Aryeh Shander

Use of cell salvage (CS) in obstetrics (OB) has been off-label for the device use but despite that, there has been significant uptake in the use of CS, now referred to as cell recovery (CR). The limitations of this study are significant, and the fact that there was no difference in transfusion is most likely due to the very low transfusion rates. This point is important since many are now contesting these studies using transfusion rate as a primary or major outcome. Use of delta hemoglobin is also contested, since it is a slow response and is an inaccurate representation of therapy other than RBC transfusions. This brings us to the important point that is referred to in this study, and that is iron stores. Blood loss in this situation leads to iron-restricted erythropoiesis, and iron is the primary therapy immediately as well as late post op. Raising awareness of iron deficiency regardless of hemoglobin level is crucial. Additionally, the authors ought to be commended for the study (despite the many limitations) that raises awareness of CR in this OB clinical scenario.

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: “Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment.” The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at (1) screening for, diagnosing, and appropriately treating anemia; (2) minimizing surgical, procedural, and iatrogenic blood losses and managing coagulopathic bleeding throughout the care; and (3) supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians, and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.

As the COVID-19 pandemic runs its course around the globe, a mismatch of resources and needs arises: In some areas, health care systems are faced with an increased number of COVID-19 patients potentially exceeding their capacity, whereas, in other areas, health care systems are faced with procedural cancelations and a drop in demands. TeamHealth in Knoxville, Tennessee, a multidisciplinary health care organization, was able to roll out a systemic approach to redeploy its clinicians practicing in the fields of emergency medicine, hospital medicine, and anesthesiology from areas of less need (faced with reduced or no work) to areas outside of their normal practice facing immediate need.

Background and objectives: Previous studies by the Cost of Blood Consensus Conference (COBCON) have used a comprehensive, standardized and generalizable activity‐based costing (ABC) model to estimate the cost of red blood cell transfusions and plasma transfusion. The objective of this study was to determine the total cost of platelet transfusions in a real‐world US hospital inpatient setting.Materials and methods: This database analysis study retrospectively collected costs for all activities related to platelet transfusion in a single‐acute care US teaching hospital in 2017. Costs were collected in a stepwise manner using a custom ABC model which mapped the technical, administrative and clinical processes involved in the transfusion of platelets.Results: For the 15 024 inpatients included in the analysis, 6335 (42·2%) were given a blood type and screen, and 941 (6·3%) received a transfusion of one or more blood products. A total of 333 platelet units were transfused in 131 patients (mean 2·54 units per patient): 211 (63·4%) units in medical inpatients and 122 (36·6%) in surgical inpatients. The total cost was $1359·99 per platelet unit, corresponding to $3457·06 per inpatient. Acquisition costs made up the largest proportion of the total cost (45·1%) followed by direct and indirect overheads (38·7%) and hospital processes costs (16·3%).Conclusion: This is the first study to use an ABC costing model to determine the full cost of platelet transfusions within a US inpatient setting. This provides a useful reference point for comparisons with other transfusion products, and considerations for cost reduction.

Kirpalani et al. present a second transfusion trial in early age pediatric patients, an area where a limited number of transfusion studies have been published in comparison to adult trials. Although the dissenting button should have been pressed, I have decided to recommend this paper with a direct point of view. Liberal vs restrictive transfusion trials, regardless of the population studied, have not yielded positive results (i.e., they essentially add more to what we already know yet are revealed as new information). The 30,000-foot view of these trials leads to these conclusions: 1) the difference in hemoglobin level difference is negligible; 2) hemoglobin used as a "one size fits all" approach is erroneous; 3) no strategy to address the underlying disease or condition is offered - only an expensive temporizing measure; and 4) limitations of these studies have been addressed in previous publications {1} that address more methodological issues than protocol violation or other usual confounders. As such, a third arm, that compares other available treatment modalities would clearly shed more light on this issue of transfusion threshold that ignores the underlying source of the condition being treated. Lastly, if the practice is going to change as a result of this and other trials, additional clinical information should determine the "need" for transfusion rather than a single hemoglobin level.