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Shander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, Kor DJ, Faraoni D, Freedman J. A Global Definition of Patient Blood Management. Anesth Analg 2022; 135:476-488. [PMID: 35147598 DOI: 10.1213/ane.0000000000005873] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations, from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, and iatrogenic blood losses, managing coagulopathic bleeding throughout the care and supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey
| | - Jean-Francois Hardy
- Department of Anaesthesiology and Pain Medicine, Université de Montréal, Montréal, Quebec, Canada.,Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France
| | - Sherri Ozawa
- Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey.,Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Health, Englewood, New Jersey
| | - Shannon L Farmer
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,The Western Australia Patient Blood Management Group, The University of Western Australia, Perth, Western Australia, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Johns Hopkins Health System Patient Blood Management Program, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Michigan.,Patient Blood Management Program, Mayo Clinic, Rochester, Michigan
| | - David Faraoni
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France.,Department of Anesthesiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - John Freedman
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Ontario, Canada.,The Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Okorie CO, Pisters LL. Evolution of Bloodless Surgery: A Case for Bloodless Suprapubic Prostatectomy. Niger Med J 2019; 60:169-174. [PMID: 31831934 PMCID: PMC6892331 DOI: 10.4103/nmj.nmj_121_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 11/04/2022] Open
Abstract
Allogeneic blood transfusion is commonly prescribed to patients undergoing suprapubic prostatectomy for benign prostatic hyperplasia as a treatment option to replace blood loss. Historically, suprapubic prostatectomy has been perceived as an extremely high hemorrhagic surgery, and this has led to the association of suprapubic prostatectomy with a high rate of allogeneic blood transfusion. However, the outcome of suprapubic prostatectomy has significantly improved over the years and has become less hemorrhagic in many hands - creating the opportunity to consistently avoid allogeneic blood transfusion. On the other hand, the efficacy of blood transfusion has come under more stringent scrutiny as many clinical studies have reported inconsistent effects of blood transfusion on patient outcome. In contemporary practice, a more conservative/bloodless approach in the perioperative management of anemia in surgical patients is strongly being advocated with convincing evidence that many surgical patients can be routinely and safely managed without allogeneic blood transfusion. There is no large-scale discussion on bloodless surgery in urology in the contemporary literature, especially in the area of suprapubic prostatectomy that has been historically associated with a high rate of blood transfusion. This review article will discuss the evolution of bloodless surgery including the ongoing controversies surrounding blood transfusion in general, and then the relatively small but ongoing penetration of bloodless surgical approach in the field of suprapubic prostatectomy. Furthermore, the authors' approach to bloodless suprapubic prostatectomy will be highlighted, and in doing so, it can be emphasized that suprapubic prostatectomy is no more as hemorrhagic as was historically perceived, but rather a routine bloodless suprapubic prostatectomy is now possible in many hands.
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Affiliation(s)
- Chukwudi Ogonnaya Okorie
- Department of Surgery, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Louis L. Pisters
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Obirikorang Y, Obirikorang C, Anto EO, Acheampong E, Batu EN, Macaulary F, Paavire CK, Amankwaa B. Knowledge of bloodless medicine among nurses at the Medical/Surgical Directorate of Komfo Anokye Teaching Hospital, Ghana; a descriptive cross sectional study. BMC Res Notes 2017; 10:747. [PMID: 29258567 PMCID: PMC5735550 DOI: 10.1186/s13104-017-3094-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 12/13/2017] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE This study assessed the knowledge of bloodless medicine (BM) among nurses at the medical and surgical directorate of Komfo Anokye Teaching Hospital. A paper questionnaire was administered to 322 nurses to obtain information on socio-demographic characteristics and knowledge of BM. RESULTS More than half (52.1%) of the nurses were aware of BM. The major source of information on BM was from the internet. Out of the study population, 90.1% knew iron therapy as BM strategy. The largest proportions of the participants (51.2%) had witnessed BM treatment at the medical and surgical directorate with the Tot'hema (44.6%) being the major used drug. Flu-like symptoms (37.0%) and organ damage (50.0%) were the commonly known side effects of BM respectively. Most of the participants (97.5%) knew that doctors request for blood transfusion. The major known reason for demand of BM was religious beliefs (53.7%). Higher percentages (71.9%) of the participants were not aware of bloodless surgery although the few who were aware, had heard of this through an internet search. Participants were generally aware of BM but less knowledgeable of specific components of BM. There is the need for prompt hospital and public health education through workshops and in-service training.
