Abstract Patient Blood Management (PBM) is a holistic approach to managing blood as a resource of each patient; it is a multimodal strategy that is implemented using a set of techniques that can be applied in individual cases. In fact, the overall result of the implementation of PBM cannot be fully appreciated or explained by simply summing up the effects of the individual strategies and techniques used, since they can only produce the expected ideal result if combined. Implementing a PBM program in healthcare offers several benefits including improved patient safety, better outcomes, cost savings, conservation of resources, evidence-based practice, transfusion alternatives, improved quality of care, compliance with accreditation standards, patient-centered care, and professional education and training. (PBM cases fact used combined safety outcomes savings resources evidencebased evidence based practice alternatives care standards patientcentered centered training

Abstract Managing the patient's blood and hematopoietic system is like managing any of the other organs and organ systems during patient care. Specialists control the heart, kidneys, endocrine system, etc. and the patient's blood requires similar clinical treatment. The hematopoietic system and its circulatory products are fundamental for the healthy functioning of the human body. In simple terms, Patient Blood Management (PBM) is an organized, patient-centered approach in which the entire healthcare team coordinates efforts to improve outcomes by managing and preserving the patient's own blood. By reducing dependence on blood transfusions, PBM seeks to improve clinical outcomes, reduce the risks and costs associated with transfusions, and improve the safety and quality of patient care. Essentially, the concept of PBM is about the holistic management and preservation of the patient's own blood in the medical and surgical context. patients s care heart kidneys etc treatment body terms (PBM organized patientcentered centered transfusions Essentially context

Abstract Autologous blood transfusion can be achieved through different techniques, including by the patient donating blood before surgery (pre-deposit), collecting blood from the patient immediately before the operation and replacing the volume with colloids or plasma expanders (acute normovolemic hemodilution) or through the salvage of lost blood, during or immediately after surgery, and its retransfusion after washing (intraoperative or postoperative recovery). We will focus on the two methods used intraoperatively that are of fundamental importance in the management and conservation of the patient's own blood. techniques predeposit, predeposit pre deposit , (pre-deposit) acute hemodilution intraoperative recovery. recovery . recovery) patients s (pre-deposit

Abstract The management of major bleeding is a critical aspect of modern healthcare and it is imperative to emphasize the importance of applying Patient Blood Management (PBM) principles. Although transfusion support remains a vital component of bleeding control, treating severe bleeding goes beyond simply replacing lost blood. A more comprehensive, multidisciplinary approach is essential to optimize patient outcomes and minimize the risks associated with excessive transfusions. PBM (PBM principles control blood comprehensive transfusions

Abstract Hemostasis plays a critical role in surgical procedures and is essential for a successful outcome. Advances in hemostatic agents offer new approaches to controlling bleeding thereby making surgeries safer. The appropriate choice of these agents is crucial. Volume replacement, another integral part of Patient Blood Management (PBM), maintains adequate tissue perfusion, preventing cellular damage. Individualization in fluid administration is vital with the choice between crystalloids and colloids depending on each case. Colloids, unlike crystalloids, increase oncotic pressure, contributing to fluid retention in the intravascular space. Understanding these aspects is essential to ensure safe and effective surgery, minimizing complications related to blood loss and maintaining the patient's hemodynamic status. outcome safer crucial replacement PBM, PBM , (PBM) perfusion damage case Colloids pressure space surgery patients patient s status (PBM

Abstract Hemostasis plays a critical role in surgical procedures and is essential for a successful outcome. Advances in hemostatic agents offer new approaches to controlling bleeding thereby making surgeries safer. The appropriate choice of these agents is crucial. Volume replacement, another integral part of Patient Blood Management (PBM), maintains adequate tissue perfusion, preventing cellular damage. Individualization in fluid administration is vital with the choice between crystalloids and colloids depending on each case. Colloids, unlike crystalloids, increase oncotic pressure, contributing to fluid retention in the intravascular space. Understanding these aspects is essential to ensure safe and effective surgery, minimizing complications related to blood loss and maintaining the patient's hemodynamic status. outcome safer crucial replacement PBM, PBM , (PBM) perfusion damage case Colloids pressure space surgery patients patient s status (PBM

