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the onset of pulmonary edema and damage associated with the transfusion&#44; as well as hemolytic reactions and graft-versus-host disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> With these already known adverse effects&#44; studies have been conducted since 1980 to establish the hemoglobin objective&#44; with a more restrictive perspective and considering the product&#8217;s limited availability&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These studies&#44; mainly conducted with critically ill patients hospitalized in intensive care units&#44; have established a consensus on limits for hemoglobin levels for indicating transfusion&#44; assessing the accompanying disease as well as the hemoglobin&#46; The current limits are more restrictive than the old &#8220;10&#47;30&#8221; maxim and support an indication for transfusion starting from a hemoglobin level of 7&#8239;g&#47;dL for patients admitted with stable ischemic heart disease&#44; levels of 7&#8211;9&#8239;g&#47;dL for critically ill patients with head injuries&#44; gastrointestinal hemorrhage or sepsis and levels of 8&#8211;9&#8239;g&#47;dL for patients with exacerbated ischemic heart disease or subarachnoid hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;7</span></a> These new criteria have shown a favorable risk-benefit balance&#44; without increasing mortality or readmissions despite the persistence of anemia at discharge&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;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&#44; the number of patients with anemia &#40;and thus the number of transfusions&#41; continues to increase&#44; constituting a significant health problem&#46; Just a few facts to frame the problem&#58; in the United States&#44; 15 million red blood cell units are transfused per year&#59; worldwide&#44; this figure rises to 85 million&#46; Forty percent of patients hospitalized as critically ill will undergo a transfusion of 2&#8211;5 units&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and transfusions are performed for 10&#37; of patients hospitalized for a procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Conscious of these problems&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">These policies have clearly been effective&#59; thus&#44; for example&#44; 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&#37; to 43&#37; and the total number of transfused units by 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Education and dissemination of indications have reduced by 27&#37; the number of units without increasing the risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">If we focus on the emergency departments&#44; the problem of transfusion overuse&#44; which is similar to that reported in other departments&#44;<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&#46; For unstable patients with active bleeding and shock criteria&#44; there is no discussion regarding the early use of transfusions&#44; and there are even protocols for urgent and massive transfusions&#46; For patients admitted for acute or chronic anemia with no signs of instability&#44; however&#44; 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&#46; 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&#44; 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&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The study by et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#44; which illustrated the current situation of transfusions in emergency departments&#44; is therefore of significant interest to us&#44; as it compared data from 2 centers with different profiles and avoided the bias of acute anemia with criteria of instability or shock&#44; to focus mainly on patients for whom we should apply the guidelines&#46; The study is important&#44; not only for the appropriateness and overtransfusion data it provides&#44; 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&#46; We wish to note that more than 90&#37; of transfusions were for medical reasons and that the most common was bleeding related to treatment of heart disease &#40;due to the use of antiplatelet and&#47;or anticoagulants&#41;&#44; indicating another possible area for the improvement with the review and adjustment of medication&#46; Another interesting finding is the high percentage of patients who were not hospitalized after the transfusion&#46; This situation converts emergency departments not only into the department that prescribes transfusions but also into the coordinator of subsequent patient follow-up&#44; referring to the appropriate healthcare level and indicating future actions&#46; It is therefore essential that this indication should once again be adjusted as much as possible to the recommendations with clinical evidence&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The authors indicated interesting strategies for improvement&#44; such as monitoring after each transfused unit&#44; increasing training on transfusion guidelines&#44; and obtaining information on the results&#44; adverse effects&#44; and the policies implemented in our departments&#46; We believe it should be a global commitment by emergency departments to offer their patients the best treatment for their anemia&#46;</p></span>"
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2019-11-05"
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Amores Arriaga B&#44; Garc&#233;s Horna V&#46; Transfusi&#243;n en urgencias &#191;podemos mejorar&#63; Rev Clin Esp&#46; 2020&#59;220&#58;432&#8211;433&#46;</p>"
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    ]
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Editorial
Transfusion in the emergency department. Can it be improved?
Transfusión en urgencias ¿podemos mejorar?
B. Amores Arriagaa,b,c,
Corresponding author
amoresarriaga@yahoo.es

Corresponding author.
, V. Garcés Hornaa,b
a Servicio de Medicina Interna, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Instituto de Investigación Sanitaria de Aragón, Zaragoza, Spain
c Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
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