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Lin Y, Levinson W, Day D, Lett R, Petraszko T, Huynh T, Patey AM. Using Blood Wisely: lessons learnt in establishing a national implementation programme to reduce inappropriate red blood cell transfusion. BMJ Open Qual 2024; 13:e002660. [PMID: 38569664 PMCID: PMC11002408 DOI: 10.1136/bmjoq-2023-002660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/17/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Up to 50% of blood is transfused inappropriately despite best evidence. In 2020, Choosing Wisely Canada launched a major national programme, 'Using Blood Wisely', the aim was to engage hospitals to audit their red blood cell transfusion use against national benchmarks and participate in a programme to decrease inappropriate use. STUDY DESIGN Using Blood Wisely is a quality improvement programme including national benchmarks, an audit tool, recommended evidence-based effective interventions and a designation to reward success. Hospital engagement was measured using the number of hospitals signing up, performing a baseline audit, submitting the planning survey, entering two or more audits and achieving hospital designation. Barriers to implementation were collected. RESULTS From 1 September 2020 to 31 December 2022, 229 individual hospitals signed up over time to participate. Their results are reported as 159 hospitals and hospital groups. Collectively, this accounts for 72% of the blood used in Canada. Overall, 147 (92%) performed a baseline audit, 10 (6%) submitted a planning survey and 130 (82%) entered two or more audits. At baseline (time of enrolment), 75 (51%) met both benchmarks. The designation was awarded to 62 (39%) hospital groups (a total of 105 individual hospitals) that met and sustained benchmarks. Barriers to implementation included human resource shortages, lack of local expertise to advise the team, need for more education of transfusion prescribers and competing priorities. CONCLUSION In its initial phase, Using Blood Wisely engaged a substantial number of hospitals in transfusion quality improvement work and maintained that engagement. This large-scale engagement across a big country was more successful than anticipated. Additional efforts are needed to rigorously evaluate the programme's impact on utilisation.
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Affiliation(s)
- Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Wendy Levinson
- Choosing Wisely Canada, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Doreen Day
- Choosing Wisely Canada, Toronto, Ontario, Canada
| | - Ryan Lett
- Department of Anesthesiology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Tanya Petraszko
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Tai Huynh
- Choosing Wisely Canada, Toronto, Ontario, Canada
| | - Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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2
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Czempik PF, Wilczek D, Herzyk J, Krzych ŁJ. Appropriateness of Allogeneic Red Blood Cell Transfusions in Non-Bleeding Patients in a Large Teaching Hospital: A Retrospective Study. J Clin Med 2023; 12:jcm12041293. [PMID: 36835829 PMCID: PMC9963308 DOI: 10.3390/jcm12041293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
In hemodynamically stable patients, both anemia and red blood cell (RBC) transfusion may be detrimental to patients; hence, a decision regarding RBC transfusion should be based on thorough risk-benefit assessment. According to hematology and transfusion medicine organizations, RBC transfusion is indicated when recommended hemoglobin (Hb) triggers are met, and symptoms of anemia are present. The aim of our study was to examine the appropriateness of RBC transfusions in non-bleeding patients at our institution. We performed a retrospective analysis of all RBC transfusions performed between January 2022 and July 2022. The appropriateness of RBC transfusion was based on the most recent Association for the Advancement of Blood and Biotherapies (AABB) guidelines and some additional criteria. The overall incidence of RBC transfusions at our institution was 10.2 per 1000 patient-days. There were 216 (26.1%) RBC units appropriately transfused and 612 (73.9%) RBC units that were transfused with no clear indications. The incidence of appropriate and inappropriate RBC transfusions were 2.6 and 7.5 per 1000 patient-days, respectively. The most frequent clinical situations when RBC transfusion was classified as appropriate were: Hb < 70 g/L plus cognitive problems/headache/dizziness (10.1%), Hb < 60 g/L (5.4%), and Hb < 70 g/L plus dyspnea despite oxygen therapy (4.3%). The most frequent causes of inappropriate RBC transfusions were: no Hb determination pre-RBC transfusion (n = 317) and, among these, RBC transfused as a second unit in a single-transfusion episode (n = 260); absence of anemia sings/symptoms pre-transfusion (n = 179); and Hb concentration ≥80 g/L (n = 80). Although the incidence of RBC transfusions in non-bleeding inpatients in our study was generally low, the majority of RBC transfusions were performed outside recommended indications. Red blood cell transfusions were evaluated as inappropriate mainly due to multiple-unit transfusion episodes, absence of anemia signs and/or symptoms pre- transfusion, and liberal transfusion triggers. There is still the need to educate physicians on appropriate indications for RBC transfusion in non-bleeding patients.
