BLOOD MANAGEMENT

Perioperative blood conservation. Eur J Anaesthesiol. 2009 May 14. [Epub ahead of print]. Review

Blood loss in surgical oncology: Neglected quality indicator? J Surg Oncol. 2009 May 22;99(8):508-512. [Epub ahead of print] Blood loss is a modifiable quality indicator for oncologic cancer surgery. Surgical oncologists need to alter their surgical technique to promote bloodless surgery and decrease the variability in reported blood loss and rates of blood transfusion

MELD score and blood product requirements during liver transplantation: no link. Transplantation. 2009 Jun 15;87(11):1689-94. In recent years, improvements in surgical and anesthetic techniques have greatly decreased the amount of blood products transfused. We have published a median of 0 for all intraoperative blood products transfused. Some authors argue that these results could be possible merely because of the relatively healthy cohort in terms of model of end-stage liver disease (MELD) score.The logistic regression analysis found that only two variables were linked to RBC transfusion; starting hemoglobin value and phlebotomy. In this series, the MELD score was as high as US series and did not predict blood losses and blood product requirement during liver transplantation. If the MELD system has to be implemented to prioritize orthotopic liver transplantation, it should be revisited, and the starting hemoglobin value should be added to the equation.

Red blood cell use outside the operating theater: a prospective observational study with modeling of potential blood conservation during severe blood shortages. Transfusion. 2009 Jun 4. [Epub ahead of print] National guidance recommends planning for future blood shortages, but few studies have evaluated how reduced demand could be achieved acutely. The relative use of RBC units across specialties was as follows: medical, 74%; surgical, 22%; and other, 4%. For medical and surgical patients, respectively, 31 and 10% of all RBC units were transfused for anemia without evidence of bleeding, and 38 and 12% were transfused for non-life-threatening bleeding. Eight-five percent of all patients who received transfusions had stable vital signs before transfusion. Our model suggested that only 11% of RBCs would be conserved by cancellation of major surgery, whereas 23% to 47% of all RBCs could be conserved by controlling transfusions to medical patients. In institutions with patterns of blood use similar to ours, control of transfusions to medical patients is the most effective response to acute blood shortages.

Blood transfusion in obstetrics: the pregnant women's point of view. J Obstet Gynaecol. 2009 Apr;29(3):220-2. A total of 41% of participants were aware of the possible need for blood transfusion in pregnancy and 88% of all women would accept blood transfusion when necessary. The remaining 12% would refuse blood transfusion, even if it was life-saving, because of the fear of blood transfusion complications. It is concluded that counselling and a management plan should be scheduled for pregnancy, and management protocols should be developed for women who refuse blood transfusion. Transfusion alternatives should be discussed with women who will not accept the allogenic blood transfusion.

Blood conservation in practice: an overview. Br J Hosp Med (Lond). 2009 Jan;70(1):16-21. Review

The clinical utility of an index of global oxygenation for guiding red blood cell transfusion in cardiac surgery. Transfusion. 2009 Apr;49(4):682-8.If a normal O2ER in anemic patients with no evidence of organ dysfunction indicates adequate tissue oxygen delivery, then our findings suggest that incorporating O2ER into the transfusion decision will substantially reduce post-cardiac surgery RBC transfusions by allowing us to safely avoid transfusing this group of patients. Future studies are needed to assess the validity of this conclusion.

To transfuse, or not to transfuse: that is the question. Crit Care Resusc. 2009 Mar;11(1):71-7. Recent research on clinical outcomes has examined the impact of blood transfusion on critically ill patients, patients with trauma, those undergoing cardiac surgery, those experiencing acute coronary syndromes, oncology patients and others. Evidence is mounting of adverse outcomes associated with blood transfusion in a wide variety of clinical contexts. Here, we highlight the deficit in the current literature guiding transfusion practice, and call for an Australasian study to fill this deficit.

Transfusion in the intensive care unit. Surg Infect (Larchmt). 2005;6 Suppl 1:s33-9. A conservative transfusion strategy appears safe in nearly all critically ill patients without active hemorrhage, including patients with cardiovascular disease. Whether a lower transfusion threshold could be adopted is unknown.

Rationale for blood conservation. Surg Infect (Larchmt).2005;6 Suppl 1:s3-8.Pharmacologic stimulation of erythropoiesis offers substantial potential to progress toward a goal of bloodless medicine. The potential of artificial blood substitutes is still being defined.

