老年患者围术期血液保护专家共识

1 概述

# 1.1 老年患者围术期血液保护的临床意义

血液保护是指以减少或避免异体输血为原则,以改善患者预后和保护患者权益为目标的一系列措施[3-4]。老年患者术前贫血发生率高,美国65岁以上男性贫血的发生率为11%,女性为10.2%,85岁以上则达到20%[5]。老年患者对失血和输血相关并发症和器官功能损害的耐受能力差,国术期血液保护对维持老年患者脆弱器官的氧供需平衡、减少贫血和输血并发症、改善预后具有重要意义。

1.2 衰老的病理生理变化与围术期血液保护

老年人的血液系统变化以骨髓细胞数量减少为标志,人类出生时骨髓造血组织的含量占90%,70岁以上老年人下降至30%,导致骨髓增殖性疾病和贫血的风险增加。单纯由衰老引起的变化一般不具备临床意义,但在面对手术引起的应激时,生理储备的下降导致对应激的反应能力下降。老年患者红细胞在应激或疾病中产生的速度降低,对失血和贫血的代偿反应速度减慢[6]。老年患者合并的多种疾病和治疗用药对凝血功能有一定影响,同时高龄也是深静脉血栓形成

的高危因素,因此围术期抗凝药物的管理对于术后结局具有 重要影响。

2 术前管理

2.1 术前评估

老年人贫血的主要原因为缺铁性贫血或营养不良、慢性感染、胃肠道出血、其他疾病或药物导致[7]。贫血门诊的设计对术前筛查和治疗贫血从而改善老年患者术后结局具有重要意义[7-8]。对接受择期大手术的老年患者,建议术前至少6~8周筛查贫血,发现贫血的患者建议测定血清铁、转铁蛋白、铁蛋白、转铁蛋白饱和度、血清叶酸和维生素B12水平以及炎症反应指标如C-反应蛋白和肾功能相关指标,鉴别术前贫血的原因[9]。对于个人史、家族史或体格检查提示有出血性疾病的患者,应进行相应的筛查试验,通常包括血小板计数和凝血功能。对于服用抗凝药物的患者,应复查相应的止血指标[10]。

推荐意见1:有条件的机构建议设立贫血门诊,对接受大手术的老年患者,术前通过病史采集、体格检查和适当的实验室检查筛选贫血的患者并采取针对性的血液保护措施(证据等级II,推荐强度B)。

2.2 术前贫血的纠治

2.2 铁剂治疗

老年患者最常见的是缺铁性贫血,原因是营养不良加吸收功能下降,或继发于抗血小板、抗凝药物或肿瘤病变导致的慢性胃肠道出血。口服铁剂安全性较高,但是较难耐受,血红蛋白浓度完全恢复需要至少6~8周。静脉补铁可以更快地提高血红蛋白浓度,适用于口服补铁不耐受或胃肠道吸收功能受损、距离手术时间<6周的患者。现有证据支持静脉补充铁剂在老年人的安全性和有效性[11]。一项针对接受大手术的老年患者的观察性研究[12]提示对术前诊断缺铁性贫血的患者,静脉补充铁剂可提高血红蛋白浓度并降低输血风险。大型随机对照研究结果提示对血红蛋白浓度95~130g/L的老年髋骨骨折手术患者,术前联合输注去铁麦芽糖联合氨甲环酸可将输血风险降低50%[13]。

推荐意见2:术前缺铁性贫血的老年患者排除慢性出血性疾病后,考虑口服或静脉补充铁剂(证据等级Ⅲ,推荐强度B)。

2.2.2 红细胞生成素刺激剂的使用

红细胞生成素刺激剂(erythropoiesis-stimulating agents, ESAs)是人工合成的重组促红细胞生成素,可以增加红细胞

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表1 循证医学证据等级

|证据等级|分级释义| |---|---| |I|基于多个随机对照试验的Meta分析或系统评价;大样本试验| |II|基于至少1个质量较高的随机对照试验;设计规范、结果明确的观察性研究或横断面研究;前瞻性队列研究| |III|基于设计良好的非随机性病例对照研究,观察性研究,非前瞻性队列研究| |IV|基于非随机性回顾性研究;病例报道;专家共识|

表2 临床推荐强度分级

|推荐强度|等级释义及临床建议| |---|---| |A(强)|循证证据肯定或良好(I或II级)或循证证据一般(II—IV级),但在国内外指南中明确推荐; 能够明确改善健康结局,利大于弊| |B(中)|循证证据一般(III或IV级),可以改善健康结局| |C(弱)|循证证据不足或矛盾,无法明确利弊,但可能改善健康结局|

数量,从而增加血红蛋白浓度,减少输血[14]。主要的风险是可能增加血栓形成风险以及包括乳腺癌、非小细胞肺癌、宫颈癌、头颈部肿瘤、淋巴瘤等肿瘤进展风险[15-16]。老年患者择期骨科大手术前使用ESAs可提高血红蛋白浓度,减少围术期输血,并未显著增加血栓栓塞并发症[17-20]。对接受心脏手术的老年患者,ESAs可改善贫血,减少围术期输血,且不良事件发生率与安慰剂对照无差异[21-23]。维生素B12、叶酸和铁储备充足时,ESAs起效至少需要4~6d。使用ESAs的同时注意补充铁剂,以避免在红细胞生成量增加时发生功能性铁缺乏。

