Transfundir salva vidas? Não necessariamente. Transfusão sanguínea é medida tomada em excesso

Coleta de sangue de doador. Foto: MartinD/ Commons Licensed

“Condutas e Tecnologias para Realizar Cirurgias de Grande Porte sem Transfusão de Sangue” é o tema da palestra, no 8º AnestEdu, do Dr. Enis Donizetti Silva, coordenador da Residência Médica em Anestesia e do Serviço de Anestesia da Sociedade Beneficente de Senhoras do Hospital Sírio Libanês

Inscreva-se no simpósio! Ainda dá tempo!

Cirurgias com restrição de transfusão sanguínea deixaram de ser um tabu religioso e passaram a ser uma situação à qual é preciso se adequar. Segundo a Joint Commission Accreditation, metade das transfusões de sangue é desnecessária e causa prejuízos de saúde aos pacientes e financeiros às instituições de saúde. Os autores do estudo publicado pelo The Joint Commission Journal on Quality and Patient Safety afirmam que “O custo e os riscos das transfusões de hemácias, além das evidências de uso excessivo das transfusões, demonstram que aprimorar as práticas de transfusão sanguínea é uma oportunidade chave para os sistemas de saúde melhorarem tanto a qualidade quanto o valor do atendimento ao paciente”.

“Transfundir significa salvar vidas? Não”, afirmou o Dr. Enis Donizetti Silva, coordenador da Residência Médica em Anestesia e do Serviço de Anestesia da Sociedade Beneficente de Senhoras do Hospital Sírio Libanês, em aula sobre assunto, em março de 2015, quando era presidente da Sociedade de Anestesiologia do Estado de São Paulo. Segundo ele, evidências demonstram que medidas restritivas em relação à transfusão de sangue têm resultado mais benéfico ao paciente do que as terapias liberais. E indicar uma transfusão de sangue pode ser o mesmo que indicar um transplante, ou seja, um transplante de sangue. “É um transplante de células. Indicamos transplante a torto e a direito? Não, temos critérios muito bem definidos para indicar um transplante de órgãos como rim, fígado, coração, pulmão, e talvez devêssemos utilizar os mesmos critérios em relação à transfusão”, disse ele durante a aula.

O Dr. Donizetti Silva trará ao 8º AnestEdu a palestra “Condutas e Tecnologias para Realizar Cirurgias de Grande Porte sem Transfusão de Sangue”, no Simpósio de Inovação de Gestão em Anestesiologia: Soluções para a Segurança do Paciente com Resultados para as Organizações de Saúde, em 12 de maio, às 15h10. Inscreva-se aqui!

Transfusão de sangue e desfecho

Para o Dr. Enis Donizetti Silva, pode estar havendo uma carência na educação sobre transfusão sanguínea. Em sua mencionada aula, ele disse: “Quantas horas os programas de residência em anestesia, terapia intensiva, cirurgia, cirurgia do trauma reservam, em seus três, quatro, cinco anos, a temas específicos relacionados ao tema transfusão de sangue? Muito pouco. Se a informação é menor, fico acreditando no passado, acredito sempre que transfundir salva vidas”.

Ele explicou que a transfusão tem sido utilizada na medicina moderna há mais de cem anos, acreditando-se que, em pacientes anêmicos, poderia melhorar os resultados clínicos. Mas essa tese nunca foi plenamente investigada ou provada e pode não ser necessariamente verdade.

Na década de 1980 e durante muito tempo, acreditava-se também que transfundir tinha um efeito benéfico do ponto de vista imunológico, ideia que, contou o Dr. Donizetti Silva, veio da observação dos pacientes de transplante de rim. Segundo ele, geralmente sendo pacientes anêmicos, antes da cirurgia, esses pacientes eram transfundidos com uma até três unidades, e observava-se que esses pacientes tinham uma recidiva menor de perda do enxerto. “A verdade é que o sistema HLA do doador competia com o do receptor, com o rim novo que estava chegando. É como se o sistema imunológico tivesse que trabalhar para o novo sangue e não para o novo rim. Repito: quando fazemos uma transfusão, não estamos fazendo um transplante? É como se fizéssemos um mecanismo, passando dois órgãos com o segundo órgão gerando uma resposta imunológica do receptor muito menor. Então, por muito tempo, acreditamos que valia a pena transfundir porque melhorava a imunologia. Hoje sabemos que não, porque quanto mais transfundo, mais infecção, mais recidiva tumoral, mais metástases.”

O Dr. Donizetti Silva afirma que o desfecho é um dos pontos importantes quando se discute Medicina, portanto, é preciso saber o que vai ocorrer com o paciente daqui a um ano, cinco anos e em diante. E quando pacientes transfundidos são analisados depois de três, cinco, 10 anos, verifica-se a incidência muito maior de complicações associadas à transfusão.

Dados brasileiros sobre transfusão sanguínea (2014)*

  • O número de transfusões é crescente.
  • Não há protocolos específicos.
  • O monitoramento é ineficaz.
  • Não há dados de custo-efetividade.
  • A partir de sete dias na UTI, mais de 50% dos pacientes serão submetidos a uma transfusão.
  • A partir de duas semanas na UTI, quase 90% dos pacientes serão submetidos a uma transfusão.

*Fonte: Risco e Segurança do Paciente (FSP, 2016)

 

Veja também no site da WMC Anestesia: Transfusão de sangue – Estamos indicando transfusão… qual a indicação mesmo?

“Não é mais aceitável que a gente recomende transfundir usando ‘Ah, eu julguei que precisa’. Não: você tem de estar baseado em evidências, não é apenas uma conjectura.”

Dra. Ludhmila Abrahão Hajjar, coordenadora da UTI cirúrgica do InCor e do Icesp, coordenadora das UTIs cardiológica e da Insuficiência Cardíaca do Hospital Sírio-Libanês e professora da Faculdade de Medicina da USP.

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