Optimal Use Of Blood Products Research Articles

Comparison between Our Results in the Maturity Assessment Patient Blood Management (MAPBM) Project and Other 34 National Hospitals

INTRODUCTIONAllogeneic red blood cell (RBC) transfusions are vital and effective and effective to treat anemia. RBC transfusions increase hospitalizations in 2.5 days, risk of death in 1.7 times and risk of infection in 1.9 times. The cost of discharges from the hospital is 1.83 times higher and it represents 7.8% of the hospitalization total expenses. However, there is little awareness and knowledge about this transfusion practice, as well as an inexplicable and enormous inter-center variability.In attempt to reduce unnecessary transfusions and improve postoperative evolution, as well as to reduce hospital costs, “Patient Blood Management” (PBM) program has been developed, which includes hospital policies, procedures and protocols. In literature, evidence of PBM programs effectiveness is growing.METHODIn view of the need to evaluate these issues, the Maturity Assessment Patient Blood Management (MAPBM) project was constituted in 2014, which involves a group of clinical and management experts nationwide, with the participation of 35 Spanish hospitals (including our center since 2015). It evaluates and compares:•The knowledge of professionals about transfusion practice and PBM programs (anonymous survey). Figure 1.•The PBM process indicators of each participating center. Figure 2.•Inter-transfusion variability and factors related to transfusion in different procedures adjusted by age, sex and comorbidity. Figure 3We will analyze the results of our center comparing them with the rest of hospitals.RESULTSIn general, there is a high awareness of the indication and minimization of transfusions in different procedures, as well as a dissemination of our PBM programs above the average, especially the protocol of preoperative anemia (Figure 1).Despite this, the results of our circuit for the correction of preoperative anemia are unfavorable, since they are detected in a higher percentage than the rest of the centers, but they are not effectively treated in the studied procedures (Figure 2).Our strategies to minimize bleeding, both spinal anesthesia in orthopedic and traumatological surgeries and perioperative use of tranexamic acid are noteworthy, except in the cases of hip fracture surgeries, where its use was contraindicated by multidisciplinary consensus.Our transfusion threshold is close to the standard. In all the studied procedures, transfusion with Hb ≥ 8gr / dl is not considered.Regarding the results of transfusion and factors related to transfusion (Figure 3), a globally superior transfusion rate is observed, mainly at the expense of cardiac and open colorectal surgery.Regarding other items, our mortality and complications rates are, in general, unfavorable. However, hospitalizations and readmissions are lower.CONCLUSIONSAlthough the dissemination of our PBM strategies is adequate, its implementation has not meant an improvement in the transfusion rate of the procedures studied, being even higher than the expected rate.We assume that the lack of efficacy of the circuit for the correction of preoperative anemia is due to the intrinsic obstacles of our center. Among them:•Premature programming in some patients, especially the case of cardiovascular surgery, which determines that the time between the surgical indication and the preoperative visit, is very limited.•Lack of adequacy of the treatment at the date of intervention caused by lack of knowledge, especially in general surgery.•The rigid criteria for the delivery of carboxymaltose iron limit the inclusion of patients who are closer to the intervention date, or determine an insufficient dosage of iron sucrose.•Lack of diffusion of our program to different services when correcting postoperative anemia with iron.Strategies will be established by the Transfusion commission to solve the problems identified.As for the unfavorable results on transfusion practice (transfusion index, mortality and complications), it is essential to introduce improvements and update the optimal use of blood products by our professionals.This contradicts the results of the Transfusion Practice Survey. Therefore, we will take this data with caution, insisting on the awareness of adequate transfusion policies and PBM strategies, with the support of the hospital's management, and the dissemination of knowledge about these programs to achieve the commitment of the professionals involved. DisclosuresNo relevant conflicts of interest to declare.

Blood Transfusions in Major Pancreatic Surgery: A 10-Year Cohort Study Including 1404 Patients Undergoing Pancreatic Resections in Finland.

