Transfusion and coagulation management in liver transplantation

There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.

Perioperative blood management strategies for patients undergoing total knee replacement:Where do we stand now?

Total knee replacement(TKR) is one of the most common surgeries over the last decade. Patients undergoing TKR are at high risk for postoperative anemia and furthermore for allogeneic blood transfusions(ABT). Complications associated with ABT including chills, rigor, fever, dyspnea, light-headedness should be early recognized in order to lead to a better prognosis. Therefore, perioperative blood management program should be adopted with main aim to reduce the risk of blood transfusion while maximizing hemoglobin simultaneously. Many blood conservation strategies have been attempted including preoperative autologous blood donation, acute normovolemic haemodilution, autologous blood transfusion, intraoperative cell saver, drain clamping, pneumatic tourniquet application, and the use of tranexamic acid. For practical and clinical reasons we will try to classify these strategies in three main stages/pillars: Pre-operative optimization, intra-operative and post-operative protocols. The aim of this work is review the strategies currently in use and reports our experience regarding the perioperative blood management strategies in TKR.

Effect of Point-of-care Hemoglobin/Hematocrit Devices and Autologous Blood Salvage on Reduction of Perioperative Allogeneic Blood Transfusion

Objective To evaluate the effect of point-of-care hemoglobin/hematocrit(POC HGB/HCT) devices and intraoperative blood salvage on the amount of perioperative allogeneic blood transfusion and blood conservation in clinical practice. Methods A total of 46 378 medical records of 22 selected hospitals were reviewed. The volume of allogeneic red blood cell and plasma, number of patients transfused, number of intraoperative autologous blood salvage, total volume of autologous blood transfusion, and amount of surgery in the year of 2011 and 2013 were tracked. Paired t-test was used in intra-group comparison, while t-test of two isolated samples carried out in inter-group comparison. P<0.05 was defined as statistically significant difference. Results In the hospitals where POC HGB/HCT device was used(n=9), the average allogeneic blood transfusion volume per 100 surgical cases in 2013 was significantly lower than that in 2011(39.86±20.20 vs. 30.49±17.50 Units, t=3.522, P=0.008). In the hospitals without POC HGB/HCT meter, the index was not significantly different between 2013 and 2011. The average allogeneic blood transfusion volume was significantly reduced in 2013 than in 2011 in the hospitals where intraoperative autologous blood salvage ratio [autologous transfusion volume/(autologous transfusion volume+allogeneic transfusion volume)] was increased(n=12, t=2.290, P=0.042). No significant difference of the above index was found in the hospitals whose autologous transfusion ratio did not grow. Conclusion Intraoperative usage of POC HGB/HCT devices and increasing autologous transfusion ratio could reduce perioperative allogeneic blood transfusion.

Patient Blood Management:Single Center Evidence and Practice at Fuwai Hospital

Blood loss and blood transfusion requirement are important quality control indicators of cardiovascular surgery and cardiovascular anesthesia.Patient blood management(PBM)is an evidence-based,multidisciplinary approach to optimizing the care of patients who may need transfusion,which encompasses anemia management,hemodilution,cell salvage,hemostatic treatment,and other approaches to reducing bleeding and minimizing blood transfusion.PBM in cardiovascular surgery is a"team sport"that involves cardiac and vascular surgeons,anesthesiologists,perfusionist,intensivists,and other health care providers.The current work provides an overview of evidence and practice of PBM at Fuwai Hospital.Implementation of PBM should also take local resource availability and costeffectiveness of different devices,drugs,technologies,and techniques into consideration.

Risk Assessment and Refined Management of Blood Collection and Supply during the COVID-19 Epidemic

Since the end of 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has continued to spread worldwide and has become a major global public health threat. SARS-CoV-2 has the characteristics of a long incubation period and asymptomatic infection, which are undoubtedly major challenges to blood transfusion safety. Although no research has suggested that there is a risk of SARS-CoV-2 transmission through blood transfusion, the safe use of clinical blood during the epidemic is a serious problem faced by blood collection and supply institutions. Herein, we elaborate on the management of blood collection and supply during the coronavirus disease 2019 (COVID-19) pandemic from aspects such as blood inventory management, clinical blood use, and reducing the risk of transmission of SARS-CoV-2 via blood transfusion. Blood service departments should adopt flexible policies to ensure that blood collection networks can meet clinical needs, while at the same time protecting staff and blood donors, maintaining blood safety, and reducing blood risks during the epidemic.

