ABSTRACT
Estos últimos años han aparecido alertas de seguridad, no siempre bien sustentadas, que cuestionan el uso de algunas alternativas farmacológicas a la transfusión de sangre alogénica y/o lo restringen en indicaciones establecidas. Asistimos también a la preconización de otras alternativas, incluyendo productos hemáticos y fármacos antifibrinolíticos, sin que haya una base científica sólida que lo justifique. Por iniciativa del Grupo de Estudios Multidisciplinares sobre Autotransfusión y del Anemia Working Group España se reunió a un panel multidisciplinar de 23 expertos del área de cuidados de la salud en un foro de debate para: 1) analizar las diferentes alertas de seguridad en torno a ciertas alternativas a la transfusión; 2) estudiar los antecedentes que las han propiciado, la evidencia que las sustentan y las consecuencias que conllevan para la práctica clínica, y 3) emitir una valoración argumentada de la seguridad de cada alternativa a la transfusión cuestionada, según el uso clínico de la misma. Los integrantes del foro mantuvieron contactos por vía telemática y una reunión presencial en la que presentaron y discutieron las conclusiones sobre cada uno de los elementos examinados. Se elaboró un primer documento que fue sometido a 4 rondas de revisión y actualización hasta alcanzar un consenso, unánime en la mayoría de los casos. Presentamos la versión final del documento, aprobada por todos los miembros del panel, esperando sea de utilidad para nuestros colegas
In recent years, several safety alerts have questioned or restricted the use of some pharmacological alternatives to allogeneic blood transfusion in established indications. In contrast, there seems to be a promotion of other alternatives, based on blood products and/or antifibrinolytic drugs, which lack a solid scientific basis. The Multidisciplinary Autotransfusion Study Group and the Anemia Working Group España convened a multidisciplinary panel of 23 experts belonging to different healthcare areas in a forum for debate to: 1) analyze the different safety alerts referred to certain transfusion alternatives; 2) study the background leading to such alternatives, the evidence supporting them, and their consequences for everyday clinical practice, and 3) issue a weighted statement on the safety of each questioned transfusion alternative, according to its clinical use. The members of the forum maintained telematics contact for the exchange of information and the distribution of tasks, and a joint meeting was held where the conclusions on each of the items examined were presented and discussed. A first version of the document was drafted, and subjected to 4 rounds of review and updating until consensus was reached (unanimously in most cases). We present the final version of the document, approved by all panel members, and hope it will be useful for our colleagues
Subject(s)
Humans , Blood Transfusion, Autologous/methods , Blood Transfusion/methods , Postoperative Hemorrhage/therapy , Critical Care/methods , Intensive Care Units/organization & administration , Erythropoiesis/physiology , Factor VIII/pharmacokinetics , Colloids/pharmacokinetics , Patient SafetyABSTRACT
The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities.
Subject(s)
Anemia/therapy , Blood Banks/statistics & numerical data , Blood Transfusion , Health Care Surveys , Perioperative Care/methods , Anemia/diagnosis , Anemia/drug therapy , Anesthesiology , Antifibrinolytic Agents/therapeutic use , Blood Banks/organization & administration , Blood Loss, Surgical , Blood Transfusion, Autologous/statistics & numerical data , Erythropoietin/therapeutic use , Hematinics/therapeutic use , Hemoglobins/analysis , Hospital Departments , Humans , Iron/administration & dosage , Iron/therapeutic use , Operative Blood Salvage/statistics & numerical data , Organizational Policy , Perioperative Care/standards , Perioperative Care/statistics & numerical data , Postoperative Hemorrhage/therapy , Professional Staff Committees/statistics & numerical data , Recombinant Proteins/therapeutic use , SpainABSTRACT
Hemoglobin optimization and treatment of preoperative anemia in surgery with a moderate to high risk of surgical bleeding reduces the rate of transfusions and improves hemoglobin levels at discharge and can also improve postoperative outcomes. To this end, we need to schedule preoperative visits sufficiently in advance to treat the anemia. The treatment algorithm we propose comes with a simple checklist to determine whether we should refer the patient to a specialist or if we can treat the patient during the same visit. With the blood count test and additional tests for iron metabolism, inflammation parameter and glomerular filtration rate, we can decide whether to start the treatment with intravenous iron alone or erythropoietin with or without iron. With significant anemia, a visit after 15 days might be necessary to observe the response and supplement the treatment if required. The hemoglobin objective will depend on the type of surgery and the patient's characteristics.
