Puesta al día sobre transfusión masiva / Massive transfusion update / Atualização sobre transfusão maciça

La transfusión masiva plantea desafíos clínicos, organizacionales y logísticos para el personal de la salud en general y los servicios de Medicina Transfusional en particular. No existe una definición universalmente aceptada de transfusión masiva, las definiciones más comúnmente utilizadas se basan en el número de unidades de sangre administradas dentro de un cierto período de tiempo. La mayoría de los eventos de transfusión masiva ocurren en el contexto de hemorragias graves en pacientes quirúrgicos, politraumatizados, con hemorragia gastrointestinal u obstétrica. La reanimación de control de daños y los protocolos de transfusión masiva son las estrategias más utilizadas actualmente para el tratamiento inicial, seguidas de un tratamiento personalizado, dirigido por objetivos, mediante la monitorización de la coagulación en tiempo real mediante estudios viscoelásticos. Existen una serie de controversias alrededor del tratamiento óptimo, incluyendo el uso de sangre total, la relación de hemocomponentes a utilizar, el uso de concentrados de factores de la coagulación, y la indicación óptima del ácido tranexámico. El estudio de los productos ideales para el tratamiento de los pacientes con sangrado masivo se ha convertido en un área de gran interés de la investigación científica. El contexto clínico en el que ocurrió el evento hemorrágico, el número de hemocomponentes transfundidos, la edad del paciente y las comorbilidades son los predictores más importantes de la sobrevida a corto y largo plazo. Esta revisión narrativa explora el estado actual del conocimiento sobre la transfusión masiva, así como los avances que podemos esperar en el futuro cercano.

Massive transfusion poses clinical, organizational and logistic challenges for the health staff in general, and the Transfusion Medicine Services in particular. There is no universally accepted definition for massive transfusion, the most widely used being based on the number of blood units administered in a certain period of time. Most massive transfusion events occur in the context of severe hemorrhage on surgical or multiple-trauma patients or patients with gastrointestinal or obstetric bleeding. Today, damage control resuscitation and massive transfusion protocols are the most common strategies for initial treatment, followed by personalized therapy, goal-directed, my means of monitoring coagulation in real time with viscoelastic studies. There are disputes as to the best surgical treatment, including using whole blood, the relation of blood components to be used, the use of coagulation factor concentrates and the optimal indication of tranexamic acid. The study of ideal products to treat patients with massive hemorrhage has become an area of great interest for scientific research. The clinical context of the hemorrhagic event, the number of blood components transfused, patient's age and comorbilities are the most important predictors for survival in the short and long term. This narrative review explores the current state of affairs on knowledge about massive transfusion, as well as progress to be expected in the near future.

A transfusão maciça apresenta desafios clínicos, organizacionais e logísticos para o pessoal de saúde em geral e para os serviços de Medicina Transfusional em particular. Não existe uma definição universalmente aceita de transfusão maciça; as definições mais comumente usadas são baseadas no número de unidades de sangue administradas em um determinado período de tempo. A maioria dos eventos de transfusão maciça ocorre no contexto de sangramento maior em pacientes cirúrgicos, politraumatizados, com sangramento gastrointestinal ou obstétrico. Atualmente, a ressuscitação para controle de danos e os protocolos de transfusão maciça são as estratégias mais usadas para o tratamento inicial, seguidos por tratamento personalizado e orientado por objetivos usando monitoramento de coagulação em tempo real usando testes viscoelásticos. Há uma série de controvérsias em torno do tratamento ideal, incluindo o uso de sangue total, a proporção de componentes sanguíneos a serem usados, o uso de concentrados de fator de coagulação e a indicação ideal de ácido tranexâmico. O estudo dos produtos ideais para o tratamento de pacientes com sangramento maciço tornou-se uma área de grande interesse na pesquisa científica. O contexto clínico em que ocorreu o evento hemorrágico, o número de hemocomponentes transfundidos, a idade do paciente e as comorbidades são os preditores mais importantes de sobrevida a curto e longo prazo. Esta revisão narrativa explora o estado atual do conhecimento sobre transfusão maciça, bem como os avanços que podemos esperar no futuro próximo.

