BACKGROUND:Although the Hypotension Prediction Index (HPI) reduces intraoperative hypotension, improvements in patient-centered outcomes remain inconsistent. We performed a high-resolution signal analysis to describe the coexistence of arterial pressure, preload-related hemodynamic signals, and algorithm-derived hypotension risk during surgery. METHODS:We conducted a retrospective high-resolution signal analysis (20-second intervals) of 181 patients from the multicenter HYT trial. We quantified hypotension (mean arterial pressure [MAP] <65 mmHg), preload-dependent physiology (stroke volume variation [SVV] >13%), and their temporal relationship with HPI-derived risk signals. Patients were classified into four descriptive groups based on combinations of MAP and SVV burden. RESULTS:Overall hypotension exposure was low (median 1.3% of monitored time), whereas preload-dependent physiology was more frequent (approximately 10%) and often persisted during periods classified as low hypotension risk (HPI <80). SVV >13% preceded hypotensive events significantly earlier than HPI alerts (median 8.7 vs. 1.8 minutes; P=0.0119). Higher vasopressor burden was observed in patients with preserved MAP despite sustained SVV elevation. CONCLUSIONS:During HPI-guided care, preserved arterial pressure frequently coexists with sustained preload-dependent hemodynamic signals. These findings describe patterns of pressure and preload-related signal behavior during algorithm-guided hemodynamic management and should be interpreted as hypothesis-generating.

BACKGROUND:Transfusion practices in cardiac valve surgery remain variable despite evidence supporting integrated patient blood management strategies. This study evaluated the independent and combined effects of preoperative hemoglobin status and intraoperative blood conservation techniques on transfusion requirements in elective open cardiac valve surgery. METHODS:We conducted a nationwide retrospective multicenter cohort study using data from the national Maturity Assessment Model for Patient Blood Management registry. Adult patients undergoing elective open cardiac valve surgery between 2016 and 2022 in 23 Spanish hospitals were included. Anemia was defined as preoperative hemoglobin <13 g/dL, irrespective of sex. The primary outcome was red blood cell transfusion during the index hospital admission. RESULTS:A total of 9889 patients were analyzed, with an overall transfusion rate of 53%. Anemic patients (37.3%) had higher transfusion rates than non-anemic patients (70.2% vs. 42.7%). In a separate model restricted to 5763 patients with intraoperative data, combined use of tranexamic acid and intraoperative cell salvage was associated with lower transfusion risk compared with no blood conservation strategy (47.7% vs. 52.3%; adjusted odds ratio 0.83; 95% confidence interval 0.71-0.97), whereas use of either strategy alone showed no meaningful transfusion reduction. When preoperative hemoglobin status and intraoperative strategies were analyzed jointly, the lowest transfusion rate (37.6%) occurred in non-anemic patients receiving both strategies, whereas anemic patients without blood conservation had the highest rate (74.9%; adjusted odds ratio 4.95; 95% confidence interval 4.10-5.97). CONCLUSIONS:Combined implementation of adequate preoperative hemoglobin levels and intraoperative blood conservation strategies was associated with lower transfusion rates in elective cardiac valve surgery, supporting the value of integrated perioperative patient blood management pathways in real-world practice.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease primarily affecting motor neurons. Neurofilament light chain (NfL) is the most established prognostic biomarker; however, its diagnostic resolution is limited, particularly within intermediate concentration ranges, and it does not capture the molecular heterogeneity of ALS. This study aimed to identify complementary cerebrospinal fluid (CSF) biomarkers and pathway-specific signatures through a non-targeted multiomic approach. We performed SWATH-MS-based proteomics and LC-MS/MS lipidomics on CSF from ALS patients stratified by survival (ALS-SS and ALS-LS) and healthy controls. Weighted protein co-expression network analysis (WPCNA) was applied to identify biologically coherent protein modules associated with disease phenotype and progression. Top biomarker candidates were further evaluated using immunoassays in an independent cohort. Post-mortem ALS spinal cord tissues were analyzed to explore the pathophysiological relevance of identified proteins. CSF proteomic profiles robustly distinguished ALS patients from controls and stratified patient subgroups by survival, revealing a molecular signature characterized by inflammation, downregulation of detoxification mechanisms, and synaptic dysregulation in aggressive disease forms. In contrast, lipidomic profiles showed limited discriminatory power. WPCNA identified modular proteomic signatures capturing ALS heterogeneity, and machine learning models based on these profiles yielded optimal biomarker panels for diagnosis and prognosis. CXCL7 emerged as a promising complementary biomarker, and shed light in disease physiopathology. Immunoassay validation supported the diagnostic and prognostic potential of CXCL7 and its association with survival time. Histopathological analysis further confirmed CXCL7 localization in anterior horn motor neurons, despite no detectable changes in whole spinal cord lysates at late disease stages. Comprehensive CSF proteomic profiling, combined with network-based analysis, enhances our understanding of ALS molecular heterogeneity and provides a framework for precision biomarker discovery. CXCL7 complements NfL as a diagnostic and prognostic biomarker, supporting improved patient stratification and advancing the development of personalized therapeutic strategies in ALS.

