TRANSFUSION CRITERIA
RESTRICTIVE TRANSFUSION CRITERIA
SAFEST TRANSFUSION IS TRANSFUSION NOT MADE IT
USE IT WISELY
OPTIMAL USE OF BLOOD TRANSFUSION: SAFER, MORE EFFECTIVE, MORE EFFECTIVENESS AND CHEAPER
Clase 17 Artrologia MMII 3 de 3 (Pie) 2024 (1).pdf
Awge giemsa 2012. criterios transfusionales. dr garcía erce
1. Actualización en Anemia y Medicina Transfusional
UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
Alicante (España), viernes 23 de noviembre de 2012
Dr José Antonio García Erce.
GIEMSA-AWGE; SEHH; SETS; NATA
2. www.awge.org
Declaración de Conflicto de intereses
Asesor externo
- AMGEN Oncología 2010/2012
- Roche Anemia 2009
- Ditassa-Ferrer 2004
Charlas, estudios investigación y ayudas a congresos
-Vifor-Uriach/Ferralinze
-Janssen-Cilag
-Astra-Tech de Aztra Zeneca/GSK
-Sanofi Aventis/Esteve/Novartis
-Cobe-Caridian/Roche Oncología
Miembro del CAT 2002-2005
Miembro del Documento de Sevilla “Alternativas a la Transfusión”
Miembro del Documento LatinoAmericano de la Anemia
Miembro de GIEMSA/ Secretario AWGE/Socio SETS/AEHH/NATA
Editor Asociado Revista ANEMIA www.revistaanemia.org
Miembro Comité Científico NATA y TATM
TRANSFUSIÓN DE COMPONENTES SANGUÍNEOS
5. It is necessary to reduce the unnecessary transfusions. This
can be achieved through the appropriate clinical use of blood,
avoiding the needs for transfusion and use of alternatives to
transfusion.
The commitment of the health authorities, health care providers
and clinicians are important in prevention, early diagnosis
and treatment of diseases/ conditions that could lead to the
need for blood transfusion.
http://www.who.int/bloodsafety/clinical_use/en/
Blood transfusion is an essential part of modern health care.
Used correctly, it can save life and improve health. However, as
with any therapeutic intervention, it may result in acute or
delayed complications and carries the risk of transmission of
infectious agents.
7. Med Clin (Barc) 2002;119(4):138-9
“Los facultativos usamos la sangre a diario, a veces a la ligera, sin
evidencias científicas de que este uso liberal se traduzca en un
beneficio real para el paciente y obviando los riesgos, inherentes al
«trasplante de un tejido extraño», de la transfusión sanguínea.
El derroche de este bien tan escaso e insustituible de momento provoca
serios problemas de abastecimiento que inciden muy negativamente en
la asistencia sanitaria. Por ello, ante la escasez de la oferta en España,
tendremos que reducir y racionalizar la demanda.”
CRITERIOS TRANSFUSIONALES
2002
9. CRITERIOS TRANSFUSIONALES
To promote improvements in the quality of the clinical
transfusion process, which is defined as:
Transfusion of the right unit of blood to the right
patient at the right time, and in the right
condition and according to appropriate
guidelines.
A chain of integrated events that begins with a correct
decision that the patient needs blood and ends with an
assessment of the clinical outcome of the transfusion. Its
goal is to achieve optimal use of blood.
2010
10. CRITERIOS TRANSFUSIONALES
The outcome, optimal use of blood is defined as:
The safe, clinically effective and efficient use of
donated human blood
Safe: No adverse reactions or infections
Clinically effective: Benefits the patient
Efficient: No unnecessary transfusions.
Transfusion at the time the patient needs it
2010
13. ¿Necesidad de Criterios Transfusionales?
“Primun non noccere”
No deberíamos administrar tratamiento alguno que
no vaya a obtener un beneficio esperado y objetivable
CRITERIOS TRANSFUSIONALES
Deberíamos realizar aquella práctica clínica que
tenga la máxima evidencia cíentífica/recomendación
Deberíamos aplicar aquella terapia o acción más
eficiente y con el máximo coste-beneficio.
14. ¿Necesidad de Criterios Transfusionales?