Practices for rational use of blood components in a universitary hospital / Práticas para uso racional de hemocomponentes em um hospital universitário

SummaryObjective:to produce improvements in transfusion practices through the implementation of an educational program for health professionals in a university hospital.Methods:this is an interventional and prospective study, with pre- and postanalysis of an educational intervention. The research was developed at the University Hospital of the Universidade Federal de Sergipe, involving participation of health professionals in the stage of training, during the month of February 2011, in addition to the monitoring of blood transfusions performed in the preand post-intervention periods. Transfusion practices were investigated upon request for transfusion or devolution of unused blood components. Knowledge of health professionals was assessed based on the responses to a questionnaire about transfusion practices.Results:during the educative campaign, 63 professionals were trained, including 33 nurses or nursing technicians and 30 physicians. Among the doctors, there was a statistically significant gain of 20.1% in theoretical knowledge (p=0.037). Gain in the nursing group was even higher: 30.4% (p=0.016). The comparative analysis of transfusion request forms showed a non-significant decrease from 26.7 to 19.5% (p=0.31) in all forms with incomplete information. We also observed a statistically significant improvement in relation to the filling of four items of transfusion request.Conclusion:there was a significant improvement of the entire process related to blood transfusions after interventional project conducted in February 2011.

ResumoObjetivo:produzir melhorias em práticas transfusionais a partir da implementação de um programa educacional para profissionais de saúde em um hospital universitário.Métodos:este é um estudo intervencional e prospectivo, com análises pré e pós-intervenção educacional. A pesquisa foi desenvolvida no Hospital Universitário da Universidade Federal de Sergipe, envolvendo a participação de profissionais de saúde no estágio de capacitação, durante o mês de fevereiro de 2011, além da monitorização de transfusões sanguíneas feitas nos períodos pré e pós-intervencionais. A busca por práticas transfusionais foi checada via requerimentos de transfusão e devolução de hemocomponentes não utilizados. O conhecimento dos profissionais de saúde foi medido por meio de questionário relacionado a práticas transfusionais.Resultados:durante a campanha educativa, foram capacitados 63 profissionais de saúde, sendo 33 enfermeiros e técnicos de enfermagem e 30 médicos. Entre os médicos, houve um ganho estatisticamente significante de 20,1% nos conhecimentos teóricos (p=0,037). O ganho no grupo da enfermagem foi ainda maior, de 30,4% (p=0,016). A análise comparativa dos formulários de requisição transfusional mostrou uma diminuição não significativa de 26,7 para 19,5% (p=0,31) em todas as formas de preenchimento incompleto. Observou-se uma melhoria estatisticamente significativa no preenchimento de quatro itens da requisição transfusional.Conclusão:houve melhorias significativas em todo o processo relacionado às transfusões sanguíneas após intervenção conduzida em fevereiro de 2011.

Contribution of the Retrovirus Epidemiology Donor Study (REDS) to research on blood transfusion safety in Brazil

The Retrovirus Epidemiology Donor Study (REDS) program was established in the United States in 1989 with the purpose of increasing blood transfusion safety in the context of the HIV/AIDS and human T-lymphotropic virus epidemics. REDS and its successor, REDS-II were at first conducted in the US, then expanded in 2006 to include international partnerships with Brazil and China. In 2011, a third wave of REDS renamed the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) was launched. This seven-year research program focuses on both blood banking and transfusion medicine research in the United States of America, Brazil, China, and South Africa. The main goal of the international programs is to reduce and prevent the transmission of HIV/AIDS and other known and emerging infectious agents through transfusion, and to address research questions aimed at understanding global issues related to the availability of safe blood. This article describes the contribution of REDS-II to transfusion safety in Brazil. Articles published from 2010 to 2013 are summarized, including database analyses to characterize blood donors, deferral rates, and prevalence, incidence and residual risk of the main blood-borne infections. Specific studies were developed to understand donor motivation, the impact of the deferral questions, risk factors and molecular surveillance among HIV-positive donors, and the natural history of Chagas disease. The purpose of this review is to disseminate the acquired knowledge and briefly summarize the findings of the REDS-II studies conducted in Brazil as well as to introduce the scope of the REDS-III program that is now in progress and will continue through 2018.

