Blood Transfusion

Patient Blood Management - what is it as a concept?

2024-10-06T22:58:37+00:00

Patient Blood Management (PBM) is an innovative and multidisciplinary approach that optimizes patient outcomes by managing and preserving a patient's own blood. Initially introduced as an alternative to traditional blood transfusion practices, PBM has evolved into a comprehensive strategy encompassing four key elements: blood conservation modalities, anemia management, coagulation optimization, and patient-centered decision-making. PBM promotes a patient-centered, multidisciplinary structure, shifting focus from reactive to proactive care across all levels of prevention. PBM's goal is to become the standard of care in clinical practice, ensuring that the blood is treated with the same care as any other organ system. PBM has the potential to transform healthcare, aligning with principles of quality care, patient safety, and empowerment. Ultimately, PBM envisions a future where its proactive strategies become so ingrained in practice that the need for the term itself may fade away, as patient-centered blood health becomes a standard of care.

PBM and ERAS: mandatory bedfellows

2024-09-22T11:10:04+00:00

The concept of Enhanced Postoperative Recovery (ERAS) is a multimodal effort, and where patient blood management (PBM) contributes and should be included in future combined research strategies.

Anemia is a disease, not a number

2024-09-19T09:12:18+00:00

Anemia is one of the most common health conditions in the world but remains widely underrecognized and undertreated. This is largely due to the lack of recognition of anemia as a disease worthy of prevention and treatment. In clinical practice, anemia is identified by reference population-based hemoglobin concentration cutoff values. While simple to use, these reference values are based on limited data, oversimplify anemia diagnosis to a single hemoglobin value at which intervention such as transfusion may be warranted, do not incorporate patient signs and symptoms, lack clinical context, fail to provide information on underlying disease drivers, and ignore the complex relationships between oxygen delivery and consumption. Hence, there is an urgent need to recognize anemia as a disease that should be identified and addressed in each patient rather than as another laboratory value falling outside of a reference range. To improve anemia diagnosis, we must enhance our understanding of the relationships between hemoglobin concentrations and other laboratory and physiological markers with patient symptoms and patient-centered outcomes across a variety of clinical settings.

Reticulocyte hemoglobin in the evaluation of erythropoietic activity and iron availability

2024-09-23T10:52:12+00:00

The clinical laboratory plays a central role and impacts each of the Patient Blood Management (PBM) pillars: from detecting anemia and iron deficiency to reducing blood loss, an strategy to enable efficiency and thereby to improve patient care.

Perioperative iron deficiency and anemia are common in patients presenting for surgery, increase surgical risk, perioperative blood transfusions and can delay surgery date. Those conditions are independently associated with increased mortality and prolonged hospital stay after surgery. Rapid and effective diagnosis and treatment of iron deficiency is a key component of PBM Program.

Reticulocyte hemoglobin (Hb), a parameter for diagnosis and management of iron deficient erythropoiesis, can assist in early detection of iron deficiency, latent, absolute or functional and iron restricted erythropoiesis. The main concepts of Reticulocyte Hb are:

Hematology parameter which reflects the Hb content of reticulocytes
Is readily available from a routine EDTA blood sample analysis in the laboratory, without additional sampling.
Provides an early assessment of the available iron that was utilized in erythropoiesis over the previous 2-4 days.
-Reflects the bioavailability of iron for erythropoiesis, comparable to transferrin saturation, with the advantage that is not affected by the acute-phase reaction
Is useful in the diagnosis of patients at risk for latent and/or functional iron deficiency.

Reticulocyte Hb allows obtaining a fast and accurate picture of the erythropoiesis status, guiding the clinicians in their selection of the best and most efficient therapy for every patient. Is also an early indicator of the response to iron therapy. Measuring Reticulocyte Hb as a routine preoperative parameter could thus be a valuable, quite inexpensive option for a strategic adoption of PBM, contributing to reducing costs and improve outcomes of the patients undergoing surgery.

Inflammation and iron homeostasis – what do blood tests mean?

