Optimal Use Of Blood Research Articles

Patient Blood Management: Moving Above and Beyond the Optimal Use of Blood!

Transfusion of blood components or products is among the most common procedures performed during a patient’s stay in the hospital. However, apart from being life-saving in exsanguination, blood transfusion is also associated with adverse events such as transfusion-transmitted infections, allergic reactions, transfusion-associated circulatory overload, transfusion-related acute lung injury, and transfusion-related immunomodulation with nosocomial infections and cancer recurrence. These potentially fatal complications have raised perennial concerns among healthcare professionals with regard to blood transfusion and patient outcomes. Thus, in the last few decades, the safety of the blood product has remained the key focus area for almost every stakeholder, whether end user or policy maker. Optimal use of blood is a globally recognized and recommended policy that ensures that the right amount and type of blood component is transfused to the right patient at the right time. Essentially, it focuses on improving the safety and effectiveness of the clinical transfusion process. However, with the evolving knowledge around transfusion science, increasing involvement of surgeons, anesthesiologists, and other specialists in transfusion offerings and proceedings, and the accumulating evidence on the fact that blood transfusion can, often, be more detrimental to a patient’s clinical status rather than benefiting it, has led to the endorsement and establishment of policy(ies) for optimal use of blood. Patient blood management (PBM), a concept coined and introduced almost two decades ago, encompasses, rather comprehensively, not just the policies and procedures of optimal use of blood and restricting transfusion to as minimum as possible but has a scope that spans much beyond that. PBM is driven and implemented through the three-pillar and nine-field matrix that incorporates the objectives of optimizing hematopoiesis, minimizing bleeding and blood loss, and harnessing and optimizing the physiological tolerance of anemia within the preoperative, intraoperative, and postoperative settings. PBM focuses on patient safety rather than product safety and, thus, ensures adopting a customized approach toward judicious and clinical use of the precious resource, blood. The principles and practices of PBM gained significant relevance and acceptability in the past few years, especially after the pandemic of COVID-19 when the World Health Organization issued a policy brief on its urgent implementation. Through this review article, we intend to establish not just the impact of PBM implementation towards improvement in patient outcomes but also the fact that the relevance and means of PBM extend far above and beyond just the optimal use of blood.

Blood Supply and Demand in Korea: What is in Store for the Future?

PurposePresently, Korea is facing new challenges associated with an imbalance in blood supply and demand. The purpose of this study was to examine trends in blood supply and demand in Korea over the past 10 years through 2018 and to propose what to prepare in the future.Materials and MethodsAge demographics in Korea were analyzed using data from the Statistics Korea. Blood donation and blood supply data were analyzed using Blood Services Statistics 2018 by the Korean Red Cross. Blood transfusion data from hospitals in 2018 were obtained from the Health Insurance Review and Assessment Service.ResultsIn 2018, 2883270 whole blood and apheresis units were collected in Korea. The Korean Red Cross supplied 4277762 blood components to 2491 hospitals. The overall blood donation rate was 5.6%, and the most frequent donors were young male donors. Leukoreduced red blood cells (RBCs) constituted 25% of all RBCs used, and 40% of all platelets were supplied by single-donor platelets. The self-sufficiency rate of domestic plasma with which to produce plasma-derived medicinal products was 68.7% in 2018. Blood use was the most frequent among patients aged 70–79 years.ConclusionBlood management in Korea is changing rapidly due to a low birth rate, rapid aging, and an increase in severely ill patients who require most of the blood supply. Therefore, future plans to promote donation at a national level and optimal use of blood in hospitals is necessary.

Residents' knowledge in transfusion medicine and educational programs: A pilot study.

