Best practice & research. Clinical anaesthesiology
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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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Conditions known as iron-deficiency syndromes are very common in various patient populations, and they can adversely affect the outcomes of the patients, in addition to increasing their risk of getting transfused. Iron-deficiency syndromes include absolute iron deficiency (absence of storage iron), functional iron deficiency (when demand for iron exceeds the supply in face of intense stimulation erythropoiesis) and iron sequestration (in which existing storage iron becomes unavailable); these conditions often co-exist in hospitalised patients, making the diagnosis and management more difficult. ⋯ Notably, several intravenous iron formulations are available and they can be used safely and effectively to restore the body iron levels (possibly even in a single treatment episode). Data from ongoing clinical trials are expected to further establish the role of these products in treatment of patients with anaemia.
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Best Pract Res Clin Anaesthesiol · Mar 2013
ReviewThe three-pillar matrix of patient blood management--an overview.
Allogeneic blood transfusion has had a central role in the development and practice of numerous medical and surgical advances. In recent years, transfusion has no longer been regarded as essential for the management of a wide range of diseases and most uncomplicated elective surgeries in well-prepared patients should now be conducted without the use of transfusions. With the exception of chronic haematopoietic deficiencies, the 'transplantation' of allogeneic blood is usually supportive therapy and is generally only required in relationship to complicated major surgery, trauma and until the basic disease processes can be corrected. ⋯ The corollary to avoiding blood transfusion is that potential transfusion hazards need not be considered. This article focusses on the three-pillar matrix of patient blood management. The understanding of basic physiology and pathophysiology is at the core of evidence-based approaches to optimising erythropoiesis, minimising bleeding and tolerating anaemia.
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In the case of acute bleeding, the use of the anaemia tolerance of a patient enables the physician to either avoid blood transfusions or delay them after bleeding has ceased. This concept is the cornerstone of the third pillar of modern patient blood management programmes. ⋯ Fortunately, the specifications of anaemia tolerance can be influenced by the anaesthesiologist. This article presents the concept of anaemia tolerance and highlights the options for how anaemia tolerance can be optimised in the pre-, intra-, and postoperative periods.