心脏手术中红细胞输注相关溶血：观察性队列研究
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Red Cell Transfusion–Associated Hemolysis in Cardiac surgery: An Observational Cohort Study
背景与目的
红细胞活力在储存期间易受损，从而发生储存期间和输血后溶血过多的现象。因此，输血可能使得血红蛋白清除途径过度饱和，导致易感患者（例如经心脏手术进行心脏手术的患者）的血红蛋白释放，以及发生铁中毒。为了探讨这一假设，我们在心脏手术患者的连续队列中评估了输注红细胞与游离血红蛋白及转铁蛋白饱和度之间的关系。
方 法
在旁路建立后15-30分钟内，测量心脏手术患者实验室溶血结果。为控制重要混杂因素，构建多变量回归模型，以确定旁路建立期间输注红细胞与旁路结束后游离血红蛋白及转铁蛋白饱和度是否独立关联，以连续变量进行分析（线性回归），并以第90百分位数进行分类（逻辑回归）。
结 果
在543例患者中，82例（15.1％）在旁路期间接受红细胞输注（中位数1;四分位间距1-2单位）。所有患者均检测游离血红蛋白水平（平均11.3;标准差±9.3;第90百分位数18μmol/ L），转铁蛋白饱和度相对较高（平均41±19％;第90百分位数66％）。在控制混杂因素后，输注红细胞与游离血红蛋白水平无关（P> 0.25，线性回归和逻辑回归），但与转铁蛋白饱和度直接相关（线性和逻辑回归中P <0.001）。输注红细胞患者的转铁蛋白饱和度增高（即转铁蛋白饱和度> 66％）的风险增加6.2倍（95％置信区间：2.4-16.1）。
结 论
以上结果说明，输注红细胞可引起过度溶血，并可能导致急性铁超载和铁中毒。同时也是输血相关不良事件的部分病因。这些结果表明，能够减轻或避免与输血相关急性铁超载的策略可能会提高输血的安全性。
原始文献摘要
Karkouti, K., et al., Red Cell Transfusion-Associated Hemolysis in Cardiac Surgery: An Observational Cohort Study. Anesth Analg, 2017. 124(6): 1986-1991.
BACKGROUND ：
Red cell viability is impaired during storage, resulting in excess hemolysis during storage and after transfusion. As a result, transfusions may oversaturate the hemoglobin clearance pathways, resulting in cell-free hemoglobin and iron toxicity in susceptible patients, such as those undergoing cardiac surgery with cardiopulmonary bypass. To explore this hypothesis, we assessed the relationship of red cell transfusions with cell-free hemoglobin and transferrin saturation levels in a consecutive cohort of cardiac surgical patients.
METHODS:
Laboratory measures of hemolysis were obtained in consecutive cardiacsurgical patients 15 to 30 minutes after bypass. Multivariable regression models controlling for important confounders were constructed to determine the independent relationship of red cell transfusions during bypass with cell-free hemoglobin and transferrin saturation levels postbypass, analyzed as continuous variables (linear regression) and categorized at the 90th percentiles (logistic regression).
RESULTS:
Of the 543 included patients, 82 (15.1%) received red cell transfusions duringbypass (median 1; interquartile range 1–2 units). Cell-free hemoglobin was detected in all patients (mean 11.3; standard deviation ±9.3; 90th percentile 18 μmol/L), and transferrin saturations were relatively high (mean 41±19%; 90th percentile 66%). After controlling for confounders, transfusions were not associated with cell-free hemoglobin (P>0.25 in linear and logistic regression) but were directly associated with transferrin saturation levels (P<0.001 in linear and logistic regression). Transfused patients had a 6.2-fold (95% confidence interval: 2.4–16.1) risk-adjusted increase in the odds of having high (>66%) transferrin saturation levels.
CONCLUSION:
The findings support the hypothesis that transfusion-related adverse events may be in part caused by the excessive hemolysis of transfused red cells, which can lead to acute iron overload and related toxicity. This suggests that strategies aimed at avoiding or mitigating transfusion-related acute iron overload may improve the safety of red cell transfusions.
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