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Affiliation(s)
- Yaa Obirikorang
- Department of Nursing, Faculty of Health and Allied Sciences, Garden City University College (GCUC), Kenyasi, Kumasi, Ghana
| | - Christian Obirikorang
- Department of Molecular Medicine, School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
| | - Enoch Odame Anto
- Department of Molecular Medicine, School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana.,Department of Medical Laboratory Technology, Royal Ann College of Health, Atwima Manhyia, Kumasi, Ghana
| | - Emmanuel Acheampong
- Department of Molecular Medicine, School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana.
| | - Emmanuella Nsenbah Batu
- Department of Nursing, Faculty of Health and Allied Sciences, Garden City University College (GCUC), Kenyasi, Kumasi, Ghana
| | - Flora Macaulary
- Department of Nursing, Faculty of Health and Allied Sciences, Garden City University College (GCUC), Kenyasi, Kumasi, Ghana
| | - Christopher Kwaku Paavire
- Department of Nursing, Faculty of Health and Allied Sciences, Garden City University College (GCUC), Kenyasi, Kumasi, Ghana
| | - Bright Amankwaa
- Department of Molecular Medicine, School of Medical Science, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi, Ghana
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Epinephrine Injection in Greater Palatine Canal: An Alternative Technique for Reducing Hemorrhage During Septoplasty. J Craniofac Surg 2017; 27:548-51. [PMID: 27159854 DOI: 10.1097/scs.0000000000002413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Obtaining adequate hemostasis during otolaryngology operations is necessary because a small amount of blood can be problematic and obscure the visual field. The authors aimed to compare the efficacy of combined greater palatine canal (GPC) and transnasal injection of lidocaine + epinephrine to transnasal injection alone in patients who underwent septoplasty. METHODS Patients with nasal septum deviation who were eligible for surgical correction of deviations were enrolled. Transnasal injections of 2 mL of 1% lidocaine + epinephrine 1:100,000 were performed in both groups and for patients in the combination group the same solution was also injected in the GPC. Objective (amount of suctioned blood) and subjective (intraoperative bleeding score) assessments were done during operation. Close hemodynamic monitoring was performed for all patients. RESULTS A total of 50 patients were enrolled and randomly allocated to study groups. No significant differences were observed in systolic and diastolic blood pressure, heart rate, and mean arterial pressure of study subjects between 2 groups. The amount of bleeding in patients who received GPC injection and their counterparts in the other arm of the trial were 34.64 ± 26.66 and 100.48 ± 20.90 mL, respectively (P < 0.001). The mean intraoperative bleeding score in combination group was 0.79 ± 0.42 and significantly lower than the corresponding figure in monotherapy group, which was 1.75 ± 0.41 (P < 0.001). CONCLUSIONS Based on the findings of the current study, the authors suggest that combined GPC and transnasal injection of lidocaine and epinephrine is a safe and effective method for reducing bleeding during septoplasty.
