Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2013
Comparative StudyThe chiasm: transfusion practice versus patient blood management.
In recent years it became increasingly clear that allogeneic red blood cell (RBC) transfusions result in increased mortality and major adverse clinical outcomes. The major risk factors for RBC transfusions are preoperative anaemia, high perioperative blood loss and liberal transfusion triggers. ⋯ PBM has been adopted by the World Health Organization as the new standard of care and all member states are urged to implement this concept. Australia is leading the world in that PBM is indeed implemented at the current time.
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Best Pract Res Clin Anaesthesiol · Mar 2013
ReviewPatient blood management and outcome, too early or not?
Patient blood management (PBM) seeks to improve the clinical outcomes of patients through the application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss. Hence, assessment of the outcomes of patients is essential in evaluating the success of PBM programmes. Clinical outcomes measure the meaningful impact of interventions on patients in terms of living longer or healthier or experiencing fewer complications. ⋯ Creating registries of patients managed under PBM can be an effective and feasible approach to provide safety and effectiveness data on various clinical outcomes. While outcome data on PBM programmes are limited, the emerging studies support that PBM can be effective in reducing transfusion and, more importantly, improving the outcomes of the patients. Continued and further research in this field is imperative.
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Erythropoiesis-stimulating agents (ESAs) have long been approved for the management of anaemia in a variety of clinical settings. Subsequently, a number of clinical trials were undertaken in which the haemoglobin end points were targeted to be maintained at normal or high-normal ranges, in an attempt to demonstrate improvements in long-term survival. ⋯ Informed choice by patients for risks of ESA therapy as well as for blood transfusion should be part of the consent process for management of anaemia. Despite current regulations restricting ESA use, these agents are an effective treatment of anaemia, particularly for those who would be transfusion dependent without ESA therapy.
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As one of the oldest and most common procedures in clinical practice, allogeneic blood transfusions face many issues including questionable safety and efficacy, increasing costs and limited supply. The need to provide effective care for a relatively small population of patients who could not be transfused for various reasons gave rise to 'bloodless medicine and surgery', which was subsequently proposed as a care strategy for all patients, with the goal of minimising the use of allogeneic blood components. The next evolution came from the shift from a 'product-centred' approach towards a 'patient-centred' approach, that is, a focus on patient outcome rather than use of blood components, which gave birth to 'patient blood management'. Defined as "the timely application of evidence-based medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis and minimise blood loss in an effort to improve patient outcome", patient blood management is expected to reshape the future of transfusion medicine and the way blood components are used in clinical practice.
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Best Pract Res Clin Anaesthesiol · Mar 2013
ReviewAnaemia: can we define haemoglobin thresholds for impaired oxygen homeostasis and suggest new strategies for treatment?
Observational clinical studies in perioperative medicine have defined a progressive increase in mortality that is proportional to both chronic preoperative anaemia and acute interpretative reductions in haemoglobin concentration (Hb). However, this knowledge has not yet helped to define the critical Hb threshold for organ injury and mortality in specific patient populations or in individual patients. Nor has this knowledge enabled us to develop effective treatment strategies for anaemia, as evident from the lack of a demonstrable improvement in survival in patients randomised to higher Hb levels by various treatment strategies including allogeneic red blood cell transfusion, erythropoiesis-stimulating agents (ESAs) and haemoglobin-based oxygen carriers (HBOCs). ⋯ The mechanisms include: (1) effective sensing of anaemia-induced tissue hypoxia; (2) adaptive cardiovascular responses to maintain adequate tissue oxygen delivery; (3) heterogeneity of organ-specific oxygen delivery to preferentially sustain vital organs which are essential for acute survival (heart and brain); (4) evidence of increased vital organ injury with interruption of cardiovascular responses to anaemia and (5) evidence of activation of adaptive cellular responses to maintain oxygen homeostasis and support survival during acute anaemia. Understanding these mechanisms may allow us to define treatment thresholds and novel treatment strategies for acute anaemia based on biological markers of tissue hypoxia. The overall goal of these approaches is to improve patient outcomes, including event-free perioperative survival.