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Hess AS. What's in Your Transfusion? A Bedside Guide to Blood Products and Their Preparation. Anesthesiology 2024; 140:144-156. [PMID: 37639622 DOI: 10.1097/aln.0000000000004655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
An understanding of the contents of blood products and how they are modified before transfusion will help any physician. This article will review five basic blood products and the five most common product modifications.
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Affiliation(s)
- Aaron S Hess
- Departments of Anesthesiology and Pathology & Transfusion Medicine, University of Wisconsin-Madison, Madison, Wisconsin
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2
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Lu W. A Concise Synopsis of Current Literature and Guidelines on the Practice of Plasma Transfusion. Clin Lab Med 2021; 41:635-645. [PMID: 34689970 DOI: 10.1016/j.cll.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence-based indications for plasma transfusion are limited, and much of the clinical practice relies on expert opinion. This article highlights key studies, meta-analyses, and guidelines for plasma transfusion in adults. The goal is to limit non-evidence-based plasma transfusion that is outside of clinical guideline, because as with all transfusions, the administration of plasma is not without risk. Any intended potential benefit must be appraised against the real risks associated with transfusion. Moving forward, the practice of plasma transfusion would benefit greatly from randomized controlled trials to update and expand the existing guidelines.
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Affiliation(s)
- Wen Lu
- Department of Pathology, Brigham and Women's Hospital, 75 Francis Street Cotran 260, Boston, MA 02115, USA.
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Jarczak D, Kluge S, Nierhaus A. Sepsis-Pathophysiology and Therapeutic Concepts. Front Med (Lausanne) 2021; 8:628302. [PMID: 34055825 PMCID: PMC8160230 DOI: 10.3389/fmed.2021.628302] [Citation(s) in RCA: 118] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/09/2021] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition and a global disease burden. Today, the heterogeneous syndrome is defined as severe organ dysfunction caused by a dysregulated host response to infection, with renewed emphasis on immune pathophysiology. Despite all efforts of experimental and clinical research during the last three decades, the ability to positively influence course and outcome of the syndrome remains limited. Evidence-based therapy still consists of basic causal and supportive measures, while adjuvant interventions such as blood purification or targeted immunotherapy largely remain without proof of effectiveness so far. With this review, we aim to provide an overview of sepsis immune pathophysiology, to update the choice of therapeutic approaches targeting different immunological mechanisms in the course of sepsis and septic shock, and to call for a paradigm shift from the pathogen to the host response as a potentially more promising angle.
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Affiliation(s)
- Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Adam EH, Fischer D. Plasma Transfusion Practice in Adult Surgical Patients: Systematic Review of the Literature. Transfus Med Hemother 2020; 47:347-359. [PMID: 33173453 DOI: 10.1159/000511271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/31/2020] [Indexed: 12/18/2022] Open
Abstract
Background Plasma transfusions are most commonly used therapeutically for bleeding or prophylactically in non-bleeding patients prior to invasive procedures or surgery. Although plasma transfusions generally seem to decline, plasma usage for indications that lack evidence of efficacy prevail. Summary There is wide international, interinstitutional, and interindividual variance regarding the compliance with guidelines based on published references, supported by appropriate testing. There is furthermore a profound lack of evidence from randomized controlled trials comparing the effect of plasma transfusion with that of other therapeutic interventions for most indications, including massive bleeding. The expected benefit of a plasma transfusion needs to be balanced carefully against the associated risk of adverse events. In light of the heterogeneous nature of bleeding conditions and their rapid evolvement over time, fibrinogen and factor concentrate therapy, directed at specific phases of coagulation identified by alternative laboratory assays, may offer advantages over conventional blood product ratio-driven resuscitation. However, their outcome benefit has not been demonstrated in well-powered prospective trials. This systematic review will detail the current evidence base for plasma transfusion in adult surgical patients.
