Transfus Apher Sci
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Clinical decision making in transfusion medicine has received greater attention in recent years driven by concern about the potential hazards, especially since the recognition that HIV can be transmitted by homologous blood transfusion. These concerns about the risks of homologous transfusion has precipitated interest in the appropriateness of many transfusions and in the decision making processes in transfusion medicine. There has been increasing expenditure on the blood supply side to address the real or perceived potential infectious hazards. ⋯ This imbalance is now being addressed with the development of evidence based clinical guidelines for individual blood components, transfusion monitoring systems and quality assurance programmes. In this review of the process of clinical decision making in transfusion medicine and the factors involved in the ensuring a patient receives a safe and effect transfusion are addressed. The responsibilities of the patient's clinical carers are emphasised.
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The application of blood conservation strategies to minimise or avoid allogeneic blood transfusion is seen internationally as a desirable objective. Bloodless surgery is a relatively new practice that facilitates that goal. However, the concept is either poorly understood or evokes negative connotations. ⋯ It encompasses the peri-operative period with surgeons, anaesthetists, haematologists, intensivists, pathologists, transfusion specialists, pharmacists, technicians, and operating room and ward nurses utilising combinations of the numerous blood conservation techniques and transfusion alternatives now available. A comprehensive monograph on the subject of bloodless surgery along with detailed coverage of risks and benefits of each modality (some modalities are discussed in more detail elsewhere in this issue) is beyond the scope of this article. Accordingly, a brief overview of the history, theory and practice of bloodless surgery is presented, along with the clinical and institutional management requirements.
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Excessive surgical bleeding can be predicted and then prevented in most patients with a recognised hereditary bleeding tendency or in those on anti-thrombotic therapy. However the clinical consultation of an individual patient can be challenging because the diagnosis can be unclear or a balance needs to be achieved between minimising bleeding without precipitating thrombosis. Laboratory testing does provide assistance in assessment of a bleeding tendency but it is not uncommon for the results to be inconclusive. ⋯ Appropriate replacement therapy prior to surgery is effective in preventing surgical bleeding. Aggressive anti coagulant therapy around the time of surgery in patients who usually are on warfarin more often lead to unnecessary haemorrhage rather than preventing further thrombosis. A risk assessment of both bleeding versus thrombosis for the particular operation is necessary to ensure the best outcome.
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The evolution of cardiac surgery has been accompanied by a wide variety of techniques and equipment available for blood conservation. It has also given us data that allows identification of preoperative risk factors for transfusion needs in other surgical specialties. There is however great diversity of opinion as to how this technology should be applied. ⋯ It is the authors' observation that the success of an intra-operation blood management program is twofold, early identification of patients and a multi-team approach of Surgeon, Haematologist, Transfusion services, Anaesthetist and Perfusionist. This team approach offers far greater depth for management of intra-operative blood conservation and transfusion practice. Interventions must be patient specific and targeted toward the best possible patients outcome.
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Massive haemorrhage in elective surgery can be either anticipated (e.g. organ transplantation) or unexpected. Management requires early recognition, securing haemostasis and maintenance of normovolaemia. Transfusion management involves the transfusion of packed red cells, platelet concentrates and plasma (fresh frozen plasma and cryoprecipitate). ⋯ Complications of massive transfusion result in significant morbidity and mortality. These may be secondary to the storage lesion of the transfused blood products, disseminated intravascular coagulation, hypothermia or hypovolaemic shock. The use of fresh blood products and leucocyte-reduced packed red cells and platelets, may minimise some of the adverse clinical sequelae.