老年骨质疏松性髋部骨折患者的围手术期贫血和输血管理：对当前证据和新兴策略的叙述性综述

摘要(中文译文)

骨质疏松性髋部骨折在老龄人口中构成重大且不断加剧的公共卫生负担，伴随显著的发病率、死亡率和医疗费用。围手术期贫血在这一脆弱人群中极为常见，据报道术前患病率为40%至50%以上，并且是已确立的独立预测因子，可预示不良的短期和长期结局，包括死亡率、功能恢复受损、术后谵妄和住院时间延长。贫血的管理和异体输血的审慎使用是这些患者多学科诊疗的核心。本叙述性综述对当代老年骨质疏松性髋部骨折患者围手术期贫血管理的证据进行了全面而批判性的评价，依据通过检索主要文献数据库所识别的随机对照试验、荟萃分析和大型观察性研究。我们批判性地审视了围手术期贫血的流行病学和多因素病因学；输血风险预测从传统临床指标到机器学习的演变；药物性血液保护，其中氨甲环酸和静脉铁剂具有强有力的证据；限制性与开放性输血阈值之间的争论以及个体化、生理学指导决策的必要性；接受抗血栓治疗患者的围手术期管理；以及手术技术、骨折类型、营养和衰弱状态的影响。由此得出若干实践性信息：限制性输血策略（血红蛋白7-8 g/dL）适用于大多数患者，但应个体化，对于衰弱、心血管脆弱或易发生谵妄的患者以及养老院居民，倾向于采用更为开放的策略；早期和术中应用氨甲环酸及静脉铁剂可显著减少输血需求；手术通常不应仅因抗血栓药物而延迟；通过嵌入整合性骨科老年医学诊疗路径中的多模式、阶梯式患者血液管理方法实施诊疗效果最佳。未来研究的优先方向包括个体化、生理学指导输血算法的前瞻性验证，以患者为中心的结局指标的采用，以及新兴技术的严格评估。

Abstract

Osteoporotic hip fractures represent a major and escalating public health burden in aging populations, carrying substantial morbidity, mortality, and healthcare costs. Perioperative anemia is exceedingly common in this frail cohort, with reported preoperative prevalence ranging from 40% to over 50%, and is an established independent predictor of adverse short- and long-term outcomes including mortality, impaired functional recovery, postoperative delirium, and prolonged hospitalization. The management of anemia and the judicious use of allogeneic blood transfusion are central to the multidisciplinary care of these patients. This narrative review provides a comprehensive and critical appraisal of the contemporary evidence governing perioperative anemia management in elderly osteoporotic hip fracture patients, drawing on randomized controlled trials, meta-analyses, and large observational studies identified through searches of major bibliographic databases. We critically examine the epidemiology and multifactorial etiology of perioperative anemia; the evolution of transfusion-risk prediction from traditional clinical indices to machine learning; pharmacological blood conservation, with robust evidence for tranexamic acid and intravenous iron; the debate between restrictive and liberal transfusion thresholds and the need for individualized, physiologically guided decision-making; the perioperative management of patients on antithrombotic therapy; and the influence of surgical technique, fracture type, and nutritional and frailty status. Several practical messages emerge: a restrictive transfusion strategy (hemoglobin 7-8 g/dL) is appropriate for most patients but should be individualized, favoring a more liberal approach in frail, cardiovascularly vulnerable, or delirium-prone patients and nursing-home residents; early and intraoperative tranexamic acid and intravenous iron meaningfully reduce transfusion requirements; surgery should generally not be delayed solely because of antithrombotic medication; and care is best delivered through a multimodal, stepwise Patient Blood Management approach embedded within integrated orthogeriatric care pathways. Priorities for future research include the prospective validation of individualized, physiologically guided transfusion algorithms, the adoption of patient-centered outcome measures, and the rigorous evaluation of emerging technologies.

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