Kan tasarrufu: cerrahi kan kaybını ve transfüzyon gereksinimini azaltıcı yaklaşımlar

Kan tasarrufu, allojenik kan transfüzyonu gereksinimini en aza indirmek veya ortadan kaldırmak için uygulanan işlemleri içerir. Bu yaklaşım, organ nakli olarak kabul edilmesi gereken kan transfüzyonunun sakıncalarından kaçınmayı sağlarken, özellikle yeterli ya da güvenli kan sağlanmasının güç veya imkansız olduğu veya transfüzyonun medikal ya da dini nedenlerle istenmediği durumlarda önemlidir. Ayrıca verilen kanlar güvenli kabul edilmekle birlikte az da olsa enfeksiyon riski taşımakta, yeni ve bilinmeyen etkenlerle enfeksiyon da söz konusu olabilmektedir.Bu yazıda, kan tasarrufu konusundaki gelişmeler ve yararlanılabilecek yöntemler gözden geçirilmektedir. Kan tasarrufu yöntemleri ile allojenik transfüzyon girişimleri minimale indirilebilir veya tamamen önlenebilir. Bu amaçla bir ekip anlayışı içinde çeşitli ilaç kombinasyonları, teknolojik veya cerrahilmedikal yaklaşımlar gibi yöntemler kullanılabilir. Sonuç olarak her anestezist kan korunması ve kan transfüzyonuna alternatif teknolojiler konusunda duyarlı olmalı, kan transfüzyonunu ilk değil son endikasyon olarak düşünmeli ve bu konuda gerekli çabayı göstermelidir.
Anahtar Kelimeler:

Kan nakli, Kan fizyolojisi, Kan

Blood conservation: Measures to reduce surgical blood loss and the need for transfusions

Blood conservation refers to medical care with minimal or no use ofallogenic blood transfusions. This is especially important in clinical settings when sufficient and/or safe blood is not readily available, when blood is medically contraindicated and when the patient refuses a blood transfusion. A blood transfusion should be considered as an organ transplant with its associ¬ated risks, including a finite risk of transfusion-transmitted infections, along with risks from new and unknown pathogens. In this paper, general principles for reducing surgical blood loss and minimizing allogenic transfusion are reviewed from an anesthesiologist's point of view. These strategies utilize drug combinations, technological devices, and surgical or medical techniques with the emphasis on an interdisciplinary team approach. It should be stressed that it is the duty of each anesthesiologist to evolve overall thinking so that blood management initiatives are his/her standard of care. Transfusion should be viewed as an alternative; that is, the last resort rather than the first.

