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Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.

Introduction Autologous salvaged blood, commonly referred to as “cell saver” or “cell salvage” blood, is an important method of blood conservation. Understanding the mechanism of action and summarizing the existing evidence regarding the safety, efficiency, and the relative costs of cell salvage may help educate clinicians on how and when to best utilize autotransfusion. Methods This review focuses on issues concerning the quality of red blood cells (RBC), efficiency, and the cost effectiveness relative to autotransfusion. The key considerations of safe use and clinical applicability are described along with the challenges for wider dissemination. Results Cell salvage can reduce requirements for allogeneic transfusions, along with the associated risks and costs. Autologous salvaged RBCs provide high-quality transfusion, since the cells have not been subjected to the adverse effects of storage as occurs with banked blood. The risks for RBC alloimmunization and transfusion-related infectious diseases are also avoided. With a careful selection of cases, salvaged blood can be more cost effective than donor blood. Cell salvage may have a role in cardiac, major vascular, orthopedic, transplant, and trauma surgeries. However, there remain theoretical safety concerns in cases with bacterial contamination or in cancer surgery. Conclusion In addition to other methods of blood conservation used in patient blood management programs, autologous salvaged blood adds value and is cost effective for appropriate surgical cases. Evidence suggests that autologous salvaged blood may be of higher quality and confer a cost reduction compared with the allogeneic banked blood, when used appropriately.

Objective Several strategies are employed for administering fresh frozen plasma (FFP) during weaning from cardiopulmonary bypass (CPB). This study evaluated by coagulation function aimed to compare two strategies of administering FFP in cardiovascular surgery: administering 4 units of FFP before separating from CPB or administering it after weaning from CPB. Methods Thirty patients who underwent CPB and were expected to receive 8 units of FFP and 20 units of platelet concentrate were randomly allocated into group A (8 units of FFP and 20 units of platelet concentrate administered after separating from CPB) and group B (4 units of FFP administered before separation, and 4 units of FFP and 20 units of platelet concentrate administered after separating from CPB). Thromboelastography (TEG6s ® , HAEMONETICS Japan GK, Tokyo, Japan) was conducted at four time points before and after separation. Blood test results, blood loss, and required amounts of blood transfusion were compared. The primary outcome was the difference in coagulation function evaluated by TEG6s 90 min after protamine administration. Results Twenty-eight patients were enrolled in the study. Coagulation function after separating from CPB was not significantly different between the groups. Additionally, no significant differences were found in intensive care unit outcomes, such as 24-h transfusion requirements. Conclusions Coagulation function 90 min after separating from CPB was not significantly different between the groups. Prior FFP administration before separation did not provide significant improvement in coagulation function.

This book is a practical and easily readable guide for neurologists, obstetricians, and primary care doctors treating female patients with neurological illness in their reproductive years. * Offers wide ranging coverage, including family planning and lactation * Presents information in approachable tables and summaries, focusing on high yield information useful for clinical consultation * Is written by a team of experts and edited by recognized leaders in the field

Objectives: Blood component waste is an important issue at all hospitals. As an initiative of the patient blood management program at a regional health care system, the causes and extent of blood product wastage were identified, and targeted interventions to effect a reduction were implemented. Methods: Multiple low-cost interventions, including educational outreach, print and digital messaging, and improved transportation and component identification modalities, were implemented beginning in January 2013. The impact on reducing RBC, platelet (PLT), and plasma wastage in the 16 months after intervention implementation was compared with the wastage rates in the 16 months before these interventions had been implemented. Results: Overall, the RBC wastage rate as a percentage of the number of units issued decreased from 0.67% to 0.56% (P = .001) after the interventions were implemented, while the PLT wastage rate decreased from 3.71% to 2.81% (P < .001). The plasma wastage rate increased from 1.14% to 1.40% (P < .001). The initial cost of these interventions was approximately $310. The net cost savings of the reduced waste was estimated at $131,520, excluding intervention costs. Conclusions: Relatively inexpensive interventions can have a prompt and dramatic impact on reducing blood wastage with regard to both cost and resource savings.

