Markus M. Müller

Transfusion of Packed Red Cells: Indications, Triggers and Adverse Events.

BACKGROUND About four million units of packed red cells are transfused in Germany every year. The safety of blood transfusions is further improved by modern production methods and molecular diagnostic techniques. METHODS This review is based on selected publications,including the German guidelines and regulations and the German Transfusion Act. RESULTS Packed red blood cells are transfused to prevent tissue hypoxia. As the clinical manifestations of anemia are nonspecific, the indication for transfusion is based on surrogate parameters, such as the hemoglobin (Hb) concentration, in addition to clinical criteria. For patients with unimpaired cardiopulmonary and vascular function, transfusion is generally indicated at hemoglobin values of 6 g/dL (3.7 mmol/L) or less. Randomized controlled trials have shown that a restrictive transfusion strategy (trigger: Hb 7-8 g/dL) in certain patient groups is as effective as a more liberal strategy (trigger: Hb about 10 g/dL). The most frequent causes for transfusion errors are lack of informed consent, lack of identity checking and/or AB0 identity testing, and the drawing of blood samples in unlabelled tubes. CONCLUSION Overtransfusion, undertransfusion, as well as other transfusion errors can be markedly reduced by means of appropriate organizational measures and training.

Safety and effectiveness of a Patient Blood Management (PBM) program in surgical patients - the study design for a multi-centre prospective epidemiologic non-inferiority trial

BackgroundPreoperative and hospital-acquired anaemia is common among surgical patients. It is associated with an increased risk of morbidity and mortality and a strong risk factor for allogeneic blood transfusions with their own inherent risks. Patient Blood Management (PBM) concepts aim to increase and preserve autologous erythrocyte volume and to optimise haemotherapy. They thus have great potential to benefit patients.Methods/DesignThis prospective, multi-centre clinical trial tests the hypothesis that PBM programs are safe and effective in the care of adult surgical patients. Primary outcome is a composite endpoint of adverse events and in-hospital mortality.DiscussionThis trial will determine whether the implementation of a PBM program is safe and effective in terms of clinical outcome compared to a pre-implementation cohort. This trial is registered at www.clinicaltrials.gov (NCT01820949).

Patient Blood Management – Wie geht das praktisch? – Die interdisziplinäre Zusammenarbeit

Patient blood management (PBM), as a multidisciplinary, evidence-based treatment concept for reducing anemia and blood losses, should be realized in individual hospitals after local adaptation according to the available facilities.The implementation of a PBM program in clinical institutions will be a challenging but in every case worthwhile task. The local facilities may be insufficient to fulfill the training requirements of a large group of different personnel. Accordingly, sustained support by the hospitals management with provision of the necessary resources for personnel and materials is essential. The formation of the core PBM team, in our case consisting initially of anaesthesiologists, surgeons, internists and transfusion medicine specialists as well as - the particularly important - motivated nursing personnel, is one of the most pressing and primary tasks in the establishment of a PBM project.It is also extremely important to firmly anchor the PBM project permanently within the hospital. Possible steps and details for this purpose are presented and discussed in terms of value and weighting by the authors on the basis of their actual experience in Frankfurt University Hospital.

Perioperative Red Blood Cell Transfusion: Harmful or Beneficial to the Patient?

Although the transfusion of red blood cells (RBCs) is safer than ever regarding infections, it is still associated with several adverse reactions and therefore should only be used on the basis of evidence-based triggers. However prevention of RBC transfusion and subsequent substitution of blood losses with acellular solutions will inevitably result in dilutional anemia. Acute dilutional anemia can be compensated by the body over a wide range of hemoglobin concentrations without a critical restriction of tissue oxygenation. On the other hand, chronic anemia is known to be a potent cause of morbidity and mortality. As a consequence, the impact of perioperative anemia on mortality is difficult to describe, because anemia, as well as the transfusion of RBCs, can influence the clinical outcome. The resulting ‘Gordian knot’ cannot be cut easily, and this circumstance forces clinical physicians to make a daily trade-off between transfusion-associated and anemia-associated risks. This review focuses on the physiology of oxygen transport, the hazards of acute anemia, the hazards of RBC transfusion, and the literature putting these problems into perspective.

Microparticles from stored red blood cells enhance procoagulant and proinflammatory activity: EFFECTS OF RBC-DERIVED MICROPARTICLES

The pathomechanisms of morbidity due to blood transfusions are not yet entirely understood. Elevated levels of red blood cell–derived microparticles (RMPs) are found in coagulation‐related pathologies and also in stored blood. Previous research has shown that RMPs mediate transfusion‐related complications by the intrinsic pathway. We hypothesized that RMPs might play a role in post‐transfusion thrombotic complications by enhancing procoagulant activity also through the extrinsic pathway of coagulation.

