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#62
28.08.2009, 22:59
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[Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] [Ссылки доступны только зарегистрированным пользователям ] 
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#63
29.08.2009, 16:18
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Но похоже во всех этих случаях речь идет о вынужденном отказе врачей от переливания у Свидетелей. Т.е. абсолютные показания имелись, но не были выполнены из-за немедицинских причин. Больные выжили благодаря удачному стечению обстоятельств и профессионализму врачей, которые были вынуждены назначать неоптимальное лечение, что и явилось причиной для публикаций. "Despite haemoglobin concentrations of less than 3 g/dl both women survived." Напомню разговор: Цитата:
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#64
29.08.2009, 16:44
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Осмелюсь напомнить, чем именно была спровоцирована данная дискуссия - насильственной гемотрансфузией по медицинским показаниям вопреки желанию пациента и не могу согласиться с тем, что "во всем топике шла речь об отказе переливания крови у больных с экстремальными анемиями, по медицинским резонам".
Мне кажется, приведенные ссылки демонстрируют, что существуют способы ведения пациентов с экстремальными анемиями кроме гемотрансфузий. И, конечно, не следует расценивать их как аргумент в пользу отказа от трансфузий тогда, когда они действительно необходимы. P.S. Данные ссылки были предоставлены мною в ответ на просьбу доктора MAX_, а не Вашу, ибо мне неизвестны случаи "если непереливали по медицинским соображениям, а не потому что она рожала в деревне, небыло крови или была Свидетелем чего-то там", но я склонен расценивать отказ пациента от трансфузии как "медицинское соображение" и не считаю вправе возможным отказывать такому пациенту в лечении другими способами либо вынуждать к применению трансфузии, ежели он/она в сознании.
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#65
29.08.2009, 17:48
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Об отказе в помощи пациентам, вообще речь не шла.
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#66
29.08.2009, 18:19
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#67
29.08.2009, 18:43
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Ссылку посмотрю, спасибо.
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#68
02.09.2009, 01:16
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#69
02.09.2009, 10:50
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Возможны 3 варианта: 1)Стабильных больных с таким уровнем гемоглобина небывает. 2)Несмотря на стабильность, такой критический уровень гемоглобина является показанием для переливания. 3)Подобный опыт существует, но или я плохо искал (что возможно) или авторы этого опыта почему-то не захотели с ним делиться. Повторюсь. я не говорю что Вы с коллегой не правы. Но данных подтверждающих Вашу правоту пока не представлено.
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#70
02.09.2009, 10:52
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#71
02.09.2009, 17:19
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некоторые тезисы 30-летней давности:
Arch Intern Med. 1979 Sep;139(9):1053-4. Severe anemia. Clinical observations in 100 patients with very low hemoglobin levels. Al-Mondhiry H, Al-Hilali A. One hundred consecutive patients with hemoglobin concentration less than 3.5 g/dL (hematocrit reading, less than 10%) were admitted to the University of Baghdad Teaching Hospital, Iraq, during a 30-month period. Twenty-eight patients had aplastic anemia, 27 had leukemia or other hemopoietic malignancies, 16 had chronic renal failure, eight had iron-deficiency anemia, eight had hemolytic anemia, seven had thalassemia major, and six had other conditions. Twenty-three patients died within seven days of admission, mostly due to the underlying disease or complications thereof. Heart failure developed in ten patients, and five had retinal exudates and hemorrhages attributed to severe anemia. Arrhythmias and ECG abnormalities were noted in 20 of 68 patients. Blood transfusion was instituted in all but three patients, whose anemia was corrected with specific therapy without blood transfusion. The tolerance of the 100 patients to such severe anemia was remarkable. P N G Med J. 1979 Dec;22(4):29-36. Severe anaemia in Port Moresby. A review of 101 adult Melanesian patients with haemoglobin level of 4G/100 ml or less. Williams G, Naraqi S. Causes of anaemia in 101 adult Melanesian patients admitted to Port Moresby General Hospital over a 3-year period with haemoglobin levels of 4.0 gms per 100 ml or less were studied retrospectively. Cases of anaemia due to acute haemmorrage were excluded. Iron deficiency was found in 80, haemolysis in 39, megloblastosis in 26 and anaemia of chronic diseases in 5 patients. Anaemia was secondary to multiple causes in 56 and to a single cause in 45 patients. In the group with multiple causes, a combination of iron deficiency and haemolysis was found in 28, iron deficiency and megaloblastosis in 18, iron deficiency, haemolysis and megaloblastosis in 6 and haemolysis and megaloblastosis in 5 patients. In the group with a single cause, iron deficiency was found in 34, anaemia of chronic diseases in 5, haemolysis in 4 and megaloblastosis in 2 patients. Hookworm infestation and malaria appeared to be the major underlying causes of anaemia in the majority of these patients. Three of 45 patients who had received blood transfusions shortly after admission to the hospital died, while there was only one death in the nontransfused group. It is concluded that: i) severe anaemia in Papua New Guinea is commonly secondary to multiple causes; ii) administration of iron and folic acid as well as treatment for malaria and hookworm is a responsible approach when these patients can not be investigated; and iii) blood transfusion does not appear to be necessary in this group of patients despite a very low haemoglobin level.