2.2.3 围术期抗血栓药物的管理

较多的老年患者因心房颤动、机械瓣及既往血栓事件等原因长期接受抗凝或抗血小板治疗,围术期药物管理尤为复杂。现有证据显示,老年髋部骨折患者术前使用阿司匹林或氯吡格雷并不应成为延迟手术的唯一理由,尽早手术(通常≤24~48 h)可降低并发症和死亡率[24]。对于使用直接口服抗凝药(direct oral anticoagulants, DOAC)的老年患者,需根据肾功能和手术出血风险决定停药时间,部分研究提示在多学科协作诊疗指导下尽早手术是可行的,但仍存在出血和输血风险增加的可能[25]。大型随机对照研究(BRIDGE 研究)[26]表明,老年房颤患者(对照组平均年龄为71.6岁,试验组平均年龄为71.8岁)接受择期手术前停华法林期间不进行桥接治疗可降低出血概率同时不增加血栓事件风险;PAUSE 研究[27]在老年(平均年龄72.5岁)房颤人群中证实使用 DOAC 围术期标准化停药和复用方案、不使用肝素桥接治疗的动脉血栓形成风险低,不增加大出血风险。2022年CHEST 湾南亦强测,应避免不必要的桥接,按手术出血风险、患者血栓风险及肾功能综合决策,抗血小板药物的停用时间需结合药物特性与患者缺血风险权衡[28]。

推荐意见3:接受抗栓药物治疗的老年患者拟行择期非心脏手术前,应当综合考虑停药所致血栓检塞风险及手术患者自身出血风险,必要时进行多学科会诊,共同决定围术期抗栓药物的个体化管理方案(证据等级Ⅱ,推荐强度B)。

对于因房颤服用维生素K拮抗剂的患者,因接受择期手术需要停用时,不推荐常规进行肝素桥接治疗(证据等级II,推荐强度A)。

对于因房颤服用 DOAC的患者,因接受择期手术需要停用时,可考虑不进行肝素桥接治疗(证据等级Ⅲ,推荐强度B)。

2.2.4 术前自体储血

术前自体储血是血液保护的一种选择,提供给健康状况相对良好、无贫血并且预计手术会导致大量失血的等待手术患者。由于术前自体储存血液费用昂贵、浪费的风险高、多数患者会因连续采血导致贫血,从而增加输血风险,并存在储存费用较高等缺点,目前已较少建议术前自体储血[29]。老年患者健康状况下降,合并疾病较多且术前贫血发生率高,应谨慎采用术前自体储血。

3 术中管理

3.1 减少手术失血

减少手术失血的措施包括:精细的外科止血;维持正常体温;抬高手术部位和避免手术部位静脉回流受阻;维持正常的钙离子水平;保障组织灌注,避免酸中毒;拟实施手术切除血供丰富的病变组织时,预先应用适当的介入技术栓塞其主要供血血管,以减少术中出血;应用抗纤溶药物减少出血;对严重出血患者,宜使用床旁凝血功能监测,根据检测结果进行目标导向治疗[14]。

3.2 急性等容血液稀释

急性等容血液稀释(acute normovolemic hemodilution,

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ANH)是一种血液保护技术,初始血红蛋白浓度正常或升高,术中预计会失去超过500~750ml血液的患者,可以考虑ANH。ANH可能是一些信仰特殊宗教的手术人群的唯一选择。一项小样本随机对照研究[30]表明接受肝脏肿瘤手术的老年患者可以安全使用ANH,减少库存血的输入,且对凝血功能和纤溶系统活性无显著影响。亦有证据支持老年患者接受全膀胱切除和前列腺切除术[31],髋、膝关节置换术[32],心脏手术[33],腰椎融合术[34]时ANH的安全性和有效性。老年患者使用ANH的禁忌证包括血流动力学不稳定的心律失常、急性感染、心功能受损(如左心室射血分数<45%、存在明显的主动脉瓣狭窄)、肾功能受损、基线血红蛋白浓度<110g/L、存在先天性/遗传性血红蛋白病、凝血蛋白或血小板浓度过低、凝血或血小板功能检查异常、不具备快速监测血红蛋白浓度、血小板数量和凝血功能的条件。

推荐意见4:对符合指征的老年患者可考虑实施 ANH (证据等级Ⅲ, 推荐强度C)。

3.3 术中血液回收

通过术中自体血液回输能够减少或避免异体输血及相关的并发症,且不良事件发生率非常低,建议在实施预计失血量较大(>400 ml)的外科操作时采用术中血液回收。某些情况下(如交叉配血困难或拒绝输注成分血),失血量不足400 ml也建议采取术中血液回收[35-36]。老年患者可以安全使用术中血液回收机回收、分离、洗涤和浓缩后的红细胞。