Risk of anemia and transfusion triggers: implications for bloodless care. Surg Infect (Larchmt). 2005;6 Suppl 1:s17-21 A restrictive transfusion threshold (7 g/dL) is recommended in most patients. In patients with cardiovascular disease, a 9-10 g/dL may be advisable, but definitive guidelines await further clinical trials. However, as with all such treatments, the decision to transfuse should be based on individual assessment of patients' signs, symptoms, and co-morbidity

Guidelines of the German Medical Association for Therapy with Blood Components and Plasma Derivatives - An Introduction. Evidence-Based recommendations for the Risk-Benefit Analysis in Hemotherapy.] Anasthesiol Intensivmed Notfallmed Schmerzther. 2009 Mar;44(3):186-99. Epub 2009 Mar 5. German. Because the collection of such products requires the willingness of numerous volunteers to donate blood, the responsible and carefully considered application of blood products is mandatory. For the first time, the recommendations have been evaluated on evidence-based criteria and listed for many specific medical interventions so that comprehensive procedures can now be created for the transfusion personnel in hospitals and clinics.

Transfusion insurgency: practice change through education and evidence-based recommendations. Am J Surg. 2009 Mar;197(3):279-83.Implementation of an evidence-based transfusion guideline reduced the number of infused units and patients transfused without an increase in mortality.

Guidelines for the diagnosis and management of disseminated intravascular coagulation. Br J Haematol. 2009 Feb 12. [Epub ahead of print]. Review

Blood Transfusion Reduction in Cardiac Surgery: Multidisciplinary Approach at a Community Hospital. Ann Thorac Surg. 2009 Feb;87(2):532-539. Mounting evidence exists for more restrictive blood transfusion practices in patients undergoing cardiac surgery. Using a multidisciplinary approach to quality improvement, and with the goal of using fewer blood products, our incidence of allogeneic red blood cell transfusion was decreased, from 43% in 2003 to 18% in 2007. Patient outcomes were not significantly changed. Cardiac surgery in a community hospital can be performed safely with low utilization of allogeneic red blood cell transfusions. A multidisciplinary approach to blood conservation can result in lower transfusion rates and equivalent patient outcomes.

Exsanguination in trauma: A review of diagnostics and treatment options. Injury. 2009 Jan 7. [Epub ahead of print]The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma.The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.

Neurodevelopmental Outcome of Extremely Low Birth Weight Infants Randomly Assigned to Restrictive or Liberal Hemoglobin Thresholds for Blood Transfusion. Pediatrics. 2009 Jan;123(1):207-213. Maintaining the hemoglobin of extremely low birth weight infants at these restrictive rather than liberal transfusion thresholds did not result in a statistically significant difference in combined death or severe adverse neurodevelopmental outcome.

A Management Guideline to Reduce the Frequency of Blood Transfusion in Very-Low-Birth-Weight Infants.Am J Perinatol. 2008 Dec 15. [Epub ahead of print] The combination of a 30-second delay in cord clamping, early protein and iron, and a change of transfusion thresholds reduced the number of blood transfusions by half.

Patient blood management: the pragmatic solution for the problems with blood transfusions. Anesthesiology. 2008 Dec;109(6):951-3. No abstract available.

An evaluation of cyclooxygenase-1 inhibition before coronary artery surgery: aggregometry versus patient self-reporting. Anesth Analg. 2008 Dec;107(6):1791-7. Patients with abnormal aggregation before intervention (<51 U) received significantly more platelet transfusion than patients with normal aggregation (1.1 U compared to 0.3 U, P = 0.001). Our results suggest that arachidonic acid-induced aggregation in whole blood may be a better predictor of platelet-related coagulopathy and platelet transfusion than the assessment of aspirin intake by patient self-reporting.

Tissue oxygen saturation predicts the need for early blood transfusion in trauma patients.

Am Surg. 2008 Oct;74(10):1006-11. Near-infrared spectroscopy (NIRS) has been used to measure regional tissue oxygen saturation (StO2) in skeletal muscle as an indicator of perfusion in trauma patients. The need for blood transfusion within 24 hours of arrival was not predicted by hypotension, tachycardia, arterial lactate, base deficit, or hemoglobin. StO2 may represent an important screening tool for identifying trauma patients who require blood transfusion or other limited medical resources.

Perioperative coagulation management and blood conservation in cardiac surgery: a Canadian Survey.

