[Transfusion management]

Contemporary transfusion medicine is based on the application of correct indication, volume and regiment of therapy with blood components and plasma preparations according to individual needs and clinical condition of each patient. The goal is to achieve maximally efficient transfusion therapy, rational usage of donor blood, prolonged possibility for blood conservation and decrease of the risk for side effects, complications and infections during the blood transfusion. The new tendency in transfusion therapy is applied in protocols and methodological manuals which give the guidelines, therapeutical algorithms for good medical practice. An example of such manual is the one given by the Council of Europe, which is issued annually and is corrected by wide number of specialists.

Finding alternatives to blood transfusion

Here, you'll find out how to reduce your patient's need for donated blood and discover what's new in the search for an artificial blood substitute.

[Haemoglobin levels and transfusion practice among Norwegian anesthesiologists]

BACKGROUND

Blood transfusions can be lifesaving, but definite transfusion triggers for different clinical situations need to be determined.

MATERIAL AND METHODS

We carried out a survey among Norwegian anaesthesiologists regarding haemoglobin levels and transfusion triggers during surgery and in an intensive care setting. Blood conservation techniques were also explored. The results for surgical patients were compared with those from a similar survey in 1996.

RESULTS

Compared with 1996, Norwegian anaesthesiologists now accept significantly lower transfusion triggers for surgical patients. Acceptable haemoglobin levels varied in the different patient examples in both the surgical and intensive care groups. With regard to surgery, junior doctors accept a lower transfusion trigger than do senior anaesthesiologists. A more liberal transfusion strategy is apparently used in patients with coronary disease.

INTERPRETATION

Norwegian anaesthesiologists have changed their attitude to acceptable transfusion triggers over the 1996-2002 period. In an intensive care setting, they appear to have a more liberal transfusion policy compared to anaesthesiologists in other western European countries.

Live donor liver transplantation without blood products: strategies developed for Jehovah's Witnesses offer broad application

OBJECTIVE

Developing strategies for transfusion-free live donor liver transplantation in Jehovah's Witness patients.

SUMMARY BACKGROUND DATA

Liver transplantation is the standard of care for patients with end-stage liver disease. A disproportionate increase in transplant candidates and an allocation policy restructuring, favoring patients with advanced disease, have led to longer waiting time and increased medical acuity for transplant recipients. Consequently, Jehovah's Witness patients, who refuse blood product transfusion, are usually excluded from liver transplantation. We combined blood augmentation and conservation practices with live donor liver transplantation (LDLT) to accomplish successful LDLT in Jehovah's Witness patients without blood products. Our algorithm provides broad possibilities for blood conservation for all surgical patients.

METHODS

From September 1998 until June 2001, 38 LDLTs were performed at Keck USC School of Medicine: 8 in Jehovah's Witness patients (transfusion-free group) and 30 in non-Jehovah's Witness patients (transfusion-eligible group). All transfusion-free patients underwent preoperative blood augmentation with erythropoietin, intraoperative cell salvage, and acute normovolemic hemodilution. These techniques were used in only 7%, 80%, and 10%, respectively, in transfusion-eligible patients. Perioperative clinical data and outcomes were retrospectively reviewed. Data from both groups were statistically analyzed.

RESULTS

Preoperative liver disease severity was similar in both groups; however, transfusion-free patients had significantly higher hematocrit levels following erythropoietin augmentation. Operative time, blood loss, and postoperative hematocrits were similar in both groups. No blood products were used in transfusion-free patients while 80% of transfusion-eligible patients received a median of 4.5+/- 3.5 units of packed red cell. ICU and total hospital stay were similar in both groups. The survival rate was 100% in transfusion-free patients and 90% in transfusion-eligible patients.

CONCLUSIONS

Timely LDLT can be done successfully without blood product transfusion in selected patients. Preoperative preparation, intraoperative cell salvage, and acute normovolemic hemodilution are essential. These techniques may be widely applied to all patients for several surgical procedures. Chronic blood product shortages, as well as the known and unknown risk of blood products, should serve as the driving force for development of transfusion-free technology.

Geographic location of commercial plasma donation clinics in the United States, 1980-1995

OBJECTIVE

We examined the location of commercial plasma donation centers in the United States over the period 1980 to 1995 relative to the geographic distribution of risk behaviors associated with transfusion-transmissible infections.

METHODS

The census tract locations of commercial source plasma clinics were described by measures of neighborhood social disadvantage and the prevalence of illicit drug use and active local drug economies.

RESULTS

Depending on the measure of social environment used, commercial plasma clinics were 5 to 8 times more likely to be located in census tracts designated high-risk than would be expected by chance.

CONCLUSIONS

Commercial source plasma clinics were overrepresented in neighborhoods with very active local drug economies. These patterns persisted after the links between human immunodeficiency virus and hepatitis C virus infections and plasma products had been established and may present risks to blood system safety.