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Affiliation(s)
- Piotr F. Czempik
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
- Transfusion Committee, University Clinical Center, Medical University of Silesia, 40-752 Katowice, Poland
- Correspondence: ; Tel.: +48-32-789-42-01
| | - Dawid Wilczek
- Students’ Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Jan Herzyk
- Students’ Scientific Society, Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Łukasz J. Krzych
- Department of Anaesthesiology and Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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Hamilton CM, Davenport DL, Bernard AC. Demonstration of a U.S. nationwide reduction in transfusion in general surgery and a review of published transfusion reduction methodologies. Transfusion 2021; 61:3119-3128. [PMID: 34595745 DOI: 10.1111/trf.16677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/24/2021] [Accepted: 08/04/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell transfusions in surgical procedures can be lifesaving. However, recent studies show transfusions are associated with a dose-dependent increase in postoperative morbidity and mortality; hospitals and physicians have attempted to reduce them. We sought to determine the success of these efforts and review and summarize published reduction methods employed. STUDY DESIGN/METHODS An analysis of transfusion data from ACS-NSQIP public use files of general surgical procedures for 2012 and 2018; a retrospective review of the literature surrounding general surgical transfusion reduction from 2008 to 2018. RESULTS The rate of general surgical transfusion in the NSQIP dataset decreased from 5.5% in 2012 to 4.0% in 2018, a 27% relative reduction in transfusion. After extensive multivariable adjustment for patient risk and operative complexity, this effect remained (Odds ratio 0.65, 95% CI 0.63-0.67, p < .001). Furthermore, there was a positive correlation between specific procedure decreases in transfusion and decreases in 30-day morbidity (rho =0.41, p = .003) and mortality (rho = 0.37, p = .007). There were 866 published studies matching our search term "red blood cell transfusion reduction." Forty-four were relevant to general surgery. Seven dominant strategies for transfusion reduction by descending frequency of report included restrictive transfusion thresholds, management of preoperative anemia, perioperative interventions, educational programs, electronic clinical decision support, waste reduction, and audits of transfusion practices. CONCLUSION Our study demonstrates a 27% decrease in general surgery transfusion between 2012 and 2018 with associated reductions in morbidity and mortality, suggesting published employed strategies have been successful and safely implemented.
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Affiliation(s)
| | | | - Andrew C Bernard
- Department of Surgery, University of Kentucky, Lexington, Kentucky, USA
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Roubinian NH, Murphy EL, Mark DG, Triulzi DJ, Carson JL, Lee C, Kipnis P, Kleinman S, Liu VX, Escobar GJ. Long-Term Outcomes Among Patients Discharged From the Hospital With Moderate Anemia: A Retrospective Cohort Study. Ann Intern Med 2019; 170:81-89. [PMID: 30557414 PMCID: PMC6639156 DOI: 10.7326/m17-3253] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Randomized clinical trial findings support decreased red blood cell (RBC) transfusion and short-term tolerance of in-hospital anemia. However, long-term outcomes related to changes in transfusion practice have not been described. OBJECTIVE To describe the prevalence of anemia at and after hospital discharge and associated morbidity and mortality events. DESIGN Retrospective cohort study. SETTING Integrated health care delivery system with 21 hospitals serving 4 million members. PARTICIPANTS 445 371 surviving adults who had 801 261 hospitalizations between January 2010 and December 2014. MEASUREMENTS Hemoglobin levels and RBC transfusion, rehospitalization, and mortality events within 6 months of hospital discharge. Generalized estimating equations were used to examine trends over time, accounting for correlated observations and patient-level covariates. RESULTS From 2010 to 2014, the prevalence of moderate anemia (hemoglobin levels between 7 and 10 g/dL) at hospital discharge increased from 20% to 25% (P < 0.001) and RBC transfusion declined by 28% (39.8 to 28.5 RBC units per 1000 patients; P < 0.001). The proportion of patients whose moderate anemia had resolved within 6 months of hospital discharge decreased from 42% to 34% (P < 0.001), and RBC transfusion and rehospitalization within 6 months of hospital discharge decreased from 19% to 17% and 37% to 33%, respectively (P < 0.001 for both). During this period, the adjusted 6-month mortality rate decreased from 16.1% to 15.6% (P = 0.004) in patients with moderate anemia, in parallel with that of all others. LIMITATION Possible unmeasured confounding. CONCLUSION Anemia after hospitalization increased in parallel with decreased RBC transfusion. This increase was not accompanied by a rise in subsequent RBC use, rehospitalization, or mortality within 6 months of hospital discharge. Longitudinal analyses support the safety of practice recommendations to limit RBC transfusion and tolerate anemia during and after hospitalization. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Nareg H Roubinian
- Kaiser Permanente Northern California, Oakland, and Blood Systems Research Institute and University of California, San Francisco, San Francisco, California (N.H.R.)