BACKGROUND:Balanced crystalloids are widely used as alternatives to 0.9% saline, yet their effects on patient-important outcomes remain uncertain. Cluster-randomized trials provide a pragmatic framework for evaluating fluid strategies as implemented in routine clinical practice. We performed a hierarchical Bayesian meta-analysis to estimate the effectiveness of balanced versus saline fluid policies. METHODS:We searched MEDLINE, Embase, and CENTRAL through September 2025 for cluster-randomized and cluster-allocated trials comparing balanced crystalloids with saline across perioperative, emergency, and critical care settings. The primary outcome was all-cause mortality; acute kidney injury (AKI) was secondary. Hierarchical Bayesian random-effects models were fitted using published study-level estimates that accounted for clustering whenever available. RESULTS:Six trials involving 42,223 patients met the inclusion criteria. For mortality, the pooled Bayesian relative effect was 0.92 (95% CrI 0.77-1.18), corresponding to an 83% posterior probability of benefit. For AKI, the pooled Bayesian relative effect was 1.02 (95% CrI 0.86-1.23), corresponding to a 40% posterior probability of benefit. Sensitivity analyses yielded similar findings. CONCLUSIONS:Balanced crystalloid policies were not associated with a clear reduction in mortality or AKI in cluster-randomized evaluations of routine care. Any true effect is likely modest and dependent on exposure and clinical context. The available evidence remains compatible with modest benefit or no meaningful effect and complements patient-level evidence by informing the real-world effectiveness of fluid policies under routine implementation conditions. PROSPERO ID:CRD420251146439.

Study objective To determine whether routinely recorded intraoperative hemodynamic data can identify clinically meaningful patterns associated with postoperative complications after major abdominal surgery. Design Retrospective observational cohort study. Setting Single tertiary academic center; analysis of the INSPIRE perioperative research database. Patients 13,143 adult patients undergoing elective major abdominal surgery with continuous invasive arterial pressure monitoring. Interventions None. Measurements Intraoperative hemodynamics were summarized using median mean arterial pressure (MAP), percentage of measurements with MAP <65 mmHg, vasopressor use, and fluid administration. Unsupervised k-means clustering was used to derive intraoperative hemodynamic phenotypes. Associations with postoperative acute kidney injury (AKI), intensive care unit (ICU) admission, in-hospital mortality, and hospital length of stay were assessed using adjusted regression models controlling for age, sex, body mass index, ASA physical status, and surgical department. Main results Four distinct intraoperative hemodynamic patterns were identified. Most procedures were hemodynamically stable (phenotype 1, 63.9%). Two intermediate (phenotype 2 and 3; 35.0% combined) were characterized by greater hypotension burden with increased vasopressor or fluid requirements. A small group (phenotype 4, 1.0%) showed sustained hypotension and high vasopressor use. Postoperative outcomes followed a graded pattern: AKI increased from 4.9% in phenotype 1 to 41.4% in phenotype 4, ICU admission from 8.3% to 93.2%, and in-hospital mortality from 0.7% to 6.0%. After adjustment, phenotypes 2 and 3 were associated with approximately two- to threefold higher odds of AKI and ICU admission compared with phenotype 1. Conclusions Distinct intraoperative hemodynamic phenotypes are associated with graded increases in postoperative complications after major abdominal surgery.

