PBM Survey: Organisation of Transfusion...100% participatie van de Belgische ziekenhuizen...

06/06/2019

Infosessie 2019

Prof. R. SchotsUZ [email protected]

President BeQuinT

Inleiding PBM project

Tijdslijn nationale enquêtes BeQuinT

2012 2014 2016

Vooruitgang per domein

❑ 100% participatie van de Belgische ziekenhuizen

❑ Belangrijke sensibilizering gedurende 5 jaar

▪ 90% heeft actie ondernomen ter verbetering transfusie

▪ Investeringen in ICT, personeel en materiaal in 49%

❑ Significante verbetering in de kwaliteit van transfusie

❑ Evolutie naar 100% electronische tracing

❑ Bewaring bloedcomponenten binnen en buiten bloedbanken is uitstekend

❑ Methodologie goed bevonden door grote meerderheid ziekenhuizen

Conclusies BeQuinT enquêtes

0

10

20

30

40

50

49,42

46,99

37,81

- 5%

-23,5%

Data FAGG

28,5

35,96

Aantal EC per 1000 inwoners

SensibiliseringAlgemene kwaliteitsverbetering

PBM

Specifiekebenchmark Self

assessment

Specifieke guidelines

e-voorschriftCDSS

EC verbruik per 1000

47

36

2011

2017

Data collection

Optimalisatie verbruik EC

PBM (2018-2023)

PBM comité

Data comité

Transfusiebeleid (2012-2017)

Stuurgroep

Werkgroep e-voorschrift

Werkgroep E-learning

PBM project

Data collectionDashboard

BeQuinT

❑ Totaalconcept voor optimaal gebruik van bloedcomponenten

❑ Ondersteund door WHO en Europese Commissie

(“Practical implementation guideline”)

❑ Patiënt geöriënteerd, evidence-based

▪ Maakt deel uit van het zorgpad van de patient in diverse specialiteiten

(heelkunde, intensive care, verloskunde, interne geneeskunde, ..)

❑ Vereist grote betrokkenheid van klinische diensten!

Patient Blood Management

Data FOD 2016

Verbruik EC in top 20 DRG voor transfusie bloedcomponenten(gehospitalizeerde patiënten) (totaal = 104 502)

Hemato-onco (36%)

Andere geneeskundige diensten (31.5%)

Orthopedie (12%)

Cardiovasculaire HK (8%)

Andere HK (10%)

Obstetrie (2.5%)

Verbruik erytrocytenconcentraten

❑ Sensibilizeren

▪ Introductie PBM concept

• Ziekenhuisbreed

• In verschillende diensten

❑ Informeren

▪ Via toelichting aan de enquête

▪ Via de vragen zelf

❑ Optimalizeren verbruik bloedcomponenten

▪ Spaarzaam omgaan met bloed

▪ Veiliger voor de patiënt

▪ Minder kost!

PBM enquête - doelstellingen

❑ NL en FR versies

❑ Opgesteld in werkgroepen van PBM comité

❑ Besproken met specialisten in het domein

❑ Enkel gericht op gebruik erytrocytenconcentraten

❑ Transfusie >> anemia management

❑ Bevraging mbt verschillende domeinen:

▪ Organisatie

▪ Peri-operatoir

▪ Interne geneeskunde - geriatrie

▪ Hemato-oncologie

▪ Pediatrie/neonatale

▪ Obstetrie

PBM enquête - inhoud

PBM enquête - structuur

❑ Algemene inleiding

▪ Gericht aan de voorzitter van het transfusiecomité

▪ Hoe dit aan te pakken..

❑ Toelichting per domein

▪ Literatuur overzicht

▪ Algemene richtlijnen

▪ Rationale voor de vragen

❑ Vragen per hoofdstuk

▪ Vaak “ja” (aanwezig) of “neen” (afwezig) antwoorden

▪ Waar het kan semi-kwantitatief (% range) of kwantitatief (%)

❑ Elektronisch in te vullen

❑ Onder verantwoordelijkheid voorzitter transfusiecomité

▪ Door de verschillende diensten of

▪ Via “PBM” referentiepersonen in transfusiecomité

❑ Deadline = 4 maanden na ter beschikking stellen aan ziekenhuizen

❑ Scores per domein

▪ → individuele scores per ziekenhuis

▪ Benchmarking mogelijk (anoniem)

▪ Meten van vooruitgang nav de volgende enquêtes

• Lokaal niveau

• Nationaal niveau

PBM enquête - methode

Nog steeds open voor discussie!!