| | - Edward L Murphy
- Blood Systems Research Institute and University of California, San Francisco, San Francisco, California (E.L.M.)
| | - Dustin G Mark
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Darrell J Triulzi
- Institute for Transfusion Medicine, Pittsburgh, Pennsylvania (D.J.T.)
| | - Jeffrey L Carson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (J.L.C.)
| | - Catherine Lee
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Patricia Kipnis
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Steven Kleinman
- University of British Columbia, Victoria, British Columbia, Canada (S.K.)
| | - Vincent X Liu
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
| | - Gabriel J Escobar
- Kaiser Permanente Northern California, Oakland, California (D.G.M., C.L., P.K., V.X.L., G.J.E.)
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Qiang JK, Thompson T, Callum J, Pinkerton P, Lin Y. Variations in RBC and frozen plasma utilization rates across 62 Ontario community hospitals. Transfusion 2018; 59:545-554. [DOI: 10.1111/trf.15070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 09/29/2018] [Accepted: 09/30/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Judy K. Qiang
- Division of General Internal Medicine, Department of MedicineUniversity of Toronto Toronto Ontario Canada
| | - Troy Thompson
- Ontario Regional Blood Coordinating Network Toronto Ontario Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences Centre Toronto Ontario Canada
- Department of Laboratory Medicine and PathobiologyUniversity of Toronto Toronto Ontario Canada
| | - Peter Pinkerton
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences Centre Toronto Ontario Canada
- Department of Laboratory Medicine and PathobiologyUniversity of Toronto Toronto Ontario Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Molecular DiagnosticsSunnybrook Health Sciences Centre Toronto Ontario Canada
- Department of Laboratory Medicine and PathobiologyUniversity of Toronto Toronto Ontario Canada
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6
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Nixon CP, Sweeney JD. Severe iron deficiency anemia: red blood cell transfusion or intravenous iron? Transfusion 2018; 58:1824-1826. [PMID: 30198610 PMCID: PMC7465692 DOI: 10.1111/trf.14819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Christian P Nixon
- Center for International Health Research Rhode Island Hospital and Alpert Medical School of Brown University Providence, Rhode, Island
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
| | - Joseph D Sweeney
- Department of Transfusion Medicine, Rhode Island Hospital and The Miriam Hospitals Alpert Medical School of Brown University, Providence, Rhode, Island
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7
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Benites BD, Addas‐Carvalho M. Implementing a patient blood management programme in Brazil: challenges and implications for developing countries. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/voxs.12433] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- B. D. Benites
- Hematology and Transfusion Medicine Center University of Campinas Campinas Brazil
| | - M. Addas‐Carvalho
- Hematology and Transfusion Medicine Center University of Campinas Campinas Brazil
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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9
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Khadadah F, Callum J, Shelton D, Lin Y. Improving quality of care for patients with iron deficiency anemia presenting to the emergency department. Transfusion 2018; 58:1902-1908. [PMID: 29664169 DOI: 10.1111/trf.14626] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/06/2018] [Accepted: 03/06/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients presenting to the emergency department (ED) with iron deficiency anemia (IDA) are underrecognized, undertreated with iron, and overtransfused. A 3-month audit of red blood cell (RBC) transfusions at the Sunnybrook Health Sciences Centre ED in 2013 showed that only 53% of transfusions for IDA were appropriate. The aim of this quality improvement project was to increase the rate of appropriate transfusion to greater than 80%. STUDY DESIGN AND METHODS Since November 2013, several quality improvement interventions have been implemented, including educational presentations, development of an algorithm on IDA management in the ED, and development of an ED IDA toolkit. The primary outcome was appropriateness of RBC transfusions per month. The process measure was monthly intravenous (IV) iron use in IDA patients managed exclusively by ED staff. Balancing measures included IV iron use according to the algorithm and undertransfusion. RESULTS Over a 24-month period beginning January 2014, assessment of 193 units transfused in the ED showed an improvement of RBC appropriateness to 91% (range 50%-100%). IV iron use increased from one dose in the 3-month audit to an average of 2.6 and 4.7 per month in 2014 and 2015, respectively. IV iron use did not follow the algorithm in 19% (18 of 93) of cases: 12 were given to patients with less severe iron deficiency or bleeding. CONCLUSION Improved RBC transfusion appropriateness for IDA in the ED can be achieved and maintained with the implementation of simple educational and practical interventions.