Residents' knowledge in transfusion medicine significantly impacts the optimal use of blood and patient safety. Little is known regarding this topic in France in particular. The objectives were to evaluate their basic knowledge, to determine whether the objectives of the curricula were attained and subsequently to suggest ways for improvement. A cross-sectional study was conducted on 50 first year medical and surgical specialty residents rotating in a French university hospital. Major gaps in the knowledge were noted among residents of various specialties, equally between those with low and sustained transfusion practice. The majority of these young doctors expressed difficulties in prescribing and handling transfusions, identifying and managing its complications and understanding their responsibilities. The roles of hemovigilance practitioners were further somehow unclear for participants. Given these results, action plans appear needed to limit consequences. A special transfusion medicine educational program should be added to the currently available medical education curriculum in order to ensure physicians have adequate knowledge of transfusion basics; at least a practical assisted situation during residency would be of valuable interest.

How to mitigate the risk of inducing transfusion-associated adverse reactions

Transfusion has become extremely safe but can still be associated with adverse reactions. Some adverse reactions can be mitigated by applying measures to donor selection, the process of separating blood components as well as hospital-based procedures consisting in matching the donor and the recipient; special attention is given to optimizing the best fit between the component and the beneficiary, which is not only an immuno-hematological challenge (fresh versus old blood, testing for certain viruses such as CMV, parvovirus B19, etc.). Considerable progress has also been achieved to strengthen the overall quality and safety of the whole transfusion chain. Guidelines and recommendations have resulted in substantial progress, and the recent revisiting of patients as part of a more holistic approach has enabled blood management programs to be created. Such programs, when wisely applied in a context of optimal blood use, reinforce patient safety; they enhance hospital recognition of transfusion and hemovigilance specialists as useful players acting in the interests of patients in full compliance with hospital budgets. This review considers the step-by-step processes that reinforce transfusion safety and identifies hurdles that cannot yet be properly addressed; it proposes steps for further progress, in light of personalized medicine.

Status of Transfusion Medicine Education in Iran.

Optimal use of blood and blood components requires theoretical and practical knowledge in transfusion medicine. While the importance of education in transfusion medicine has long been recognized, a vacancy is widely felt in this regard in Iran. In this study, the current status of transfusion medicine education in Iran is evaluated using a review of studies conducted in this field. To access articles related to transfusion medicine education in Iran, an electronic search was performed in databases, including Magiran, SID, IranMedex, Google Scholar, PubMed, ScienceDirect, and Scopus and the related articles were evaluated. Knowledge of transfusion medicine was not optimal in various medical groups and there was no effective theoretical and practical education and training for transfusion medicine in medical universities. Almost all the studies concluded that transfusion medicine curricula should be implemented for both undergraduate and postgraduate students, because of its great importance in clinical practice. Educational program of transfusion medicine is a basic need of medical education for medical students, interns, residents, nursing, and midwifery students in Iran. Considering our status and capacities and by using educational programs in the world, curricula are suggested for different educational levels. Implementation of these training programs plays a vital role in improving patients' safety and also reduces the high costs of treatment with blood products.

Quality in blood components – it all starts with the donation

Blood transfusion is not risk free, so should only be prescribed when it is in the patient's best interest to do so. Blood establishments have a recognized obligation to promote optimal use of blood and blood components while minimizing risk to the health of the recipient. Processes are therefore focused on producing quality components that are efficacious and safe. In manufacturing processes, the quality of final products is heavily dependent on the quality and reliability of the starting materials, and therefore, control of these materials to reduce variation is a critical quality assurance activity. The starting material or primary product for the manufacture of blood components is the blood donation. If the quality of that donation is not assured, the efficacy and safety of the blood components manufactured from it will be potentially compromised no matter how good the rest of the manufacturing process may be. The challenge, however, is that blood is a biological material and collection is subject to a number of variations: Donations are collected from donors of various ages with different demographics, health profiles and behaviours. The donations have different characteristics, for example volume of donation, numbers of platelets, levels of immunoglobulin, blood group antibodies. The collection process depends largely on manual procedures with the exception of apheresis collections. Donations may be collected, stored and transported under varying environmental conditions. Because of these variations, controlling the quality and consistency of the primary blood donation can be more challenging than controlling starting material for an industry such as pharmaceutical manufacture. In recent years, there have been a number of developments aimed at improving the quality of the blood donation. These have largely focused on controlling and reducing variations in the process steps that are most likely to have an impact on quality or safety. These are called critical control points, and for the donation process, it includes the following: Selection of blood donors, Collection of the donation, Handling and storage of the donation, Transport of the donation to the processing centre. A number of the developments are new technologies that automate the critical control points as far as possible, such as decision support systems to improve the consistency of interpretation of donor selection guidelines, vein viewer systems that improve the venepuncture process and transport containers that can control temperatures. There have also been developments of internationally accepted component standards and principles of good manufacturing practices that provide the framework for quality in blood establishments and have been able to drive significant improvements in processes and component quality. In combination, these recent developments can provide a high degree of assurance that the starting point for the manufacture of safe and efficacious blood components will be a quality donation.