J Cardiothorac Vasc Anesth. 2008 Oct;22(5):662-9. Epub 2008 May 12. The majority of Canadian institutions do not use point-of-care tests other than ACT. Most institutions do not have algorithms for management of bleeding following cardiac surgery and at least 30% do not monitor their transfusion practice perioperatively. Cardiac surgery patients in Canada may benefit from a standardized approach to blood conservation in the perioperative period.

The surgical application of point-of-care haemostasis and platelet function testing.

Br J Surg. 2008 Oct 9;95(11):1317-1330.. 2008 Oct 9;95(11):1317-1330.. 2008 Oct 9;95(11):1317-1330. [Epub ahead of print] POC tests identifying perioperative bleeding tendency are already widely used in cardiovascular and hepatic surgery. They are associated with reduced blood loss and transfusion requirements. POC tests to identify thrombotic predisposition are able to determine antiplatelet resistance, predicting thromboembolic risk.

Bloodless cardiac surgery and the pediatric patient: a case study.

Perfusion. 2008 Mar;23(2):131-134.We report a 5.9 kg male infant who underwent successful surgical correction of a ventricular septal defect without the use of homologous blood transfusion. Our strategies included the pre-operative administration of erythropoietin and iron to increase red blood cell mass, acute normovolemic hemodilution (ANH) before the institution of CPB, retrograde autologous priming (RAP), cell salvage, continuous ultrafiltration, vacuum-assisted venous drainage to minimize the circuit size and priming volume, and the use of near infrared spectroscopy (NIRS) to monitor the patient during the entire procedure. The utilization of these strategies is now standard for our entire pediatric cardiac surgical population.

Effect of laboratory testing guidelines on the utilization of tests and order entries in a surgical intensive care unit.

Crit Care Med. 2008 Sep 26. [Epub ahead of print] Guidelines designed to optimize laboratory tests use in an intensive care unit can produce rapid and long-lasting effects, can be safe and may affect the number of red blood cell units transfused.

Red cell transfusion triggers.

Transfus Apher Sci. 2008 Sep 10. [Epub ahead of print] The epidemiology of red cell transfusion is changing. Surgical use has decreased due to reduced transfusion triggers and better operative techniques. Medical use increases partly due to the increasing age of the population. The evidence for and against transfusion at different levels of anaemia is discussed. The appropriate level of haemoglobin at which to recommend transfusion depends on the indication for transfusion, the patient's co-morbidities and the quality of the red cells available.

Donor deferral and resulting donor loss at the American Red Cross Blood Services, 2001 through 2006.

Transfusion. 2008 Aug 20 . 2008 Aug 20. 2008 Aug 20. [Epub ahead of print] A mean of 12.8 percent of a total of 47,814,370 donor presentations between 2001 and 2006 resulted in a deferral. While majority of the deferrals were related to donor safety reasons, deferrals for recipient safety reasons accounted for 22.6 percent of deferrals or 2.9 percent of total presentations. Temporary and indefinite deferrals for recipient safety-related reasons collectively caused an estimated loss of 647,828 donors during the 6 years. An additional 1,042,743 donors were lost due to deferrals for donor safety-related reasons during the same period.

A massive transfusion protocol to decrease blood component use and costs.

Arch Surg. 2008 Jul;143(7):686-91. The massive transfusion protocol resulted in a reduction in the use of blood components with improved turnaround times and significant savings. Mortality was unaffected. The use of recombinant factor VIIa did not increase thromboembolic complications in these patients.

Subclinical haemostatic activation and current surgeon volume predict bleeding with open radical retropubic prostatectomy.

BJU Int. 2008 Jul 29. [Epub ahead of print] Haemostatic activation before retropubic prostatectomy was associated with significantly less bleeding when assessed by objective measures, predicting the decrease in haemoglobin level better than prothrombin time, aPTT or platelet counts. Current surgeon volume might also predict both subjective and objective bleeding variables.

Pre-operative injections of epoetin-{alpha} versus post-operative retransfusion of autologous shed blood in total hip and knee replacement: A PROSPECTIVE RANDOMISED CLINICAL TRIAL.

J Bone Joint Surg Br. 2008 Aug;90(8):1079-83 Pre-operative epoetin injections are more effective but more costly in reducing the need for allogeneic blood transfusions in mildly anaemic patients than post-operative retransfusion of autologous blood

Blood conservation in a congenital cardiac surgery program.

AORN J. 2008 Jun;87(6):1180-6; quiz 1187-90. Review

Effectiveness of preoperative autologous plateletpheresis combined with intraoperative autotransfusion on the blood coagulation in orthopaedic patients

Zhonghua Wai Ke Za Zhi. 2008 Jan 15;46(2):118-21. Chinese Preoperative plateletpheresis combined with intraoperative autotransfusion can ameliorate the blood coagulation in orthopaedic patients, and it is an effective way to decrease blood loss and homologous blood-transfusions requirements.