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Affiliation(s)
| | - Jeannie Callum
- Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, and Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada
| | - Dominick Shelton
- Department of Emergency Medicine, Sunnybrook Health Sciences Centre, and University of Toronto, Toronto, Canada
| | - Yulia Lin
- Department of Laboratory Medicine & Molecular Diagnostics, Sunnybrook Health Sciences Centre, and Department of Laboratory Medicine & Pathobiology, University of Toronto, Toronto, Canada
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10
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Voorn VMA, van Bodegom-Vos L, So-Osman C. Towards a systematic approach for (de)implementation of patient blood management strategies. Transfus Med 2018; 28:158-167. [PMID: 29508467 DOI: 10.1111/tme.12520] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.
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Affiliation(s)
- V M A Voorn
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.,Department of Orthopaedic Surgery, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - L van Bodegom-Vos
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - C So-Osman
- Unit Transfusion Medicine, Sanquin, Leiden, The Netherlands.,Department of Internal Medicine, Groene Hart Hospital, Gouda, The Netherlands
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11
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Ellingson KD, Sapiano MRP, Haass KA, Savinkina AA, Baker ML, Chung KW, Henry RA, Berger JJ, Kuehnert MJ, Basavaraju SV. Continued decline in blood collection and transfusion in the United States-2015. Transfusion 2017; 57 Suppl 2:1588-1598. [PMID: 28591469 DOI: 10.1111/trf.14165] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/10/2017] [Accepted: 04/10/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND In 2011 and 2013, the National Blood Collection and Utilization Survey (NBCUS) revealed declines in blood collection and transfusion in the United States. The objective of this study was to describe blood services in 2015. STUDY DESIGN AND METHODS The 2015 NBCUS was distributed to all US blood collection centers, all hospitals performing at least 1000 surgeries annually, and a 40% random sample of hospitals performing 100 to 999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, deferred, distributed, transfused, and outdated. RESULTS Response rates for the 2015 NBCUS were 78.4% for blood collection centers and 73.9% for transfusing hospitals. In 2015, 12,591,000 units of red blood cells (RBCs) (95% confidence interval [CI], 11,985,000-13,197,000 units of RBCs) were collected, and 11,349,000 (95% CI, 10,592,000-11,747,000) were transfused, representing declines since 2013 of 11.6% and 13.9%, respectively. Total platelet units distributed (2,436,000; 95% CI, 2,230,000-2,642,000) and transfused (1,983,000; 95% CI, 1,816,000 = 2,151,000) declined by 0.5% and 13.1%, respectively, since 2013. Plasma distributions (3,714,000; 95% CI, 3,306,000-4,121,000) and transfusions (2,727,000; 95% CI, 2,594,000-2,859,000) in 2015 declined since 2013. The median price paid per unit in 2015-$211 for leukocyte-reduced RBCs, $524 for apheresis platelets, and $54 for fresh frozen plasma-was less for all components than in 2013. CONCLUSIONS The 2015 NBCUS findings suggest that continued declines in demand for blood products resulted in fewer units collected and distributed Maintaining a blood inventory sufficient to meet routine and emergent demands will require further monitoring and understanding of these trends.