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Kisilevsky AE, Stobart L, Roland K, Flexman AM. Optimization and outcomes of patients who decline blood transfusion during complex spine surgery: a retrospective cohort study. Can J Anaesth 2016; 63:1108-9. [PMID: 27324893 DOI: 10.1007/s12630-016-0683-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/25/2016] [Accepted: 06/10/2016] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alexandra E Kisilevsky
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Liam Stobart
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Kristine Roland
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alana M Flexman
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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Abstract
A small group of people belonging to a certain religion, called Jehovah's witness do not accept blood transfusion or blood products, based on biblical readings. When such group of people are in need of health care, their faith and belief is an obstacle for their proper treatment, and poses legal, ethical and medical challenges for attending health care provider. Due to the rapid growth in the membership of this group worldwide, physicians attending hospitals should be prepared to manage such patients. Appropriate management of such patients entails understanding of ethical and legal issues involved, providing meticulous medical management, use of prohaemostatic agents, essential interventions and techniques to reduce blood loss and hence, reduce the risk of subsequent need for blood transfusion. An extensive literature search was performed using search engines such as Google scholar, PubMed, MEDLINE, science journals and textbooks using keywords like ‘Jehovah's witness’, ‘blood haemodilution’, ‘blood salvage’ and ‘blood substitutes’.
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Affiliation(s)
- N Kiran Chand
- Department of Anaesthesiology and Critical Care, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India
| | - H Bala Subramanya
- Department of Anaesthesiology and Critical Care, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India
| | - G Venkateswara Rao
- Department of Anaesthesiology and Critical Care, Vijayanagara Institute of Medical Sciences, Bellary, Karnataka, India
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Gombotz H, Hofmann A. [Patient Blood Management : three pillar strategy to improve outcome through avoidance of allogeneic blood products]. Anaesthesist 2014; 62:519-27. [PMID: 23836145 DOI: 10.1007/s00101-013-2199-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Blood transfusions are commonly viewed as life-saving interventions; however, current evidence shows that blood transfusions are associated with a significant increase of morbidity and mortality in a dose-dependent relationship. Not only explanatory models of basic research but also the results from randomized controlled trials suggest a causal relationship between blood transfusion and adverse outcome. Therefore, it can be claimed that the current state of science debunks the long held belief in the so-called life-saving blood transfusion by exposing the potential for promoting disease and death. Adherence to the precautionary principle and also the fact that blood transfusions are more costly than previously assumed require novel approaches in the treatment of anemia and bleeding. Patient Blood Management (PBM) allows transfusion rates to be dramatically reduced through correcting anemia by stimulating erythropoiesis, minimization of perioperative blood loss and harnessing and optimizing the physiological tolerance of anemia. A resolution of the World Health Assembly has endorsed PBM and therefore morbidity and mortality should be significantly reduced by lowering of the currently high blood utilization rate of allogeneic blood products in Austria, Germany and Switzerland.
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Affiliation(s)
- H Gombotz
- Abteilung für Anästhesiologie und Intensivmedizin, Allgemeines Krankenhaus der Stadt Linz, Krankenhausstr. 9, 4020, Linz, Österreich.
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Digieri LA, Pistelli IP, de Carvalho CE. The care of a child with multiple trauma and severe anemia who was a Jehovah's Witness. Hematology 2013; 11:187-91. [PMID: 17325960 DOI: 10.1080/10245330600774942] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Jehovah's Witness followers do not accept blood derived transfusions and available methods for avoiding transfusion have been used with degrees of success, demonstrating that the probability of death after trauma in these patients may not be significantly different from religious groups. In this report, we describe the case of a child victim of a multiple trauma with severe anemia due to blood loss, whose family would not authorize blood transfusion because of their Jehovah's Witness faith. We discuss the current indications for restricting transfusion, as well as highlighting new tools that contribute to the success of minimizing blood loss, thus avoiding transfusion.
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Affiliation(s)
- Luciana Andrea Digieri
- Intensive Care Unit, Pediatric Department, Faculty of Medical Sciences, Santa Casa de São Paulo, Rua Cesário Mota Júnior, 112-CEP 01221-020, São Paulo, Brazil.