Risks and benefits of deliberate hypotension in anaesthesia: a systematic review.

Int J Oral Maxillofac Surg. 2008 May 27. [Epub ahead of print] Hypotensive anaesthesia appears to be effective in reducing blood loss. Serious consequences due to organ hypoperfusion are uncommon. Hypotensive anaesthesia can be justified as a routine procedure for orthognathic surgery especially bimaxillary osteotomy.

Pharmacologic methods to reduce perioperative bleeding.

Transfusion. 2008 Mar;48(1 Suppl):31S-38S. No abstract available.

The ongoing variability in blood transfusion practices in cardiac surgery.

Transfusion. 2008 Apr 14; [Epub ahead of print] Utilization of red blood cells (RBCs), fresh-frozen plasma (FFP), and platelets (PLTs) was assessed daily, before, during, and after surgery until hospital discharge. Intraoperative RBC transfusion varied from 9 to 100 percent among the 16 countries, and 25 to 87 percent postoperatively (percentage of transfused patients). Similarly, frequency of transfusion of FFP varied from 0 to 98 percent intraoperatively and 3 to 95 percent postoperatively, and PLT transfusion from 0 to 51 and 0 to 39 percent, respectively. Moreover, there were not only marked differences in transfusion rates between centers in different countries but also in interinstitutional comparison of multiple centers within countries. In cardiac surgical patients, marked variability in transfusion practice exists between centers in various countries and suggests differences in perioperative practice patterns as well as possible inappropriate use. International standardization of perioperative practice patterns as well as transfusion regimes appears necessary.

Evidence for indications of fresh frozen plasma.

Transfus Clin Biol. 2008 Apr 18; [Epub ahead of print] The strongest randomised controlled trial (RCT) evidence indicates that prophylactic plasma for transfusion is not effective across a range of different clinical settings and this is supported by data from non-randomised studies in patients with mild to moderate abnormalities in coagulation tests. There are also uncertainties whether plasma consistently improves the laboratory results for patients with mild to moderate abnormalities in coagulation tests. There is a need to undertake new trials evaluating the efficacy and adverse effects of plasma, both in bleeding and non-bleeding patients, to understand whether the "presumed" benefits outweigh the "real risks". In addition, new haemostatic tests should be validated which better define risk of bleeding.

Anemia, Blood Loss, and Blood Transfusions in North American Children in the Intensive Care Unit.

Am J Respir Crit Care Med. 2008 Apr 17; [Epub ahead of print] Critically ill children are at significant risk for developing anemia and receiving blood transfusions. Transfusion in the Pediatric Intensive Care Unit was associated with worse outcomes. It is imperative to minimize blood loss from blood draws and to set clear transfusion thresholds.

Coagulation Defects Do Not Predict Blood Product Requirements During Liver Transplantation.

Transplantation. 2008 Apr 15;85(7):956-962. The avoidance of plasma transfusion was associated with a decrease in RBC transfusions during liver transplantation. There was no link between coagulation defects and bleeding or RBC or plasma transfusions. Previous reports indicating that it is neither useful nor necessary to correct coagulation defects with plasma transfusion before liver transplantation seem further corroborated by this study. We believe that this work also supports the practice of lowering central venous pressure with phlebotomy to reduce blood loss, during liver dissection, without any deleterious effect.

Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty.

Clin Orthop Relat Res. 2008 Mar;466(3):714-21. Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. Clinical pulmonary embolus occurs despite the use of anticoagulants. Patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban nticoagulants were associated with the highest all-cause mortality of the three modalities studied.

Optimal hemoglobin concentration in patients with subarachnoid hemorrhage, acute ischemic stroke and traumatic brain injury.

Curr Opin Crit Care. 2008 Apr;14(2):156-162. Both severe anemia and red blood-cell transfusion may negatively influence clinical outcome in neurocritical patients. Acceptance of low hemoglobin concentrations may be justified by avoiding negative transfusion effects. No evidence-based transfusion trigger in neurocritical patients can be recommended.

Restrictive red blood cell transfusion: not just for the stable intensive care unit patient.

