Patient blood management in Europe

Preoperative anaemia is common in patients undergoing orthopaedic and other major surgery. Anaemia is associated with increased risks of postoperative mortality and morbidity, infectious complications, prolonged hospitalization, and a greater likelihood of allogeneic red blood cell (RBC) transfusion. Evidence of the clinical and economic disadvantages of RBC transfusion in treating perioperative anaemia has prompted recommendations for its restriction and a growing interest in approaches that rely on patients' own (rather than donor) blood. These approaches are collectively termed ‘patient blood management’ (PBM). PBM involves the use of multidisciplinary, multimodal, individualized strategies to minimize RBC transfusion with the ultimate goal of improving patient outcomes. PBM relies on approaches (pillars) that detect and treat perioperative anaemia and reduce surgical blood loss and perioperative coagulopathy to harness and optimize physiological tolerance of anaemia. After the recent resolution 63.12 of the World Health Assembly, the implementation of PBM is encouraged in all WHO member states. This new standard of care is now established in some centres in the USA and Austria, in Western Australia, and nationally in the Netherlands. However, there is a pressing need for European healthcare providers to integrate PBM strategies into routine care for patients undergoing orthopaedic and other types of surgery in order to reduce the use of unnecessary transfusions and improve the quality of care. After reviewing current PBM practices in Europe, this article offers recommendations supporting its wider implementation, focusing on anaemia management, the first of the three pillars of PBM

Constructing connections between theory and practice. Analysis of teacher’s assistance to favour reflection and knowledge construction

La gran mayoría de programas de formación de profesorado incluyen la reflexión como estrategia para la construcción de conocimiento. Sin embargo, en la literatura existen desacuerdos en la dirección y en el modo en que debería promoverse esta reflexión. Algunos autores (Korthagen, 2010) postulan que la reflexión debería estar basada en establecer conexiones entre el conocimiento teórico y práctico. Otros (Yoon & Kim, 2010; Pareja Roblin & Margalef, 2013) proponen que en todos los contextos educativos subyacen dilemas internos sobre los que los profesores deben reflexionar. Además, también existe debate entre el tipo de intervenciones que el docente debería realizar y el papel de las ayudas para suscitar niveles complejos de reflexión (Moore-Russo & Wilsey, 2014; Gelfuso & Dennis, 2014). Por tanto, ante esta realidad, la investigación que se presenta pretende contribuir a una mejor comprensión sobre los elementos que facilitan las competencias de reflexión en el alumnado y la conexión entre el conocimiento situacional y el conocimiento práctico (Clarà & Mauri, 2009, 2010). Se han estudiado 8 casos, ocho grupos de estudiantes de magisterio con su correspondiente tutor (112 alumnas/os y 8 tutoras/es). Los grupos proceden de 3 Universidades diferentes: Universidad de Barcelona, Universidad de Sevilla y Mondragon Unibertsitatea. El objetivo de dichos grupos es reflexionar sobre situaciones vividas durante sus prácticas, partiendo de situaciones elegidas y descritas por ellas/os. Se ha grabado el proceso reflexivo (5 sesiones por grupo) y analizado posteriormente mediante el método denominado análisis de contenido, poniendo el foco en la forma de organización de la reflexión conjunta y su concreción en diferentes segmentos de interactividad y tipos de ayudas que se proporcionan. Se han identificado diferentes patrones de interacción y ayudas específicas de las tutoras para abordar la reflexión conjunta. Los resultados nos permiten profundizar en la influencia de estos patrones en los procesos de reflexión.Most teacher training programs include reflection as strategy for the construction of knowledge. Nevertheless, there is discrepancy in literature in regard to the way reflection should be directed and fostered. Some experts (Korthagen, 2010) argue that reflection should be based on establishing links between theoretical and practical knowledge. Others (Yoon & Kim, 2010; Pareja Roblin & Margalef, 2013) claim that internal dilemmas underlie every educational context, on which teachers must reflect. Besides, there is debate between the teacher’s type of intervention and the role of assistance so as to foster more complex reflection levels (Moore-Russo & Wilsey, 2014; Gelfuso & Dennis, 2014). Therefore, this being the reality, the research we present aims at contributing a better understanding of the elements that facilitate students’ reflecting competences and the link between situational knowledge and practical knowledge (Clarà & Mauri, 2009, 2010). 8 cases have been analyzed, eight teacher students with their corresponding tutors (112 students and 8 tutors). Groups are from 3 different Universities: Universidad de Barcelona, Universidad de Sevilla and Mondragon Unibertsitatea. The aim of these groups is to reflect on the situations experienced during their teaching practice placements, based on the situations chosen and described by them. The reflective process (5 sessions per group) have been recorded and subsequently analyzed using the method called content analysis, placing the focus on how joint reflection is organized and its realization in different interaction sections and the types of assistance provided. Different interaction patterns and specific assistance from the tutors to deal with joint reflection have been identified. The results allow us for deepening in the influence of those patterns in reflection processes