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#72
02.09.2009, 18:00
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Уважаемые коллеги,
Попутно хочется тиснуть в анемический топик некоторые фрагменты недавнего критического обзора по теме половых различий в гемоглобине. Автор на протяжении 10 лет изучал данный вопрос (множество его комментов было опубликовано в разных журналах) и наконец разродился весьма содержательной публикацией, постулирующей, что нетутя в природе мужеского доминирования в концентрации гемоглобина, а нынешние "нормы" образовались из-за включения большой (преобладающей?) группы женщин, пребывающей в хроническом железодефиците большую часть своей сознательной жизни... Фрагменты оттуда: In pre-pubertal humans there is no significant gender difference in haemoglobin, red blood cell count or serum ferritin concentration [30]. However, a difference emerges after the onset of menstruation [30] which continues until many years after the menopause. At this time, haemoglobin concentrations in both genders become similar [56]. This divergence between genders is aggravated by the lifestyle of modern women who have a very different reproductive history from their forebears. They reach sexual maturity at an earlier age, have fewer pregnancies and breastfeed for shorter periods of time; as a result they menstruate more frequently and therefore become more iron deficient [57,58]. The Bantu in South Africa [34], Ethiopians [35], and Aborigines [36] often ingest in excess of 100mg of elemental iron per day fromtheir cooking utensils, contaminated food, iron rich soil, and have scanty menses. In these populations, anaemia in both pregnant and non-pregnant women is rare [34,37]. It is noteworthy that the haemoglobin level in Ethiopian females is as high as 19.4 g/dL [37] and there is no mean difference in haemoglobin concentration between Aboriginal males (16.4 g/dL) and females (16.2 g/dL), with the female level 1.8 g/dL higher than the European Australian [36]. Hallberg et al. [13] found an absence of iron stores with iron deficient erythropoiesis starting already at serum ferritin concentrations between 25 and 40 ug/L. In iron replete (grades I–III) women, the 50th centile haemoglobin was 13.6 g/dL with a serum ferritin of 42 ug/L; interestingly these parameters are very similar to the lower reference values generally employed for men. In 1936 Widdowson and McCance [54] gave normal healthy men and women 100mg of elemental iron daily, there was a significant increase in the female haemoglobin concentrations but no change in the males. In women “the administration of iron raised the haemoglobin in every case” and the mean value reached “was very close to the mean for the men before or after taking additional iron”. Sankaran and Rajagopal [55] in 1938 also gave 100mg of elemental iron daily to non-anaemic healthy young girls, all had an increase in haemoglobin concentration while therewas no increase in aged matched controls who received no iron. In mammals that do not have menses (oestrus mammals) there is no difference in haemoglobin concentrations between males and females. In menstruating non-human mammals, the Old World monkeys and apes, there is also no difference in the lower haemoglobin limit [63], however, the upper limit is higher in males and suggests menses is responsible for limiting females attaining higher haemoglobin concentrations [72]. What is the evidence for gender differences in ferritin and haemoglobin? Critical Reviews in Oncology/Hematology
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#73
02.09.2009, 23:29
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#74
04.09.2009, 15:36
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Спасибо, уважаемые коллеги, за интересное обсуждение, особенно Вам, уважаемый Вадим Валерьевич за любопытные ссылки. Насколько они валидны в настоящий момент, трудно сказать, но все равно большое спасибо.
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#75
09.09.2009, 18:00
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Вот исчо абстрактец посвежее из деццко-американской практики:
Pediatr Hematol Oncol. 2002 Apr-May;19(3):157-61. Severe iron deficiency anemia in 42 pediatric patients. Sandoval C, Berger E, Ozkaynak MF, Tugal O, Jayabose S. Department of Pediatrics, New York Medical College, Valhalla 10595, USA. The objective of this study was to determine the clinical and laboratory features of children with severe iron deficiency anemia. The authors retrospectively reviewed the charts of 198 children with iron deficiency anemia to ascertain cases of severe iron deficiency anemia. Forty-two children with severe iron deficient anemia were evaluated. The median age was 21 months (range, 7-240 months) at diagnosis and 27 children were 13-24 months of age. For 35 children the major source of calories was derived from cow's milk. The median hemoglobin was 4.6 g/dL (range, 2.1-6 g/dL) and the median serum ferritin was 5 microg/L (range, 1-11 microg/L). Twenty-nine received oral iron and 13 required parked red blood cell transfusions because of co-morbid cardiorespiratory distress. Severe iron deficiency anemia mostly affects children during their second year of life. Oral iron therapy is sufficient for most children, but packed red blood cell transfusions may be needed.
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Линейный вид
