ISSN 2531-1379 VOLUME 46, SUPPLEMENT 1, APRIL, 2024 HEMATOLOGY TRANSFUSION AND CELL THERAPY PATIENT BLOOD MANAGEMENT
TaggedH1Hematology, Transfusion and Cell Therapy TaggedP ISSN 2531-1379 print version ISSN 2531-1387 online versionTaggedEnd EDITOR INCHIEF Eduardo Magalh~aes Rego, Ribeir~ao Preto, Brazil DEPUTYEDITOR Erich Vinicius de Paula, Campinas, Brazil ASSOCIATE EDITORS Alfredo Mendrone Junior S~ao Paulo, Brazil Belinda Pinto Sim~oes Ribeir~ao Preto, Brazil Behnaz Bayat Giessen, Germany Carla Luana Dinardo S~ao Paulo, Brazil CarlosS ergio Chiattone S~ao Paulo, Brazil C armino Antonio de Souza Campinas, Brazil DanteM ario Langhi Junior S~ao Paulo, Brazil Dimas Tadeu Covas Ribeir~ao Preto, Brazil Elvira Deolinda Rodrigues Pereira Velloso S~ao Paulo, Brazil Fabiola Traina Ribeir~ao Preto, Brazil Helio Moraes de Souza Uberaba, Brazil Irene Lorand-Metze Campinas, Brazil Jos e Orlando Bordin S~ao Paulo, Brazil Luis Fernando S. Bouzas Rio de Janeiro, Brazil Marcelo Pasquini Wisconsin, USA M arcio Nucci Rio de Janeiro, Brazil Marcos Borato Viana Belo Horizonte, Brazil Marcos de Lima Cleveland, USA Margareth Castro Ozelo Campinas, Brazil Maria Helena Pitombeira Fortaleza, Brazil Maria Stella Figueiredo S~ao Paulo, Brazil Marilda de Souza Gon¸calves Salvador, Brazil Nelson Hamerschlak S~ao Paulo, Brazil Nelson Spector Rio de Janeiro, Brazil Nicola Conran Campinas, Brazil PauloS ergio da Silva Santos S~ao Paulo, Brazil Roberto Passetto Falc~ao Ribeir~ao Preto, Brazil Rodrigo Tocantins Calado Ribeir~ao Preto, Brazil Sara Teresinha Olalla Saad Campinas, Brazil Silvia Maria Meira Magalh~aes Fortaleza, Brazil Valder Arruda Philadelphia, USA Vanderson Rocha S~ao Paulo, Brazil Vania Tietsche de Moraes Hungria S~ao Paulo, Brazil Editorial Board Alois Gratw€ohl Basel, Switzerland Alvaro Urbano-Ispizua Barcelona, Spain Andrea Bacigalupo Genoa, Italy ^Angelo Maiolino Rio de Janeiro, Brazil Antonio Fabron J unior Marilia, Brazil Christian Gisselbrecht Paris, France Corrado Tarella Turin, Italy Daniel Tabak Rio de Janeiro, Brazil DavidG omez Almaguer Mexico City, Mexico Elbio A. DAmico S~ao Paulo, Brazil Enric Carreras Barcelona, Spain Eugenia Maria Amorim Ubiali - Ribeir~ao Preto, Brazil Fernando Ferreira Costa, Campinas, Brazil Frederico Luiz Dulley S~ao Paulo, Brazil Gino Santini Genoa, Italy Guillermo Dighiero Montevideo, Uruguay Guillermo Ruiz-Arguelles Puebla, Mexico Jesus Fernando San Miguel Salamanca, Spain Jo~ao Carlos Pina Saraiva Bel em, Brazil La ercio de Melo Belo Horizonte, Brazil L ılian Maria Castilho Campinas, Brazil Linamara Rizzo Batistella S~ao Paulo, Brazil Lucia Mariano da Rocha Silla Porto Alegre, Brazil Marcos Antonio Zago Ribeir~ao Preto, Brazil Maria de Lourdes L. F. Chauffaile S~ao Paulo, Brazil Maria do Socorro P. de Oliveira Rio de Janeiro, Brazil Mario Cazolla Pavia, Italy Mary Evelyn Flowers Seattle, USA Nelson Abrahin Fraiji Manaus, Brazil Nelson J. Chao Durham, USA Paul M. Ness Baltimore, USA PauloC esar Naoum S~ao Jos e do Rio Preto, Brazil Raul C. Ribeiro Memphis, USA Raul Gabus Montevideo, Uruguay Ricardo Pasquini Curitiba, Brazil Richard K. Burt Chicago, USA Sergio Giralt New York, USA V^ania Tietsche Hungria S~ao Paulo, Brazil Vicente Odone Filho S~ao Paulo, Brazil PAST EDITORS Antonio P. Capanema 1973-1981; Milton A. Ruiz 1981-1990; Carlos S. Chiattone 1991-1994; Milton A. Ruiz 1995-2014; Fernando Ferreira Costa 2015-2022. The Hematology, Blood Transfusion and Cell Therapy succeeded the Revista Brasileira de Hematologia e Hemoterapia (Brazilian Journal of Hematology and Hemotherapy) , ISSN 1516-8484, which succeeded the Boletim da Sociedade Brasileira de Hematologia e Hemoterapia (Bulletin of the Brazilian Society of Hematology and Hemotherapy) ISSN 0102-7662, which was published from 1973 to 1998 with 179 issues in 20 volumes. ABHH Rua Diogo de Faria, 775/conjunto 133 04037-002 Vila Clementino - S~ao Paulo/SP - Brazil (11) 2369-7767 / (11) 2338-6764 (WhatsApp) E-mail: abhh@abhh.org.br www.abhh.org.br HTCT Internal Editorial Committee Executive Secretary: Luciana de Souza secretaria@rbhh.org | www.htct.com.br The Hematology, Transfusion and Cell Therapy is the offi cial publication of the Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), the Associazione Italo-Brasiliana di Ematologia (AIBE), Eurasian Hematology Oncology Group (EHOG), and the Sociedade Brasileira de Oncologia Pedi atrica (SOBOPE), published by Elsevier Editora Ltda. The journal is indexed to the Literatura Latino-Americana e do Caribe em Ci^encias da Sa ude (Lilacs), SciELO Brazil, PubMed/PMC, Web of Science (ESCI), Extramed and Scopus. It is distributed for free to regional libraries and Medical, Pharmacy and Biochemistry Schools in Brazil and sister societies in South, Central and North America and Europe. 2023 Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular. Published by Elsevier Editora Ltda. All rights reserved. All rights reserved and protected by law 9.610 - 19/02/98. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording or any information storage and retrieval system, without permission in writing from ABHH and the Publisher. 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Board Of Directors 2022-2023 President Angelo Maiolino Vice-President Eduardo Magalh~aesRego Administrative Director Glaciano Nogueira Ribeiro Vice Administrative Director Silvia Maria Meira Magalh~aes Scientific Director Carmino Antonio de Souza Vice-Scientific Director Dimas Tadeu Covas Financial Diretor Celso Arrais Rodrigues da Silva Vice Financial Director Leny Nascimento da Motta Passos Director of Communications Renato Sampaio Tavares Vice-Director of CommunicationsVania T. de Moraes Hungria Director of Institutional RelationsCarlosS ergio Chiattone Vice-Director of Institutional RelationsDante Langhi Junior Director of Professional PracticeEdvan de Queiroz Cruso e Vice-Director of Professional PracticeJos e Francisco Comenalli Marques Jr Director Social Action BoardJorge Vaz Pinto Neto Vice-Director Social Action BoardViolete Petitto Laforga Emeritus Scientific Director Roberto Passetto Falc~ao General Manager AlineAch^e Deliberative Committee Elected 2022-2025 Thiago Xavier Carneiro Aderson da Silva Araujo Silvia Maria Meira Magalh~aes Renato Sampaio Tavares Karina Correia Barcelos Jo~ao Paulo de Oliveira Guimar~aes Angelo Maiolino Carla Luana Dinardo Eduardo Magalh~aesRego Monika Conchon Renato Luiz Guerino Cunha Rodolfo Delfini Can¸cado Talita Maira Bueno da Silveira Vanderson Rocha Vaneuza Araujo Moreira Funke Elected 2024-2027 