https://academic.oup.com/eurheartj/article/42/36/3599/6358045?login=false
https://academic.oup.com/eurheartj/article/42/36/3599/6358045?login=false
WHO/BTS is convening a two-day meeting of this forum in March 2011, to highlight the importance of effective blood management for patient health and safety in health-care systems, consider barriers to its implementation and identify factors causing variability in transfusion practices in different countries. Lessons learnt and strategies to address the major challenges faced by both developed and developing countries in managing blood use for quality patient care will also be discussed. This forum is, jointly organized by the Sharjah Blood Transfusion and Research Centre and co-sponsored by the Government of the United Arab Emirates, to be held on 14─15 March 2011 in Dubai, United Arab Emirates.
https://www.who.int/bloodsafety/events/gfbs_01_pbm_concept_paper.pdf?ua=1
https://eviteatransfusao-2021.dev2.server.diamondbybold.com/app/uploads/2021/05/Proposta-PDF-Dark.pdf
This PBM implementation guide was developed as a supporting tool for hospitals in the implementation of PBM at the operational level. It has taken inspiration from successfully implemented programmes in different parts of the world, recommending a well-recognised model for introducing change. It is acknowledged that alternative change management models could also be applied successfully. The guide focuses on how to implement the PBM concept in hospitals in a practical way, building on already recognised best practices (44-47). It does not aim to review the clinical evidence for PBM or to provide clinical PBM guidelines. A substantial list of publications that provide the rationale for PBM and that define good clinical practice supporting PBM is included at the end of this document. This guide is the result of the combined expertise of an international, multidisciplinary team of clinicians and PBM professionals and the collective experience gathered from a 30 month pilot programme for the implementation of PBM in five European teaching hospitals. The final goal is to support PBM as a sustainable standard of care across the EU. Given the multi-disciplinary and holistic approach required for PBM implementation, the guide is relevant for all medical professionals and organisations involved in caring for patients suffering from anaemia, blood loss and medical conditions that might require transfusion. It should stimulate hospital management to invest greater efforts in the evaluation and treatment of patients with low iron status prior to admission or surgery and should encourage transfusion stakeholders to take a fresh look at their professional fields and discover new opportunities for safely reducing the transfusion rate in their hospitals.
https://op.europa.eu/en/publication-detail/-/publication/93e1bbbf-1a8b-11e7-808e-01aa75ed71a1/language-en
Transfusions are one of the most overused treatments in modern medicine, at a cost of billions of dollars.
Transfusions are common procedures, at least in developed nations. In 2011, US doctors transfused 21 million units of blood and blood products; in the United Kingdom, the number was nearly 3 million. But although transfusions can be lifesaving, they are often unnecessary and are sometimes even harmful. “I think we were kind of brainwashed into thinking that blood saves lives, and the more you give the better,” says Steven Frank, an anaesthesiologist and
director of the blood-management programme at the Johns Hopkins Health System in Baltimore, Maryland. “We’ve gone 180 degrees, and now we think that less is more.”
Scientists are now recommending a more conservative approach to transfusions. But changing decades of established medical practice is not easy. Even when guidelines are clear, evidence suggests that clinicians often fail to follow them.
https://www.nature.com/news/polopoly_fs/1.17224!/menu/main/topColumns/topLeftColumn/pdf/520024a.pdf
The present study aimed to characterize the prevalence of anemia and iron deficiency in older Portuguese adults, and to compare it with the prevalence in younger individuals.
Anemia was more prevalent (P < 0.001) in participants aged ≥80 years (31.4%) compared with participants aged <65 years (19.6%) and 65–79 years (17.3%). At a 30-ng/mL ferritin cut-off, iron deficiency was more prevalent in participants aged ≥80 years (42.8%) compared with participants aged <65 years (31.5%) and 65–79 years (30.2%). Alternative ferritin cut-offs showed overall similar patterns. Anemia and iron deficiency were significantly more prevalent in older individuals who self-reported heart failure, coronary heart disease and gastritis. Anemia was more prevalent in participants aged <65 years in the north of Portugal and participants aged ≥65 years in central Portugal, following the prevalence of iron deficiency in the regions. In all regions, anemia was more prevalent in participants aged ≥80 years (reaching 39.0% in Lisbon and Tagus Valley, and 51.0% in the south).
Anemia and iron deficiency are highly prevalent in older Portuguese adults, particularly among those aged ≥80 years. Better diagnosis, prevention and treatment strategies should be implemented taking into account the outstanding role of iron deficiency in older Portuguese adults, the differences between regions and the intrinsic characteristics of this population.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/ggi.12966
Anaemia and iron deficiency are major public health problems with great implications on quality of life.
Aims
To establish the general prevalence of anaemia and iron deficiency in the adult Portuguese population and the prevalence by age, gender and region.
The measured prevalence of anaemia was 19.9% (95% confidence interval: 19.0–20.8%); 84% of cases were previously undiagnosed. Anaemia was more prevalent among women (20.8%), young adults (18−34 years) (22.8–30.5%), older adults (21.0%), and pregnant women (54.2%). Anaemia varied across regions: from 15.5% in the Center region to 24.9% in the South. Iron deficiency was also highly prevalent: 16.7% (ferritin <15 ng/mL), 31.9% (<30 ng/mL), 53.3% (<50 ng/mL) and 84.3% (<100 ng/mL). Iron deficiency anaemia represented most anaemia cases: 29.0% (ferritin <15 ng/mL), 54.8% (<30 ng/mL), 75.4% (<50 ng/mL) and 92.5% (<100 ng/mL).
Anaemia and iron deficiency are highly prevalent in Portugal and largely undiagnosed. Women, young adults and older individuals are more prone to present these conditions and there are marked regional asymmetries. Nationwide strategies for prevention, diagnosis and treatment of these conditions should be implemented.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/imj.13020
Before major surgery, 30 to 40% of patients are anemic, an important consideration that is associated with increased erythrocyte transfusions, prolonged hospital length of stay, more frequent intensive care admissions, infections, and thromboembolic events, and mortality. Surgical bleeding contributes to anemia, increases transfusions, and independently increases mortality. In addition, transfusion of allogeneic blood products is associated with increased morbidity and mortality and increased costs, and allogeneic blood products are a limited resource. Therefore, as a pragmatic solution, the concept of Patient Blood Management was developed and published in its preliminary form, first in the anesthesia literature as an editorial in Anesthesiology in 2008. The authors hypothesized that “Patient Blood Management will decrease the use of allogeneic erythrocyte transfusion and its cost and adverse sequelae significantly.” Currently, 12 yr later, we can conclude this is indeed the case.