Optimal use of blood and innovative approaches to stem cells, regenerative medicine and donor recruitment

The annual scientific meeting of the Scotblood National Blood Transfusion Service, (SNBTS), continues to enjoy success. Scotblood 2013 focused on the contemporary issues affecting the various essential areas of blood transfusion and transfusion medicine. Presentations ranged from the challenges of recruiting young donors, forecasting future blood demand and celebrating the success of the better blood transfusion program. The meeting also discussed potential future developments in regenerative medicine particularly the potential of mesenchymal stromal cells and discussion of the ongoing Bloodpharma project, the ultimate aim of developing cultured red blood cells. This commentary comprises summaries of the presentations, based in part on the abstracts provided by the speakers. The Scotblood Conference began with the welcoming introduction by SNBTS Director Mrs. Mary Morgan, during which she updated the ongoing developments within SNBTS over the last year. Mrs. Morgan described how SNBTS met the challenges and obstacles that have been prevalent in all Blood Transfusion Services, whilst also meeting the transfusion needs of the people of Scotland. Mrs. Morgan then introduced the keynote speaker Dr. Aileen Keel CBE, Deputy Chief Medical Officer of Scotland. Dr. Keel's presentation was entitled "Twenty years in the Scottish Government-edited highlights" in which she described the various challenges that have presented themselves to her throughout her career. Dr. Keel highlighted how the various risks in the blood transfusion field (from HCV, HIV through to nvCJD) have arisen and then reduced to miniscule levels through hard work and perseverance. The highlights of the conference are summarised below.

A survey of resident physicians' knowledge concerning transfusion medicine in Shiraz, Iran.

Objective:The knowledge of physicians concerning blood transfusion has a significant impact on the optimal use of blood and blood products. The aim was to survey their knowledge regarding this area and identify whether additional training is required.Material and Methods:This cross-sectional study was conducted on all 1st year resident physicians at Shiraz University of Medical Sciences, Iran in 2011. The questionnaire solicited information on demographic variables, knowledge regarding transfusion medicine, education and experience regarding blood transfusion.Results:The mean total knowledge score regarding transfusion medicine was 15.44 ± 3.3 (7-25) out of 29. Only about one-fourth (27.4%) replied correctly to over 60% of questions. The mean score of knowledge was higher among residents who stated that they received special training regarding blood transfusion in their medical courses (P < 0.01). Seventy-five percent of residents believed that they had received insufficient education and 97.8% believed that they need additional training.Conclusion:The results reflect the uncertainties among resident physicians regarding blood transfusion. It has been suggested that a special transfusion medicine educational program should be added to the medical education curriculum.

Lessons from the response to the threat of transfusion-transmitted vCJD in Ireland