PBM enquête

PBM SURVEY:ORGANISATION OF TRANSFUSION

Jana Vanden Broeck Project Coordinator, BeQuinTFPS Health, Food Chain Safety and EnvironmentTransfusion Practitioner, UZ Brussel

OVERVIEW CHAPTER

A.1. Involvement of key PBM stakeholders

A.2. Hospital-wide procedures/policies

A.3. Evaluation of PBM implementation

A.4. Patient information

A.5. Education on PBM

A.6. Guidance

PBM: RECOMMENDATIONS FROM THE 2018 FRANKFURT CONSENSUS CONFERENCE

Recommendation 9: Implementation of PBM programs to improve appropriate RBC utilization = recommended

Recommendation 10: Computerized or electronic decision support Systems to improve appropriate RBC utilization = recommended

Research recommndation10-12:Further research suggested on the effect of PBM programs on (A) adverse events and patient-important outcomes; (B) compliance, adherence, and acceptability; and (C) cost-effectiveness. Reproducible definitions and outcome parameters have to be defined beforehand to evaluate the sustainability of PBM programs

M.M. Mueller, H. Van Remoortel, P. Meybohm et al. JAMA. 2019;321(10):983-997

A.1. INVOLVEMENT OF KEY PBM STAKEHOLDERS

Question A.1.1.

How is PBM managed in your hospital?

o PBM is not managed by any committee or working group in our hospital

o PBM is covered by the Transfusion Committee agenda

o PBM is managed by dedicated collaborators within the Transfusion Committee (for example an anesthesiologist who dedicates a

certain % of his FTE to support/realize the implementation of PBM)

o A separate PBM working group / committee has been established to implement PBM initiatives

Question A.1.4.

Are PBM projects integrated within the hospital-wide quality management program?

o Yes, there is a quality coordinator in the PBM committee/transfusion committee

o Yes, education, auditing and other quality improvement initiatives related to PBM are aligned with hospital-wide education, auditing and quality

improvement initiatives

o Yes, the implementation of PBM is part of the general policy plan

o No

PBM THE ROLE OF THE TC

j

PBM THE ROLE OF THE TP

Question A.1.5. Do you have a Transfusion Reference Person employed in your hospital?

o No

o Yes

o If yes, for how many Full Time Equivalents?

• ……………. FTE

Question A.1.6.

Does the Transfusion Reference Person has specific allocated time for PBM?

o No

o Yes

o If yes, what % of their contracted time does the TP('s) spend on PBM activities

• … %

A.1. INVOLVEMENT OF KEY PBM STAKEHOLDERS

Question A.1.8. (non-obligatory)

What Which initiatives would your hospital like to prioritize for future (further) PBM implementation in the coming 2 years? Describe shortly 3 initiatives. …


In your opinion, what are your local constraints for the successful implementation of your PBM program? …

o more training for clinical staff for them to commit to PBM

o poor engagement from clinical staff

o cumbersome processes to implement change

o PBM is not seen as a priority by the direction

o improvements to IT systems

o lack of reimbursement of IV iron therapy for preoperative anemia management

o closer links with primary care needed for preoperative anemia management

o needing more resources e.g. money, time and staff

o Others: …


What could BeQuinT provide to assist your hospital to implement PBM initiatives? …

A.2. HOSPITAL-WIDE PROCEDURES/POLICIES

A.2.2. Single-unit transfusion (SUT)

Question A.2.2.1.a

Is a written procedure "single unit red cell transfusion policy" implemented in your hospital?

o Yes, the policy covers all areas (except for operation room and emergencies)

o Yes, but it covers only specific areas

• Specify: ……………………

o No single unit transfusion procedure available > Question A.2.2.1.b

Question A.2.2.1.b

Is the reason for not having a “single unit red cell transfusion policy” related to the distance between the different hospital sites (practical difficulties for implementation)?

Yes / No

Question A.2.2.2.

