Best practice & research. Clinical anaesthesiology
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In clinical practice, the decision to transfuse is linked to the hope of increasing oxygen transport (TO2) to tissues. Physiologic transfusion triggers should progressively replace arbitrary hemoglobin-based transfusion triggers. These 'physiologic' transfusion triggers can be based on signs and symptoms of impaired global oxygenation (lactate, venous O2 saturation [SvO2]) or, even better, of regional tissue oxygenation (electrocardiographic ST-segment, electroencephalographic P300 latency). The SvO2 or its surrogate, the central venous 02 saturation (ScvO2), is a clinical tool which integrates the relationship between whole-body O2 uptake and TO2, and as such can be proposed as a simple physiologic transfusion trigger.
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Best Pract Res Clin Anaesthesiol · Jun 2007
ReviewEstimating the cost of blood: past, present, and future directions.
Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. ⋯ Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.
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Inherent risks and increasing costs of allogeneic transfusions underline the socioeconomic relevance of safe and effective alternatives to banked blood. The safety limits of a restrictive transfusion policy are given by a patient's individual tolerance of acute normovolaemic anaemia. latrogenic attempts to increase tolerance of anaemia are helpful in avoiding premature blood transfusions while at the same time maintaining adequate tissue oxygenation. Autologous transfusion techniques include preoperative autologous blood donation (PAD), acute normovolaemic haemodilution (ANH), and intraoperative cell salvage (ICS). ⋯ Currently, some controversy regarding contraindications of ICS needs to be resolved. Artificial oxygen carriers based on perfluorocarbon (PFC) or haemoglobin (haemoglobin-based oxygen carriers, HBOCs) are attractive alternatives to allogeneic red blood cells. Nevertheless, to date no artificial oxygen carrier is available for routine clinical use, and further studies are needed to show the safety and efficacy of these substances.
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Best Pract Res Clin Anaesthesiol · Jun 2007
TRALI--definition, mechanisms, incidence and clinical relevance.
Transfusion-related acute lung injury (TRALI) is defined as new acute lung injury (ALI) that occurs during or within six hours of transfusion, not explained by another ALl risk factor. Transfusion of part of one unit of any blood product can cause TRALI. The mechanism may include factors in unit(s) of blood, such as antibody and biologic response modifiers. ⋯ Management is similar to that for ALI and is predominantly supportive. When TRALI is suspected, Blood banks should be notified to quarantine other components from the same donation. No special blood product is required for subsequent transfusion of a patient who has developed TRALI.
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According to the global study of the burden of disease, violence and accidental injury account for 12% of deaths worldwide; 30-40% of trauma mortality is attributable to haemorrhage. The highly complex haemostatic system is severely impaired as a result of haemorrhagic shock, acidosis, hypothermia, haemodilution, hyperfibrinolysis, and consumption of clotting factors. Thus it is important to prioritize the prevention of the development of coagulopathy. ⋯ In the absence of international guidelines, there is an ongoing debate about a generally accepted treatment algorithm, mass transfusion protocols, and adverse events that have been observed as a result of transfusion. Thus many recommendations are based upon expert opinion rather than on evidence. In this chapter we address key issues of transfusions of red blood cells and plasma products in the acute control of bleeding in traumatized patients.