2024-11-28T11:31:05+00:00

Multiple links between inflammation and iron homeostasis exist, the most important being centered on hepcidin, the master regulator of iron homeostasis, a defensin-like peptide that acts by binding and inactivating the cell iron exporter ferroportin. The pro-inflammatory cytokine IL-6 is one of the most powerful stimuli to hepcidin synthesis, which causes macrophage iron retention and a reduction of enterocyte iron absorption. This results in a reduction of extracellular iron, which is essential for many pathogens but also for immune cells. Inflammation perturbates the levels of classical laboratory markers of iron status, like ferritin, serum iron, and transferrin (and hence transferrin saturation [TSAT). Thus, they are often difficult to interpret during infections or other acute and chronic sterile inflammatory states. Other laboratory parameters, like hepcidin, soluble transferrin receptor (sTfR), percentage of hypochromic erythrocytes (%HYPO), and reticulocyte hemoglobin content (CHr), have been proposed to better assess iron status during inflammation. An accurate evaluation of iron status in the anemia of inflammation and anemia of chronic disorders (ACD) is key to establishing a possible indication to iron supplementation and represents an area of active research.

Management of preoperative anemia: iron replacement

2024-11-05T09:30:01+00:00

Preoperative anaemia is prevalent in surgical patients and is associated with worse patient outcomes. Iron deficiency (ID), either absolute or functional is the leading cause of anaemia in this patient population. Therefore, in the surgical setting iron supplementation seems to be central to the implementation of the first pillar of Patient Blood Management(PBM).

Oral iron salts may be useful for the preoperative treatment of ID and mild to moderate iron deficiency anaemia (IDA), as well as replenishing low iron stores, provided there is adequate tolerance and sufficient time. The role of the newer oral iron formulations (e.g, sucrosomial iron) with greater iron bioavailability and improved gastrointestinal tolerance are currently being evaluated.

Intravenous (IV) iron has been demonstrated as a safe and effective alternative for patients who have intolerance or contraindication to oral iron, anaemia with inflammation, moderate to severe anaemia, persistent bleeding, or a short time before major surgery (≤4 weeks). IV iron formulations allowing administration of high doses (1,000-1,500 mg) in a single session (e.g., ferric derisomaltose) facilitate treatment and may be more cost-effective and patient centred than multiple lower dose infusions.

Managing preoperative anemia: EPO is needed

2024-12-09T09:52:43+00:00

Erythropoietin (EPO) is one of the treatments available for managing preoperative anemia and has now been included in several international recommendations on Patient Blood Management, particularly in major orthopedic and cardiac surgeries. Iron deficiency being the leading cause of anemia, iron supplementation is often the first-line treatment prescribed by clinicians; however, it frequently fails to raise hemoglobin levels enough to correct preoperative anemia or reduce perioperative transfusion needs. Here, we discuss the benefits and potential risks of preoperative EPO use as shown or observed in studies, particularly its superior effectiveness compared to iron alone for correcting anemia and reducing transfusion, and we present the clinical situations in which its use should be considered to improve patient outcomes.

Which should be the target for preoperative hemoglobin optimization?

2024-10-30T10:42:10+00:00

Preoperative anemia and non-anemic iron deficiency are risk factors for postoperative morbidity and mortality. In the context of a comprehensive patient blood management program, both preoperative anemia and hematinic deficiencies, especially iron deficiency, should be screened and treated, as appropriate. According to most recent clinical guidelines and consensus documents, patients scheduled for a major surgical procedure and presenting with preoperative hemoglobin <13 g/dL, irrespective of gender, should be considered anemic. This hemoglobin cutoff has been recently challenged, but we consider data inconclusive. Waiting for new evidence, the treatment target should be the correction of hematinic deficiencies and attaining a hemoglobin of at least 13 g/dL on admission, with its upper level tailored to patient and procedure characteristics.

Postoperative anemia: prevention without cure is not enough

2024-11-05T09:21:19+00:00

Postoperative anemia is common after major surgery. It is largely overlooked, and often considered a benign but inevitable outcome of surgery. However, it has an impact on postoperative complications, unplanned readmissions after surgery, recovery time and return to intended oncological treatment. While all international guidelines and consensus statements focus on preoperative anemia management and intraoperative blood loss limitation, there is little advice on postoperative anemia treatment. This commentary provides an overview on key considerations for postoperative anemia and its management.

Postoperative anemia: is there a role for iron replacement therapy?

2024-09-26T10:46:19+00:00

Postoperative anemia (PA) is very common in major surgical procedures. PA increases the risk of transfusion and could hinder early rehabilitation and quality of life. Treatment of PA involves a multifaceted approach, including iron therapy, ESAs, and blood transfusions, but also no treatment at all. Each method has its advantages and limitations, and the choice of treatment should be tailored to the patient's specific condition and needs. Further research is needed to optimize the treatment of PA and improve patient outcomes.

