Cell salvage for minimising perioperative allogeneic blood transfusion

Blood management in total knee arthroplasty: state-of-the-art review

Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.

Current Status of the Use of Salvaged Blood in Metastatic Spine Tumour Surgery

To review the current status of salvaged blood transfusion (SBT) in metastatic spine tumour surgery (MSTS), with regard to its safety and efficacy, contraindications, and adverse effects. We also aimed to establish that the safety and adverse event profile of SBT is comparable and at least equal to that of allogeneic blood transfusion. MEDLINE and Scopus were used to search for relevant articles, based on keywords such as "cancer surgery," "salvaged blood," and "circulating tumor cells." We found 159 articles, of which 55 were relevant; 20 of those were excluded because they used other blood conservation techniques in addition to cell salvage. Five articles were manually selected from reference lists. In total, 40 articles were reviewed. There is sufficient evidence of the clinical safety of using salvaged blood in oncological surgery. SBT decreases the risk of postoperative infections and tumour recurrence. However, there are some limitations regarding its clinical applications, as it cannot be employed in cases of sepsis. In this review, we established that earlier studies supported the use of salvaged blood from a cell saver in conjunction with a leukocyte depletion filter (LDF). Furthermore, we highlight the recent emergence of sufficient evidence supporting the use of intraoperative cell salvage without an LDF in MSTS.

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP)

BACKGROUND

Risk of red blood cell transfusion (RBCT) in partial hepatectomy is 17-27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database.

METHODS

TRIPOD guidelines were followed. A validation cohort was created with the ACS-NSQIP dataset. Risk groups for RBCT were created using the TRS: anemia (hematocrit ