NO BLOOD Medicine Meets the Challenge Narrator: Dorothy MacPhee has a lifethreatening medical problem. An artery that could burst at any time. Doctor: " The. Some institutions recognize that groups of patients may have similar blood product needs protocol group, blood components meeting these “special” requirements are This should not present a problem for routine transfusions for most patients. a request for “fresh” blood will involve two challenges: the first involves the. Keywords: challenges, blood transfusion, Sub-Saharan Africa, alternatives . with no other option than to seek commercialy remunerated, high-risk blood donors. .. vitro management of anemia has opened a new era in transfusion medicine.
This ability to offer a premium level of care is one of the reasons I became an anaesthetist in the first place. On the wards each doctor will be responsible for up to 30 people a day, and even more at night. The speciality is a broad church, so there is room for all personality types. But given the precision involved there is perhaps a tendency to obsessive traits.
Our postgraduate exams are renowned for being tricky but they are really a test of commitment. NHS 'in perpetual winter of Narnia' as waiting list reaches record 3. Every anaesthetist will have their spiel, some small talk to distract the patient from their imminent surgery. I ask them about family, talk about their favourite place to visit, what they do for a living.
The more nervous they are, the longer they take to go to sleep. Many young, usually male, patients have commented as the drugs take effect that it feels just like a Saturday night. Every anaesthetist has a secret weapon when working in the operating theatre.
We always work with an assistant, who might be a nurse or an operating department practitioner ODP. We argue that these complexities require the consent process to be inclusive and representative of the different family interests in the cord blood.
Further, it is our view that the consent given by the parents should expressly recognise that they are also consenting on behalf of the child. It has been claimed that private banks in the United States have capitalised on the chance that families will overestimate the true likelihood of needing stored cord blood.
However, there is no evidence that Australian private cord blood banks have engaged in any form of misleading or deceptive conduct in relation to their services. Indeed, our own view of Australian private cord blood banks is that their advertising seems rather modest, raising notions of insurance and explicitly acknowledging the low chance of the family ever needing to access the cord blood.
In any event, the strictures of the Australian Consumer Law would be likely to prevent misleading and deceptive advertising. Cord blood banking and property rights As tissue economies have emerged, the common law of property has changed to recognise that people have property rights over their human tissue.
Traditionally, the common law refused to recognise property rights in human tissue, unless the tissue had been preserved through some work or skill.
This broader recognition of property rights is a challenge to those who see human tissue donation as a form of gift that is devoid of proprietary rights. Indeed, the very notion of a gift in law is a property relationship where property passes hands without payment. Gifts can be given without conditions attached, but property law also recognises that gifts can be made conditionally in ways that preserve some rights of control and access for the donor. Property law may be very useful in regulating cord blood banking because it creates a language for understanding conditional donation.
Property laws may help to explain how cord blood could be gifted to a public bank on the condition that the donor parent s have the option to withdraw donated cord blood should the donor child or their sibling require the cord blood for their own medical use, and on the condition that the family are contacted before the cord blood is used in treatment or research which is standard practice in some public banks.
Property law also provides a model for understanding how, in the private banking context, a relative such as a grandparent could pay for the banking on the grounds that it is made available to a range of family members through a form of discretionary trust.
We believe that the current practice in the private banking industry has already effectively adopted property forms. The contracts for storage are bailments.
Management of patients who refuse blood transfusion
The contracts also treat the cord blood as being held on behalf of an individual child or on behalf of the family group. This idea of holding property for the benefit of another is clearly a trust, where the legal title held normally by the parents is exercised for the benefit of the child or family group. In public banking, there appears to be more reticence to adopt property language, arguably because of its non-commercial focus.
Devices used can vary from simple, inexpensive, sterile bottles filled with anticoagulant to expensive, sophisticated, high-speed cell washing devices.
Management of patients who refuse blood transfusion
The experience in St. The postoperative hemoglobin level increased to Only 1 patient received an additional homologous unit of blood.
ABT seems a feasible, effective, and secure method that could be implemented in Sub-Saharan African countries. It may be a solution to the problems of shortage of blood products and transfusion safety. However training and motivation are necessary for its successful implementation. A randomized, controlled trial conducted in an inner city trauma unit in Johannesburg, Republic of South Africa in patients with penetrating torso injury requiring a laparotomy showed that IBS significantly reduced allogeneic blood use with no discernable effect on postoperative infection or mortality rates.
Results have shown that ABT can be implemented in an African setting and that it can help optimize the use of the limited allogenic blood stock. This technique reduces exposure to allogeneic blood. The anticoagulated blood is then reinfused during or shortly after surgical blood loss has stopped in reverse order of collection. A study was carried out in Bugando Medical Centre, Mwanza, Tanzania to identify the best method of ABT to be applied in an East African hospital among consecutive patients for whom major blood loss was expected.
Seventeen patients donated 1 unit of blood 3 days preoperatively and 92 underwent acute isovolemic hemodilution prior to induction of anesthesia. For the hemodiluted patients a 2: One of the 16 patients from whom 2 units were withdrawn by hemodilution experienced hypovolemia, which was rapidly restored by additional transfusion of colloid.
Of the patients who donated blood preoperatively only Of the latter Only 1 received homologous blood in addition. The investigators concluded that in hospitals with limited blood bank facilities and regular cancellation of surgery, the use of acute isovolemic hemodilution is recommended.
No clinical or biological effects have been reported by the patients themselves. The authors recommend the use of ABT by other hospital units and the development of regulations governing its implementation. Many studies have emphasized the major role of hypothermia in the onset of bleeding during surgical procedures. Valeri and associates observed the effects of skin temperature in 33 patients undergoing cardio pulmonary bypass operation.
Local hypothermia produced an increased bleeding time and a significant reduction in the thromboxane B2 level at the bleeding time site. Local rewarming produced a significant increase in the shed blood and thromboxane B2 level. Hypothermia can cause a reversible platelet dysfunction and rewarming can improve platelet function and reduce both bleeding time and blood loss. This hypothesis has been confirmed in a report that demonstrated the involvement of platelet glycoprotein receptor glycoprotein Ib and granule membrane protein alterations in this hemostatic defect.
Other studies have shown an important prolongation of prothrombin time and activated partial thromboplastin time, which was inversely correlated with temperature.
DVD Transcript - NO BLOOD--Medicine Meets the Challenge (2)
Erythropoietin EPO was the first hemopoietic growth factor identified. Many anemic patients being managed with EPO alone or with some combined strategy of EPO plus red cell replacement have shown that the RBC transfusion requirement is substantially reduced.
A systematic literature review — to produce evidence-based guidelines on the use of EPO in anemic patients with cancer shows that RBC transfusion requirements are significantly reduced with EPO protein therapy in patients with chemotherapy-induced anemia or when used to prevent cancer anemia. Level I and III evidence indicates that patients with chemotherapy-induced anemia or anemia of chronic disease initially classified as nonresponders to standard doses proceed to respond to treatment following a dose increase.
The response was greater in patients treated with radiotherapy alone than in those receiving combined therapy. The duration of EPO treatment was shorter in the group treated with radiotherapy alone than in the combined treatment group. Poor use of EPO is more likely in countries that have lower annual per capita health care expenditures, lower proportions of privately funded health care, and a national health service.
Intravenous iron treatment is a readily available option for treating women with postnatal anemia. In a study of repeated RBC transfusion in anemic gynecologic cancer patients receiving platinum-based chemotherapy comparing intravenous and oral iron showed that intravenous iron is an alternative treatment in these patients and reduces the incidence of RBC transfusion without serious adverse events.
Antifibrinolytics Concerns about the safety of transfused blood have led to the development of a range of interventions to minimize blood loss during major surgery. Although the use of antifibrinolytics may not seem cost-effective in most African settings, studies have shown that antifibrinolytics aprotinin, tranexamic acid, epsilon-aminocaproic acid reduce blood loss in orthopedic surgery, scoliosis, and coronary bypass surgery.
Antifibrinolytic drugs provide worthwhile reductions in blood loss and the need for allogeneic RBC transfusion. It also contributes to maternal morbidity as women may require a hysterectomy to control bleeding, or may require a blood transfusion, which can transmit viral infections.
Antifibrinolytics have been proposed as a treatment for postpartum hemorrhage. A review of the use of aprotinin as prophylaxis to prevent bleeding indicates that it reduces the need for RBC transfusion, and the need for reoperation due to bleeding, without serious adverse effects. It is indicated for the treatment of bleeding and perioperative prophylaxis of bleeding in acquired deficiency of the prothrombin complex coagulation factors, such as deficiency caused by treatment with vitamin K antagonists, or in case of overdose of vitamin K antagonists, when rapid correction of the deficiency is required.
A report by McCall and colleagues in Canada on the audit of FVIIa use for the management of bleeding following complex cardiac surgery showed that use of rFVIIa in cardiac surgery may be effective, but definitive clinical trials are needed to clarify its role in clinical practice and safety. Major blood loss can often be life-threatening and is most commonly encountered in the settings of surgery and trauma.
Patients receiving anticoagulant therapy are also at increased risk of bleeding. The results of this study highlight a potential role for PCC in controlling bleeding in patients undergoing cardiac surgery and other surgical procedures and in reducing, and sometimes abolishing, the need for allogenic blood in surgical and nonsurgical patients.
However, some of these may remain unavailable to patients, particularly in Sub-Saharan Africa, because of financial constraints on the healthcare system. Nonetheless, physicians in Africa must always keep in mind that the first and foremost strategy to avoid transfusion of allogenic blood is their thorough understanding of the pathophysiologic mechanisms involved in anemia and coagulopathy, and their thoughtful adherence to evidence-based good practices in the developed world can potentially reduce the likelihood of allogenic blood transfusion in many patient groups.
Use of restrictive RBC transfusion practices and transfusion triggers Most clinical practice guidelines recommend restrictive RBC transfusion practices, with the goal of minimizing exposure to allogeneic blood. The current evidence supports the use of restrictive transfusion triggers in patients who are free of serious cardiac disease and suggests that critically ill patients tolerate anemia well and that blood transfusions may increase the risk of adverse outcomes.
In fact, a restrictive strategy may be associated with decreased adverse outcomes in younger and less sick critical care patients. In Russia, a perflourocarbon Perftoran is available locally and in South Africa the only approved hemoglobin-based oxygen carrier Hemopure is little used. Other products, just prior to filing for FDA approval, did not achieve convincing study results and research and production was stopped. Adverse reactions such as hypotension and pulmonary complication have significantly affected their widespread use despite their potential role in the reduction of preoperative allogeneic blood transfusion.
In the light of these challenges, it seems that the global clinical establishment of artificial oxygen carriers should not be expected in the near future.
Cryoprecipitates are considered the mainstay hemostatic therapies in such situations. Purified factor concentrates fibrinogen of plasma origin and from recombinant synthesis are increasingly used in the management of bleeding associated with dilutional coagulopathy to rapidly restore targeted factors. Countries in Sub-Saharan Africa need to find ways of maintaining sufficient blood supply from voluntary nonremunerated donors and improving blood safety from the available replacement donors.
In brief, the reason why replacement donors remain the main source of blood in Sub-Saharan Africa is that it costs less to procure and fits well with the African culture of extended family support. The mentality of altruism through the voluntary donation of blood is not as accepted in Sub-Saharan Africa as in most developed countries.