Leny Nascimento da Motta Passos Edvan de Queiroz Cruso e Jorge Vaz Pinto Neto Gustavo Henrique Silveira Marcos Daniel de Deus Santos Amanda Pifano Soares Ferreira Glaciano Nogueira Ribeiro Adriana Alves Scheliga Clarisse Lopes de Casto Lobo Roberto Jos e Pessoa de Magalh~aes Celso Arrais Rodrigues da Silva Jos e Eduardo Bernardes Jos e Francisco Comenalli Marques J unior V^ania Tietsche de Moraes Hungria Violete Petitto Laforga Lifelong Deliberative Committee Carlos Sergio Chiattone Carmino Antonio de Souza DanteM ario Langhi J unior Dimas Tadeu Covas Eur ıpedes Ferreira Fernando Ferreira Costa H elio Moraes de Souza H elioRamos Jo~ao Carlos Pina Saraiva Jos e Orlando Bordin Jos eKerbauy Marco Antonio Zago Milton Artur Ruiz Nelson Ibrahim Fraiji Nelson Hamerschlak Nelson Spector Orion de Bastos Ricardo Pasquini Roberto Passetto Falc~ao Romeu Ibrahim de Carvalho Sara Teresinha Olalla Saad Therezinha Verrastro de Almeida Ubiratan Ouvinha Peres Past Presidents of Sociedade Brasileira de Hematologia e Hemoterapia 1950 Walter Oswaldo Cruz 1951 Michel Abujamra 1954 Darcy Lima 1955 Jos e Candido C. Villela 1957 Joaquim M. Barreto 1959 Oswaldo Kessler Ludwing 1961 Walter Hupsel 1963 Rui Faria 1965 Orion Bastos 1967 Ubiratan Ouvinha Peres 1970 Oswaldo Mellone 1973 Pedro Cl ovis Junqueira 1975 Pedro Cl ovis Junqueira 1977 Maria Nazareth Petrucelli 1979 Celso Carlos de C. Guerra 1981 Jacob Rosenblit 1983 Luiz Gast~ao M. Rosenfeld 1985 Augusto Luiz Gonzaga 1987 Helio Ramos 1988 Milton Artur Ruiz 1990 Nelson Hamerschlak 1992Eur ıpedes Ferreira 1994 Jo~ao Carlos Pina Saraiva 1996 Jo~ao Pedro E. M. Pereira 1998 Celso Carlos de C. Guerra 2000 Dante M ario Langhi Junior 2002 Dante M ario Langhi Junior 2004 Carlos S ergio Chiattone 2006 Carlos S ergio Chiattone 2008 Carlos S ergio Chiattone Past Presidents of Col egio Brasileiro de Hematologia 1965 Hildebrando M. Marinho 1967 Michel Abujamra 1969 Romeu Ibrahim de Carvalho 1971 Paulo Barbosa da Costa 1973 Romildo Lins 1975 Renato Rego Failance 1977 Dilson Jos e Fernandes 1981 Jos eKerbauy 1985 Eurico Coelho 1989 Romeu Ibrahim de Carvalho 1993 Jos eKerbauy 1997 Roberto Passetto Falc~ao 2005 Jos e Orlando Bordin Past Presidents of Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular 2009 Carlos S ergio Chiattone Jos e Orlando Bordin 2010-2013: Carmino Antonio deSouza 2014-2017: Dimas Tadeu Covas 2018-2021: Dante Langhi J unior Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular
Associazione Italo-Brasiliana di Ematologia Board of Directors President Carlos S. Chiattone (Brazil) Vice-President Stefano Luminari Scientific Director −Brazil Carmino Antonio de Souza Treasurer −Brazil Natalia Zing Honorary PresidentsGino Santini and Angelo Maiolino and Ricardo Pasquini Scientific Director −ItalyMaurizio Martelli Treasurer −ItalyLuca Arcaini Board of Advisors - Brazil Eduardo Magalh~aes Rego, Eliana C. M. Miranda, Guilherme Duffl es, Irene de Almeida Biasoli, Marcia Torresan Delamain, Milton Artur Ruiz, Sergio A.B. Brasil, Thais Fischer Board of Advisors - Italy Angelo Michelle Carella, Gian Luca Gaidano, Ignazio Majolino, Maurizio Martelli, Robin Fo a, Teodoro Chisesi Associazione Italo-Brasiliana di Ematologia Viale Benedetto XV 16100 - Genoa GE Italy Eurasian Hematology Oncology Group Board of Directors President Giuseppe Saglio Vice-President Birol Guvenc General Secretaryehmus Ertop Member Ahmad Ibrahim, Lebanonn Member Burhan Ferhanoglu, Turkiye Member Carmino de Souza, Brazil Member Claudio Cerchione, Italy Member Jean FranO´ ois Rossi, France Member Moshe Mittelman, Israel Member Tariq Mughal, USA Member Vera Donnenberg, USA Eurasian Hematology Oncology Group www.ehog.net - sekreterlik@hematoloji.org.tr Yurt Mahallesi Kurttepe Cad. 71517 Sokak No.2 Sabahattin Akg€un Apt. Kat.1 Daire.1 ¸Cukurova - Adana Phone: 00 90 555 881 01 99 Sociedade Brasileira de Oncologia Pedi atrica Board of Directors - 2023-2024 President Nevi¸colino Pereira de Carvalho Filho 1st Vice-President Flavia Delgado Martins 1st SecretaryMaristela Francisco dos Reis 1st Treasurer Carolina Madalena Souza Pinto Alvares 2nd Vice-President Mario Jos e Aguiar de Paula 2nd SecretaryAnnemeri Livinalli 2nd Treasurer Patrick Rezende Godinho Members of Advisory Board Andrea Maria Capellano, Elione Soares de Albuquerque, Elvis Terci Valera, Simone dos Santos Aguiar, Val eria Pereira Paiva Sociedade Brasileira de Oncologia Pedi atrica www.sobope.org.br - sobope@uol.com.br / sobope@sobope.org.br 94/53 04077-020 S~ao Paulo-SP Phone: 55 11 5052-7537
pilares Conheça os Social Educação Ciência Carreira Eventos; Hemoteca; HEMO.educa; Webinars; Podcast. Acesso a Medicamentos; Equidade; Um Só Sangue. Consensos e Diretrizes; Revista Científica HTCT; Registros; Plataforma Pesquisa Clínica. Sangue Jovem; Programa de Apoio em Residência Médica; Títulos e Certificações. Qualidade Serviço de Acreditação; CQI - Controle de Qualidade de Imunohematologia. www.abhh.org.br pilares Conheça os Social Educação Ciência Carreira Eventos; Hemoteca; HEMO.educa; Webinars; Podcast. Acesso a Medicamentos; Equidade; Um Só Sangue. Consensos e Diretrizes; Revista Científica HTCT; Registros; Plataforma Pesquisa Clínica. Sangue Jovem; Programa de Apoio em Residência Médica; Títulos e Certificações. Qualidade Serviço de Acreditação; CQI - Controle de Qualidade de Imunohematologia. www.abhh.org.br
Padrão de excelência em qualidade Segurança no processo de trabalho visando doador e receptor Certificação Internacional pela Association for the Advancement of Blood & Biotherapies (AABB) Disponibilidade de um coordenador brasileiro do programa Padrões em Bancos de Sangue, Serviços de Transfusão e Terapia Celular em Português, facilitando a linguagem e entendimento Auditores nacionais qualificados Assessoria científica e de processos de gestão Motivos para acreditar seu serviço no programa de Acreditação AABB / ABHH: www.abhh.com.br/acreditacao
