History of patient blood management.

This article traces the development of modern patient blood management (PBM) from its origins in 17th-century transfusion to the present day.

The economic burden of anemia in heart failure.

Anemia is a complex issue in patients with heart failure (HF). In past years, clinicians accepted anemia as a given or an "accessory" diagnosis in HF patients. This attitude has changed since understanding of the causes and morbidity of anemia in HF has improved and with the introduction of targeted treatments. Increasing health care costs have stimulated vigorous debate about the cost-effectiveness of such treatments. It behooves clinicians to understand the effectiveness of specific treatments, risks and benefits, and costs. This review addresses the impact of anemia's prevalence, etiology, associated outcomes, and treatments on the economic burden of HF patients.

Can intravenous iron therapy meet the unmet needs created by the new restrictions on erythropoietic stimulating agents?

In 2008, after reports of an association between erythropoietic stimulating agent (ESA) therapy and the potential for either thrombotic cardiovascular events or more rapid tumor progression in some cancers, the Food and Drug Administration changed the product labeling for ESAs, adding a black box warning as well as more restrictive indications, especially in oncology patients. In addition the Centers for Medicare and Medicaid Services has placed significant restrictions on payments for ESA therapy. These new limitations on ESA have led to increased use of transfusions in anemic cancer patients. This increase in allogeneic transfusions potentially will place an additional burden on the US blood supply. Although allogeneic blood transfusion is one answer to ESA restrictions, the use of intravenous iron therapy (IV iron) is another possible alternative. We will discuss the use of IV iron as primary therapy for anemia, the use of combination IV iron and ESA therapy to improve efficiency and decrease costs, and evidence that IV iron with and without ESA therapy can reduce allogeneic blood transfusions in surgical patients. We will also review the available IV iron agents and their comparative safety profiles.

Timing and incidence of postoperative infections associated with blood transfusion: analysis of 1,489 orthopedic and cardiac surgery patients.

BACKGROUND: Transfusion rates remain high in cardiac and orthopedic surgery and differ widely across physician practices in spite of growing knowledge that allogeneic blood transfusion (ABT) is associated with a risk of postoperative infection. METHODS: This prospective observational study compared the timing and incidence of ABT-associated postoperative infections (PIs) in 1,489 orthopedic or cardiac surgery patients at nine hospitals. RESULTS: Of 455 cardiovascular and 1,034 orthopedic surgery patients, 415 (55.6% of the cardiovascular patients and 15.7% of the orthopedic patients) were given ABT. The overall rate of PI during hospitalization was 5.8%. The relative risk of PI was 3.6-fold greater after ABT (50 patients; 12.1%) than in patients not having ABT (36 patients; 3.4%; 95% confidence interval 2.4, 5.4; p = 0.001). Postoperative infections appeared both during hospitalization (n = 86) and within four weeks after discharge (n = 81). CONCLUSIONS: Patients should be followed for as long as four weeks after discharge to determine the true incidence and risk of ABT-associated PI.

Medical and economic impact of anemia in hospitalized patients.

PURPOSE: Studies indicate that the prevalence of anemia in a number of patient populations is more common than originally thought, and that more patients go untreated. Current trends in the prevalence of anemia and the consequences of untreated anemia are described. SUMMARY: Untreated anemia is linked as an independent risk factor to increased mortality, morbidity, decreased efficacy of chemotherapy and radiotherapy in cancer treatment, and lengthened hospital or intensive care unit length of stay. Anemia is also associated with increased mortality in patients with congestive heart failure or left ventricular dysfunction. CONCLUSION: Anemia is prevalent in the oncology and critical care populations, yet is a neglected diagnosis. It is well established that anemia has been associated with increased morbidity and mortality, and can adversely impact therapy effectiveness. Effective treatment of anemia should be based on an understanding of the patient's physiological response to anemia and achieving optimal oxygenation levels while minimizing risks and complications common to the critical care patient.

Clinical use of plasma and plasma fractions.

The use of plasma and plasma-derived products has always involved a careful balance of anticipated benefit versus risk. Risk reduction through pathogen-inactivated products has been successful, but the expense of manufacture does not warrant widespread use. Although plasma has always had limited indications for use, these are often misunderstood or ignored in favor of received knowledge and tradition. Solid evidence from multiple trials support the limited indications for FFP described here and support products that target specific coagulation defects.

Perioperative assessment of the elective orthopedic surgery patient.

There are a number of safe and cost-effective therapeutic options for the potential management of all patients without allogeneic blood transfusion. Orthopedic surgeons should consider blood management using these options for all patients to provide them with safe and effective therapy, while minimizing the risks of allogeneic blood and preserving our decreasing blood resources.

Blood management in orthopaedic surgery.

The need to provide the best possible care for patients, while balancing risk against benefit and respecting the patients' wishes, is the major reason to pursue blood management strategies. This is underscored by the decreasing supply of blood and its concomitant increasing cost. A philosophy of blood management is centered in the recognition of transfusion-associated risks and their avoidance through limited exposure to allogeneic blood and the use of appropriate alternatives.

Current concepts and issues in blood management.

Blood management in orthopedic surgery is no longer an option; it is a requirement. The combination of patient desire to avoid transfusion, increasing evidence of multiple risks, decreasing blood supplies, and increasing costs mandate attention. This article addresses the balance of risk versus benefit in blood transfusion and presents a perioperative plan of blood management for patients undergoing orthopedic surgery.

Thigh compartment syndrome: diagnosis and surgical treatment.

Thigh compartment syndrome is uncommon and may go unrecognized. Signs and symptoms include a history of thigh swelling and/or hematoma and pain after minor injury in a patient who is anticoagulated. Surgical approaches to the deep thigh compartments are described.

The theory and practice of bloodless surgery.

The application of blood conservation strategies to minimise or avoid allogeneic blood transfusion is seen internationally as a desirable objective. Bloodless surgery is a relatively new practice that facilitates that goal. However, the concept is either poorly understood or evokes negative connotations. Bloodless surgery is a term that has evolved in the medical literature to refer to a peri-operative team approach to avoid allogeneic transfusion and improve patient outcomes. Starting as an advocacy in the early 1960s, it has now grown into a serious practice being embraced by internationally respected clinicians and institutions. Central to its success is a coordinated multidisciplinary approach. It encompasses the peri-operative period with surgeons, anaesthetists, haematologists, intensivists, pathologists, transfusion specialists, pharmacists, technicians, and operating room and ward nurses utilising combinations of the numerous blood conservation techniques and transfusion alternatives now available. A comprehensive monograph on the subject of bloodless surgery along with detailed coverage of risks and benefits of each modality (some modalities are discussed in more detail elsewhere in this issue) is beyond the scope of this article. Accordingly, a brief overview of the history, theory and practice of bloodless surgery is presented, along with the clinical and institutional management requirements.

The effect of improving communication competency on the certifying examination of the American Board of Surgery.

BACKGROUND: Since 1991 the authors have offered a course that identifies content deficits, but only provides instruction directed at improving verbal and nonverbal behaviors. We report the outcome of this 10-year effort as success on the certifying examination of the American Board of Surgery between 1991 and 2001. METHODS: Sixteen 5-day courses were scheduled over 10 years. Participants included those who had not taken the oral examination or had failed at least once and invited senior faculty (n = 26). Sites were chosen to replicate the actual examination setting. RESULTS: There were 122 participants, with follow-up data available on 88. Success in the certifying examination after completing the course is 96 percent. CONCLUSIONS: Evaluation of communication deficits and training to improve them is strongly associated with success. Clearly, this course is effective at identifying communication behaviors that are interfering with success on the certifying examination of the American Board of Surgery.