By the time vCJD was first described in 1996, it was already far too late to offset further disaster from transmission of the disease by blood transfusion: almost all the humans who would be infected and infectious were already diseased. Nothing done by the blood transfusion services around that time, with the exception of excluding transfusion recipients as blood donors, would have made any useful contribution to containing the extent of the epidemic. The ability to spread emerging diseases before the problem is manifest or understood is a fixed and unavoidable feature of blood transfusion as it is practiced today. A second fixed property of blood transfusion is that the root cause of disaster is not within the control of the blood transfusion universe. Strategies that have emerged to cope with similar threat in other enterprises that also contain these properties comprise the components of robust design: surveillance, preparedness for action, engagement, herding together, evasion or avoidance, early adoption of potentially useful measures, engineered resilience, defence in depth, damage limitation including modularity and removal of feedback loops, and contingency, redundancy and failure management, and ultimately, individual escape. Early adoption of leucodepletion based on the possibility that it might work rather than any hard evidence was a good example of threat management. Exclusion of previously transfused donors is a robust mechanism for containing any future infection; optimal blood use structures that provide a national transfusion rate as low as possible also constitute an effective threat management strategy.

How Does the Global Economic Crisis Affect the Quality of Blood Services?

How Does the Global Economic Crisis Affect the Quality of Blood Services?

European Blood Alliance (EBA) et EuroNet TMS : quels enjeux pour la transfusion de demain ?

The primary mission of the European Blood Alliance (EBA) is to contribute to the safety and efficiency of the supply of blood products, cells and tissues, in developing an active network of blood establishments in Europe (25 countries). Its strategic objectives are to improve performance (through working groups and projects funded by the European Union), to engage in regulatory affairs (particularly at the European Commission level) to promote best practices and to facilitate a network to collect and share knowledge and experiences. The main objective of EuroNet TMS, combining the blood scientific societies from more than 30 countries in Europe, is to update and publish regularly, intended for policymakers, a White Book on the transfusion chain from donor to patient and probable or possible changes in the coming 5 years. Since 2008, EBA and EuroNet TMS actively collaborate on the drafting of the 2nd edition to be published in 2011. The two presidents jointly drafted the final chapter outlining the major issues of transfusion for tomorrow, summarized thereafter. Transfusion will still be useful for a long time and for reasons of safety and ethics the voluntary and unpaid donations, with non-profit blood establishments, will remain, the cornerstone of the supply of blood products. This renders crucial the continuous improvement of donor management and optimal blood use. On the regulatory side, after 5 years of implementation, EU directives must be independently evaluated and the Blood Guide of the Council of Europe should gradually become a regulatory standard. Finally, if a competition should be introduced for the blood products, it should be strictly regulated to prevent any threat to the security of their supply and quality for patients.

Demographic changes and predicting blood supply and demand in the Netherlands

Concerns have been raised that aging of the general population will increase the demand for blood products. Modeling can be applied to assess trends in blood demand and supply and predict how these will develop over time. We developed mathematical models to describe and predict the national demand of red blood cell (RBC) products. The first demand model assumes that the mean numbers of transfusions per inhabitant per age and sex are constant. A second demand model incorporates observed changes in clinical blood use over time. Further, a donation model is developed to predict future RBC supply. To estimate the supply of whole blood donations, we used annual donor retention rates, donor recruitment rates, and mean numbers of donations per donor year. The model based on demography only predicts an increase of 23% in RBC demand over 2008 to 2015. The second model, incorporating both demographic changes and trends in clinical RBC use, predicts a decrease of RBC demand by 8% over the same period. The predicted RBC supply closely follows the demand as predicted by the second model. Despite an aging population, RBC demand may not increase as much as predicted in other studies. This depends on the extent to which other effects, like that of optimal blood use, will neutralize the effects of aging of the transfusion recipient population. Still, the observed downward trend in donor recruitment in the Netherlands must be stopped to maintain a sufficient RBC supply.

Clinical appropriateness of blood component transfusion: regulatory requirements and standards set by the Scientific Society in Italy.

