围手术期非心脏手术患儿输血后引起肺并发症的发生率和流行病学：单中心，5年研究经验
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Incidence and Epidemiology of Perioperative Transfusion-Related Pulmonary Complications in Pediatric Noncardiac Surgical Patients: A Single-Center, 5-Year Experience.
背景与目的：输血相关的急性肺损伤和循环超负荷是导致输血相关死亡的原因，虽然输血相关肺部并发症在成人很详细，但在儿科却没有清晰的定义，我们对儿童输入血液制品后引起的输血相关肺部并发症的发病率和行病学进行了描述。
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方法：回顾性研究，我们对2010年1月到2014年12月期间围手术期输注血制品的儿科非心脏手术病人进行评估，排除紫绀型心脏病、呼吸功能不全和使用体外膜肺和美国麻醉协会物理状态VI的疾病，用电子方法对医疗记录进行筛选，找到低氧血症的依据，并对24小时内的手术病人拍摄胸片，由两名医师进行手动检查记录，以确定他们是否符合输血相关的循环超负荷和输血相关的急性肺损伤的诊断标准。由高年资医师裁定。
结果：总共有19288例儿外科手术病人，411例符合条件，病人的输血相关肺部并发症发生率为3.6%（(95%置信区间，2.2-5.9），输血相关的循环超负荷发生率为3.4% (95%置信区间，2.0-5.6），确定输血相关的急性肺损伤占1.2% (95% 置信区间, 0.5-2.8)，1.0% (95% CI, 0.4-2.5) 的输血相关的急性肺损伤和输血相关的循环超负荷有证据，男性(3.4%)和女性(3.8%; P = .815)发病率并没有差异，虽然输血相关肺部并发症在年轻患者发病率有增加的趋势，但这没有统计学意义(P = .088)。输血量和各外科之间的发病率是可比较的，在15例输血相关肺部并发症患者中，分别给予红细胞13例、血浆3例、血小板3例、冷冻沉淀2例，输入自体血液3例，3例输血相关肺部并发症患者采用输输入了血混合血液成分。
结论：输血相关肺部并发症在儿外科的发生率是3.6%，主要原因是输血相关的循环超负荷，与报道的成人文献一致，不同性别、不同外科手术和输血量的输血相关肺部并发症发生频率相当，观察到在更小的儿童在输血量的输血相关肺部并发症有增加的趋势。虽然血小板被证明是高风险成分，但红细胞是引起大多数输血相关肺部并发症的主要构成成分。依赖于将来进一步的多机构研究模式和预测这个高致病因素来降低儿科患者中与输血相关的肺部并发症围手术期风险。
BACKGROUND:
Transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO) are the leading causes of transfusion-related fatalities. While these transfusion-related pulmonary complications (TRPCs) have been well detailed in adults, their burden in pediatric subsets remains poorly defined. We sought to delineate the incidence and epidemiology of pediatric TRPCs after intraoperative blood product transfusion.
METHODS:
In this retrospective cohort study, we evaluated all consecutive pediatric patients receiving intraoperative blood product transfusions during noncardiac surgeries between January 2010 and December 2014. Exclusion criteria were cyanotic heart disease, preoperative respiratory insufficiency, extracorporeal membrane oxygenation, and American Society of Anesthesiologists physical status VI. Medical records were electronically screened to identify those with evidence of hypoxemia, and in whom a chest x-ray was obtained within 24 hours of surgery. Records were then manually reviewed by 2 physicians to determine whether they met diagnostic criteria for TACO or TRALI. Disagreements were adjudicated by a third senior physician.
RESULTS:
Of 19,288 unique pediatric surgical patients, 411 were eligible for inclusion. The incidence of TRPCs was 3.6% (95% confidence interval [CI], 2.2-5.9). TACO occurred in 3.4% (95% CI, 2.0-5.6) of patients, TRALI was identified in 1.2% (95% CI, 0.5-2.8), and 1.0% (95% CI, 0.4-2.5) had evidence for both TRALI and TACO. Incidence was not different between males (3.4%) and females (3.8%; P = .815). Although a trend toward an increased incidence of TRPCs was observed in younger patients, this did not reach statistical significance (P = .109). Incidence was comparable across subsets of transfusion volume (P = .184) and surgical specialties (P = .088). Among the 15 patients experiencing TRPCs, red blood cells were administered to 13 subjects, plasma to 3, platelets to 3, cryoprecipitate to 2, and autologous blood to 3. Three patients with TRCPs were transfused mixed blood components.
CONCLUSIONS:
TRPCs occurred in 3.6% of transfused pediatric surgical patients, with the majority of cases attributable to TACO, congruent with adult literature. The frequency of TRPCs was comparable between genders and across surgical procedures and transfusion volumes. The observed trend toward increased TRPCs in younger children warrants further consideration in future investigations. Red blood cell administration was the associated component for the majority of TRPCs, although platelets demonstrated the highest risk per component transfused. Mitigation of perioperative risk associated with TRPCs in pediatric patients is reliant on further multiinstitutional studies powered to examine patterns and predictors of this highly morbid entity.
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