https://pubs.asahq.org/anesthesiology/article/133/1/212/109158/Patient-Blood-ManagementEffectiveness-and-Future
Patient Blood Management (PBM) is a multimodal, multidisciplinary approach adopted to limit the use and the need for allogeneic blood transfusion in all at-risk patients with the aim of improving their clinical outcomes. Although PBM usually refers to surgical patients, its clinical use has gradually evolved over the last few years and it now also refers to medical conditions. This review will critically analyse the current knowledge on the use of PBM programmes in surgical
and non-surgical patients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6596379/pdf/blt-17-191.pdf
More than 30% of the world's population are anemic with serious economic consequences including reduced work capacity and other obstacles to national welfare and development. Red blood cell transfusion is the mainstay to correct anemia, but it is also 1 of the top 5 overused procedures. Patient blood management (PBM) is a proactive, patient-centered, and multidisciplinary approach to manage anemia, optimize hemostasis, minimize iatrogenic blood loss, and harness tolerance to anemia. Although the World Health Organization has endorsed PBM in 2010, many hospitals still seek guidance with the implementation of PBM in clinical routine. Given the use of proven change management principles, we propose simple, cost-effective measures enabling any hospital to reduce both anemia and red blood cell transfusions in surgical and medical patients. This article provides comprehensive bundles of PBM components encompassing 107 different PBM measures, divided into 6 bundle blocks acting as a working template to develop institutions' individual PBM practices for hospitals beginning a program or trying to improve an already existing program. A stepwise selection of the most feasible measures will facilitate the implementation of PBM. In this manner, PBM represents a new quality and safety standard.
https://www.sciencedirect.com/science/article/pii/S088779631630030X
Patient blood management (PBM) programs are associated with improved patient outcomes, reduced transfusions and costs. In 2008, the Western Australia Department of Health initiated a comprehensive health-system–wide PBM program. This study assesses program outcomes.
Implementation of a unique, jurisdiction-wide PBM program was associated with improved patient outcomes, reduced blood product utilization, and product-related cost savings.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/trf.14006
Patient blood management programs are gaining popularity as quality improvement and patient safety initiatives, but methods for implementing such programs across multihospital health systems are not well understood. Having recently incorporated a patient blood management program across our health system using a clinical community approach, we describe our methods and results.
Implementing a health system-wide patient blood management program by using a clinical community approach substantially reduced blood utilization and blood acquisition costs.
https://pubs.asahq.org/anesthesiology/article/127/5/754/19141/Implementing-a-Health-System-wide-Patient-Blood
Os programas de Patient Blood Management (PBM), para além de visarem a melhoria dos resultados em saúde dos doentes, estão associados a um menor consumo de recursos e à redução de custos em Saúde.
Reconhecendo a importância desta temática e a elevada prevalência que a anemia apresenta no nosso país, a Associação Portuguesa para o Estudo da Anemia juntamente com a EXIGO Consultores, desenvolveram um modelo para avaliação do impacto da implementação de um programa nacional de PBM na saúde pública em Portugal.
A implementação de um PBM a nível nacional poderá representar um impacto substancial na redução da mortalidade intra-hospitalar e carga global das doenças associadas (DALY). Embora Portugal não seja um dos países Europeus com maior consumo de sangue per capita, um programa de PBM representará uma melhoria fundamental nos resultados em saúde relativos à utilização de transfusões e suas consequências na duração do internamento e na taxa de reinternamento.
Em suma, todos estes factores representam um elevado valor em termos de saúde pública, o que também implica um grande valor económico para o Serviço Nacional de Saúde, face à possibilidade de uma poupança substancial após um ano da implementação de um programa de PBM em Portugal.
Na eventualidade da implementação de um PBM em Portugal, a administração de ferro e a estratégia transfusional restritiva de concentrado eritrocitário seriam as intervenções de eleição de acordo com a opinião do grupo de peritos nacionais.
https://awgp.pt/wp-content/uploads/2019/09/20170222_PBM_AWGP_Relato%CC%81rio_vfinal.pdf
Given the recent emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the ensuing worldwide, widespread human-to-human transmission of the related Coronavirus Disease 2019 (COVID-19), the World Health Organization (WHO) has declared a pandemic status for this virus and the virus-related disease. As one of the corollaries, public health authorities and blood services are concerned with decreasing blood donations, ultimately resulting in blood shortages that will unquestionably lead to difficult and controversial transfusion rationing decisions by frontline health care providers. Considering that blood is a perishable commodity with a very short expiration time, as with past pandemics, blood services are being challenged to maintain their inventory during the current COVID-19 pandemics. On the other hand, analyses after past natural and man-made disasters have demonstrated either no change or a reduction in the demand for blood and its use.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173035/pdf/ane-publish_ahead_of_print-10.1213_ane.0000000000004844.pdf
For many physicians and clinicians and across many different specialties, blood transfusion is still considered the first line treatment when facing anaemia and/or blood loss. In the European Union (EU), more than 5 million patients are receiving around 24 million units of blood or blood components each year (Annual Summary of the Reporting of Serious Adverse Reactions and Events, 2015, European Commission). However, a large body of clinical evidence shows that in many clinical scenarios both anaemia and blood loss can be effectively treated with a series of evidence-based measures to better manage and preserve a patient’s own blood, rather than resorting to a donor’s blood, thus leading to a significant overall reduction of blood transfusions.
This is why over the last decade the focus in the EU, and elsewhere, has shifted from ensuring safety and quality of blood and blood components (product focused) towards a broader concept that takes a holistic, multi-disciplinary approach to caring for each patient’s haematopoietic system in a manner that aims to ensure the best possible outcome (patient-focused). This widely accepted approach is referred to as Patient Blood Management (PBM).
This guide for national authorities, and an equivalent one for hospitals, were delivered to the European Commission under that contract. They have no regulatory or legally–binding status but are intended as tools to support NAs and hospitals in EU Member States in establishing PBM as a standard to improve quality and safety of patient care. In order to ensure appropriate and optimal use of blood and blood components, transfusion decisions should always adhere to current evidence-based guidelines, and be taken after careful evaluation of a variety of patient-specific and patient-group-specific factors.
https://ec.europa.eu/health/sites/default/files/blood_tissues_organs/docs/2017_eupbm_authorities_en.pdf
Intravenous ferric carboxymaltose has been shown to improve symptoms and quality of life in patients with chronic heart failure and iron deficiency. We aimed to evaluate the effect of ferric carboxymaltose, compared with placebo, on outcomes in patients who were stabilised after an episode of acute heart failure.
In patients with iron deficiency, a left ventricular ejection fraction of less than 50%, and who were stabilised after an episode of acute heart failure, treatment with ferric carboxymaltose was safe and reduced the risk of heart failure hospitalisations, with no apparent effect on the risk of cardiovascular death.
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32339-4/fulltext
Patient blood management (PBM) is a multidisciplinary concept focused on the management of anaemia, minimisation of iatrogenic blood loss and rational use of allogeneic blood products. The aims of this study were: (i) to analyse post-operative outcome in patients with liberal vs restrictive exposure to allogeneic blood products and (ii) to evaluate the cost-effectiveness of PBM in patients undergoing surgery.
Our results indicate that PBM may be associated with fewer adverse clinical outcomes compared to control management and may, thereby, be cost-effective.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6343592/pdf/blt-17-016.pdf
More than 100 million units of blood are collected worldwide each year, yet the indication for red blood cell (RBC) transfusion and the optimal length of RBC storage prior to transfusion are uncertain.
To provide recommendations for the target hemoglobin level for RBC transfusion among hospitalized adult patients who are hemodynamically stable and the length of time RBCs should be stored prior to transfusion.
