主要内容儿童输血相关生理特点血液成分在儿科领域应用儿童输血不良事件特点

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1 儿科输血特点安徽医科大学附属阜阳医院张循善

2 主要内容儿童输血相关生理特点血液成分在儿科领域应用儿童输血不良事件特点

3 重视儿科输血的意义输血治疗在儿科领域中是常用的治疗手段目前, 我国对于儿童输血似乎没有得到应有的重视, 例如卫生部颁布的临床输血技术规范临床输血技术规范中, 有手术及创伤输血指南手术及创伤输血指南和内科输血指南内科输血指南, 但缺少儿科输血指南, 在成分输血指南中也缺少儿科患者的具体使用剂量和方法导致在国内, 缺少儿科输血法规性的指南和标准在欧美等经济发达国家输血研究水平较高, 在国家层面上的输血指南中, 儿科输血都是作为不可缺少并且是十分重要的内容加以阐述, 这些做法值得我们借鉴由于儿童, 特别是婴幼儿, 正值生长发育阶段, 各器官和系统尚未成熟, 与成年人相比, 存在显著差异, 因此, 输血治疗与成人相比也存在许多不同儿科和临床输血工作者应当注意研究儿科患者的输血特点, 为儿科患者提供安全及时和有效的输血治疗

4 儿童输血相关生理特点

5 Blood volume (neonate to adult) Age Blood Vol ml/kg Age Blood Vol ml/kg Preterm yr Term yr mnth Adults yr 74 82

6 Pediatric transfusions - Physiology Physiology differences neonate vs child/adult Children have higher oxygen consumption and a higher cardiac output to blood volume ratio than adults The neonatal myocardium operates at near maximum level of performance as a baseline. The newborn s heart may be unable to compensate for a decreased oxygen carrying capacity by increasing cardiac output. The neonatal myocardium will also suffer a greater degree of decompensation when exposed to decreased oxygen delivery.

7 Pediatric transfusions -Physiology Immature coagulation system in neonate and is not comparable with adult level until six months of age. Main differences: vitamin K dependent factors (II, VII, IX, X) that are less than 70% of adult levels inhibitors of coagulation (including antithrombin III and proteins C and S) are 50% of adult levels Platelets numbers are at a similar level to that of adults but take 2 weeks to develop adult levels of reactivity

8 Pediatric transfusions -Physiology Fetal hemoglobin (HbF) comprises 70% of full term and 97% of premature infants total hemoglobin at birth. Red blood cells (RBCs) containing HbF have a shorter life span (90 days) than those containing primarily adult hemoglobin (HbA) (120 days) The optimal hemoglobin values in the newborn are higher than those of older patients (14-20 g/dl). Physiologic nadir for hemoglobin occurs at approximately 2 3 months of age (term -11, prem 9.5)

9 人类珠蛋白肽链变化规律

10 The threshold for transfusing RBCs to a neonate should be at a higher hemoglobin trigger than an older child or healthy adult. 1) HbF interacts poorly with 2 3-diphosphoglycerate (2 3 DPG). Therefore the P50 (the partial pressure of oxygen at which hemoglobin is 50% saturated) decreases from 26 mmhg with HbA to 19 mmhg with HbF. This leftward displacement of the oxygen hemoglobin dissociation curve results in decreased oxygen delivery to tissue because of the high affinity of HbF for oxygen. 2) HbF production diminishes during the first few months of life until only a trace is present at 6 months of age. In clinical terms, the younger the infant, the higher the fraction of HbF and thus the lower the oxygen carrying capacity.. Premature infants have higher percentages of HbF than their full-term counterparts and decreased erythropoietin production which inhibits them from responding to anemia appropriately

11 氧解离曲线

12 Normal hemoglobin values for full-term and premature infants Full term(g/dl) of blood Premature(g/dl) of blood Birth 19.3 Slightly less than full term 0.5 months month Age at Hb nadir 9 12 weeks 6 10 weeks Mean Hb at nadir months months

14 儿童输血的特殊性血容量小, 对失血敏感新生儿失血量占其血容量的 10%( 失血 30~ 50ml) 即可出现明显症状而需要输血 ; 新生儿 HbF 含量高,2,3-DPG 含量低, 红细胞与氧的亲和力大,Hb 需维持在相对较高水平才能满足生理需要 Clinical judgment must be applied to individual cases. 更易受输血潜在感染和毒性的影响潜在感染的影响 :CMV 等输血相关移植物抗宿主病 (TA-GVHD) GVHD)* 红细胞保存液中添加剂的影响 : 腺嘌呤甘露醇的肾脏神经毒性作用

