输血治疗传统观念的变革与更新 安徽医科大学第一附属医院 张循善.

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1 输血治疗传统观念的变革与更新 安徽医科大学第一附属医院 张循善

2 主要内容 输血医学发展简史 询证输血医学新观念 现代输血疗法的临床应用 临床输血的有关问题 术前输血 大量输血 相容血液的输注
R hD血型不相同血液成分输注

3 人类输血简史 1818年英国产科医生Blundell在动物试验的基础上，将人类血液输给严重大出血的产妇，8例中有5例获得了成功，这是人类历史上首次进行人类个体间输血并得以成功的学者。但以后的输血实践发现，在随机个体间输血，患者可能发生较为严重的输血反应，约有35％的受血者发生溶血性输血反应，其中许多患者经治疗无效而伤亡。直到1900年维也纳大学病理解剖研究所的助教Landsteiner首先发现了人类血型，这一划时代的发现，为以后的安全、有效输血，做出了重大贡献，为此他获得了1930年的诺贝尔奖。

4 -- 1900 The elucidation of the ABO blood group system by Landsteiner
. Animal to human --- Jean Denis , 1667 . Human to human , James Blundell The elucidation of the ABO blood group system by Landsteiner Lewisohn - used citrate Landsteiner and Wiener, in, describe Rh typing

5 成分输血的简史 输血医学发展的第二个里程碑是成分输血，早期的输血都是输注全血，1950年Walter发明了塑料血袋，使血液分离较为便利，血液成分疗法正式提出。随着塑料多联血袋的问世，二十世纪六十年代起输血医学进入了成分输血时代。美国成分输血发展为例，浓缩红细胞输血的比例1967～1978年间，由0.8%增加到88％。临床输血的主流是红细胞，节省的大量血浆可用于制备Ⅷ因子，用来治疗血友病。粒细胞输注趋势；血小板的输注也具有明显上升的趋势。

6 成分输血的意义 提高输血疗效 减少和预防输血不良反应和并发症* 有利于血液各种成分的保存 节约血液资源

7 减少和预防输血不良反应和并发症 输注添加液红细胞，可减少或避免输注血浆导致的过敏反应，这种反应占42.6%；
输注去白细胞红细胞或血小板可避免或减少以后患者输血由于产生白细胞抗体而发生的非溶血性发热输血反应，这种反应占52.6%。避免HLA同种免疫，避免今后器官或骨髓移植的超急性排斥反应；可避免血小板输注无效等； 减少输血感染病毒的危险性； 为血液成分的病毒灭活创造条件。

8 现代成分输血的主要趋势 输注添加液红细胞为主流； 血小板输注的增加； 去白细胞血液成分广泛应用； 病毒灭活血液成分临床应用；
特殊成分的输注 外周血干细胞移植 DC抗肿瘤疫苗； 白细胞输注减少； 促进血细胞生长的药物的应用，减少了血液成分的使用量。rhEpo , G-CSF

9 询证输血医学新观念 输血作为重症患者的支持疗法没有询证依据 同种输血能够导致外科患者及重症患者出现不良转归 输血不能促进伤口愈合
“失多少血，补多少血”“缺多少血，补多少血”是过时、错误观念

10 输血作为支持疗法不再是现代红细胞输注指征
Crit Care Med 2009 Vol. 37, No Crit Care Med 2004; 32[Suppl.]:S542–S547 意大利国家指南 Blood Transfus 2009; 7: 49-64 Annals of Internal Medicine 2012 ； 157（1）：50

11 败血症患者要求较高Hb水平的适应证 不包括支持目的
Conditions in septic patients that may require a higher hemoglobin Cardiovascular disease Coronary artery disease Low cardiac output Pulmonary disease Severe arterial hypoxemia（低氧血症） Organ or tissue ischemia Severe mixed venous desaturation（混合静脉血氧饱和度，过低表明组织氧合障碍） Elevated lactate level Use of blood products in sepsis: An evidence-based review. Crit Care Med 2004; 32(Suppl):S542–S547.

12 FFP适应证不包括抗感染 输注FFP不能作为支持疗法
Fresh-Frozen Plasma Transfusion Question: When should FFP be transfused in patients with severe sepsis? Recommendation: Routine use of FFP to correct laboratory clotting abnormalities in the absence of bleeding or planned invasive procedures is not recommended. FFP is indicated for coagulopathy due to documented deficiency of coagulation factors (increased PT APTT) in the presence of active bleeding or before surgical or invasive procedures. Use of blood products in sepsis: An evidence-based review. Crit Care Med 2004; 32(Suppl):S542–S547.

