Algorithmic and consultative integration of transfusion medicine and coagulation: a personalized medicine approach with reduced blood component utilization.

ABSTRACT

BACKGROUND: Therapy customized for the individual patient defines personalized medicine. Current transfusion therapy is performed primarily using general guidelines such as keeping the platelet count at >100,000/µL, the INR at ≤ 1.7 and fibrinogen at >100mg/dL for patients undergoing surgery. OBJECTIVE: The purpose of this report is to provide an algorithmic and consultative approach for the delivery of personalized and targeted blood component, blood derivative, and recombinant therapies in order to minimize unnecessary exposure to such therapies and to deliver an optimal risk-benefit ratio for a particular patient. METHODS: The initiative involved a step-wise process that included 1. establishing "triggers" to alert and permit the clinical pathologist to intervene in the utilization of blood components for a given patient in the context of the blood bank inventory; 2. developing algorithms for the assessment of the patient's procoagulant/anticoagulant status so that appropriate blood component, derivative, and/or recombinant therapies could be instituted while minimizing the risk of thrombophilia; 3. a real time assessment and interpretation of the coagulation data so that dialogue between the pathologist and the patient's clinical team could be effected 24 hours a day, 7 days a week; and 4. monitoring the outcome of these efforts by comparing blood component utilization prior to or during development, early implementation and following full implementation of the program. RESULTS: "Triggers" (i.e., administration of six units of fresh frozen plasma [FFP] or ten units of cryoprecipitate or two single donor [apheresis] platelets in a 24-hour period) were approved. A diagnostic and therapeutic algorithm was constructed, with multidisciplinary input to assist in defining the coagulopathy contributing to the patient's microvascular bleeding in the adult cardiac surgery/cardiac intensive care unit (CICU) and the adult intensive care unit (AICU). Monitoring of utilization, prior to or during development, early implementation and following full implementation of this initiative, revealed a decline in the number of units of FFP, cryoprecipitate and single donor (apheresis) platelets administered. CONCLUSION: We report on the successful development of a model - based on the algorithmic and consultative integration of transfusion medicine and coagulation - that customizes blood component, derivative, and recombinant therapies appropriate for an individual patient's need, resulting in targeted transfusion therapy and associated with reduced blood component utilization.