Preoperative anemia and transfusion are common in gastric cancer surgery and have been associated with adverse short-term outcomes. Their impact on long-term oncologic prognosis remains unclear. We aimed to assess the association between preoperative anemia, perioperative red blood cell transfusion, and disease-free survival (DFS) after gastrectomy. This was a prespecified long-term analysis of the prospective POWER4 multicenter cohort conducted across 72 Spanish hospitals. Patients undergoing elective gastrectomy for gastric cancer between 2019 and 2020 were followed for ≥ 36 months. DFS was defined as time from surgery to recurrence or death. Primary exposures were preoperative anemia (World Health Organization criteria) and perioperative transfusion (within 72 h). Analyses included Kaplan–Meier estimates, multivariable Cox regression, logistic regression for delayed or omitted adjuvant chemotherapy (RIOT), and causal mediation analysis. Generalized additive models (GAMs) explored nonlinear associations between hemoglobin and DFS. Among 386 patients, 47

BACKGROUND:Postoperative acute kidney injury (AKI) after major abdominal surgery leads to poor outcomes. The Hypotension Prediction Index (HPI; Edwards Lifesciences, USA) may aid in managing intraoperative hemodynamic instability. This study assessed whether HPI-guided therapy reduces moderate-to-severe AKI incidence in moderate- to high-risk elective abdominal surgery patients. METHODS:This multicenter randomized trial was conducted from October 2022 to February 2024 across 28 hospitals evaluating HPI-guided management compared to a wide range of real-world hemodynamic approaches. A total of 917 patients (65 yr or older or older than 18 yr with American Society of Anesthesiologists Physical Status greater than II) undergoing moderate- to high-risk elective abdominal surgery were included in the intention-to-treat analysis. HPI-guided management triggered interventions when the HPI exceeded 80, using fluids and/or vasopressors/inotropes based on hemodynamic data. The primary outcome was the incidence of moderate-to-severe AKI within the first 7 days after surgery. Secondary outcomes included overall complications, the need for renal replacement therapy, duration of hospital stay, and 30-day mortality. RESULTS:Median age was 71 yr (interquartile range, 65 to 77) in the HPI group and 70 yr (interquartile range, 63 to 76) in standard care group. American Society of Anesthesiologists Physical Status III/IV was 58.3% (268 of 459) in the HPI group and 57.9% (263 of 458) in standard care group. The incidence of moderate-to-severe AKI was 6.1% (28 of 459) in the HPI group and 7.0% (32 of 458) in the standard care group (risk ratio, 0.89; 95% CI, 0.54 to 1.49; P = 0.66). Overall complications occurred in 31.9% (146 of 459) of the HPI group and 29.7% (136 of 458) of the standard care group (risk ratio, 1.08; 95% CI, 0.85 to 1.37; P = 0.52). The incidence of renal replacement therapy did not differ between groups. Median length of hospital stay was 6 days (interquartile range, 4 to 10) in both groups. The 30-day mortality was 1.1% (5 of 459) in the HPI group versus 0.9% (4 of 458) in standard care group (risk ratio, 1.35; 95% CI, 0.36 to 5.10; P = 0.66). CONCLUSIONS:HPI-guided hemodynamic therapy did not reduce the incidence of postoperative AKI or overall complications compared to standard care.

BACKGROUND:Goal-directed haemodynamic therapy (GDHT) aims to optimize haemodynamic variables. However, its effectiveness in reducing postoperative complications in major abdominal surgery, particularly when targeting both arterial pressure and flow variables, remains unclear. This meta-analysis addresses this by evaluating GDHT using uncalibrated pulse contour (uPC) methods. METHODS:We conducted a systematic review and meta-analysis of randomized controlled trials (RCT) in adult patients undergoing major abdominal surgery who received GDHT using uncalibrated pulse contour (uPC) methods for cardiac output monitoring, with predefined targets for both blood flow and blood pressure. The primary outcome was postoperative complications; secondary outcomes included postoperative acute kidney injury (AKI), hospital length of stay (EH), intraoperative fluid administration and mortality. RESULTS:Initial search retrieved 860 reports, with 12 RCTs (1367 patients) meeting the inclusion criteria. Our meta-analysis showed a significant reduction in postoperative complications (RR 0.78, 95% CI 0.68-0.90), AKI (RR 0.7, 95% CI 0.51-0.97), and hospital LOS (SMD -0.30, 95% CI -0.54 to -0.06) with uPC-guided GDHT. No significant differences were observed in intraoperative fluid volume and mortality. CONCLUSIONS:Implementing GDHT in major abdominal surgery with predefined arterial pressure and blood flow targets significantly reduces postoperative morbidity and hospital EH without increasing intraoperative fluid administration.