Despite guidelines on blood transfusion (TF) thresholds, there seems to be great variation in transfusion policies between hospitals and surgeons. In order to improve and unify blood transfusion policies, the Finnish Red Cross Blood Service carried out a project concerning the optimal use of blood products (Verivalmisteiden optimaalinen käyttö) between 2002 and 2011. In this study, we determined the blood transfusion trends in major pancreatic surgery in Finland. Initially, 1337 patients who underwent major pancreatic resections between 2002 and 2011 were classified into the TF+ or TF- groups. Centers were divided into high-, medium-, and low-volume centers. The blood transfusion trends and the trigger points for blood transfusions in these patients were determined. There were no differences between high-, medium- and low-volume centers in blood usage, trigger points or the use of reserved blood units after pancreatoduodenectomy or total pancreatectomy. However, the trigger points were lowered significantly during the study period at high-volume centers (p = 0.003), and a better use of reserved blood units was found in high- (p < 0.001) and medium-volume (p = 0.043) centers. In addition, a better use of reserved blood units was found in high-volume centers after distal pancreatectomy (p = 0.020). Although only minor changes in blood transfusion trends after pancreatoduodenectomy or total pancreatectomy were found generally, the lowering of the transfusion trigger point and the best use of reserved blood units during the study period occurred in high-volume centers.

Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry.

Critically bleeding patients requiring massive transfusion (MT) are clinically challenging, and limited data exist to support management decisions. This study describes patient characteristics, transfusion support and clinical outcomes from the Australian and New Zealand (NZ) Massive Transfusion Registry (ANZ-MTR). Retrospective, cohort study of all adult patients receiving MT (≥5 units red blood cells [RBC] in 4 h) at participating ANZ-MTR hospitals, 2011-2015. Mortality information was collected from the Australian National Death Index and NZ Ministry of Health. Associations between patient characteristics and outcomes were modelled using logistic regression. A total of 3560 MT cases were identified. For in-hospital deaths, cardiothoracic surgery was the most frequent bleeding context (24·5%) followed by trauma (18·3%). Age (OR = 1·03; 95% CI: 1·02-1·04), more comorbidities (OR = 1·14; 95% CI: 1·09-1·21), larger volume of RBC in first 24 h from MT onset (OR = 1·04; 95% CI: 1·02-1·06), higher platelet to RBC ratio at 4 h (OR = 2·76; 95% CI: 1·14-6·65) and higher activated partial thromboplastin time (OR = 1·02; 95% CI: 1·01-1·03) were associated with in-hospital mortality. Patients with more comorbidities, older age, traumatic or surgical bleeding or requiring more blood components had higher in-hospital mortality. These findings provide a basis to evaluate and monitor practice relating to optimal use of blood products, variation in transfusion practices and patient outcomes, and also enable benchmarking of hospital performance for management of MT in specific patient groups.

Curbing Inflammation in hemorrhagic trauma: a review.

Trauma is one of the world's leading causes of death within the first 40 years of life and thus a significant health problem. Trauma accounts for nearly a third of the lost years of productive life before 65 years of age and is associated with infection, hemorrhagic shock, reperfusion syndrome, and inflammation. The control of hemorrhage, coagulopathy, optimal use of blood products, balancing hypo and hyperperfusion, and hemostatic resuscitation improve survival in cases of trauma with massive hemorrhage. This review discusses inflammation in the context of trauma-associated hemorrhagic shock. When one considers the known immunomodulatory effects of traumatic injury, allogeneic blood transfusion, and the overlap between patient populations, it is surprising that so few studies have assessed their combined effects on immune function. We also discuss the relative benefits of curbing inflammation rather than attempting to prevent it.

Blood transfusion after percutaneous coronary intervention and risk of subsequent adverse outcomes: a systematic review and meta-analysis.

