Reasons for moving toward a patient‐centric paradigm of clinical transfusion medicine practice

Abstract

The combination of patient blood management (PBM) modalities and multicomponent apheresis permits us to administer even safer transfusions than those using the "safer-than-ever" blood components distributed in the beginning of the 21st century. PBM identifies a patient at risk of transfusion and formulates a multidisciplinary and multimodal-yet individualized-plan for reducing the need for allogeneic transfusion. Multicomponent apheresis can collect any combination of red blood cells, platelets, and plasma from the same donor during the same donation, and it should eventually reserve all components harvested from the same donation for transfusion to the same recipient. Together, PBM and multicomponent apheresis represent a new paradigm-the patient-centric paradigm-of transfusion medicine whose purpose is to reduce the transfusion risk for each individual patient to the level of the ALARA (as-low-as-reasonably-achievable) risk. PBM and multicomponent apheresis can meet a patient's transfusion needs with at least twofold fewer allogeneic donor exposures, thereby reducing the risk of infectious and immunologic complications of transfusion by at least twofold. The reduction in risk includes the leading cause of transfusion-related mortality (transfusion-related acute lung injury) and the cardinal threat to transfusion safety (the next "HIV-like" pathogen to emerge in the future). Once it is determined that PBM and multicomponent apheresis can replace the current blood-procurement system at a "reasonable" cost and without jeopardizing the supply of blood and components, the patient-centric paradigm should replace the current, component-centric paradigm of transfusion medicine to reduce the transfusion risk to the level of the ALARA risk.

Foro de debate: seguridad de las alternativas a la transfusión alogénica en el paciente quirúrgico y/o crítico

“…Recientemente, se ha podido comprobar que, a pesar de la aplicación de criterios restrictivos, los pacientes críticos y quirúrgicos que reciben transfusión presentaban un peor desenlace clínico que los no transfundidos 96,97 . Para resolver estas cuestiones, de acuerdo con los principios del Patient Blood Management, debemos avanzar hacia una indicación TSA centrada en el paciente para satisfacer sus necesidades individuales («a medida») 98 . Ello supondrá un cambio del paradigma de «uso restrictivo» al de «uso M. Muñoz Gómez et al…”

“…En muchas ocasiones, la administración de un solo concentrado de hematíes puede ser una opción válida 98 . Deberemos considerar, además de las citadas recomendaciones, la dinámica/cinética del sangrado postoperatorio, el contexto de la situación y el entorno del paciente (grado de monitorización), los problemas logísticos de la obtención de concentrado de hematíes «cuando se necesitan» (tiempo de respuesta), ya que es responsabilidad del equipo médico detectar y satisfacer los requerimientos de TSA de manera oportuna 9 .…”

Bloodless medicine: what to do when you can't transfuse

“…Based on prior reports and our experience thus far, we follow 5 tenets of patient blood management in caring for bloodless patients at our institution [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][26][27][28] : (1) minimizing iatrogenic blood loss for laboratory testing, (2) tolerating lower hemoglobins, (3) diagnosing and treating preoperative anemia, (4) salvaging intraoperative blood, and (5) optimizing surgical hemostasis (Table 1). We request that all surgical patients seeking bloodless care obtain a preoperative complete blood count as soon as possible, preferably at least 4-8 weeks before the surgery.…”

“…[1][2][3] In fact, several academic health centers are establishing "Bloodless Medicine & Surgery Programs" that specialize in treating patients who do not accept allogeneic blood transfusions (ABTs). [4][5][6][7][8][9][10][11][12][13][14][15][16] A multidisciplinary approach is frequently required to optimize clinical outcomes for these patients, particularly in the setting of multiple comorbidities or high-risk surgical procedures.…”

Patient Blood Management Bundles to Facilitate Implementation

“…Despite the demonstrated benefits of PBM, many barriers and challenges limit translation of PBM guidelines into clinical practice [22][23][24][25], in particular due to lack of knowledge (eg, staff members are not aware of the latest discoveries and new guidelines; imprudent practice is endorsed by common misconceptions), lack of interdisciplinary commitment (eg, many patients have contact with different clinicians from different departments with different opinions about the "best treatment"; resistance from hospital's "culture"), lack of resources (eg, limited staff with limited time; hospital administrators need to invest initially before saving money), and concerns (eg, PBM may initially "cut down" jobs in blood donor service or transfusion medicine).…”