“Primun non noccere”
“Even though blood transfusion has been used
for over 100 years there is little evidence of it’s
efficacy in many clinical situations.
Blood transfusion should only be prescribed to
increase the oxygen consumption, and there are
many reasons supporting this statement”
CRITERIOS TRANSFUSIONALES
18. UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
www.awge.org
Evitar la trasfusión: una opción con criterio
PERO, ¿CUÁNDO SE DEBERÍA
TRANSFUNDIR?
19. ¿Beneficios de la transfusión?
La transfusión de hematíes sólo es necesaria
cuando existe la necesidad documentada de
incrementar el aporte de oxígeno en aquellos
pacientes que son incapaces de satisfacer las
demandas a través de los mecanismos
compensatorios cardio-pulmonares normales
www.awge.org
CRITERIOS TRANSFUSIONALES
“PALORE, PALORE MILE”
20. • Aumento del Gasto de Cardíaco
• Redistribución del flujo sanguíneo
• Aumento de la extracción tisular de O2
• Desplazamiento a la derecha de la curva de
saturación de la Hemoglobina
Mecanismos compensadores de la anemia
CRITERIOS TRANSFUSIONALES
www.awge.org
21. Determinantes de la transfusión
El nivel de hemoglobina
Consumo de oxígeno dependiente del transporte
22. Weiskopf RB et al. Human cardiovascular and
metabolic response to acute, severe
isovolemica anemia. JAMA 1998; 279: 217-21.
¿ Cuál es la tolerancia a la anemia?
¿Cuál es la tolerancia a la anemia?
EL UMBRAL TRANSFUSIONAL
www.awge.org
23. ¿Beneficios de la transfusión?
Aumentar la hemoglobina
Aumentar el transporte de oxígeno
Aumentar la oxigenación tisular local
Aumentar el consumo de oxígeno
Aumentar la supervivencia
SIN EVIDENCIA
ALGUNA
CRITERIOS TRANSFUSIONALES
www.awge.org
24.
25. UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
www.awge.org
Evitar la trasfusión: una opción con criterio
¿CÓMO DEBERÍAMOS TRANSFUNDIR?
26. Objetivo:
•Corregir la hipoxia tisular
Medio:
•Aumentar la capacidad de transporte de oxígeno
de la sangre
Cuestiones a valorar:
•Indicación de la transfusión (riesgo/beneficio)
•Cantidad a transfundir
•Alternativas
Tratamiento transfusional
www.awge.org
27. Criterios generales de indicación
Uso adecuado:
•Presencia de signos o síntomas de hipoxia
tisular
•Ausencia de tratamiento específico de la
anemia
•Refractariedad al tratamiento específico
•La situación clínica del paciente precisa
una reposición inmediata de la masa
eritrocitaria
Tratamiento transfusional
www.awge.org
28. Criterios generales de indicación
Uso adecuado:
•Presencia de signos o síntomas de hipoxia
tisular
•Ausencia de tratamiento específico de la
anemia
•Refractariedad al tratamiento específico
•La situación clínica del paciente precisa
una reposición inmediata de la masa
eritrocitaria
Tratamiento transfusional
www.awge.org
29.
30. UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
www.awge.org
Evitar la trasfusión: una opción con criterio
¿LIMITACIONES/RIESGOS
DE LA TRANSFUSIÓN?
31. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
CRITERIOS TRANSFUSIONALES
FALTA DE EVIDENCIA CLÍNICA DEL
BENEFICIO DE SU USO UNIVERSAL
32. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
Costes de producción elevados
CRITERIOS TRANSFUSIONALES
33. Problemas de la TSA
Coste de la transfusión de
una unidad de concentrado de hematíes
País Año Coste Referencia
Estados Unidos* 2000 297 $ MacLaren & Sullivan, 2005
Suecia** 2003 351 € Glenngard et al, 2005
Reino Unido 2001 235 ₤ Varney & Guest, 2003
Grecia 2002 340 € Kanavos et al, 2004
España 2005 320 € Muñoz et al, 2007
*No incluye la leucorreducción
**Incluye efectos adversos y coste social
En España se transfundieron en 2010: 1.612.424 CH
Más de 560 millones de euros
34. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
Costes de producción elevados
Sangre humana: un recurso limitado
CRITERIOS TRANSFUSIONALES
35. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
Costes de producción elevados
Sangre humana: un recurso limitado
TSA no está libre de riesgos:
Errores de identificación
TRALI
Sobrecarga de fluidos (TACO)
Infección postoperatoria (TRIM)
Recidiva de cáncer (TRIM)
CRITERIOS TRANSFUSIONALES
39. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
Costes de producción elevados
Sangre humana: un recurso limitado
TSA no está libre de riesgos:
Errores de identificación
TRALI
Sobrecarga de fluidos (TACO)
Infección postoperatoria (TRIM)
Recidiva de cáncer (TRIM)
Legislación vigente
CRITERIOS TRANSFUSIONALES
40. Problemas de la TSA
12. Patients should be informed of the known risks and
benefits of blood transfusion and/or alternative
therapies and have the right to accept or refuse the
procedure. Any valid advance directive should be
respected.