Special article TaggedAPTARAH1Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood managementTaggedAPTARAEnd History and scenario of patient blood management in the world and in Brazil TaggedAPTARAPJuan Carlos Montano-Pedroso a,b, Silvana Biagini c, Maria Cristina Martins de Almeida Macedod,e, Glaciano Ribeirof,g, Jos e Franciscos Comenalli Marques Juniorh, Silvia Renata Corn elio Parolin Rizzo i, Guilherme Rabello j,*, Dante Mario Langhi Junior k TaggedAPTARAEnd TaggedAPTARAP aUniversidade Federal de S~ao Paulo (Unifesp), S~ao Paulo, SP, Brazil bInstituto de Assist^enciaM edica do Servidor P ublico Estadual (Iamspe), S~ao Paulo, SP, Brazil c Hospital Guilherme Alvaro e Complexo Hospitalar dos Estivadores, Santos, SP, Brazil dInstituto Brasileiro de Controle do C^ancer (IBCC), S~ao Paulo, SP, Brazil e Hospital S~ao Camilo Pomp eia, S~ao Paulo, SP, Brazil f Hospital das Clínicas da Universidade Federal de Minas Gerais (HC UFMG), Belo Horizonte, MG, Brazil g Grupo HHEMO, S~ao Paulo, SP, Brazil hHospital Vera Cruz, Campinas, SP, Brazil i Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), S~ao Paulo, SP, Brazil j Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~aoPaulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil kEscola Paulista de Medicina, Universidade Federal de S~ao Paulo (EPM UNIFESP), S~ao Paulo, SP, Brazil TaggedAPTARAEnd TAGGEDAPTARAPARTICLE INFO Article history: Received 6 February 2024 Accepted 18 February 2024 Available online 11 March 2024TaggedAPTARAEnd TAGGEDAPTARAPA B S T R A C T Patient Blood Management (PBM) is a multidimensional approach that seeks to optimize the use of blood and its components in patients. This matter emerged as a response to the need to reduce unnecessary exposure to blood transfusions and their potential risks. In the past, blood transfusion was often overused resulting in complications and high costs. The advent of Patient Blood Management has caused a paradigm shift, highlighting anemia prevention, bleeding control and maximizing the production of blood cells by the organism itself. Patient Blood Management guidelines include the early identification of anemia, strategies to minimize blood loss during surgery, intraoperative blood conservation techniques, preoperative hemoglobin optimization and evidence-based approaches to the rational use of blood TaggedAPTARAEndTaggedAPTARAPKeywords: Empowerment World health organization Patient blood management TaggedAPTARAEnd * Corresponding author at: Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~ao Paulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil. E-mail address: grabello.inovaincor@fz.org.br (G. Rabello). https://doi.org/10.1016/j.htct.2024.02.008 2531-1379/ 2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). TaggedAPTARAEndhematol transfus cell ther. 2024;46(S1):S1−S4 TaggedAPTARAFigure TaggedAPTARAEnd Hematology, Transfusion and Cell Therapy www.htct.com.br TaggedAPTARAFigure TaggedAPTARAEnd
transfusions. Aiming to improve clinical outcomes, decrease transfusion-related complications and reduce associated costs, this multidisciplinary approach counts on doctors, nurses, pharmacists and other healthcare professionals. Based on research and clinical evidence, Patient Blood Management continues to evolve thereby promoting safer, more effective patient-centered practices. Its implementation has proven beneficial in various medical contexts thereby contributing to improvements in the quality of care provided to patients. Our goal with this Consensus is to present readers with a broad and diverse view of Patient Blood Management so that they have the building blocks to implement this new technique. 2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).TaggedAPTARAEnd Rational use of blood Evidence-based medicineTaggedAPTARAEnd TaggedAPTARAH1Introduction to patient blood management − historyTaggedAPTARAEnd TaggedAPTARAPBlood has been used as a treatment for various diseases since ancient times. Pharaohs used blood to cure filariasis, while in ancient Rome, the blood of defeated gladiators was drunk to treat epilepsy. However, blood transfusion began to be considered in a more physiological way only after the description of the circulatory system by Harvey in 1628.1 TaggedAPTARAEnd TaggedAPTARAPThefirst blood transfusion in a human being was performed in Paris by Jean Baptiste Denis in 1667, who transfused blood from an animal to a young man.2 James Blundell, a London obstetrician, published the use of blood transfusions between humans in 1818, but frequent incompatibility reactions and the impossibility of storage were obstacles to the dissemination of the practice.3 TaggedAPTARAEnd TaggedAPTARAPThe discovery of blood types in 1901 by the physician Karl Landsteiner reduced incompatibility reactions and the anticoagulation of blood using citrate, which allowed blood to be stored, was reported in 1914. In 1932, the first blood bank was created in the city of Leningrad. A recommendation based merely on expert opinion published in 1942 became the reference for decades; it was to transfuse when the patient had a hemoglobin (Hb) level below 10 g/dL.1 TaggedAPTARAEnd TaggedAPTARAPIn response to the demand created by open heart surgery and advances in the treatment of trauma, the 1950s were marked by an intense increase in the use of blood. In 1950, the Brazilian Society of Hematology and Hemotherapy was founded, consolidating two sister specialties.4 TaggedAPTARAEnd TaggedAPTARAPBlood became a valuable commodity to be bought and sold. However, in 1975, with the emergence of post-transfusion hepatitis, which occurred mainly with blood obtained from donors who received payment, the Food and Drug Administration (FDA) prohibited this practice. Despite this, cases of non-A/non-B hepatitis still occurred frequently, and in 1982, the blood-borne HIV virus was discovered. In 1988, the hepatitis C virus was identified as the causative agent of non-A/non-B hepatitis. Safety measures were implemented, including donor screening and more effective testing to promote safer blood transfusions.1,5 TaggedAPTARAEnd TaggedAPTARAH1Introduction to patient blood management −global and Brazilian scenariosTaggedAPTARAEnd TaggedAPTARAPCurrently, blood transfusion is one of the most commonly performed procedures during hospital admissions in the United States.6 In 2019, Brazil carried out more than 2.95 million transfusions,7 while the World Health Organization (WHO) estimates that more than 112 million bags of blood are collected annually around the world.8 TaggedAPTARAEnd TaggedAPTARAPOn the other hand, a concept, which has been gaining momentum in the scientific world, is that of Evidence-Based Medicine (EBM), an approach to optimize medical decisionmaking, emphasizing the use of evidence from well-conducted research that proves the efficacy and safety of treatments. This term was first used by researchers at McMaster University, Canada, in the 1990s with the aim of incorporating clinical researchfindings into the decision-making process to bring more science to medicine.9 Thus, the EBM movement began to take shape only after blood transfusion had become a very widespread