Research in RBC transfusion medicine has significantly advanced the science in recent years and provides high-quality evidence to inform guidelines. A restrictive transfusion threshold is safe in most clinical settings and the current blood banking practices of using standard-issue blood should be continued.
https://jamanetwork.com/journals/jama/article-abstract/2569055
The Circular was designed as an extension of container labeling to provide specific instructions for the administration and use of blood and blood components intended for transfusion. The Circular must be available for review by Transfusion Services, prescribing physicians, and staff anywhere blood is issued or transfused. If the environment includes blood transfusion, the Circular should be available.
https://www.aabb.org/docs/default-source/default-document-library/resources/circular-of-information-10-17.pdf
Vigilance is essential in the perioperative period. When blood is not an option for the patient, especially in a procedure/surgery that normally holds a risk for blood transfusion, complexity is added to the management. Current technology and knowledge has made avoidance of blood transfusion a realistic option but it does require a concerted patient-centered effort from the perioperative team. In this article, we provide suggestions for a successful, safe, and bloodless journey for patients. The approaches include preoperative optimization as well as intraoperative and postoperative techniques to reduce blood loss, and also introduces current innovative substitutes for transfusions. This article also assists in considering and maneuvering through the legal and ethical systems to respect patients’ beliefs and ensuring their safety.
https://journals.lww.com/anesthesia-analgesia/Fulltext/2019/01000/Proceedings_From_the_Society_for_Advancement_of.23.aspx
Therapy with i.v. iron in patients with chronic heart failure (CHF) and iron deficiency (ID) improves symptoms, functional
capacity, and quality of life. We sought to investigate whether these beneficial outcomes are independent of anaemia.
Treatment of ID with FCM in patients with CHF is equally efficacious and shows a similar favourable safety profile irrespective of anaemia. Iron status should be assessed in symptomatic CHF patients both with and without anaemia and treatment of ID should be considered.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3806282/pdf/hft099.pdf
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the riskbenefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
A great number of Guidelines have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organisations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC website. ESC Guidelines represent the official position of the ESC on a given topic and are regularly updated.
Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the field undertook a comprehensive review of the published evidence for management (including diagnosis, treatment, prevention and rehabilitation) of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk-benefit ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of the recommendation of particular management options were weighed and graded according to predefined scales.
https://academic.oup.com/eurheartj/article/37/27/2129/1748921
Iron deficiency may impair aerobic performance. This study aimed to determine whether treatment with intravenous iron (ferric carboxymaltose) would improve symptoms in patients who had heart failure, reduced left ventricular ejection fraction, and iron deficiency, either with or without anemia.
Treatment with intravenous ferric carboxymaltose in patients with chronic heart failure and iron deficiency, with or without anemia, improves symptoms, functional capacity, and quality of life; the side-effect profile is acceptable. (ClinicalTrials.gov number, NCT00520780.)
https://www.nejm.org/doi/pdf/10.1056/NEJMoa0908355?articleTools=true
The aim of this study was to assess the net clinical and prognostic effects of intravenous (i.v.) iron therapy in patients with systolic heart failure (HF) and iron deficiency (ID). We performed an aggregate data meta-analysis (random effects model) of randomized controlled trials that evaluated the effects of i.v. iron therapy in iron-deficient patients with systolic HF. We searched electronic databases up to September 2014. We identified five trials which fulfilled the inclusion criteria (509 patients received i.v. iron therapy in comparison with 342 controls). Intravenous iron therapy has been shown to reduce the risk of the combined endpoint of all-cause death or cardiovascular hospitalization [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.30–0.64, P < 0.0001], and the combined endpoint of cardiovascular death or hospitalization for worsening HF (OR 0.39, 95% CI 0.24–0.63, P = 0.0001). Intravenous iron therapy resulted in a reduction in NYHA class (data are reported as a mean net effect with 95% CIs for all continuous variables) (−0.54 class, 95% CI −0.87 to −0.21, P = 0.001); an increase in 6-min walking test distance (+31 m, 95% CI 18–43, P < 0.0001); and an improvement in quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ) score +5.5 points, 95% CI 2.8–8.3, P < 0.0001; European Quality of Life–5 Dimensions (EQ-5D) score +4.1 points, 95% CI 0.8–7.3, P = 0.01; Minnesota Living With Heart Failure Questionnaire (MLHFQ) score −19 points, 95% CI:–23 to −16, P < 0.0001; and Patient Global Assessment (PGA) +0.70 points, 95% CI 0.31–1.09, P = 0004]. The evidence indicates that i.v. iron therapy in iron-deficient patients with systolic HF improves outcomes, exercise capacity, and quality of life, and alleviates HF symptoms.
http://www.arcothova.com/wp-content/uploads/2019/10/Effects-of-intravenous-iron-therapy-in-iron-deficient-patients-with-systolic-heart-failure_Lasocki.pdf
The aim of this study was to evaluate the benefits and safety of long-term i.v. iron therapy in iron-deficient patients with heart failure (HF).
Treatment of symptomatic, iron-deficient HF patients with FCM over a 1-year period resulted in sustainable improvement in functional capacity, symptoms, and QoL and may be associated with risk reduction of hospitalization for worsening HF (ClinicalTrials.gov number NCT01453608).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4359359/pdf/ehu385.pdf
Erythropoiesis‐stimulating agents (ESAs) are commonly used to treat chemotherapy‐induced anemia (CIA). However, about half of patients do not benefit.
Our systematic review shows that addition of iron to ESAs offers superior hematopoietic response, reduces the risk of RBC transfusions, and improves Hb levels, and appears to be well tolerated. None of the included RCTs reported overall survival. We found no evidence for a difference in quality of life with iron supplementation.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009624.pub2/full
While patient blood management (PBM) principles are not specific to cancer patients, their application contains the pathophysiological premises that could also benefit this patient population. In this study, we assessed the effects of implementing a PBM bundle for cancer patients in the postoperative period.
Our PBM bundle positively impacted RBC transfusion appropriateness in postsurgical cancer patients, both in terms of quality and quantity. A structured PBM programme specifically dedicated to surgical oncology should cover the entire perioperative period and might further improve transfusion appropriateness in these patients. The publication of guidelines on the management of anaemia in surgical oncology should be a priority.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7592164/pdf/blt-18-359.pdf
Patient Blood Management (PBM) is a systematic quality improving clinical model to reduce anemia and avoid transfusions in all kinds of clinical settings. Here, we investigated the potential of PBM in oncologic surgery and hypothesized that PBM improves 2-year overall survival (OS).