Decision-making in health care is strongly conditioned by values of patients and providers, available resources, and information showing effectiveness/efficacy of a particular health care intervention. Clinical decisions concerning treating patients should, as far as possible, be evidence-based1; this is, to a great extent, current clinical dogma, and many medical practitioners in all disciplines are now, to some extent, utilising it2. Evidence-based medicine (EBM) can be defined as conscientious, explicit and judicious use of current best evidence in making decisions about care of individual patients3. It combines clinical judgment and experience with best available scientific evidence to improve medical decision-making and should provide clinicians, health care systems and policy-makers with instruments to appropriately evaluate scientific evidence supporting various diagnostic and therapeutic activities. This represents a radical departure from usual and customary methods for making treatment decisions concerning patients and has led to EBM being a discipline taught in medical schools and teaching hospitals4. Transfusion medicine (TM) is currently adopting principles and research methodologies that support EBM5, and high-level research has actually been undertaken at same rate as in all medical specialties combined in terms of numbers of randomised controlled trials and meta-analyses1. EBM in TM not only refers to best research evidence, but is often based on a broader range of inputs, including public expectations about transfusion safety and issues concerning precautionary principle; this implies that criteria for evaluating efficacy and cost-effectiveness of interventions in TM may differ substantially from those used in other areas6. The increasing need to deliver sufficient and safe blood components of high quality may be cause of an excessive focus on supply side of blood transfusion chain rather than clinical problem facing patients and clinicians7. An overwhelming concentration on blood supply can lead to appropriate clinical utilisation of blood components being ignored as a potentially useful instrument to maintain blood supply itself, although physicians should always consider clinical appropriateness as a must, under professional, scientific and ethical points of view. Hence, the appropriateness of transfusion practices will only improve, not by expecting clinicians to be gatekeepers of blood supply, but with better patient blood management based on a sound understanding of pathophysiology and better evidence for transfusion efficacy7. Based on above considerations, appropriateness of transfusion practices should systematically mean that blood components are transfused only when there is evidence for potential benefit, there are no valid alternatives, safe and quality products are available, and risks and benefits are carefully assessed before decision to transfuse is made. Recent European regulatory acts in field of blood transfusion (Directive of Council 2002/98/EC8 and Directives of Commission 2005/61/EC9 and 2005/62/EC10), while focusing on fundamental issues concerning quality, safety, traceability, haemovigilance, etc., do not actually take into consideration promotion and assessment of appropriateness of clinical use of blood components11. Indeed, Community's legislative framework excludes actual therapeutic use of blood components. Moreover, its provisions are no longer applicable when components are sent for further processing into medicinal products, when pharmaceutical legislation comes into force12. The appropriateness of clinical use of blood components is addressed by Recommendation Rec(2002)1113, which is indeed an excellent guideline to member states on how and what to do to implement optimal use of blood and blood products in clinical setting, but no mandatory act at European level establishes that appropriateness of transfusion practices must be promoted, monitored, assessed and, when necessary, improved. This review is aimed at providing an overview of Italian regulatory framework and of requirements of Italian standards of TM on assessment of appropriateness of blood transfusion.

The EU optimal blood use project

The EU optimal blood use project (EUOBUP) is cofunded by the European Commission and led by the Scottish National Blood Transfusion Service (SNBTS). Its purpose is to develop, evaluate and disseminate a manual that provides practical guidance and support for those seeking to improve the safety of the clinical transfusion process and the effectiveness of the prescribing of blood components. We define the optimal use of blood components as the safe, clinically effective and efficient use of the scarce resource of donated human blood. The project will build on the experience of a pilot project in optimal use of blood in the national health service in Scotland. This pilot developed training resources in the safe and effective use of blood and delivered training to a large number of practitioners. It has also developed systems to provide hospitals with comparative information on their use of blood components for specific clinical groups of patients to assist them in reviewing practice against that of their peers.

