Abstract
The ready availability of blood and blood components has resulted in a liberal use of blood transfusions; however, the transfusion of blood is still associated with significant risks for the recipient. The appearance of the acquired immunodeficiency syndrome and the evidence that homologous blood can induce immunosuppression and thereby impair the host resistance of surgical patients has led to a reconsideration of the indications for blood transfusions. It has also fostered application of alternative methods with the aim of reducing the number of homologous blood transfusions. Based on the data available from studies on intentional perioperative hemodilution in patients undergoing elective surgery, and data from patients in intensive care, a hematocrit level of about 30% is acceptable for surgical patients, provided oxygen transport is not impaired by the reduced saturation of arterial blood or inadequate perfusion. The basic mechanism that compensates for the reduced oxygen capacity of the blood is a rise in cardiac output and stroke volume, both depending on adequate venous return and myocardial function. The hematocrit setpoint has to be determined for the individual patient with regard to the history of the underlying disease, circulating blood volume, and actual oxygen needs. By accepting a perioperative hematocrit level of 30% for patients without respiratory and cardiac disease or increased oxygen demand, respectively, the number of transfusions of homologous blood can be reduced and dangerous side effects can be avoided.
Résumé
La grande facilité à disposer de sang ou de constituants a abouti à l'emploi excessif des transfusions sanguines. D'autre part la transfusion de sang présente toujours des risques pour le receveur. L'apparition du SIDA et le fait indiscuté que le sang homologue peut induire une immunosuppression préjudiciable à la résistance des malades chirurgicaux ont conduit à reconsidérer les indications de la transfusion de sang et à favoriser l'emploi d'autres méthodes dont le but est de réduire le nombre des transfusions de sang homologue. En se référant aux données fournies par les études de l'hémodilution péri-opératoire intentionnelle dans la chirurgie élective et aux données fournies par les malades traités par soins intensifs, il a été établi qu'un hématocrit aux environs de 30% est acceptable chez les malades chirurgicaux dés lors que le transport de l'oxygène n'est pas altéré par une réduction de la saturation du sang artériel ou par une perfusion inadéquate. Le mécanisme de base qui intervient pour compenser la réduction de l'oxygénation du sang consiste en une élévation du débit cardiaque et du sang éjecté, ces deux facteurs dépendant d'un retour veineux et d'une fonction myocardique adéquats. Le point de l'hematocrit à prendre en considération doit être déterminé pour chaque malade en fonction de la maladie qu'il présente, du volume de sang circulant, et des besoins réels en oxygène. En fixant ce point à 30% chez les patients qui ne présentent pas d'affections cardiaque ou respiratoire ou encore une augmentation de la demande en oxygène, il est possible de réduire le nombre de transfusions de sang homologue et d'éviter les effects secondaires indésirables de la transfusion.
Resumen
La fácil disponibilidad de sangre y de componentes sanguíneos ha resultado en la liberación en el uso de transfusiones. Sin embargo, la transfusión de sangre todavía se halla asociada con riesgos de significación por parte del recipiente. La aparición del SIDA y la evidencia de que la sangre homóloga puede inducir inmunosupresíon y con ello alterar los factores de resistencia de huésped en los pacientes quirúrgicos, ha llevado a reconsiderar las indicaciones para transfusion sanguínea y ha promovido la aplicación de métodos alternativos de autotransfusión con el propósito de reducir el número de transfusiones homólogas. Con base en la información disponible derivada de estudios con hemodilución perioperatoria intencional en cirugía electiva y de pacientes en cuidado intensivo se considera que un hematocrito de 30% es aceptable en pacientes quirúrgicos, siempre y cuando el transporte del oxǵeno no se encuentre alterado por una saturación reducida de la sangre arterial o por perfusión inadecuada. El mecanismo basico de compensación ante una reducida capacidad de oxigenación de la sangre es el aumento en el gas to cardíaco y en el volumen de eyección, factores que a su vez dependen de adecuado retorno venoso y de buena función miocárdica. El nivel crítico del hematocrito debe ser establecido para cada paciente individual en relación a la historia de la enfermedad actual, del volumen circulatorio, y de las demandas reales de oxígeno. Al aceptar un hematocrito preoperatorio de 30% para pacientes libres de enfermedad respiratoria y cardíaca o de demanda aumentada de oxígeno, se puede lograr la reducción en el número de transfusiones de sangre homóloga y evitar los peligrosos efectos colaterales.
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Messmer, K.F.W. Acceptable hematocrit levels in surgical patients. World J. Surg. 11, 41–46 (1987). https://doi.org/10.1007/BF01658458
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DOI: https://doi.org/10.1007/BF01658458