PBM is a quality improvement tool that is associated with better mid-term surgical oncologic outcome. The root cause for improvement is the increase of patients entering surgery with normal hemoglobin values.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6081799/pdf/12957_2018_Article_1456.pdf
Patient Blood Management (PBM) é um método seguro que visa melhorar a gestão médico-cirúrgica dos doentes de modo a que o seu próprio sangue seja conservado. Cerca de 32 a 60% dos doentes oncológicos têm deficiência de ferro, a maioria tem anemia e, por isso, é importante discutir estratégias que evitem o uso excessivo de sangue e redução da progressão de tumores e recor-rência do cancro. Neste artigo de posicionamento, um grupo de especialistas em conjunto com a Associação Portuguesa para o Estudo da Anemia (AWGP) discute o programa PBM em hematologia e oncologia tendo em conta diver-sos fatores que são atualmente utilizados para aprovar os tratamentos em uso, baseados nas últimas informações atualizadas das orientações internacionais do National Comprehensive Cancer Network® (NCCN).
https://rponcologia.com/index.php/rpo/article/view/21/15
Anaemia and iron deficiency (ID) are frequent complications in patients with solid tumours or haematological malignancies, particularly in patients treated with chemotherapeutic agents. Frequently, anaemia is associated with fatigue, impaired physical function and reduced quality of life (QoL). Consequences of anaemia may include impaired response to cancer treatment and reduced overall survival (OS), even though a causal direct relationship has not yet been established. These new ESMO Clinical Practice Guidelines provide tools to evaluate anaemia, also in patients with myelodysplastic syndromes (MDS), and include recommendations on how to safely manage chemotherapy-induced anaemia (CIA) with erythropoiesis-stimulating agents (ESAs), iron preparations for intravenous (i.v.) or oral administration, red blood cell (RBC) transfusions and combinations of these treatments. The major aims of anaemia management are the reduction or resolution of anaemia symptoms, particularly fatigue, and an improved QoL with the minimum invasive treatment that corrects the underlying causes and proves to be safe. Underlying causes of anaemia, mainly impaired erythropoietic activity and disturbed iron homeostasis, can be consequences of increased release of inflammatory cytokines due to the underlying cancer and/or toxicity of cancer therapy. Furthermore, vitamin B12 and folate deficiency are relatively rare causes of anaemia in cancer patients.
https://www.annalsofoncology.org/article/S0923-7534(19)31688-6/pdf
Anemia is prevalent in 30% to 90% of patients with cancer. Anemia can be corrected through treating the underlying cause or providing supportive care through either transfusion with packed red blood cells (PRBC) or administration of erythropoiesisstimulating agents (ESAs), with or without iron supplementation. Recent studies showing detrimental
health effects of ESAs sparked a series of FDA label revisions and a sea change in the perception of these once commonly used agents. In light of this, these guidelines underwent substantial revisions. The purpose of these guidelines is 2-fold: 1) to operationalize the evaluation and treatment of anemia in adult patients with cancer, with an emphasis on those with anemia who are receiving concomitant chemotherapy, and 2) to enable the patient and clinician to assess anemia treatment options based on individual patient conditions.
The pathophysiologic origins of anemia can be grouped into 3 categories: 1) decreased production of functional red blood cells (RBCs), 2) increased destruction of RBCs, and 3) blood loss. Hence, anemia is characterized by a decrease in hemoglobin (Hb) concentration, RBC count, or packed cell volume to subnormal levels.
https://oncolife.com.ua/doc/nccn/Cancer-and_Chemotherapy-Induced_Anemia.pdf
Hysterectomy is one of the most common surgeries performed worldwide. Identification of modifiable risk factors for complications or readmissions could lead to targeted interventions to improve patient care and reduce health care costs. Preoperative anemia has been identified as a risk factor for adverse postoperative outcomes following noncardiac surgery. However, studies have not focused on young and healthy surgical populations, such as women undergoing gynecologic surgery for benign indications.
The purpose of this study was to evaluate whether preoperative anemia in women undergoing elective hysterectomy or myomectomy for benign indications was associated with increased 30 day postoperative morbidity and mortality.
Preoperative anemia in women undergoing elective hysterectomy/myomectomy was common and is an independent risk factor for 30 day postoperative adverse outcomes, especially in older women.
https://www.ajog.org/article/S0002-9378(19)30902-0/fulltext
A anemia tem etiologia multifatorial: patologias genéticas, deficiência da ingestão de micronutrientes (ferro, folato, vitamina B12) ou outras condições que induzem perda ou necessidade aumentada ou absorção diminuída dos mesmos (infeção aguda ou crónica, doença inflamatória intestinal, insuficiência cardíaca crónica, doença renal crónica, neoplasias, doenças autoimunes). A anemia na gravidez é definida por valores de hemoglobina (Hb) <11 g/dL e hematócrito (Hct) <33% no 1º e no 3º trimestres da gravidez; Hb <10,5 g/dL e Hct <32% no 2º trimestre, e Hb <10 g/dL no puerpério. A anemia constitui um problema global de saúde pública, afetando cerca de um quarto da população mundial. Em 2011, a OMS estimou uma prevalência de anemia gestacional de 38%, sendo de 26% na Europa. Em Portugal, um estudo prospetivo de 2016 refere uma prevalência de anemia na grávida de 2,5% (mas com uma prevalência de défice de ferro >38%), enquanto que o estudo EMPIRE descreveu uma prevalência de
anemia de 54,2% nas mulheres grávidas, com variações regionais. Assim, a SPOMMF recomenda que se realize o rastreio de anemia e ferropénia na gravidez, através do hemograma e da determinação da ferritina sérica.
https://www.spommf.pt/wp-content/uploads/2019/07/Norma-Anemia-na-Gravidez-e-no-Puerpe%CC%81rio.pdf
Anaemia is a frequent condition during pregnancy, particularly among women in low- and middle-income countries. Traditionally, gestational anaemia has been prevented with daily iron supplements throughout pregnancy, but adherence to this regimen due to side eGects, interrupted supply of the supplements, and concerns about safety among women with an adequate iron intake, have limited the use of this intervention. Intermittent (i.e. two or three times a week on non-consecutive days) supplementation has been proposed as an alternative to daily supplementation.
This review includes 27 trials from 15 countries, but only 21 trials (with 5490 women) contributed data to the review. All studies compared daily versus intermittent iron supplementation. The methodological quality of included studies was mixed and most had high levels of attrition.The overall assessment of the quality of the evidence for primary infant outcomes was low and for maternal outcomes very low. Of the 21 trials contributing data, three studies provided intermittent iron alone, 14 intermittent iron + folic acid and four intermittent iron plus multiple vitamins and minerals in comparison with the same composition of supplements provided in a daily regimen.
This review is the most comprehensive summary of the evidence assessing the benefits and harms of intermittent iron supplementation in pregnant women on haematological and pregnancy outcomes. Findings suggest that intermittent regimens produced similar maternal and infant outcomes as daily supplementation but were associated with fewer side eGects and reduced the risk of high levels of Hb in mid and late pregnancy, although the risk of mild anaemia near term was increased. While the quality of the evidence was assessed as low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092533/pdf/CD009997.pdf
Anaemia is a condition in which the number of red blood cells is insufficient to meet physiologic needs; it is caused by many conditions,particularly iron deficiency. Traditionally, daily iron supplementation has been a standard practice for preventing and treating anaemia.However, its long-term use has been limited, as it has been associated with adverse side effects such as nausea, constipation, and teethstaining. Intermittent iron supplementation has been suggested as an effective and safer alternative to daily iron supplementation forpreventing and reducing anaemia at the population level, especially in areas where this condition is highly prevalent.
We included 25 studies involving 10,996 women. Study methods were not well described in many of the included studies and thus assessingrisk of bias was difficult. The main limitations of the studies were lack of blinding and high attrition. Studies were mainly funded byinternational organisations, universities, and ministries of health within the countries. Approximately one third of the included studies didnot provide a funding source.