17 血液成分在儿科领域应用

18 红细胞输注

19 组织氧运输

20 红细胞输注

21 红细胞输注

22 红细胞输注

23 红细胞输注

24 红细胞输注

25 新生儿或宫内输血红细胞输注注意事项

27 新生儿或宫内输血红细胞输注注意事项 1. 应当选择 O 型红细胞或 ABO 血型与母亲相容的红细胞, 如果是新生儿 RhD 血型不合溶血病患儿, 应当选择 RhD 阴性红细胞 2. 母亲存在任何红细胞抗体时, 应当选择抗体对应抗原是阴性的红细胞 3. 最好使用母亲血清进行交叉配血试验, 并且选择与母亲血清相容的红细胞进行输注 4. 应当输注保存期 5 天以内的红细胞, 以确保红细胞生理功能受到的影响较小以及游离 K+ 水平较低 5. 采血袋应当使用 CPD 保养液

28 新生儿或宫内输血红细胞输注注意事项 6. 输注少白细胞和 CMV 抗体阴性的红细胞 7. 最好输注辐照红细胞特别是新生儿伴有宫内输血史需要输血和新生儿交换输血都应当输注辐照红细胞 8. 输注的红细胞 HCT 在不能直接输注刚刚从 4 冰箱中取出的红细胞, 输注前最好加温 10. 新生儿交换输血时, 对于足月儿, 红细胞输注剂量是 ml/kg ; 对于早产儿红细胞输注剂量是 ml/kg 这些红细胞剂量范围指的是 1 个血容量至 2 个血容量交换输血的剂量, 如何选择应当依据患儿临床情况来决定

29 To minimize exposure to multiple donors, a unit of RBCs Should not be washed (outdates in 24 hrs) Should be used for the same neonate for the life of the unit (up to 42 days)

31 Pediatric transfusions 新观念 Pediatric red blood cell transfusions increase resource use, Allyson M. Goodman - Journal of Pediatrics Vol 142 Num 2 Feb groups: hemoglobin 6.5 to 7.4 g/dl (54 patients), 7.5 to 7.9 g/dl (40 patients), and 8 to 9 g/dl (105 patients); 131 were transfused and 109 were not transfused significant increase in hospital and intensive care resources used for transfused patients. PICU and hospital length of stay significantly increased by more than 4 days and 7 days, respectively, and there was substantial increases in the use of oxygen, mechanical ventilation, and vasoactive agent infusions.

33 A Lower Hemoglobin Transfusion Threshold Is Safe for Stable Critically Ill Children 1. A lower hemoglobin threshold for transfusion was not inferior to hemoglobin thresholds generally used. 2. The study suggests that using a hemoglobin level of 7 g/dl for a transfusion threshold led to a significant decrease in the number of transfusions compared to 9.5 g/dl, and did not lead to an increase in multiple organ dysfunction, death, nosocomial infections, adverse events, or duration of intensive care unit (ICU) stay.

34 红细胞输注剂量和速度标准红细胞输注剂量 Infuse over 2 to 4 hours (routine). May infuse faster if acute blood loss

35 Fresh frozen plasma 输注问题 Maintain minimum of 30% plasma factor concentration ml/kg

36 儿科 FFP 输注问题

37 不应把输注 FFP 作为支持疗法

38 儿科 FFP 输注适应证

39 Platelet transfusions platelet count is less than /L 5 ml/kg - 10 ml/kg causes a rise of platelets of 50 to /L

40 儿科血小板输注问题

41 儿科血小板输注

42 血小板输注指征

43 四个月以下儿童血小板输注问题

44 预防性血小板输注指征

45 输注剂量和速度

46 儿童输血不良事件特点

47 SHOT events in childr Proportion of red cells given to patients under 18 years: 4.2% Reports to SHOT: 10% (321/3239) Proportion red cells given to infants under 12 months: 1.7% Reports to SHOT: 4.5% (147/3239) 儿童发生 SHOT 的几率明显高于成年人

48 SHOT events in children 264 cases of IBCT - 26 suffered actual or potential morbidity including 9 AHRs due to ABO incompatibility 6 Rh D- girls who received Rh D+ red cells 33 acute and delayed transfusion reactions 20 cases of TRALI (3 fatal) 2 cases TA-GvHD (both fatal) 2 TTIs (1 bacterial contamination of platelets, 1 Hepatitis B)

49 Summary Transfusion adverse events are disproportionately high in children AVOID unnecessary transfusion 82% of events in children were IBCT or wrong blood incidents - preventable! Errors at every stage of the transfusion chain Failure to meet special requirements is the commonest error

临床输血

临床输血合理科学输血上海市血液中心钱开诚 qiankaicheng@sbc.org.cn 钱开诚 1 输血对医学发展的贡献输血是医学发展史上的重要里程碑输血是最早获得成功的组织移植输血是现代医学的重要支持手段输血是未来医学的重要载体钱开诚 2

主要内容 儿童输血相关生理特点 血液成分在儿科领域应用 儿童输血不良事件特点

主要内容儿童输血相关生理特点血液成分在儿科领域应用儿童输血不良事件特点