Deploying Healthcare Providers during COVID-19 Pandemic.

As the COVID-19 pandemic runs its course around the globe, a mismatch of resources and needs arises: In some areas, healthcare systems are faced with increased number of COVID-19 patients potentially exceeding their capacity, while in other areas, healthcare systems are faced with procedural cancellations and drop in demands. TeamHealth (Knoxville, TN), a multidisciplinary healthcare organization was able to roll out a systemic approach to redeploy its clinicians practicing in the fields of emergency medicine, hospital medicine and anesthesiology from areas of less need (faced with reduced or no work) to areas outside of their normal practice facing immediate need.

Essential Role of Patient Blood Management in a Pandemic: A Call for Action.

The World Health Organization (WHO) has declared coronavirus disease 2019 (COVID-19), the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a pandemic. Global health care now faces unprecedented challenges with widespread and rapid human-to-human transmission of SARS-CoV-2 and high morbidity and mortality with COVID-19 worldwide. Across the world, medical care is hampered by a critical shortage of not only hand sanitizers, personal protective equipment, ventilators, and hospital beds, but also impediments to the blood supply. Blood donation centers in many areas around the globe have mostly closed. Donors, practicing social distancing, some either with illness or undergoing self-quarantine, are quickly diminishing. Drastic public health initiatives have focused on containment and "flattening the curve" while invaluable resources are being depleted. In some countries, the point has been reached at which the demand for such resources, including donor blood, outstrips the supply. Questions as to the safety of blood persist. Although it does not appear very likely that the virus can be transmitted through allogeneic blood transfusion, this still remains to be fully determined. As options dwindle, we must enact regional and national shortage plans worldwide and more vitally disseminate the knowledge of and immediately implement patient blood management (PBM). PBM is an evidence-based bundle of care to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This multinational and diverse group of authors issue this "Call to Action" underscoring "The Essential Role of Patient Blood Management in the Management of Pandemics" and urging all stakeholders and providers to implement the practical and commonsense principles of PBM and its multiprofessional and multimodality approaches.

In Vitro Evaluation of a Novel Image Processing Device to Estimate Surgical Blood Loss in Suction Canisters.

BACKGROUND: Clinicians are tasked with monitoring surgical blood loss. Unfortunately, there is no reliable method available to assure an accurate result. Most blood lost during surgery ends up on surgical sponges and within suction canisters. A novel Food and Drug Administration-cleared device (Triton system; Gauss Surgical, Inc, Los Altos, CA) to measure the amount of blood present on sponges using computer image analysis has been previously described. This study reports on performance of a complementary Food and Drug Administration-cleared device (Triton Canister System; Gauss Surgical, Inc, Los Altos, CA) that uses similar image analysis to measure the amount of blood in suction canisters. METHODS: Known quantities of expired donated whole blood, packed red blood cells, and plasma, in conjunction with various amounts of normal saline, were used to create 207 samples representing a wide range of blood dilutions commonly seen in suction canisters. Each sample was measured by the Triton device under 3 operating room lighting conditions (bright, medium, and dark) meant to represent a reasonable range, resulting in a total of 621 measurements. Using the Bland-Altman method, the measured hemoglobin (Hb) mass in each sample was compared to the results obtained using a standard laboratory assay as a reference value. The analysis was performed separately for samples measured under each lighting condition. It was expected that under each separate lighting condition, the device would measure the various samples within a prespecified clinically significant Hb mass range (±30 g per canister). RESULTS: The limits of agreement (LOA) between the device and the reference method for dark (bias: 4.7 g [95% confidence interval {CI}, 3.8-5.6 g]; LOA: -8.1 g [95% CI, -9.7 to -6.6 g] to 17.6 g [95% CI, 16.0-19.1 g]), medium (bias: 3.4 g [95% CI, 2.6-4.1 g]; LOA: -7.4 g [95% CI, -8.7 to -6.1 g] to 14.2 g [95% CI, 12.9-15.5 g]), and bright lighting conditions (bias: 4.1 g [95% CI, 3.2-4.9 g]; LOA: -7.6 g [95% CI, -9.0 to -6.2 g] to 15.7 g [95% CI, 14.3-17.1 g]) fell well within the predetermined clinically significant limits of ±30 g. Repeated measurements of the samples under the various lighting conditions were highly correlated with intraclass correlation coefficient of 0.995 (95% CI, 0.993-0.996; P < .001), showing that lighting conditions did not have a significant impact on measurements. Hb mass bias was significantly associated with hemolysis level (Spearman ρ correlation coefficient, -0.137; P = .001) and total canister volume (Spearman ρ correlation coefficient, 0.135; P = .001), but not ambient illuminance. CONCLUSIONS: The Triton Canister System was able to measure the Hb mass reliably with clinically acceptable accuracy in reconstituted blood samples representing a wide range of Hb concentrations, dilutions, hemolysis, and ambient lighting settings.