Abstract The use of strategies to reduce blood loss and transfusions is essential in the treatment of surgical patients, including in complex cardiac surgeries and those that use cardiopulmonary bypass. Antifibrinolytics, such as epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA), are widely used in these procedures, as well as in other types of surgeries. These medicines are included in the World Health Organization (WHO) list of ‘essential medicines’. Scientific evidence demonstrates the effectiveness of EACA in reducing bleeding and the need for transfusions in heart surgery. EACA is highly recommended for use in heart surgery by the American Society of Anesthesiology Task Force on Perioperative Blood Management. Regarding the safety of EACA, there is no robust evidence of any significant thrombotic potential. TXA has also been shown to be effective in reducing the use of blood transfusions in cardiac and non-cardiac surgeries and is considered safer than other antifibrinolytic agents. There is no evidence of any increased risk of thromboembolic events with TXA, but doses greater than 2 g per day have been associated with an increased risk of seizures. It is also important to adjust the dose in patients with renal impairment. In conclusion, antifibrinolytics, such as EACA and TXA, are effective in reducing blood loss and transfusion use in cardiac and non-cardiac surgeries, without causing serious adverse effects. bypass Antifibrinolytics epsilonaminocaproic epsilon aminocaproic (EACA , (TXA) procedures WHO (WHO medicines. . medicines’ Management potential noncardiac non agents seizures impairment conclusion antifibrinolytics effects (TXA

Abstract Patient Blood Management (PBM) is a multidimensional approach that seeks to optimize the use of blood and its components in patients. This matter emerged as a response to the need to reduce unnecessary exposure to blood transfusions and their potential risks. In the past, blood transfusion was often overused resulting in complications and high costs. The advent of Patient Blood Management has caused a paradigm shift, highlighting anemia prevention, bleeding control and maximizing the production of blood cells by the organism itself. Patient Blood Management guidelines include the early identification of anemia, strategies to minimize blood loss during surgery, intraoperative blood conservation techniques, preoperative hemoglobin optimization and evidence-based approaches to the rational use of blood transfusions. Aiming to improve clinical outcomes, decrease transfusion-related complications and reduce associated costs, this multidisciplinary approach counts on doctors, nurses, pharmacists and other healthcare professionals. Based on research and clinical evidence, Patient Blood Management continues to evolve thereby promoting safer, more effective patient-centered practices. Its implementation has proven beneficial in various medical contexts thereby contributing to improvements in the quality of care provided to patients. Our goal with this Consensus is to present readers with a broad and diverse view of Patient Blood Management so that they have the building blocks to implement this new technique. PBM (PBM patients risks past costs shift prevention itself surgery techniques evidencebased evidence based outcomes transfusionrelated related doctors nurses professionals safer patientcentered patient centered practices technique