Perioperative anemia management in colorectal cancer patients:A pragmatic approach

Anemia,usually due to iron deficiency,is highly prevalent among patients with colorectal cancer.Inflammatory cytokines lead to iron restricted erythropoiesis further decreasing iron availability and impairing iron utilization.Preoperative anemia predicts for decreased survival.Allogeneic blood transfusion is widely used to correct anemia and is associated with poorer surgical outcomes,increased post-operative nosocomial infections,longer hospital stays,increased rates of cancer recurrence and perioperative venous thromboembolism.Infections are more likely to occur in those with low preoperative serum ferritin level compared to those with normal levels.A multidisciplinary,multimodal,individualized strategy,collectively termed Patient Blood Management,minimizes or eliminates allogeneic blood transfusion.This includes restrictive transfusion policy,thromboprophylaxis and anemia management to improve outcomes.Normalization of preoperative hemoglobin levels is a World Health Organization recommendation.Iron repletion should be routinely ordered when indicated.Oral iron is poorly tolerated with low adherence based on published evidence.Intravenous iron is safe and effective but is frequently avoided due to misinformation and misinterpretation concerning the incidence and clinical nature of minor infusion reactions.Serious adverse events with intravenous iron are extremely rare.Newer formulations allow complete replacement dosing in 15-60 min markedly facilitating care.Erythropoiesis stimulating agents may improve response rates.A multidisciplinary,multimodal,individualized strategy,collectively termed Patient Blood Management used to minimize or eliminate allogeneic blood transfusion is indicated to improve outcomes.

Management of occult hepatitis B virus infection:An update for the clinician

Occult hepatitis B virus(HBV) infection(OBI) is defined by the presence of HBV DNA in the liver tissue of individuals who test negative for hepatitis B surface antigen(HBsAg).Patients who have recovered from acute hepatitis B can carry HBV genomes for a long time and show histological patterns of mild necro-inflammation,even fibrosis,years after the resolution of acute hepatitis,without showing any clinical or biochemical evidence of liver disease.At least in conditions of immunocompetence,OBI is inoffensive itself,but when other relevant causes of liver damage are present it might make the course of the liver disease worse.The risk of HBV transmission through transfusion is related to blood donations negative for HBsAg that have been collected during the pre-seroconversion period or during chronic OBI.Use of HBV nucleic acid amplification testing and multivalent anti-HBs antibodies in the HBsAg assays is recommended for detection of true and false OBI,respectively.It is not known if prior hepatitis B immunization with an optimal anti-HBs response in cases of HBV transmission through organ transplantation can effectively modulate or abort the infection.Use of anti-viral agents as prophylaxis in patients with serological evidence of past HBV infection prevents reactivation of OBI after transplantation in most cases.Reactivation of OBI has been observed in other conditions that cause immunosuppression,in which antiviral therapy could be delayed until the HBV DNA or HBsAg becomes detectable.OBI might contribute to the progression of liver fibrosis and hepatocellular carcinoma development in patients with chronic liver disease.

Reducing transfusion requirements in liver transplantation

Liver transplantation(LT) was historically associated with massive blood loss and transfusion. Over the past two decades transfusion requirements have reduced dramatically and increasingly transfusionfree transplantation is a reality. Both bleeding and transfusion are associated with adverse outcomes in LT. Minimising bleeding and reducing unnecessary transfusions are therefore key goals in the perioperative period. As the understanding of the causes of bleeding has evolved so too have techniques to minimize or reduce the impact of blood loss. Surgical "piggyback" techniques, anaesthetic low central venous pressure and haemodilution strategies and the use of autologous cell salvage, point of care monitoring and targeted correction of coagulopathy, particularly through use of factor concentrates, have all contributed to declining reliance on allogenic blood products. Pre-emptive management of preoperative anaemia and adoption of more restrictive transfusion thresholds is increasingly common as patient blood management(PBM) gains momentum. Despite progress, increasing use of marginal grafts and transplantation of sicker recipients will continue to present new challenges in bleeding and transfusion management. Variation in practice across different centres and within the literature demonstrates the current lack of clear transfusion guidance. In this article we summarise the causes and predictors of bleeding and present the evidence for a variety of PBM strategies in LT.

基于电子病历六级评审和等级医院评审的智能化输血系统的设计与应用

目的构建智能化的闭环输血系统,满足国家电子病历六级和等级医院评审细则要求,提升用血的安全性和合理性。方法分析现有系统的缺陷,以输血知识库、临床决策支持系统等工具为媒介对现有系统进行改造和升级,利用集成平台与医院信息系统、电子病历、手麻系统及输血系统的信息交互,实现临床用血质量控制指标的一键上报功能,实现输血管理从申请、配血、用血及用血后效果评价的全流程管理。比较系统上线前后的输血质量及终末病历检查结果进行系统成效评价。结果系统上线后,输血申请合理率、标本正确率、未超时输注率和输血不良反馈率较上线前显著提高(P<0.01),输血终末病历较上线前更加规范化、标准化(P<0.01)。结论智能化的闭环输血管理系统在临床用血的关键环节设置质控提醒,建立安全、合理、规范的用血模式,有效降低了输血风险,提高了医院用血的管理水平。

