


背景

我们之前曾报告,在有中至高死亡风险,接受心脏手术的患者中,在由以下各项组成的复合结局方面,限制性输血策略不劣于宽松性输血策略:截至出院或术后28日时(以先到者为准)任何原因死亡、心肌梗死、卒中或接受透析的新发肾衰竭。我们现在报告术后6个月时的临床结局。

 

方法

我们将接受心脏手术的5,243例成人患者随机分组,接受限制性红细胞输血策略(如果术中或术后血红蛋白浓度<7.5 g/dL,则进行输血)或宽松性红细胞输血策略(对于重症监护病房[ICU]患者,如果术中或术后血红蛋白浓度<9.5 g/dL,或者对于非ICU病房患者,如果术中或术后血红蛋白浓度<8.5 g/dL,则进行输血)。主要复合结局包括初次手术后6个月内的任何原因死亡、心肌梗死、卒中或接受透析的新发肾衰竭。扩展次要复合结局包括主要结局的所有组成部分,以及初次手术后6个月内的急诊就诊、再次住院或冠状动脉血运重建。次要结局包括两个复合结局的各组成部分。

 

结果

术后6个月时,限制性阈值组2,317例患者中的402例(17.4%)和宽松性阈值组2,347例患者中的402例(17.1%)出现了主要复合结局(舍入前的绝对风险差异,0.22个百分点;95%置信区间[CI],-1.95~2.39;比值比,1.02;95% CI,0.87~1.18;非劣效性P=0.006)。在限制性阈值组和宽松性阈值组中,死亡率分别为6.2%和6.4%(比值比,0.95;95% CI,0.75~1.21)。次要结局无显著组间差异。

 

结论

在有中至高死亡风险,接受心脏手术的患者中,在由以下各项组成的复合结局方面,限制性红细胞输血策略不劣于宽松性策略:术后6个月时任何原因死亡、心肌梗死、卒中或接受透析的新发肾衰竭(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., Emilie Belley-Cote, M.D., Katherine Connolly, M.D., Boris Khanykin, M.D., Alexander J. Gregory, M.D., Étienne de Médicis, M.D., François M. Carrier, M.D., Shay McGuinness, M.B., Ch.B., Paul J. Young, F.C.I.C.M., Ph.D., Kelly Byrne, M.B., Ch.B., Juan C. Villar, M.D., Ph.D., Alistair Royse, M.B., B.S., M.D., Hilary P. Grocott, M.D., Manfred D. Seeberger, M.D., Chirag Mehta, M.D., François Lellouche, M.D., Ph.D., Gregory M.T. Hare, M.D., Ph.D., Thomas W. Painter, M.B., Ch.B., Stephen Fremes, M.D., Summer Syed, M.D., Sean M. Bagshaw, M.D., Nian-Chih Hwang, M.B., B.S., G.D.Acu., Colin Royse, M.B., B.S., M.D., Judith Hall, M.Sc., David Dai, M.Sc., Nikhil Mistry, M.Sc., Kevin Thorpe, M.Math., Subodh Verma, M.D., Ph.D., 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., N.M.) and the Department of Surgery, Division of Cardiac Surgery (S.V.), St. Michael’s Hospital, Keenan Research Centre for Biomedical Science, the Li Ka Shing Knowledge Institute of St. Michael’s Hospital (C.D.M., G.M.T.H., K.T., S.V., P.J.), Applied Health Research Centre (J.H., D.D., K.T., S.V., P.J.), Sunnybrook Health Sciences Centre (S.F.), Division of Hematology, Mount Sinai Hospital (N.S.), the Departments of Medicine (P.J., N.S.), Physiology (C.D.M., G.M.T.H), and Laboratory Medicine and Pathobiology (N.S.), Dalla Lana School of Public Health (K.T.), and Institute of Health Policy, Management and Evaluation, University of Toronto, and Canadian Blood Services (N.S.), Toronto, the Population Health Research Institute (R.P.W., E.B.-C.), Hamilton Health Sciences Center (R.P.W., E.B.-C., K.C., S.S.), McMaster University (R.P.W., E.B.-C., K.C., S.S.), Hamilton, ON, the Ottawa Hospital Research Institute, University of Ottawa, Ottawa (D.A.F.), the Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Calgary (A.J.G.), and the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (S.M.B.), CHUS–Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (É.M.), and the Department of Anesthesiology and Critical Care Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Laval (F.L.), QC, the Departments of Anesthesia and Medicine, Division of Critical Care, Centre Hospitalier de l’Université de Montréal, Montreal (F.M.C.), and the Department of Anesthesia, Perioperative and Pain Medicine, St. Boniface Hospital, University of Manitoba, Winnipeg (H.P.G.) — 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; Fundación Cardioinfantil–Instituto de Cardiología and Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia (J.C.V.); 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, and the Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA (T.W.P.) — all in Australia; University of Basel, Department of Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, and Klinik Hirslanden Zurich, Zurich — both in Switzerland (M.D.S.); Heart Care Associates, SAL Hospital, Gujarat, India (C.M.); and the Department of Cardiothoracic Anaesthesia, National Heart Center, and the Department of Anaesthesiology, Singapore General Hospital — both in Singapore (N.-C.H.). Address reprint requests to Dr. Mazer at the Department of Anesthesia, St. Michael’s Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada, or at mazerd@smh.ca. *A complete list of the Transfusion Requirements in Cardiac Surgery (TRICS) trial investigators is provided in the Supplementary Appendix, available at NEJM.org.

 

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