bloodjourГематология и трансфузиологияRussian journal of hematology and transfusiology0234-57302411-3042ООО Издательский дом «Практика»10.35754/0234-5730-2021-66-3-395-416bloodjour-300Research ArticleОБЗОРЫ ЛИТЕРАТУРЫREVIEWS OF LITERATUREБережное отношение к крови больного как приоритетная стратегия в кардиохирургииOptimal blood management as priority route in cardiac surgeryhttps://orcid.org/0000-0001-7673-4762КупряшовА. А.KupryashovА. А.

 Купряшов Алексей Анатольевич*, доктор медицинских наук,заведующий отделом клинической и производственной трансфузиологии с диагностической лабораторией

 121552, Москва 

 Alexey A. Kupryashov*, Dr. Sci. (Med.), Head of the Department of Clinical and Occupational Transfusiology with Diagnostic Unit 

 121552, Moscow 

kupriashov2007@rambler.ruhttps://orcid.org/0000-0003-0048-4116СамуиловаО. В.SamuilovaО. V.

 Самуилова Дания Шавкетовна, доктор биологических наук,главный научный сотрудник отдела клинической и производственной трансфузиологии с диагностической лабораторией

 119991, Москва 

 Daniya Sh. Samuilova, Dr. Sci. (Biol.), Principal Researcher, Department of Clinical and Occupational Transfusiology with Diagnostic Unit 

 119991, Moscow 

d.samuilova@gmail.comhttps://orcid.org/0000-0002-1195-9116СамуиловаД. Ш.SamuilovaD. Sh.

 Самуилова Ольга Витальевна, кандидат биологических наук, доцент кафедры биохимии

 121552, Москва 

 Olga V. Samuilova, Cand. Sci. (Biol.), Associate Professor, Chair of Biochemistry 

 121552, Moscow 

olga.v.samuilova@gmail.comФГБУ «Национальный медицинский исследовательский центр сердечно-сосудистой хирургии им. А.Н. Бакулева» Министерства здравоохранения Российской ФедерацииРоссияBakulev National Medical Research Center of Cardiovascular SurgeryRussian FederationФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» (Сеченовский университет) Министерства здравоохранения Российской ФедерацииРоссияSechenov First Moscow State Medical University (Sechenov University)Russian Federation202123102021663395416Copyright © Купряшов А.А., Самуилова О.В., Самуилова Д.Ш., 20212021Купряшов А.А., Самуилова О.В., Самуилова Д.Ш.Kupryashov А.А., Samuilova О.V., Samuilova D.S.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.htjournal.ru/jour/article/view/300Введение

Введение. Несмотря на многочисленные предыдущие публикации на протяжении многих десятилетий, до сих пор ведутся исследования, посвященные оценке последствий периоперационного кровотечения, предоперационной анемии, переливания эритроцитсодержащих компонентов крови (ЭСК) у кардиохирургических больных. В последнее десятилетие наметилась тенденция к ограниченному переливанию ЭСК. Однако риск и оправданность при выборе рестриктивной или либеральной трансфузионной стратегии в кардиохирургии по-прежнему остается предметом дискуссий.

Цель — представить результаты исследований, касающиеся оценки влияния кровотечений, предоперационной анемии, трансфузий ЭСК, рестриктивной по сравнению с либеральной трансфузионной стратегии на риск летального исхода и других негативных событий у взрослых больных, перенесших операцию на сердце.

Методы

Методы. Поиск соответствующих исследований проводился с использованием базы данных PubMed, опубликованных с 2012 г. по 2019 г. Поисковые термины включали слова: кардиохирургия, кровотечение, предоперационная анемия, переливание эритроцитов, рестриктивная и либеральная трансфузионная стратегия. Было включено 18 исследований с данными о последствиях, связанных с кровотечениями, предоперационной анемией различной степени тяжести, переливанием различных объемов ЭСК у больных, перенесших операции на сердце. Представлены 9 исследований, касающихся сравнительной оценки клинических последствий после операций на сердце при использовании рестриктивной и либеральной трансфузионной стратегии. Всего проанализировано 24 полных текста медицинской литературы, 1 реферат рандомизированного клинического исследования (РКИ), 1 реферат ретроспективного исследования, 1 обзор с метаанализом. Также были рассмотрены дополнительные исследования, представляющие интерес для обсуждения.