Real-time evaluation of an image analysis system for monitoring surgical hemoglobin loss.

Monitoring blood loss is important for management of surgical patients. This study reviews a device (Triton) that uses computer analysis of a photograph to estimate hemoglobin (Hb) mass present on surgical sponges. The device essentially does what a clinician does when trying to make a visual estimation of blood loss by looking at a sponge, albeit with less subjective variation. The performance of the Triton system is reported upon in during real-time use in surgical procedures. The cumulative Hb losses estimated using the Triton system for 50 enrolled patients were compared with reference Hb measurements during the first quarter, half, three-quarters and full duration of the surgery. Additionally, the estimated blood loss (EBL) was calculated using the Triton measured Hb loss and compared with values obtained from both visual estimation and gravimetric measurements. Hb loss measured by Triton correlated with the reference method across the four measurement intervals. Bias remained low and increased from 0.1 g in the first quarter to 3.7 g at case completion. The limits of agreement remained narrow and increased proportionally from the beginning to the end of the cases, reaching a maximum range of -15.3 to 22.7 g. The median (IQR) difference of EBL derived from the Triton system, gravimetric method and visual estimation versus the reference value were 13 (74), 389 (287), and 4 (230) mL, respectively. Use of the Triton system to measure Hb loss in real-time during surgery is feasible and accurate.

Patient Blood Management in the Intensive Care Unit.

Patient Blood Management underscores a fundamental shift from a product-centered approach to a patient-centric approach through timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcome. In this concept, allogeneic blood transfusion is not viewed as the treatment of default for anemic patients, but one among many treatment modalities that should be weighed based on its merits-potentials risks and benefits-for the individual patient in the context of other alternatives. Patient blood management provides a multidisciplinary framework for patient-centered decision making with strategies focusing on the management of anemia, optimization of coagulation and hemostasis, and utilization of blood conservation modalities. Among the critically ill patients, Patient Blood Management can be particularly effective given the extremely high prevalence of anemia, variable and unjustified transfusion practices, high frequency of coagulation disorders, and avoidable sources of blood loss such as unnecessary diagnostic blood draws. Proper management of anemia-prevention, screening/monitoring, diagnostic workup, and treatment including hematinic agents-is the key to effective implementation of patient blood management. Blood transfusions should be used in accordance of current guidelines, which are supportive of more restrictive transfusion strategies in most critically ill patients. Emerging studies report on the success of Patient Blood Management programs in reducing transfusion utilization, reducing the burden of anemia in patients, and improving patient outcomes including shortened length of hospital stays, less frequency of complications and lower risk of mortality.

Management of anemia in patients with congestive heart failure.

Anemia is an independent risk factor for adverse patient outcomes. There are no guidelines for management of anemia in patients with congestive heart failure (CHF), despite its high incidence. Four objectives were defined by the International Anemia Management and Clinical Outcomes Expert Panel (AMCO), a multinational group of interdisciplinary experts identified by the Society for the Advancement of Blood Management (SABM) to: determine the prevalence of anemia in outpatients; to determine the prevalence of hospital-acquired anemia; to assess the impact of anemia management on clinical outcomes such as quality of life and functional status; and to provide recommendations for primary care physicians and specialists for the diagnosis, evaluation, and management of anemia in patients with CHF. Anemia and iron deficiency were confirmed to be highly prevalent in patients with CHF. Intravenous iron therapy improves anemia, cardiac function and exercise tolerance, leading to improvement in quality of life. Anemia management has been demonstrated to be cost-effective. Clinical care pathways to manage anemia in patients with CHF are recommended as best practices in order to improve patient outcomes. Am. J. Hematol. 92:88-93, 2017. © 2016 Wiley Periodicals, Inc.

Anesthesia for Patients with Anemia.

Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.

The patient with anemia.

PURPOSE OF REVIEW: Anemia remains a global health issue. This review addresses the recent findings on anemia in surgical patients and its significance in perioperative setting. RECENT FINDINGS: The prevalence of anemia in surgical populations is high, ranging from one-third of population to nearly 100%. Anemia is an independent, modifiable risk factor for a growing list of unfavorable events, complications and diminished functional outcomes (lasting for months following discharge), as well as a major predisposing factor for allogeneic blood transfusions. Therefore, timely screening and diagnosis of anemia prior to elective surgeries is of great importance. Nonetheless, studies suggest that many opportunities to properly manage anemia in perioperative setting are lost. Patient blood management provides a framework of evidence-based strategies to effectively reduce the risk of occurrence of anemia and treat it with the ultimate goal of improving patient outcomes. Studies on the clinical impact of patient blood management strategies are emerging. SUMMARY: Active screening for anemia and proper management of it in perioperative setting is essential. Several strategies to prevent anemia - including elimination of unnecessary diagnostic blood draws - are effective and reasonable approaches.

Transfusion practices and infectious risks.