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Lee J, Kim Y, Park C, Jeon Y, Kim D, Joo J, Kang H. Comparison between Dexmedetomidine and Remifentanil for Controlled Hypotension and Recovery in Endoscopic Sinus Surgery. Ann Otol Rhinol Laryngol 2013; 122:421-6. [DOI: 10.1177/000348941312200702] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: We compared the efficacy of dexmedetomidine and remifentanil hydrochloride in intraoperative field conditions and recovery during endoscopic sinus surgery. Methods: Sixty-six patients (American Society of Anesthesiologists physical status I and II) scheduled for elective endoscopic sinus surgery were enrolled in this prospective, double-blinded, randomized study. The patients were randomly assigned to two groups. Propofol, 2 to 2.5 mg/kg, was administered to both groups to induce anesthesia, which was maintained with desflurane. One group received dexmedetomidine 1 μg/kg over 10 minutes at anesthesia induction, followed by 0.4 to 0.8 μg/kg per hour infusion during maintenance, whereas the other group received remifentanil 1 μg/kg over 1 minute at anesthesia induction, followed by 0.2 to 0.4 μg/kg per minute infusion during maintenance. Surgical conditions, hemodynamic parameters, intraoperative blood loss, time to extubation, sedation, and pain in the postanesthesia care unit (PACU) were recorded. Results: There were no significant differences between the two groups with respect to surgical field conditions, blood loss, or extubation time. The sedation score (Modified Observer's Assessment of Alertness/Sedation) in the PACU was significantly lower in the dexmedetomidine group than in the remifentanil group (p < 0.001). No differences were found in total blood loss, surgical field conditions, hemodynamic parameters, time to extubation, or pain in the PACU when the two groups were compared (p > 0.05). Conclusions: Although remifentanil and dexmedetomidine both enabled hypotensive anesthesia and good intraoperative fields for endoscopic sinus surgery, recovery was faster with remifentanil than with dexmedetomidine in the immediate postoperative period.
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Jo KI, Shin JW. Can maximum surgical blood order schedule be used as a predictor of successful completion of bloodless surgery? Ann Lab Med 2013; 33:116-20. [PMID: 23482941 PMCID: PMC3589636 DOI: 10.3343/alm.2013.33.2.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/16/2012] [Accepted: 12/05/2012] [Indexed: 11/19/2022] Open
Abstract
Background The Soonchunhyang University Hospital Bloodless Center was established in 2000, and more than 2,000 bloodless surgeries have been performed there since. In this study, the lowest postoperative Hb/preoperative Hb (Hblow/pre) ratio and mortality rates of patients who underwent bloodless surgery were analyzed for each maximum surgical blood order schedule (MSBOS) category to assess whether MSBOS can be used as a predictor of successful completion of bloodless surgery. Methods A total of 971 patients were included. MSBOS was defined as the average number of units of RBCs transfused during each elective surgery. We used the Hblow/pre ratio as an alternative to intraoperative blood loss. Frequency of Hblow/pre ratios ≤0.5, use of transfusion alternatives, and mortality rates were compared across MSBOS categories. Results Out of the 971 patients, 701 (72.2%) were categorized as type and screen (T&S), 184 (18.9%) as MSBOS 1, 64 (6.6%) as MSBOS 2, and 22 (2.3%) as MSBOS 4. Transfusion alternatives were used by 397 (40.9%) patients. The frequency of the use of simultaneous erythropoietin and iron, hemostatics, acute normovolemic hemodilution, and Cell Saver (Haemonetics corp., USA) was higher in patients in the higher MSBOS categories. Six (0.6%) patients died within 30 days of surgery. Hblow/pre ratios tended to be lower as the level of MSBOS category increased. Conclusions Surgeries in the higher MSBOS categories tended to be associated with high blood loss and mortality. Active use of transfusion alternatives is recommended in patients in high MSBOS categories who are scheduled to undergo bloodless surgery.