Principle of patient’s autonomy
15. Genuine clinical need should be the only basis for
transfusion therapy.
Ethical principles of beneficence and justice
Legislación vigente
41. Problemas de la TSA
Regan y Taylor, BMJ 2002
Shander, Semin Hematol 2004
Muñoz, 2007
Costes de producción elevados
Sangre humana: un recurso limitado
TSA no está libre de riesgos:
Errores de identificación
TRALI
Sobrecarga de fluidos (TACO)
Infección postoperatoria (TRIM)
Recidiva de cáncer (TRIM)
Legislación vigente
Variabilidad
CRITERIOS TRANSFUSIONALES
46. UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
www.awge.org
Evitar la trasfusión: una opción con criterio
¿CRITERIOS TRANSFUSIONALES?
¿NIVEL DE HEMOGLOBINA?
47. AABT
John S. Lundy, MD. Anesthesiologist who set up
the Mayo Clinic Blood Bank in 1935
Lund with an anesthesia
colleague, R Charles Adams at
Mayo Clinic, advocated the use
of a hemoglobin trigger of 8 to
10 g% for patients considered
to be of poor surgical risk.
Adams RC, Lundy JS: Anesthesia in cases of poor
surgical risk. Some suggestions for decreasing the
risk. Surg Gynecol Obstet 64:1011- 1019, 1942
CRITERIOS TRANSFUSIONALES
48. Determinantes de la transfusión
El nivel de hemoglobina
Nivel óptimo de hemoglobina
Nivel de Hb al cual la funcionalidad orgánica es máxima, al
tiempo que se evitan los efectos adversos de concentraciones
de Hb demasiado altas o demasiado bajas.
Por tanto, la regla de 10/30
refleja una situación funcional
óptima y, por tanto, este no
sería el umbral de transfusion
sino, como mucho, el objetivo a
alcanzar cuando se transfunde
a un paciente.
54. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
1º Mantener volemia al 100% con cristaloides o coloides
Anemia aguda:
CRITERIOS TRANSFUSIONALES
55. Clasificación de la gravedad de la hemorragia
Red cell transfusion is likely to be required when 30–40%
blood volume is lost; over 40% blood volume loss is
immediately life-threatening (American College Surgeons 1997).
CRITERIOS TRANSFUSIONALES
56. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
Anemia aguda:
1º Mantener volemia al 100% con cristaloides o coloides
2º Transfusión de concentrados de hematíes si:
· Hb < 7 g/dL en paciente previamente sano
· Hb < 8 g/dL en paciente con hemorragia incontrolada
o dificultad de adaptación a la anemia (diabetes, >65
años, enfermedad vascular, respiratoria)
· Hb < 9 g/dL en paciente con antecedentes de
insuficiencia cardiaca o coronaria
CRITERIOS TRANSFUSIONALES
57. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
Anemia aguda:
1º Mantener volemia al 100% con cristaloides o coloides
2º Transfusión de concentrados de hematíes si:
· Hb < 7 g/dL en paciente previamente sano
· Hb < 8 g/dL en paciente con hemorragia incontrolada o dificultad
de adaptación a la anemia (diabetes, >65 años, enfermedad
vascular, respiratoria)
· Hb < 9 g/dL en paciente con antecedentes de insuficiencia
cardiaca o coronaria
3º Reponer factores de coagulación según estudio de
hemostasia
CRITERIOS TRANSFUSIONALES
58. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
1º Tratamiento causal: ferroterapia, vitamina B12, ácido
fólico, etc.