推荐意见5:老年患者可以安全使用术中血液回收机回收、分离、洗涤和浓缩后的红细胞进行回输(证据等级I,推荐强度A)。

3.4 输注红细胞阈值

血液保护指南通常建议无贫血相关症状成人采用血红蛋白浓度阈值为70~80g/L的限制性输血策略。一项以老年患者为主要研究对象的输血试验的Meta分析[37]则发现,当老年患者使用较高的血红蛋白阈值时,死亡率较低,心脏并发症较少。可能的原因是随着年龄的增长,衰老相关的心排血量峰值递减降低了代谢应激下可达到的最大供氧量,在贫血状态下,老年患者比年轻患者更容易发生组织缺氧。根据模型预测血红蛋白浓度为100g/L的老年患者与血红蛋白为70g/L的年轻患者具有相似的峰值供氧能力,提示老年患者对低血红蛋白浓度的耐受能力更差,应该采取适当宽松的血红蛋白管理阈值。根据年龄和合并疾病的不同,老年患者之间的差异很大。目前缺乏专门针对老年患者输血相关研究的高质量证据,输血决策不应仅仅基于血红蛋白浓度,而应基于患者的合并疾病和器官功能代偿状态、出血的速度和预计术后失血的风险等因素综合考虑,采用适度宽松的血红蛋白浓度阈值[38]。

推荐意见6:对于老年患者的输血决策应根据有无临床症状、有无基础疾病、围术期出血情况及个体对于贫血的耐受情况,采用较为宽松的输血阈值(证据等级Ⅲ,推荐强度C)。

3.5 控制性降压

控制性降压是通过药物、麻醉技术或二者联合,将SBP降至80~90 mmHg, MAP降至50~65 mmHg或MAP较基础值降低30%,目的是改善手术视野,减少出血[39]。由于老年患者的重要脏器功能下降,控制性低压血压用于老年患者有所顾虑、低质量的研究证据支持在老年患者髋、膝关节手术中使用控制性降压技术可减少失血和输血的需求,采用的控制性降压手段包括药物和椎管内麻醉[40-41]。但是由于老年患者器官功能个体差异大,应谨慎评估控制性降压的安全性,高危患者加强术中监测,尤其脑功能监测,尽量缩短降压持续时间。

3.6 凝血功能的监测与调控

老年患者常合并多种疾病,服用影响凝血功能的药物,存在与出凝血功能相关的疾病(例如静脉血栓栓塞或出血并发症)床,床旁的即时凝血功能检测对老年患者的围术期管理,指导成分输血尤为重要。在脊柱大手术中,血栓弹力测定有助于低纤维蛋白原血症的早期识别和治疗。低纤维蛋白原血症是上述手术中遇到的凝血病的一个重要原因,积极处理这一并发症与减少术中出血量、减少输血需求和输血相关费用相关[42]。抗纤溶药可防止纤溶蛋白的溶解,包括ε-氨基己酸和氨甲环酸。近年来越来越多的研究支持使用抗纤溶药预防术中出血和减少输血,并且得到多项专业协会指南推荐,与安慰剂比较,氨甲环酸显著降低了接受髋部骨折手术的老年患者围术期的出血和输血量,且不增加静脉血栓栓塞的风险或死亡率[43-45]。术中使用氨甲环酸还可降低行冠脉搭桥手术的老年患者围术期出血的风险,并且不增加术后30d内死亡和血栓栓塞事件的发生率[46]。在心脏、骨科大手术中,术前和/或术中使用6-氨基己般可有效减少围术期总失血量和输血量[47-48]。抗纤溶药物的剂量根据手术类型确定,以静脉应用为主,骨科手术和心脏手术中手术部位局部使用也有报道。可在切皮前和缝合切口前各静脉给予氨甲环酸1g,肾功能不全、严重营养不良者减量使用[49]。虽然血栓事件的风险通常很低,但是对血栓形成高危患者,仍应权衡出血和输血的风险,谨慎使用。应注意氨甲环酸与心脏手术后癫痫发作相关,这种风险可能与剂量有关。

推荐意见7:老年患者行心脏手术、大型骨科手术、肝移植术和复杂创伤手术推荐术中使用抗纤溶药物,降低出血和输血的风险。必要时使用床旁凝血功能监测指导成分输血(证据等级I,推荐强度B)。

3.7 抗凝药物的紧急逆转

需进行抗凝药物紧急逆转的适应证包括需进行紧急手术或出现危及生命的出血。创伤本身并不是需要抗凝药物紧急逆转的适应证,不伴有大出血的服用抗凝药物的创伤患者并不需要抗凝药物的紧急逆转[50]。维生素K作为IV因子凝血酶原复合物的补充来辅助逆转华法林的作用是有效的,但单独使用维生素K不足以实现INR的快速逆转,静脉注射维生素K比口服能更快地运转INR[51]。新型的口服抗凝药有其

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特异性拮抗药物,依达珠单焦抗是唯一可口服直接逆转比达加群的药物,andexanet-α是一种重组的凝血因子Xa的诱导蛋白,可逆转Xa因子抑制剂的作用。在无法获得特异性拮抗药物的情况下,也可使用IV因子凝血酶原复合物[52]。

推荐意见8:推荐IV因子凝血酶原复合物与维生素K用于华法林的紧急逆转(证据等级II,推荐强度B)。andexanet-α被推荐作为凝血因子Xa抑制剂的特异性逆转剂,当不可用时,可使用凝血酶原复合物(证据等级II,推荐强度C)。依达赛珠单抗推荐用于服用达比加群出现大出血或需要紧急手术的患者(证据等级II,推荐强度C)。