Intermittent iron supplementation may reduce anaemia and may improve iron stores among menstruating women in populations withdifferent anaemia and malaria backgrounds. In comparison with daily supplementation, the provision of iron supplements intermittentlyis probably as effective in preventing or controlling anaemia. More information is needed on morbidity (including malaria outcomes), sideeffects, work performance, economic productivity, depression, and adherence to the intervention. The quality of this evidence base rangedfrom very low to moderate quality, suggesting that we are uncertain about these effects.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009218.pub3/epdf/full
Each year, worldwide about 530,000 women die from causes related to pregnancy and childbirth. Of the deaths 99% are in low and middle income countries. Obstetric haemorrhage is the leading cause of maternal mortality, most occurring in the postpartum period. Systemic antifibrinolytic agents are widely used in surgery to prevent clot breakdown (fibrinolysis) in order to reduce surgical blood loss. At present there is little reliable evidence from randomised trials on the effectiveness of tranexamic acid in the treatment of postpartum haemorrhage.
The main analyses will be on an 'intention to treat' basis, irrespective of whether the allocated treatment was received or not. Subgroup analyses for the primary outcome will be based on type of delivery; administration or not of prophylactic uterotonics; and on whether the clinical decision to consider trial entry was based primarily on estimated blood loss alone or on haemodynamic instability. A study with 15,000 women will have over 90% power to detect a 25% reduction from 4% to 3% in the primary endpoint of mortality or hysterectomy.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864262/pdf/1745-6215-11-40.pdf
Estes consensos têm como objetivo fornecer uma ferramenta alicerçada na evidência científica atual, que possa ter aplicabilidade prática e que contribua para a abordagem multidisciplinar, transversal e sistemática, da hemorragia em obstetrícia. Constituem uma revisão das recomendações existentes, visando facilitar a sua divulgação e implementação, e introduzir consistência na prática clínica. Estas orientações foram elaboradas, sob a égide da Sociedade Portuguesa de Anestesiologia, por consenso multidisciplinar, entre especialistas de Anestesiologia, Ginecologia/Obstetrícia, Imunohemoterapia e Hematologia. A hemorragia em obstetrícia é a principal causa de morbimortalidade materna, mesmo em países desenvolvidos, sendo a causa mais evitável de mortalidade. A hemorragia pós-parto é a sua forma mais frequente (5% - 10% dos partos), tendo vindo a aumentar na última década. Os fatores que contribuem para outcomes adversos são: atraso no tratamento pela subestimação das perdas, atraso na disponibilidade de componentes sanguíneos, ausência de algoritmos de atuação, falta de conhecimentos/treino, comunicação interdisciplinar insuficiente e organização inadequada.
É fundamental identificar os fatores de risco para hemorragia obstétrica.
A definição clássica de hemorragia pós-parto minor é perdas sanguíneas > 500 mL após parto vaginal e > 1000 mL após cesariana e hemorragia pós-parto major com perdas > 1000 mL. A hemorragia pós-parto major pode, ainda, ser subdividida em moderada (1000-2000 mL) e severa (> 2000 mL), no entanto o American College of Obstetricians and Gynecologists reviu recentemente esta definição como sendo perdas sanguíneas cumulativas ≥ 1000 mL ou perdas hemáticas acompanhadas de sinais e sintomas de hipovolemia nas 24 horas após o parto. Esta definição vai de encontro à definição de hemorragia massiva da European Society of Anesthesiologists e da Direção Geral de Saúde. Todas as Unidades Obstétricas devem ter um protocolo institucional multidisciplinar para gestão da hemorragia em obstetrícia, devendo envolver precocemente uma equipa multidisciplinar. Este protocolo deve dar origem a um algoritmo de atuação, prático e sucinto, cujo objetivo é sistematizar e organizar a resposta dos profissionais e da instituição, de acordo com a gravidade da hemorragia. É recomendável monitorização “point-of-care” para orientação terapêutica e a possibilidade de utilização imediata de ácido tranexâmico, concentrado de fibrinogénio e balões hemostáticos.
Todos os profissionais envolvidos nos cuidados maternos devem realizar regularmente treino multidisciplinar na hemorragia em obstetrícia.
http://www.spanestesiologia.pt/ficheiros/Hemorragia-Obstetrica.pdf
Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed to maintain haemoglobin concentration, optimise haemostasis, and minimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommendations on the prevention and treatment of postpartum haemorrhage as part of PBM in obstetrics. A multidisciplinary panel of physicians with expertise in obstetrics, anaesthesia, haematology, and transfusion medicine was convened by the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federation of Gynaecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the European Society of Anaesthesiology (ESA). Members of the task force assessed the quantity, quality and consistency of the published evidence, and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group.
The recommendations in this consensus statement are intended for use by clinical practitioners managing perinatal care of women in all settings, and by policymakers in charge of decision making for the update of clinical practice in health care establishments.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6476742/pdf/blt-17_112.pdf
Patient blood management (PBM) is the timely application of evidence-informed medical and surgical concepts designed tomaintain haemoglobin concentration, optimise haemostasis andminimise blood loss in an effort to improve patient outcomes. The aim of this consensus statement is to provide recommenda-tions on the management of anaemia and haematinic deficiencies in pregnancy and in the post-partum period as part of PBM in obstetrics. A multidisciplinary panel of physicians with exper-tise in obstetrics, anaesthesia, haematology, policy making and epidemiology was convened by the Network for the Advance-ment of Patient Blood Management, Haemostasis and Thrombosis (NATA) in collaboration with the International Federationof Gynaecology and Obstetrics (FIGO) and the European Boardand College of Obstetrics and Gynaecology (EBCOG). Members of the task force assessed the quantity, quality and consistency of the published evidence and formulated recommendations using the system developed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) working group. The recommendations in this consensus statement are intended for use by clinical practitioners managing the perinatalcare of women in all settings and by policy makers in charge of decision making for the update of clinical practice in health-care establishments. They need to be tailored for application in individual patients or any population after consideration of the values and preferences of both health-care providers and patients,as well as equity issues; explicit assessment of harms and benefits of each recommendation; feasibility including resources, capacity and equipment; and implementability.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/tme.12443
In developed countries, rates of postpartum hemorrhage (PPH) requiring transfusion have been increasing. As a result, anesthesiologists are being increasingly called upon to assist with the management of patients with severe PPH. First responders, including anesthesiologists, may adopt Patient Blood Management (PBM) recommendations of national societies or other agencies.
However, it is unclear whether national and international obstetric societies’ PPH guidelines account for contemporary PBM practices. We performed a qualitative review of PBM recommendations published by the following national obstetric societies and international groups: the American College of Obstetricians and Gynecologists; The Royal College of Obstetricians and Gynecologists, United Kingdom; The Royal Australian and New Zealand College of Obstetricians and Gynecologists; The Society of Obstetricians and Gynecologists of Canada; an interdisciplinary group of experts from Austria, Germany, and Switzerland; an international multidisciplinary consensus group; and the French College of Gynaecologists and Obstetricians. We also reviewed a PPH bundle, published by The National Partnership for Maternal Safety. On the basis of our review, we identified important differences in national and international societies’ recommendations for transfusion and PBM. In the light of PBM advances in the nonobstetric setting, obstetric societies should determine the applicability of these recommendations in the obstetric setting. Partnerships among medical, obstetric, and anesthetic societies may also help standardize transfusion and PBM guidelines in obstetrics.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161642/pdf/nihms-790169.pdf
Intraoperative blood cell salvage is an efficacious technique for blood replacement and its use is well established in other areas of medicine, but there are theoretical safety concerns when it is used in obstetric practice. Data
collection is therefore important and clinicians should report all complications to the Medicines and Healthcare products Regulatory Agency. Whenever possible, patients should be fully informed of the potential complications. In addition, use of the Institute's information for the public is recommended.
