06/06/2019
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. …
Question A.1.9. (non-obligatory)
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: …
Question A.1.10. (non-obligatory)
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
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
PBM survey for hemato-oncology
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
PBM survey for hemato-oncology
PBM survey for hemato-oncology
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
Enquête BeQuinT 2019
Enquête BeQuinT 2019
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
Gestion de l’anémie – Gériatrie
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)
Gestion de l’anémie – Gériatrie
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
Enquête BeQuinT 2019
Enquête BeQuinT 2019
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
Enquête BeQuinT 2019
Enquête BeQuinT 2019
Enquête BeQuinT 2019
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: ……………………………………………………………
Enquête BeQuinT 2019
Enquête BeQuinT 2019