The Emerging Dutch Hemovigilance System: Voluntary and State‐of‐the‐Art

SUMMARyIn 1996 the Dutch Inspectorate of Health enquired whether a national surveillance system for hemovigilance could be developed for the Netherlands. This request was inspired by the Untied Kingdom's initiative to install a reporting system for serious hazards of transfusion (SHOT).An independent foundation named TRIP (Transfusion Reactions in Patients) was established, owned by the professional medical societies engaged in blood transfusion. TRIP was formally launched at the 5th European Hemovigilance Seminar in Amsterdam on February 6–7, 2003.The TRIP office has the aim to anonymously collate, register, analyze and report on the safety of blood transfusion. In addition, TRIP aims to enhance the safety of blood transfusion by educational programs on blood transfusion safety.The TRIP program closely resembles the British SHOT system, in being a voluntary system supporting professionals and in its focus on serious adverse events. It is recognized that underreporting may exist, but it is felt that in The Netherlands a voluntary system would be more productive than a compulsory system.TRIP holds the view that the correct and optimal use of blood is as important for blood transfusion safety as is the prevention of adverse events. In the future, it is envisaged that TRIP will participate in the education of nurses, doctors and technicians in blood transfusion safety.

PREVENTIVE MEASURES FOR THE IMPROVEMENT OF THE SAFETY OF BLOOD TRANSFUSION AND VIRTUAL TRANSFUSION LABORATORY

Background. Even though blood transfusion is a relatively safe form of therapy, because of the eventual administrative errors in the transfusion chain between the blood donor and the recipient of blood, transfusion errors still occur. Therefore, it is imperative to ensure an utmost extent of safety and reliability of all transfusion related procedures. The safety of blood transfusion can be improved by preventive actions, i.e. implementation of the total quality management concept, haemovigilance and virtual transfusion laboratory. In the resulting system, the information web, robotics, computer sciences and communication technologies ensure safe and reliable identification of the patients, blood donors, corresponding test samples and blood products. Apart form this; the modern technologies enable the automation of laboratory testing, the integrity of laboratory results and enable an optimal use of blood. Conclusions. For an improved transfusion safety in Slovenia, adoption of corresponding prevention as well as haemovigilance is necessary. Identification errors can be prevented by implementation of the wristbands systems with the code bars for the tagging of the patient and his biological samples, whereas the administrative errors in the blood bank and transfusion laboratory can be prevented by implementation of information systems and automation. We assume that the virtual transfusion laboratory will become an integral part of the new Slovenian transfusion web and will speed up, unify and simplify today’s methods of ordering and administering blood products. To the attending physician, it will enable the choice of optimal transfusion therapy schedule and at the same time, it will enable the supervision of individual orders, deviations and indications, all of which is needed in order to analyse and improve the quality and the costs of the treatment. These services represent the first obligatory step for the modernisation of the transfusion medicine and accordingly, of the Slovenian health system in sense of the total quality assurance.

Hemostatic Abnormalities in Cardiopulmonary Bypass: Pathophysiologic and Transfusion Considerations

Cardiac surgical procedures typically use cardiopulmo nary bypass (CPB), a technique that diverts blood from the heart and lungs, where it is oxygenated and pumped back into the circulation. CPB is associated with significant pathophysiologic changes leading to an increased bleeding risk. Bleeding during CPB occurs for multiple reasons; the primary reason is the expo sure of blood to the material components of the CPB system, with intense systemic coagulation and platelet, fibrinolytic, and endothelial activation. To counteract the coagulation activation, extremely high levels of heparin anticoagulation are required to prevent sys temic thrombosis. Thrombin generation through tissue factor pathway activation is now thought to be the predominant mechanism of coagulation activation in CPB. The stimulus for tissue factor exposure to blood is thought to be a systemic activation of tissue factor on monocytes and endothelial cells caused by comple ment activation by the CPB materials and circulating inflammatory mediators. Despite improvements in the CPB system, surgical techniques, and blood conserva tion methods, the demand for blood in such procedures remains sustantial. Optimal blood use can be achieved by combining blood conservation measures with the transfusion of blood components according to strict guidelines. Blood is a limited resource and must be used wisely and cautiously. The risks and costs associ ated with transfusion are compelling reasons to mini mize unnecessary exposure to blood. However, the bene fits of transfusion are well established, and the risks are reasonably low. New developments in the surfaces of the CPB system, use of established and new protease inhibitors, and new blood conservation measures offer promise in decreasing the bleeding risk associated with CPB.

Additional Articles: Optimal Use of Blood and Blood Products

Additional Articles: Optimal Use of Blood and Blood Products