Introduction: Blood transfusion is a traditional, popular treatment and considered by society and the medical community as a treatment that has great benefits in reducing mortality. Evidence-based medicine is an approach to medical practice that aims at making decisions based on up-to-date scientific evidence tested by the scientific method. The objective of this study was to evaluate blood transfusion through the lens of evidence-based medicine. Methods: Non-systematic search of the literature, without restriction of type of study, date or language, in the scientific databases: MEDLINE, LILACS, EMBASE, Cochrane Library, SciELO, Scopus and Web of Science, prioritizing publication of systematic reviews and meta-analysis. Results: Systematic review of randomized clinical trials showed that more restrictive blood transfusion reduces mortality when compared to less restrictive transfusions. No randomized placebo-controlled clinical trials evaluating the efficacy of blood transfusion were found, setting up an uncertainty of the effect of both restrictive and liberal blood transfusion on mortality. Systematic review of the quality of guidelines on blood transfusion showed that the guidelines were carried out with low methodological rigor. Systematic review concluded that most studies did not demonstrate improvement of tissue oxygenation with blood transfusion. Systematic reviews of observational studies demonstrated an association of blood transfusion with increased mortality and all Bradford Hill causality criteria were met pointing to a causal relationship between blood transfusion and increased adverse outcomes. Systematic reviews have shown that both patients and physicians tend to overestimate the true benefits of treatments and underestimate their harms. Conclusion: The scientific evidence base for recommending blood transfusion is weak, with no robust evidence that the treatment reduces mortality. There is a significant accumulation of evidence showing worse clinical outcome with this treatment, revealing clear disagreement on how this treatment is perceived by society and the medical community. This leads to ethical and legal implications related to the quality of information that is offered to patients to obtain their informed consent and respect for their autonomy regarding the use of this treatment. The medical and legal communities, as well as society, should urgently re-evaluate blood transfusion under the principles of evidence-based medicine.

Introducción: La transfusión de sangre es un tratamiento tradicional, popular y considerado por la sociedad y la comunidad médica como un tratamiento que presenta grandes beneficios en la reducción de la mortalidad. La medicina basada en la evidencia es un enfoque de la práctica médica que pretende tomar decisiones basadas en pruebas científicas actualizadas y comprobadas por el método científico. El objetivo de este estudio fue evaluar la transfusión de sangre bajo los lentes de la medicina basada en la evidencia. Métodos: Búsqueda no sistemática de la literatura, sin restricción de tipo de estudio, fecha o idioma, en las bases de datos científicas: MEDLINE, LILACS, EMBASE, Cochrane Library, SciELO, Scopus y Web of Science, priorizando la publicación de revisiones sistemáticas y meta-análisis. Resultados: La revisión sistemática de los ensayos clínicos aleatorios mostró que las transfusiones de sangre más restrictivas reducen la mortalidad en comparación con las transfusiones menos restrictivas. No se encontraron ensayos clínicos aleatorios controlados con placebo que avalaran la eficacia de la transfusión de sangre, configurando la incertidumbre del efecto de la transfusión de sangre, tanto en la modalidad restrictiva como en la liberal, en la mortalidad. La revisión sistemática de la calidad de las directrices sobre transfusión de sangre mostró que las directrices se realizaron con poco rigor metodológico. La revisión sistemática concluyó que la mayoría de los estudios no demostraron una mejora de la oxigenación tisular con la transfusión de sangre. Las revisiones sistemáticas de los estudios observacionales mostraron una asociación de la transfusión de sangre con el aumento de la mortalidad, y se cumplieron todos los criterios de causalidad de Bradford Hill, lo que apunta a una relación causal entre la transfusión de sangre y el aumento de los resultados adversos. Las revisiones sistemáticas han demostrado que tanto los pacientes como los médicos tienden a sobrestimar los verdaderos beneficios de los tratamientos sanguíneos y a subestimar sus daños. Conclusión: La base de pruebas científicas para recomendar la transfusión de sangre es débil, sin pruebas sólidas de que el tratamiento reduzca la mortalidad. Existe una importante acumulación de pruebas que demuestran un peor resultado clínico con este tratamiento, lo que revela un claro desacuerdo sobre cómo perciben este tratamiento la sociedad y la comunidad médica. Este hallazgo conlleva implicaciones éticas y legales relacionadas con la calidad de la información que se ofrece a los pacientes para obtener su consentimiento informado, así como el respeto a su autonomía respecto al uso de este tratamiento. La comunidad médica, la comunidad jurídica y la sociedad deben reevaluar urgentemente la transfusión de sangre bajo los principios de la medicina basada en la evidencia.

