'배움/외과학'에 해당되는 글 2건

  1. 2010.04.13 [배움]Indication for Platelet Transfusion
  2. 2010.04.09 [배움]간질환 평가 척도 ; MELD, CTP

An Example of a Guideline for Platelet Transfusion

 Transfusions of platelets are appropriate to prevent or control bleeding associated with deficiencies in platelet number or function. A platelet concentrate produced from a unit of whole blood contains, on average, 7.5 X 1010 platelets and should increase the platelet count by 5 to 10 X 109/L (5,000 - 10,000/uL) in a 70 kg recipient. Apheresis platelet concentrates generally contain 3 - 6 X 1011 platelets, depending on local collection practice, and physicians should be cognizant of the doses provided in their community. A pool of 4 - 8 platelet concentrates or a single donor platelet usually is sufficient to provide hemostasis in a thrombocytopenic, bleeding patient. The efficacy of platelet transfusions can be influenced by other conditions in the recipient such as uremia, medications, concomitant coagulation disorders, alloimmunization to HLA, or platelet antigens, infections or splenomegaly.

Platelet concentrate infusions can be administered to patients without further justification
in the following circumstances:

1. Active bleeding and platelet count less than 50,000/uL or platelet function defect *

2. Non bleeding patients with:

1) Temporary myelosuppression due to chemo-radiotherapy or underlying disease in a stable patient with platelet count less than 10,000/uL.9-12 Patients with temporary myelosuppression due to chemotherapy or underlying disease (e.g. leukemia) may require prophylactic transfusions at levels between 10,000 and 20,000/uL in the presence of fever or minor hemorrhagic signs.

2) Impending surgery or invasive procedures involving the CNS (including eye) , or other critical areas in which microvascular bleeding is harmful and a platelet count of less than 100,000/uL.**

3) Other surgery or invasive procedures where the operative field can be visualized or external pressure can be utilized to maintain hemostasis and a platelet count of less than 50,000/uL.**

4) Surgery or invasive procedure and documented qualitative platelet function defect. (DDAVP (0.3ug/kg) should be considered for patients with von Willebrand disease or qualitative platelet function defects, e.g. cirrhosis or uremia).

3. Open heart surgery patients with:

1) Microvascular bleeding and platelet count less than 150K.**

2) Microvascular bleeding and non-diagnostic coagulation panel abnormality (e.g. post-operative chest tube drainage greater than 500 ml within 6 hours)

3) Microvascular bleeding and platelet function defect.*

4. Active microvascular bleeding with a platelet count of less than 75K.**

Contraindications for Platelet Transfusions

1. Platelet transfusions generally are contraindicated in thrombotic thrombocytopenic purpura (TTP) and immune thrombocytopenias including heparin-induced thrombocytopenia (HIT) unless life-threatening hemorrhage exists.

2. Prophylactic platelet transfusions generally are not indicated for patients with chronic aplastic anemia or myelodysplastic diseases. Platelet transfusion for symptomatic thrombocytopenia (minor or moderate bleeding) is a more rational approach in such patients.5

3. There is no role for prophylactic platelet transfusion in routine primary open heart surgery.

*Platelet function defect should be documented by template bleeding time greater than two times the upper limit of normal, or greater than 12 minutes, or presumed defect based on medication ingestion, hypothermia, or instrumentation affecting platelet function.

**Platelet counts listed represent maximal levels; procedures have been performed at lower levels without hemorrhage.

Reference : http://www.scbcinfo.org/publications/bulletin_v2_n2.htm

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ⅠMELD score

이전의 간 이식 정도 체계는 지역적인 요인과 간 이식 대기 기간, 의사의 주관적인 평가 등으로 이루어져 있었다. 그러나 대기 기간이나 지역적 요인은 간질환의 중증도와는 관련이 없으며 의사의 의견도 지나치게 주관적이라는 오류를 내포하고 있으므로 이 체계가 올바르지 못하다는 전문가 사이의 논란이 있었다. 따라서 이를 대체하기 위해 등장한 점수 제도가 ‘MELD(Model for End-stage Liver Disease) score’ 이며 bilirubin, prothrombin time, creatine 으로 계산한다.

MELD Score =

(0.957 * ln(Serum Cr) + 0.378 * ln(Serum Bilirubin) + 1.120 * ln(INR) + 0.643 ) * 10 (if hemodialysis, value for Creatinine is automatically set to 4.0)



Ⅱ CTP score

CTP score(Child-Pugh score ; Child - Turcotte - Pugh score)는 만성 간질환, 그 중에서도 간경화의 예후를 평가하는 데 쓰인다.




Measure

1점

2점

3점

Hepatic encephalopathy

none

GradeⅠ-Ⅱ

GradeⅢ-Ⅳ

Prothrombine time

< 1.7

1.71 - 2.20

> 2.20

Bilirubin (mg/dL)

< 2

2 - 3

> 3

Serum Albumin (g/L)

> 35

28-35

< 28

Ascites

none

mild

severe





점수

등급

1년 생존율 (%)

2년 생존율 (%)

5 - 6

A

100

85

7 - 9

B

81

57

10 - 15

C

45

35

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