Avaliação do Sistema de Vigilância Sanitária do Sangue em âmbito federal, Brasil, 2007 / Evaluation of the System of Sanitary Vigilance of Blood at the federal level, Brazil, 2007

Este estudo consistiu em avaliar o Sistema de Vigilância Sanitária do Sangue em âmbito federal (Vigisan). Trata-se de um estudo de avaliação em saúde que contemplou os seguintes componentes selecionados do Vigisan: sistema gerencial de cadastro de serviços hemoterápicos, programa de avaliação externa da qualidade de serviços de hemoterapia, sistema de hemovigilância, normatização e inspeção dos serviços de sangue e seus componentes. Além da descrição e do cálculo da eficiência (razão custo-efetividade) do Vigisan, a avaliação foi composta de duas fases com base em três métodos. O Vigisan apresentou uma estrutura mal definida, funcionamento regular e utilidade aceitável para a saúde pública. De um total de quatro indicadores definidos para a avaliação de desempenho, um obteve resultado satisfatório. Dos sete atributos estudados, três alcançaram uma avaliação positiva. A razão custo-efetividade foi de R$ 80.865,80 por atividade executada, o que resultou em perda de eficiência para o Sistema. Este estudo demonstra a importância da realização de avaliações de Sistemas de Vigilância em Saúde Pública, as quais devem ser realizadas periodicamente com a finalidade de contribuir no aperfeiçoamento do Sistema e, consequentemente, melhorar a saúde pública do país.

This study evaluated the Sanitary Vigilance System for Blood at federal government level (VIGISAN). This assessment included the following components: managerial system of registration of hemotherapeutic services; external evaluation program of quality of hemotherapy services; hemovigilance system; standardization and inspection of health services for blood and its components. Besides the description and the calculation of efficiency (cost-effectiveness ratio) of VIGISAN, the assessment consisted of two phases based on three methods. VIGISAN had a poorly defined structure, though it operated smoothly and its utility was acceptable for public health. From a total of four defined indicators to evaluate performance, one obtained a satisfactory result. Three out of the seven evaluation attributes achieved positive assessment in this study. The cost-effectiveness ratio was US$ 37,965.16 per activity performed, which resulted in loss of efficiency for the system. This study demonstrates the importance of conducting evaluations of vigilance systems in public health, which should be performed periodically in order to contribute to improvement of the system and thus improve public health in the country.

Estándares de trabajo para servicios de sangre / Standards is working for blood services

El objetivo de este documento es proporcionar a quienes tienen a su cargo la gerencia de los servicios de sangre una guía para garantizar su calidad y la de los productos que distribuyen. Su contenido puede ser utilizado para la implementación de normas y de buenas prácticas de manufactura por las autoridades de salud, así como para establecer programas voluntarios de acreditación. Es por ello que, a pesar que los estándares están diseñados para ser implementados en los bancos de sangre a nivel individual, su aplicación requiere de un sistema nacional que vele por la calidad técnica, científica y administrativa de los servicios de sangre. A través de este sistema nacional el Gobierno formaliza su compromiso y apoyo a la medicina transfusional, y desarrolla una política y un plan nacional de acción, de financiamiento y evaluación de sus operaciones.

Availability and suitability of rapid diagnostic kits for screening donated blood in Afghanistan

As health infrastructure is being rebuilt in Afghanistan, military, public, and private facilities offer donor blood collection/ transfusion services. This study aims to measure availability and type of blood screening test kits in the military, public and private facilities in Afghanistan. This national cross-sectional assessment targeted all facilities providing donor blood collection/transfusion services across all sectors. Descriptive statistics were generated with screening test availability compared by setting [urban vs. rural], province/region, and facility type [private vs public] using Chi-square test. A total of 243 facilities were assessed, with all 34 provinces represented with urban settings containing 63% of the facilities. Screening rapid tests were widely present for most pathogens, including HIV [87.7% of facilities], hepatitis B surface antigen [HB[s]Ag] [93.8%], hepatitis [HCV] antibody [90.5%], and syphilis [70.0%]. Private facilities were less likely to have syphilis tests available [51.4% vs. 84.1% [public], p<0.01]. Nineteen percent of facilities use the WHO evaluated test kit for HIV, 2.1% for HB[s]Ag, and none for HCV Ab. Of sites with available test kits, 7.5% of HIV, 0.9% of HB[s]Ag, 2.3% of HCV, and 6.5% of syphilis tests were expired at time of assessment. For expired tests, private facilities were more likely to have expired HIV and syphilis tests [p=0.07 and p=0.02, respectively] than other facility types. Blood collection/transfusion is a multisectoral service in Afghanistan, with substantial differences in test availability and type between sectors. Mechanisms are needed that ensure availability of quality test kits at all levels where blood collection/transfusion is performed. Test kits that have been evaluated by the WHO should be used for blood screening in all facility types

Cumplimentación del consentimiento informado para la transfusión de hemoderivados en los Servicios de Urología y Cirugía / Enforcement of informed consent request for blood transfusion in urology and surgery departments

Objetivo: Aplicar un círculo de mejora a la petición de consentimiento informado (CI) para la transfusión de hemoderivados en los servicios de Cirugía General y Urología. Métodos: Durante 8 meses se incluyeron 120 pa­cientes intervenidos en el Hospital General Reina Sofía de Murcia. Tras realizar un análisis de causa-efecto de Ishikawa, se establecieron 4 criterios: C1: identifica­ción del médico; C2: identificación del paciente; C3: firma del paciente; C4: fecha del documento. En el pri­mer periodo se incluyeron 60 pacientes. Se analizaron Ias causas de incumplimiento y se aplicaron las medidas correctoras, reevaluando los criterios en otros 60 pacientes. Resultados: Todos los criterios estaban por debajo del estándar: C1: 3%; C2: 95%; C3: 16% y C4: 65%. En la segunda evaluación el cumplimiento de C1 (70%), C3 (98%) y C4 (88%) mejoró significativamente pero aún así los resultados continúan, también significativamente, por debajo de los estándares establecidos. Los resultados se expresan en porcentaje de cumplimiento con un intervalo de confianza del 95%. Conclusiones: La realización de un ciclo de mejora ha permitido detectar y corregir incumplimientos en el C1 de transfusiones sanguíneas. El nivel de cumplimiento de los criterios mejoró en la segunda evaluación aunque continuamos por debajo del estándar establecido. Hemos conseguido una mayor concienciación por parte de los profesionales a la hora de cumplimentar el consentimiento.

Objective: To analyze the degree of compliance with a variety of standards defined for the quality control of the informed consent request for human blood products transfusion in our departments of Surgery and Urology. Material and method: Retrospective study of patients treated during 8 consecutive months in a university teaching hospital (n=120). Assessment of quality was performed through measurements of compliance using 4 criteria: C1, Physician Identification; C2, patient identification; C3, patient signature; C4, document date. In the first period 60 patients were included. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria during one month, paying particular attention to those criteria with the highest percentage of errors in the study. During a third period of six months (60 patients) the information of all criteria was gathered again and the improvement with regard to the standard values and to the compliance of the first period was evaluated. Results: Compliance of all criteria was significantly below standard values in the first evaluation: C1 :3%; C2: 95%; C3: 16% and C4: 65%. In the second period all the criteria below its standard improved with regard to the first period; nonetheless the results are, also significantly, below the established standards. Conclusions: This improvement cycle enabled us to detect and correct breaches on the informed consent request for human blood products transfusion. Corrective measures introduced were effective since it was improved in all the criteria below standard. We have achieved a good awareness of health professionals to complete the authorization.