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Affiliation(s)
- Katherine D Ellingson
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,The University of Arizona College of Public Health, Tucson, Arizona
| | - Mathew R P Sapiano
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,Surveillance Branch, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kathryn A Haass
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Alexandra A Savinkina
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Misha L Baker
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia.,Northrop Grumman Corporation, New York, New York
| | - Koo-Whang Chung
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Richard A Henry
- Office of HIV/AIDS and Infectious Disease Policy, Office of the Assistant Secretary for Health, US Department of Health & Human Services, Washington, DC
| | - James J Berger
- Office of HIV/AIDS and Infectious Disease Policy, Office of the Assistant Secretary for Health, US Department of Health & Human Services, Washington, DC
| | - Matthew J Kuehnert
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sridhar V Basavaraju
- Office of Blood, Organ, and Other Tissue Safety, Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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12
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Nixon CP, Tavares MF, Sweeney JD. How do we reduce plasma transfusion in Rhode Island? Transfusion 2017; 57:1863-1873. [PMID: 28681548 DOI: 10.1111/trf.14223] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Plasma transfusions are given to patients with coagulopathy, either prophylactically, before an invasive procedure; or therapeutically, in the presence of active bleeding; and as an exchange fluid in therapeutic plasma exchange for disorders such as thrombotic thrombocytopenic purpura. There is consensus that many prophylactic plasma transfusions are non-efficacious, and the misdiagnosis of thrombotic thrombocytopenic purpura results in unnecessary therapeutic plasma exchange. STUDY DESIGN AND METHODS Beginning in 2001, programs to reduce plasma transfusion in the three major teaching hospitals in Rhode Island were initiated. The programs evolved through the establishment of guidelines, education for key prescribers of plasma, screening of plasma prescriptions, and engagement of individual prescribing physicians for out-of-guidelines prescriptions with modification or cancellation. Establishment of an in-house ADAMTS13 (ADAM metallopeptidase with thrombospondin type 1, motif 13) assay in 2013 was used to prevent therapeutic plasma exchange in patients with non-thrombotic thrombocytopenic purpura microangiopathy. Transfusion service data were gathered at the hospital level regarding blood component use, hospital data for discharges, inpatient mortality, and mean case-mix index, and, at the state level, for units of plasma shipped from the community blood center to in-state hospitals. RESULTS Between 2006 and 2016, a reduction in plasma use from 11,805 to 2677 units (a 77% decrease) was observed in the three hospitals and was mirrored in the state as a whole. This decline was not associated with any increase in red blood cell transfusion. Inpatient mortality either declined or was unchanged. CONCLUSION An active program focused on education and interdiction can achieve a large decrease in plasma transfusions without evidence of patient harm.
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Affiliation(s)
- Christian P Nixon
- Transfusion Service, Rhode Island Hospital, Providence, Rhode Island.,Transfusion Service, The Miriam Hospital, Providence, Rhode Island
| | - Maria F Tavares
- Blood Bank, Roger Williams Hospital, Providence, Rhode Island
| | - Joseph D Sweeney
- Transfusion Service, Rhode Island Hospital, Providence, Rhode Island.,Transfusion Service, The Miriam Hospital, Providence, Rhode Island.,Blood Bank, Roger Williams Hospital, Providence, Rhode Island
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13
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Bosch X, Montori E, Guerra-García M, Costa-Rodríguez J, Quintanilla MH, Tolosa-Chapasian PE, Moreno P, Guasch N, López-Soto A. Haemoglobin responses to transfusion in severe iron deficiency anaemia: potential impact of gastrointestinal disorders. Vox Sang 2017; 112:257-267. [PMID: 28198025 DOI: 10.1111/vox.12491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/19/2016] [Accepted: 12/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Red blood cell (RBC) transfusion may be justified in iron deficiency anaemia (IDA) when an increase in oxygen delivery is needed, as sometimes occurs in subjects with haemoglobin <8·0 mg/dL, serious comorbidities or at risk of cardiovascular instability. Earlier investigations showed that some patients with severe IDA requiring transfusion had lower than expected post-transfusion haemoglobin levels with poorer clinical outcomes than other patients. After hypothesizing that haemoglobin responses to transfusion were different and that the underlying gastrointestinal (GI) disorders causing IDA could be a confounder explaining this association, these responses were analysed in a prospective cohort of IDA adults referred for outpatient GI investigation. MATERIALS AND METHODS Transfused patients with proven IDA, baseline haemoglobin at referral <9·0 g/dL and no extraintestinal bleeding were eligible. To assess a homogeneous population, only GI disorders known to cause occult bleeding were considered. Haemoglobin increments per 100 mL of RBCs were investigated. RESULTS In total, 2818 patients were enrolled over 10·5 years. On multivariable regression, diffuse angiodysplasias and GI cancer independently predicted for reduced increments in post-transfusion haemoglobin [adjusted regression coefficients: -0·082 (95% confidence interval, -0·093 to -0·072) and -0·073 (95% confidence interval, -0·081 to -0·066), respectively, P < 0·001 in both]. Haemoglobin responses in the remaining bleeding disorders were adequate and agreed with the principle that one RBC unit increases the haemoglobin an average of 1 g/dL. CONCLUSION The potential differential impact of GI disorders on changes in haemoglobin levels after RBC transfusion could be useful for transfusing physicians, especially for diagnostic purposes.