Anemia crónica:
CRITERIOS TRANSFUSIONALES
59. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
1º Tratamiento causal.
2º Transfusión de concentrados de hematíes si
sintomatología anémica (astenia, taquicardia,
taquipnea).
Orientativo según cifra de Hb:
•Hb < 5 g/dL: Indicación de transfusión
•Hb 5-9 g/dL: Decisión clínica
•Hb >10 g/dL: casi nunca
Anemia crónica:
CRITERIOS TRANSFUSIONALES
60. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
• Paciente sin descompensación cardiopulmonar: Si
Hb < 7 g/dL
• Paciente con antecedentes cardiopulmonares: Si Hb
< 8 g/dL
• Paciente con descompensación cardiopulmonar Si
Hb < 9 g/dL
Anemia pre, per y postoperatoria:
CRITERIOS TRANSFUSIONALES
61. 1. Recomendaciones para transfusión de
concentrados de hematíes en adultos
www.awge.org www.sets.es
Uso inapropiado de hematíes
• Como expansor plasmático
• De manera “profiláctica” (antes de pérdidas)
• Para mejora del estado general del paciente, la
cicatrización o la nutrición
• En anemias tratables con productos específicos
CRITERIOS TRANSFUSIONALES
65. UMBRALES DE TRANSFUSIÓN:
PUESTA AL DÍA
www.awge.org
Evitar la trasfusión: una opción con criterio
¿CRITERIOS DE TRANSFUSIÓN
COMO ALTERNATIVA A
LA TRANSFUSIÓN?
66. Protocolos restrictivos
de transfusión
Hb <7-8,5 g/dL
Uso de sangre
autóloga
Predonación, Hemodilución
Recuperación perioperatoria
Reducción del
sangrado
perioperatorio
Tranexámico
CCP y rFVIIa
Adhesivos y geles
Corrección
de la anemia
perioperatoria
Hierro, folato,
B12, EPO
Optimización
del uso
de la TSA
Alternativas a la TSA
AABT
67. Protocolos restrictivos
de transfusión
Hb <7- 8,5 g/dL
Uso de sangre
autóloga
Predonación, Hemodilución
Recuperación perioperatoria
Reducción del
sangrado
perioperatorio
Tranexámico
CCP y rFVIIa
Adhesivos y geles
Corrección
de la anemia
perioperatoria
Hierro, folato,
B12, EPO
Optimización
del uso
de la TSA
Alternativas a la TSA
AABT
68. Actualización Documento Sevilla
ATSA Criterios restrictivos de transfusión
Adecuada reposición de volumen
Aceptación de la anemia normovolémica
• Expansión de volumen
• Perfusión tisular
• Aporte de oxígeno
• Cristaloides y Coloides
70. Criterios restrictivos de transfusiónATSA
Transfusión y supervivencia en pacientes críticos
e
e
RESTRICTIVO
Umbral Hb <7g/dL
Objetivo: Hb 7-9 g/dL
LIBERAL
Umbral: Hb <10g/dL
Objetivo: Hb 10-12 g/dL
Supervivencia(%)
Días
TSA: 67%
2.6 ± 4.1 U/pte
TSA: 100%
5.6 ± 4.1 U/pte
P<0.01
Hebert y cols. NEJM 1999; 340:409-417
71. Estudio prospectivo con 838 pacientes críticos euvolémicos
moderada-mente anémicos (Hb<9 g/dL) randomizados en
dos grupos:
- “RESTRICTIVOS”: Tfx si Hb < 7g/dL, para mantenerla
entre 7 y 9
- “LIBERALES”: Tfs si Hb< 10 g/dL, mantener entre 10 y 12
0
5
10
15
20
25
30
Mort 30d Mort Hosp APACHE<20 EDAD<55 CARDIACA
LIBERAL RESTRICTIVO
p=0,11
p=0,05
p=0,03
p=0,02
p=0,69
AABT
Transfusión y mortalidad en pacientes críticos
75. 0
10
20
30
40
50
Control group Study group
P = 0.005
P = 0.842
Intraoperative Postoperative
%ofpatients
A. Transfusión perioperatoria B. Complicaciones postoperatorias
Complications, n (%)
Study
Group
(n=212)
Control
group
(n=216)
Atrial arrhytmia
Ventricular arrhytmia
Myocardial infraction
Neurologic déficit
Pulmonary complications
Renal failure
Infection
30 (14)
13 (6)
1 (0.5)
11 (5)
57 (27)
8 (4)
5 (2)
40 (19)
9 (4)
0 (0)
9 (4)
64 (30)
5 (2)
3 (1)Control group: Hb <9 g/dL
Study group: Hb <8 g/dL
Criterios restrictivos de transfusiónATSA
76. Diseño:
• Estudio multicéntrico, aleatorizado y controlado.