This procedure should only be performed by multidisciplinary teams who develop regular experience of intraoperative blood cell salvage.
https://www.nice.org.uk/guidance/ipg144/resources/intraoperative-blood-cell-salvage-in-obstetrics-pdf-1899863219663557
Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.
Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5446563/pdf/main.pdf
Em 2001, a Sociedade Portuguesa de Ginecologia, por intermédio da sua Secção de Ginecologia Oncológica, promoveu o primeiro Consenso sobre Hemorragias Uterinas Anormais (HUA).
Em aplicação de conceitos que vigoravam à época, as hemorragias anormais com origem no corpo uterino classificavam-se em menorragia/hipermenorreia, metrorragia e menometrorragias.
O impacto da HUA é muito variável, podendo em fase aguda provocar disrupções severas com risco de vida para a mulher. Atendendo a que as situações que atinjam essa fase requerem da parte dos profissionais atuações rigorosas e concertadas considerou-se útil abordá-las em capítulo próprio.
Procurando fazer uma revisão temática exaustiva e abrangente, optou-se por incluir neste documento o tratamento da anemia ferropénica, inevitavelmente ligada a quadros clínicos de hemorragia e que muitas vezes é negligenciada.
Os consensos registados no presente documento foram obtidos com base numa ampla pesquisa bibliográfica, permitindo estabelecer níveis de evidência e graduações em relação a cada recomendação aplicando o sistema GRADE.
Os consensos obtidos deverão ser vistos como instrumentos de reflexão para os profissionais que se confrontam com casos dessa natureza proporcionando informação utilizável no exercício da sua prática clínica, designadamente, nas fases de diagnóstico e da escolha da terapêutica a adotar na HUA.
https://spginecologia.pt/wp-content/uploads/2021/02/spg-consenso-nacional-sobre-hemorragias-uterinas-anormais-2018.pdf
Iron deficiency anaemia (IDA) occurs in 2-5% of adult men and postmenopausal women in the developed world and is a common cause of referral to gastroenterologists. Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought.
These guidelines are primarily intended for Western gastroenterologists and gastrointestinal (GI) surgeons, but are applicable for other doctors seeing patients with iron deficiency anaemia (IDA). They are not designed to cover patients with overt blood loss or those who present with GI symptoms. GI symptoms or patients at particular risk of GI disease should be investigated on their own merits.
https://gut.bmj.com/content/gutjnl/60/10/1309.full.pdf
Anaemia is the most common systemic complication and extraintestinal manifestation of inflammatory bowel disease [IBD]. In the majority of cases, IBD-associated anaemia is a unique example of the combination of chronic iron deficiency and anaemia of chronic disease [ACD]. Other more rare causes of anaemia in IBD include vitamin B12 and
folate deficiency, toxic effects of medications, and others. The impact of anaemia on the quality of life of IBD patients is substantial. It affects various aspects of quality of life such as physical, emotional, and cognitive functions, the ability to work, hospitalization, and healthcare costs. Anaemia in IBD is not just a laboratory marker; it is a complication of IBD that needs appropriate diagnostic and therapeutic approaches.
Despite the broad use of anti-inflammatory therapy, anaemia may recur fast after successful therapy. As anaemia is a serious medical condition that may become life threatening [if blood transfusions are not available or compatible], preventive measures should be considered. Prevention of anaemia and maintenance of iron and vitamin stores are therefore warranted.
https://academic.oup.com/ecco-jcc/article/9/3/211/361529
The approach to the patient with gastrointestinal bleeding (GIB) can be very complex. A multidisciplinary panel of physicians with expertise in Gastroenterology, Anesthesiology, and Transfusion Medicine worked together to provide the best knowledge and guide clinical practitioners in the real setting of health institutions, characterized by disparate availability of human and technical resources. The authors propose a global and personalized approach according to different clinical scenarios to improve the outcomes of patients with GIB, for whom the reduction of inappropriate transfusions is crucial. The goal of this document is to provide clear and objective guidance through interventional algorithms toward a goal-directed approach according to the clinical situation and supported by the latest available scientific data on GIB management in different settings.
http://www.spanestesiologia.pt/webstspa/wp-content/uploads/2020/10/interventional-algorithm-in-gastrointestinal-bleeding.pdf
Anemia is considered a public health issue and is often caused by iron deficiency. Iron-deficiency anemia (IDA) often originates from blood loss from lesions in the gastrointestinal tract in men and postmenopausal women, and its prevalence among patients with gastrointestinal bleeding has been estimated to be 61%. However, few guidelines regarding the appropriate investigation of patients with IDA due to gastrointestinal bleeding have been published.
These recommendations may serve as a starting point for clinicians to better diagnose and treat IDA in patients with gastrointestinal bleeding, which ultimately may improve health outcomes in these patients.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7723662/pdf/WJG-26-7242.pdf
Anaemia is a commonly diagnosed complication among patients suffering with chronic kidney disease. If left untreated, it may affect patient quality of life. There are several causes for anaemia in this patient population. As the kidney function deteriorates, together with medications and dietary restrictions, patients may develop iron deficiency, resulting in reduction of iron supply to the bone marrow (which is the body organ responsible for the production of different blood elements). Chronic kidney disease patients may not be able to utilise their own body’s iron stores effectively and hence, many patients, particularly those receiving haemodialysis, may require additional iron treatment, usually provided by infusion.
With further weakening of kidney function, patients with chronic kidney disease may need additional treatment with a substance called erythropoietin which drives the bone marrow to produce its own blood. This substance, which is naturally produced by the kidneys, becomes relatively deficient in patients with chronic kidney disease. Any patients will eventually require treatment with erythropoietin or similar products that are given by injection.
Over the last few years, several iron and erythropoietin products have been licensed for treating anaemia in chronic kidney disease patients. In addition, several publications discussed the benefits of each treatment and possible risks associated with long term treatment. The current guidelines provide advice to health care professionals on how to screen chronic kidney disease patients for anaemia, which patients to investigate for other causes of anaemia, when
and how to treat patients with different medications, how to ensure safe prescribing of treatment and how to diagnose and manage complications associated with anaemia and the drugs used for its treatment.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709852/pdf/12882_2017_Article_688.pdf
This Clinical Practice Guideline document is based upon systematic literature searches last conducted in October 2010, supplemented with additional evidence through March 2012. It is designed to provide information and assist decision making. It is not intended to define a standard of care, and should not be construed as one, nor should it be interpreted as prescribing an exclusive course of management. Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of individual patients, available resources, and limitations unique to an institution or type of practice. Every health-care professional making use of these recommendations is responsible for evaluating the appropriateness of applying them in any particular clinical situation. The recommendations for research contained within this document are general and do not imply a specific protocol.