Subject(s)
Algorithms , Anemia/therapy , Preoperative Care/methods , Anemia/diagnosis , Anemia/drug therapy , Blood Transfusion , Elective Surgical Procedures , Folic Acid/therapeutic use , Hematinics/therapeutic use , Hemoglobins/analysis , Humans , Iron/administration & dosage , Iron/adverse effects , Iron/therapeutic use , Medical Errors/prevention & control , Risk Factors , Unnecessary Procedures , Vitamin B 12/therapeutic useABSTRACT
El objetivo de este artículo es conocer la disponibilidad de un programa de gestión de la transfusión perioperatoria («Patient Blood Management») en distintos hospitales a través de una encuesta que incluía una descripción de la visita preanestésica, la disponibilidad y utilización de las diferentes técnicas de ahorro de sangre y los factores limitantes de su implementación para cirugía programada. La encuesta constaba de 42 preguntas dirigidas a servicios de anestesiología representativos de los hospitales del territorio español (n = 91), y se realizó durante los meses de septiembre a noviembre de 2012. Fueron analizadas las 82 encuestas que contestaron a todas las preguntas (90%). La consulta preoperatoria se realizó de forma habitual (> 70%) en el 87% de los hospitales. El tiempo desde la consulta hasta la cirugía osciló entre 1 semana y 3 meses en el 74% de pacientes programados para cirugía ortopédica y traumatológica, en el 78% de cirugía oncológica y en el 77% de cirugía cardíaca. Casi la totalidad de hospitales, 77 (94%), disponen de comité de transfusión, con presencia del anestesiólogo en el 90% de ellos. Se dispone de un programa de ahorro de sangre en el 79% de los hospitales y la técnica más frecuentemente utilizada es el uso de antifibrinolíticos en el 75% de los hospitales, seguida de la recuperación de sangre intra y postoperatoria en parecida proporción (67%). La optimización de la hemoglobina preoperatoria se realiza con hierro intravenoso de forma habitual en el 39% de los hospitales y con eritropoyetina recombinante en el 28%. La ausencia de un circuito bien establecido y la falta de implicación y colaboración con el equipo quirúrgico se presentan como los principales factores limitantes de la implantación del «Patient Blood Management». En la actualidad, su aplicación en España se puede considerar aceptable, pero podrían mejorarse aspectos, especialmente en el tratamiento de la anemia preoperatoria. La implementación del «Patient Blood Management» requiere colaboración multidisciplinar de todo el personal responsable de la atención perioperatoria, incluidas las autoridades sanitarias (AU)
The objective of this article is to determine the availability of a perioperative transfusion management program (Patient Blood Management [PBM]) in various hospitals through a survey that included a description of the preanesthesia visit, the availability and use of the various blood-sparing techniques and the factors limiting their implementation in elective surgery. The survey included 42 questions, directed at the representative departments of anesthesiology of hospitals in Spain (n=91). The survey was conducted from September to November 2012. We analyzed the 82 surveys in which all the questions were answered (90%). Preoperative consultations are routinely performed (>70%) in 87% of the hospitals. The time from the consultation to surgery varied between 1 week and 2 months for 74% of the patients scheduled for orthopedic or trauma surgery, 78% of those scheduled for oncologic surgery and 77% of those scheduled for cardiac surgery. Almost all hospitals (77, 94%) had a transfusion committee, and 90% of them had an anesthesiologist on the committee. Seventy-nine percent of the hospitals had a blood-sparing program, and the most widely used technique was the use of antifibrinolytic agents (75% of hospitals), followed by intraoperative and postoperative blood recovery in equal proportions (67%). Optimization of preoperative hemoglobin was routinely performed with intravenous iron in 39% of the hospitals and with recombinant erythropoietin in 28% of the hospitals. The absence of a well-established circuit and the lack of involvement and collaboration with the surgical team were the main limiting factors in implementing PBM. Currently, the implementation of PBM in Spain could be considered acceptable, but it could also be improved, especially in the treatment of preoperative anemia. The implementation of PBM requires multidisciplinary collaboration among all personnel responsible for perioperative care, including the health authorities (AU)
Subject(s)
Blood Transfusion , Operative Blood Salvage , Anemia/drug therapy , Anemia/epidemiology , Antifibrinolytic Agents/therapeutic use , Iron/therapeutic use , Erythropoietin/therapeutic use , Iron/blood , Preoperative Period , Epidemiological Monitoring/trends , Patient Safety , Perioperative Period , Postoperative Period , Anesthesiology , 17140 , Blood Transfusion, Autologous , Observational Study , Spain/epidemiologyABSTRACT
La optimización de la hemoglobina o el tratamiento de la anemia preoperatoria en cirugía con riesgo moderado-alto de sangrado quirúrgico reduce la tasa de transfusión y puede mejorar la evolución postoperatoria, así como la hemoglobina al alta. Para ello se requiere programar una visita preoperatoria con suficiente antelación para poderla corregir. El algoritmo de tratamiento que proponemos se acompaña de un «check list» sencillo para saber si debemos remitir al paciente al especialista o podemos tratarlo en ese mismo momento. Con el hemograma, algún test complementario del metabolismo del hierro, un parámetro de inflamación y la tasa de filtrado glomerular podremos decidir si iniciar el tratamiento con hierro intravenoso solo o asociar eritropoyetina, con o sin hierro. En la anemia importante puede ser necesaria alguna visita de control a los 15 días, para ver la respuesta y complementar el tratamiento, si el paciente lo precisa. La hemoglobina objetivo dependerá del tipo de cirugía y las características del paciente (AU)
Hemoglobin optimization and treatment of preoperative anemia in surgery with a moderate to high risk of surgical bleeding reduces the rate of transfusions and improves hemoglobin levels at discharge and can also improve postoperative outcomes. To this end, we need to schedule preoperative visits sufficiently in advance to treat the anemia. The treatment algorithm we propose comes with a simple checklist to determine whether we should refer the patient to a specialist or if we can treat the patient during the same visit. With the blood count test and additional tests for iron metabolism, inflammation parameter and glomerular filtration rate, we can decide whether to start the treatment with intravenous iron alone or erythropoietin with or without iron. With significant anemia, a visit after 15 days might be necessary to observe the response and supplement the treatment if required. The hemoglobin objective will depend on the type of surgery and the patients characteristics (AU)