Management of postpartum anemia

2024-10-22T08:08:07+00:00

Anemia is a global problem with an immense gender gap. The postpartum period can be seen as a window of opportunity to treat women of the reproductive age with anemia. Overall, oral iron is recommended for mild to moderate anemia, and intravenous iron for severe anemia. It is crucial with sufficient specialized postpartum follow-up to ensure adequate treatment, to prevent recurrent iron deficiency and maintain health and wellbeing in women of the reproductive age and for future pregnancies.

Implementing first pillar of PBM in the Emergency Area: a missed opportunity?

2024-12-17T10:08:05+00:00

Anemia is a common condition in emergency care, with a significant proportion of patients presenting with low hemoglobin levels. Despite clinical guidelines promoting a more restrictive approach to blood transfusion, many transfusions remain inappropriate. This is often due to the use of incorrect hemoglobin thresholds or failure to address underlying causes, such as iron deficiency. Excessive use of transfusions exposes patients to avoidable risks, including circulatory overload and other transfusion-related complications.

The first pillar of Patient Blood Management aims to reduce the need for transfusions through early detection and targeted treatment of anemia. In patients with iron deficiency anemia, an effective strategy is the administration of intravenous iron, which allows for rapid and sustained increases in hemoglobin even in cases with severe anemia. This approach reduces reliance on transfusions, shortens hospital stays, and lowers healthcare costs. While the efficacy of intravenous iron is well established, its application in emergency care is often limited, highlighting the need for structural changes and improved clinical practice.

A promising solution is the establishment of anemia clinics within emergency departments. These clinics facilitate rapid diagnosis, early treatment and comprehensive follow-up care. This model supports more efficient use of healthcare resources by reducing transfusions, minimizing hospital admissions, and alleviating the strain on emergency department capacity. Additionally, it offers long-term benefits for chronic anemia management, promoting a patient-centred approach that aligns with Patient Blood Management principles.

The implementation of anemia clinics in emergency care presents a valuable opportunity to fully realise the first pillar of Patient Blood Management, optimising patient care and healthcare efficiency. Addressing this gap could improve patient safety, reduce healthcare costs, and promote the sustainable use of limited blood supplies. Greater awareness, education, and system-wide changes are required to embed this evidence-based approach into emergency care workflows.

Direct oral anticoagulants measurement: when is it necessary?

2024-10-28T15:29:47+00:00

Background. Direct oral anticoagulants (DOAC) are the mainstay for treatment/prevention of thrombosis in cardiovascular diseases. They are prescribed at fixed dosage based on patients’ characteristics. However, there are situations when laboratory assessment of DOAC plasma concentrations is crucial to help clinicians make decision.

Materials and Methods. This Commentary discusses the reasons for testing and the type of testing to be used.

Results. The occasions for testing include (i) adverse events; (i) before surgical or invasive procedures; (iii) before initiation of thrombolytic therapy; (iv) testing to look for interaction with additional drugs. The tests to be used are the dilute thrombin time for dabigatran and the anti-FXa assays for rivaroxaban, apixaban and edoxaban.

Discussion. Although DOACs are prescribed at fixed dosage without laboratory assistance for dose-adjustment, there are occasions when laboratory testing may be useful for patients’ management.

Viscoelastic monitoring of direct oral anticoagulants (DOAC)

2024-09-16T06:50:39+00:00

The management of procedures at risk of major or critical bleeding in patients treated with direct oral anticoagulants (DOAC) is challenging, making urgent monitoring to detect and quantify residual effects, optimal for accurate clinical decision making. Conventional coagulation tests such as prothrombin time and activated partial thromboplastin time can be used as screening tests to detect the non-specific presence of DOAC, but do not correlate well with plasma concentrations. Quantitative methods such as diluted thrombin time for direct thrombin inhibitors and calibrated anti-Xa assays or activated FX inhibitors provide limited therapeutic monitoring. Viscoelastic analysis offers a reliable option for urgent assessment of the presence of DOAC. The tests and parameters that have been shown to be useful in differentiating between types of DOAC are those that evaluate the kinetics and generation of thrombin with modification of the reagents, and correlate the times obtained with residual plasma concentrations. Viscoelastic monitoring with specific assays (Russell's Viper Venom and Ecarin) provides a rapid and reliable tool with greater sensitivity than conventional laboratory tests in urgent procedures with critical bleeding risk, enabling a quantitative assessment of the residual effect of a DOAC and its possible therapeutic reversal. Although clinical practice guidelines do not currently support the widespread use of viscoelastic testing for DOAC monitoring due to limited evidence, these tests provide a global hemostatic perspective and have the advantage of speed, individualization, and the possibility of quantitative monitoring. Research and further distribution of rapid and accurate viscoelastic-specific monitoring devices should be encouraged to improve clinical decision making and patient outcomes.