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Affiliation(s)
- Kyung Il Jo
- Department of Laboratory Medicine, Soonchunhyang University Hospital, Seoul, Korea
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Jo KI, Shin JW, Choi TY, Park YJ, Youm W, Kim MJ. Eight-year experience of bloodless surgery at a tertiary care hospital in Korea. Transfusion 2012; 53:948-54. [DOI: 10.1111/j.1537-2995.2012.03859.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Vamvakas EC. Reasons for moving toward a patient-centric paradigm of clinical transfusion medicine practice. Transfusion 2012; 53:888-901. [DOI: 10.1111/j.1537-2995.2012.03825.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Simou M, Thomakos N, Zagouri F, Vlysmas A, Akrivos N, Zacharakis D, Papadimitriou CA, Dimopoulos MA, Rodolakis A, Antsaklis A. Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes. World J Surg Oncol 2011; 9:142. [PMID: 22051161 PMCID: PMC3225312 DOI: 10.1186/1477-7819-9-142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 11/03/2011] [Indexed: 11/29/2022] Open
Abstract
This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques.
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Affiliation(s)
- Maria Simou
- Department of Obstetrics and Gynecology, Alexandra Hospital, School of Medicine, University of Athens, Greece
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. II. The intra-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:189-217. [PMID: 21527082 PMCID: PMC3096863 DOI: 10.2450/2011.0075-10] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Five Drivers Shifting the Paradigm from Product‐Focused Transfusion Practice to Patient Blood Management. Oncologist 2011; 16 Suppl 3:3-11. [DOI: 10.1634/theoncologist.2011-s3-3] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. I. The pre-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:19-40. [PMID: 21235852 PMCID: PMC3021395 DOI: 10.2450/2010.0074-10] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Giancarlo Maria Liumbruno
- Units of Immunohaematology, Transfusion Medicine and Clinical Pathology, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
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Madrazo González Z, García Barrasa A, Rafecas Renau A. Anemia, hierro, transfusión y alternativas terapéuticas. Revisión desde una perspectiva quirúrgica. Cir Esp 2010; 88:358-68. [DOI: 10.1016/j.ciresp.2010.03.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 11/27/2009] [Accepted: 03/12/2010] [Indexed: 12/31/2022]
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Abstract
This review examines the science and methodology of blood conservation in modern anaesthetic and surgical practice. Blood transfusion is associated with increased morbidity and mortality in all surgical patients, and the reduction or even elimination of transfusion has been and continues to be the subject of much research. Blood substitutes, despite extensive investigation, have not been proved successful in trials to date, and none have entered clinical practice. Pharmacological treatments include antifibrinolytic drugs (although aprotinin is no longer in clinical use), recombinant factor VIIa, desmopressin, erythropoietin and topical haemostatic agents, and the role of each of these is discussed. Autologous blood transfusion has recently fallen in popularity; however, cell salvage is almost ubiquitous in its use throughout Europe. Anaesthetic and surgical techniques may also be refined to improve blood conservation. Blood transfusion guidelines and protocols are strongly recommended, and repetitive audit and education are instrumental in reducing blood transfusion.
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Nagarsheth NP, Sasan F. Bloodless Surgery in Gynecologic Oncology. ACTA ACUST UNITED AC 2009; 76:589-97. [DOI: 10.1002/msj.20146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Thomson A, Farmer S, Hofmann A, Isbister J, Shander A. Patient blood management - a new paradigm for transfusion medicine? ACTA ACUST UNITED AC 2009; 4:423-435. [PMID: 32328164 PMCID: PMC7169263 DOI: 10.1111/j.1751-2824.2009.01251.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropriate transfusion is still not sufficiently tangible for the public and many clinicians. This has to change. The medical, ethical, legal and economic evidence cannot be ignored. Patient blood management needs to be implemented as the standard of care for all patients.