Objective: To assess the perioperative management of haemostasis and transfusion practices in adult patients undergoing craniotomies. Method: Online questionnaire addressed to Spanish anaesthesiologists and promoted by the Neurosciences and Haemostasis, Transfusion Medicine and Fluid Therapy Sections of SEDAR. The questionnaire was sent by email and social media, and was active between June and October 2022. Results: We obtained 155 responses from 67 centres; 59.4% perform >100 craniotomies per year. 61.7%were regularly involved in neuroanaesthesiology. Only 21.9%of respondents had pre- anaesthesia assessment performed by a member of that section, and in most of them (83.0%) the assessment was performed <= 3 weeks in advance. Of the respondents with Patient Blood Management programmes, 58.2% had no specific protocols for craniotomies. 90.3% reported that haemoconcentrates are systematically reserved. A lower platelet limit of 100,000/mcL is considered acceptable by 76.8%. 99.4% of respondents discontinued antiplatelet medication based on half-life. Only 23.9% respondents routinely discontinued non-steroidal anti-inflammatory drugs. The transfusion threshold for haemoglobin during surgical bleeding was <10g/dl in 18.7%, <9g/dl in 38.1%, <8g/dl in 38.7% and <7 g/dl in 4.5%. Conclusions: Preoperative anaemia screening and treatment programmes are not implemented and blood product reserves are systematised in patients scheduled for craniotomy. Anti- aggregation therapy is discontinued according to the half-life of the drug without checking platelet functionality. (c) 2024 Sociedad Espanola de Anestesiolog& imath;a, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

BACKGROUND:Patient blood management (PBM) is a set of evidence-based practices that reduces the need for blood transfusions. However, its impact on relevant clinical outcomes remains unclear. The authors evaluated the association between adherence to guideline-recommended PBM care and 30-day postoperative complications in patients undergoing primary total knee and hip arthroplasty. Secondary outcomes included the length of hospital stay and erythrocyte utilization. METHODS:This was a retrospective, multicenter cohort study including patients from 43 hospitals. The PBM clinical pathway comprised nine major guideline-recommended interventions, and adherence was assessed using a composite quality indicator. Multilevel multivariable regression models were used to evaluate the associations between PBM adherence and outcomes at the patient level while accounting for hospital characteristics and hospital variation. RESULTS:A total of 30,926 patients who underwent primary total knee or hip arthroplasty between 2016 and 2022 at 43 hospitals were included. Of these, 1,335 (4.3%) had 30-day postoperative complications. The median adherence to the PBM clinical pathway was 60.0%. Higher PBM adherence was associated with fewer 30-day postoperative complications (adjusted odds ratio, 0.43; 95% CI, 0.32 to 0.58; P < 0.001), including 65% lower odds of major adverse cardiac events and 45% lower odds of infection. Additionally, higher adherence was associated with shorter hospital stays (adjusted incidence rate ratio, 0.77; 95% CI, 0.76 to 0.79; P < 0.001) and reduced transfusion rates (adjusted odds ratio, 0.11; 95% CI, 0.09 to 0.14; P < 0.001). Sensitivity analyses confirmed these associations. CONCLUSIONS:Adherence to the PBM clinical pathway was associated with improved outcomes. While causality cannot be established, these findings support the potential effectiveness of PBM in reducing postoperative complications and its efficiency in shortening hospital stays, beyond minimizing blood transfusions, in patients undergoing knee and hip arthroplasty.

The objective of this study is to evaluate biomarkers for neurodegenerative disorders in adult SMA patients and their potential for monitoring the response to nusinersen. Biomarkers for neurodegenerative disorders were assessed in plasma and CSF samples obtained from a total of 30 healthy older adult controls and 31 patients with adult SMA type 2 and 3. The samples were collected before and during nusinersen treatment at various time points, approximately at 2, 6, 10, and 22 months. Using ELISA technology, the levels of total tau, pNF-H, NF-L, sAPPβ, Aβ40, Aβ42, and YKL-40 were evaluated in CSF samples. Additionally, plasma samples were used to measure NF-L and total tau levels using SIMOA technology. SMA patients showed improvements in clinical outcomes after nusinersen treatment, which were statistically significant only in walkers, in RULM (p = 0.04) and HFMSE (p = 0.05) at 24 months. A reduction in sAPPβ levels was found after nusinersen treatment, but these levels did not correlate with clinical outcomes. Other neurodegeneration biomarkers (NF-L, pNF-H, total tau, YKL-40, Aβ40, and Aβ42) were not found consistently changed with nusinersen treatment. The slow progression rate and mild treatment response of adult SMA types 2 and 3 may not lead to detectable changes in common markers of axonal degradation, inflammation, or neurodegeneration, since it does not involve large pools of damaged neurons as observed in pediatric forms. However, changes in biomarkers associated with the APP processing pathway might be linked to treatment administration. Further studies are warranted to better understand these findings.