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Affiliation(s)
- X Bosch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain.,Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - E Montori
- Quick Diagnosis Unit, Department of Internal Medicine, Hospital Plató, Barcelona, Spain
| | - M Guerra-García
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - M H Quintanilla
- Department of Internal Medicine, Hospital San Roque, Gonnet, La Plata, Argentina
| | | | - P Moreno
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - N Guasch
- Quick Diagnosis Unit, Adult Day Care Center, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - A López-Soto
- Department of Internal Medicine, Hospital Clínic, University of Barcelona, Barcelona, Spain
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14
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Effectiveness of Provider Education Followed by Computerized Provider Order Entry Alerts in Reducing Inappropriate Red Blood Cell Transfusion. JOURNAL OF BLOOD TRANSFUSION 2016; 2016:2859720. [PMID: 28050312 PMCID: PMC5165151 DOI: 10.1155/2016/2859720] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/15/2016] [Indexed: 01/28/2023]
Abstract
To reduce the rate of inappropriate red blood cell transfusion, a provider education program, followed by alerts in the computerized provider order entry system (CPOE), was established to encourage AABB transfusion guidelines. Metrics were established for nonemergent inpatient transfusions. Service lines with high order volume were targeted with formal education regarding AABB 2012 transfusion guidelines. Transfusion orders were reviewed in real time with email communications sent to ordering providers falling outside of AABB recommendations. After 12 months of provider education, alerts were activated in CPOE. With provider education alone, the incidence of pretransfusion hemoglobin levels greater than 8 g/dL decreased from 16.64% to 6.36%, posttransfusion hemoglobin levels greater than 10 g/dL from 14.03% to 3.78%, and number of nonemergent two-unit red blood cell orders from 45.26% to 22.66%. Red blood cell utilization decreased by 13%. No additional significant reduction in nonemergent two-unit orders was observed with CPOE alerts. Provider education, an effective and low-cost method, should be considered as a first-line method for reducing inappropriate red blood cell transfusion rates in stable adult inpatients. Alerts in the computerized order entry system did not significantly lower the percentage of two-unit red blood cells orders but may help to maintain educational efforts.
