择期手术围手术期贫血的管理。根据 Delphi-UCLA 方法得出的结论和建议

V. Moral , A. Abad Motos , C. Jericó , M.L. Antelo Caamaño , J. Ripollés Melchor , E. Bisbe Vives , J.A. García Erce , on behalf of the Expert Panel selected to carry out the Delphi Method
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引用次数: 0

摘要

导言术前贫血影响着约三分之一的手术患者。贫血会增加输血风险,影响短期和中期功能预后,增加合并症、并发症和费用。患者血液管理"(PBM)计划是对患者进行多学科综合管理,被视为优质护理的典范,其基本目标之一是纠正围术期贫血。PBM 已被纳入手术患者的强化恢复计划:最近的《2021 年术后强化恢复路径》(西班牙语:RICA 2021)包括近 30 项有关 PBM 的间接建议。目标采用兰德/加州大学洛杉矶分校德尔菲法编制一份共识文件,以提高 RICA 2021 有关 PBM 建议在日常临床实践中的渗透率和优先级。材料和方法成立一个由来自血液学-血液治疗学、麻醉学和内科学的 6 名专家组成的协调小组,这些专家在贫血和 PBM 方面具有专长。采用德尔菲-兰德/加州大学洛杉矶分校的方法制定了一份调查问卷,以便就目前改善围手术期贫血管理的关键领域和优先专业行动达成共识。调查问题摘自 RICA 2021 路径中的 PBM 建议。参与者是应邀从 AWGE-GIEMSA 科学会议的发言者和 PBM 相关工作组的国家代表(塞维利亚文件、SEDAR HTF 部分和 RICA 2021 途径参与者)中选出的:在第一轮调查中,匿名在线问卷共有 28 个问题:其中 20 个是关于 ERAS 指南中的 PBM 概念(2 个是关于一般 PBM 组织,10 个是关于术前贫血的诊断和治疗,3 个是关于术后贫血的管理,5 个是关于输血标准),8 个是关于有待研究的方面。回答采用 10 分制(0 分:非常不同意,10 分:非常同意)。参与者还可以提出他们认为合适的其他意见。除了一个问题(问题 14)外,所有问题的平均得分都超过了 9 分,因此这些问题被认为是一致同意的。第二轮调查包括 37 个问题,是对第一轮调查的问题进行重新编排并吸收了参与者的意见后产生的。第二轮调查包括 37 个问题,这些问题是对第一轮调查问题的重新制定,并纳入了参与者的意见。第二轮调查包括 2 个关于 PBM 计划一般组织的问题、15 个关于术前贫血诊断和治疗的问题、3 个关于术后贫血管理的问题、6 个关于输血标准的问题,以及 11 个关于有待未来调查的方面的问题。统计处理:将每个调查问题的平均值、中位数和 25-75 分位间值列表(表 1、表 2 和表 3)。除 3 项建议外,其他建议均在 8 分以上,大多数建议的平均分在 9 分或以上。这些建议分为1.- "对所有有潜在出血风险的外科手术患者(包括孕妇)进行术前贫血检测和病因诊断是非常重要和必要的"。2.- "术前治疗贫血应充分提前,并提供所有必要的血液捐助,以纠正这种状况"。3.- "对于中度贫血(Hb 8-10 g/dL)且病情稳定的患者,术前输注任何单位的包装红细胞都是不合理的,因为这些患者可能要进行出血手术,而手术时间又不能延迟"。4.- "建议普及外科和产科患者输注红细胞的限制性标准"。5.- "应治疗术后贫血,以改善术后效果,加快术后短期和中期恢复"。结论在大多数问题上都达成了广泛共识,具有最大的接受度、较强的证据水平和较高的推荐度。我们的工作有助于确定适合在每家医院和所有患者中实施 PBM 计划的举措和绩效。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Management of peri-surgical anemia in elective surgery. Conclusions and recommendations according to Delphi-UCLA methodology

Introduction

Preoperative anemia affects approximately one third of surgical patients. It increases the risk of blood transfusion and influences short- and medium-term functional outcomes, increases comorbidities, complications and costs. The “Patient Blood Management” (PBM) programs, for integrated and multidisciplinary management of patients, are considered as paradigms of quality care and have as one of the fundamental objectives to correct perioperative anemia. PBM has been incorporated into the schemes for intensified recovery of surgical patients: the recent Enhanced Recovery After Surgery 2021 pathway (in Spanish RICA 2021) includes almost 30 indirect recommendations for PBM.

Objective

To make a consensus document with RAND/UCLA Delphi methodology to increase the penetration and priority of the RICA 2021 recommendations on PBM in daily clinical practice.

Material and Methods

A coordinating group composed of 6 specialists from Hematology-Hemotherapy, Anesthesiology and Internal Medicine with expertise in anemia and PBM was formed. A survey was elaborated using Delphi RAND/UCLA methodology to reach a consensus on the key areas and priority professional actions to be developed at the present time to improve the management of perioperative anemia. The survey questions were extracted from the PBM recommendations contained in the RICA 2021 pathway. The development of the electronic survey (Google Platform) and the management of the responses was the responsibility of an expert in quality of care and clinical safety.

Participants were selected by invitation from speakers at AWGE-GIEMSA scientific meetings and national representatives of PBM-related working groups (Seville Document, SEDAR HTF section and RICA 2021 pathway participants).

In the first round of the survey, the anonymized online questionnaire had 28 questions: 20 of them were about PBM concepts included in ERAS guidelines (2 about general PBM organization, 10 on diagnosis and treatment of preoperative anemia, 3 on management of postoperative anemia, 5 on transfusion criteria) and 8 on pending aspects of research. Responses were organized according to a 10-point Likter scale (0: strongly disagree to 10: strongly agree). Any additional contributions that the participants considered appropriate were allowed. They were considered consensual because all the questions obtained an average score of more than 9 points, except one (question 14).

The second round of the survey consisted of 37 questions, resulting from the reformulation of the questions of the first round and the incorporation of the participants' comments. It consisted of 2 questions about general organization of PBM programme, 15 questions on the diagnosis and treatment of preoperative anemia; 3 on the management of postoperative anemia, 6 on transfusional criteria and finally 11 questions on aspects pending od future investigations.

Statistical treatment: tabulation of mean, median and interquartiles 25–75 of the value of each survey question (Tables 1, 2 and 3).

Results

Except for one, all the recommendations were accepted. Except for three, all above 8, and most with an average score of 9 or higher. They are grouped into:

 1.- “It is important and necessary to detect and etiologically diagnose any preoperative anemia state in ALL patients who are candidates for surgical procedures with potential bleeding risk, including pregnant patients”.

 2.- “The preoperative treatment of anemia should be initiated sufficiently in advance and with all the necessary hematinic contributions to correct this condition”.

 3.- “There is NO justification for transfusing any unit of packed red blood cells preoperatively in stable patients with moderate anemia Hb 8−10 g/dL who are candidates for potentially bleeding surgery that cannot be delayed.”

 4.- “It is recommended to universalize restrictive criteria for red blood cell transfusion in surgical and obstetric patients.”

 5.- “Postoperative anemia should be treated to improve postoperative results and accelerate postoperative recovery in the short and medium term”.

Conclusions

There was a large consensus, with maximum acceptance,strong level of evidence and high recommendation in most of the questions asked. Our work helps to identify initiatives and performances who can be suitables for the implementation of PBM programs at each hospital and for all patients.

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