• 260 pacientes PTC o PTR, sin evidencia de isquemia miocárdica.
• Criterio de transfusión restrictivo (Hb <8 g/dL) o liberal (Hb <10 g/dL).
• ECG ambulatorio continuo (Holter) desde 12h preOP hasta 72h postOP.
Conclusiones:
La aplicación de un criterio restrictivo de transfusión:
• No se asoció a una mayor incidencia de isquemia subendocárdica.
• No incrementó la duración de la estancia hospitalaria.
• Redujo significativamente la tasa de transfusión.
Criterios restrictivos de transfusiónATSA
77.
78. The FOCUS study
Carson y cols. NEJM 2011; 365: 2453-62
• 2016 pacientes ancianos con Hb <10 g/dL tras cirugía por fractura de cadera
• Antecedentes o factores de riesgo de enfermedad cardiovascular
• Criterio liberal: transfundir si Hb < 10 g/dL
• Criterio restrictivo: transfundir si síntomas de anemia o Hb < 8 g/dL
Pacientes(%)
TSA: CR 41% vs. CL 96%
IAM
Angina inestable
FCC
Infección
Mortalidad hospital
FACIT-Fatiga 60d
No deambulación 60d
Mortalidad 60d
Liberal Restrictivo
2.3% 3.8%
0.2% 0.3%
2.7% 3.5%
8.3% 5.9%
2.0% 1.4%
41.8±7.3 42.3±7.4
40.9% 43.8%
5.2% 4.3%
Efectos adversos postoperatorios
Criterios restrictivos de transfusiónATSA
79.
80. Clinical Guidelines
Red Blood Cell Transfusion:
A Clinical Practice Guideline
rom the AABBy L. Carson, MD; Brenda J. Grossman, MD, MPH; Steven Kleinman, MD; Alan T. Tinmouth, MD; Marisa B. Marques, MD; Mark K. Fung,
John B. Holcomb, MD; Orieji Illoh, MD; Lewis J. Kaplan, MD; Louis M. Katz, MD; Sunil V. Rao, MD; John D. Roback, MD, PhD;
Shander, MD; Aaron A.R. Tobian, MD, PhD; Robert Weinstein, MD; Lisa Grace Swinton McLaughlin, MD; and Benjamin Djulbegovic, MD,
for the Clinical Transfusion Medicine Committee of the AABB*
81. Question 1
• In hospitalized, hemodynamically stable patients,
at what hemoglobin concentration should a
decision to transfuse RBCs be considered?
Recommendations
The AABB recommends adhering to a restrictive
transfusion strategy.
In adult and pediatric intensive care unit patients, transfusion
should be considered at Hb concentrations of 7 g/dL or less.
In postoperative surgical patients, transfusion should be
considered at a Hb concentration of 8 g/dL or less or for
symptoms (chest pain, orthostatic hypotension or tachycardia
unresponsive to fluid resuscitation, or congestive heart
failure).
Quality of evidence: high; strength of recommendation: strong.
82. Question 2
• In hospitalized, hemodynamically stable patients
with preexisting cardiovascular disease, at what
hemoglobin concentration should a decision to
transfuse RBCs be considered?
Recommendations
The AABB suggests adhering to a restrictive transfusion
strategy.
Quality of evidence: moderate; strength of recommendation: weak.
Transfusion should be considered at a Hb concentration of 8
g/dL or less or for symptoms (chest pain, orthostatic
hypotension or tachycardia unresponsive to fluid
resuscitation, or congestive heart failure).
