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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Anemia has become one of the most common diseases in emergency departments, either as the main reason for consultation or as part of the comorbidity of patients treated in our departments.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Transfusion has been the standard treatment for anemia for the past 100 years, but the politics of when and how to transfuse have undergone considerable changes. Transfusion was initially considered a risk-free technique in the presence of anemia, opting to reach “10/30” objectives (10 g of hemoglobin and 30% hematocrit). Later, reports of adverse effects and diseases linked to the use of transfusion began to surface, Among these the danger of transmitting infections, the onset of allergic reactions, volume or iron overload and, less frequently, the onset of pulmonary edema and damage associated with the transfusion, as well as hemolytic reactions and graft-versus-host disease.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> With these already known adverse effects, studies have been conducted since 1980 to establish the hemoglobin objective, with a more restrictive perspective and considering the product’s limited availability.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These studies, mainly conducted with critically ill patients hospitalized in intensive care units, have established a consensus on limits for hemoglobin levels for indicating transfusion, assessing the accompanying disease as well as the hemoglobin. The current limits are more restrictive than the old “10/30” maxim and support an indication for transfusion starting from a hemoglobin level of 7 g/dL for patients admitted with stable ischemic heart disease, levels of 7–9 g/dL for critically ill patients with head injuries, gastrointestinal hemorrhage or sepsis and levels of 8–9 g/dL for patients with exacerbated ischemic heart disease or subarachnoid hemorrhage.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–7</span></a> These new criteria have shown a favorable risk-benefit balance, without increasing mortality or readmissions despite the persistence of anemia at discharge.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Despite the establishment of consensus guidelines and recommendations with increasingly restrictive starting levels for transfusions, the number of patients with anemia (and thus the number of transfusions) continues to increase, constituting a significant health problem. Just a few facts to frame the problem: in the United States, 15 million red blood cell units are transfused per year; worldwide, this figure rises to 85 million. Forty percent of patients hospitalized as critically ill will undergo a transfusion of 2–5 units,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and transfusions are performed for 10% of patients hospitalized for a procedure.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Conscious of these problems, the Joint Commission and the American Medical Association in 2013 included transfusions among the 5 most overused procedures in hospitals and insisted on the need for implementing policies that properly regulate the use of transfusions.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These policies have clearly been effective; thus, for example, strategies for reassessment after the administration of the first red blood cell unit<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> have managed to decrease the number of transfusions of 2 units from 65% to 43% and the total number of transfused units by 50%.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Education and dissemination of indications have reduced by 27% the number of units without increasing the risk.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">If we focus on the emergency departments, the problem of transfusion overuse, which is similar to that reported in other departments,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> is more complex due to the intrinsic characteristics of patients treated in emergency departments. For unstable patients with active bleeding and shock criteria, there is no discussion regarding the early use of transfusions, and there are even protocols for urgent and massive transfusions. For patients admitted for acute or chronic anemia with no signs of instability, however, we should be more cautious and implement the guidelines and consensus documents to assess improvement in emergency patients and clearly select the point for starting the transfusion. There have been studies conducted in emergency departments observing increased mortality in patients in whom more than 2 packed red blood cell units were transfused, which is probably related to the underlying cause of the anemia but also to the adverse effects of the transfusion itself as an added factor.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The study by et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>, which illustrated the current situation of transfusions in emergency departments, is therefore of significant interest to us, as it compared data from 2 centers with different profiles and avoided the bias of acute anemia with criteria of instability or shock, to focus mainly on patients for whom we should apply the guidelines. The study is important, not only for the appropriateness and overtransfusion data it provides, which indicates the road to improvement but also for the description of the diseases that motivate the indication for transfusion and the departments from which the patients originate. We wish to note that more than 90% of transfusions were for medical reasons and that the most common was bleeding related to treatment of heart disease (due to the use of antiplatelet and/or anticoagulants), indicating another possible area for the improvement with the review and adjustment of medication. Another interesting finding is the high percentage of patients who were not hospitalized after the transfusion. This situation converts emergency departments not only into the department that prescribes transfusions but also into the coordinator of subsequent patient follow-up, referring to the appropriate healthcare level and indicating future actions. It is therefore essential that this indication should once again be adjusted as much as possible to the recommendations with clinical evidence.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The authors indicated interesting strategies for improvement, such as monitoring after each transfused unit, increasing training on transfusion guidelines, and obtaining information on the results, adverse effects, and the policies implemented in our departments. We believe it should be a global commitment by emergency departments to offer their patients the best treatment for their anemia.</p></span>"
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