This study sought to define the prevalence and prognostic impact of blood transfusions in contemporary percutaneous coronary intervention (PCI) practice. Although the presence of anemia is associated with adverse outcomes in patients undergoing PCI, the optimal use of blood products in patients undergoing PCI remains controversial. A search of EMBASE and MEDLINE was conducted to identify PCI studies that evaluated blood transfusions and their association with major adverse cardiac events (MACE) and mortality. Two independent reviewers screened the studies for inclusion, and data were extracted from relevant studies. Random effects meta-analysis was used to estimate the risk of adverse outcomes with blood transfusions. Statistical heterogeneity was assessed by considering the I(2) statistic. Nineteen studies that included 2,258,711 patients with more than 54,000 transfusion events were identified (prevalence of blood transfusion 2.3%). Crude mortality rate was 6,435 of 50,979 (12.6%, 8 studies) in patients who received a blood transfusion and 27,061 of 2,266,111 (1.2%, 8 studies) in the remaining patients. Crude MACE rates were 17.4% (8,439 of 48,518) in patients who had a blood transfusion and 3.1% (68,062 of 2,212,730) in the remaining cohort. Meta-analysis demonstrated that blood transfusion was independently associated with an increase in mortality (odds ratio: 3.02, 95% confidence interval: 2.16 to 4.21, I(2) = 91%) and MACE (odds ratio: 3.15, 95% confidence interval: 2.59 to 3.82, I(2) = 81%). Similar observations were recorded in studies that adjusted for baseline hematocrit, anemia, and bleeding. Blood transfusion is independently associated with increased risk of mortality and MACE events. Clinicians should minimize the risk for periprocedural transfusion by using available bleeding-avoidance strategies and avoiding liberal transfusion practices.

Optimal use of blood products in severely injured trauma patients.

Injury is the leading cause of life years lost in the United States, and uncontrolled hemorrhage is the leading cause of potentially preventable death. Traditionally, these patients have been serially resuscitated with large volumes of crystalloid and/or colloids and red blood cells, followed by smaller amounts of plasma and platelets. Transfusion data coming first from the ongoing war in Iraq and Afghanistan and followed by multiple civilian studies have brought into question this tradition-based practice. Numerous recent retrospective single and multicenter studies have associated improved outcomes with earlier and increased use of plasma and platelets. These data have stimulated significant interest in studying massively transfused trauma patients. Most clinicians have concluded that the optimal timing and quantity of blood products in the treatment of hypothermic, coagulopathic, and acidotic trauma patients are unclear. Although there are strongly held opinions and long-standing traditions in their use, there are little quality data within which to logically guide resuscitation therapy. A multicenter prospective observational study is ongoing, and randomized trials are planned. This review will address the issues raised previously and describe recent trauma patient outcome data utilizing predetermined plasma:platelet:red blood cell transfusion ratios, and possibilities for future transfusion products and research.

Use of clotting factors and other prohemostatic drugs for obstetric hemorrhage

To guide the optimal use of blood products and to clarify the indications for prohemostatic drugs in obstetric hemorrhage. The literature emphasizes the usefulness of transfusing packed red blood cells, fresh frozen plasma and platelets earlier and in defined ratios to prevent dilutional coagulopathy during obstetric hemorrhage. The value of fibrinogen concentrate and prohemostatic drugs such as tranexamic acid and recombinant factor VIIa is also pointed out. It seems reasonable to use blood products for transfusion earlier and in a 1: 1 fresh frozen plasma: red blood cell ratio during acute obstetric hemorrhage; however, this analysis is mainly based on trauma literature. Fibrinogen concentrate should be added if the fibrinogen plasma level remains below 1.0 g l(-1) and perhaps even as soon as it falls below 1.5-2.0 g l(-1); the addition of tranexamic acid (1 g) is cheap, likely to be useful and appears safe. Data on the proactive administration of platelets are insufficient to recommend this practice routinely. Presently, recombinant factor VIIa (60-90 microg kg(-1)) is advocated only after failure of other conventional therapies, including embolization or conservative surgery, but prior to obstetric hysterectomy. Prospective randomized controlled trials are highly desirable.