83. Question 3
• In hospitalized, hemodynamically stable patients
with the acute coronary syndrome, at what
Hemoglobin concentration should an RBC
transfusion be considered?
Recommendations
The AABB cannot recommend for or against a liberal or
restrictive RBC transfusion threshold.
Further research is needed to determine the optimal
threshold.
Quality of evidence: very low; strength of recommendation: uncertain.
84. Question 4
• In hospitalized, hemodynamically stable patients,
should transfusion be guided by symptoms rather
than hemoglobin concentration?
Recommendations
The AABB suggests that transfusion decisions be influenced
by symptoms as well as hemoglobin concentration.
Quality of evidence: low; strength of recommendation: weak.
85. •Clinical Guidelines
Red Blood Cell Transfusion:
A Clinical Practice Guideline
From the AABB
If a restrictive transfusion strategy were widely implemented
and replaced a liberal strategy, exposure of patients to RBC
transfusions would decrease by an average of approximately
40% (RR, 0.61 [CI, 0.52 to 0.72]).
This would have a large effect on blood use and the risks for
infectious and noninfectious complications of transfusion.
86.
87. The existing evidence supports the use of restrictive
transfusion triggers in most patients including those with
pre-existing cardiovascular disease.
As there are no trials, the effects of restrictive transfusion
triggers in high risk groups such as acute coronary
syndrome need to be tested in further large clinical trials.
In countries with inadequate screening of donor blood, the
data may constitute a stronger basis for avoiding
transfusion with allogeneic red cells.
88. Overall, 39% fewer patients received transfusions in the
restrictive group than in the liberal group.
The mean number of units of RBCs transfused was 1.19
units lower and the mean hemoglobin concentration
before transfusion was 1.48 g/dL lower in the restrictive
group.
These findings confirm that a restrictive transfusion
strategy leads to a clinically important reduction in RBC
use and a lower mean hemoglobin concentration.
En España se transfundieron en 2010: 1.612.424 CH
Más de 224 millones de euros
89. Restrictive transfusion strategies were associated with a
statistically significant reduction in hospital mortality (RR
0.77, 95% CI 0.62-0.95) but not 30 day mortality (RR
0.85, 95% CI 0.70 to 1.03).
The use of restrictive transfusion strategies did not reduce
functional recovery, hospital or intensive care length of
stay.
94. Actualización Documento Sevilla
ATSA Transfusión de sangre alogénica
En pacientes críticos, politraumatizados y/o quirúrgicos, sin
afectación cardiológica y/o del Sistema Nervioso Central
recomendamos la transfusión de CH para mantener cifras de
hemoglobina entre 7 y 9 g/dL, con objeto de disminuir la tasa
transfusional.
1A
Concentrado de hematíes (CH)
En pacientes críticos, politraumatizados y/o quirúrgicos, con
afectación cardiológica y/o del Sistema Nervioso Central
recomendamos la transfusión de CH para mantener cifras de
hemoglobina entre 8 y 10 g/dL, con objeto de disminuir la
tasa transfusional.
1A
99. If you can keep your head when all about you
Are losing their blaming it on you,
If you can trust yourself when all men doubt you
But make allowance for their doubting too
If you can wait and not be tired by waiting,
Or being lied about, don't deal in lies,
Or being hated, don't give way to hating,
And yet don't look good, nor talk too wise:
If you can dream – and not make dreams your master,
If you can think – and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you've spoken
Twisted by knaves to make a trap for fools,
Or watch things you gave your life to, broken,
And stoop and buid’em up with worn-out tools:
100. If you can make one heap of all your winnings
And risk it all on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breath a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: “Hold on!”