Introdução: A transfusão de sangue é um tratamento tradicional, popular e considerada pela sociedade e pela comunidade médica como um tratamento que apresenta grandes benefícios na redução da mortalidade. A medicina baseada em evidências é uma abordagem a prática médica que visa a tomada de decisões a partir de provas científicas atualizadas e testadas pelo método científico. O objetivo deste estudo foi avaliar a transfusão de sangue sob as lentes da medicina baseada em evidências. Métodos: Busca não sistemática da literatura, sem restrição de tipo de estudo, data ou idioma, nas bases de dados científicas: MEDLINE, LILACS, EMBASE, Biblioteca Cochrane, SciELO, Scopus e Web of Science, priorizando publicação de revisões sistemáticas e metanálises. Resultados: Revisão sistemática de ensaios clínicos randomizados demonstrou que transfusão de sangue mais restritiva reduz a mortalidade quando comparada a transfusões menos restritivas. Não foram encontrados ensaios clínicos randomizados placebo-controlados que avaliaram a eficácia da transfusão de sangue, configurando uma incerteza do efeito da transfusão de sangue, tanto na modalidade restritiva como na liberal, na mortalidade. Revisão sistemática da qualidade das diretrizes sobre transfusão de sangue demonstrou que as diretrizes foram realizadas com baixo rigor metodológico. Revisão sistemática concluiu que a maioria dos estudos não demonstrou melhora da oxigenação tecidual com a transfusão de sangue. Revisões sistemáticas de estudos observacionais demonstraram uma associação da transfusão de sangue com aumento da mortalidade e todos os critérios de causalidade de Bradford Hill foram contemplados, apontando uma relação causal entre a transfusão de sangue e aumento dos desfechos adversos. Revisões sistemáticas demonstraram que tanto pacientes quanto médicos apresentam tendência a superestimar os verdadeiros benefícios de tratamentos e subestimar seus danos. Conclusão: A base de evidências científicas para recomendar a transfusão de sangue é fraca, não havendo evidências robustas de que o tratamento reduza a mortalidade. Há acúmulo significativo de evidências demonstrando pior desfecho clínico com este tratamento, revelando nítida discordância sobre o modo que este tratamento é percebido pela sociedade e pela comunidade médica. Tal constatação leva a implicações éticas e legais relacionadas à qualidade das informações que são oferecidas ao paciente para obtenção do seu consentimento informado e esclarecido, assim como o respeito à sua autonomia quanto ao uso deste tratamento. A comunidade médica, jurídica e a sociedade devem, com urgência, reavaliar a transfusão de sangue sob os princípios da medicina baseada em evidências.

Introduction: Blood transfusion is traditional and popular, considered beneficial in reducing mortality. Evidence-based medicine (EBM) seeks medical decisions based on scientific evidence. Method: This study evaluated blood transfusion from the perspective of EBM through a narrative review. Results: Review of randomized controlled trials (RCTs) showed that restrictive transfusion reduces mortality compared to less restrictive transfusion. No randomized placebo-controlled trials evaluating the efficacy of blood transfusion were found, creating uncertainty about the effect of blood transfusion, both in the restrictive and liberal modalities, on mortality. Systematic review of the quality of blood transfusion guidelines demonstrated that the guidelines were developed with low methodological rigor. Reviews of observational studies have linked transfusion to increased mortality, with Bradford Hill criteria suggesting a causal relationship. Systematic literature review demonstrates that Patient Blood Management (PBM) promotes reduced mortality and improved clinical outcomes. Although PBM provides an approach to reducing the use of stored blood, it does not challenge the basic assumption that blood transfusion is necessary or beneficial at some point. Conclusion: Following the important bioethic principle guiding the medical profession, "Primum non nocere" (First, do no harm), it is necessary to urgently reevaluate the inclusion of blood transfusion in the medical arsenal, a therapy that presents dubious benefit but proven harms. Until this reevaluation is fully undertaken by the medical community, patients must be fully and adequately informed about all these facts from now on, so that they can fully exercise their autonomy.