PDCA循环在临床输血检验标本质量管理中的应用

为探究在输血检验标本中应用PDCA循环进行质量管理的临床效果,研究纳入了100份输血检验标本,研究时间为2022年2月~2023年2月。通过双盲法将标本随机分为PDCA组和常规组,每组各50例。常规组采用传统的质量管理方式,而PDCA组应用PDCA循环进行质量管理。比较了输血副反应率、合理用血率、护理操作及血标本错误率、填写申请单错误率和标本不合格率等指标,结果显示,与常规组相比,PDCA组的输血副反应率显著较低,合理用血率显著较高(P<0.05)。PDCA组中,送血标本出现非医护人员操作、血标本量少、标本溶血、采集管错误标签或无标签等问题的比例显著低于常规组(P<0.05)。此外,PDCA组在漏填红细胞比容(Hct)和血红蛋白(Hb)及输血前4项、错填或漏填血量及血液品种、错填或漏填预约用血日期、错填或漏填妊娠史或输血史、错填或漏填血型、漏填医生签字等方面的错误比例显著低于常规组(P<0.05)。与常规组相比,PDCA组的标本不合格率更低(P<0.05)。因此,在输血检验标本中应用PDCA循环进行质量管理的效果显著,可以有效减少输血副反应,确保合理用血,减少差错事件和不合格标本的发生,进一步保障标本质量,具有良好的推广和借鉴价值。

机器学习模型在肝移植手术用血分析预测中的应用

目的 探讨机器学习在肝移植手术前科学合理备血及手术用血分析预测中的应用。方法 收集356例肝移植手术患者的性别、年龄、临床诊断、手术方式等临床基本信息,收集手术时长(Time)和术前血红蛋白(Hb)、红细胞压积(Hct)、血小板计数(Plt)、凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、纤维蛋白原(Fib)、总胆红素(TBIL)、白蛋白(ALB)、肌酐(Crea)、总蛋白(TP)的检验结果以及术中输血量,应用Python机器语言建立能够预测肝移植手术大量输血风险的机器学习模型,并对模型进行评价,选择出最优预测模型。结果 对构建的7个机器学习模型评价,其中线性回归模型(logistic regression)表现最佳(AUROC:0.90,F1得分:0.82),准确度79.44%,精密度79.69%;随机森林(random forest classifier)表现次佳(AUROC:0.87,F1得分:0.83),准确度79.44%,精密度77.94%。结论 通过运行Python机器语言建立机器学习预测模型,对科学合理备血和大量输血风险预测,保证肝移植手术用血安全具有重要临床意义。

临床输血科经血传播相关病原体分子生物学检测规范管理中国专家共识

为了减少医疗机构院内交叉感染,降低医护人员的职业暴露风险,提高经血传播性疾病溯源性,确保临床输血安全,规避医患纠纷,中国输血协会临床输血管理学专业委员会结合国内外临床研究成果和相关规范指南,召集了临床输血、感染病学等领域的专家共同制定了此专家共识。以期能够规范临床输血科开展经血传播相关病原体分子生物学检测相关规则,降低经血传染性疾病发生率。

红细胞输注指征的研究现状与进展

在临床实践中,红细胞输注需要参考患者的血红蛋白浓度水平,但不同指南推荐的红细胞输注启动阈值都不尽相同。这些不同范围的存在导致输血启动的时机也仍有争议。同时,使用异体血制品就存在着一定发生输血相关感染性损伤或器官损伤的风险,因此启动红细胞输注需要更多循证医学证据。本文综述了中心静脉氧饱和度、动静脉氧差和近红外光谱法这3种新指标以及围术期输血指征评分等新方法来帮助评估输血指征,为临床医生进行输血决策提供参考。

初次全髋关节置换术患者围手术期输血危险因素的研究进展

围手术期输血在全髋关节置换术中非常普遍,受术前、术中,及术后多种因素影响。异体血液输注已被证实与多种不良结局相关,尽管临床医师已提高对全髋关节置换术围手术期血液管理的认识,但输血率仍居高不下。近年来,随着研究的不断深入,越来越多围手术期输血的危险因素被阐明,使早期预防和干预成为可能。本文总结初次全髋关节置换术患者围手术期输血的危险因素,旨在为临床医师优化初次全髋关节置换术围手术期血液管理提供思路和帮助,改善患者预后。