13 重症患者输注红细胞导致的不良转归 From 571 articles screened, 45 met inclusion criteria
In 42 of the 45 studies the risks of RBC transfusion outweighed the benefits; Seventeen of 18 studies, demonstrated that RBC transfusions were an independent predictor of death; Twenty-two studies examined the association between RBC transfusion and nosocomial infection; in all these studies blood transfusion was an independent risk factor for infection. RBC transfusions similarly increased the risk of developing multi-organ dysfunction syndrome (three studies) and acute respiratory distress syndrome (six studies). Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature [J]. Crit Care Med. 2008;36(9):

14 相对危险度 腹腔间隙综合征

15

16

17 Propensity score（倾向指数） matched
Prospective, multiple center, observational cohort study（观测队列研究） of 4,892 ICU pts in the US Propensity score（倾向指数） matched Designed to examine the relationship of anemia and RBC transfusion with clinical outcomes Almost 95% of patients admitted to the ICU have a Hb level below “normal” by day 3 In total, 11,391 RBC units were transfused. Overall, 44% of pts admitted to the ICU received one or more RBC units while in the ICU Crit Care Med Jan;32(1):39-52

18 35% of Blood transfused in patients with Hgb  9
Crit Care Med Jan;32(1):39-52 35% of Blood transfused in patients with Hgb  9 RBC transfusion was independently associated with higher mortality (OR 1.65 CI ). OR 2.62 if 3-4 units transfused p < The mean pre-transfusion Hb was 8.6 ± 1.7 g/dL

19 Association between transfusion and outcome
Analysis of 24,112 enrollees in 3 large international trials of patients with acute coronary syndromes Association between transfusion and outcome Cox proportional hazards modeling Main outcome = 30 day mortality Rao SV et al. JAMA. 2004;292:

20 Blood Transfusion and Clinical Outcome in Acute Coronary Syndrome
Adjusted hazard ratio 3.94 ( ) No Transfusion Rao SV et al. JAMA. 2004;292:

21 研究对象 研究结论

22 老年退伍军人局

23

24 15,592 Cardiovascular operations Infection endpoints bacteremia, SSI
55% of pts received PRBCs, 21% plts, 13% FFP, 3% cryoprecipitate Increased RBC tx associated with increased infection (p < ), confirmed by logistic regression analysis（回归分析）. J Am Coll Surg 2006;202:

25 Effect of Blood Transfusion on Long-Term Survival After Cardiac Operation
1915 CABG pts After correction for comorbidities and other factors, tx was still associated with a 70% increase in mortality (RR 1.7; 95% CI 1.4 to 2.0; p ). Engoren MC et al. (MCO, Toledo) Ann Thorac Surg 2002;74:1180–6

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27 Methods We enrolled 838 critically ill patients who had hemglobin concentrations of less than 9.0 g /dl and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g /dl and hemoglobin concentrations were maintained at 7.0 to 9.0 g /dl, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g /dl and hemoglobin concentrations were maintained at 10.0 to 12.0 g /dl. Results Overall, 30-day mortality was similar in the two groups (18.7 percent vs percent, P=0.11). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.2 percent vs percent, P=0.05).

28 患者输注红细胞导致的不良转归机制 Storage lesion 同种输血的免疫负向调节作用 Metabolic acidosis
库存红细胞2.3-DPG含量下降 Metabolic acidosis Altered oxygen carrying capacity 库存红细胞变形能力下降 库存红细胞携带NO能力减弱 Increased red cell death with increased age of blood (~30% dead) No improvement in oxygen utilization at the tissue level 同种输血的免疫负向调节作用

29

30 March 20, 2008

31 研究结果 The median duration of storage was 11 days for newer blood and 20 days for older blood. Patients who were given older units had higher rates of in-hospital mortality (2.8% vs. 1.7%, P = 0.004), intubation beyond 72 hours (9.7% vs. 5.6%, P<0.001), renal failure (2.7% vs. 1.6%, P = 0.003), and sepsis or septicemia (4.0% vs. 2.8%, P = 0.01). A composite of complications was more common in patients given older blood (25.9% vs. 22.4%, P = 0.001). Similarly, older blood was associated with an increase in the risk-adjusted rate of the composite outcome (P = 0.03). At 1 year, mortality was significantly less in patients given newer blood (7.4% vs. 11.0%, P<0.001).

