Vox sanguinis
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Audits of practice and incident reporting, most notably to national haemovigilance schemes, indicate that poor hospital transfusion practice is frequent and occasionally results in catastrophic consequences for patients. Improvements in practice are needed and depend on a combined approach including a better understanding of the causes of errors; a reduction in the complexity of routine procedures taking advantage of new technology systems, which enforce agreed guidelines and policies; the setting and regular monitoring of performance standards for key aspects of the hospital transfusion process, improved organisation of transfusion in hospitals and staff training; and further research on the safe and effective use of blood and alternatives to donor blood. There needs to be a greater recognition that 'transfusion safety' applies to the hospital transfusion process as well as the contents of blood bags and that resources need to be provided for the improvement of transfusion safety and management in hospitals commensurate to their importance.
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During storage of red blood cells (RBC), these cells develop storage lesions. The clinical relevance of these storage lesions is heavily discussed in literature. ⋯ An overview of the conflicting literature on the clinical relevance of prolonged storage is given, summarizing the evidence on associations with mortality, length of stay, (postoperative) infections and organ failure. Subsequently, possible explanations are given for the conflicting results in the clinical studies and suggestions on how to proceed.
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Variant Creutzfeldt-Jakob (vCJD) is a fatal transfusion transmissible prion infection. No test for vCJD in the donor population is currently available. Therefore, prion removal by filtration of red cell concentrate (RCC) is an attractive option for prevention. ⋯ This phase 1/11 clinical study provides encouraging data on safety of prion filtration which can be used to plan more extensive studies on the use of filtered blood in adults and children.
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Practice misalignments can occur in any clinical trial investigating a pre-existing therapy that is typically adjusted based on clinical characteristics outside of the trial setting. To eliminate the heterogeneity in clinical practice, recent trials investigating titrated therapies have randomized patients to fixed-dose regimens without including a routine care control group receiving titrated therapy. In these trials, the normal relationships between clinically important characteristics and therapy titration are disrupted. ⋯ In addition, comparisons of trial arms with practice misalignments have limited interpretability and generalizability. In this review, we use examples from the literature to discuss how practice misalignments can impact the safety, results and conclusions of clinical trials. In addition, we discuss methods to characterize relationships between therapy titration and clinical characteristics and trial design strategies that may minimize practice misalignments.
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Multicenter Study
A pilot study of the possibility and the feasibility of haemoglobin dosing with red blood cells transfusion.
Red blood cell concentrates (RBCs) are the major blood component transfused. Although the haemoglobin content is variable, the transfusion dose is prescribed as units of red cell concentrates. Thus, by chance, large volume patients may receive a low haemoglobin dose and low volume patients may be transfused with haemoglobin-rich RBCs. The aim of this study was to evaluate whether the haemoglobin increment (grams per litre) in the patient can be predicted from the haemoglobin dose (in grams) transfused, with and without correction for estimated blood volume. If this is true, it may be possible to achieve the predicted transfusion outcome by selecting RBCs for each patient. ⋯ Post-transfusion increment in circulating haemoglobin can be predicted from the haemoglobin content of transfused cells, but knowledge of the patient's blood volume improves the accuracy of prediction. It may be feasible to select the high haemoglobin content RBC for patients with largest blood volume and vice versa.