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15
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Lin Y, Cserti-Gazdewich C, Lieberman L, Pendergrast J, Rammler W, Skinner I, Callum J. Improving transfusion practice with guidelines and prospective auditing by medical laboratory technologists. Transfusion 2016; 56:2903-2905. [DOI: 10.1111/trf.13848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 06/27/2016] [Accepted: 07/29/2016] [Indexed: 01/09/2023]
Affiliation(s)
- Yulia Lin
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
| | - Christine Cserti-Gazdewich
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine; University Health Network; Toronto ON Canada
| | - Lani Lieberman
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine; University Health Network; Toronto ON Canada
| | - Jacob Pendergrast
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
- Department of Laboratory Medicine; University Health Network; Toronto ON Canada
| | - Wendy Rammler
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
| | - Irene Skinner
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
| | - Jeannie Callum
- Department of Laboratory Medicine; Lakeridge Health; Oshawa ON Canada
- Department of Clinical Pathology; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Department of Laboratory Medicine and Pathobiology; University of Toronto; Toronto ON Canada
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16
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Covello TPC, Quinn JG, Kumar-Misir A, Watson S, Almohammadi M, Crocker BD, Conrad DM, Tennankore K, Sadek I, Kahwash E, Cheng CK. Assessing the efficacy of a single-unit red blood cell transfusion policy at a multisite transfusion service using a computerized retrospective audit. ACTA ACUST UNITED AC 2016. [DOI: 10.1111/voxs.12288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- T. P. C. Covello
- Faculty of Medicine and Dentistry; University of Alberta; Edmonton AB Canada
| | - J. G. Quinn
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - A. Kumar-Misir
- Pathology Informatics Group; Central Zone; Nova Scotia Health Authority; Halifax NS Canada
| | - S. Watson
- Pathology Informatics Group; Central Zone; Nova Scotia Health Authority; Halifax NS Canada
| | - M. Almohammadi
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - B. D. Crocker
- Pathology Informatics Group; Central Zone; Nova Scotia Health Authority; Halifax NS Canada
| | - D. M. Conrad
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - K. Tennankore
- Division of Nephrology; Department of Medicine; Dalhousie University; Halifax NS Canadaa
| | - I. Sadek
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - E. Kahwash
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
| | - C. K. Cheng
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; Dalhousie University; Halifax NS Canada
- Pathology Informatics Group; Central Zone; Nova Scotia Health Authority; Halifax NS Canada
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17
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van Gammeren AJ, Haneveer MMC, Slappendel R. Reduction of red blood cell transfusions by implementation of a concise pretransfusion checklist. Transfus Med 2016; 26:99-103. [PMID: 26748760 DOI: 10.1111/tme.12273] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 12/16/2015] [Accepted: 12/16/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy. OBJECTIVES To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm. METHODS To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre- and post-implementation period of 1 year. RESULTS Transfusion requests decreased by 17·0%. The proportion of 1-unit and 2-unit transfusions decreased by 5·6% and 29·2%, respectively, corresponding with a total red blood cell units reduction of 22·6% and a yearly direct local cost reduction of 190·000 €. The median length of stay of transfused patients on wards decreased by 1·07 days (P < 0·05). Average pre- and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0·32-0·35 g L(-1) (P < 0·05) for one unit red blood cell transfusions and 0·72-0·87 g L(-1) (P < 0·05) for two units of red blood cell transfusions. CONCLUSION Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.
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Affiliation(s)
- A J van Gammeren
- Department of Clinical Chemistry and Haematology, Amphia Hospital, Breda, the Netherlands
| | - M M C Haneveer
- Department of Clinical Chemistry and Haematology, Amphia Hospital, Breda, the Netherlands
| | - R Slappendel
- Department of Quality and Safety, Amphia Hospital, Breda, the Netherlands
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18
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Delobel J, Garraud O, Barelli S, Lefrère JJ, Prudent M, Lion N, Tissot JD. Storage lesion: History and perspectives. World J Hematol 2015; 4:54-68. [DOI: 10.5315/wjh.v4.i4.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 09/01/2015] [Accepted: 10/19/2015] [Indexed: 02/05/2023] Open
Abstract
Red blood cell concentrates (RBCCs) are the major labile blood component transfused worldwide to rescue severe anemia symptoms. RBCCs are frequently stored in additive solutions at 4 °C for up to 42 d, which induces cellular lesion and alters red blood cell metabolism, protein content, and rheological properties. There exists a hot debate surrounding the impact of storage lesion, with some uncertainty regarding how RBCC age may impact transfusion-related adverse clinical outcomes. Several studies show a tendency for poorer outcomes to occur in patients receiving older blood products; however, no clear significant association has yet been demonstrated. Some age-related RBCC alterations prove reversible, while other changes are irreversible following protein oxidation. It is likely that any irreversible damage affects the blood component quality and thus the transfusion efficiency. The present paper aims to promote a better understanding of the occurrence of red blood cell storage lesion, with particular focus on biochemical changes and microvesiculation, through a discussion of the historical advancement of blood transfusion processes.
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