Introducción: La transfusión de sangre es tradicional y popular, considerada beneficiosa en la reducción de la mortalidad. La medicina basada en la evidencia (MBE) busca decisiones médicas basadas en pruebas científicas. Método: Este estudio evaluó la transfusión sanguínea desde la perspectiva de la MBE a través de una revisión narrativa. Resultados: La revisión de ensayos clínicos aleatorizados (ECA) mostró que la transfusión restrictiva reduce la mortalidad en comparación con la transfusión menos restrictiva. No se encontraron ensayos clínicos aleatorizados controlados con placebo que evaluaran la eficacia de la transfusión de sangre, lo que crea incertidumbre sobre el efecto de la transfusión de sangre, tanto en las modalidades restrictivas como en las liberales, sobre la mortalidad. La revisión sistemática de la calidad de las pautas de transfusión sanguínea demostró que las pautas se desarrollaron con un bajo rigor metodológico. Las revisiones de estudios observacionales han vinculado la transfusión con un aumento de la mortalidad, y los criterios de Bradford Hill sugieren una relación causal. La revisión sistemática de la literatura demuestra que la Gestión de Sangre del Paciente (PBM) promueve una reducción de la mortalidad y mejores resultados clínicos. Aunque la PBM proporciona un enfoque para reducir el uso de sangre almacenada, no cuestiona la suposición básica de que la transfusión de sangre es necesaria o beneficiosa en algún momento. Conclusión: Siguiendo el principio hipocrático más importante que guía la profesión médica, "Primum non nocere" (Primero, no hacer daño), es necesario reevaluar con urgencia la inclusión de la transfusión de sangre en el arsenal médico, una terapia que presenta beneficios dudosos pero daños comprobados. Hasta que esta reevaluación sea llevada a cabo completamente por la comunidad médica, los pacientes deben ser informados plenamente y de manera adecuada sobre todos estos hechos a partir de ahora, para que puedan ejercer plenamente su autonomía.

Introdução: A transfusão de sangue é tradicional e popular, considerada benéfica na redução da mortalidade. A medicina baseada em evidências (MBE) busca decisões médicas embasadas em provas científicas. Método: Este estudo avaliou a transfusão sob a ótica da MBE através de uma revisão narrativa. Resultados: Revisão de ensaios clínicos randomizados (ECRs) mostrou que transfusão restritiva reduz mortalidade comparada a menos restritiva. Não foram encontrados ensaios clínicos randomizados placebo controlados que avaliaram a eficácia da transfusão de sangue, configurando uma incerteza do efeito da transfusão de sangue, tanto na modalidade restritiva como na liberal, na mortalidade. Revisão sistemática da qualidade das diretrizes sobre transfusão de sangue demonstrou que as diretrizes foram realizadas com baixo rigor metodológico. Revisões de estudos observacionais associaram transfusão a aumento de mortalidade, sendo que os critérios de Bradford Hill sugerem uma relação causal. Revisão sistemática da literatura demonstra que o Gerenciamento de Sangue do Paciente (PBM) promove redução da mortalidade e melhores desfechos clínicos. Embora o PBM forneça uma abordagem para reduzir o uso de sangue armazenado, ele não desafia a suposição básica de que a transfusão em algum momento é necessária ou benéfica. Conclusão: Seguindo o importante princípio bioético que rege a profissão médica, “Primum non nocere” (antes de tudo, não fazer mal), se faz necessário reavaliar com urgência a permanência no arsenal médico da transfusão de sangue, uma terapia que apresenta benefício duvidoso, mas danos comprovados. Até que esta reavaliação seja feita de forma cabal pela comunidade médica, os pacientes devem ser integralmente e adequadamente informados desde já a respeito de todos estes fatos para que possam exercer de forma plena sua autonomia.