Am J Surg. 2008 Mar 18; [Epub ahead of print] A transfusion guideline accompanied by intensive education is effective in reducing RBC transfusions in a trauma-burn ICU. A lower hematocrit was well tolerated in both the symptomatic and asymptomatic groups of surgical patients. With education and follow-up, the changes in transfusion practices were durable and affected transfusion practices for both asymptomatic and symptomatic patients.

Minimising blood loss and transfusion requirements in hepatic resection.

HPB (Oxford). 2002;4(1):5-10. Blood-saving strategies (preoperative autologous blood donation, low central venous pressure anaesthesia, aprotinin administration, ultrasonic dissection, hepatic vascular inflow occlusion and a Cell Saver) resulted in decreased estimated blood loss (4500 mL vs. 1000 mL p<0.001). In addition, the number of patients requiring transfusion decreased (91.8% vs. 25.5% respectively, p<0.001) and the mean number of units of HB transfusion was lower (I 3.7 vs. 2.3, p<0.001). Morbidity and mortality were also decreased (57.1% vs. 25.5%, p<0.001 and 10.2% and 4.9% p<0.001, respectively).

Programmatic blood conservation in cardiac surgery.

Semin Cardiothorac Vasc Anesth. 2007 Dec;11(4):242-6. Early preoperative planning and a coordinated perioperative plan allow the appropriate use of blood conservation modalities to ensure that their benefits span the entire perioperative period. This article describes some of the modalities currently used in patients undergoing cardiac surgery.

Postoperative blood loss and transfusion associated with use of Hextend in cardiac surgery patients at a blood conservation center.

Transfusion. 2008 Feb 1; [Epub ahead of print] To minimize transfusion and bleeding in these patients, it is recommended that HEX be used in amounts of not more than 20 mL per kg together with point-of-care coagulation tests and other blood conservation strategies

Current opinions on safer red cell transfusion practice and the appropriate use of alternative strategies.

Transfus Apher Sci. 2007 Oct;37(2):201-7. The current opinions on "safer transfusion" through the use of currently available alternatives are highlighted with the goal of promoting the use of transfusion alternatives in everyday clinical practice.

Improving outcomes of percutaneous coronary intervention through the application of guidelines and benchmarking: reduction of major bleeding and blood transfusion as a model.

Clin Cardiol. 2007 Oct;30(10 Suppl 2):II44-8. Authors describe a model for the application of a continuous quality improvement program including benchmarking and available guidelines for blood transfusion, aimed toward reducing transfusion rates among patients undergoing PCI.

Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC]).

Transfusion. 2007 Nov 13; [Epub ahead of print] The implementation of a provincial network of transfusion coordinators was feasible and allogeneic transfusion rates declined over the period the program has been in place.

Changing age distribution of the blood donor population in the United States.

Transfusion. 2007 Nov 13; [Epub ahead of print] The aging patterns of blood donors suggest the need for improved recruitment and retention in the young adult and middle-aged groups. A severe shortage of blood and blood components may be forecast in the foreseeable future unless offset by significant increased supply or reduced usage of blood and blood components.

Acute coagulopathy of trauma: mechanism, identification and effect.
Curr Opin Crit Care. 2007 Dec;13(6):680-685. Acute coagulopathy results in increased transfusion requirements, incidence of organ dysfunction, critical care stay and mortality. Recognition of an early coagulopathic state has implications for the care of shocked patients and the management of massive transfusion. Identification of novel mechanisms for traumatic coagulopathy may lead to new avenues for drug discovery and therapeutic intervention.

Implications of bleeding and blood transfusion in percutaneous coronary intervention.
Rev Cardiovasc Med. 2007;8 Suppl 3:S18-26. Reduction in bleeding risk is a desirable goal that may potentially improve survival and increase comfort for patients undergoing PCI. Using strategies such as careful vascular access, alternative radial artery access, and modified antithrombotic regimen may reduce bleeding during PCI as well as improve patient outcomes.

Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials
Can J Anaesth. 2007 Oct;54(10):799-810. Review

Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs.
Br J Anaesth. 2007 Oct 9; [Epub ahead of print] In this study, the implementation of an algorithm for transfusion strategy changed practice and improved quality of care. The costs for EPO, its administration, and monitoring outside hospital were offset by the reduction in hospital transfusion costs.

Blood management: a primer for clinicians.
Pharmacotherapy. 2007 Oct;27(10):1394-411.
The purpose of this primer is to broaden the awareness of health care practitioners in terms of the risks versus benefits of blood transfusions, their economics, and alternative treatments.

