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• W4213056907 abstract "THE UNITED STATES BLOOD SUPPLY (Fig 1) is built on volunteer donations, a system that dates to World War II. It is estimated that there are 200 million potential blood donors in the United States, or roughly two-thirds of the population.1To L Dunnington T Thomas C et al.The United States' potential blood donor pool: Updating the prevalence of donor-exclusion factors on the pool of potential donors.Transfusion. 2020; 60: 206-215Crossref PubMed Scopus (10) Google Scholar The number of eligible donors has grown during the past 15 years, mainly through the inclusion of older persons (age ≥65 years) in the donor pool.1To L Dunnington T Thomas C et al.The United States' potential blood donor pool: Updating the prevalence of donor-exclusion factors on the pool of potential donors.Transfusion. 2020; 60: 206-215Crossref PubMed Scopus (10) Google Scholar Despite this, blood supply has decreased as more donor restrictions have been put into place and demand has fallen, offsetting growth in the potential donor pool.1To L Dunnington T Thomas C et al.The United States' potential blood donor pool: Updating the prevalence of donor-exclusion factors on the pool of potential donors.Transfusion. 2020; 60: 206-215Crossref PubMed Scopus (10) Google Scholar,2Jones JM Sapiano MRP Savinkina AA et al.Slowing decline in blood collection and transfusion in the United States - 2017.Transfusion. 2020; 60 Suppl 2: S1-S9PubMed Google Scholar It currently is estimated that <5% of eligible donors or around 7 million persons annually donate blood. This fact, coupled with an aging donor population, highlights vulnerabilities in the national blood supply.1To L Dunnington T Thomas C et al.The United States' potential blood donor pool: Updating the prevalence of donor-exclusion factors on the pool of potential donors.Transfusion. 2020; 60: 206-215Crossref PubMed Scopus (10) Google Scholar The American Red Cross, which supplies approximately 40% of the nation's blood supply, estimates the demand for red blood cells (RBCs) is approximately 14 million units per year.3American Red Cross. Red Cross Declares first-ever blood crisis amid omicron surge. Available at: https://www.redcross.org/about-us/news-and-events/press-release/2022/blood-donors-needed-now-as-omicron-intensifies.html. Accessed February 10, 2022.Google Scholar In addition, annually, 2 million platelet and 2.5 million plasma units are transfused. Surgical patients, particularly cardiac surgical patients, continue to be major consumers of allogeneic blood products. There are more than 300,000 cardiac surgical procedures performed with cardiopulmonary bypass each year in the United States, with conservative estimates suggesting that at least one-third of adult patients undergoing cardiac surgery are transfused. 4Nguyen TC Thourani VH Nissen AP et al.The Effect of COVID-19 on Adult Cardiac Surgery in the United States in 717 103 Patients.Ann Thorac Surg. 2022; 113: 738-746Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,5Robich MP Koch CG Johnston DR et al.Trends in blood utilization in United States cardiac surgical patients.Transfusion. 2015; 55: 805-814Crossref PubMed Scopus (40) Google Scholar However, transfusion risk varies greatly with surgical complexity, and transfusion rates for complex surgeries (eg, combined valve replacement and coronary artery bypass grafting) exceed 80%.6D'Agostino RS Jacobs JP Badhwar V et al.The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 update on outcomes and quality.Ann Thorac Surg. 2019; 107: 24-32Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Given the trend of increasing surgical complexity, it is likely that allogeneic transfusion rates will remain high in cardiac surgery for the foreseeable future. The COVID-19 pandemic has dramatically impacted nearly all aspects of life in the United States, including the national blood system. Supply chain disturbances have been numerous, affecting the building industry, auto industry, food industry, and healthcare. In June 2020, industry leaders from across the United States were surveyed regarding these challenges, with 93% of respondents acknowledging a need to make supply chains more “flexible, agile, and resilient.”7Alicke K, Barriball E, Trautwein V. How COVID-19 is reshaping supply chains. Available at: https://www.mckinsey.com/business-functions/operations/our-insights/how-covid-19-is-reshaping-supply-chains. Accessed February 10, 2022.Google Scholar These disturbances have magnified blood collection challenges in the United States, leading to blood shortages that have worsened progressively throughout the pandemic. In this setting, the United States Department of Health and Human Services issued a report to Congress on the adequacy of the national blood supply, describing multiple “stressors” in the current system (Table 1).Table 1Key Themes From the 2020 Health and Human Services Report on the Adequacy of United States Blood Supply.VulnerabilityRecommendationLack of “real-time” data on national blood availability• Create an apparatus for “real-time” monitoring of the national blood supplyDependence on volunteer donations and eroding culture of donation, particularly among young adults• Nurture a culture of donation, particularly among young adults and those with lesser access to healthcare• Better understand through research the reasons people donate blood and whether there is equitable access to blood donationFragmented/disparate local models for blood donation and supplyCurrent regulations may stifle innovation and rapid adoption of important technology• Modernize the business model for blood donation, storage, and supply• Create novel regulatory approaches to foster innovation