treatment.TaggedAPTARAEnd TaggedAPTARAPIn the conception of EBM, randomized clinical trials are considered the study type that provide the greatest scientific evidence. Although there are no randomized clinical trials comparing blood transfusion with placebo, 10,11randomized clinical trials comparing a liberal transfusion strategy, where more is transfused to maintain higher Hb values, versus a restrictive one, where less is transfused to maintain lower Hb values, have been conducted. The Transfusion Requirements in Critical Care (TRICC) trial was thefirst to make this type of comparison at the end of the 90s. 12 This study, carried out on patients admitted to the Intensive Care Unit (ICU), concluded that there were no statistical differences in overall survival, but observed lower mortality in the restrictive group during hospitalization.TaggedAPTARAEnd TaggedAPTARAPAfter the publication of the TRICC trial, other randomized clinical trials were carried out comparing restrictive transfusion strategies with liberal ones in different clinical situations, such as in cardiac surgery and digestive tract bleeding. These studies concluded that more restrictive transfusion strategies presented lower mortality and fewer adverse clinical outcomes. A systematic review with meta-analysis of randomized clinical trials confirmedthesefindings.13 TaggedAPTARAEnd TaggedAPTARAPBased on systematic reviews of randomized clinical trials, current guidelines recommend restrictive rather than liberal transfusion for most patients.14 However, these guidelines do not consider an important limitation of the clinical trials: the lack of a placebo control group. Trentino et al.15 mentioned that these studies were not designed to specifically test the effectiveness of transfusion as they do not compare blood transfusion with placebo.TaggedAPTARAEnd TaggedAPTARAPAlthough there are no randomized clinical trials that have compared blood transfusion versus no transfusion, there is observational research that made this type of comparison. A systematic review with meta-analysis of these studies evaluated TaggedAPTARAEndS2 hematol transfus cell ther. 2024;46(S1):S1−S4
clinical outcomes in 272,596 critically ill patients and observed that in 42 of the 45 studies the risks of transfusions outweighed thebenefits. In 17 of 18 studies, transfusion was an independent factor associated with higher mortality.16An analysis of the Bradford Hill causality criteria concluded that all criteria were met regarding transfusion-associated adverse outcomes.17,18 TaggedAPTARAEnd TaggedAPTARAPThe clinical effects observed with blood transfusion are mainly attributed to a phenomenon called transfusion-associated immunomodulation,19 the deleterious effects that the transfusion can cause on the recipient’s immune system, and to the various changes that occur in red blood cells stored in blood bags. Denominated storage injury, these alterations, some of which are irreversible, include biomechanical, biophysical and morphological changes. 20 They start to appear after just a few hours of storage,21 thereby impairing the functioning of red blood cells and causing damage to the recipient’sbody.22,23 TaggedAPTARAEnd TaggedAPTARAH2The emergence of patient blood managementTaggedAPTARAEnd TaggedAPTARAPGiven the scenario reported in the literature by Shander et al.,25 in which a significant portion of blood transfusions are considered inappropriate,24 and the accumulation of evidence that indicates that greater restriction of transfusions promotes better clinical outcomes,25 a new treatment approach called Patient Blood Management (PBM) is being recommended in the medical literature. 26 A systematic review with meta-analysis involving 235,779 patients concluded that the use of PBM is associated with a reduction in blood transfusions, as well as complications such as acute renal failure, infection, thromboembolic events, mortality and length of hospital stay. 27 In addition to promoting better clinical outcomes, scientific studies have concluded that PBM provides significant savings infinancial resources.28,29 TaggedAPTARAEnd TaggedAPTARAPThe term PBM was originally proposed in 2005 by James Isbister at a board meeting of the Medical Society for Blood Management and first appeared in the literature in 2008.30 The concept of PBM was endorsed in 2010 by the World Health Assembly through resolution WHA 63.12. In 2017, it was recommended as standard of care by the European Commission and, in 2019, by the American Society of Hematology.31 In 2021, the WHO published a warning about the urgent need to adopt PBM all around the world.32 A future article will address thedefinition and concept of this new medical approach.TaggedAPTARAEnd TaggedAPTARAP Recommendation It is necessary for health professionals, medical societies, hospital managers and government agencies, directly and indirectly involved in the blood chain, to discuss the management of patients’ blood within the PBM concept. TaggedAPTARAEnd TaggedAPTARAH1ConclusionTaggedAPTARAEnd TaggedAPTARAPPBM represents an innovative and comprehensive approach to optimizing the use of blood and its components while prioritizing patient safety and well-being. By adopting evidencebased strategies for anemia prevention, bleeding control and the rational use of blood transfusions, this multidisciplinary approach has demonstrated significant benefits in improving clinical outcomes, and reducing complications and associated costs. With the continuous advancement of research and growing awareness of the importance of PBM, it is expected that its implementation will become increasingly widespread, providing quality, patient-centered care, contributing to improvements in the medical practice as a whole (Fig. 1).TaggedAPTARAEnd TaggedAPTARAFigure Figure1–Historical timeline of developments in Patient Blood Management.TaggedAPTARAEnd hematol transfus cell ther. 2024;46(S1):S1−S4 S3