[Problems of hemotransfusion from the evidence-based medicine point of view]

The operational analysis of hospital is conducted on blood transfusion for 5 years. For this time the main parameters of activity were improved and the quantity of blood transfusions has decreased The parameters of activity have not worsened. The number of AIDS--carriers was considerably increased, high there is still the level of a morbidity by hepatitis B and hepatitis C. Presently blood transfusion is equated to transplantation of an organs. From the attitude of evidential medicine it is necessary to prune the number of blood transfusions. The complications of a blood transfusion have been analyzed. The alternate methods of treatment are induced.

Current status of transfusion triggers for red blood cell concentrates

Clinical practice guidelines on red blood cell transfusion (RBC) are based on expert opinion, animal studies and the few human trials available. Twelve randomized controlled trials on the benefits of RBC transfusions in humans have been published. In the absence of definitive outcome studies, numerous theoretical arguments have been put forward in favor or against the classic transfusion threshold of 100 g/l. However, data from randomized controlled trials suggest that overall morbidity (including cardiac) and mortality, hemodynamic, pulmonary and oxygen transport variables are not different between restrictive (transfusion threshold between 70 and 80 g/l) and liberal transfusion strategies and that a restrictive transfusion strategy is not associated with increased adverse outcomes. In fact, a restrictive strategy may be associated with decreased adverse outcomes in younger and less sick critical care patients. The majority of existing guidelines conclude that transfusion is rarely indicated when the hemoglobin concentration is greater than 100 g/l and is almost always indicated when it falls below a threshold of 60 g/l in healthy, stable patients or more in older, sicker patients. In anesthetized patients, this threshold should be modulated by factors related to the dynamic nature of surgery such as uncontrolled hemorrhage, microvascular bleeding, etc. Another important role of RBC relates to primary hemostasis and higher triggers may be appropriate in coagulopathic patients. RBC concentrates are administered to correct inadequate oxygen delivery and/or to sustain primary hemostasis. Reliable monitors of tissue oxygenation and hemostasis will be required to study the benefits (or lack thereof) of RBC transfusions. The quest for a universal transfusion trigger, i.e., one that would be applicable to patients of all ages under all circumstances, must be abandoned. All RBC transfusions must be tailored to the patient's needs, at the moment the need arises. In conclusion published recommendations are commensurate with existing knowledge and, unfortunately, their conclusions are limited. Future research and development should focus on the determination of optimal transfusion strategies in various patient populations and on reliable monitors to guide transfusion therapy.

[Blood transfusion safety: current progress]

For the past ten years, a real improvement in knowledge and methods concerning blood transfusion safety has been made. In this observation, concerning a polytraumatism patient who received massive blood transfusion with no immunologic nor infectious complications occurring one year later, brings evidence of real progress on blood transfusion safety for improvement in short and long term prognosis for polytransfused patients.

Alternatives to blood in the 21st century

Persons who suffer traumatic injury are likely to be transfused with considerable amounts of blood during initial resuscitation efforts. Oxygen-carrying solutions are currently in clinical testing as substitutes for red blood cells. Although these agents may eliminate many concerns associated with blood administration (short shelf life, infectious and immunologic risks, the need to type and cross-match), early cell-free hemoglobin solutions demonstrated nephrotoxicity and were associated with pulmonary and systemic hypertension, among other adverse events. Newer polymerized hemoglobin solutions show acceptable safety profiles in the surgical setting and studies are being designed, some with funding from the US Department of Defense, to evaluate their efficacy in hemorrhaging trauma victims.

Blood on tap. Part 1. History in the making

Emergency services around the United States are about to become part of the front lines in the race to bring to market the first blood substitute with oxygen-carrying capabilities. Take a look inside the high-tech world of biopharmaceuticals and the innovative pioneers who are chasing after a scientific holy grail; a synthetic substitute for blood. In the process, they have made and lost fortunes, advanced our understanding of the nature of blood and launched one of the biggest ethical controversies in modern medical history. As phase three clinical trials move to the prehospital arena, biotechnology firms are staking everything on the notion that they're about to change the way we treat trauma patients. They may be right.

Human blood groups: inheritance and importance in transfusion medicine

Human blood group antigens are unique, inherited polymorphisms on the extracellular surface of red blood cells. They have been used as genetically discrete markers of human polymorphism since the discovery of the ABO system in 1900. Since then, many blood group antigens have been identified, the genes cloned, and their biological significance elucidated. Blood group antigens and antibodies play an important role in Transfusion Medicine. In addition, blood groups have provided anthropologists with a tool to study polymorphism in the different peoples across the world and provided geneticists with inherited markers to understand complex mechanisms of linkage and disease inheritance.

Cancer-related anemia

Anemia is the most common hematological abnormality in cancer patients, unfortunately, it is often under-recognized and under-treated. The pathogenesis of cancer anemia is complex and most of the time multifactorial; involving factors related to the tumor itself or its therapy. While anemia can present in a wide range of symptoms, involving almost every organ, it is believed that it contributes much to cancer-related fatigue, one of the most common symptoms in cancer patients. In addition, there is increasing evidence to suggest that anemia is an independent factor adversely affecting tumor response and patient survival. While blood transfusion was the only option to treat cancer-related anemia, the use of recombinant human erythropoietin (rHuEPO) is becoming the new standard of care, more so with the recent studies demonstrating the feasibility of a single weekly injection. Things are even getting better with the recent approval of a new form of rHuEPO; Darbepoetin, an analogue with a 3-fold longer half-life. In addition to its effect in raising hemoglobin, several well-controlled studies demonstrated decrease in transfusion requirements and better quality of life assessed objectively using standard assessments scales.