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  • 1. Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. Transfusion Medicine, Part I: Blood Transfusion. N Engl J Med 1999: 340: 439-447, 342: 1666-8.
  • 2. Weber EW, Slappendel R, Prins MH, van der Schaaf DB, Durieux ME, Strumper D. Perioperative blood transfusions and delayed wound healing after hip replacement surgery: effects on duration of hospitalizatfon. Anesth Analg 2005; 100: 1416-21.
  • 3. Van der Linden P, De Hert S, Daper A, et al. A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiac surgery. Can J Anaesth 2001; 48: 894-901.
  • 4. Cartotto R, Musgrave MA, Beveridge M, et al. Minimizing blood loss in burn surgery. J Trauma 2000; 49: 1034-9.
  • 5. Wittmann PH, Wittmann FW. Total hip replacement surgery without blood transfusion in Jehovah's Witnesses. Br J Anaesth 1992; 68: 306-7.
  • 6. Helm RE, Rosengart TK, Gomez M, et al. Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion. Ann Thorac Surg 1998; 65: 125-36.
  • 7. Hutchinson AB, Fergusson D, Graham ID, Laupacis A, Herrin J, Hillyer CD. Utilization of technologies to reduce allogeneic blood transfusion in the United States. Transf Med 2001; 11: 79-85.
  • 8. Goodnough LT, Monk TG, Andriole GL. Erythropoietin therapy. N Engl J Med 1997; 336: 933.
  • 9. Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation. Transfusion 2001; 41: 1459-62.
  • 10. Goodnough LT, Shander A, Brecher ME. Transfusion medicine: looking to the future. Lancet. 2003, 17; 361: 161-9.
  • 11. Kleinman S, Marshall D, AuBuchon J, Patton M. Survival after transfusion as assessed in a large multistate US cohort. Transfusion 2004; 44: 386-90.
  • 12. Van der Linden P, De Hert S, Daper A, et al. A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiac surgery. Can J Anaesth 2001; 48:894-901.
  • 13. Kurtz SB, Frost DB. A comparison of two surgical techniqueus for performing mastectomy. Eur J Surg Oncol 1995; 21: 143-5.
  • 14. Braswell C, Campos J, Spence RK. Reducing operative blood loss during hepatic surgery: from the middle ages to the space age. Curr Surg 2001; 58: 472-7.
  • 15. Goodnough LT, Brecher ME, Kanter MH, Aubuchon JP. Transfusion Medicine Part II. Blood Conservation. N Engl J Med 1999; 340: 525-33.
  • 16. Hofer CK, Worn M, Tavakoli R, et al. Influence of body core temperature on blood loss and transfusion requirements during off- pump coronary artery bypass grafting: A comparison of 3 warming systems. Thorac Cardiovasc Surg. 2005; 129: 838-43.
  • 17. Suttner S, Piper SN, Kumle B, Lang K, Röhm KD, Isgro F, Boldt J. The influence of allogeneic red blood cell transfusion compared with 100% oxygen ventilation on systemic oxygen transport and skeletal muscle oxygen tension after cardiac surgery. Anesth Analg 2004; 99: 2-11
  • 18. Sorensen ER, Lorme TB, Heath D.Thromboelastography: a means to transfusion reduction. Nurs Manage 2005; 36: 27-33.
  • 19. Messmer K.Acceptable hematocrit levels in surgical patients. World J Surg 1987; 11: 41-6.
  • 20. Allen JB, Allen FB. The minimum acceptable level of hemoglobin. Int Anesth Clins, 1982; 20: 1.
  • 21. Hebert PC, Yetişir E, Martin C, et al. Is a low transfusion threshold safe in patients with cardiovascular disease? Crit Care Med 2001; 29: 227-34.
  • 22. Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who receive blood transfusion. Transfusion 2002; 42: 812-8.
  • 23. Shander S, Rijhwani TS, Seeber P. Tolerance of Acute Anemia: The Anesthesiology Perspective. TATM 2005; 6: 43-51.
  • 24. Corwin HL. Anemia and blood transfusion in the critically ill patient. TATM 2005; 6: 38-42.
  • 25. Goodnough LT, Monk TG, Brecher ME. Acute normovolemic hemodilution should replace the preoperative donation of autologous blood as a method of autologous-blcod procurement. Transfusion 1998; 38: 473-6.
  • 26. Martin E, Hansen E, Peter K. Acute limited normovolemic hemo-dilution: a method for avoiding homologous transfusion. World J Surg 1987; 11: 53-9.
  • 27. Rees JE, Jeavons R, Dixon JH. An economic justification for autologous blood re-infusion in primary total knee replacement surgery. Ann R Coll Surg Engl 2005; 87: 102-5.
  • 28. Huet C, Salmi LR, Fergusson D, et al. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators. Anesth Analg 1999; 89: 861-9.
  • 29. Goodnough LT, Monk TG, Sicard G, et al. Intraoperative salvage in patients undergoing elective abdominal aneurism repair: an analysis of costs and benefits. J Vase Surg 1996; 24: 213-8.
  • 30. Schmied H, Schiferer A, Sessler DI, Meznik C. The effects of redcall scavenging, hemodilution, and active warming on allogenic blood requirements in patients undergoing hip or knee arthroplasty. Anesth Analg 1998; 86: 387-91.
  • 31. Scottish Intercollegiate Guidelines Network. Perioperative blood transfusion for elective surgery. A National Clinical Guideline, 2001.
  • 32. Salas J, Munoz M, Perân S, Negri S, de Vega NG. Autotransfusion of shed mediastinal blood after cardiac operations. Ann Thorac Surg 1995; 59: 257-8.
  • 33. Ramirez G, Romero A, Garcia-Vallejo JJ, Munoz M. Detection and removal of fat particles from postoperative salvaged shed blood in orthopedic surgery. Transfusion 2002; 42: 66-75.