Objective: To evaluate the clinical impact of optimizing stroke volume (SV) through fluid administration as part of goal-directed hemodynamic therapy (GDHT) in adult patients undergoing elective major abdominal surgery. Methods: This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and was registered in the PROSPERO database in January 2024. The intervention was defined as intraoperative GDHT based on the optimization or maximization of SV through fluid challenges, or by using dynamic indices of fluid responsiveness, including stroke volume variation, pulse pressure variation, and plethysmography variation index compared to usual fluid management. The primary outcome was postoperative complications. Secondary outcome variables included postoperative acute kidney injury (AKI), length of stay (LOS), intraoperative fluid administration, and 30-day mortality. Results: A total of 29 randomized controlled trials (RCTs) met the inclusion criteria. There were no significant differences in the incidence of postoperative complications (RR 0.89; 95% CI, 0.78 to 1.00), postoperative AKI (OR 0.97; (95% IC, 0.55 to 1.70), and mortality (OR 0.80; 95% CI, 0.50 to 1.29). GDHT was associated with a reduced LOS compared to usual care (SMD: -0.17 [-0.32; - 0.03]). The subgroup in which hydroxyethyl starch was used for hemodynamic optimization was associated with fewer complications (RR 0.79; 95% CI, 0.65 to 0.94), whereas the subgroup of patients in whom crystalloids were used was associated with an increased risk of postoperative complications (RR 1.08; 95% CI, 1.04 to 1.12). Conclusions: In adults undergoing major surgery, goal-directed hemodynamic therapy focused on fluid-based stroke volume optimization did not reduce postoperative morbidity and mortality. (c) 2024 Sociedad Espanola de Anestesiolog & imath;a, Reanimacion y Terapeutica del Dolor. Published by Elsevier Espana, S.L.U. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

The administration of intravenous fluids is the most common intervention in hospitalised patients in the perioperative setting and critical care units. The aim of this narrative review is to provide an overview of balanced solutions for fluid therapy in the perioperative period in adult patients, and to review new trends and solutions in fluid therapy.The evidence was grouped into 3 areas: intraoperative fluid administration, fluid administration in critically ill patients, and the importance / benefit of balanced crystalloid solutions.Although a number of high-quality studies have been published in recent years, the scientific evidence regarding the type of fluid, the dose, and rate of administration is still limited. The choice of fluid therapy during the perioperative period must be tailored to patient-specific factors, the nature of the surgery, expected fluid loss, and other relevant factors. Finally, more robust clinical evidence and physician training is of the utmost importance.

La administración de líquidos intravenosa es la intervención más común en los pacientes hospitalizados en el ámbito perioperatorio y las unidades de cuidados críticos. El objetivo de esta revisión narrativa es aportar una visión general de las soluciones balanceadas en fluidoterapia en el periodo perioperatorio en pacientes adultos, así como revisar las nuevas tendencias y soluciones de la fluidoterapia.Se agrupó la evidencia en tres áreas: administración intraoperatoria de líquidos, administración de líquidos en pacientes críticos, y relevancia/beneficio de las soluciones de cristaloides balanceadas.Aunque en los últimos años se ha producido una mejora de los estudios de gran calidad publicados, la evidencia científica en cuanto a la elección de los líquidos, así como sus dosis y la tasa de administración, sigue siendo limitada. Debe individualizarse la elección de fluidoterapia durante el periodo perioperatorio, considerando los factores específicos del paciente, la naturaleza de la cirugía, la pérdida de sangre prevista y otros factores relevantes. Por último, deberá ser de máxima importancia la evidencia clínica robusta y la formación de los facultativos.