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Affiliation(s)
- Elisabeth Hannah Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Dania Fischer
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
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Kim CH, Simmons SC, Wattar SF, Azad A, Pham HP. Potential impact of a delayed ADAMTS13 result in the treatment of thrombotic microangiopathy: an economic analysis. Vox Sang 2020; 115:433-442. [PMID: 32227485 DOI: 10.1111/vox.12912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/23/2020] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND A pre-plasma exchange ADAMTS13 measurement differentiates thrombotic thrombocytopenic purpura (TTP) from other forms of thrombotic microangiopathy (TMA). Given that many hospitals do not perform the ADAMTS13 assay in-house and that the turnaround time (TAT) differs among reference laboratories, we performed an analysis investigating the potential impact of a delay in obtaining the results on the healthcare system. METHODS An economic model was developed to estimate the impact of a delay in obtaining the pretreatment ADAMTS13 results on patients admitted with TMA with cost (US dollars) as the primary outcome. Incremental cost-effectiveness ratio (ICER) as a composite outcome was calculated from both cost and life days [LDs], an effectiveness surrogate marker. Model parameters were gathered from the medical literature, except for the institutional cost of the ADAMTS13 test. RESULTS In patients with TMA, during the 6-day study period, the incremental cost to the healthcare system ranged from approximately $4155 to $5123 for every 1-day delay in obtaining the pre-exchange ADAMTS13 results with virtually no change in the effectiveness marker. The ICER composite outcome established the cost-effectiveness of having a fast TAT for pre-exchange ADAMTS13 results. Probabilistic sensitivity analyses also confirmed the robustness of the model. CONCLUSIONS In patients with clinical presentations of TMAs, having a rapid TAT for pre-exchange ADAMTS13 measurement appeared to be cost-effective. If testing cannot be performed in-house, then our findings support the necessity of contracting with a reference laboratory that can reliably provide the result, preferably within 1 day of admission.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sierra C Simmons
- Department of Pathology, Michigan Pathology Specialists, Spectrum Health Hospitals, Grand Rapids, MI, USA
| | - Sarah F Wattar
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Ameneh Azad
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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6
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Abstract
Health care professionals must understand the impact of blood product transfusions and transfusion therapy procedures to ensure high-quality patient care, positive outcomes, and wise use of resources in blood management programs. Understanding transfusions of blood and blood products is also important because of the number of treatments performed, which affects individual patients and health care system resources. This article reviews research findings to acquaint health care professionals with the most successful protocols for blood, blood product, and coagulation factor transfusions. Damage control resuscitation in bleeding trauma patients, protocols for patients without trauma who are undergoing surgical procedures that place them at risk for excessive bleeding, and protocols for patients with sepsis are addressed. Emerging research continues to help guide mass transfusion treatments (restrictive vs liberal, balanced, and goal-directed treatment). Although available study results provide some guidance, questions remain. Additional research by health care professionals is needed.
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Affiliation(s)
- Heather M Passerini
- Heather M. Passerini is Nurse Practitioner, Surgical and Trauma Intensive Care Unit, University of Virginia Medical Center, PO Box 801443, Charlottesville, VA 22908-1443
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Kim CH, Simmons SC, Wang D, Najafzadeh P, Azad A, Pham HP. An economic analysis of different treatments for bleeding in patients with acquired haemophilia. Vox Sang 2019; 115:192-199. [PMID: 31879973 DOI: 10.1111/vox.12877] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 11/07/2019] [Accepted: 11/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Acquired haemophilia A (AHA), with potentially high risk of morbidity and mortality, occurs as a result of inhibitors against factor VIII. Bleeding due to AHA can be treated with activated prothrombin complex concentrate (aPCC), recombinant activated factor VII (rFVIIa) or recently, recombinant porcine-sequence factor VIII (rpFVIII). We extended our previous cost-effectiveness analysis (CEA) comparing rpFVIII against the available traditional options. METHODS For high-titred, haemorrhaging AHA patients treated with either aPCC, rFVIIa or rpFVIII, over the course of 6-days, a Markov simulation was conducted to evaluate the outcomes when these patients transitioned into any of the four following health states: (1) continuous bleeding, (2) thrombosis, (3) stop bleeding and (4) death, with states (2), (3) and (4) modelled as absorbing states. All model parameters were obtained from the medical literature, except the costs of aPCC, rFVIIa and the factor VIII assay, which came from our institutional data. RESULTS Excluding the cost of the initial treatment on day 0, the total subsequent treatment cost of rFVIIa was substantially more than the costs of aPCC and rpFVIII ($13 925 vs. $1778 vs. $6957, respectively). The average quality-adjusted life days (QALDs) gained from rpFVIII was lowest (4·89 vs. 4·9 for rFVIIa and 4·91 for aPCC). Overall, aPCC dominated the other two treatments. The model was determined to be robust across the tested ranges for all input variables. CONCLUSION Based on this economic model, for AHA patients with high titres who were bleeding, aPCC was the most cost-effective treatment option and may be considered for use if there is no clinical contraindication.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sierra C Simmons
- Department of Pathology, Michigan Pathology Specialists and Spectrum Health Hospitals, Grand Rapids, MI, USA
| | - Dandan Wang
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Parisa Najafzadeh
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ameneh Azad
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Huy P Pham
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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9
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Garraud O, Coppo P. Types of fresh plasma with focus on therapeutic plasma exchange. Transfus Apher Sci 2019; 58:258-261. [DOI: 10.1016/j.transci.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Simmons SC, Wang D, Liu H, Staley EM, Pham HP. Changes in International Normalized Ratio After Plasma Transfusion in Clinical Settings. Anesth Analg 2019; 128:e47. [DOI: 10.1213/ane.0000000000003984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kim CH, Simmons SC, Bui CM, Jiang N, Pham HP. aPCC vs. rFVIIa for the treatment of bleeding in patients with acquired haemophilia - a cost-effectiveness model. Vox Sang 2018; 114:63-72. [DOI: 10.1111/vox.12726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 01/27/2023]
Affiliation(s)
- Chong H. Kim
- Department of Clinical Pharmacy; University of Colorado Anschutz Medical Campus; Aurora CO USA
| | | | | | - Ning Jiang
- Center for Family Life at Sunset Park; SCO Family of Services; Brooklyn NY USA
| | - Huy P. Pham
- Department of Pathology; Keck School of Medicine; University of Southern California; Los Angeles CA USA
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Garraud O, Aubron C, Ozier Y, Coppo P, Tissot JD. Plasma for direct therapeutic use, for today and tomorrow: A short critical overview. Transfus Clin Biol 2018; 25:281-286. [PMID: 30131289 DOI: 10.1016/j.tracli.2018.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Plasma for direct therapeutic use is a fast-evolving blood component in terms of its production and presentation. More than a dozen forms are available worldwide, which is often overlooked since most countries apply policies making only one or very few forms available for treating patients in need. It is most often reserved for the same three clinical indications, i.e. overall clotting-factor deficiency, reversal of vitamin K antagonists in the context of active bleeding or prior to urgent surgery, and therapeutic plasma exchange. The level of evidence is often less robust than generally acknowledged for such major indications while novel indications are tending to emerge in medical and trauma settings. This short review explores classical views and new prospects opened up by novel presentations and statuses for therapeutic plasma.