Prescripción inadecuada de transfusión sanguínea en un hospital de referencia de Lima, Perú / To inadequate indication of blood transfusion in a reference hospital in Lima, Peru

Objetivos. Determinar la frecuencia y los criterios clínicos asociados a la prescripción inadecuada de hemocomponentes. Materiales y métodos. Estudio transversal realizado entre junio y octubre de 2002. Se revisó las historias médicas y los exámenes de laboratorio de los pacientes que recibieron transfusiones sanguíneas. Para valorar las indicaciones de transfusión como adecuadas o inadecuadas se empleó una guía de transfusión elaborada en base a consensos publicados. Resultados. Se evaluaron 311 indicaciones de transfusión. El porcentaje global de prescripción inadecuada fue de 33.8 por ciento. Los glóbulos rojos (GR) se usaron inadecuadamente en 25 por ciento, el plasma fresco congelado en 59 por ciento, las plaquetas en 13 por ciento y el crioprecipitado en 88 por ciento. En Cirugía, una de cada dos indicaciones fue inadecuada mientras que en los servicios de Medicina, UCI y Emergencia, una de cada tres lo fue. El plasma fresco congelado fue el componente peor utilizado. Conclusiones. Existe una elevada frecuencia de prescripción inadecuada de hemocomponentes en la población de estudio. La identificación de los criterios clínicos específicos de indicación inapropiada de transfusión puede ayudar a diseñar estrategias para el uso racional.

Objectives. To determine frequency and clinical criteria associated to the inadequate indication of blood products. Materials and methods. A cross-sectional study was performed between June and October 2002. Clinical charts and the laboratory tests from patients receiving blood transfusions were examined. A blood transfusion guideline was elaborated based on published consensus, and used to determine whether the indications for blood products transfusion was adequate or inadequate. Results. A total of 311 blood transfusions were evaluated. The global prevalence of inappropriate indication was of 33.8 percent. Red blood cells (RBC) were used inappropriately in 25 percent, fresh frozen plasma (FFP) in 59 percent, platelets in 13 percent and cryoprecipitate in 88 percent. From surgery related transfusions half of the indications were inadequate. In internal medicine, ICU and emergency related transfusions, approximately one third of the indications were inadequate. The FFP is the worst used blood product. Conclusions. We found a high frequency of inadequate blood transfusion. The identification of the specific clinical criteria used in inadequate indications transfusions will help in designing a better educational strategy towards a more rational use of the blood products.

O controle da transmissão transfusional / Control of transfusional transmission

A alta prevalência de doadores chagásicos nos bancos de sangue do Brasil (6,9 por cento) e da América Latina (6,5 por cento), nas décadas de 60 e 70, aliada ao combate ao vetor a partir dos anos setenta, fez com que a doença de Chagas transfusional, a partir da década de oitenta, se tornasse o principal mecanismo de transmissão da doença na maioria dos países endêmicos. Contudo, os resultados altamente favoráveis do combate ao vetor e da cobertura sorológica dos doadores, reduziu a prevalência de soropositividade para 0,2 por cento e 1,3 por cento, respectivamente, no Brasil e América Latina e o índice de transmissão anual, via transfusão de sangue no Brasil, de 20.000 para 13 em quatro décadas. Entretanto, paralelamente aos grandes avanços obtidos pelos países endêmicos, a doença de Chagas alcançou, via processo migratório, os países não endêmicos da América do Norte e da Europa, além do Japão e Austrália, colocando em risco os receptores de sangue destes países e transformando a doença de Chagas num problema de saúde global. A segurança transfusional, propiciada pela triagem sorológica, trouxe, porém outro importante problema, qual seja, a alta proporção de reações inconclusivas e dois grandes desafios: o significado de tais exames e que orientação proporcionar ao doador. Contudo, as estratégias adotadas pelos países não endêmicos e os avanços alcançados pelos endêmicos, prenunciam o breve, auspicioso e intensamente sonhado controle vetorial e transfusional da doença de Chagas.