Safety and effectiveness of a Patient Blood Management Programme in surgical patients – the study design for a multicentre epidemiological non-inferiority trial by the German PBM network

Patient blood management (PBM) concepts aim to identify patients with anemia and optimize their treatment including use of preoperative iron substitution, blood‐sparing techniques and adequate transfusion practice. PBM concepts thus have great potential to increase patient safety and clinical outcome. Nevertheless, up to now, structured PBM programmes have only been implemented in very few hospitals in Germany and safety data regarding clinical outcome parameters is rare.

Researching Religious Education Journals: Methodology and Selected Results from a German Study.

This article is based on a research project concerning the development of religious education as an academic discipline in Germany during the twentieth century. Applying a methodology that has been of growing interest in a number of fields, the project proceeded by analysing major religious education journals published between 1900 and 1975. The present report focuses on the procedures developed and used in this research project in order to make it available to others in other countries. This is why the procedures are described in detail while the material results of the study are presented only selectively, to the degree that they indicate the results that can be reached by the methodology applied, and give readers an impression of how general theories of modernization, professionalization, scientification, etc. can be used for interpreting the development of religious education as an academic discipline. The authors suggest that research of this kind may eventually create a better basis for international comparative research in religious education.

Production of standard blood components

In the past three decades, the production of standard blood components from whole blood donations and from apheresis collections has reached a widely accepted high technical standard, paralleled by semi‐automated methodology to safeguard the stability of the production process and an internationally harmonized pharmaceutical quality. More recent methodological advances include pathogen inactivation as well as novel separation methods, which are challenging the previous achievements. The current review aims (1) to summarize the current status of implementation of novel techniques into the routine preparation process of blood components, (2) to discuss upcoming approaches in the area of component preparation, (3) to identify clinical needs that justify novel investigations into blood component quality and (4) to point out the status on the production of standard blood components by in vitro differentiation from stem and progenitor cells in vitro.

Konventionelle vs. pathogeninaktivierte Thrombozytenkonzentrate bei perioperativer Koagulopathie

BACKGROUND The aim of the present study was to assess ex-vivo function of pathogen-inactivated versus conventional platelet concentrates (PC) in the perioperative setting. MATERIAL AND METHODS A total of 30 patients who underwent cardiac surgery and who postoperatively depended on the transfusion of two platelet concentrates were enrolled into this study. Of the patients 15 received conventional buffy coat PC (conv. PC) and 15 received pathogen-inactivated PC (PI-PC). Age, volume and platelet content of each PC were recorded. Before (T0) and 30 min after PC transfusion (T1), blood samples were taken and platelet function analyses (MEA) and conventional laboratory coagulation analyses were performed. The transfusion-associated increment of platelet concentration (increment) and the corrected count increment (CCI) were assessed at timepoint T1. RESULTS There were no significant group differences between the groups in MEA analyses or conventional laboratory at T0 or T1. The platelet content per PC was significantly higher in the PI-PC group [3.3 (3.1/3.5)× 10(11) platelets per PI-PC versus 3 (2.9/3)× 10(11) platelets per conv. PC, p<0.001]. Platelet increment (42±27×10(9)/l versus 69.4±29×10(9)/l, p=0.013) was significantly lower in the PI-PC group. CONCLUSION Whereas ex-vivo analyses of platelet function did not show any group differences at T1, a significantly lower increment was seen in the pilot study after transfusion of PI-PC as compared to conventional PC.

[Conventional vs pathogen-inactivated platelet concentrates for the treatment of perioperative coagulopathy. A prospective cohort study].

BACKGROUND The aim of the present study was to assess ex-vivo function of pathogen-inactivated versus conventional platelet concentrates (PC) in the perioperative setting. MATERIAL AND METHODS A total of 30 patients who underwent cardiac surgery and who postoperatively depended on the transfusion of two platelet concentrates were enrolled into this study. Of the patients 15 received conventional buffy coat PC (conv. PC) and 15 received pathogen-inactivated PC (PI-PC). Age, volume and platelet content of each PC were recorded. Before (T0) and 30 min after PC transfusion (T1), blood samples were taken and platelet function analyses (MEA) and conventional laboratory coagulation analyses were performed. The transfusion-associated increment of platelet concentration (increment) and the corrected count increment (CCI) were assessed at timepoint T1. RESULTS There were no significant group differences between the groups in MEA analyses or conventional laboratory at T0 or T1. The platelet content per PC was significantly higher in the PI-PC group [3.3 (3.1/3.5)× 10(11) platelets per PI-PC versus 3 (2.9/3)× 10(11) platelets per conv. PC, p<0.001]. Platelet increment (42±27×10(9)/l versus 69.4±29×10(9)/l, p=0.013) was significantly lower in the PI-PC group. CONCLUSION Whereas ex-vivo analyses of platelet function did not show any group differences at T1, a significantly lower increment was seen in the pilot study after transfusion of PI-PC as compared to conventional PC.