ObjectiveThis report aimed to describe the characteristics and impact of subdural hematoma (SDH) after labor epidural analgesia.Case ReportsEleven obstetric patients had SDHs associated with the use of labor epidural analgesia over 7 years at a tertiary care hospital. Ten of 11 patients had signs consistent with postdural puncture headache before the diagnosis of SDH. Five patients (45%) had a recognized unintentional dural puncture, 1 (9%) had a combined spinal-epidural with a 24-gauge needle, and 5 (45%) had no recognized dural puncture. For 10 of the 11 cases, SDH was diagnosed at a mean of 4.1 days (range, 1–7 days) after performance of labor epidural analgesia; one case was diagnosed at 25 days. Ten (91%) of 11 cases had a second hospital stay for a mean of 2.8 days (range, 2–4 days) for observation, without further requirement for neurosurgical intervention. One case (9%) had decompressive hemicraniectomy after becoming unresponsive. The observed rate of labor epidural analgesia-associated SDH was 0.026% (11 in 42,969, approximately 1:3900), and the rate of SDH was 1.1% (5 in 437, approximately 1:87) if a recognized dural puncture occurred during epidural catheter placement.ConclusionsSubdural hematoma after labor epidural anesthesia is rare but potentially more common than historically estimated. Cases of postdural puncture headache after labor epidural anesthesia should be monitored closely for severe neurologic signs and symptoms that could herald SDH.

SUMMARY POINTS Use of evidence based guidelines minimises the adverse effects of transfusion and wastage of products, which are donated by volunteers, costly, and sometimes in short supply Consider red cell transfusion only if haemoglobin is 80 g/L or less in haemodynamically stable patients, including asymptomatic patients with cardiovascular disease Patients with platelet counts greater than 50×109/L or an international normalised ratio less than 2.0 can safely undergo invasive procedures without correcting the abnormal laboratory values Use alternative approaches to patient management to reduce or eliminate the need for transfusion The safe and appropriate use of blood is facilitated by the use of information technology throughout the transfusion process Obtain and document informed consent for blood transfusion, including the risks, benefits, and alternatives

To reduce unnecessary RBC transfusions, the computerized physician order entry (CPOE) system was programmed to require prescribers to select an indication for transfusion. An alert appeared if the patient's hemoglobin (Hb) level was above the threshold determined by the selected indication (adaptive alerts). Data on RBC orders from the 4 months before the adaptive alerts were implemented were compared with the 10 months after implementation. Significantly fewer alerts were generated after the implementation, and the rate at which the alerts were heeded also increased. There was a trend toward fewer RBC units transfused after adaptive alert implementation. A large number of RBCs were ordered using a nonspecific transfusion indication, although many of these patients had antecedent Hb values close to the threshold. Electronically generated alerts can reduce but are insufficient to eliminate non-evidence-based transfusions. Analysis of the alerts suggests areas for CPOE improvement.

To evaluate cryoprecipitate and platelet ordering practices after the implementation of real-time clinical decision support systems (CDSSs) in a computerized physician order entry (CPOE) system. Uniform platelet and cryoprecipitate transfusion thresholds were implemented at 11 hospitals in a regional health care system with a common CPOE system. Over 6 months, a variety of information was collected on the ordering physicians and the number of alerts generated by the CDSSs when these products were ordered outside of the institutional guidelines. There were 1,889 orders for platelets and 152 orders for cryoprecipitate placed in 6 months. Of these, 1,102 (58.3%) platelet and 74 (48.7%) cryoprecipitate orders triggered an alert. The proportion of orders canceled after an alert was generated ranged from 13.5% to 17.9% for platelets and 0% to 50.0% for cryoprecipitate orders. CDSS alerts reduce, but do not eliminate, platelet and cryoprecipitate transfusions that do not meet institutional guidelines.

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.