Reversal of oral anticoagulation in emergency conditions

2025-01-08T08:06:52+00:00

Anticoagulation is the mainstay of prevention and treatment of thromboembolic phenomena and is a life-saving therapy involving a very high number of people in the world. However, the mechanisms by which anticoagulants provide beneficial effects to the cure of patients also cause an increase in bleeding risk. The availability of antidotes for the reversal of their anticoagulant effects is extremely important. In this commentary, we review all the available and approved antidotes of oral anticoagulant drugs, either vitamin K antagonists (i.e., vitamin K + 4F-PCC) or direct anti-IIa and anti-Xa agents (i.e., idarucizumab or andexanet alfa, respectively). We also describe the indications and modalities of their use in emergency, in patients with intracranial hemorrhage (ICH) or severe gastrointestinal (GI) bleeding.

Coagulation Factor XIII - Last to think about?

2024-10-23T10:18:12+00:00

This commentary thoroughly examines extensive bleeding, evaluating the current knowledge and analyzing whether earlier administration of coagulation factor XIII (FXIII) could be beneficial. The timely administration of FXIII is advised in managing massive bleeding to enhance clot stability, reduce the risk of rebleeding, and improve overall patient outcomes. While FXIII may not always be the first factor considered in the initial stages of bleeding management, its early administration can significantly prevent further bleeding complications and support adequate hemostasis in critically ill patients. Although this concept is initially intuitive, more solid scientific evidence is needed to support or indicate the optimal time point for the therapy with FXIII.

Administration of fibrinogen concentrates to patients with severe bleeding. How much is enough?

2024-10-21T08:51:20+00:00

Fibrinogen concentrate (FC) should be administered to patients with severe bleeding, preferably guided by viscoelastic hemostatic assays (VHAs) or plasma fibrinogen level (Clauss method) if VHAs are not available. However, it may be blindly prescribed (without coagulation testing) in patients with life-threatening hemorrhage. Preemptive or prophylactic FC administration in patients without moderate or severe bleeding is not recommended. There is no consensus regarding the minimum FC dose that should be prescribed, although it seems reasonable to administer 3-4 g as soon as possible. FC appears to have a good safety profile and is well tolerated; available evidence does not suggest an increased rate of thromboembolic events associated with its administration.

Fibrinogen: the higher the better?

2025-01-07T10:07:22+00:00

Fibrinogen supplementation is commonly used to manage severe bleeding. Guidelines mostly recommend supplementation by cryoprecipitates or fibrinogen concentrates to maintain fibrinogen concentration above 1.5-2 g/L. However, evidence supporting these targets is weak and debates persist.

Fibrinogen plays a key role in hemostasis by forming clot fibrin network and promoting platelet aggregation. A decrease in fibrinogen concentration is a predictor of bleeding severity, particularly in surgery, postpartum hemorrhage and trauma. In vitro and clinical studies reported that low fibrinogen levels impair fibrin clot strength, and that clot strength is restored with fibrinogen repletion. All these data suggest that the higher the fibrinogen concentration, the better the management of bleeding. Nevertheless, randomized controlled trials have often failed to show significant benefits of fibrinogen supplementation during severe bleeding. Similarly, preemptive fibrinogen administration in surgery has shown no positive effect in patients without hypofibrinogenemia. These studies suggest that normal fibrinogen concentrations often remain sufficient to maintain clot function.

There are safety concerns with excessive fibrinogen supplementation. Elevated fibrinogen levels may promote thrombosis by enhancing clot density and resistance to breakdown. Some studies suggest a possible association between fibrinogen levels and adverse cardiovascular events. Costs are another issue.

In summary, current guidelines recommend target fibrinogen levels of 1.5-2 g/L during bleeding whereas higher targets are not supported due to lack of clinical benefit, cost, and potential risks. Further research is needed to optimize fibrinogen administration practices and evaluate their impact on clinical outcomes.

Tranexamic acid in hip fracture repair surgery: safe and effective?