TaggedAPTARAH1Complementary virtual referencesTaggedAPTARAEnd TaggedAPTARAP TaggedAPTARAEndTaggedAPTARAP1. - PBM−Patient Blood Management: II S erie de Webinar de Hemoterapia−link de acesso: https://youtu.be/PByJcH9gFzoTaggedAPTARAEnd TaggedAPTARAP2. - HEMO PLAY Podcast #Ep48 - Conhe¸ca o projeto PBM da ABHH−link de acesso: https://youtu.be/TyegH31£7cITaggedAPTARAEnd TaggedAPTARAP3. - WEBINAR COLABORATIVO SOBRE PATIENT BLOOD MANAGEMENT−link de acesso: https://youtu.be/V1-iIHN_KZoTaggedAPTARAEnd TaggedAPTARAH1Conflicts of interestTaggedAPTARAEnd TaggedAPTARAPThe author declares no conflicts of interest.TaggedAPTARAEnd taggedaptarah1referencestaggedaptaraend TaggedAPTARAListItem TaggedAPTARAListLabel1TaggedAPTARAEnd. TaggedAPTARAListBodyZauder HL, Stehling L. Transfusion medicine and alternatives to blood transfusion. First. Network for Advancement of Transfusion Alternatives; 200011TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel2TaggedAPTARAEnd. TaggedAPTARAListBodyFarr a D. Thefirst human blood transfusion. Med Hist. 1980;24 (2):143–62TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel3TaggedAPTARAEnd. TaggedAPTARAListBodyFastag E, Sternbach G. Richard lower: the origins of blood transfusion. J Emerg Med. 2013: 1–5TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel4TaggedAPTARAEnd. TaggedAPTARAListBodyJunqueira PC, Rosenblit J, Hamerschlak N. Hist oria da Hemoterapia no Brasil. Rev Bras Hematol Hemoter. 2005;27(3):201–7. [cited 2023 Apr 26]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel5TaggedAPTARAEnd. TaggedAPTARAListBodyTobler LH, Busch MP. History of posttransfusion hepatitis. Clin Chem. 1997;43(8):1487–93. Pt 2TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel6TaggedAPTARAEnd. TaggedAPTARAListBodyPfuntner A, Wier L, Stocks C. Statistical Brief - Most Frequent Procedures Performed. U.S. Hospitals: Agency for Healthcare Research and Quality; 2010. p. 1–9TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel7TaggedAPTARAEnd. Minist erio da Sa ude. Brasil consegue ampliar transfus~oes de sangue, mas coleta diminui —Minist eriodaSa ude. 2022 [cited 2023 Apr 26]. Available from: https://www.gov.br/saude/pt-br/ assuntos/noticias/2020/junho/brasil-consegue-ampliar-transfusoes-de-sangue-mas-coleta-diminuiTaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel8TaggedAPTARAEnd. TaggedAPTARAListBodyRoberts N, James S, Delaney M, Fitzmaurice C. The global need and availability of blood products: a modelling study. Lancet Haematol. 2019;6(12):e606–15. [cited 2023 May 7]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItem TaggedAPTARAListLabel9TaggedAPTARAEnd. TaggedAPTARAListBodyStraus SE, McAlister FA. Evidence-based medicine: a commentary on common criticisms. Can Med Assoc J. 2000;163(7):841.. 837 LP -T aggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel10TaggedAPTARAEnd. TaggedAPTARAListBodyCarson JL, Reynolds RC, Klein HG. Bad bad blood? Crit Care Med. 2008;36(9):2707–8. [cited 2018 Jul 27]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel11TaggedAPTARAEnd. TaggedAPTARAListBodyKumar A. Perioperative management of anemia: limits of blood transfusion and alternatives to it. Cleve Clin J Med. 2009;76(Suppl 4):S112–8TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel12TaggedAPTARAEnd. TaggedAPTARAListBodyH ebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. New England Journal of Medicine. 1999;340(6):409–17TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel13TaggedAPTARAEnd. TaggedAPTARAListBodySalpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med. 2014;127(2):124–31.e3TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel14TaggedAPTARAEnd. TaggedAPTARAListBodyPavenski K, Stanworth S, Fung M, Wood EM, Pink J, Murphy MF, et al. Quality of evidence-based guidelines for transfusion of red blood cells and plasma: a systematic review. Transfus Med Rev. 2018;32(3):135–43TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel15TaggedAPTARAEnd. TaggedAPTARAListBodyTrentino KM, Farmer SL, Isbister JP, Sanfilippo FM, Leahy MF, Hofmann A, et al. Restrictive versus liberal transfusion trials: are they asking the right question? Anesth Analg. 2020;131 (6):1950–5TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel16TaggedAPTARAEnd. TaggedAPTARAListBodyMarik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med. 2008;36(9):2667–74TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel17TaggedAPTARAEnd. TaggedAPTARAListBodyTrentino K, Farmer S, Gross I, Shander A, Isbister J. Observational studies - should we simply ignore them in assessing transfusion outcomes? BMC Anesthesiol. 2016;16(1):96TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel18TaggedAPTARAEnd. TaggedAPTARAListBodyIsbister JP, Shander A, Spahn DR, Erhard J, Farmer SL, Hofmann A. Adverse blood transfusion outcomes: establishing causation. Transfus Med Rev. 2011;25(2):89–101TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel19TaggedAPTARAEnd. TaggedAPTARAListBodyRefaai MA, Blumberg N. Transfusion immunomodulation from a clinical perspective: an update. Expert Rev Hematol. 2013;6(6):653–63TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel20TaggedAPTARAEnd. TaggedAPTARAListBodyAzouzi S, Romana M, Arashiki N, Takakuwa Y, el Nemer W, Peyrard T, et al. Band 3 phosphorylation induces irreversible alterations of stored red blood cells. Am J Hematol. 2018;93(5): E110–2TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel21TaggedAPTARAEnd. TaggedAPTARAListBodyBennett-Guerrero E, Veldman TH, Doctor A, Telen MJ, Ortel TL, Reid TS, et al. Evolution of adverse changes in stored RBCs. Proc Nat Acad Sci. 2007;104(43):17063–8TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel22TaggedAPTARAEnd. TaggedAPTARAListBodyYoshida T, Prudent M, D’Alessandro A. Red blood cell storage lesion: causes and potential clinical consequences. Blood Transfusion. 2019;17(1):27–52TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel23TaggedAPTARAEnd. TaggedAPTARAListBodyBruun-Rasmussen P, Andersen PK, Banasik K, Brunak S, Johansson PI. Intervening on the storage time of RBC units and its effects on adverse recipient outcomes using real-world data. Blood. 2022;139(25). [cited 2022 Jun 24]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel24TaggedAPTARAEnd. TaggedAPTARAListBodyShander A, Fink A, Javidroozi M, Erhard J, Farmer SL, Corwin H, et al. Appropriateness of allogeneic red blood cell transfusion: the international consensus conference on transfusion outcomes. Transfus Med Rev. 2011;25(3). [cited 2023 May 6]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel25TaggedAPTARAEnd. TaggedAPTARAListBodyIvascu Girardi N, Cushing MM, Evered LA, Benedetto U, Schwann TA, Kurlansky P, et al. Incidence and impact of a single-unit red blood cell transfusion: analysis of the society of thoracic surgeons database 2010-2019. Ann Thorac Surg. 2023;115(4). [cited 2023 May 1]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel26TaggedAPTARAEnd. TaggedAPTARAListBodySpahn DR. Patient Blood Management: The New Standard. Transfusion. Blackwell Publishing Inc.; 2017. p. 1325–7TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel27TaggedAPTARAEnd. TaggedAPTARAListBodyAlthoff FC, Neb H, Herrmann E, Trentino KM, Vernich L, F€ullenbach C, et al. Multimodal patient blood management program based on a three-pillar strategy: a systematic review and meta-analysis. Ann Surg. 2019;269(5):794–804TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel28TaggedAPTARAEnd. TaggedAPTARAListBodyMeybohm P, Straub N, F€ullenbach C, Judd L, Kleiner€uschkamp A, Taeuber I, et al. Health economics of patient blood management: a cost-benefit analysis based on a meta- analysis. Vox Sang. 2020;115(2):182–8. [cited 2023 May 9]TaggedAPTARAEnd.TaggedAPTARAEnd Ta ggedAPTARAListItemTaggedAPTARAListLabel29TaggedAPTARAEnd. TaggedAPTARAListBodyKaserer A, R€ossler J, Braun J, Farokhzad F, Pape HC, Dutkowski P, et al. Impact of a patient blood management monitoring and feedback programme on allogeneic blood transfusions and related costs. Anaesthesia. 