Prioridades de investigación en términos de fluidoterapia perioperatoria y monitorización hemodinámica: encuesta de consenso Delphi del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasia, Medicina Transfusional y Fluidoterapia (SHTF) de la Sociedad Española de Anestesiología y Reanimación (SEDAR)

Background Research in fluid therapy and perioperative hemodynamic monitoring is difficult and expensive. The objectives of this study were to summarize these topics and to prioritize these topics in order of research importance. Methods Electronic structured Delphi questionnaire over three rounds among 30 experts in fluid therapy and hemodynamic monitoring identified through the Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care. Results 77 topics were identified and ranked in order of prioritization. Topics were categorized into themes of crystalloids, colloids, hemodynamic monitoring and others. 31 topics were ranked as essential research priority. To determine whether intraoperative hemodynamic optimization algorithms based on the invasive or noninvasive Hypotension Prediction Index versus other management strategies could decrease the incidence of postoperative complications. As well as whether the use of renal stress biomarkers together with a goal-directed fluid therapy protocol could reduce hospital stay and the incidence of acute kidney injury in adult patients undergoing non-cardiac surgery, reached the highest consensus. Conclusions The Fluid Therapy and Hemodynamic Monitoring Subcommittee of the Hemostasis, Transfusion Medicine and Fluid Therapy Section of the Spanish Society of Anesthesiology and Critical Care will use these results to carry out the research.Antecedentes La investigación sobre fluidoterapia y monitorización hemodinámica perioperatorias es difícil y costosa. Los objetivos del presente estudio fueron resumir y priorizar estas cuestiones, en orden de importancia investigadora. Métodos Cuestionario estructurado electrónico Delphi a lo largo de tres rondas entre 30 expertos en fluidoterapia y monitorización hemodinámica identificados a través del Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación. Resultados Se identificaron 77 cuestiones, que se clasificaron en orden de priorización. Las cuestiones se categorizaron en temas de cristaloides, coloides, monitorización hemodinámica y otros. Se categorizaron 31 cuestiones como de prioridad investigadora esencial, para determinar si los algoritmos de optimización hemodinámica intraoperatorios basados en el Índice de predicción de hipotensión invasivo o no invasivo frente a otras estrategias de manejo podrían reducir la incidencia de complicaciones postoperatorias, así como si el uso de biomarcadores del estrés renal junto con un protocolo de fluidoterapia dirigido por objetivos podría reducir la estancia hospitalaria y la incidencia de insuficiencia renal aguda en pacientes adultos sometidos a cirugía no cardiaca, lográndose el más alto consenso. Conclusiones El Subcomité de Fluidoterapia y Monitorización hemodinámica de la Sección de Hemostasis, Medicina Transfusional y Fluidoterapia de la Sociedad española de Anestesiología y Reanimación utilizará estos resultados para la realización de investigació

Accelerated surgery versus standard care in hip fracture (HIP ATTACK) : an international, randomised, controlled trial

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4\u20139) in the accelerated-surgery group and 24 h (10\u201342) in the standard-care group (p<0\ub70001). 140 (9%) patients assigned to accelerated surgery and 154 (10%) assigned to standard care died, with a hazard ratio (HR) of 0\ub791 (95% CI 0\ub772 to 1\ub714) and absolute risk reduction (ARR) of 1% ( 121 to 3; p=0\ub740). Major complications occurred in 321 (22%) patients assigned to accelerated surgery and 331 (22%) assigned to standard care, with an HR of 0\ub797 (0\ub783 to 1\ub713) and an ARR of 1% ( 122 to 4; p=0\ub771). Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared with standard care. Funding: Canadian Institutes of Health Research

Human health risk assessment for aluminium, aluminium oxide, and aluminium hydroxide.

International audienc