Kidney Disease: Improving Global Outcomes (KDIGO) makes every effort to avoid any actual or reasonably perceived conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the Work Group. All members of the Work Group are required to complete, sign, and submit a disclosure and attestation form showing all such relationships that might be perceived or actual conflicts of interest. This document is updated annually and information is adjusted accordingly. All reported information will be printed in the final publication and are on file at the National Kidney Foundation (NKF), Managing Agent for KDIGO.
https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-Anemia-Guideline-English.pdf
Anemia is a common extraintestinal manifestation of inflammatory bowel disease (IBD), both in pediatric and in adult patients. Iron deficiency is the main cause of anemia in patients with IBD. Anemia is a clinically relevant comorbidity,
with impact on patients’ quality of life and it should be timely diagnosed and adequately treated. Currently, an active
treatment approach is the recommended strategy, with evidence showing efficacy and safety of intravenous iron formulations. However, evidence in pediatric age remains scarce and no clinical recommendations exist for the diagnosis and treatment of this particular age group. The present document represents the first national consensus on the management of anemia in pediatric IBD and is therefore particularly relevant. The authors anticipate that the proposed recommendations will be useful in daily clinical practice for diagnosing and managing iron deficiency and iron-deficiency anemia in the pediatric population with IBD.
https://www.karger.com/Article/Pdf/505071
Background: Severe traumatic injury continues to present challenges to healthcare systems around the world, and
post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in
its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy
following traumatic injury and encourages adaptation of the guiding principles described here to individual
institutional circumstances and resources.
Conclusions: A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient
outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform
standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6436241/pdf/13054_2019_Article_2347.pdf
There has been an explosion of interest in the ability of tranexamic acid to reduce morbidity and mortality in surgical and traumatic bleeding. Tranexamic acid has been shown to reduce mortality due to traumatic bleeding by a third, without apparent safety issues. It is now clearly established that intravenous tranexamic acid reduces blood loss in patients with surgical bleeding and the need for transfusion. It can also be used topically to reduce bleeding. Its use is being explored further in large pragmatic trials in traumatic head injury, postpartum haemorrhage and in upper gastro-intestinal haemorrhage. There are few side effects from the use of tranexamic acid except when administered in high dose where neurological events have been noted, possibly relating to tranexamic acid interfering with cerebral GABA and glycine receptors. However, clinical studies suggest that there is no increased efficacy in using a higher dose, and that a dose of 1 g intravenously in an adult patient has maximal efficacy, which is not increased by higher doses. The CRASH-2 trauma trial clearly showed no increase in thrombotic events after its use in trauma, indeed there was a significant reduction in myocardial infarction. However, trials of tranexamic acid in surgery have failed to adequately study its effects on the risk of postoperative venous and possible reduction in arterial thrombo-embolism, and this needs to be the subject of future research.
https://pubmed.ncbi.nlm.nih.gov/25440395/
Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical
patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patient’s target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for
nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.
https://bjanaesthesia.org/action/showPdf?pii=S0007-0912%2817%2933356-1
In cardiac surgical patients it is a complex challenge to find the ideal balance between anticoagulation and hemostasis. Preoperative anemia and perioperative higher transfusion rates are related to increased morbidity and mortality. Patient blood management (PBM) is an evidence based patient specific individualized protocol used in the perioperative setting in order to reduce perioperative bleeding and transfusion rates and to improve patient outcomes. The three pillars of PBM in cardiac surgery consist of optimization of preoperative erythropoiesis and hemostasis, minimizing blood loss, and improving patient specific physiological reserves. This narrative review focuses on the challenges with special emphasis on PBM in the preoperative phase and intraoperative transfusion management and hemostasis in cardiac surgery patients. It is a “must” that PBM is a collaborative effort between anesthesiologists, surgeons, perfusionists, intensivists and transfusion laboratory teams. This review represents an up to date overview over “PBM in cardiac surgery patients”.
Cardiac surgery is associated with perioperative blood loss and a high risk of allogeneic blood transfusion. Patient blood management (PBM) in cardiac surgery contributes to the maintenance of perioperative haemostasis and the minimization of bleeding, which reduce blood transfusion requirements. PBM in cardiac surgery comprises an interaction between the cardiothoracic surgeon, the anaesthesiologist and the clinical perfusionist. The impact of cardiopulmonary bypass distinguishes this discipline from other surgical specialities.In a joint effort, the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA) provide evidence-based recommendations for PBM in adult-acquired cardiac surgery. Literature searches were based on the Population, Intervention, Comparison, Outcome and Time (PICOT) method using standardized Medical Subject Headings (MeSH) terms from the National Library of Medicine, PubMed and Embase database lists of search terms. The PICOT study end points included bleeding, transfusions and reoperations for bleeding. The guideline was reviewed by an external review method and endorsed by the EACTS and the EACTA in collaboration with the editors of the European Journal of Cardio-Thoracic Surgery and the Journal of Cardiothoracic and Vascular Anesthesia.This guideline provides practical recommendations for all clinicians working in the field of PBM in cardiac surgery, with emphasis on preoperative patient optimization and risk reduction, intraoperative maintenance of haemostasis and postoperative treatment for bleeding complications.
https://www.jcvaonline.com/article/S1053-0770(17)30552-9/fulltext
Pediatric cardiac surgery is associated with a substantial risk of bleeding, frequently requiring the administration of allogeneic blood products. Efforts to optimize preoperative hemoglobin, limit blood sampling, improve hemostasis, reduce bleeding, correct coagulopathy, and incorporate blood sparing techniques (including restrictive transfusion practices) are key elements of patient blood management (PBM) programs, and should be applied to the pediatric cardiac surgical population as across other disciplines. Many guidelines for implementation of PBM in adults undergoing cardiac surgery are available, but evidence regarding the implementation of PBM in children is limited to systematic reviews and specific guidelines for the pediatric cardiac population are missing. The objective of the task force from the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA, www.nataonline.com) is to provide evidence-based recommendations regarding anemia management and blood transfusion practices in the perioperative care of neonates and children undergoing cardiac surgery, and to highlight potential areas where additional research is urgently required.
https://pubmed.ncbi.nlm.nih.gov/31076306/
Since the Transfusion Requirements in CriticalCare (TRICC) trial published in 1999 demon-strated equivalent or improved outcomes whenusing a restrictive versus a liberal transfusionthreshold in critically ill patients,1providers and institu-tions have sought to decrease utilization of allogeneicred blood cells by promoting restrictive transfusionpractices. Since that landmark trial, multiple other studiesin different p opulations, including patients undergoingcardiac surgery,2,3elderly patients undergoing hip replace-ment,4medical patients with gastrointestinal bleeds,5andpatients with traumatic brain injury,6have re-demonstrated the equivalence or superiority of restrictiveover liberal transfusion thresholds with regard to patientoutcomes. However, despite a growing body of evidencesupporting this practice, individuals and institutions havefound it surprisingly difficult to adhere to these guidelines.Nonetheless, there remain multiple motivations for reduc-ing superfluous transfusion; blood products are a finiteresource subject to shortage, there are numerous risksassociated with transfusion, and transfusion is an expen-sive endeavor from both direct (acquisition) and indirect(materials, labor , administration) costs.