32 Immune Effects of Blood
Immunologic effects of allogenic blood Tx Decreased T-cell proliferation Decreased CD3, CD4, CD8 T-cells Increased soluble cytokine receptor sTNF-R, sIL-2R Increased cell-mediated lympholysis（淋巴细胞溶解） Increased suppressor T-cell activity Reduced natural killer cell activity McAlister FA et al, Br J Surg 1998;85:171-8. Innerhofer P et al, Transfusion 1999;39:

33 输血不能促进伤口愈合

34 手术切口愈合紊乱诊断标准 结果和机制

35 underwent laparotomy（剖腹术）
underwent gastrectomy （胃切除） underwent gastroduodenostomy（胃十二指肠吻合术） CONCLUSIONS: Blood transfusions increased the incidence of anastomotic abscess（脓肿） and impaired anastomotic wound healing.

36 2001 and June 2005 we have performed a prospective observational study in 1553 elective and emergency patients who underwent median sternotomy for heart surgery. CONCLUSIONS: According to our results, the total amount of allogeneic blood transfused is a major factor contributing to sternal dehiscence （胸骨裂开）regardless of other risk preconditions. European Journal of Anaesthesiology: May Volume 23 - Issue - p 1-2

37 Colorectal Dis.2007V9N4:362-7

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40 “缺多少血，补多少血”与“失多少血，补多少血”是否合理？？

41 英国输血一般原则

42 Guidelines for Blood Transfusion: PRBCs
RBCs should be administered as single units for most operative and inpatient indications (transfuse and reassess strategy) except for ongoing blood loss with hemodynamic instability. Tx decisions are clinical judgments that should be based on the overall clinical assessment of the individual patient. Transfusion decisions should not be based on laboratory parameters alone. Routine premedication is not advised unless the patient has a history of previous transfusion reactions. Premedication has not been shown to reduce the risk of transfusion reactions.

43 现代红细胞输注适应症和输注指征 一 、慢性贫血
贫血时机体的反应* 慢性贫血的输血目的 提高血红蛋白水平，以保证组织供氧。因此应当输注红细胞即可，不应输注全血。 慢性贫血的输血原则 临床上输注红细胞主要是消除或减轻缺氧症状，只要将Hb水平提高到能保证足够的组织供氧即可，不需要通过输血将患者的Hb水平恢复到正常水平。..\红细胞保存\输血到HB正常水平不能改变患者的转归.PDF

44 贫血时机体生理反应 增加心脏输出量 减少外周血管阻力 增加红细胞释放氧的能力 增加心率、每搏输出量、心肌收缩力 降低血液粘滞性

45 人类耐受低Hb的能力

46 输红细胞指征 一般认为（国内）Hb降低到正常值的 50％以下，才需要输注红细胞；Hb降低不到上述水平但是患者伴有心、肺功能受损或心、脑等重要脏器的血管硬化，使组织得不到足够的氧时，也需要输注红细胞。 贫血病因的确定和治疗

47 英国红细胞输注指南 （2002年）

48 Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB
直立 Ann Intern Med.2012V157N1:49-58

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50 2010版

51

52 Methods We enrolled 838 critically ill patients who had hemglobin concentrations of less than 9.0 g /dl and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g /dl and hemoglobin concentrations were maintained at 7.0 to 9.0 g /dl, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g /dl and hemoglobin concentrations were maintained at 10.0 to 12.0 g /dl. Results Overall, 30-day mortality was similar in the two groups (18.7 percent vs percent, P=0.11). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.2 percent vs percent, P=0.05).