Criteria for transfusion in severe postpartum hemorrhage: analysis of practice and risk factors

OBJECTIVE

To analyze the accuracy of postpartum hemorrhage risk factors to determine patients at risk of severe postpartum hemorrhage and transfusion.

POPULATION AND METHODS

Retrospective cohort study from a database in one high-risk obstetric unit over a 7-year period.

RESULTS

In a cohort of 19,204 deliveries, 44 patients were transfused of whom five were given frozen fresh plasma only. Of the 39 who received red blood cells, 35 received at least three units. Multivariate analysis of postpartum hemorrhage risk factors revealed a significant role of placenta previa/accreta, cesarean section, multiple pregnancy, prematurity and vascular disease. Nevertheless 28% of women transfused had none of these risk factors.

CONCLUSION

The percentage of patients transfused has probably decreased markedly with improved prevention, surveillance and treatment. This study emphasizes that the transfusion risk in the presence of anomalous placental insertion justifies special obstetrical and anesthetic management.

[Update on transfusion practice among anesthesiologists and its impact on the surgical patient]

OBJECTIVE

To determine the effectiveness of a new educational program on transfusion practice, directed to the staff of an anesthesia and postoperative recovery service, by evaluating its impact on intraoperative transfusion (IOT).

MATERIAL AND METHODS

We reviewed the incidence of IOT during the first semesters of 1996 and 2001 for general, urologic, otolaryngologic, maxillofacial, thoracic, and vascular surgery. Other factors such as sex, age, type of intervention, emergency status, duration of operation, and use of blood products were also taken into consideration.

RESULTS

A statistically significant overall reduction in IOT occurred between 1996 (4.9%) and 2001 (3.6%). The decrease in transfusions (a reduction of 18.8% in transfused patients) was even greater in general surgery and urology, particularly in scheduled surgery (4.1% in 1996 vs 2.6% in 2001). However, the total use of packed red blood cells did not change inasmuch as the number of units per patient was higher in 2001 (2.8 units/patient) than in 1996 (2.4 units/patient). In emergency surgery, the IOT rate increased from 7.6% in 1996 to 8.1% in 2001. We also noticed a higher rate of multiple transfusions (defined as the use of 5 or more units of packed red blood cells during surgery) in 2001.

CONCLUSION

The introduction of an educational program directed to anesthesiologists has been useful for reducing IOT, although the overall use of blood products has not decreased.

Pathogen reduction technology: methods, status of clinical trials, and future prospects

Transfusion-transmitted infections caused by viruses, bacteria, and protozoa have been extensively reported for the past three decades. In the early 1980s, the HIV epidemic heightened the focus on transfusion safety and demonstrated the potential for new pathogens to enter the donor population and rapidly spread through the transfusion of blood components. The foundation for the prevention of transfusion-transmitted infections has been donor screening and testing, and significant advances have been made to reduce the risk of transfusion-associated infection. However, despite these efforts, transfusion-transmitted infections continue to be reported, and new infectious agents, such as the West Nile virus, continue to enter the donor population with transmission to recipients. For the past decade, several technologies to inactivate infectious pathogens that may contaminate donor blood have been developed and several of these methods have been introduced into clinical practice. These technologies offer the potential for a paradigm shift to further improve the safety of blood transfusion.

The economic benefit of organizational restructuring of the cardiothoracic intensive care unit

OBJECTIVES

Compare cost/benefits of organizational restructuring of the cardiac intensive care unit (CICU).

DESIGN

Prospective, with a retrospective control period.

SETTING

Academic medical center.

PARTICIPANTS

Sixty-six CICU patients (prospective) and 57 patients who received care before restructuring (retrospective) were compared. Entrance criteria were constant for both study periods.

INTERVENTIONS

The CICU was restructured from a level III ICU to a level I ICU with the initiation of a consultant CICU service. The CICU service provided an attending physician dedicated to ICU care daily. All cardiac patients admitted into the CICU received consultation by the CICU service.

MEASUREMENTS AND MAIN RESULTS

The average postoperative intubation time decreased during the intervention period (61% extubated within 6 hours v 12%, p = 0.004). Pharmacy, radiology, laboratory, and ICU costs decreased 279 US dollars (p = 0.004), 196 US dollars (p = 0.003), 190 US dollars (p = 0.15), and 470 US dollars (p = 0.12), respectively. The ICU length of stay (0.28 days shorter) as well as the overall postsurgery stay (0.54 days shorter) were reduced in the intervention period (p = 0.11 and 0.10, respectively).

CONCLUSIONS

The CICU service significantly reduced both total ICU-related costs ($1,173/patient) and overall costs (2,285 US dollars/patient) during the intervention period. Professional fees only reduced overall savings by 8%. These results indicate that organizational restructuring of the CICU to newer models can reduce costs associated with cardiac surgery.