The high prevalence of chagasic blood donors in blood centers in Brazil (6.9 percent) and in Latin America (6.5 percent) in the 60's and 70's, together with the combat to the vector since the 70's have made transfusion Chagas disease the main mechanism of the disease transmission in the 80's. However, the highly favorable results achieved to eliminate the vector and the serologic screening of blood donors, reduced the prevalence of serum positivity to 0.2 percent and 1.3 percent, respectively and the rate of annual transmission through blood transfusion from 20.000 to 13 in four decades in Brazil. Nevertheless, despite outstanding advancements in endemic countries, Chagas disease reached, via migration, non-endemic countries in North America and Europe besides Japan and Australia, placing their blood recipients at risk and turning Chagas disease into a worldwide health problem. Transfusion safety through serologic selection raised another big issue i.e. high proportion of inconclusive reactions as well as two great challenges: the meaning of such exams and what guidelines to provide the donor. However, the strategies adopted by non-endemic countries and the advancements achieved by endemics so far forecast the highly wished vector and transfusion control of Chagas disease.

Prevenção referente às modalidades alternativas de transmissão do trypanosoma cruzi no Brasil / Prevention concerning the different alternative routes for transmission of Trypanosoma cruzi in Brazil

Consideram-se habituais em doença de Chagas humana os mecanismos vetorial, transfusional e congênito de transmissão. Acidental, oral e por transplantes são ditos alternativos. Possibilidades como por outros vetores, sexual, criminal e por secreção de marsupiais são consideradas excepcionais. A prevenção dos mecanismos alternativos, incluindo o congênito, está hoje consensuada: TRANSMISSÃO CONGÊNITA: detecção precoce do caso e seu tratamento específico. Se possível começar, no pré-natal com sorologia de gestantes. Quando viável, pesquisar parasitologicamente o RN de mães reagentes, tratando-se imediatamente os que resultarem positivos. Sendo negativos, sorologia convencional aos 8 meses de vida, tratando imediatamente os que estiverem reagentes. TRANSMISSÃO ACIDENTAL: Usar treinamento e equipamentos de proteção. Se acidente, desinfecção local, sorologia convencional e inicio de tratamento específico por dez dias. Revisão da sorologia em 30 dias, seguindo-se o tratamento até a dose total, no caso de reação positiva. TRANSPLANTES DE ÓRGÃOS: sorologia prévia no doador e receptor. Sendo o primeiro positivo e o segundo negativo, evitar o transplante ou tratar especificamente o doador por 10 dias antes da cirurgia e o receptor nos dez dias subsequentes à mesma. TRANSMISSÃO ORAL: de modo geral, higiene alimentar e cozimento de carnes de possíveis reservatórios. Hoje se recomenda a detecção precoce e tratamento imediato do caso, com intensa busca ativa entre os circunstantes mais próximos do paciente.

Vectorial, transfusion and congenital are considered the main transmission mechanisms in human Chagas disease. Alternative mechanisms are accidental, oral and by organ transplantation. Other hypothetic mechanisms could be by other vectors, sexual, criminal and by means of marsupial anal secretions. The present accorded strategies for prevention are: CONGENITAL: early case detection and immediate treatment. If possible, start during the pre natal period, throughout mothers serology, performing parasitological tests in the new born from positive women. For positive cases, immediate treatment; for those negative babies, conventional serology at the 8th month, treating specifically those with positive results. ACCIDENTAL TRANSMISSION: Rigorous training and utilization of protection equipments. IF accident occurs, immediate disinfection, conventional serology and beginning of specific treatment by ten days. Revision of the serology after 30 days: if positive, extend the treatment until the total dose (60 days or more). ORGAN TRANSPLANTATION: previous serology for donor and receptor. When the former is infected and the last negative, cancel the surgery or install the specific treatment by ten days before the surgery for the donor, followed by the receptor during ten days after the transplantation. ORAL TRANSMISSION: Specific measures are not available, food hygiene is recommended, including the cooking of meats delivered from possible reservoirs. Nowadays, the detection and immediate treatment of the case is recommended, followed by active research of new cases around the detected one.