外科加護病房內使用紅血球血品之原因分析與改善方案

Blood utilization in a surgical intensive care unit: cause analysis and solutions to reduce inappropriate red blood cell transfusions

背景與目的：雖然許多醫學會都有發表如何正確使用紅血球的血品的照顧指引，然而，臨床醫師決定輸血的動機，常是根據個人的喜好，或是多年類累積的經驗而非實證醫學。因此，本研究的宗旨是探討外科加護病房病人的輸血適應症是否遵循這些照顧指引，同時分析輸血的正確與合適性是否影響病人的臨床結果，與探討造成不正確輸血的因素，以達到持續提升病人照顧品質。研究方法：本研究收納在2015年7月至2016年6月中入住成人外科加護病房之病人，組成一個專家小組依回顧性的方式評估加護病房住院期間所有使用紅血球血品的適當性，並比較輸血的正確性與非正確性的兩組病人的背景資料及臨床結果。研究結果：研究期間共有617名病人入住外科加護病房，其中245名(39.7%)病人接受了紅血球血品。比起沒有手術的病人，較多的術後病人有接受輸血(87.3% vs. 75.8%)，同時輸血的病人有較高的APACHE II 分數(22.1 ± 8.5 vs. 15.5 ± 7.4)，更長的加護病房的住院天數(8.0 ± 9.1 vs. 3.0 ± 3.7天)，與較高的加護病房死亡率(14.3% vs. 6.2%)。在651次輸血當中，有38.4%符合適應症，但61.6%則未符合適應症。手術後在外科加護病房接受輸血的病人有顯著較高的比率病人在手術當中失血超過500 C.C. (P<0.05)。結論：目前醫院的努力措施仍無法有效的減少外科加護病房不必要的使用紅血球血品。除了持續加強教導醫護人員正確的使用血品之外，其他的方法例如強化資訊系統的提示與阻擋功能，也都是重要的努力方向。

 

Objectives: Despite the fact that many published guidelines for optimal usage of blood products are available, RBC transfusions are frequently guided by personal preference and tradition. The purpose of the study was to examine the appropriateness of RBC transfusions for surgical patients admitted to the SICU and how it might affect the clinical outcomes. Methods: We retrospectively reviewed all RBC transfusions that occurred in a general SICU between July 1, 2015 and June 30, 2016. Each RBC transfusion was critically ap-praised using four criteria to determine whether or not the transfusion was indicated. De-mographic data and clinical outcome measures of transfused and non-transfused patients as well as patients with indicated or non-indicated RBC transfusions were compared. Results: There were 617 patients admitted to the SICU and 245 (39.7%) of them required RBC transfusions. Transfused patients were more likely to have had operations prior to ICU ad-mission (87.3% vs. 75.8%) and have higher APACHE II scores (22.1 ± 8.5 vs. 15.5 ± 7.4). They also had longer ICU stays (8.0 ± 9.1 vs. 3.0 ± 3.7 days) and higher ICU mortality rates (14.3% vs. 6.2%). Among 651 transfusions, 38.4% of them fulfilled at least one crite-rion for transfusion and 61.6% were not considered appropriate. Patients who had non-indicated postoperative RBC transfusion were more likely to have had intraoperative blood loss ≥ 500 mL (p < 0.05). Conclusions: Our efforts to reduce unnecessary RBC transfusion in the SICU appear inadequate. Educating medical personnel is important, but additional measures should also be taken in order to improve compliance.