and move important technology into practice more quickly• Create a public-private partnership that, in coordination with FDA, reviews how current regulations impact innovation, safety, and outcomesRevenue losses and negative balance sheets for many blood collection centers• Move away from treatment of blood as a commodity and move towards treatment of nation's blood supply as a public health programAbbreviation: FDA, United States Food and Drug Administration. Open table in a new tab Abbreviation: FDA, United States Food and Drug Administration. These include a lack of “real-time” monitoring of the national blood inventory, reliance on a loosely connected system of nonprofit blood centers and hospital-based collection centers without robust integration or central coordination, an aging donor pool, disparate local collection and supply models, and regulations that do not promote innovation and rapid adoption of new technology.8United States Department of Health and Human Services. Adequacy of the national blood supply: Report to Congress 2020. Available at: https://www.hhs.gov/sites/default/files/hhs-adequacy-national-blood-supply-report-congress-2020.pdf. Accessed February 10, 2022.Google Scholar By late 2021, numerous blood collections across the nation, including critically important mobile drives at high school and college campuses, had been canceled because of COVID-19. Staffing shortages and associated social and economic disturbances resulted in a 10% drop in the United States blood collections from prepandemic levels. When coupled with high volumes of surgical and intensive care unit admissions, this resulted in the depletion of local and regional blood inventories. The American Red Cross and other blood collection organizations offered numerous incentives to attract donors to available blood donation sites, including opportunities to win Super Bowl tickets, luxury travel packages to popular music festivals, gift cards, and home electronic devices. Nevertheless, blood shortages worsened, and in January 2022, the American Red Cross declared a “National Blood Emergency” for the first time in its history.3American Red Cross. Red Cross Declares first-ever blood crisis amid omicron surge. Available at: https://www.redcross.org/about-us/news-and-events/press-release/2022/blood-donors-needed-now-as-omicron-intensifies.html. Accessed February 10, 2022.Google Scholar In response, the American Medical Association, American Nurses Association, and American Hospital Association issued a joint statement outlining the dire nature of the national blood crisis and encouraging all eligible persons to donate blood. Shortly thereafter, the Association for the Advancement of Blood and Biotherapeutics, in collaboration with 17 leading American healthcare and blood collection organizations including but not limited to the American Society of Anesthesiologists, American College of Emergency Physicians, American College of Surgeons, American Society of Hematology, America's Blood Centers, Blood Centers of America, American Red Cross, Federation of American Hospitals, and the Society for the Advancement of Patient Blood Management, launched the “Alliance for a Strong Blood Supply” to facilitate communication regarding the state of the United States blood supply, share best practice initiatives, and coordinate public communications and advocacy efforts. Although strengthening the United States blood supply is critically important and receives appropriate media coverage, far less attention is given to equally important efforts to decrease the demand for allogeneic blood products. In light of the national blood crisis, coupled with the multitude of well-described benefits to patients and the broader healthcare system that accompany reduction in allogeneic transfusion, it is past time for hospitals across the nation, including cardiac surgery programs, to evaluate current transfusion practices and further invest in evidence-based patient blood management (PBM). PBM can be loosely defined as evidence-based clinical practice and educational tools to optimize the blood health of each patient, minimize transfusion exposure, and improve clinical outcomes. These initiatives are a win-win for patients and hospitals—conserving blood resources for those most in need, reducing transfusion, expenditures and waste, and improving patient outcomes.9Gupta PB DeMario VM Amin RM et al.Patient blood management program improves blood use and clinical outcomes in orthopedic surgery.Anesthesiology. 2018; 129: 1082-1091Crossref PubMed Scopus (32) Google Scholar,10Warner MA Schulte PJ Hanson AC et al.Implementation of a comprehensive patient blood management program for hospitalized patients at a large United States medical center.Mayo Clin Proc. 2021; 96: 2980-2990Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In 2021, the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists published an updated joint guideline outlining contemporary PBM practices in cardiac surgery.11Tibi P McClure RS Huang J et al.STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management.J Cardiothorac Vasc Anesth. 2021; 35: 2569-2591Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In the guideline, the authors provided multiple recommendations, including the evaluation and treatment of preoperative anemia (Class IIa), minimization of phlebotomy for the prevention of iatrogenic anemia (Class IIa), implementation of standardized transfusion protocols (Class IIa), appropriate withholding of anticoagulation (Class I and Class IIa), employment of antifibrinolytics in cardiopulmonary bypass cases (Class I) and off-pump coronary artery bypass grafting (Class IIa), appropriate utilization of factor concentrates (Class IIa), retrograde autologous priming (Class I), acute normovolemic hemodilution (Class IIa), and cell salvage (Class I), and goal-directed hemostasis management based on coagulation testing (Class I).11Tibi P McClure RS Huang J et al.STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management.J Cardiothorac Vasc Anesth. 