In case a single unit policy is implemented, is the number of single unit transfusions recorded?in how many % of the prescriptions of red cells (for stable, normovolaemic adult patients who do not have clinically significant bleeding)

a single unit of red cells was issued?

o If you can calculate it exactly, state the % here: … %

o Otherwise, make an estimation: … %

o No reliable data available

A.2.3. Blood bank policy

Question A.2.3.1.

How many units of red cells can be distributed at the same time from the blood bank for a patient who is NOT actively bleeding (outside the situation of emergency and/or intensive care)

o 1, 2, 3, 4, 5, more

A.3. EVALUATION OF PBM IMPLEMENTATION

A.3.1. Internal auditing

Question A.3.1.

Is the implementation of your PBM measures evaluated by an internal audit?

o No PBM measures implemented

o PBM measures implemented but not audited

o Yes (at least one procedure/measure per year)

A.3.2. Data collection

Question A.3.2.1.

In your hospital, have data been collected at least once in the past year to evaluate procedures regarding PBM?

o From the laboratory information system, electronic order of blood components, blood bank information system

the electronic blood tracking system

o From the operating room (OR) management system

o None of these

Question A.3.2.2.

If you do undertake data exports from the electronic patient record (incl. blood bank information system) to evaluate local

procedures regarding PBM, what were the subjects of these record audits in the past year?

EPD, AUDITS

j

A.4. PATIENT INFORMATION

Question A.4.1.

Information on RBC transfusion is made available to patients:

o As a general hospital-wide procedure

o In some departments only

o Not available in a systematic way

Question A.4.2.

Information on RBC transfusion is made available to patients:

o Through oral communication by the MD

o Through oral communication by the nurse

o Via print brochure

o Other: …………………………….

o This information is not provided systematically

Question A.4.3.

Informed consent (IC) from patients is obtained before RBC transfusion

o Written informed consent (document to be signed by the patient or representative)

o IC obtained orally and written down in the paper patient record.

o IC obtained orally and reported in the electronic patient record

o No there is not a procedure on IC for transfusion

A.5. EDUCATION ON PBM

Question A.5.1.

Are there educational initiatives specifically related to PBM (at least one session per year)?

o No educational activities

o Educational activities are organized for:

• Physicians

• Nurses, midwives

• Quality managers

• Others: …

Question A.5.2.

Educational initiatives specifically related to PBM involved:

o No educational activities

o Preoperative anemia management

o Use of blood conservation techniques

o Use of hemostatic products

o Transfusion triggers and targets

o Indications for transfusion

o Risk and benefits of transfusion

o Volume of blood sampling (analysis to avoid iatrogenic anemia)

o Training on the use of available massive hemorrhage protocols

o Others: …

A.6. GUIDANCE

Involvement of key PBM stakeholders:

Transfusion committee, Multidisciplinary transfusion

team, Reference person transfusion, PBM

infrastructure in a hospital, PBM initiatives

Hospital-wide procedures/policy:

Massive hemorrhage, Single Unit Transfusion Policy

of red blood cells, Restrictive transfusion policy

Evaluation of PBM implementation:

Clinical Decision Support System (CDSS), Electronic

OR management system, Electronic blood component

tracking system, Quality Indicators

QUESTIONS ?

Peri-Operative Patient Blood Management

Dr. Gregory Hans, MD, PhD, EDA

Department of Anesthesia and Intensive Care Medicine

CHU of Liège, Liège, Belgium

“Patient blood management (PBM) is a patient-focused, evidence-

based and systematic approach to optimize the management of patient

and transfusion of blood products for quality and effective patient care.

It is designed to improve patient outcomes through the safe and

rational use of blood and blood products and by minimizing

unnecessary exposure to blood products.”

Mueller MM, et al. Patient Blood Management. JAMA 2019. WHO.

• World Health Organization has officially adopted PBM since 2010 (WHA63.12)

• PBM is supported by the National Health Service and Blood Transplant and the

National Transfusion Committee in the UK

• National PBM Program in Australia

• Successfull Programs in Induvidual Hospitals

• Europe

• US

• Asia

Meybohm P et al. Transfus Med Rev 2017;31:62–71.

Practical patient blood management

• Iron

• EPO

• Vitamines

• Timing

• Bleeding disorders

• Medications

• Surgery

• Cell Salvage

• Hemostatic agents

• Hypovolemia

• Hypoxemia

• Restrictive trigger

• Single unit

Why perioperative PBM ?