Introduction: The COVID-19 pandemic caused a significant shortage of blood stocks in several countries. Different strategies used in this scenario, such as suspension of elective surgeries, calling for more donors and loosening of regulations used in blood centers have limitations. The objective of this study was to evaluate the effectiveness, safety and cost-effectiveness of a set of medical care called Patient Blood Management (PBM) through a narrative review of the literature. Methods: Non-systematic literature search, without restriction of type of study, date or language, in the scientific databases: MEDLINE, LILACS, EMBASE, Cochrane Library, SciELO, Scopus and Web of Science. Results: Randomized clinical trials and meta-analysis of observational studies demonstrated that the use of PBM promoted a reduction in blood transfusions, length of hospital stay, complications such as acute renal failure, infection, thromboembolic events, and mortality. Economic analysis studies have observed significant savings in financial resources in the places where the PBM was implemented. Conclusion: PBM is effective, safe and cost-effective, promoting a reduction in blood transfusions, improving clinical outcomes and saving financial resources, characteristics that make it relevant in the face of a health system overburdened by the pandemic.

Introdução: A pandemia de COVID-19 provocou uma significativa escassez dos estoques de sangue em diversos países. Diferentes estratégias utilizadas neste cenário, como suspensão de cirurgias eletivas, chamamento de mais doadores e afrouxamento de normativas usadas nos hemocentros apresentam limitações. O objetivo deste estudo foi avaliar a eficácia, segurança e custo-efetividade de um conjunto de cuidados médicos chamado de Gerenciamento de Sangue do Paciente (Patient Blood Management – PBM) através de uma revisão narrativa da literatura. Métodos: Busca não sistemática da literatura, sem restrição de tipo de estudo, data ou idioma, nas bases de dados científicas: MEDLINE, LILACS, EMBASE, Biblioteca Cochrane, SciELO, Scopus e Web of Science. Resultados: Ensaios clínicos randomizados e metanálises de estudos observacionais demonstraram que o uso de PBM promoveu redução das transfusões de sangue, do tempo de internação hospitalar, das complicações como insuficiência renal aguda, infecção, eventos tromboembólicos, e da mortalidade. Estudos de análise econômica observaram relevante economia de recursos financeiros nos locais em que o PBM foi implementado. Conclusão: O PBM é eficaz, seguro e custo-efetivo, promovendo redução das transfusões de sangue, melhora nos desfechos clínicos e economia de recursos financeiros, características que o tornam relevante diante de um sistema de saúde sobrecarregado pela pandemia.

O estudo anatômico do encéfalo em cortes é facilitado empregando-se métodos de coloração para substância cinzenta. Os métodos mais freqüentemente empregados são os de Barnard, Robert e Brown, Mulligan e Green. O objetivo deste estudo foi determinar qual dessas técnicas apresenta melhores resultados com relação à diferenciação entre substâncias branca e cinzenta. Trinta cortes coronais de hemisfério cerebral humano foram submetidos às três técnicas, comparados entre si e analisados de acordo com três parâmetros estabelecidos: grau de diferenciação entre as substâncias branca e cinzenta; presença de linha única e contínua separando a substância branca do córtex cerebral; grau de impregnação da coloração em outros locais de substância branca. Atribuíram-se pontuações de 0 a 3 conforme a presença destes parâmetros, cada corte recebendo pontuação total que variava de 0 a 9. Após análise estatística, a técnica de Barnard, Robert e Brown apresentou média 8,33; a de Green 7,93 e a de Mulligan, 7,5, com diferença estatisticamente significativa.

Studing neuroanatomy at brain slices with gray matter staining techniques has several advantages. More often, the models described by Barnard, Robert and Brown, Mulligan, and Green are used. The aim of this study was to identify which of them achieves the best results on differentiation between the gray and the white matter. Thirty coronal slices of human brains underwent staining by the three techniques, and thus compared and analysed according this three parameters: degree of differentiation between white and gray matter, presence of a single and uninterrupted line dividing the white matter from the brain cortex; and degree of impregnation of the color staining in the white matter; scores from 0 to 3 have been given for the three parameters, with total score from 0 to 9. After statistic analysis, the Barnard, Robert and Brown model showed the best results, followed by Green's and Mulligan's.