Haemovigilance for the optimal use of blood products in the hospital

H. W. Reesink, S. Panzer, C. A. Gonzalez, N. Lena, P. Muntaabski, S. Gimbatti, E. Wood, M. Lambermont, V. Deneys, D. Sondag, T. Alport, D. Towns, D. Devine, P. Turek, M.-K. Auvinen, T. Koski, C. K. Lin, C. K. Lee, W. C. Tsoi, E. Lawlor, G. Grazzini, V. Piccinini, L. Catalano, S. Pupella, H. Kato, S. Takamoto, H. Okazaki, I. Hamaguchi, J. C. Wiersum-Osselton, A. J. W. van Tilborgh, P. Y. Zijlker-Jansen, K. M. Mangundap, M. R. Schipperus, D. Dinesh, P. Flanagan, O. Flesland, C. T. Steinsvag, A. Espinosa, M. Letowska, A. Rosiek, J. Antoniewicz-Papis, E. Lachert, M. B. C. Koh, R. Alcantara, M. Corral Alonso & E. Muniz-Diaz

Assessment of physicians knowledge in transfusion medicine, Iran, 2007

Knowledge of physicians has an important role in optimal use of blood products. This study was carried out to assess Iranian physicians' knowledge in transfusion medicine. In this cross-sectional study, 1242 physicians were selected through multistage sampling method in March 2007. Physicians' knowledge was assessed by the questionnaire comprising of 50 questions addressing basic knowledge, clinical aspects of blood use and transfusion reactions. One point was awarded for each correct answer. Approximately 22%, 37%, and 40% of the questions referring to basic knowledge, clinical aspects of blood use and transfusion reactions, respectively, were replied correctly. Thirty three percent came out to be the average figure for the questions receiving correct answers. Knowledge score of the specialists who were more frequently involved in blood use was not significantly different from other specialists (radiologists or psychiatrics) and general practitioners. Knowledge score decreased with increasing years in practice (P < 0.001). Ninety nine percent of physicians under the study believed that they required special education to raise their transfusion medicine knowledge. Knowledge of physicians was about one-third lower than the expected level. Therefore, educational materials concerning transfusion medicine should be provided for medical students, residents and fellows. For practicing physicians, continuous medical education programmes should be offered so that the level of transfusion medicine knowledge can be improved.

Haemovigilance: recent achievements and developments in the near future

Since the introduction of haemovigilance in the 1990s, the majority of the European countries has established a national haemovigilance system and communication between these systems was organized through the European Haemovigilance Network (EHN). The concept of haemovigilance has steadily expanded and the number of haemovigilance systems outside Europe is increasing. Several of these systems have also joined the EHN. Furthermore, initiated by the World Health Organization, a Global Steering Committee for Haemovigilance has been installed to promote haemovigilance particularly in developing countries. Both these haemovigilance systems and the network have documented the safety of blood transfusion and indicated where the main problems and opportunities for improvement are. Furthermore, they have suggested measures for improvement of the safety and, last but not least, documented the effect of these measures. Therefore, they have contributed considerably to the improvement of the quality and safety of the blood transfusion chain. In the near future, the EHN will become an official International Haemovigilance Network. Ongoing developments concerning the scope of vigilance include the vigilance of optimal use of blood products and safety of cells and tissues of human origin (biovigilance).

Coagulation Factor Concentrate Usage and the Risk of Lymphadenopathy: A Prospective Study

A prospective evaluation of 115 patients with hemophilia was performed between July 1982 and July 1983. During that period, 24 patients were seen with unexplained, generalized lymph node enlargement. The date lymphadenopathy occurred was recorded. No lymphadenopathy was found in 22 patients who did not receive coagulation factor concentrate. Factor usage was most closely related to the risks of lymphadenopathy (p = 0.004) even after controlling for age. A patient's age affected the risk of lymphadenopathy when the data were analyzed categorically (p = 0.008). A tendency was seen for heavily treated patients to develop lymph node enlargement earlier in the study period. Twenty-one of twenty-four (88%) patients with lymphadenopathy eventually developed HTLV-III/LAV antibodies and had abnormal T4/T8 ratios. These studies emphasize a close relationship between patients with hemophilia using coagulation factor concentrates and those with other risks for immune deficiency and lymphadenopathy. Close follow-up, optimal use of blood products, and further efforts to understand the importance of such changes are indicated in patients with hemophilia.