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• W2000534144 abstract "*The ancient medical concept of humourism (Hippocrates), states that four bodily fluids affect human personality traits and behaviours. Blood, or ‘sanguine’, according to Galen, means pleasure-seeking and sociable. In June 2014, the National Blood Transfusion Committee launched Patient Blood Management, supported by NHS England and the Department of Health (see http://www.transfusionguidelines.org.uk/uk-transfusion-committees/national-blood-transfusion-committee/patient-blood-management), by writing to the Chief Executive of every UK hospital and NHS Trust. The stated aims of this initiative, aimed at national and regional leaders, hospital managers and health professonals, are patient benefit by reducing inappropriate transfusions. It is an evidence-based, multidisciplinary approach to blood product utilisation and incorporates optimisation of erythropoiesis, and employment of restrictive transfusion thresholds, together with methods to minimise blood loss and allogeneic transfusion. It is therefore fitting, in this era of increased focus on blood at a high level, that Anaesthesia has decided to publish this special supplement Transfusion, Thrombosis and Management of Bleeding, a collaboration between anaesthetists, haematologists, surgeons and others, that pulls together state-of-the-art research and recommendations into a comprehensive guide to all things blood-related. Over the last decade, there has been a massive expansion of interest in blood conservation, testing of coagulation profiles, and the use of haemostatic agents. Many have challenged the elective transfusion of red cells and other blood products, and one of this supplement's major themes is the effort to reduce transfusion via more rapid testing-based protocols 1 and substitution with pooled factor concentrates 2. Advances have been also been made in preservation techniques for red cells, reducing the potentially deleterious effects of blood storage 3. However, blood usage still remains high, especially in trauma, obstetrics and cardiac surgery, and there is increasing evidence that red cell transfusions themselves may be harmful, and not simply surrogate markers of illness. Red cells are administered in order to improve the oxygen carrying capacity of blood, yet doing so by increasing the haemoglobin level does not necessarily increase tissue oxygen delivery or uptake. Randomised trials have, so far, consistently supported the restrictive use of red cells, with no evidence of benefit for maintaining higher haemoglobin thresholds (a so-called liberal strategy), but the results of further large, randomised controlled trials are awaited (ISRCTN 70923932, see http://www.controlled-trials.com/isrctn). Although most clinical practice guidelines recommend restrictive use of red cells, and many blood transfusion services have seen marked falls in overall usage, the use of haemostatic blood components such as fresh frozen plasma, platelets and cryoprecipitate has risen. In addition, individualised patient blood management has led to increased demand for specific blood concentrates and clotting factors. A recurring theme in this supplement is the increasing use of ‘point-of-care’ testing, which appears to be either replacing or supplementing laboratory testing, depending on your point of view 4. Point-of-care (or ‘near-patient’) testing includes thromboelastography (TEG®, Haemonetics, Braintree, MA, USA) and thromboelastometry (ROTEM®, TEM International, Munich, Germany) and is increasingly employed in both elective and emergency cases, despite concerns about accuracy and reproducibility 5. This supplement also closely follows the publication of the latest National Institute for Health and Care Excellence Diagnostics Guidance, addressing visco-elastometric point-of-care testing 6. There is increasing evidence that point-of-care testing results in reduced use of blood and blood products, and this is covered in detail in a number of reviews in this supplement. Another major, recurring theme is the replacement of fresh frozen plasma by prothrombin complex concentrate, and cryoprecipitate by fibrinogen concentrate. The use of factor concentrates is widely practised in mainland Europe, but there is inadequate literature showing their use is associated with patient benefit. There is still no data looking at the safety of using of factor concentrates in a bleeding patient, and little data on risks such as venous thrombo-embolism;it is also often forgotten that these are produced using patient-donated products and are neither artificial nor recombinant. However, despite a lack of high-quality evidence, some clinicians now use them routinely, especially in cardiac and trauma surgery, and the controversies associated with such practice are explored in detail in this supplement 7. Other areas of practice are also controversial 8. In trauma, the mainland European way is to ‘stay and play’, with early administration of tranexamic acid and utilisation of visco-elastic testing 9, whereas the North American approach is to ‘scoop and run’, and administer red cells:fresh frozen plasma:platelets in a 1:1:1 ratio 10. The optimal approach remains unclear. Advances in the management of obstetric bleeding, notably postpartum haemorrhage, include increased interest in the implications of relative hypofibrinogenaemia, point-of-care monitoring and the potential to provide goal-directed therapy 11. There is still a lack of knowledge about haemostatic impairment in parturients, and whether this differs from trauma-induced bleeding. There is ongoing debate regarding the relatively large proportion of critically ill patients who have some form of coagulopathy, with attention focusing on the identification of coagulation problems, prophylaxis against vascular thrombo-embolic events and heparin-induced thrombocytopenia 12. All these issues are discussed within the pages of this supplement. Intra-operative cell salvage, previously only found in the cardiac operating theatre, is now routinely used in obstetrics, major cancer surgery and large joint arthroplasty surgery. Other advances in therapeutic options include the widespread use of tranexamic acid in preventing excessive surgical bleeding 13, although not in high dose due to concerns about convulsions 14. Trials of tranexamic acid in fields as diverse as obstetric haemorrhage, neurosurgical trauma and gastrointestinal bleeding are in progress. There are also several topical haemostatic agents on the market and, although they show potential, safety and efficacy profiles have yet to be established and large scale randomised trials performed 15. Finally, the management of patients with inherited bleeding disorders 16, pre-operative anaemia 17, or those on anti-thrombotic therapy, particularly dual antiplatelet therapy 18, has been the subject of great discussion over the last few years. Humourism's legacy persists in terms such as ‘humoural immunity’, but the ancient concept of the four humours has been replaced by more modern explanations of how the body works. As the reviews in this supplement demonstrate, we have come a long way – but still have some distance to travel." @default.
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• W2000534144 title "Blood - the most important humour?*" @default.
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