Algorithmic and consultative integration of transfusion medicine and coagulation: A personalized medicine approach with reduced blood component utilization

Background. Therapy customized for the individual patient defines personalized medicine. Current transfu - sion therapy is performed primarily using general guidelines such as keeping the platelet count at >100,000/µL, the INR at ≤1.7 and fibrinogen at >100mg/dL for patients undergoing surgery. Objective: The purpose of this report is to provide an algorithmic and consultative approach for the delivery of person - alized and targeted blood component, blood derivative, and recombinant therapies in order to minimize unnecessary exposure to such therapies and to deliver an optimal risk-benefit ratio for a particular patient. Methods: The initiative involved a step-wise process that included: 1. establishing "triggers" to alert and permit the clinical pathologist to intervene in the utilization of blood components for a given patient in the context of the blood bank inventory; 2. developing algorithms for the assessment of the patient's procoagulant/anticoagulant status so that appropriate blood component, derivative, and/or recombinant therapies could be instituted while minimizing the risk of thrombophilia; 3. a real time assessment and interpretation of the coagulation data so that dialogue between the pathologist and the patient's clinical team could be effected 24 hours a day, 7 days a week; and 4. monitoring the outcome of these efforts by comparing blood component utilization prior to or during development, early implemen - tation and following full implementation of the program. Results: "Triggers" (i.e., administration of six units of fresh frozen plasma (FFP) or ten units of cryoprecipitate or two single donor (apheresis) platelets in a 24-hour period) were approved. A diagnostic and therapeutic algorithm was con- structed, with multidisciplinary input to assist in defining the coagulopathy contributing to the patient's microvascular bleeding in the adult cardiac surgery/cardiac intensive care unit (CICU) and the adult intensive care unit (AICU). Monitoring of utilization, prior to or during development, early implementation and following full implementation of this initiative, revealed a decline in the number of units of FFP, cryoprecipitate and single donor (apheresis) plate- lets administered. Conclusion: We report on the successful development of a model - based on the algorithmic and consultative integration of transfusion medicine and coagulation - that customizes blood component, derivative, and recombinant therapies appropriate for an individual patient's need, resulting in targeted transfusion therapy and as- sociated with reduced blood component utilization.