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Affiliation(s)
- A Thomson
- Department of Haematology and Pathology North, Royal North Shore Hospital, Sydney & Australian Red Cross Blood Service, Sydney, NSW, Australia
| | - S Farmer
- Implementation Board, Western Australia Department of Health Patient Blood Management Program & Centre for Population Health Research, Curtin Health Innovation Research Institute (CHIRI), Curtin University, Perth WA, Australia
| | - A Hofmann
- Medical Society of Blood Management, Laxenburg, Austria
| | - J Isbister
- Department of Haematology, Royal North Shore Hospital, University of Sydney, Sydney, NSW, Australia
| | - A Shander
- Department of Anesthesiology, Critical Care Medicine Pain Management and Hyperbaric Medicine, Englewood Hospital and Medical Center, Englewood, NJ, Clinical Professor of Anesthesiology, Medicine and Surgery, Mt Sinai School of Medicine, New York, NY & Executive Medical Director, New Jersey Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, USA
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21
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Abstract
Bovine and human hemoglobin (bHb and hHb, respectively) was purified from bovine and human red blood cells via tangential flow filtration (TFF) in four successive stages. TFF is a fast and simple method to purify Hb from RBCs using filtration through hollow fiber (HF) membranes. Most of the Hb was retained in stage III (100 kDa HF membrane) and displayed methemoglobin levels less than 1%, yielding final concentrations of 318 and 300 mg/mL for bHb and hHb, respectively. Purified Hb exhibited much lower endotoxin levels than their respective RBCs. The purity of Hb was initially assessed via SDS-PAGE, and showed tiny impurity bands for the stage III retentate. The oxygen affinity (P(50)) and cooperativity coefficient (n) were regressed from the measured oxygen-RBC/Hb equilibrium curves of RBCs and purified Hb. These results suggest that TFF yielded oxygen affinities of bHb and hHb that are comparable to values in the literature. LC-MS was used to measure the molecular weight of the alpha (alpha) and beta (beta) globin chains of purified Hb. No impurity peaks were present in the HPLC chromatograms of purified Hb. The mass of the molecular ions corresponding to the alpha and beta globin chains agreed well with the calculated theoretical mass of the alpha- and beta- globin chains. Taken together, our results demonstrate that HPLC-grade Hb can be generated via TFF. In general, this method can be more broadly applied to purify Hb from any source of RBCs. This work is significant, since it outlines a simple method for generating Hb for synthesis and/or formulation of Hb-based oxygen carriers.
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Affiliation(s)
- Andre F Palmer
- Dept. of Chemical and Biomolecular Engineering, The Ohio State University, Columbus, OH 43210, USA.
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22
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Kanakaris NK, Petsatodis G, Chalidis B, Manidakis N, Kontakis G, Giannoudis PV. The role of erythropoietin in the acute phase of trauma management: evidence today. Injury 2009; 40:21-7. [PMID: 19117559 DOI: 10.1016/j.injury.2008.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 09/05/2008] [Accepted: 09/05/2008] [Indexed: 02/02/2023]
Abstract
Trauma patients often present in a state of haemorrhagic shock. Blood products remain the gold standard of resuscitation, but allogeneic blood transfusions (ABTs) are associated with several risks. The stimulating effect of recombinant-erythropoietin (EPO-A) on erythropoiesis has raised interest in its administration as an alternative. The existing evidence on the early use of EPO-A in the acute phase of trauma patients management consists of only 14 publications. The level of evidence of these studies and the number of treated patients was not found to be adequate to support its generalised use, despite their favourable results. Its safety profile, the preliminary proofs of its efficacy, and the additional cyto-protective properties of EPO-A strongly encourage further controlled studies assessing its use in the acute setting of initial trauma management.
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Affiliation(s)
- N K Kanakaris
- Academic Department of Trauma & Orthopaedics, Leeds Teaching Hospitals, Leeds, UK
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23
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Adelola OA, Ahmed I, Fenton JE. Management of Jehovah's Witnesses in otolaryngology, head and neck surgery. Am J Otolaryngol 2008; 29:270-8. [PMID: 18598840 DOI: 10.1016/j.amjoto.2007.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2006] [Revised: 08/09/2007] [Accepted: 08/20/2007] [Indexed: 12/19/2022]
Abstract
It is imperative that surgeons should have some knowledge and understanding of the beliefs of Jehovah's Witnesses to respect the patient's wishes and effectively minimize and manage blood loss. The objective of this review was to provide a management strategy for Jehovah's Witness patients undergoing otolaryngology, head and neck surgery, because there is paucity of information regarding this within our literature. A systematic review of medical literature was conducted. Articles were identified using MEDLINE (1966-2007). The search strategy used Medical Subject Heading terms Jehovah's Witnesses, Beliefs, Ethical and Legal issues, Blood transfusion alternatives, ENT, Head and Neck surgery in Jehovah' witnesses. There is a broad range of nonblood surgical management strategies available in other specialities, making major surgery possible within this population. This review suggests recommendations in elective surgery, trauma, and emergencies.