  • 34. Hansen E, Hansen MR Reasons against the retransftision of unwashed wound blood. Transfusion 2004; 44: 45S-53S.
  • 35. Bauer C, Kurtz A. Oxygen sensing in the kidney and its relation to erythropoietin production. Annu Rev Physiol 1989; 51: 845-56.
  • 36. Donnelly S. Why is erythropoietin made in the kidney? The kidney functions as a critmeter. Am J Kidney Dis 2001; 38: 415-25.
  • 37. Macdougall IC. Meeting the challenges of a new millennium: optimizing the use of recombinant human erythropoietin. Nephrol Dial Transplant 1998; 13 Suppl 2: 23-7.
  • 38. Goodnough LT, Price TH, Rudnick S. Soegiarso RW. Preoperative red blood cell production in patients undergoing aggressive autologous blood phlebotomy with and without erythropoietin therapy. Transfusion 1992; 32: 441-5.
  • 39. Muirhead M, Bargman J, Burgess E, Jindal KK, Levin A, Nolin L, Parfrey P. Evidence-based recommendations for the clinical use of recombinant human erythropoietin. Amer J Kid Dis 1995; 26: SI.
  • 40. Cothren C, Moore EE, Offner PJ, Haenel JB, Johnson JL. Blood substitute and erythropoietin therapy in a severely injured Jeho-vah's Witness. N Engl J Med 2002; 346: 1097-8.
  • 41. Goodnough LT, Rudnik S, Price TH, et al. Increased preoperative collection of autologus blood with recombinant human erythropoietin therapy. N Engl J Med 1989; 321: 1163.
  • 42. Meara JG, Smith EM, Harshbarger RJ, Farlo JN, Matar MM, Levy ML. Blood-conservation techniques in craniofacial surgery. Ann Plast Surg 2005; 54: 525-9.
  • 43. Levi M, Peters M, Buller HR. Efficacy and safety of recombinant factor Vila for treatment of severe bleeding: a systematic review. Crit Care Med 2005; 33: 883-90.
  • 44. Goodnough LT, Skikne B, Brughara C. Erythropoietin, iron, and erythropoiesis. Blood 2000; 96: 823-33.
  • 45. Kokoszka A, Kuflik P, Bitan F, Casden A, Neuwirth M. Evidence Based Review of the Role of Aprotinin in Blood Conservation During Orthopaedic Surgery. J Bone Joint Surg (American) 2005; 87: 1129-36.
  • 46. Miller BE, Tosone SR, Tam VKH, et al. Hematologic and economic impact of aprotinin in reoperative pediatric cardiac surgery. Ann Thorac Surg 1998; 66: 535-40.
  • 47. Lentschener C, Roche K, Ozier Y. A review of aprotinin in orthotopic liver transplantation: can its harmful effects offset its beneficial effects? Anesth Analg 2005; 100: 1248-55.
  • 48. Munoz JJ. Birkmeyer NJ. Birkmeyer JD. O'Connor GT. Dacey LJ. Is epsilon-aminocaproic acid as effective as aprotinin in reducing bleeding with cardiac surgery?: a meta-analysis. Circulation 1999; 99: 81-9.
  • 49. Vander Salm TJ, Ansell JE, Okike ON. The role of epsilon-amino-caproic acid in reducing bleeding after cardiac operation: A double blind randomized study. J Thorac Cardiovasc Surg 1988; 95: 538-42.
  • 50. Despotis GJ. Levine V. Saleem R. Spitznagel E. Joist JH. Use of point-of-care test in identification of patients who can benefit from desmopressin during cardiac surgery: a randomised controlled trial. Lancet 1999; 354: 106-10.
  • 51. Levi M, Cromheecke ME, de Jonge E et al. Pharmacological strategies to decrease excessive blood loss in cardiac surgery: a metaanalysis of clinically relevant endpoints. Lancet 1999: 1940-7.
  • 52. Kayhan Z. Kontrollü Hipotansiyon. Klinik Anestezi, 3. baskı. Logos Yayıncılık, İstanbul, 2004, pp 496-501.
  • 53. Raff JP, Dobson CE, Tsai HM. Transfusion of polymerised human haemoglobin in a patient with severe sickle-cell anemia. Lancet 360: 464, 2002.
  • 54. Scott MG, Kucik DF, Goodnough LT, Monk TG. Blood substitu- tes: evolution and future applications. Clin Chem 43: 1724, 1997.
  • 55. Winslow RM. Blood substitutes - a moving target. Nat Med 1995; 1: 1212-5.
  • 56. Stowell CP, Levin J, Spiess BD, Winslow RM. Progress in the development of RBC substitutes. Transfusion 2001; 41: 287-99.
  • 57. Ma Z, Monk TG, Goodnough LT, McClellan A, Gawryl M, Clark T, et al. Effect of hemoglobin- and perflubron-based oxygen carriers on common clinical laboratory tests. Clin Chem 1997; 43: 1732-7.
  • 58. Scott MG, Kucik DF, Goodnough LT, Monk TG. Blood substitutes: evolution and future applications. Clin Chem 1997; 43: 1724-31.
  • 59. Winslow RM. Blood substitutes. Curr Opinion Hematol 2002; 9: 146-51.
  • 60. Brecher ME, Goodnough LT, Monk T. The value of oxygen-carrying solutions in the operative setting, as determined by mathe- matical modeling. Transfusion 1999; 39: 396-402.
  • 61. Mullon J, Giacoppe G. Clagett C. McCurie D, Dillard T. Transfusions of polymerized bovine hemoglobin in a patient with severe autoimmune hemolytic anemia. N Engl J Med 2000; 342: 1638-43.
  • 62. Klein HG. The prospects for red cell substitutes. N Engl J Med 2001; 342: 1666-8.
  • 63. Raff JP, Dobson CE, Tsai HM. Transfusion of polymerised human haemoglobin in a patient with severe sickle-cell anemia. Lancet 2002; 360: 464-5.
  • 64. Klein HG. The prospects for red cell substitutes. N Engl J Med 2001; 342: 1666-8.
  • 65. Lu X, Zheng C, Xu Y, Su Z. Disuccinimidyl suberate cross-linked hemoglobin as a novel red blood cell substitute. Sci China C Life Sci. 2005; 48: 49-60.
Anestezi Dergisi-Cover
  • ISSN: 1300-0578
  • Yayın Aralığı: Yılda 4 Sayı
  • Başlangıç: 1993
  • Yayıncı: Betül Kartal
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