基于PDCA循环法完善临床输血病程记录管理制度的研究

目的研究应用戴明循环法(Plan,Do,Check,Action cycle,PDCA)对临床输血病程记录进行改进及改进成效。方法检查嘉兴市第二医院2020年10月—2021年8月临床输血病程记录,研究应用PDCA循环法对输血前后实验室指标检测率、内科患者输血前血红蛋白值和临床输血病程记录规范率的影响。结果应用PDCA循环法对输血病程记录改进后,输血前实验室指标检测率由90.25%提高到了97.80%,输血后实验室指标检测率由77.75%提高到了96.37%,差异有统计学意义(P<0.05)。改进后内科患者红细胞输血指征血红蛋白均值由(61.69±12.38)g/L降到了(58.52±10.01)g/L,差异有统计学意义(P<0.05)。临床输血病历规范率也有了明显的提升(P<0.05)。结论采取PDCA循环法对临床输血病程记录进行改进,可有效提高病程记录的规范率和实验室指标的检测率,进而提升临床合理用血水平,保障医疗质量安全。

临床用血闭环管理的信息化建设

目的:通过构建临床用血闭环管理系统,实现临床用血医疗全流程的闭环管理和监控。方法:与医院HIS、LIS及南京市血液中心平台系统建立无缝对接,实时准确采集和监管各节点数据。结果:保障血液质量安全和科学合理用血,规范输血诊疗行为,提高输血诊疗活动的安全性。结论:临床用血闭环管理系统实现了医院用血信息化管理,提高了医护人员的工作效率和输血准确率,保障医院可持续安全健康发展。

关节手术患者术中输血合理性分析评价

目的:分析髋关节手术术中用血合理性,为科学、合理用血积累经验。方法:回顾性分析2022年5月-2023年4月髋关节手术术中输注异体红细胞病例资料,以限制性输血和开放性输血标准对患者术后24小时的Hb水平进行合理性输血分组分析,合理性输血组(Hb≤100g/L)140例,欠合理输血组(100<Hb≤120g/L)470例,不合理输血组371例(Hb>120g/L),比较分析三组患者性别、年龄、术前血红蛋白、术前白细胞计数(WBC)、手术信息(术中出血量和异体红细胞输注量)、临床相关指标(术后输血率、术后并发症发生率)。结果:髋关节手术输血率为38.62%,合理性输血占比14.27%,欠合理输血占比47.91%,不合理输血占比37.82%。三组患者术中失血量、术中异体红细胞输注量、术后并发症发生率,差异无统计学意义(P>0.05)。合理性输血组年龄大于欠合理输血组和不合理输血组,差异显著(P<0.05);合理性输血组术前血红蛋白水平和术后白细胞计数低于欠合理输血组和不合理输血组,具有显著性差异(P<0.05);合理性输血组术后异体红细胞输注率高于欠合理输血组和不合理输血组,差异显著(P<0.05),欠合理输血组和不合理输血组无差异(P>0.05)。结论:髋关节术中输血率高,合理输血率低,年龄和术前血红蛋白水平对指导髋关节手术患者合理术中输血具有指导意义,促进自体输血、精细化和个体化的合理性手术输血。

结直肠癌贫血患者围手术期用血影响因素分析:一项单中心2013-2020年数据

目的通过分析影响结直肠癌贫血患者围手术期红细胞输注量的主要因素,为临床围术期用血提供依据,提高临床输血的合理性。方法收集2013年1月—2020年1月我院295例结直肠癌贫血患者的临床资料、实验室检查资料和围手术期红细胞输注情况。对输血过程中涉及的主要因素,如患者年龄、性别、术前血红蛋白水平、术前凝血、手术时间、肿瘤部位、肿瘤体积、肿瘤分期、住院时间等进行分类分析。结果295例术中失血量大于600 mL者106例(35.9%),术中红细胞输注率为49.2%。红细胞输注率较高与术前贫血(Hb<100 g/L)率(51.0%)较高有关。术中红细胞输血量占围手术期用血的52.1%。通过多变量logistic回归分析,发现对术中红细胞输注影响最大的因素是年龄(P<0.001)和肿瘤部位(结肠癌P=0.004;直肠癌P=0.003)。对于围手术期红细胞输注量而言,显著相关的变量是肿瘤体积(P=0.037),而患者年龄、性别与围手术期红细胞输注量无显著相关性(P>0.05)。红细胞输注量与住院时间(术中P=0.428,围手术期P=0.604)、手术切口类型(P=0.784)或切口愈合(P=0.056)等均无显著相关性。术中红细胞与血浆输注比例合理,无“匹配全血输注”。结论影响围手术期红细胞输注量的主要因素是患者肿瘤部位和肿瘤体积,与患者年龄、性别、术前血红蛋白水平、手术时间及肿瘤TNM分期关系不大。围手术期血液管理对于减少输血和缩短住院时间至关重要。