Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices
AMERICAN JOURNAL OF HEMATOLOGY
2015; 90 (10): 927-933
Transfusions for anemia in adult and pediatric patients with malignancies
2015; 29 (5): 291-299
Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices. Am. J. Hematol. 90:927-933, 2015. © 2015 Wiley Periodicals, Inc.
View details for DOI 10.1002/ajh.24101
View details for Web of Science ID 000362663900020
View details for PubMedID 26113442
The Next Chapter in Patient Blood Management Real-Time Clinical Decision Support
AMERICAN JOURNAL OF CLINICAL PATHOLOGY
2014; 142 (6): 741-747
Restrictive blood transfusion practices are associated with improved patient outcomes
2014; 54 (10): 2753-2759
Restrictive blood transfusion practices are associated with improved patient outcomes.
2014; 54 (10): 2753-2759
Anemia is present in over two-thirds of patients with malignant hematological disorders. The etiology of anemia predominates from ineffective erythropoiesis from marrow infiltration, cytokine related suppression, erythropoietin suppression, and vitamin deficiency; ineffective erythropoiesis is further exacerbated by accelerated clearance due to antibody mediated hemolysis and thrombotic microangiopathy. As the anemia is chronic in nature, symptoms are generally well tolerated and often non-specific. Transfusion of red blood cells (RBCs) is a balance between providing benefit for patients while avoiding risks of transfusion. Conservative/restrictive RBC transfusion practices have shown equivalent patient outcomes compared to liberal transfusion practices, and meta-analysis has shown improved in-hospital mortality, reduced cardiac events, re-bleeding, and bacterial infections. The implications for a lower threshold for transfusion in patients with malignancies are therefore increasingly being scrutinized. Alternative management strategies for anemia with IV iron and erythropoietin stimulating agents (ESAs) should be considered in the appropriate settings.
View details for DOI 10.1016/j.blre.2015.02.001
View details for Web of Science ID 000362134700002
Role of ADAMTS13 in the management of thrombotic microangiopathies including thrombotic thrombocytopenic purpura (TTP)
BRITISH JOURNAL OF HAEMATOLOGY
2013; 163 (4): 514-519
Blood transfusion has been cited as one of the five most overutilized therapeutic procedures in the United States. We assessed the impact of clinical decision support at computerized physician order entry and education on red blood cell (RBC) transfusions and clinical patient outcomes at our institution.Clinical patient outcomes and RBC transfusions were assessed before and after implementation of a best practice alert triggered for transfusions when the hemoglobin level was higher than 7 g/dL for all inpatient discharges from January 2008 through December 2013. Retrospective clinical and laboratory data related to RBC transfusions were extracted: case-mix complexity, patient discharges and selected surgical volumes, and patient outcomes (mortality, 30-day readmissions, length of stay).There was a significant improvement in RBC utilization as assessed by RBC units transfused per 100 patient-days-at-risk. Concurrently, hospital-wide clinical patient outcomes showed improvement (mortality, p = 0.034; length of stay, p = 0.003) or remained stable (30-day readmission rates, p = 0.909). Outcome improvements were even more pronounced in patients who received blood transfusions, with decreased mortality rate (55.2 to 33.0, p < 0.001), length of stay (mean, 10.1 to 6.2 days, p < 0.001), and 30-day readmission rate (136.9 to 85.0, p < 0.001). The mean number of units transfused per patient also declined (3.6 to 2.7, p < 0.001). Acquisition costs of RBC units per 1000 patient discharges decreased from $283,130 in 2009 to $205,050 in 2013 with total estimated savings of $6.4 million and likely far greater impact on total transfusion-related costs.Improved blood utilization is associated with improved clinical patient outcomes.
View details for DOI 10.1111/trf.12723
View details for PubMedID 24995770
Warfarin reversal: schism between clinical practice and published guidelines
2013; 53 (3): 476-479
Thrombotic thrombocytopenic purpurawhat is new?
JOURNAL OF CLINICAL APHERESIS
2013; 28 (1): 30-35
The clinical presentation of thrombotic thrombocytopenia purpura (TTP) and other thrombotic microangiopathies (TMAs) can often be similar. The role of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) in diagnosing TTP is accepted by most researchers but continues to be debated in a few studies. We report the experience of our single-centre academic institution, where ADAMTS13 is used to diagnose TTP and guide plasma exchange (PLEX). Patients presenting to our institution with thrombotic microangiopathy (60 patients) between January 2006 and December 2012 were divided into two groups based on ADAMTS13 activity and clinical history. Patients with ADAMTS13 activity <10% were included in the TTP (n = 30) cohort while patients with activity >11% were classified as 'other microangiopathies' (TMA, n = 30). PLEX was only initiated in patients with a high likelihood of TTP and discontinued when the baseline ADAMTS13 activity was >11%. Patients with severe ADAMTS13 deficiency (TTP group) showed significant presenting differences: lower platelet counts, less renal dysfunction, higher presence of neurological abnormalities, and greater haemolysis markers as compared to non-deficient patients (TMA group). Most importantly, patients without severe ADAMTS13 deficiency were safely managed without increased mortality despite receiving no PLEX or discontinuing PLEX after a short course (upon availability of ADAMTS13 results). In conclusion, ADAMTS13 can be used to diagnose TTP and guide appropriate PLEX therapy.
View details for DOI 10.1111/bjh.12569
View details for Web of Science ID 000326034200013
View details for PubMedID 24111495
A functional deficiency of ADAMTS13 (a disintegrin and metalloproteinase with a thrombospondin type 1 motif), a von-Willebrand factor (VWF) cleaving protease, is central to the pathogenesis of congenital and acquired thrombotic thrombocytopenic purpura (TTP). ADAMTS13 testing has evolved from assays that required long denaturation and incubation times to ones that employ a modified recombinant VWF with improved standardization and turn around times. While plasma exchange is a mainstay in the treatment of TTP, increased use of rituximab, an antibody against CD20, has proved helpful in the treatment of patients with exacerbations and relapses. The next generation of drugs focuses on using recombinant ADAMTS13 and molecules that block the interaction of VWF and platelets to prevent thrombotic microangiopathy. The increased awareness and availability of ADAMTS13 testing has also made it possible to detect atypical presentations of TTP such as patients with macrovascular neurological symptoms without accompanying hematological findings as well as help diagnose other causes of thrombotic microangiopathies e.g. atypical hemolytic uremic syndrome. The use of ADAMTS13 testing in the management of TTP should continue to grow especially with newer assays with greater sensitivity, reproducibility, and timelier availability.
View details for DOI 10.1002/jca.21264
View details for Web of Science ID 000315218300006
View details for PubMedID 23420593