Search

Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need. [ABSTRACT FROM AUTHOR]

Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources. [ABSTRACT FROM AUTHOR]

SUMMARY: 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. [ABSTRACT FROM AUTHOR]

Background and Objectives Patient Blood Management ( PBM) optimises the care of patients in need of transfusion using the best available evidence. ISBT's Clinical Transfusion Working Party conducted an international survey to benchmark PBM activities. Material and Methods Members of the working party developed a survey on hospital-based PBM activities that was electronically sent to all ISBT members who were encouraged to complete the survey if they were actively involved in PBM. Results Of the 277 ISBT members who responded to the survey, 194 were actively involved in PBM and completed the survey. The majority came from Europe and the Western Pacific (63·9%) and mostly from either university (43·8%) or large general hospitals (20·1%). Most (63·9%) respondents came from high-income countries. 61·9% of respondents indicated that audits were performed and their hospitals participated in accreditation programs, 75·3% performed informed consent before transfusion. In 78·4%, a transfusion committee was present. In 84%, institution-wide transfusion guidelines were implemented and 63·4% offered outpatient preoperative risk screening. In 38·1%, a protocol to diagnose preoperative anaemia was used, 51% collected autologous blood transfusions, and in 50%, tranexamic acid was used in the perioperative setting. Overall, the highest percentages were found in university and large general hospitals and in high-income countries. Conclusion PBM initiatives have been implemented to different degrees at hospitals around the world. [ABSTRACT FROM AUTHOR]

Background and Objectives To determine the value of erythropoietin in reducing allogeneic transfusions, it is important to assess the effects, safety and costs for individual indications. Previous studies neither compared the effects of erythropoietin between total hip and total knee arthroplasty, nor evaluated the safety or costs. We performed a meta-analysis to assess the effects of erythropoietin in total hip and knee arthroplasty separately. Safety and costs were evaluated as secondary outcomes. Materials and Methods A systematic literature search was performed to identify randomized controlled trials evaluating the effect of erythropoietin in total hip and knee arthroplasty until April 2014. Study data were extracted using standardized forms and pooled using a random-effects model. Strength of the evidence was evaluated using Cochrane's Collaboration's tool for risk of bias assessment. Results Seven studies were included (2439 patients). Erythropoietin significantly reduced exposure to allogeneic transfusion in both hip ( RR 0·45; 95% CI 0·33-0·61) and knee ( RR 0·38; 95% CI 0·27-0·53) arthroplasty, without differences between indications ( P = 0·44). Mean number of transfused red blood cell units was significantly decreased in erythropoietin-treated patients (mean difference −0·57; 95% CI −0·86 to −0·29)(unable to split). No differences in thromboembolic or adverse events were found. Only one study evaluated costs, so that no pooled cost-effectiveness estimates could be given. Conclusion Erythropoietin is effective in both hip and knee arthroplasty and can be considered as safe. However, the decision to use erythropoietin on a routine base should be balanced against its costs, which may be relatively high. [ABSTRACT FROM AUTHOR]

Background A randomized study was conducted on the integrated use of patient blood management methods as erythropoietin (Epo), cell saver and/or postoperative drain reinfusion to evaluate the effect on red blood cell ( RBC) transfusion reduction and costs in 2442 adult elective hip and knee surgery patients while applying a restrictive transfusion threshold. Methods Firstly, patients were stratified by the preoperative haemoglobin (Hb) level: low Hb (10-13 g/dl) patients were randomized for Epo or no Epo and normal Hb patients (above 13 g/dl) were ineligible for Epo. Secondly, patients from both strata were randomized for autologous reinfusion by cell saver device or postoperative drain reinfusion device or for no blood salvage device. Outcome measures: RBC use and cost-effectiveness. Results Epo resulted in a significant 50% reduction of transfused patients ( OR 0·5, 95% CI: 0·35-0·75) and a non-significant 29% mean reduction in RBC use (ratio 0·71, 0·42-1·13). Epo, however, increased costs by €785 per patient (262-1309), that is €7300 per avoided transfusion (1900-24000). In both strata, autologous blood reinfusion did not result in a RBC reduction and increased costs by €378 per patient (161-595). Conclusions In elective knee and hip surgery, while using a restrictive transfusion trigger, autologous reinfusion by cell saver and postoperative drain reinfusion were no longer found to be effective in reducing RBC use and are consequently not cost-effective, while Epo, although it is effective in reducing RBC use, is not cost-effective due to its high costs. Therefore, these interventions are no longer considered as appropriate transfusion alternatives. [ABSTRACT FROM AUTHOR]

Objective In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. Study Design and Methods A randomized, controlled study. A new uniform, restrictive transfusion policy was compared with standard care, which varied among the three participating hospitals. Only prestorage leucocyte-depleted RBC(s) were used. Primary end-point was RBC usage, related to length of hospital stay. Secondary end-points were Hb levels, mobilization delay and postoperative complications. Results Six hundred and three patients were evaluated. Adherence to the protocol was over 95%. Overall mean RBC usage was 0·78 U/patient in the new policy group and 0·86 U/patient in the standard care policy group (mean difference 0·08;95% CI [−0·3; 0·2]; P = 0·53). In two hospitals, the new transfusion policy resulted in a RBC reduction of 30% (0·58U RBC/patient) ( P = 0·17) and 41% (0·29 U RBC/patient) ( P = 0·05) respectively. In the third hospital, however, RBC usage increased by 39% (0·31 U RBC/patient) ( P = 0·02) with the new policy, due to a more restrictive standard care policy in that hospital. Length of hospital stay was not influenced by either policy. Conclusions Implementation of a uniform transfusion protocol for elective lower joint arthroplasty patients is feasible, but does not always lead to a RBC reduction. Length of hospital stay was not affected. [ABSTRACT FROM AUTHOR]