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Affiliation(s)
- O Garraud
- EA3064, university of Lyon, faculty of medicine, 42023 Saint-Étienne cedex 2, France; Institut national de la transfusion sanguine, 75039 Paris cedex 15, France.
| | - C Aubron
- Medical intensive care unit, centre hospitalier et universitaire de Brest, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest, France; Université de Bretagne Occidentale, 29009 Brest, France
| | - Y Ozier
- Medical intensive care unit, centre hospitalier et universitaire de Brest, CHRU de Brest, boulevard Tanguy-Prigent, 29609 Brest, France; Université de Bretagne Occidentale, 29009 Brest, France
| | - P Coppo
- CNR-MAT, groupe hospitalier Cochin, AP-HP, 184, rue du Faubourg-Saint-Antoine, 75571 Paris cedex, France; Université Paris Pierre-et-Marie-Curie, 75006 Paris, France; Faculté de médecine de Sorbonne université, 91-105, boulevard de l'Hôpital, 75013 Paris, France; Inserm_U1009, Institut Gustave Roussy, rue Edouard Vaillant, 94800 Villejuif, France
| | - J-D Tissot
- Faculté de Biologie et de Médecine de Lausanne, 1011 Lausanne, Switzerland
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Kim CH, Simmons SC, Williams LA, Staley EM, Zheng XL, Pham HP. ADAMTS13 test and/or PLASMIC clinical score in management of acquired thrombotic thrombocytopenic purpura: a cost-effective analysis. Transfusion 2017. [PMID: 28646526 DOI: 10.1111/trf.14230] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The ADAMTS13 test distinguishes thrombotic thrombocytopenic purpura (TTP) from other thrombotic microangiopathies (TMAs). The PLASMIC score helps determine the pretest probability of ADAMTS13 deficiency. Due to inherent limitations of both tests, and potential adverse effects and cost of unnecessary treatments, we performed a cost-effectiveness analysis (CEA) investigating the benefits of incorporating an in-hospital ADAMTS13 test and/or PLASMIC score into our clinical practice. STUDY DESIGN AND METHODS A CEA model was created to compare four scenarios for patients with TMAs, utilizing either an in-house or a send-out ADAMTS13 assay with or without prior risk stratification using PLASMIC scoring. Model variables, including probabilities and costs, were gathered from the medical literature, except for the ADAMTS13 send-out and in-house tests, which were obtained from our institutional data. RESULTS If only the cost is considered, in-house ADAMTS13 test for patients with intermediate- to high-risk PLASMIC score is the least expensive option ($4,732/patient). If effectiveness is assessed as measured by the number of averted deaths, send-out ADAMTS13 test is the most effective. Considering the cost/effectiveness ratio, the in-house ADAMTS13 test in patients with intermediate- to high-risk PLASMIC score is the best option, followed by the in-house ADAMTS13 test without the PLASMIC score. CONCLUSIONS In patients with clinical presentations of TMAs, having an in-hospital ADAMTS13 test to promptly establish the diagnosis of TTP appears to be cost-effective. Utilizing the PLASMIC score further increases the cost-effectiveness of the in-house ADAMTS13 test. Our findings indicate the benefit of having a rapid and reliable in-house ADAMTS13 test, especially in the tertiary medical center.
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Affiliation(s)
- Chong H Kim
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Sierra C Simmons
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lance A Williams
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elizabeth M Staley
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - X Long Zheng
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Huy P Pham
- Division of Laboratory Medicine, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
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