Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group.

BACKGROUND AND OBJECTIVES: Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce. MATERIALS AND METHODS: To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016. RESULTS: Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron. CONCLUSION: Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

Medical student education in transfusion medicine, part II: Moving forward to building up a "Know How" education program in transfusion medicine for under-graduate medical students.

There is a general trend in changing paradigm in teaching medicine; the emerging concept relies on a competence-based approach. Transfusion is either a discipline or a subsidiary of others depending on the countries and systems; this variability can be explained because transfusion is a medical care that is transdisciplinary. As a collective of professionals in both transfusion medicine practice and education, authors aim to propose a revision of the way education in transfusion medicine is delivered in this era of the 'global competency approach'. They advocate in favor of a Know How on 5 key issues: Diagnosing the patient condition in line with the Patient Blood Management principles; Facing acute blood loss; Addressing compatibility and avoiding immunization; Seeking for maximized benefits and dampening complications; and Inlaying competence within global health care issues, also comprising od economy. The methods used would be those developed for medical education at large, such as assessment tools. The global objective is to deliver the necessary competence to manage patients by an intern/resident. At the end of the curriculum, students should be able to self-evaluate the following items: 1) Do I know why my patient is anemic, thrombocytopenic, bleeding….? 2) Do I know the best approach to treat anemia, thrombocytopenia, bleeding (including the "no treatment" option)? 3) Do I know whether a transfusion approach is appropriate for my patients? 4) Do I know how to evaluate and anticipate benefits from blood transfusion and to avoid side-effects in the patient? 5) Do I know how to avoid unnecessary use of the products?

Medical student education in transfusion medicine: Proposal from the "European and Mediterranean initiative in transfusion medicine".

A large body of observations indicate that there is an inconsistent knowledge of Transfusion Medicine among health care professionals as well as inconsistent knowledge in all aspects of the transfusion process, from blood donation to transfusion on the ward. It is obvious to consider that appropriate education in Transfusion Medicine should be achieved in the education of specialists who will prescribe transfusion on a regular basis (hematologists, critical care specialists, anaethesiologists and others.) However,we also believe that education in Transfusion Medicine should also be delivered to almost all other medical specialists who may prescribe blood components. The variability in education of undergraduates in medical schools is universal most likely due to an absence of a predefined common platform. This paper, therefore, focuses on education at the undergraduate level and advocates coverage of the essential physiology and pathophysiology of blood as applied to blood transfusion as well as the medical and societal aspects of issues related to blood donation. It proposes incremental levels of training in Transfusion Medicine, with what is being therefore referred to as 'A', 'B', 'C' etc. curricula in ascending order of complexity; for example, 'A' and 'B' levels would involve medical, midwifery and nursing students, covering a broad base of the subject: they will be detailed in the present essay; ongoing further curricula will focus on physicians and other professionals working within the area or with responsibility for different aspects of the transfusion chain. It is intended that these courses include aspects of donor care, patient care and the appropriate use, safety and effectiveness of blood products. Next, it is advocated that curricula are addressed not only for high-income countries but also for middle- and low-income ones.

Education in transfusion medicine, Part III - The importance of haemovigilance education.

According to the literature, there are significant differences in the availability of education and training in transfusion medicine worldwide, with significant heterogeneity in the existing curricula. Recognising the need for education with the aim of achieving globally standardised competencies in transfusion medicine, a group of experts collaborating in the European and Mediterranean Initiative in Transfusion medicine (EMITm) proposed a process of incremental training and education. Subsequent to two previous papers published by this group on general education in transfusion medicine, this paper specifically refers to the field of education in haemovigilance. This topic is of particular importance when one considers the role of haemovigilance in improving the safety of transfusion practice, and the fact that this role can only be realised through the cooperation of all participants in the transfusion chain. In addition to promoting the importance of education in haemovigilance, this paper provides an overview of the available literature on this topic and proposes an education programme on haemovigilance for medical students and residents.

Thirty years of hemovigilance - Achievements and future perspectives.

Since its emergence in the early 1990s, hemovigilance has gradually evolved from a blood safety concept focused on surveillance of adverse reactions and events in patients, to a well-defined system that monitors the entire transfusion chain and improves its safety. The importance of hemovigilance has been recognized globally in a relatively short time, but the level of its implementation varies significantly between countries. The cooperation of international organizations has significantly contributed to the promotion, implementation, and education in this field. Thanks to initiatives taken, the safety of transfusion practice has been improved in many segments, primarily related to the risks of adverse events in recipients of blood components. In parallel with changing transfusion practice, the hemovigilance process has also matured. In addition to the reduction of existing risks and the early detection of emerging risks, hemovigilance has also embraced the principles of patient blood management. Research in hemovigilance is more increasingly focused on specific categories of patients, specific blood components and methods of their preparation, rare reactions, and transfusion efficacy and efficiency. A proactive approach and use of big data can play an important role in achieving these goals. Additional and sustained efforts should be made to prevent underreporting of events and to improve data comparability through clear definitions and grading systems. This review provides a historical overview of hemovigilance and its achievements, current challenges, and future plans.

Ethics in transfusion medicine: Are the intricate layers of ethics all universal? A global view.