https://onlinelibrary.wiley.com/doi/epdf/10.1111/trf.14083
Almost 150 years after the first autologous blood transfusion was reported, intraoperative blood salvage has become an important method of blood conservation. The primary goal of autologous transfusion is to reduce or avoid allogeneic red blood cell transfusion and the associated risks and costs. Autologous salvaged blood does not result in immunological challenge and its consequences, provides a higher quality red blood cell that has not been subjected to the adverse effects of blood storage, and can be more cost-effective than allogeneic blood when used for carefully selected surgical patients. Cardiac, orthopaedic and vascular surgery procedures with large anticipated blood loss can clearly benefit from the use of cell salvage. There are safety concerns in cases with gross bacterial contamination. There are theoretical safety concerns in obstetrical and cancer surgery; however, careful cell washing as well as leucoreduction filters makes for a safer autologous transfusion in these circumstances. Further studies are needed to determine whether oncologic outcomes are impacted by transfusing salvaged blood during cancer surgery. In this new era of patient blood management, where multimodal methods of reducing dependence on allogeneic blood are becoming commonplace, autologous blood salvage remains a valuable tool for perioperative blood conservation. Future studies will be needed to best determine how and when cell salvage should be utilized along with newer blood conservation measures.
https://pubmed.ncbi.nlm.nih.gov/28580663/
A cirurgia eletiva é aquela que não se reveste das características de urgência ou emergência, ou seja, quando o doente não está sob o risco de vida, podendo ser efetuada em data programada, desde que essa data não comprometa a eficácia da intervenção.
O conceito de “gestão do sangue do doente” (Patient Blood Management: PBM) corresponde a uma estratégia global de boas práticas de transfusão, que permite a melhor utilização do sangue e dos seus componentes. O PBM é um exemplo de medicina baseada na evidência centrada no doente que, otimizando e conservando o próprio sangue do doente, visa melhorar os seus resultados em saúde.
Existem Recomendações Europeias, publicadas em março de 2017, dirigidas aos Hospitais e Autoridades Nacionais de Saúde, que recomendam o PBM como estratégia a implementar.
https://normas.dgs.min-saude.pt/wp-content/uploads/2019/10/gestao-do-sangue-do-doente-patient-blood-management-pbm-em-cirurgia-eletiva.pdf
Despite current recommendations on the management of pre-operative anaemia, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in surgical patients. A number of experienced researchers and clinicians took part in an expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the peri-operative period. These statements include: a diagnostic approach for anaemia and iron deficiency in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up. We urge anaesthetists and peri-operative physicians to embrace these recommendations, and hospital administrators to enable implementation of these concepts by allocating adequate resources.
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.13773
Despite numerous guidelines on the management of anaemia in surgical patients, there is no pragmatic guidance for the diagnosis and management of anaemia and iron deficiency in the postoperative period. A number of experienced researchers and clinicians took part in a two-day expert workshop and developed the following consensus statement. After presentation of our own research data and local policies and procedures, appropriate relevant literature was reviewed and discussed. We developed a series of best-practice and evidence-based statements to advise on patient care with respect to anaemia and iron deficiency in the postoperative period. These statements include: a diagnostic approach to iron deficiency and anaemia in surgical patients; identification of patients appropriate for treatment; and advice on practical management and follow-up that is easy to implement. Available data allow the fulfilment of the requirements of Pillar 1 of Patient Blood Management. We urge national and international research funding bodies to take note of these recommendations, particularly in terms of funding large-scale prospective, randomised clinical trials that can most effectively address the important clinical questions and this clearly unmet medical need.
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.14358
PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.
https://pubs.asahq.org/anesthesiology/article/122/2/241/12287/Practice-Guidelines-for-Perioperative-Blood
The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work. pré-operatórios
https://journals.lww.com/ejanaesthesiology/Fulltext/2017/06000/Management_of_severe_perioperative_bleeding__.3.aspx
Clinically significant bleeding can occur as a consequence of surgery, trauma, obstetric complications, anticoagulation, and a wide variety of disorders of hemostasis. As the causes of bleeding are diverse and not always immediately apparent, the availability of a safe, effective, and non-specific hemostatic agent is vital in a wide range of clinical settings, with antifibrinolytic agents often utilized for this purpose. Tranexamic acid (TXA) is one of the most commonly used and widely researched antifibrinolytic agents; its role in postpartum hemorrhage, menorrhagia, trauma-associated hemorrhage, and surgical bleeding has been well defined. However, the utility of TXA goes beyond these common indications, with accumulating data suggesting its ability to reduce bleeding and improve clinical outcomes in the face of many different hemostatic challenges, without a clear increase in thrombotic risk. Herein, we review the literature and provide practical suggestions for clinical use of TXA across a broad spectrum of bleeding disorders.
https://onlinelibrary.wiley.com/doi/10.1111/ejh.13348
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6676023/pdf/kja-19169.pdf
AA presente Norma aborda o diagnóstico e tratamento das deficiências de ferro no adulto. Considera-se como adulto os maiores ou iguais a 18 anos.
A anemia por deficiência de ferro, constitui a deficiência mais prevalente no mundo segundo a OMS que define anemia se: 1) Hemoglobina <13g/dl no homem e <12g/dl na mulher.
A deficiência de ferro vai desde o estado de depleção de ferro sem anemia à anemia ferropénica.
https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0302013-de-31122013-pdf.aspx
Objective To develop a set of evidence-based recommendations for patient blood management (PBM) and for research.
Conclusions and Relevance The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
https://jamanetwork.com/journals/jama/article-abstract/2727453
A transfusão sanguínea é essencial para o desenvolvimento da medicina moderna, e nas últimas décadas vários tratamentos médicos e cirúrgicos não podiam ter sido implementados sem recurso a esta terapêutica de suporte. Como qualquer outra terapêutica, está associada a riscos não negligenciáveis, é de disponibilidade limitada porque é uma terapêutica dependente do altruísmo dos dadores, e tem custos que devem ser conhecidos pelos médicos prescritores. É geralmente um procedimento seguro e eficaz, permite a correcção das deficiências hematológicas, prevenindo as suas consequências e quando corretamente indicada, o seu efeito benéfico ultrapassa largamente os riscos.
A avaliação da eficácia da transfusão e a monitorização dos efeitos adversos imediatos ou tardios, devem ser contemplados numa boa prática para a garantia de segurança adicional. Todos os aspectos da terapêutica transfusional têm sido alvo de investigação clínica e epidemiológica alargada e há inúmeras publicações em que as indicações clínicas dos diferentes componentes sanguíneos são avaliadas e estabelecidas sobre a forma de guias de
orientação ou normas de boas práticas. No entanto, a maioria dos estudos publicados e planeados com a finalidade de estabelecer limites para a transfusão de Concentrado de Eritrócitos, são estudos não randomizados pelo que os resultados devem ser interpretados de forma cautelosa. Assim, a decisão clínica sobre o recurso à terapêutica transfusional apesar de baseada em evidências ou estudos observacionais, será sempre um acto individualizado em
que a avaliação clínica é determinante e as orientações devem ser entendidas como uma ajuda para decisão e revistas sempre que haja novas evidências, ou novas descobertas neste campo do conhecimento.
https://www.dgs.pt/directrizes-da-dgs/normas-e-circulares-normativas/norma-n-0382012-de-30122012-png.aspx