Antihypertensive medications and anemia.
J Clin Hypertens (Greenwich). 2007 Sep;9(9):723-7. The mechanistic basis for antihypertensive medication-related changes in hemoglobin concentration include hemodilution, hemolytic anemia, and suppression of red blood cell production, as this occurs most commonly with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. A reduction in hemoglobin concentration in a patient who is receiving treatment for hypertension and does not have an obvious source of blood loss should account for potential antihypertensive therapy involvement

Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation.
BMC Health Serv Res. 2007 Aug 31;7(1):138 [Epub ahead of print] This model demonstrates that a restrictive transfusion strategy in appropriate at risk ICU patients is dominant and could result in improved quality of care and cost savings. Given the potential savings of 40,000 TSACs and nearly $1 billion, it is incumbent upon the intensivist community to promote more ubiquitous adoption of a clinically appropriate restrictive transfusion strategy in the ICU. FREE FULL TEXT

Bleeding during critical illness: a prospective cohort study using a new measurement tool.
Clin Invest Med. 2007;30(2):E93-102. Overall, 90% of patients experienced a total of 480 bleeds of which 94.8% were minor and 5.2% were major. Inter-rater reliability of the HEME tool was excellent (phi = 0.98, 95% CI: 0.96 to 0.99). A decrease in platelet count and a prolongation of partial thromboplastin time were independent risk factors for major bleeding but neither were renal failure nor prophylactic anticoagulation. Patients with major bleeding received more blood transfusions and had longer ICU stays compared to patients with minor or no bleeding.

Anemia in patients undergoing percutaneous coronary intervention : current issues and future directions.
Am J Cardiovasc Drugs. 2007;7(4):225-33. Review.

Erythropoietic therapy: cost efficiency and reimbursement.
Am J Health Syst Pharm. 2007 Aug 15;64(16 Suppl 11):S19-29. Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.

Bloodless (Liver) Surgery? The Anesthetist's View.
Dig Surg. 2007;24(4):265-73. Epub 2007 Jul 27 A multidisciplinary effort has to be made through the entire chain, from the outpatient clinic through discharge from the hospital, with the utmost exertion of all team members in which surgeons play a key role in the adaptation of a bloodless (liver) surgery program to the specific needs of patients.

[Assessment of knowledge in blood transfusion of medical staff in 14 state-run hospitals.]
Transfus Clin Biol. 2007 Jul 12; [Epub ahead of print] French.This study has confirmed that medical staff have deficiencies in their knowledge of blood transfusion, deficiencies which are acknowledged by medical staff.

Blood management.
Arch Pathol Lab Med. 2007 May;131(5):695-701. Blood management is most successful when multidisciplinary, proactive programs are in place so that these strategies can be individualized to specific patients.

Changes in red blood cell transfusion practice during the past two decades: a retrospective analysis, with the Mayo database, of adult patients undergoing major spine surgery.
Transfusion. 2007 Jun;47(6):1022-7. In this retrospective analysis, significantly lower acceptable perioperative Hb concentrations were observed in older patients having substantially worse baseline comorbidity and exposed to longer major spine operations, without significant change in the incidence of perioperative morbidity or mortality.

Norepinephrine increases tolerance to acute anemia
Crit Care Med. 2007 Apr 20; [Epub ahead of print] Application of norepinephrine can be judged a first-line intervention to bridge acute anemia via a stabilization of MAP and coronary perfusion pressure. However, due to the relevant side effects of norepinephrine, its sole long-term use during extreme anemia without concomitant transfusion of erythrocytes is not advised.

A cluster-randomized controlled trial of a blood conservation algorithm in patients undergoing total hip joint arthroplasty.
Transfusion. 2007 May;47(5):832-41. A comprehensive approach to blood conservation was superior to usual care for reducing allogeneic transfusion in patients undergoing total hip joint arthroplasty .

Transfusion strategies for patients in pediatric intensive care units.
N Engl J Med. 2007 Apr 19;356(16):1609-19. In stable, critically ill children a hemoglobin threshold of 7 g per deciliter for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes.

Blood conservation techniques in obstetrics: a UK perspective.
Int J Obstet Anesth. 2007 May 15; [Epub ahead of print] Review

Clinicians as gatekeepers: what is the best route to optimal blood use?
Dev Biol (Basel). 2007;127:9-14. Evidence-based transfusion medicine should view a patient's own blood as a valuable and unique natural resource that should be conserved and managed appropriately. Altruistically donated allogeneic blood transfusion should only be used as therapy when there is evidence for potential benefit, there are no alternatives, a quality product is available and the risks are appropriately considered and balanced against the benefits.