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25
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Abstract
Blood transfusions are common in the hospital setting. Despite the large commitment of resources to the delivery of blood components, many clinicians have only a vague understanding of the complexities associated with blood management and transfusion therapy. The purpose of this primer is to broaden the awareness of health care practitioners in terms of the risks versus benefits of blood transfusions, their economics, and alternative treatments. By developing and implementing comprehensive blood management programs, hospitals can promote safe and clinically effective blood utilization practices. The cornerstones of blood management programs are the implementation of evidence-based transfusion guidelines to reduce variability in transfusion practice, and the employment of multidisciplinary teams to study, implement, and monitor local blood management strategies. Pharmacists can play a key role in blood management programs by providing technical expertise as well as oversight and monitoring of pharmaceutical agents used to reduce the need for allogeneic blood.
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Affiliation(s)
- Bradley A Boucher
- Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Memphis, Tennessee 38163, USA
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26
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Abstract
Inherent risks and increasing costs of allogeneic transfusions underline the socioeconomic relevance of safe and effective alternatives to banked blood. The safety limits of a restrictive transfusion policy are given by a patient's individual tolerance of acute normovolaemic anaemia. latrogenic attempts to increase tolerance of anaemia are helpful in avoiding premature blood transfusions while at the same time maintaining adequate tissue oxygenation. Autologous transfusion techniques include preoperative autologous blood donation (PAD), acute normovolaemic haemodilution (ANH), and intraoperative cell salvage (ICS). The efficacy of PAD and ANH can be augmented by supplemental iron and/or erythropoietin. PAD is only cost-effective when based on a meticulous donation/transfusion plan calculated for the individual patient, and still carries the risk of mistransfusion (clerical error). In contrast, ANH has almost no risks and is more cost-effective. A significant reduction in allogeneic blood transfusions can also be achieved by ICS. Currently, some controversy regarding contraindications of ICS needs to be resolved. Artificial oxygen carriers based on perfluorocarbon (PFC) or haemoglobin (haemoglobin-based oxygen carriers, HBOCs) are attractive alternatives to allogeneic red blood cells. Nevertheless, to date no artificial oxygen carrier is available for routine clinical use, and further studies are needed to show the safety and efficacy of these substances.
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Affiliation(s)
- Andreas Pape
- Clinic of Anoesthesiology, Intensive Care Medicine and Pain Management, J. W. Goethe University Hospital Frankfurt am Main, Theodor Stern Kai 7, 60590 Frankfurt am Main, Germany.
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27
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Abstract
Hospital pharmacists are often consulted for their knowledge about coagulation and therapeutic interventions for the management of critical bleeding. Many pharmacotherapies are available for this purpose, both systemic and topical, and others are in development. These agents and their mechanisms of action are reviewed, and perspectives are provided regarding their use in various clinical settings. Also provided are associated precautions to promote safe use. Current controversies surrounding pharmacotherapeutic agents used to control serious bleeding (e.g., in various types of surgery, trauma, obstetrics, and intracranial hemorrhage) are also discussed.
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Affiliation(s)
- Stacy Voils
- School of Pharmacy, Virginia Commonwealth University, Medical College of Virginia Hospitals, Richmond, Virginia 23298, USA.