2021; 35: 2569-2591Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Simply stated, these evidence-based tools are readily available in nearly all cardiac surgery practices to augment red cell production, prevent and treat coagulopathy, and minimize perioperative bleeding, thereby reducing the need for allogeneic transfusion. Beyond these immediately available interventions, there are other long-term aspirational goals that may help to stabilize the United States blood supply (Table 2). These include efforts to prolong the shelf-life of blood components (eg, mitigation strategies for the RBC storage lesion, delayed cold-storage of platelets), enhancing research into RBC-like products (eg, hemoglobin-based oxygen carriers, encapsulated hemoglobin products) and pooled products with longer storage durations (eg, cryopreserved platelets, freeze-dried plasma), and expanding use of fibrinogen concentrates and factor concentrates for the treatment of acquired coagulation abnormalities. Further, it is essential to establish a strong pool of recurring blood donors rather than relying on surges in one-time donations in response to critical events, as such highly publicized calls for donations may be unnecessary to meet current transfusion demand, overwhelm local blood collection capacity, and ultimately lead to increased blood waste.12Lozada MJ Cai S Li M et al.The Las Vegas mass shooting: An analysis of blood component administration and blood bank donations.J Trauma Acute Care Surg. 2019; 86: 128-133Crossref PubMed Scopus (26) Google ScholarTable 2Aspirational Goals to Stabilize the United States Blood Supply.Blood ProductPotential SolutionChallengeRBC• Mitigate RBC storage lesion and increase the safe duration of refrigerated RBC storage• Enhance the safety of HBOCs• Bring innovative RBC alternatives to FDA approval and/or licensure (eg, CRISPR edited universal donor RBCs, bioengineered encapsulated hemoglobin products)• Refrigerated RBC storage duration has not been able to successfully expand beyond 42 d; limited literature suggests that “old” RBCs may be harmful to patients• Concerns about adverse effects of HBOCs when compared against RBCs (eg, hypertension, methemoglobinemia, circulatory overload, gastrointestinal side effects)• Producers of HBOCs have had difficulty maintaining financial solvency• Products are in development, but have not entered clinical trials at this timePlasma• Continue to develop freeze-dried plasma products with increased shelf life• Freeze-dried plasma remains poorly studied compared to liquid plasma and there are no contemporary phase 3 studies comparing against liquid plasma in the United StatesCryoprecipitate• Move towards fibrinogen concentrate as the standard of care for treatment of acquired hypofibrinogenemia (as has been done in Canada and Europe)• Phase 3 study of fibrinogen concentrate has not yet been completed in the United States• Cryoprecipitate remains modestly cheaper than fibrinogen concentrate and also provides other useful pro-coagulant proteins (ie, von Willebrand factor, factors VIII and XIII)Platelets• Continue to develop and study alternative products, including cryopreserved platelets and cold-stored platelets, which would allow for longer storage durations• Clinical trials are ongoing, but current efficacy of these products is unknown.• Cold-stored platelets may be effective for hemostasis, but they have a shorter circulation time and/or life spanAbbreviations: CRISPR, Clustered Regularly Interspaced Short Palindromic Repeats; FDA, United States Food and Drug Administration; HBOC, hemoglobin-based oxygen carriers; RBC, red blood cell. Open table in a new tab Abbreviations: CRISPR, Clustered Regularly Interspaced Short Palindromic Repeats; FDA, United States Food and Drug Administration; HBOC, hemoglobin-based oxygen carriers; RBC, red blood cell. Although these aspirational goals will take years to achieve, common-sense PBM tools to decrease blood demand and improve the blood health of each patient are available for broad adoption now. Each provider (cardiothoracic anesthesiologist, cardiac surgeon, intensivist) can have an immediate impact on ongoing blood shortages by critically evaluating the appropriateness of each transfusion, becoming a recurrent blood donor if they are eligible, and by advocating for PBM initiatives in their own institution. Although the national blood crisis will continue to challenge the United States healthcare system for the foreseeable future, it should serve as a unifying call to improve blood-banking systems, promote coordination between diverse blood collection and distribution organizations, and invest in research, quality improvement, and practice optimization efforts to reduce blood demand by embracing the core principles of PBM. Matthew A. Warner and Prakash A. Patel serve on the Board of Directors for the Society for the Advancement of Patient Blood Management. Matthew A. Warner, Nadia B. Hensley, and Michael Mazzeffi serve on the American Society of Anesthesiologists Committee on Patient Blood Management. Nadia B. Hensley and Michael Mazzeffi are on the scientific advisory board for Octapharma USA, which is involved in patient blood management." @default.
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• W4213056907 title "COVID-19-Related Blood Shortages and Cardiac Surgery: Do We Have Too Many Eggs in One Basket?" @default.
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