4 术后管理

4.1 术后贫血管理

术后是患者康复的重要阶段,血液保护策略的实施仍然重要。术后贫血较为常见,原因包括术前贫血的加重、术中失血和术后出血或过度采血[14,53]。术前贫血、接受大手术(持续超过2h或失血量>500ml)的患者,术后尤其应加强对贫血和凝血功能的监测。尽早表现持续出血和快速出血的迹象,及时寻找出血的原因,根据出血的数量、速度、可能的出血部位和潜在的手术原因,排除凝血功能异常导致的出血,必要时返回手术室进行手术再次探查和干预。术后由于炎性介质导致的EPO产生减少、骨髓对EPO的反应迟钝和可利用的铁减少可能会进一步加重贫血。以往对各种手术的研究表明,术后静脉补铁有助于血红蛋白浓度恢复和减少输血需求[54]。虽然术后静脉补铁的阈值尚未明确,但术后贫血患者的铁蛋白浓度<100 µg/L及术中大量失血的患者可能需要脉冲充铁剂[55-56]。英国国家卫生与保健评价研究院(National Institute for Healthcare Excellence, NICE)指南建议术后患者口服铁剂,但是研究显示术后由于胃肠道吸收功能的减退,静脉补铁可以更有效地恢复铁储备。对于非癌症的老年患者,若术后出现重度贫血或拒绝输血,可以考虑使用ESAs[53]。

4.2 术后抗凝和抗栓药物的恢复使用

术后开始使用普通肝素或低分子肝素抗凝前应确保手术部位止血满意,确保引流量与患者的血红蛋白浓度匹配。对于出血不易判断的手术类型,例如心脏手术、骨科手术尤其应该注意[57]。大手术或高出血风险的手术通常48~72 h启动抗凝治疗,小手术或低出血风险的手术通常24 h后启动抗凝治疗(表3)。术前使用的抗栓药物的复用条件是不增加患者出血的风险,患者已经恢复经口进食。

5 特殊手术类型

5.1 心脏手术

相比其他外科手术,心脏手术有其特殊性,包括心脏手术操作复杂、术中需要使用大剂量的抗凝药物以及术中使用体外循环,这些因素易引起患者出现严重的凝血功能改变(包括凝血因子的稀释和消耗),血小板减少或血小板功能障碍和高纤溶状态,最终导致心脏手术围术期失血量大、止血困难、异体输血发生率高[58-59]。大量输血或因出血进行二次手术都是术后发生不良事件的独立危险因素[60-61]。基于心脏手术的特点和相关的研究证据,形成以下推荐意见。

推荐意见9:(1)术前管理。为改善术前贫血情况,非缺铁性贫血的患者在择期心脏手术前建议补充ESAs,同时补充铁剂。缺铁性贫血患者在择期心脏手术前建议补充铁剂[62](证据等级Ⅱ,推荐强度B)。

(2)术中管理。自体血逆预充技术可以作为一项血液保护的措施以减少输血[63](证据等级Ⅱ,推荐强度A);在抗凝药物的使用中,在抗凝血酶不足的患者中补充抗凝血酶增加肝素的敏感性[64](证据等级Ⅰ,推荐强度B);术中基于肝素水平进行肝素追加相比基于ACT结果进行肝素追加能够减少出血[65](证据等级Ⅱ,推荐强度B);术中建议常规使用抗纤溶治疗[66](证据等级Ⅰ,推荐强度A);在输血管理方面,常规使用自体血回输及使用急性等血液稀释都可以减少输血[33,67](证据等级Ⅱ,推荐强度B);相比其他血制品,需要输血时推荐使用浓缩红细胞[68],不建议预防性使用新鲜冰冻血浆、纤维蛋白原、去氨加压素、重组活化Ⅶ因子[69-72](证据等级Ⅰ,推荐等级Ⅰ,推荐强度A)。

(3)术后管理。术后对纵隔引流管的血液可用自体血回输装置进行离心和再使用,减少术后输血[73](证据等级II,推荐强度B);对行冠状动脉旁路移植术的患者,没有出血风险的情况下术后24h内建议恢复阿司匹林的使用[74-75](证据等级I,推荐强度B)。

5.2 骨科手术

全髋关节置换术(total hip arthroplasty, THA)、全膝关节置换术(total knee arthroplasty, TKA)、创伤、长骨和脊柱肿瘤手术、脊柱矫形手术出血量大,围术期输血的比例高[76]。骨科手术围术期的血液保护方案的实施有助于减少THA和TKA围术期输血、缩短住院时间、降低90d内再入院率[77]。

|药物|恢复使用时机| |---|---| |华法林|术后12~24h恢复,常需5~10d恢复,常使用原有抗凝效果| |达比加群|确保出血风险低时恢复使用起效迅速,2~3h恢复原有抗凝效果| |利伐沙班/阿哌沙班/依度沙班|确保出血风险低时恢复使用起效迅速,对高出血风险患者应谨慎复用|