Live-saving role of blood transfusion

Transfusion-associated adverse outcomes

Morton J, et al. Am J Med Qual 2010;25:289–96.

aOR=1.9 aOR=1.7

• Reduces

• Exposure to blood and blood products

• LOS

• Complication

• Mortality

Althoff FC et al. Ann Surg 2019;269:794–804.

Infections

Thromboembolic events

Where does the blood go ?

30%

70%

Surgical setting

Medical setting

Barr PJ, et al. The epidemiology of red cell transfusion. Vox Sang 2010;99:239–50.

Goodnough LT, Shander A. Patient blood management. Anesthesiology 2012.

• Insufficient knowledge

• Healthcare professionals

• Public

• Lack of education

• Undergraduate education on PBM in nursing and

medical school

• Postgraduate education for nurses and physicians

• Lack of interdisciplinarity

• Coordinated care between pre-hospitalization and

hospitalization

• Interaction between medical specialties

• Missing motivation and reluctance to changes among

physicians

• Lack of resources and incentives

• Guidelines for PBM implantation

• Hospital accreditation

• Certification for clinicians

• Concerns

• External influence on practice

• Delaying interventions

• Financial implications

Why a survey ?

• Create a first situational awareness of perioperative PMB in Belgium

• Identify the gaps between recommendations and real clinical practice

• Identify the obstacles to the implementation of PBM in the

perioperative period

• Provide support and recommandations in the future

Pre-Operative Anemia

Incidence of Preoperative Anaemia

Preoperative anemia N=46539

Mild (<12 gr/dL), % 18.4

Moderate (< 10 gr/dL), % 8.7

Severe (<8 gr/dL), % 1.6

Total, % 28.7

Baron et al., BJA 113(3): 416-23

Consequences of Preoperative Anaemia

Baron et al., BJA 113(3): 416-23

•Treat preoperative anemia

•Reduced transfusion rate

•Improved patient outcome

Pre-operative assessment

• Who does the preoperative assessment ?

• How this assessment is performed ?

• Protocol-based

• Physician-based

• How long surgery does the assessment takes place ?

Pre-operative anemia

• Threshold for diagnosis and/or treatment ?

• Delay non-urgent surgery in case of pre-operative anemia

• Standardized Work-up ?

• Reticulocyte count

• Iron status (serum iron, ferritin, transferrin level and saturation)

• Inflammation markers (CRP)

• Vitamins (B12 and folic acid)

• LDH

• Plasma creatinine level

• Other (specify)

Pre-operative anemia

• Treatment of preoperative anemia ?

• Iron

• Oral or Intravenous

• Erythropoietin

• Others

Clevenger B, Cochrane review. Eur J Heart Fail 2016.

Alsaleh K, et al. J Arthroplasty 2013.

Pre-Operative Assessment

Pre-operative assessment

• Perioperative management of anticoagulants and antiplatelet drugs

• Physician-based

• Institutionnal written policy

Intra-Operative Management

• Use of Cell-Saver

Use of anti-fibrinolytics

• Physician-based

• Protocol-based

Ortmann EBr J Anaesth 2013.

Wang G et al. Anesth Analg 2009.

• Management of intraoperative « abnormal » bleeding

• Written protocol

• Objective measurements

Avidan MS, et al. Br J Anaesth 2004.

Hans GA et al. Br J Haematol 2016.

Intraoperative PBM in Cardiac Surgery

Hofmann B et al. J Cardiothorac Surg 2018.Immer FF et al. Ann Thorac Surg 2007.

Post-Operative Management

• Restrictive transfusion triggers in stable and

non-bleeding patients

• Single Unit policy

• Management of post-operative anemia

Conclusion

• Perioperative period is ideal to apply PBM

• Proven benefits regarding the use of blood products

• Emerging evidence about improved patients outcome

• A single measure is unlikely to make any difference

Prof. R. SchotsUZ [email protected]

President BeQuinT

PBM in hemato-oncologie

AABB recommendations for RBC transfusion

❑ In hospitalized hemodynamically stable patients the AABB

recommends adhering to a restrictive transfusion strategy

(7-8 g/dL) (strong recommendation, high-quality evidence)