Transfusion-transmitted infections remain among the most-feared complications of allogeneic blood transfusion. Thanks to several strategies including donor screening and deferral, blood testing and pathogen inactivation, their risks have reached all-time low levels, particularly in developed nations. Nonetheless, new and emerging infections remain a threat that is likely to exacerbate in the coming years with continued globalization and climate change. More effective strategies of pathogen inactivation and more vigilant horizon screening are hoped to abate the risk. Additionally, allogeneic transfusion has repeatedly been shown to be associated with worsening of outcomes in patients, including the documented increased risk of infections (often nosocomial) in recipients of transfusions. The underlying mechanism is likely to be related to immunosuppressive effects of allogeneic blood, iron content, and bacterial contamination. This issue is best addressed by more judicious and evidence-based use of allogeneic blood components to ensure the potential benefits outweigh the risks.

Outcomes of Protocol-Driven Care of Critically Ill Severely Anemic Patients for Whom Blood Transfusion Is Not an Option.

OBJECTIVE: To compare the outcomes of severely anemic critically ill patients for whom transfusion is not an option ("bloodless" patients) with transfused patients. DESIGN: Cohort study with propensity score matching. SETTING: ICU of a referral center. PATIENTS: One hundred seventy-eight bloodless and 441 transfused consecutive severely anemic, critically ill patients, admitted between May 1996 and April 2011, and having at least one hemoglobin level less than or equal to 8 g/dL within 24 hours of ICU admission. Patients with diagnosis of brain injury, acute myocardial infarction, or status postcardiac surgery were excluded. INTERVENTIONS: Allogeneic RBC transfusion during ICU stay. MEASUREMENTS AND MAIN RESULTS: Primary outcome was in-hospital mortality. Other outcomes were ICU mortality, readmission to ICU, new electrocardiographic or cardiac enzyme changes suggestive of cardiac ischemia or injury, and new positive blood culture result. Transfused patients were older, had higher hemoglobin level at admission, and had higher Acute Physiology and Chronic Health Evaluation II score. Hospital mortality rates were 24.7% in bloodless and 24.5% in transfused patients (odds ratio, 1.01; 95% CI, 0.68-1.52; p = 0.95). Adjusted odds ratio of hospital mortality was 1.52 (95% CI, 0.95-2.43; p = 0.08). No significant difference in ICU readmission or positive blood culture results was observed. Analysis of propensity score-matched cohorts provided similar results. CONCLUSIONS: Overall risk of mortality in severely anemic critically ill bloodless patients appeared to be comparable with transfused patients, albeit the latter group had older age and higher Acute Physiology and Chronic Health Evaluation II score. Use of a protocol to manage anemia in these patients in a center with established patient blood management and bloodless medicine and surgery programs is feasible and likely to contribute to improved outcome, whereas more studies are needed to better delineate the impact of such programs.

Risks of Anemia in Cardiac Surgery Patients.

Anemia is an common condition in patients undergoing cardiac surgery, and it is often present in one quarter to half of patients at admission. Several studies have indicated that anemia is a major risk factor for worse outcomes, including increased risk of mortality and major morbidity and prolonged hospitalization. Anemia is a leading reason for use of allogeneic blood transfusions. Harmful effects of anemia are often attributed to the reduced oxygen carrying capacity of blood, reduced viscosity and the resulting impaired rheologic characteristics of blood, underlying comorbidities, and the side effects of treatments given for anemia, namely, allogeneic blood transfusions. Patients undergoing cardiac surgery may be at increased risk of anemia given the often-existing cardiac comorbidities and the negative impacts of cardiopulmonary bypass. However, whether less restrictive transfusion practices are justified in patients undergoing cardiac surgery is still a matter of debate. The prevalence of anemia often increases during hospital stay, and it can persist for a long time beyond hospital discharge. Given the associated risks and available management strategies, clinicians should remain vigilant to detect and treat anemia throughout the course of care for patients undergoing cardiac surgery.

Blood conservation strategies and the management of perioperative anaemia.

PURPOSE OF REVIEW: Anaemia is a global health problem with particularly high prevalence in the perioperative setting and it can significantly affect the patient outcomes. This review addresses new findings on the significance of anaemia and patient blood management (PBM) strategies to prevent and manage anaemia. RECENT FINDINGS: Studies support the independent deleterious effects of anaemia on mortality, morbidity and quality of life as well as its role as a risk factor for transfusion. Although improved understanding of iron regulators such as hepcidin is expected to revolutionize the field, simple algorithms are useful tools for more effective management of anaemia relying on currently available therapies (such as intravenous iron and erythropoiesis-stimulating agents). Other PBM strategies such as optimization of haemostasis and avoidance of blood loss are effective in preventing anaemia or its exacerbation and improving the outcomes of patients. In addition, more attention should be given to hospital-acquired anaemia (HAA) and its avoidable causes, such as unnecessary diagnostic phlebotomies. SUMMARY: Despite the high prevalence of anaemia and the significant toll it takes on patients, simple and effective strategies are available to detect, diagnose and treat it.