53 二、急性贫血 由于手术、创伤和其它疾病引起的急性贫血，临床医生在输血指征掌握、血液成分品种的选择、输注剂量的确定时，应当根据患者的临床具体情况，才能做出正确的决定，才能安全、有效、及时的进行输血治疗。值得注意的是临床医生应当严格掌握输血指征，减少不必要的输血。

54 临床医生对急性失血的输血指征把握仍然存在问题
英国2007~2008年国家输血审核发现，38%患者缺少夜间输血临床指征；消化道出血患者输血 澳大利亚学者发现某教学医院blood product use was inappropriate for 16% of red cell, 13% of platelet and 31% of fresh frozen plasma (FFP) transfusion episodes. 国外学者研究结肠、直肠癌围手术期输血存在输血指征掌握不严现象。 国内部分外科医生输血指征掌握仍然不严 美国的临床输血管理

55 急性贫血输血和血液成分选择的依据 失血量 临床情况

56 失血量与患者临床症状和体征关系 一般来说心血管功能正常的患者失血量在10％的血容量几乎不会引起任何症状；
丢失20％当患者卧床一般仍然不会出现特殊的症状和体征，一般仅出现运动时出现心动过速； 丢失30％的血容量并不及时补液或输血时，患者就会出现低血压和心动过速； 丢失30％以上的血容量，患者才出现严重的症状和体征，包括心动过速、脉搏微弱、低血压、中心静脉压和心输出量下降和面色苍白等。

57 失血量与输血指征关系 患者丢失20％（新生儿10%）的血容量以下，或成人失血量在1000毫升以内，不必输注红细胞；
失血量在20％～30％时，及时补液和输注红细胞2单位即可； 失血量在>30％时，除了及时补液和输注红细胞外，可根据患者具体情况加输全血、FFP或血小板。

58 《临床输血技术规范》 手术及创伤输血指南 一、浓缩红细胞 　　用于需要提高血液携氧能力，血容量基本政常或低血容量已被纠正的患者。低血容量患者可配晶体液或胶体液应用。 1． 血红蛋白＞100g/L,可以不输。 2． 血红蛋白＜70g/L,应考虑输。 3． 血红蛋白在70-100g/L 之间，根据患者的贫血程度、心肺代偿功能、有无代谢率增高以及年龄等因素决定。

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60 英国红细胞输注指南 （2002年）

61 临床情况 心肺功能受损或伴有心脑血管病变的患者，由于心肺功能状况可直接影响机体耐受和代偿因急性失血引起的组织供氧不足，因此应当适当放宽输血指征； 患者失血前有无贫血及贫血程度： 患者骨髓和肝脏功能状况等也是在急性出血后是否输血，选择血液制品种类及输血剂量的重要因素。

62 血小板输注 血小板输注原则 预防性血小板输注 治疗性血小板输注 外科患者的血小板输注 血小板输注后的疗效评价

63 血小板输注原则 血小板输血疗法主要应用在防止患者出血或治疗活动性出血。在临床上决定是否需要输注血小板以及输注剂量主要取决于患者临床情况、血小板减少的原因、血小板计数、患者血小板的功能。

64 安医大附院机采血小板使用情况

65 美国与我院输注血小板比较

66 2006年安徽省和我院临床输注 血液和血小板比例 我院 18004 1173 15：1 全省 417000 117 13 35（33）：1
全血和红细胞输注量 血小板输注量 比例 我院 ：1 全省 （33）：1 注：全省置备手工9901单位 Asfourb报道美国红细胞:血小板=2.88:1

67 This study was performed at the University of Texas MD Anderson Cancer Center, Houston, where we transfuse approximately 32,309 packed red blood cells (RBCs), 87,760 random-donor platelets 4878 single donor platelets 8958 units of fresh frozen plasma 549 granulocytes, and 1553 cryoprecipitate units annually. Transfusion of RhD-Incompatible Blood Components in RhD-Negative Blood Marrow Transplant Recipients M. Asfour, MD, Aida Narvios, MD, and Benjamin Lichtiger, MBA, MD, PhD.MedGenMed. 2004; 6(3): 22. 64618单位红细胞 17552手工血小板折合机采单位 22430机采血小板 每输2.88单位(200ml)红细胞输注1单位血小板

68 预防性血小板输注的有关问题 血小板输注剂量 一般预防性血小板输注剂量为每10Kg体重输注2单位血小板/d或1个治疗量的机采血小板。目前尚无证据表明此类患者需要输注更大剂量的血小板。 计算公式＝预计达到的Plt（mm3）－患者原有的Plt（mm3） ×1.4×2 5000 注：国外每单位血小板是由400ml全血中制备，国内是从200ml全血中制备；国外血小板每单位是70×109；国内24×109。