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28
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Abstract
PURPOSE The practice of blood conservation is aimed at improving patient outcomes by avoiding allogeneic transfusions via a coordinated multidisciplinary, multipronged approach. The numerous blood conservation techniques and transfusion alternatives now available are described. SUMMARY Ongoing concerns exist regarding the availability of the nation's and the world's blood supply. In addition, the number of measures required to ensure blood safety has led to increases in the price of blood and blood products over the past 10-15 years. Moreover, blood transfusion carries inherent risks even under the most favorable circumstances. Investigations have established that injudicious transfusion is associated with development of ventilator-associated pneumonia, nosocomial infection, and organ dysfunction. Because most single blood-conservation techniques reduce blood usage by a mere 1-2 units, a series of integrated conservation approaches are required. These include preoperative autologous donation, use of erythropoietic agents, blood conservation techniques such as acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. Erythropoietic agents such as epoetin alfa have been used successfully to increase hemoglobin and decrease transfusion requirements, and are appropriate when used in advance of elective surgical procedures. Acquisition costs of erythropoietic stimulating agents versus costs of blood justify economic evaluation by hospitals to make the most cost-effective choice under current economic constraints. CONCLUSION Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.
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Affiliation(s)
- David Jaspan
- Pharmacy Services, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001, USA.
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29
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Durmus M, But AK, Dogan Z, Yucel A, Miman MC, Ersoy MO. Effect of dexmedetomidine on bleeding during tympanoplasty or septorhinoplasty. Eur J Anaesthesiol 2007; 24:447-53. [PMID: 17241505 DOI: 10.1017/s0265021506002122] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE The aim of this study was to evaluate the efficacy of dexmedetomidine, an alpha(2)-adrenoceptor agonist, on intraoperative bleeding, anaesthetic drug requirement and postoperative pain. METHODS Forty patients scheduled for elective tympanoplasty and septorhinoplasty operations under general anaesthesia were included in the study. The patients were randomly assigned to receive either a dexmedetomidine 1 microg kg(-1) bolus 10 min before induction of anaesthesia plus 0.5 microg kg(-1) h(-1) infusions during maintenance or placebo. Mean arterial pressure was maintained between 60 and 80 mmHg. Perioperative mean arterial pressure, heart rate, time to extubation and time to awakening were recorded. Bleeding during surgery was assessed by the surgeon, blinded to the study drugs, both intraoperatively and postoperatively as a final personal opinion about the whole surgical process. RESULTS The heart rate and mean arterial pressure were significantly lower during induction, operation and extubation in the dexmedetomidine group (P < 0.05). Blood losses were lower in the dexmedetomidine group (P < 0.05). Propofol dose required for induction, and fentanyl and isoflurane consumption were significantly reduced in the dexmedetomidine group (P < 0.05). The total amounts of nitroglycerin and meperidine used were higher in the control group (P < 0.05). CONCLUSIONS Dexmedetomidine decreased bleeding, postoperative analgesic requirements and intraoperative anaesthetic requirements and was associated with more stable haemodynamic responses to anaesthesia. We conclude that dexmedetomidine is a useful adjuvant to decrease bleeding when a bloodless surgical field is requested.
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Affiliation(s)
- M Durmus
- Inonu University, School of Medicine, Department of Anaesthesiology, Malatya, Turkey.
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30
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Abstract
PURPOSE OF REVIEW To outline the rationale, limitations, and execution of bloodless medical and surgical programs, highlighting characteristics that contribute to successful outcomes. RECENT FINDINGS Clinical experiences with patients who refuse blood transfusions for religious reasons have provided valuable lessons and raise intriguing questions about the necessity of routine blood transfusions. Healthcare centers with bloodless medicine and surgery programs feature a novel concept of patient care aimed at improving outcomes. A one-tiered approach to minimize blood usage for all patients, regardless of religious beliefs, is being successfully adopted at an increasing number of institutions. Since most single blood-conservation techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative, and postoperative conservation approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. SUMMARY The objectives of bloodless medicine and surgery programs are straightforward but require staff with expertise in transfusion medicine, intensive teamwork, patient-specific customization, careful planning, and integrated use of multimodal strategies.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care and Hyperbaric Medicine, New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
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33
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Letter to the Editor. Dimens Crit Care Nurs 2005. [DOI: 10.1097/00003465-200505000-00012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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