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推荐意见10:(1)术前管理。接受骨科手术的老年患者术前贫血的发生率高,对于接受受期骨科手术的老年血患者,建议在术前筛查贫血原因并加以纠治,必要时建议推迟手术[78-80](证据等级Ⅰ,推荐强度A);接受骨科手术的老年患者不建议术前进行自体血采集[81-82](证据等级Ⅰ,推荐强度C);围术期抗栓药物管理的策略根据手术出血的风险、围术期心肌梗塞、脑栓塞、下肢静脉血栓的风险和术中麻醉方法的选择决定,骨科手术围术期不建议停用阿司匹林,阿司医林也是预防重大支持期下肢关节置换术后深静脉血栓形成的有效和安全的药物[83](证据等级Ⅰ,推荐强度A);麻醉选择对术中出血量可能有一定影响,推管内麻醉具有减少THA和TKA术中出血的优势[84-86](证据等级Ⅰ,推荐强度B)。

(2)术中管理。老年髋、膝手术可考虑在严格评估的条件下实施控制性降压技术,高危患者应加强监测,尽量减少降压时间[41],脊柱手术不建议常规实施控制性降压(证据等级Ⅱ,推荐强度B);氨甲环酸可有效减少骨科手术中出血和输血的需求,不会增加静脉血栓形成、脑梗塞、肺梗塞、心肌缺血的发生率,对于栓塞风险高的患者也可以局部应用[87-88](证据等级Ⅰ,推荐强度A)。

(3)术后管理。推荐阿司匹林或口服抗凝药用于大型骨科手术后的深静脉血栓预防，并持续至术后3~6个月[89-91](证据等级Ⅰ,推荐强度A)。

6 小结

老年患者合并疾病和功能代偿状态差异较大,个体化的围术期血液保护措施对老年患者尤为重要。未来应在衰老和不同合并疾病对围术期血液保护方案的影响方面开展研究。

《中国老年患者围术期血液保护专家共识》专家组成员名单

负责人

仓 静(复旦大学附属中山医院麻醉科)

黄文起(中山大学附属第一医院麻醉科)

执人笔

张晓光(复旦大学附属中山医院麻醉科)

成员

吴安石(首都医科大学附属北京朝阳医院麻醉科)

于泳浩(天津医科大学总医院麻醉科)

王迎斌(兰州大学第二医院麻醉科)

刁玉刚(北部战区总医院麻醉科)

陈世彪(南昌大学第一附属医院麻醉科)

徐桂萍(新疆维吾尔自治区人民医院麻醉科)

刘艳红(中国人民解放军总医院第一医学中心麻醉科)

张 洁(郑州大学附属第一医院麻醉科)

杨建军(郑州大学附属第一医院麻醉与围手术期及疼痛医学部)

万 茶《临床麻醉学杂志》编辑部

户锡华(河南省肿瘤医院麻醉科)

王钟兴(中山大学附属第一医院麻醉科)

参考文献

[1] American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management. Anesthesiology, 2015, 122(2): 241-275.

[2] Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anasesthesiol, 2017, 34(6): 332-395.

[3] Shander A, Hardy JF, Ozawa S, et al. A global definition of patient blood management. Anesh Analg, 2022, 135(3): 476-488.

[4] Usoro NI. Blood conservation in surgery: current concepts and practice. Int Surg, 2011, 96(1): 28-34.

[5] Guralnik JM, Eisenstaedt RS, Ferrucci L, et al. Prevalence of anemia in persons 65 years and older in the United States: evidence for a high rate of unexplained anemia. Blood, 2004, 104 (8): 2263-2268.

[6] Bone marrow, thymus and blood: changes across the lifespan. Aging health, 2009, 5(3): 385-393.

[7] Sim YE, Abdullah HR. Implications of anemia in the elderly undergoing surgery. Clin Geriatr Med, 2019, 35(3): 391-405.

[8] Ellermann I, Bueckmann A, Eveslage M, et al. Treating anemia in the preanesthesia assessment clinic: results of a retrospective evaluation. Anesth Analg, 2018, 127(5): 1202-1210.

[9] Muñoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia, 2017, 72(2): 233-247.

[10] Tibi P, McClure RS, Huang J, et al. STS/SCA/AmSECT/SABM update to the clinical practice guidelines on patient blood management. Ann Thorac Surg, 2021, 112(3): 981-1004.

[11] Serrano-Trenas JA, Ugalde PF, Cabello LM, et al. Role of perio-perative intravenous iron therapy in elderly hip fracture patients: a single-center randomized controlled trial. Transfusion, 2011, 51(1): 97-104.

[12] Blum LV, Zierentz P, Hof L, et al. The impact of intravenous iron supplementation in elderly patients undergoing major surgery. BMC Geriatr, 2022, 22(1): 293.

[13] Lasocki S, Capdevila X, Vielle B, et al. Ferric derisomaltose and tranexamic acid, combined or alone, for reducing blood transfusion in patients with hip fracture (the HiFIT trial): a multicentre, 2×2 factorial, randomised, double-blind, controlled trial. Lancet Haematol, 2023, 10(9): e747-e755.

[14] Warner MA, Shore-Lesserson L, Shander A, et al. Perioperative anemia: prevention, diagnosis, and management throughout the spectrum of perioperative care. Anesth Analg, 2020, 130(5): 1364-1380.

[15] McCullough PA, Barnhart HX, Inrig JK, et al. Cardiovascular

临床麻醉学杂志2026年1月第42卷第1期 J Clin Anesthesiol, January 2026, Vol.42, No.1

.95.

toxicity of epoetin-alfa in patients with chronic kidney disease. Am J Nephrol, 2013, 37(6): 549-558.