If you can talk with crowds and keep your virtue,
Or walk with kings – nor lose the common touch,
If neither foes nor loving friends can hurt you;
If all men count with you, but none too much,
If you can fill the unforgiving minute
With sixty seconds´ worth of distance run,
Yours is the Earth and everything that's in it,
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Notas del editor
Even though blood transfusion has been used for over 100 years there is little evidence of it’s efficacy in many clinical situations. Blood transfusion should only be prescribed to increase the oxygen consumption, and there are many reasons supporting this statement
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Adverse effects of RBC transfusion contrasted with other risks.Risk is depicted on a logarithmic scale. Shaded bars represent the risk per RBC unit transfused, and unshaded bars represent the risk for fatality per person per year for various life events. During 2007 through 2008, HIV incidence in blood donors was 3.1 per 100 000 person-years. Residual risk was estimated as 1:1 467 000 transfused blood components or 6.8 per 10 million transfused components (10). During 2007 through 2008, HCV incidence in blood donors was 5.1 per 100 000 person-years with residual risk estimate of 0.87 per million transfused blood components (1:1 149 000) or 8.7 per 10 million transfused components (10). For 2006 to 2008, HBV incidence in blood donors was 3.41 to 3.43 per 100 000 person-years. The estimated residual risk for HBV was 1 in 282 000 to 1 in 357 000 transfused blood components (11) or 2.8 per million to 3.6 per million transfused blood components. In a recently published, large, prospective study with active recipient surveillance, the rate of TRALI occurrence in 2009 was 0.81 (95% CI, 0.44 to 1.49) per 10 000 transfused blood components or 8.1 per 100 000 transfused blood components (12). Although the literature has a wide range of TRALI risk estimates (1, 13–16), we have selected the rate reported in this recent prospective study. Three studies of TACO have produced similar results. In a study of 901 intensive care unit patients, 6% of patients who received transfusions developed TACO. Median units transfused were 2 RBCs and 3 overall (including plasma and platelets) (17). The rate per transfused RBC unit was 2 to 3 per 100. In 382 patients undergoing hip and knee replacement, 1% developed TACO after surgery (18). In a study of patients having total hip and knee arthroplasty, 8% developed fluid overload necessitating diuretic use and 4% of patients who did not receive transfusions developed fluid overload, leading to a TACO estimate of 4% (19). In published studies from the late 1990s, the risk for fatal hemolysis was estimated to range from 1.3 to 1.7 per million (5.9 to 7.7 per 10 million) transfused RBC units in 1 report (20) and 1 per 1 800 000 or 8.5 per 10 million in a second report (21). More recently, transfusion-related fatalities due to hemolysis reported to the U.S. Food and Drug Administration averaged 12.5 deaths per year from 2005 to 2010 (22). With 15 million RBC units transfused per year, the estimated risk for death due to hemolysis is 1:1 250 000 or 8 per 10 million RBC units. Fever (febrile nonhemolytic transfusion reactions) was estimated to be 1.1% with prestorage leukoreduction and 2.15% with poststorage leukoreduction (23). Death from medical error as reported by the Institute of Medicine was 1.3 to 2.9 per 1000 hospital admissions (24). Life-threatening transfusion reaction, defined as reactions requiring major medical intervention (for example, vasopressors, intubation, or transfer to an intensive care unit), occurred in 1:139 908 transfusions or 7.1 per million transfusions (1). Fatal motor vehicle accidents were estimated at 13.1 per 100 000 persons in 2008 or 1.3 per 10 000 persons (25). The rate of firearm homicide (which excludes suicide) was 4 per 100 000 persons in 2008 (25). Fatal falls were estimated at 8.2 deaths per 100 000 persons in 2008 (25). Lightning fatalities ranged from 0.02 per million (2 per 100 million) persons in California and Massachusetts to 2.0 per million persons in Wyoming (0 risk in Hawaii, Rhode Island, and Alaska) (26). The odds of being killed on a single airline flight on the 30 airlines with the best accident rates were 1 per 29.4 million. Among the 25 airlines with the worst accident records, rates were 1.7 per million per flight (27). Modified from Dzik and colleagues (2002) (28). HBV = hepatitis B virus; HCV = hepatitis C virus; RBC = red blood cell; TACO = transfusion-associated circulatory overload; TRALI = transfusion-related acute lung injury.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006
Blood supply is decreasing, surgery is more and more complex and new transfusion risks are continuously being described. So, many scientific societies have issued guidelines on blood transfusion indications
Many alternatives to blood transfusions, pharmacological and non-pharmacological, have flooded medical publications often without enough scientific evidence. In fact there are a few reviews that deal with this topic.
The Spanish version of the consensus was published in 2006