Результаты

Результаты. Одно проспективное и 4 ретроспективных исследования оценивали влияние периоперационных кровотечений на риск последующих неблагоприятных событий у больных, перенесших операции на сердце. Три проспективных и 5 ретроспективных исследований и одно РКИ продемонстрировали связь переливаний ЭСК с негативными последствиями. В 5 ретроспективных исследованиях показана зависимость между предоперационной анемией и потребностью в трансфузиях ЭСК. Шесть ретроспективных исследований обнаружили независимую связь между риском послеоперационных осложнений и летальными исходами у больных, перенесших операции на сердце, и предоперационной анемией. Восемь РКИ, один метаанализ, включающий 7 РКИ, представили сравнительные результаты клинических последствий рестриктивной и либеральной трансфузионной стратегии у больных после операций на сердце.

Заключение

Заключение. Предоперационная анемия, кровотечение и переливание компонентов донорской крови, являясь независимыми факторами риска серьезных послеоперационных осложнений и летального исхода, рассматриваются как «смертельная триада» в кардиохирургии. Трансфузии ЭСК, отражая эффективность внедрения системы бережного отношения к крови больного в стационаре, являются интегральным показателем качества оказания медицинской помощи в кардиохирургии. Внедрение мероприятий по бережному отношению к крови больного на всех этапах лечения с участием мультидисциплинарной команды сохранения крови больного («blood-team») способно существенно улучшить результаты лечения больных с одновременным уменьшением его стоимости.

Introduction

Introduction. Generating manifold publications over decades, research continues assessing the burden of perioperative bleeding, preoperative anaemia and red blood component (RBC) transfusion in cardiac surgical patients. The past decade is witnessing a trend towards limited RBC transfusion. Nevertheless, the risk and justification of a restrictive or liberal transfusion strategy in cardiac surgery remain a matter of debate.

Aim — a description of evidence estimating the impact of bleeding, preoperative anaemia, red-cell transfusion and restrictive vs. liberal strategies on the risk of mortality and other adverse events in adults with cardiac surgery.

Methods

Methods. Relevant evidence was mined in PubMed for the period 2012–2019. The query phrases were: cardiac surgery [кардиохирургия], bleeding [кровотечение], preoperative anaemia [предоперационная анемия], red-cell transfusion [переливание эритроцитов], restrictive and liberal transfusion strategy [рестриктивная и либеральная трансфузионная стратегия]. The review includes 18 studies describing outcomes related to bleeding, preoperative anaemia of varying severity and variant-volume RBC transfusion in patients with cardiac surgery. Nine studies comparatively assessed the cardiac surgical clinical outcomes under restrictive and liberal transfusion strategies. A total of 24 full texts have been analysed, one randomised clinical trial (RCT) summary, one retrospective trial summary and one meta-analysis review. Additional studies of concern to discussion have also been considered.

Results

Results. One prospective and four retrospective studies evaluated the effect of perioperative bleeding on the risk of subsequent adverse events in patients with cardiac surgery. Three prospective, five retrospective studies and one RCT revealed the association of red-cell transfusion with adverse outcomes. Five retrospective studies exposed a link between preoperative anaemia and reason for RBC transfusions. Six retrospective studies found an independent association between the risk of postoperative complications and mortality in patients having cardiac surgery and preoperative anaemia. Eight RCTs and one meta-analysis of seven RCTs presented comparative data on clinical outcomes of restrictive and liberal transfusion strategies in patients after heart surgery.

Conclusion

Conclusion. Preoperative anaemia, haemorrhage and donated component transfusion independently contribute to the risk of serious postoperative complications and death unifying in the “deadly triad” of cardiac surgery. RBC transfusions are integrally indicative of the aid quality in cardiac surgery reflecting the success of blood management system in the hospital. Leveraging a good patient blood management practice at all treatment steps to involve a multispecialty blood-team approach can significantly improve patient outcomes at a higher cost efficiency.

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The authors declare that there are no conflicts of interest present.