[16] Annese T, Tamma R, Ruggieri S, et al. Erythropoietin in tumor angiogenesis. Exp Cell Res, 2019, 374(2): 266-273.

[17] Weber EW, Slappendel R, Hémon Y, et al. Effects of epoetin alfa on blood transfusions and postoperative recovery in orthopaedic surgery: the European Epoetin Alfa Surgery Trial (EEST). Eur J Anaesthesiol, 2005, 22(4): 249-257.

[18] Feagan BG, Wong CJ, Kirkley A, et al. Erythropoietin with iron supplementation to prevent allogeneic blood transfusion in total hip joint arthroplasty. A randomized, controlled trial. Ann Intern Med, 2000, 133(11): 845-854.

[19] Kateros K, Sakellariou VI, Sofianos IP, et al. Epoetin alfa reduces blood transfusion requirements in patients with interto-chanteric fracture. J Crit Care, 2010, 25(2): 348-353.

[20] Na HS, Shin SY, Hwang JY, et al. Effects of intravenous iron combined with low-dose recombinant human erythropoietin on transfusion requirements in iron-deficient patients undergoing bilateral total knee replacement arthroplasty. Transfusion, 2011, 51 (1): 118-124.

[21] Garrido-Martín P, Nassar-Mansur MI, de la Liana-Ducrós R, et al. The effect of intravenous and oral iron administration on perio- perative anaemia and transfusion requirements in patients under- going elective cardiac surgery: a randomized clinical trial. Interact Cardiovasc Thorac Surg, 2012, 15(6): 1013-1018.

[22] Podestù A, Carmagnini E, Parodi E, et al. Elective coronary and valve surgery without blood transfusion in patients treated with recombinant human erythropoietin (epoetin-alpha). Minerva Cardioangil, 2000, 48(11): 341-347.

[23] Weltert L, D'Alessandro S, Nardella S, et al. Preoperative very short-term, high-dose erythropoietin administration diminishes blood transfusion rate in off-pump coronary artery bypass: a randomized blind controlled study. J Thorac Cardiovasc Surg, 2010, 139(3): 621-627.

[24] Soo CG, Della Torre PK, Yolland TJ, et al. Clopidogrel and hip fractures, is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord, 2016, 17: 136.

[25] Leer-Salvesen S, Dybvik E, Ranhoff AH, et al. Do direct oral anticoagulants (DOACs) cause delayed surgery, longer length of hospital stay, and poorer outcome for hip fracture patients. Eur Geriatr Med, 2020, 11(4): 563-569.

[26] Douketis JD, Spyropoulos AC, Kaatz S, et al. Perioperative bridging anticoagulation in patients with atrial fibrillation. N Engl J Med, 2015, 373(9): 823-833.

[27] Douketis JD, Spyropoulos AC, Duncan J, et al. Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant. JAMA Intern Med, 2019, 179 (11): 1469-1478.

[28] Douketis JD, Spyropoulos AC, Murad MH, et al. Perioperative management of antithrombotic therapy: an american college of chest physicians clinical practice guideline. Chest, 2022, 162 (5): e207-e243.

[29] Vassallo R, Goldman M, Germain M, et al. Preoperative autologous blood donation: waning indications in an era of improved blood safety. Transfus Med Rev, 2015, 29(4): 268-275.

[30] Guo JR, Jin XJ, Yu J, et al. Acute normovolemic hemodilution effects on perioperative coagulation in elderly patients undergoing hepatic carcinectomy. Asian Pac J Cancer Prev, 2013, 14(8): 4529-4532.

[31] Takayanagi A, Masumori N, Kobayashi K, et al. Acute normovolemic hemodilution for radical retropubic prostatectomy and radical cystectomy. Urology, 2008, 72(2): 401-405.

[32] Goodnough LT, Despotis GJ, Merkel K, et al. A randomized trial comparing acute normovolemic hemodilution and preoperative autologous blood donation in total hip arthroplasty. Transfusion, 2000, 40(9): 1054-1057.

[33] Barile L, Fominskiy E, Di Tomasso N, et al. Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis of randomized trials. Anesh Analg, 2017, 124(3): 743-752.

[34] Li Y, Zhang Y, Fang X. Acute normovolemic hemodilution in combination with transecamic acid is an effective strategy for blood management in lumbar spinal fusion surgery. J Orthop Surg Res, 2022, 17(1): 71.

[35] Waters JH. Intraoperative blood recovery. ASAIO J, 2013, 59 (1): 11-17.

[36] Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus, 2011, 9 (2): 139-147.

[37] Simon GI, Craswell A, Thom O, et al. Outcomes of restrictive versus liberal transfusion strategies in older adults from nine randomised controlled trials: a systematic review and meta-analysis. Lancet Haematol, 2017, 4(10): e465-e474.

[38] Simon GI, Craswell A, Thom O, et al. Impacts of aging on anemia tolerance, transfusion thresholds, and patient blood management. Transfus Med Rev, 2019, 33(3): 154-161.

[39] Degoute CS. Controlled hypotension: a guide to drug choice. Drugs, 2007, 67(7): 1053-1076.

[40] Paul JE, Ling E, Lalonde C, et al. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anaesth, 2007, 54(10): 799-810.