69 预防性血小板输注的有关问题 血小板输注指征 Plt <5~10×109/L；
长期输注血小板者 难以达到疗效时，应当应用CCI来判断血小板的输注效果； 患者血小板功能异常 例如服用阿司匹林和尿毒症，临床医生应当根据临床具体情况决定是否需要输注血小板，不要机械的根据PLT； ITP患者血小板输注问题

70 儿童血小板输注指征

71 输注血小板治疗活动性出血 患者PLT<50×109/L并伴有活动性出血时，应当进行血小板输注。

72 外科血小板输注 较大的外科手术患者术前PLT最好维持在50×109/L以上。

73 机采血小板输注适应证

74 血小板输注的疗效评估 对长期反复输注血小板者应当进行血小板疗效评估，确定下次血小板输注时间和剂量。

75 血小板纠正指数 corrected count increment （CCI）
输注的血小板总数(1011) 血小板计数单位是109/L，输注后血小板计数 为输注后1小时Plt。 CCI<7～10表示血小板输注无效

76 血小板输注无效的原因 免疫因素 主要是同种免疫产生的HLA抗体或血小板特异性抗原抗体。
非免疫因素 患者存在发热、严重感染、脾脏肿大或DIC等增加血小板破坏和消耗因素。

77 FFP的输注问题 不应做为营养剂、扩容剂 严格掌握适应征* 输注剂量 10～15ml/kg,可提高凝血因子到正常水平的25％ 足量

78 FFP输注适应症 1. TTP; 2. 大量输血或术间急性出血，疑凝血因子缺乏； 3. 华法林过量的及时纠正（出血或即将手术）；
4. PT/APTT>1.5对照，伴急性出血或侵入性手术前出现下列情况： ※ 单个凝血因子缺乏（不包括血友病A/B）； ※ DIC; ※ 肝衰竭。

79 Guidelines for the use of fresh-frozen plasma British Journal of Haematology 2004; 126:11
Single inherited clotting factor deficiencies for which no virus-safe fractionated product is available. [ex. Factor V] Multi-factor deficiencies associated with severe bleeding (ex.DIC with bleeding) Fresh-frozen plasma is not indicated in DIC with no evidence of bleeding. Hypofibrinogenemia: Cryoprecipitate may be indicated if the plasma fibrinogen is less than 1 g/l, TTP: Single volume daily plasma exchange should ideally be begun at presentation (grade A recommendation, level Ib evidence)

80 Guidelines for FFP Surgical bleeding:
Should be guided by timely tests of coagulation FFP should never be used as a simple volume relacement in adults or children (grade B recommendation, level IIb evidence). Massive transfusion: If bleeding continues after large volumes of crystalloid, red cells and platelets have been transfused, FFP and cryoprecipitate may be given so that the PT and APTT ratios are shortened to within 1.5, and a fibrinogen concentration of at least 1.0 g/l in plasma obtained. British Journal of Haematology 2004; 126:11

81 Guidelines for FFP DIC Treating the underlying cause is the cornerstone of managing DIC. If the patient is bleeding, a combination of FFP, platelets and cryoprecipitate is indicated. If there is no bleeding, blood products are not indicated, whatever the results of the laboratory tests, and there is no evidence for prophylaxis with platelets or plasma

82 Guidelines for FFP Liver disease
Platelet count and function, as well as vascular integrity（完整）, may be more important in these circumstances. The response to FFP in liver disease is unpredictable. Complete normalization of the haemostatic defect does not always occur. If FFP is given, coagulation tests should be repeated. There is no evidence to substantiate（支持） the practice in many liver units of undertaking liver biopsy only if the PT is within 4 s of the control (grade C recommendation, level IV evidence).

83 Improper use of FFP Improvement and correction of decreasing the circulating plasma volume Nutritional supplementation as the source of protein Promotion of wound healing Treatment of severe infectious disease,treatment of burn without DIC

84 临床输血的若干问题 术前输血 大量输血 相容血液输注问题 RhD不同血液成分输注问题

85 术前输血 传统的术前Hb标准 术前Hb应维持在100g/L ； 国外学者研究发现，只有Hb＜30g/L才影响手术患者的预后；

86 大量输血 massive transfusion
大量输血的概念 大量出血的输液 输血疗法

87 大量输血定义 24小时内输血达到患者的全身的总血容量 24小时输注的红细胞达40单位以上 3小时输血达患者总血容量的50％。 儿童输注标准
6-12 year old child > 5 units（RBC） 4-5 year old child > 3 units （RBC） 2-3 year old child > 2 units （RBC） 0-1 year old child > 1 unit （RBC）