2019;74(12):1534–41. [cited 2023May9]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel30TaggedAPTARAEnd. TaggedAPTARAListBodyIsbister JP. The three-pillar matrix of patient blood management−an overview. Best Pract Res Clin Anaesthesiol. 2013;27 (1):69–84. [cited 2023 May 8]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel31TaggedAPTARAEnd. TaggedAPTARAListBodyMurphy MF, Palmer A. Patient blood management as the standard of care. Hematology: Am Soc Hematol Educ Program. 2019;2019(1):583. [cited 2023 May 7]TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel32TaggedAPTARAEnd. WHO. The urgent need to implement patient blood management: policy brief. 2021 [cited 2022 Mar 25]; Available from: https://apps.who.int/iris/bitstream/handle/10665/346655/9789 240035744-eng.pdfTaggedAPTARAEnd TaggedAPTARAEndS4 hematol transfus cell ther. 2024;46(S1):S1−S4
Special article TaggedAPTARAH1Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood managementTaggedAPTARAEnd Definition of Patient Blood Management TaggedAPTARAPJuan Carlos Montano-Pedroso a,b, Maria Cristina Martins de Almeida Macedoc,d, Silvana Biagini e, Glaciano Ribeirof,g, Jos e Francisco Comenalli Marques Juniorh, Silvia Renata Corn elio Parolin Rizzoi, Guilherme Rabello j,*, Dante Mario Langhi Juniork TaggedAPTARAEnd TaggedAPTARAP aUniversidade Federal de S~ao Paulo (Unifesp), S~ao Paulo, SP, Brazil bInstituto de Assist^enciaM edica do Servidor P ublico Estadual (Iamspe), S~ao Paulo, SP, Brazil c Instituto Brasileiro de Controle do C^ancer (IBCC), S~ao Paulo, SP, Brazil dHospital S~ao Camilo Pomp eia, S~ao Paulo, SP, Brazil e Hospital Guilherme Alvaro e Complexo Hospitalar dos Estivadores, Santos, SP, Brazil f Hospital das Clínicas da Universidade Federal de Minas Gerais (HC UFMG), Belo Horizonte, MG, Brazil g Grupo HHEMO, S~ao Paulo, SP, Brazil hHospital Vera Cruz, Campinas, SP, Brazil i Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), S~ao Paulo, SP, Brazil j Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~aoPaulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil kEscola Paulista de Medicina, Universidade Federal de S~ao Paulo (EPM UNIFESP), S~ao Paulo, SP, Brazil TaggedAPTARAEnd TAGGEDAPTARAPARTICLE INFO Article history: Received 6 February 2024 Accepted 18 February 2024 Available online 8 March 2024TaggedAPTARAEnd TAGGEDAPTARAPA B S T R A C T Managing the patient’s blood and hematopoietic system is like managing any of the other organs and organ systems during patient care. Specialists control the heart, kidneys, endocrine system, etc. and the patient’s blood requires similar clinical treatment. The hematopoietic system and its circulatory products are fundamental for the healthy functioning of the human body. In simple terms, Patient Blood Management (PBM) is an organized, patient-centered approach in which the entire healthcare team coordinates efforts to improve outcomes by managing and preserving the patient’s own blood. By reducing dependence on blood transfusions, PBM seeks to improve clinical outcomes, reduce the risks and costs associated with transfusions, and improve the safety and quality of patient care. Essentially, the concept of PBM is about the holistic management and preservation of the patient’s own blood in the medical and surgical context. TaggedAPTARAEndTaggedAPTARAPKeywords: Patient-centered approach Empowerment Patient blood management Blood transfusionTaggedAPTARAEnd TaggedAPTARAEnd * Corresponding author at: Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~ao Paulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil. E-mail address: grabello.inovaincor@fz.org.br (G. Rabello). https://doi.org/10.1016/j.htct.2024.02.003 2531-1379/ 2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). TaggedAPTARAEndhematol transfus cell ther. 2024;46(S1):S5−S7 TaggedAPTARAFigure TaggedAPTARAEnd Hematology, Transfusion and Cell Therapy www.htct.com.br TaggedAPTARAFigure TaggedAPTARAEnd
2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).TaggedAPTARAEnd TaggedAPTARAH1DefinitionTaggedAPTARAEnd TaggedAPTARAPIt is well known that the term Patient Blood Management (PBM) was originally proposed in 2005 by James Isbister at a board meeting of the Medical Society for Blood Management and first appeared in the literature in 2008.1 However, long before that there was a concept of Patient Blood Management (PBM); we can say that it began to be structured by the renowned heart surgeon Dr. Denton Cooley. Dr. Cooley, who is recognized as “the father of bloodless surgery,” pioneered open-heart surgery without blood transfusion at the Texas Heart Institute in the early 1960s. At that time, these surgeries regularly consumed dozens of units of blood to fill the circuit of the heart-lung machine and during the procedure itself.2 TaggedAPTARAEnd TaggedAPTARAPPatients who refused blood transfusions and requested a “bloodless” approach came to Cooley for surgery. He felt that these patients needed to be cared for like any other, and so he developed a different approach, ‘another way’ to manage their treatment. This involved three basic steps that would later be described as the three pillars of PBM.3 This was indeed the beginning of a new approach to surgical patient care. Rather than simply relying on the transfusion of blood from other people, this approach focused on preserving and managing the patient’s own blood.2,4 TaggedAPTARAEnd TaggedAPTARAPPBM is currently definedasa“patient-centered, systematic and evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while at the same time promoting patient safety and empowerment.”1 TaggedAPTARAEnd TaggedAPTARAPPBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts with the aim of: 1) screening patients in respect to the diagnosis and adequate treatment of anemia; 2) minimizing surgical, procedural and iatrogenic blood loss and managing bleeding linked to coagulopathies; and 3) increasing tolerance of the patient’s anemia while appropriate treatment is initiated. This definition also emphasizes the critical role of informed patient choice.TaggedAPTARAEnd TaggedAPTARAPThe goal of PBM is not limited to reducing blood transfusions as such. Rather than transfusions being the standard based on a specific hemoglobin concentration, PBM focuses on the importance of the patient’s own blood as a unique, valuable, natural resource that must be conserved and managed appropriately. Hence, a reduction in the number of transfusions is a natural consequence of the direct implementation of PBM. Adherence to the principles of rational blood use, that is, transfusions indicated at the smallest dose necessary to maintain a certain laboratory hemoglobin value, helps to minimize transfusion. However, such programs, designed to reduce transfusions, have a narrow focus compared to the broader clinical approach of PBM.TaggedAPTARAEnd TaggedAPTARAPOnce the concept and importance of PBM are understood, it is necessary to find an effective way to implement the approach in hospitals and medical services, including outpatient services. All sectors of healthcare must be aligned with the proposals and objectives of PBM. This topic will be addressed in a subsequent article of this Consensus entitled The Implementation of Patient Blood Management.TaggedAPTARAEnd TaggedAPTARAP Recommendation For the implementation of PBM to be successful, a multidisciplinary approach is required, involving professionals from different areas, including doctors, surgeons, anesthesiologists, hematologists, as well as other professionals. Education and awareness of PBM guidelines are essential to ensure their adoption and effectiveness. TaggedAPTARAEnd TaggedAPTARAH1ConclusionTaggedAPTARAEnd TaggedAPTARAPPBM takes an individualized, multidisciplinary approach to managing a patient’s blood through the assessment and development of a management plan to optimize the patient’s own blood (identify and correct conditions such as anemia and iron deficiency), minimize blood loss (such as surgical techniques that reduce blood loss) and optimize tolerance to anemia.TaggedAPTARAEnd TaggedAPTARAPThis approach should be the standard of care applied by all clinicians for patients facing a medical or surgical intervention with a high risk of significant blood loss. The best and safest blood for patients is their own circulating blood.TaggedAPTARAEnd TaggedAPTARAH1Conflicts of interestTaggedAPTARAEnd TaggedAPTARAPThe author declares no conflicts of interest.TaggedAPTARAEnd TaggedAPTARAH1Supplementary materialsTaggedAPTARAEnd TaggedAPTARAPSupplementary material associated with this article can be found in the online version at doi:10.1016/j.htct.2024.02.003.TaggedAPTARAEnd taggedaptarah1referencestaggedaptaraend TaggedAPTARAListItemTaggedAPTARAListLabel1TaggedAPTARAEnd. TaggedAPTARAListBodyShander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, et al. A global definition of patient blood management. Anesth Analg. 2022;135(3):476–88TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAEndS6 hematol transfus cell ther. 2024;46(S1):S5−S7
TaggedAPTARAListItemTaggedAPTARAListLabel2TaggedAPTARAEnd. TaggedAPTARAListBodyIsbister JP. The three-pillar matrix of patient blood management - an overview. Best Pract Res Clin Anaesthesiol. 2013;27 (1):69–84TaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel3TaggedAPTARAEnd. TaggedAPTARAListBodyCooley DA. Conservation of blood during cardiovascular surgery. Am J Surg. 1995;170:53S–9STaggedAPTARAEnd.TaggedAPTARAEnd TaggedAPTARAListItemTaggedAPTARAListLabel4TaggedAPTARAEnd. TaggedAPTARAListBodyFarmer SL, Isbister JP, Gross I, Estioko MR, Shander A. Patient choice and the drive for change. In: Farmer SL, Gross I, Shander A, eds. Blood works: an owner’s guide: what every person needs to know before they are a patient, Westport: City Point Press; 2022:42–73TaggedAPTARAEnd.TaggedAPTARAEnd hematol transfus cell ther. 2024;46(S1):S5−S7 S7
Special article TaggedAPTARAH1Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood managementTaggedAPTARAEnd Implementation of Patient Blood Management (PBM) TaggedAPTARAPMaria Cristina Martins de Almeida Macedo a,b, Silvana Biagini c, Juan Carlos Montano-Pedrosod,e, Glaciano Ribeirof,g, Jos e Francisco Comenalli Marques Juniorh, Silvia Renata Corn elio Parolin Rizzoi, Guilherme Rabello j,*, Dante Mario Langhi Juniork TaggedAPTARAEnd TaggedAPTARAP aInstituto Brasileiro de Controle do C^ancer (IBCC), S~ao Paulo, SP, Brazil bHospital S~ao Camilo Pomp eia, S~ao Paulo, SP, Brazil c Hospital Guilherme Alvaro e Complexo Hospitalar dos Estivadores, Santos, SP, Brazil dUniversidade Federal de S~ao Paulo (Unifesp), S~ao Paulo, SP, Brazil eInstituto de Assist^enciaM edica do Servidor P ublico Estadual (Iamspe), S~ao Paulo, SP, Brazil f Hospital das Clínicas da Universidade Federal de Minas Gerais (HC UFMG), Belo Horizonte, MG, Brazil gGrupo HHEMO, S~ao Paulo, SP, Brazil hHospital Vera Cruz, Campinas, SP, Brazil i Associa¸c~ao Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH), S~ao Paulo, SP, Brazil j Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~aoPaulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil kEscola Paulista de Medicina, Universidade Federal de S~ao Paulo (EPM UNIFESP), S~ao Paulo, SP, Brazil TaggedAPTARAEnd TAGGEDAPTARAPARTICLE INFO Article history: Received 6 February 2024 Accepted 18 February 2024 Available online 13 March 2024TaggedAPTARAEnd TAGGEDAPTARAPA B S T R A C T Patient Blood Management (PBM) is a holistic approach to managing blood as a resource of each patient; it is a multimodal strategy that is implemented using a set of techniques that can be applied in individual cases. In fact, the overall result of the implementation of PBM cannot be fully appreciated or explained by simply summing up the effects of the individual strategies and techniques used, since they can only produce the expected ideal result if combined. Implementing a PBM program in healthcare offers several benefits including improved patient safety, better outcomes, cost savings, conservation of resources, evidence-based practice, transfusion TaggedAPTARAEndTaggedAPTARAPKeywords: Antifibrinolytics Health care TaggedAPTARAEnd * Corresponding author at: Instituto do Cora¸c~ao do Hospital das Clínicas da Faculdade de Medicina da Universidade de S~ao Paulo (Incor −HCFMUSP), S~ao Paulo, SP, Brazil. E-mail address: grabello.inovaincor@fz.org.br (G. Rabello). https://doi.org/10.1016/j.htct.2024.02.004 2531-1379/ 2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). TaggedAPTARAEndhematol transfus cell ther. 2024;46(S1):S8−S11 TaggedAPTARAFigure TaggedAPTARAEnd Hematology, Transfusion and Cell Therapy www.htct.com.br TaggedAPTARAFigure TaggedAPTARAEnd