2024-12-16T11:00:22+00:00

Tranexamic acid (TXA) is widely used in various surgical settings to prevent bleeding. Despite extensive evidence supporting its safety and efficacy in many procedures, including hip fracture surgery, it is still largely underused. TXA could be given orally, intravenously or topically pre-, intra- and/or postoperatively. It has been shown to reduce blood transfusions and also to shorten hospital stays. Low doses are efficient. Almost all patients with hip fracture should receive TXA.

Is there still a role for cell salvage?

2024-11-11T07:59:57+00:00

Autologous blood salvage or cell salvage gained popularity during the HIV era. As HIV is not a threat to the blood supply any more, and as surgical technology has become more non-invasive, it raises the question as to whether there is still a role for autologous blood salvage. This author would argue that there are continuing threats to the blood supply, including an inadequate supply and the economic burden of allogeneic blood that it may be too soon to retire autologous blood salvage. In addition, there are growth opportunities that have been untapped such as trauma, cancer surgery and obstetrical care. If clinicians would get over their theoretical fears of salvage use in these environments, it would further extend the available blood supply.

Safety of intraoperative blood salvage in cancer surgery

2024-10-18T07:46:57+00:00

This Commentary article discusses the safety and effectiveness of intraoperative cell salvage in cancer surgery. Modern techniques, such as leukocyte reduction filters and monoclonal antibodies like Catumaxomab, have been developed to minimize this risk by removing tumor cells from salvaged blood. Ongoing studies aims to assess the safety of re-infusing filtered blood, potentially improving patient outcomes during cancer surgeries.

Restrictive versus liberal transfusion thresholds: lights and shadows

2024-10-14T07:40:09+00:00

The hemoglobin threshold below which an anemic patient needs to be transfused is the main questions of modern transfusion medicine and one of the most important issues of patient-centered blood management (PBM) programs. Considering the key function of red blood cells (RBC) in improving tissue and organs oxygenation, for many years a liberal transfusion approach (i.e., transfusion threshold of hemoglobin < 10 g/dL) was the predominant attitude among clinicians that guided transfusion decision-making. More recently, this widely adopted transfusion policy was questioned by a more restrictive (i.e., transfusion threshold of hemoglobin < 7-8 g/dL) approach. Thanks to the results of many randomized controlled trials, systematic reviews and meta-analyses nowadays, most of the international scientific societies and experts currently recommend a restrictive approach over a liberal approach for anemic, hemodynamically stable, patients. However, as not rarely happens in medicine, there are several still unsolved greys areas of uncertainty. These issues will be concisely and critically addressed in this commentary.

Physiologic transfusion thresholds, better than using Hb-based thresholds?

2024-09-20T10:17:51+00:00

Transfusion guidelines recommend using hemoglobin (Hb)-based transfusion thresholds to decide whether to transfuse packed red blood cells. In most cases, even in restrictive transfusion strategies, these thresholds are above the theoretical limits of anemia tolerance, implying a potential risk for over-transfusion. Additionally, isolated hemoglobin or hematocrit values do not adequately reflect the balance between oxygen delivery and oxygen consumption and are, therefore, not suitable to detect impaired tissue oxygenation. As a consequence, physiologic transfusion triggers have been suggested as an alternative. Despite their intuitive physiologic rationale and the past efforts to scientifically investigate different physiologic transfusion triggers, most guidelines do not recommend their use in current clinical practice. Recent randomized controlled trials and prospective observational trials have shed new light on the possible benefits of using physiologic transfusion triggers in pRBC transfusion practice. Nevertheless, there is still a lack of solid scientific evidence supporting the feasibility, benefit, and safety of physiologic transfusion triggers to challenge the current gold standard of Hb-based transfusion practice. This commentary discusses the current literature and compares the concept of Hb-based transfusion triggers with alternative physiologic transfusion triggers.

Is there no such thing as a free lunch? With Patient Blood Management, maybe there is!

2025-02-10T08:50:17+00:00

PREVIEW

Modern therapeutic options in medicine typically come with a drawback: they are either costly or not suitable for everyone. However, over the past 20 years, Transfusion Medicine has evolved into Patient Blood Management (PBM), a treatment approach that not only improves patient outcomes but also reduces healthcare costs.

PBM is an evidence-based, patient-centered strategy designed to optimize and preserve a patient's own blood while enhancing safety and clinical outcomes. It focuses on three key principles: preventing anemia, minimizing blood loss, and reducing unnecessary transfusions¹. These elements are interdependent, bleeding leads to anemia, which in turn increases the need for transfusion; each factor is associated with higher mortality and increased healthcare costs. [ ... ]