88 大量输血的并发症

89 Effect of Hypothermia on coagulation factor activity

90 大量输血原因分析 病种 比例 外科手术 % 创伤 ％ 胃肠道出血 31％ 心血管外科 12％ 肿瘤 ％ 妇产科急症 4％

91 大量出血的输液输血疗法 第一阶段 输液疗法 恢复血管容量 第二阶段 输血疗法 恢复组织供氧 第三阶段 血液成分的补充 纠正凝血障碍

92 大量输血时血液成分的 选择和使用原则 最好输注全血*
输注血小板 A dilutional effect on the platelet concentration can be seen with massive transfusion. In an adult, each 10 to 12 units of transfused red cells can produce a 50 percent fall in the platelet count; thus, significant thrombocytopenia can be seen after 10 to 20 units of blood, with platelet counts below 50,000/µL. PT和APTT延长1.5倍时，输注FFP 剂量： 10～15ml/kg 纤维蛋白原<1000mg/L输注冷沉淀 剂量：6-unit pool for fibrinogen levels between mg/L; 12-unit pool for fibrinogen levels <500mg/L.

93 Warm fresh whole blood transfusion for severe hemorrhage: U. S
Warm fresh whole blood transfusion for severe hemorrhage: U.S. military and potential civilian applications. Spinella PC. Crit Care Med Jul;36(7 Suppl):S340-5 Between March 2003 and July 2007, over 6000 units of warm fresh whole blood have been transfused in Afghanistan and Iraq by U.S. medical providers to patients with life-threatening traumatic injuries with hemorrhage. Preliminary results in approximately 500 patients with massive transfusion indicate that the amount of fresh warm whole blood transfused is independently associated with improved 48-hr and 30-day survival and the amount of stored red blood cells is independently associated with decreased 48-hr and 30-day survival for patients with traumatic injuries that require massive transfusion. Risks of warm fresh whole blood transfusion include the transmission of infectious agents.

94 CONCLUSIONS For patients with life-threatening hemorrhage at risk for massive transfusion, if complete component therapy is not available or not adequately correcting coagulopathy, the risk:benefit ratio of warm fresh whole blood transfusion favors its use. In addition, recent evidence suggests that there is potential for warm fresh whole blood to be more efficacious than stored component therapy that includes stored red blood cells in critically ill patients requiring massive transfusion.

95 Harke研究表明输注全血的患者凝血功能筛选试验基本都是正常的；
Patt等研究发现输注红细胞，尤其是输注20单位以上添加液红细胞往往患者出现PT(外源性凝血系统)、APTT（内源性凝血系统）延长；返回

96 Borgman J Trauma Oct;63(4):805-13）在观察246例军队医院大量输血患者发现，红细胞和血浆比例分别是1:8, 1:2.5 和 1:1.4，而每组死亡率分别为65%, 34%, and 19%, (p < 0.001)，作者得出结论，使用高比例红细胞和血浆可以通过降低出血导致的死亡率而降低总的大量输血患者的死亡率。 Holcomb JB （Ann Surg Sep;248(3): Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients ） The combination of high plasma and high platelet to RBC ratios were associated with decreased truncal hemorrhage, increased 6-hour, 24-hour, and 30-day survival,。Massive transfusion practice guidelines should aim for a 1:1:1 ratio of plasma:platelets:RBCs.

97

98 大量输血相关参数最低维持量

99 相容血液输注问题 ABO血型相容 Rh血型相同ABO血型相容

100 ABO血型相容输血原则

101 ABO血型不相容血小板输注原则

102 RhD血型不相同血液输注问题 红细胞输注 紧急抢救时输注 血小板输注 FFP输注 育龄妇女要谨慎使用

103 RhD血型不相同血液输注问题

104 Rh阴性患者输注Rh阳性血小板

105 结束语 Blood transfusion is a lot like marriage. It should not be entered into lightly, unadvisedly or wantonly, or more often than is absolutely necessary.” ----Beal, RW, 1976 输血与婚姻有许多相似之处，人们不应该随意的、鲁莽的、甚至放纵的步入婚姻殿堂，但他确实往往是绝对必须的

106 Thank you Q & A