[41] Jiang J, Zhou R, Li B, et al. Is deliberate hypotension a safe technique for orthopedic surgery? a systematic review and meta-analysis of parallel randomized controlled trials. J Orthop Surg Res., 2019, 14(1): 409.

[42] Naik BI, Pajewski TN, Bogdonoff DI, et al. Rotational throm-boelastometry-guided blood product management in major spine surgery. J Neurosurg Spine, 2015, 23(2): 239-249.

[43] Chen F, Jiang Z, Li M, et al. Efficacy and safety of perioperative tranexamic acid in elderly patients undergoing trochanteric fracture surgery: a randomised controlled trial. Hong Kong Med J, 2019, 25(2): 120-126.

[44] Masouros P, Antonio G, Nikolaou VS. Efficacy and safety of

·96·

临床麻醉学杂志 2026年1月第42卷第1期 J Clin Anesthesiol, January 2026, Vol.42, No.1

tranexamic acid in hip fracture surgery. How does dosage affect

transemic acid in hip fracture surgery. How does dosage affect outcomes: a meta-analysis of randomized controlled trials. Injury, 2022, 53(2): 294-300.

[45] Nikolaou VS, Masouros P, Floros T, et al. Single dose of tranex-amic acid effectively reduces blood loss and transfusion rates in elderly patients undergoing surgery for hip fracture: a randomized controlled trial. Bone Joint J, 2021, 103-B(3): 442-448.

[46] Wang G, Xie G, Jiang T, et al. Tranexamic acid reduces blood loss after off-pump coronary surgery: a prospective, randomized, double-blind, placebo-controlled study. Anesth Analg. 2012, 115(2): 239-243.

[47] Amar D, Grant FM, Zhang H, et al. Antifibrinolytic therapy and perioperative blood loss in cancer patients undergoing major orthopedic surgery. Anesthesiology, 2003, 98(2): 337-342.

[48] Daily PO, Lamphere JA, Dembitsky WP, et al. Effect of prophylactic epsilon-aminocapronic acid on blood loss and transfusion requirements in patients undergoing first-time coronary artery bypass grafting. A randomized, prospective, double-blind study. J Thorac Cardiovasc Surg, 1994, 108(1): 99-106.

[49] Alshryda S, Sarda P, Sukeik M, et al. Tranemic acid in total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Br, 2011, 93(12): 1577-1585.

[50] Chenoweth JA, Johnson MA, Shook L, et al. Prevalence of intracranial hemorrhage after blunt head trauma in patients on pre-injury dabigatran. West J Emerg Med, 2017, 18(5): 794-799.

[51] Yee J, Kaide CG. Emergency reversal of anticogulation. West J Emerg Med, 2019, 20(5): 770-783.

[52] Dhakal P, Rayamajhi S, Verma V, et al. Reversal of anticoagulation and management of bleeding in patients on anticoagulants. Clin Appl Thromb Hemost, 2017, 23(5): 410-415.

[53] Muñoz M, Acheson AG, Bisbe E, et al. An international consensus statement on the management of postoperative anaemia after major surgical procedures. Anaesthesia, 2018, 73 (11): 1418-1431.

[54] Laso-Morales MJ, Vives R, Gómez-Ramírez S, et al. Intravenous iron administration for post-operative anaemia management after colorectal cancer surgery in clinical practice: a single-centre, retrospective study. Blood Transfus, 2018, 16(4): 338-342.

[55] Muñoz M, Auerbach M. Postoperative intravenous iron: a simple strategy to improve outcomes. Lancet Haematol, 2016, 3(9): e401-402.

[56] Khalafallah AA, Yan C, Al-Badri R, et al. Intravenous ferric carboxymaltose versus standard care in the management of postoperative anaemia: a prospective, open-label, randomised controlled trial. Lancet Haematol, 2016, 3(9): e415-425.

[57] Strebel N, Prins M, Agnelli G, et al. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery. Arch Intern Med, 2002, 162(13): 1451-1456.

[58] Ranucci M. Hemostatic and thrombotic issues in cardiac surgery. Semin Thromb Hemost, 2015, 41(1): 84-90.

[59] Gross I, Seifert B, Hofmann A, et al. Patient blood management

in cardiac surgery results in fewer transfusions and better outcome. Transfusion, 2015, 55(5): 1075-1081.

[60] Karkouti K, Wijeysundera DN, Yau TM, et al. The independent association of massive blood loss with mortality in cardiac surgery. Transfusion, 2004, 44(10): 1453-1462.

[61] Ranucci M, Bozzetti G, Ditta A, et al. Surgical reexploration after cardiac operations: why a worse outcome. Ann Thorac Surg, 2008, 86(5): 1557-1562.

[62] Welter L, Rondinelli B, Bello R, et al. A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single-blind randomized controlled trial. Transfusion, 2015, 55(7): 1644-1654.

[63] Sun P, Ji B, Sun Y, et al. Effects of retrograde autologous priming on blood transfusion and clinical outcomes in adults: a meta-analysis. Perfusion, 2013, 28(3): 238-243.

[64] Avidan MS, Levy JH, Scholz J, et al. A phase III, double-blind, placebo-controlled, multicenter study on the efficacy of recombinant human antithrombin in heparin-resistant patients scheduled to undergo cardiac surgery necessitating cardiopulmonary bypass. Anesthesiology, 2005, 102(2): 276-284.