Antecedentes El objetivo de la terapia hemodinámica guiada por objetivos (THGO) es optimizar las variables hemodinámicas. Sin embargo, sigue siendo incierta su efectividad para reducir las complicaciones postoperatorias de la cirugía abdominal mayor, y en particular cuando se persiguen variables de presión y flujo arterial. Este metaanálisis aborda esta cuestión, evaluando la THGO mediante métodos no calibrados de contorno del pulso (uPC). Métodos Realizamos una revisión sistemática y metaanálisis de ensayos controlados aleatorizados (ECA) en pacientes adultos sometidos a cirugía abdominal mayor, que recibieron THGO mediante métodos no calibrados de contorno del pulso (uPC) para monitorización del gasto cardiaco, con objetivos predefinidos para presión sanguínea y flujo sanguíneo. El resultado primario fueron las complicaciones postoperatorias; los resultados secundarios incluyeron insuficiencia renal aguda (IRA) postoperatoria, duración de la estancia hospitalaria (EH), administración intraoperatoria de líquidos y mortalidad. Resultados La búsqueda inicial recuperó 860 informes, cumpliendo 12 ECA (1.367 pacientes) los criterios de inclusión. Nuestro metaanálisis reflejó una reducción significativa de las complicaciones postoperatorias (RR: 0,78; IC95%: 0,68-0,90), IRA (RR: 0,7; IC95%: 0,51-0,97) y estancia hospitalaria (DM: −0,30; IC95%: −0,54 a −0,06) con THGO guiada por uPC. No se observaron diferencias significativas en cuanto a volumen de líquidos intraoperatorios y mortalidad. Conclusiones Implementar la THGO en la cirugía abdominal con objetivos predefinidos de presión arterial y flujo sanguíneo reduce significativamente la morbilidad postoperatoria y la EH, sin incrementar la administración de líquidos intraoperatorios.

Intermediate CAG expansions in the gene ataxin-2 (ATXN2) are a known risk factor for ALS, but little is known about their role in FTD risk. Moreover, their contribution to the risk and phenotype of patients might vary in populations with different genetic backgrounds. The aim of this study was to assess the relationship of intermediate CAG expansions in ATXN2 with the risk and phenotype of ALS and FTD in the Spanish population. Repeat-primed PCR was performed in 620 ALS and 137 FTD patients in three referral centers in Spain to determine the exact number of CAG repeats. In our cohort, ≥27 CAG repeats in ATXN2 were associated with a higher risk of developing ALS (odds ratio [OR] = 2.666 [1.471–4.882]; p = 0.0013) but not FTD (odds ratio [OR] = 1.446 [0.558–3.574]; p = 0.44). Moreover, ALS patients with ≥27 CAG repeats in ATXN2 showed a shorter survival rate compared to those with <27 repeats (hazard ratio [HR] 1.74 [1.18, 2.56], p = 0.005), more frequent limb onset (odds ratio [OR] = 2.34 [1.093–4.936]; p = 0.028) and a family history of ALS (odds ratio [OR] = 2.538 [1.375–4.634]; p = 0.002). Intermediate CAG expansions of ≥27 repeats in ATXN2 are associated with ALS risk but not with FTD in the Spanish population. ALS patients carrying an intermediate expansion in ATXN2 show more frequent limb onset but a worse prognosis than those without expansions. In patients carrying C9orf72 expansions, the intermediate ATXN2 expansion might increase the penetrance and modify the phenotype.

La evolución de los programas de ahorro de sangre al Patient Blood Management (PBM) representa un enfoque más amplio y completo para optimizar el uso de la sangre del propio paciente, mejorando así los resultados clínicos y minimizando los riesgos asociados con la transfusión de sangre alogénica con una visión holística de sostenibilidad socioeconómica.Implementar las estrategias de los tres pilares PBM en cualquier centro hospitalario supone un cambio transversal en toda la organización en el que puede ser de gran utilidad aplicar la estrategia definida por Kotter a nivel del mundo empresarial para la gestión del cambio.El respaldo de instituciones de renombre como la Organización Mundial de la Salud y la Comisión Europea demuestra la importancia y urgencia de implementar programas de PBM, marcando pautas a nivel internacional y respaldando la adopción de estrategias eficaces en el manejo de la transfusión sanguínea a nivel nacional e institucional.En España, necesitamos contar con gestores sanitarios tanto a nivel Dirección-Gerencia como de las Consejerías y/o Ministerio de Sanidad que proporcionen los recursos necesarios para su adecuada implementación en el sistema sanitario desde la atención primaria hasta la atención hospitalaria y también los recursos para la oportuna evaluación de los resultados.