Ethical principles have been considered, and in several respects regulated, along the entire blood procurement chain from donor motivation to transfusion to the patient. Consent of donors and voluntary non-remunerated donation are fields which have been addressed by codes of ethics and legislation. Caring for donor health is an area of further development of ethical standards. In part, blood products have also become a market, where commercial principles may synergize, but also creating issues in equality and maintaining human dignity that challenge societal solutions. At the bedside, the main global challenge remains to procure enough blood products for each patient in medical need. Allocation of rare blood, ethical evaluation of transfusion triggers, attitudes towards refusing blood transfusion and provision of blood products to remote settings are areas which should receive consideration.

A feasibility study on the effects of Triton X-100 for the in vitro inactivation of Ebola virus on haematological assays.

AIMS: The aim of this study was to check the effect of Triton X-100 on various, commonly used haematology test parameters. METHODS: Anonymised blood samples were treated with 10 µL of 10% Triton X-100 per 1 mL of blood. Treated and untreated samples were tested in parallel for blood film morphology, complete blood counts (CBCs), flow cytometry, blood grouping and antibody screens. Samples were also taken in 3.2% citrate tubes for coagulation test analyses. RESULTS: Statistical differences were noted in all CBC parameters apart from the mean cell volume, eosinophil and basophil counts. Platelet counts were significantly different with an apparent rise after the addition of Triton X-100. Samples were noted to have a high red cell fragmentation index. Immunological platelet counting methods using flow cytometry and fluorescent methods showed no significant differences and gave reliable results. Neither flow cytometry for T-cell subsets nor blood grouping/antibody screens were affected by Triton X-100. However, coagulation samples were severely haemolysed prohibiting analysis. CONCLUSIONS: We have demonstrated that the addition of Triton X-100 to haematology blood samples impacts mainly on platelet counts and coagulation studies due to haemolysis. The platelet count is spuriously raised probably due to the presence of red cell fragments. The latter can be circumvented by the use of immunological platelet counting technology.

Flow cytometry and thromboelastography to assess platelet counts and coagulation in patients with haematological malignancies.

BACKGROUND: Accurate platelet counts (PC) are necessary in order to follow recommendations for prophylactic platelet transfusion. We carried out a study comparing the standard way of counting platelets using a routine analyser and compared it with PC determined by flow cytometry (FC) and haemostatic data obtained with thromboelastography (TEG). MATERIALS AND METHODS: The study was carried out on 24 patients with haematological malignancies, all given one adult dose of platelets. The PC was determined before and after transfusion using an automated blood cell counter and FC. Citrated, "native" whole blood TEG was carried out before and after platelet transfusion to assess global haemostasis. RESULTS: No bleeding was observed in any of the subjects. Thirty-one assessments were performed in the 24 patients. The mean pre-transfusion PC were 9.8 and 13×10(9)/L with the automated counter and FC, respectively with a difference of 3.7 (p=0.0011). Excellent correlation was observed between the two counts (r=0.89; p<0.0001). Mean post-transfusion increments were 23 and 29×10(9)/L for the routine counter and FC, respectively. Using the immunological PC, patients would not have qualified for transfusion in 18.2% of cases since their PC was >20×10(9)/L. TEG showed a shortened reaction time in 69.6% of cases and a normal mean K time of 6.7 min. Only 9% had a low α angle signifying hypocoagulability. The maximum amplitude was reduced in the majority of cases but normal in 25% despite PC<20×10(9)/L. Mean activated partial thromboplastin time, prothrombin time and fibrinogen were normal prior to transfusion. DISCUSSION: Although higher PC as assessed by FC could potentially have an impact on platelet transfusion practices, TEG was sensitive enough to detect PC<10×10(9)/L and some between 10-20×10(9)/L. Whether patients with the latter PC are more prone to bleeding remains to be verified in larger studies.

QTc prolongation in apheresis platelet donors.

BACKGROUND: Citrate infusion during apheresis procedures can cause lowering of the plasma ionized calcium leading to prolongation of the QT interval and hypotension. At the myocardial level, QTc measurement is a sensitive marker of subphysiologic calcium values caused by citrate toxicity. STUDY DESIGN AND METHODS: Seventy-six regular platelet donors were recruited into this study. QTc intervals were measured continuously for 3 minutes at four different points during the apheresis procedures. The blood pressure was recorded every 5 minutes throughout the procedure. RESULTS: The baseline QTc value for men was 406.5 +/- 13.1 milliseconds(1/2) and for women was 417.6 +/- 13.3 milliseconds(1/2) (p = 0.0016). OTc prolongation occurred in all procedures in all donors. Maximum recorded values were significantly higher in women than in men (450.8 +/- 20.8 vs. 424.8 +/- 14.3 ms(1/2); p = 0.0025). All QTc values returned to baseline by 15 minutes after the procedure. Changes in blood pressure were minimal and no donor experienced severe symptoms. CONCLUSIONS: QTc prolongation always occurs during plateletpheresis. This prolongation is greater in women than in men. This study indicates that it may be advisable to assess donors for family or personal history of syncope and family history of sudden death to exclude those at increased risk of arrhythmias because of asymptomatic carriage of a long-QT gene. In addition baseline QTc measurement is a simple noninvasive procedure that could be applied to further studies with a view to enhancing donor safety in apheresis.