Background and Objective Despite published guidelines, a proportion of red blood cell (RBC) transfusions seem unnecessary. To evaluate the indications for and the appropriateness of RBC transfusions in the postpartum patient, we performed a retrospective audit over a 1-year period in two Dutch hospitals. Study Design and Methods Observational study of transfused obstetric patients, admitted in 2006 to the Departments of Obstetrics of a university and a general hospital, was carried out. Relevant clinical and laboratory data were recorded. The appropriateness of RBC transfusions was assessed using the national and age-based transfusion guidelines for the general population; for the studied group the transfusion threshold haemoglobin (Hb) value was 6·4 g/dl for non-massive and 8·1 g/dl for massive blood loss. From these we derived target Hb levels. Results Ninety patients received one or more RBC units within 48 h of delivery. Mean pretransfusion Hb level was 6·9 [SD 1·2] g/dl. Median number of transfusions was 2. Mean Hb level at discharge was 9·7 [SD 1·1] g/dl. Taking threshold Hb and the derived target Hb level into account, 68% ( n = 61) of the patients may have received one or more RBC units inappropriately. Of 311 RBC units transfused, 143 units (46%) were possibly inappropriate, partly due to over-transfusion. Conclusion A significant proportion of postpartum RBC transfusions are possibly inappropriate, partly due to over-transfusion. If current guidelines would be more specific, in particular, with respect to the target Hb levels, the total amount of RBC transfusions may be considerably decreased. [ABSTRACT FROM AUTHOR]

To determine the safety, efficacy and user-friendliness of two different postoperative autologous blood re-infusion systems, an open, randomized, controlled study was performed. Eligible consecutive primary and revision total hip and knee replacement patients were randomized for one of the two systems or for a control group in which shed blood was not re-infused. The nursing staff scored user-friendliness. Patients were monitored after re-infusion. In all three patient groups, a restrictive transfusion trigger was used. Sixty-nine of 70 randomized patients were evaluated. Ease of use, efficacy and safety of both re-infusion systems were comparable. There was no difference in allogeneic blood use between the groups. Thirty per cent of the patients re-infused with autologous blood developed a mainly mild, febrile transfusion reaction. No other adverse reactions were seen. Signs of coagulopathy after re-infusion were not found. In multivariate analysis, autologous re-infusion was an independent factor associated with a shorter hospital stay. Both postoperative autologous blood re-infusion systems were of equal efficacy and safety. The contribution of autologous wound blood re-infusion to reduce allogeneic transfusions must be investigated in a larger study. [ABSTRACT FROM AUTHOR]

Abstract Background and Aim: To evaluate the possible antifibrotic effects of two drugs, pentoxifylline (PTX) and interferon (IFN)-α as well as their combination, on a bile-duct-ligated rat hepatic fibrosis model. Methods: Bile ducts of 34 female Wistar rats were ligated, and 24 bile ducts were sham operated. Bile-duct-ligated rats were divided into four groups, in which either sterile saline, IFN-α (100 000 IU/3 days a week), PTX (50 mg/kg/day) or IFN-α + PTX were administered. Sham-operated rats were treated at the same doses. On the 28th day, rats were decapitated to obtain blood for the measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT) and bilirubins. Serum prolidase was assayed at the beginning and at the end of the study by the modified Chinard's colorimetric method. Liver prolidase was assayed after tissue homogenization. Liver collagen content was determined by the dye elution method described by Lopez de Leon. Morphometric-densitometric measurements of hepatic fibrosis were quantified by computerized image analysis. Results: The AST, ALT, ALP, GGT and bilirubins, liver prolidase enzyme activity, collagen content and hepatic collagen surface density were found to be increased in bile-duct-ligated rats on day 28. There was no statistically significant recovery or even a change in collagen turnover rate in rats treated with alternate regimens applied in the study (P > 0.05). Conclusion: Pentoxifylline, IFN-α and their combination have no beneficial effect on experimental fibrosis induced by biliary obstruction. © 2003 Blackwell Publishing Asia Pty Ltd. [ABSTRACT FROM AUTHOR]

The proliferative effects of the mitogens phytohaemagglutinin (PHA), concanavalin A (Con A), pokeweed mitogen (PWM), and staphylococcal protein A (SpA) were investigated using two different methods which enable immunological marker analysis of proliferating cells: either surface marker labelling followed by BrdU incorporation or screening of metaphases after surface marker labelling. Therefore peripheral blood mononuclear cells from six healthy volunteers were stimulated with these four mitogens. Both PHA and con A gave rise to more CD8+ than CD4+ proliferating cells. PHA, but not Con A, induced B-cell proliferation as well. PWM mainly caused T-cell proliferation. SpA also appeared lo be a potent T-cell mitogen in addition to its capacity to induce B-cell proliferation. However, in contrast to the other mitogens SpA predominantly stimulated CD4+ cells. [ABSTRACT FROM AUTHOR]

A response by C. So-Osman, A. Brand, M. Schipperus, B. Berning and S. Scherjon to the letter to the editor about their article on postpartum blood transfusion appropriateness is presented.