[65] Vonk AB, Veerhoek D, van den Brom CE, et al. Individualized beparin and protamine management improves rotational throm-boelastometric parameters and postoperative hemostasis in valve surgery. J Cardiathone Yasc Anesth, 2014, 28(2): 235-241.

[66] Myles PS, Smith JA, Forbes A, et al. Tranexamic acid in patients undergoing coronary-artery surgery. N Engl J Med, 2017, 376(2): 136-148.

[67] Carless PA, Henry DA, Moxey AJ, et al. Cell salvage for mini-mising perioperative algeneic blood transfusion. Cochrane Data-base Syst Rev, 2010, (3): CD001888.

[68] Steiner ME, Ness PM, Assmann SF, et al. Effects of red-cell storage duration on patients undergoing cardiac surgery. N Engl J Med, Med, 2015, 372(15): 1419-1429.

[69] Desborough M, Sandu R, Brunskill SJ, et al. Fresh frozen plasma for cardiovascular surgery. Cochrane Database Syst Rev, 2015, (7): CD007614.

[70] Bilecen S, de Groot JA, Kalkman CJ, et al. Effect of fibrinogen concentrate on intraoperative blood loss among patients with intraoperative bleeding during high-risk cardiac surgery: a randomized clinical trial. JAMA, 2017, 317(7): 738-747.

[71] Bignami E, Cattaneo M, Crescenzi G, et al. Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial. Acta Anaesthesiol Scand, 2016, 60(7): 892-900.

[72] Gill R, Herbertson M, Vuylsteke A, et al. Safety and efficacy of recombinant activated factor VII: a randomized placebo-controlled trial in the setting of bleeding after cardiac surgery. Circulation, 2009, 120(1): 21-27.

[73] Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg, 2011, 91(3): 944-982.

临床麻醉学杂志 2026年1月第42卷第1期 J Clin Anesthesiol, January 2026, Vol.42, No.1

.97.

[74] Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional coronary artery bypass grafting; early and 1-year graft patency, cost, and quality-of-life outcomes; a randomized trial. JAMA, 2004, 291(15): 1841-1849.

[75] Goldman S, Copeland J, Moritz T, et al. Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a veterans administration co-operative study. Circulation, 1988, 77(6): 1324-1332.

[76] Sharma R, Huang Y, Dizdarevic A. Blood conservation techniques and strategies in orthopedic anesthesia practice. Anesthesiol Clin, 2022, 40(3): 511-527.

[77] Kotzé A, Carter LA, Scally AJ. Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth, 2012, 108(6): 943-952.

[78] Vaglio S, Prisco D, Biancofiore G, et al. Recommendations for the implementation of a patient blood management programme. Application to elective major orthopaedic surgery in adults. Blood Transfus, 2016, 14(1): 23-65.

[79] Goodnough LT, Maniatis A, Earnshaw P, et al. Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines. Br J Anaesth, 2011, 106(1): 13-22.

[80] Mueller MM, Van Remoortel H, Meybohm P, et al. Patient blood management: recommendations from the 2018 Frankfurt Consensus Conference. JAMA, 2019, 321(10): 983-997.

[81] Billote DB, Glisson SN, Green D, et al. A prospective, randomized study of preoperative autologous donation for hip replacement surgery. J Bone Joint Surg Am, 2002, 84(8): 1299-1304.

[82] Jakovina Blazekovic S, Bicanic G, Hrabac P, et al. Pre-operative autologous blood donation versus no blood donation in total knee arthroplasty: a prospective randomised trial. Int Orthop, 2014, 38(2): 341-346.

[83] Mistry DA, Chandratreya A, Lee P. A systematic review on the use of aspirin in the prevention of deep vein thrombosis in major

elective lower limb orthopedic surgery: an update from the past 3 years. Surg J (N Y), 2017, 3(4): e191-e196.

[84] Mentsoudis SG, Cozowicz C, Bekeris J, et al. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth, 2019, 123 (3): 269-287.

[85] Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg, 2006, 103(4): 1018-1025.

[86] Guay J. The effect of neuraxial blocks on surgical blood loss and blood transfusion requirements: a meta-analysis. J Clin Anesth, 2006, 18(2): 124-128.

[87] Taeuber I, Weibel S, Hermann E, et al. Association of intravenous tranexamic acid with thromboembolic events and mortality: a systematic review, meta-analysis, and meta-regression. JAMA Surg, 2021, 156(6): e210884.

[88] Fillingham YA, Ramkumar DB, Jevsevar DS, et al. Tranexamic acid in total joint arthroplasty: the endorsed clinical practice guides of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. Reg Aneshi Pain Med, 2019, 44(1): 7-11.

[89] Cionac Florescu S, Anastase DM, Munteanu AM, et al. Venous thrommbolsism following major orthopedic surgery. Maedica (Bucur), 2013, 8(2): 189-194.

[90] Eichinger S, Kyrle PA. Prevention of deep vein thrombosis in orthopedic surgery. Eur J Med Res, 2004, 9(3): 112-118.

[91] Anderson DR, Morgano GP, Bennett C, et al. American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients. Blood Adv, 2019, 3(23): 3898-3944.

(收稿日期:2024-08-12)

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