Best practice & research. Clinical anaesthesiology
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Best Pract Res Clin Anaesthesiol · Mar 2013
ReviewThe transfusion dilemma--weighing the known and newly proposed risks of blood transfusions against the uncertain benefits.
Due to its significant role in saving lives, blood transfusion became one of the most commonly used therapies in medicine. In the USA red blood cell transfusions, for instance, are given to an estimated 3-4 million patients per year. ⋯ Although methods of blood collection, preparation and storage have improved significantly, potential complications and controversial efficacy, especially of red blood cell transfusions, are still a major concern. One long-standing primary concern has been bacterial and viral contamination but recently other risks have been identified, mostly related to recipient immunomodulation and storage lesion-related changes.
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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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One of the main factors that contributes to the need for transfusion in the surgical patient is excessive blood loss. Pillar 2 of patient blood management (PBM) includes all the strategies to reduce bleeding and preserve the patient's own blood, designed with an aim to reducing or avoiding transfusion. Some of these strategies, such as identifying and planning the management of patients at high risk of bleeding, can be implemented as early as at the preoperative assessment visit. ⋯ However, there are also additional anaesthetic techniques that can help reduce blood loss and transfusion requirements, such as the use of pharmacological or haemostatic agents. After surgery, PBM continues in the postoperative recovery unit or on the ward with the monitoring and management of postoperative bleeding. The blood lost via drains can be filtered, washed and reinfused, if needed.
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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.
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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.