34 Chapter 2 in the Netherlands, equivalent to 6.4:8.0:9.7 g/dL) affected Dutch transfusion practice by setting a standard for physicians to avoid impulse transfusion (“if the [patient] looks pale, give blood” Dutch Expert 27) or transfusing based on their prior education or experience (“20 years ago, it was normal, even in the clinics, to give two or three units of blood!” Dutch Expert 26). In comparison, 70% of international experts specifically linked lowered thresholds to PBM, which brought “evidence to the forefront or made people aware of the need for transfusion research” (International Expert 9) and a strong “sense of stewardship” (International Expert 29) across various clinical specialties. Experts stated that PBM has led to steep declines in many countries. Fewer experts from the Netherlands (25%) explicitly mentioned PBM, probably due to terminology differences. Of those articles that discussed either lowered transfusion thresholds/guidelines (n = 38) or PBM or blood conservation programs (n = 34), 20 articles explicitly linked the lowered thresholds with PBM. Furthermore, these lowered thresholds were connected to both scientific and public-related evidence. Experts described how various clinical studies in the past decades supported that both the transfusion trigger and the dosage could be safely lowered, such as Hébert’s influential TRICC (Transfusion Requirements in Critical Care) trial. However, there was a noticeable difference between those who stated this with up to 20 years of experience (11%) compared to those with 21+ years of experience (35%). Public evidence was seen in the survival of Jehovah’s Witnesses. The combination of this evidence, challenged medical perspectives and brought awareness of transfusion’s adverse reactions, which was “an eye-opener” (Dutch Expert 6) due to the traditional only-beneficial perspective experts had. Four articles27–30 reflect on particular studies that have shaped the evolution of transfusion. One author questions whether transfusion has now become too restrictive29 and warns that the evidence is still limited with gaps in knowledge.27 Another author describes successful transfusion-free liver transplantations of Jehovah’s Witnesses with implications for all surgical patients,31 and Nollett32 highlights the rise of specialists caring for patients who refuse transfusion, exemplified in Japan. The second most common reason (n=22, 52%) was minimally invasive surgical techniques, alternatives to blood transfusion, and pharmacologic agents. Overall, 47% of experts with up to 20 years of experience in blood transfusion and 57% who had 21+ years of experience, indicated this. Experts verified that this cumulative driver had a profound impact on transfusion, as described by one expert who observed a radical reduction in surgical blood use: “I saw the evolution of cardiac surgery, orthopedic surgery, any surgery. I did a lot of liver transplantation … 20 years ago, the minimum transfusion was
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