Transfusion therapy in the peri-operative period

The recommendations concerning transfusion therapy in the peri-operative period, published in Blood Transfusion starting in this issue, are evidence of an important, further development of Italian Transfusion Medicine.

Behind this work there is an editorial project that the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) has pursued with determination and resolution: in the past with the publication of the "SIMTI Recommendations on the correct use of blood components and plasma derivatives" to promote therapeutically appropriate transfusion policies within the context of scientifically correct and ethically irreprehensible clinical choices^1–4, and now with the presentation of a precise and meticulous professional guide to transfusion practices in a particularly delicate moment of the clinical course of surgical patients.

The debate on the utility of guidelines is very topical, as exemplified by two recent articles published in the British Medical Journal^5,6. The "SIMTI recommendations on peri-operative transfusion"⁷, which take up and examine in more detail many of the passages of the preceding "Recommendations"^1–4, are not intended to be a final treatise, but rather an indispensable scaffold for building a project that can involve the Institutions and all medical and surgical disciplines that make use of transfusion therapy, particularly Anaesthesiology and General Surgery, two disciplines with which SIMTI has already established a fruitful and open exchange of ideas. The recommendations dealing with two broad aspects of the peri-operative management of surgical patients – the evaluation and management of patients in the pre-operative period and pre-operative strategies to limit the use of allogeneic transfusion – are published in this issue ⁸, while those on intra-operative transfusion and the management of surgical patients in the post-operative period will be published in subsequent issues of Blood Transfusion.

The development and use of strategies to prevent and reduce bleeding, as well as the promotion of alternatives to allogeneic transfusion, are among the principles that the European Recommendation Rec (2002) 11 indicates should be applied to improve quality and raise the care intensity of health services in transfusion medicine⁹.

These indications were subsequently included in Italian Law n. 219 of 21 October 2005 (New discipline for blood transfusion activities and national production of blood derivatives)¹⁰, which includes autologous transfusion and the co-ordination and organisation of peri-operative blood recovery activities among the therapeutic services of transfusion medicine.

In the last 20 years we have seen the birth, development and gradual decline of the practice of pre-operative autologous blood donation. The re-appraisal of the role of predeposit programmes, in large part due to the notable increase in the safety of homologous transfusion therapy, has also been ; i ratified by recent guidelines¹¹, which no longer recommend such programmes except in "exceptional clinical circumstances" and suggest, when appropriate, the use of techniques to recover blood in the peri-operative period.

The Ministry of Occupation, Health and Social Policies, in its "Manual on safety in the operating theatre: recommendations and checklists"¹², published in November 2009, indicates systems of peri-operative blood recovery as some of the instruments appropriate to have available for operations in which the loss of large volumes of blood can be foreseen.

Given the growing number of elderly patients, often with multiple disorders, undergoing complex surgical procedures, peri-operative medicine is gaining an ever increasing importance, such that it is almost a specialist discipline¹³. A careful, timely pre-operative evaluation and precise peri-operative medical care can reduce the number of operations that are postponed and prevent most complications and their sequelae^14–16.

In these recommendations the peri-operative period is intended to be the interval from 30 days before the intervention to 30 days after it. The prevalence of anaemia in the peri-operative period varies in relation to three factors¹⁷: (i) the definition of anaemia adopted; (ii) differences in the surgical procedures and the extent of bleeding associated with them; (iii) differences in the types of patients and their co-morbidities.

Anaemia is a common condition in the peri-operative period and is associated with increased transfusion requirements and, consequently, increased morbidity and mortality in surgical patients¹⁸. Some studies have indicated that higher levels of haemoglobin are correlated with earlier functional recovery in the post-operative period^19,20. Peri-operative anaemia and the consequent increased transfusion requirements are independent risk factors for post-operative infections, longer time spent in hospital and death in patients undergoing heart surgery or other forms of surgery^21–26. In countries with a high socio-economic level it is estimated that over 40% of the transfusions of red blood cells are given to surgical patients²⁷.

The use of transfusion therapy in the peri-operative period varies widely according to the clinical condition of the patient, the different surgical and anaesthetic techniques used, the urgency of the intervention, the different protocols on blood use and, last but not least, the availability of blood components and alternatives to transfusion²⁸.

In conclusion, in the view of growing multidisciplinary integration in modern transfusion medicine, with the aim of adaptation to different health care contexts and of being applicable in their specific care intricacy, the recommendations on transfusion therapy in the peri-operative period are intended to provide the reader with practical indications, based on available scientific evidence and the consensus of experts, on the use of strategies for a correct approach to the surgical patient and optimal peri-operative management of the therapeutic transfusion resources; they also include the use of plasma derivatives, drugs and techniques aimed at limiting the peri-operative need of homologous blood components; finally, they provide an update on the risks and benefits associated with transfusion and adjuvant therapies, such as drugs and techniques used to reduce or prevent haemorrhage and limit transfusion requirements²⁹.

All this is the premise to providing a global management of the surgical patient in order to deliver high quality transfusion medicine services as uniformly as possible throughout the country.