alternatives, improved quality of care, compliance with accreditation standards, patient-centered care, and professional education and training. 2024 Published by Elsevier España, S.L.U. on behalf of Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).TaggedAPTARAEnd Coagulopathy Hemodilution HemostasisTaggedAPTARAEnd TaggedAPTARAH1Implementation of patient blood management (PBM)TaggedAPTARAEnd TaggedAPTARAPPBM is not a simple protocol, it is not just a change of a process in isolation, it is not reduced to the individual habits of a professional, it does not only focus on reducing expenses or saving resources and it is not the search for specific clinical results alone. Implementing PBM aims to coordinate all these aspects and others, which is why it is a change to a patientcentered care philosophy.TaggedAPTARAEnd TaggedAPTARAPThe biggest difficulty in introducing a PBM program is the lack of a widely accepted, reproducible practice for implementing and monitoring it.1 However, there are suggestions and successful experiences shared by different groups. As this is a multidisciplinary process, the positive engagement of the different areas involved under the guidance of the institutional management is essential.TaggedAPTARAEnd TaggedAPTARAPIt is important to highlight that the implementation of PBM can face several difficulties.2 Doctors and other professionals may resist the implementation of a new institutional guideline because they do not understand its real clinical usefulness and consider it just another bureaucratic measure. Therefore, attitudes that promote team commitment are fundamental, such as high-tech actions, agility in procedures and sharing the clinicalandfinancial results gained with the PBM program.TaggedAPTARAEnd TaggedAPTARAPIn 2018, a conference held in Frankfurt systematically reviewed the literature for recommendations related to PBM. Ten clinical recommendations and 12 general recommendations were generated, including three for the management of preoperative anemia, six for transfusion thresholds and three for the implementation of the PBM program. These recommendations address topics such as: a) adverse effects and relevant clinical effects; b) program compliance, flexibility and flexibility; and c) cost-effectiveness.TaggedAPTARAEnd TaggedAPTARAH1The pillars of patient blood management (PBM)TaggedAPTARAEnd TaggedAPTARAPThe implementation of the PBM program must accomplish the three pillars of the practice (Figure 1):4 TaggedAPTARAEndTaggedAPTARAP1) Screening, diagnosis and adequate treatment of anemia; 2) minimization of surgical, procedural and iatrogenic blood loss and the management of bleeding due to coagulopathies throughout treatment; and 3) increasing tolerance of the patient’sanemia. TaggedAPTARAEndTaggedAPTARAP1. Anemia Management: To detect anemia, identify its cause, use supportive agents and reduce oxygen consumption.TaggedAPTARAEnd TaggedAPTARAP2. Multidisciplinary strategies to conserve the patient’s own blood, including optimization of hemostasis and/ or coagulopathies: reduce blood loss, collect tests rationally (microtubes), use surgical techniques that minimize blood loss, consider scheduled autotransfusions, employ intraoperative cell recovery and apply normovolemic hemodilution. Assess hemostasis, treat coagulopathies, reverse anticoagulation, use antifibrinolytics, consider the administration of desmopressin, lower the criteria for platelet transfusion and transfuse specific components, when necessary.TaggedAPTARAEnd TaggedAPTARAP3. Anemia Tolerance: Harness and optimize the patient’s anemia physiologic reserve by formulating a patientspecific management plan, using appropriate blood conservation modalities to minimize blood losses, optimize red blood cell mass and control anemia. Set restrictive transfusion limits and optimize oxygen supply/consumption. Reduce diagnostic phlebotomies.5 TaggedAPTARAEnd TaggedAPTARAH1Patient-centered careTaggedAPTARAEnd TaggedAPTARAPPBM, a patient-centered care conduct, places the patient as the central figure of treatment, sharing information and decisions, obtaining consent and basing therapeutic decisions on patient-specific data (age, comorbidities, diagnosis, stage of the disease, hemodynamic reserve, oxygenation, among others). Thus, the decision to perform a transfusion is based on the clinical data of the patient taking into account their specific situation rather than pre-established laboratory values.TaggedAPTARAEnd TaggedAPTARAPSpain developed a PBM implementation method that was gradually incorporated into several hospitals and is currently being used in 59 institutions. This program, called Maturity Assessment PBM (MAPBM), aims to establish objective measures, obtain a benchmark, facilitate access and disseminate the results of PBM programs.1 The European Union itself published practical guides on implementing PBM both in hospitals6 and at the national level.7 TaggedAPTARAEnd TaggedAPTARAPIn Brazil, Benites et al. reported a positive experience implementing a PBM program in a university hospital.8 According to the authors, “The project was promptly approved by the hospital Board due to the relevance of the proposal, which required fewfinancial resources, as the project is mainly based on the reorganization of workflows”.TaggedAPTARAEnd TaggedAPTARAPThe PBM program can cover more than 100 different procedures, apportioned to the three pillars. However, it is recommended that PBM proposals and measures should be implemented in the form of ‘packages’, aiming at greater effectiveness.9 These packages of measures must be considered as a basis and adapted to the conditions of each institution taking into account its complexity, staff and costs involved in the program. Therefore, the healthcare institution must select priority initiatives and define the type of PBM program to be implemented. It can be a simpler approach for hematol transfus cell ther. 2024;46(S1):S8−S11 S9
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