❑ In hospitalized patients with preexisting cardiovascular disease the

AABB suggests to adhere to a restrictive strategy and considering

transfusion for patients with symptoms or a Hb level of ≤ 8 g/dL

(weak recommendation, moderate-quality evidence)

Carson et al. Ann Intern Med 2012

❑ 31 trials including 9831 randomised patients

❑ Various domains (medicine and surgery)

❑ Restrictive (= < 7-8) versus liberal (= < 9-11) policies

❑ Results

▪ N° of patients receiving RBC transfusion is reduced by 46%

▪ Mean -1.43 n° RBC units transfused

▪ No more death, overall morbidity, fatal or non-fatal myocardial infarction

❑ Conclusion

▪ Significant reduction n° units RBC transfused

▪ Safe in most clinical settings

▪ Liberal transfusion strategies do not convey any benefit

▪ Further studies needed to establish evidence in specific subgroups

Holst et al. BMJ 2015

Meta analysis on restrictive policy for transfusion in general

❑ Patients

▪ Induction chemotherapy for acute leukemia (62 courses)

▪ Autologous stem cell transplantation (ASCT) for acute leukemia (72 courses)

❑ Triggers

▪ Liberal = ≤ 8 → 2 units

▪ Restrictive = ≤ 7 → 1 unit

❑ Results

▪ Significant decrease in RBC utilization:

• 10.5 versus 6.7 (chemotherapy)

• 2.0 versus 1.0 units (ASCT)

▪ No differences in adverse events (inpatient mortality, lenght of stay, falls, serious bleeds,

requirement for ICU, time for engraftment after ASCT)

Lamarche et al. Transfusion 2019

Restrictive trigger in high-care hematology

❑ PBM

▪ Including more restrictive, individualized thresholds, single unit policy

▪ Gradually introduced at two tertiary care hospitals > 2011

(reference year = 2010)

❑ Patients

▪ = 695 admissions

▪ Intensive chemotherapy or autologous stem cell transplantation for acute

leukemia

❑ Results

▪ Significant reduction RBC tranfusions (6.1 → 3.7 units)

▪ Mean pre-transfusion Hb level decreased from 8.0 to 6.8 g/dL

▪ Single unit transfusion increased from 39% to 67%

▪ 650 000 USD blood product cost savings (3.5 years)

▪ No changes in lenght of stay, serious bleeding events, inhospital mortality

Leahy et al. Transfusion 2017

PBM program in high-care hematology

❑ Few good quality studies available

❑ Low quality evidence

❑ Restrictive policy reduces n° of transfusions per patient

❑ Restrictive policy has little or no effect on early mortality, bleeding

or hospital stay

❑ Problem

▪ Early mortality is low (3%)

▪ n° of participants needed to show significant impact on mortality (power)

Estcourtet al. Cochrane Database Syst Rev 2017

Meta analysis (Cochrane) for high-care hematology

❑ Intensive chemotherapy or stem cell transplantation (aplasia)

❑ 139 patients receiving 272 therapy courses

❑ Multivariate analysis

❑ Introduction single unit policy →

▪ One unit transfused in 84% of cases

▪ 47% of patients received transfusion at Hb levels of ≤ 6 g/dL

▪ 25% reduction in RBC usage per therapy cycle

▪ No higher outpatient transfusion frequency

▪ Reduction of 2.7 units per treatment cycle

▪ No difference in severe bleeding, platelet transfsuions

▪ No difference in overall survival

Berger et al. Haematologica 2011

Single unit policy in high-care hematology

❑ 17 676 patients hospitalized in 57 US hospitals for acute myocardial

infarction

❑ Moderate to severe hospital acquired anemia (HAA) (Hb level

decrease < 11 g/dL) in 20%

❑ Mean phlebotomy volume higher (174 mL vs 83 mL) in HAA

❑ For every 50 mL of blood drawn, the risk of HAA increased by 18%

(multivariate analysis)

❑ Strategies to limit blood loss from laboratory testing useful to

prevent HAA

Saltsbury et al. Arch Intern Med 2011

Blood loss due to flebotomy

Key PBM interventions:

Restrictive treshold

Limit blood sampling

Single unit policy

High-care hematology

PBM survey for hemato-oncology

❑ 27 946 episodes of inpatient (24%) or outpatient (dayclinic) (76%)

admissions, all types of cancer, 2008 - 2013

❑ Introduction of PBM program as of 2010

▪ Early recognition of anemia

▪ Evaluation of Fe stores

▪ Use of IV iron

▪ Restrictive transfusion treshold

▪ Single unit policy

❑ Results

Gross et al. The Oncologist 2016

PBM in oncology

❑ The objective of transfusion is to

▪ improve quality of life and to

▪ avoid anemia-related symptoms and ischemic organ damage

❑ No single Hb concentration can be recommended as optimal trigger

❑ Decision should be based on symptoms and comorbidity

❑ All patients with severe anemia (Hb < 8 g/dL) and those with symptomatic milder anemia

should receive RBC transfusion

❑ Studies needed!

Malcovati et al. Blood 2013

Transfusion in myelodysplastic syndrome

Restrictive treshold

Comorbidities

Quality of life

IV Iron

ESA

Single unit policy

Key PBM interventions:

PBM in ambulatory hemato-oncology patients

PBM survey for hemato-oncology

Patient Blood Management- Médecine interne -

- Gériatrie -

BEQUINT – BRUXELLES – 6 JUIN 2019

CAT HERI NE ROSSEELS – RENÉ SEGHAYE

Patient Blood Management

❑ Gestion des prélèvements sanguins

❑ Gestion de l’anémie – Médecine interne

❑ Gestion de l’anémie – Gériatrie

❑ Protocole de commande/livraison unitaire de CED

❑ Utilisation du Fer intraveineux

Gestion des prélèvements sanguins

❑ Risque indépendant d’anémie acquise

18 % à chaque prél. > 50 mLPaaladinesh Thavendiranathan, MD - J Gen Intern Med 2005; 20: 520

Adam C. Salisbury, MD - Arch Intern Med 2011; 171:1646.

❑ Recommandation: procédure écrite, validée et diffusée dansl’objectif de limiter les volumes sanguins prélevés

Enquête BeQuinT 2019

Gestion de l’anémie – Médecine internePatients hémodynamiquement stables, hospitalisés

Politique/procédure institutionnelle• Seuils transfusionnels• Spécifique: groupe de patients

Politique restrictive: 7 – 8 g/dL vs libérale (9 – 10 g/dL)• CED transfusé et nb patients transfusés• Risques de décès, co-morbidités: non majorés• Infarctus myocardique: non majorés• Politique libérale : absence de bénéfice

Lars B Holst, Marie W Petersen - British Med J. 2015; 350: 1354

Politique de commande/livraison unitaire de CED• RBC transfusé et risques transfusionnels associés

Gestion de l’anémie – Gériatrie

Anémie: facteur de risque d’effets indésirables • Hospitalisation, morbidité, mortalité (cardio-vasculaire, ...)Goodnough and Schrier. Am J Hematol 2014; 89: 88-96

Etiologie de l’anémie• IRC, carence martiale, inflammation chronique• Cellules souches hématop. , insuffisance androgénique, EPO, ...

Ventilation de l’anémie selon âge - Hgb < 12 g/dL (F) ; 13 g/dL (M)• 10 % si > 65 ans• 25 % si > 85 ans• 50 % si institutionnalisés + pathologies chroniques


Seuil < 10 g/dL Hgb:• performances physiques, risque de chute, “fragilité”

• déficits cognitifs, démence, ...

Goodnough and Schrier. Am J Hematol 2014; 89: 88-96

Limitation des mécanismes compensatoires• tachycardie, adaptation volume éjectionnel (++ si cardiopathie)


Politique TRF restrictive: 9 – 10 g/dL Hgb• Pas de majoration d’événements indésirables

Politique TRF plus libérale: > 10 g/dL• Si co-morbidités (insuffisance coronarienne, défaillance cardiaque)

• Stratégie transfusionnelle: évaluation individuelle

Politique plus « restrictive »• mortalité à 30 et 90 jours (patients > 65 ans)• complications cardiaques composites (infarctus myoc.: non significatif)• Infections, longueur de séjour: stable

Définition « restrictif » vs « libéral », biais, ...

Revue systématique (9 RCT) - Simon et al. - Lancet Hematology 2017; 4: e465-e474

Evolution du risque relatif selon Hgb

Goodnough et al, Am J Hematol 2014

L ’anémie du sujet âgé est associée à des risques supplémentaires :

• Augmentation de la fréquence des chutes• Déclin cognitif• Augmentation des risques d’hospitalisation• Mortalité plus importante, notamment de causes

cardiovasculaires

Complications per/post transfusionnelles – sujet âgé

Fréquence des principales complications

Réactions fébriles 1 / 60

TACO 1 / 100*

Réactions allergiques 1 / 250

TRALI 1 / 12 000

Hémolyse fatale 1 / 1972 000

Carson et al, JAMA 2016

* Réduction du débit transfusionnel: plutôt < 120 mL/HDélivrance « Unité par unité » + réévaluation des besoinsDiurétiques en prévention ... ?

60 % des CED transfusés à patients > 65 ans25 % des CED transfusés à patients > 80 ans

Etude Libérale Restrictif Critères de jugement

Résultats

Carson et al. 2013110 patients• SCA + KT cardiaque

Seuil 10 g/dL Seuil 7 à 8 g/dL Mortalité, survenue d’un IDM / revascularisation non programmée < J30

Libéral > restrictifMais patients + jeunes et Hb à J0 dans le groupe libéral

Carson et al. 20112016 patients +75 ans• chirurgie de hanche

Seuil 10 g/dL Seuil 8 g/dL Mortalité à 3 ans Aucune différence entre les 2 groupes

Spahn et al. 2015Méta-analyse 5566 patients

Seuil 9 à 10 g/dL

Seuil 7 à 8 g/dL Durée d’hospitalisationMortalité à 6 mois

Seuil 7 g/dL = « safe » et évite les complications post-transfusionnelles

Holst et al. 2015Méta-analyse 9813 patients

Seuil 9 à 10 g/dL

Seuil 7 à 9,7 g/dL Morbidité globaleMortalité globaleIDM fatal ou non fatal

Restrictif : des transfusions sans impact sur la morbi-mortalité globale

libéral vs restrictif

Seuil Hgb en gériatrie

Protocole de commande/livraison unitaire de CED

Protocole « restrictif » recommandé si:• Patient hémodynamiquement stable, anémie symptomatique• Absence d’hémorragie active• Adulte, enfant > 1 an

Réévaluation clinico-biologique après chaque transfusion

Risques associés à la TRF CED allogénique

20 % du délai entre les épisodes TRF

% Hgb post-TRF > 10 g/dL: 40 → 20

CED transfusés: 2,3 → 1,9 /patient

Taux de mortalité inchangé

Heyes J et al. – QJM 2017 Nov 1;110(11):735-739 (rétrospectif)

NICE, Guidelines on Blood transfusion, 2015

Fer intraveineux: utilisation

❑ efficacité du Fer IV vs PO

❑ Physiopathologie - FID

• Pathologie intestinaleBonovas et al. - Medicine 2016; 95: e2308

• Défaillance cardiaqueChan-Keat Kang et al. - Cardiovascular Therapeutics 2017; 35: e12301

• Déficit en fer fonctionnel (oncologie)Rodgers et al. - Acta Haematol 2019; 142: 13-20

❑ Suivi à long terme ... ?

Fer intraveineux: critères de remboursement

Critères de remboursement INAMI (01/02/2018)

• Traitement de carence martiale, médecin spécialiste• Hémodialyse, dialyse péritonéale• Malformation vasculaire• Crohn, colite ulcéreuse (Hgb < 10,5 g/dL ou échec fer PO pdt 2 mois)• Malabsorption de fer prouvée• Intolérance fer PO et anémie persistante (8 g/dL, 1 mois)• Grossesse (Hgb =< 9 g/dL, non correction par fer PO)• Dose maximale: cf. « dose cumulée adéquate » (RCP)

The use of intravenous iron in internal medicine

Question D.3.1

In what situations do you use intravenous iron therapy on a regular basis?

In case of obvious malabsorption syndrome (e.g. postbariatric surgery)

In case of resistance/intolerance to PO iron

In cases of severe iron deficiency anemia

To treat inflammatory anemia (or cancer-related anemia)

In adjunct to ESA therapy

IV iron is not regularly used in our hospital (only rare situations)

Other: ……………………………………………………………


PBM Survey: Organisation of Transfusion...100% participatie van de Belgische ziekenhuizen...

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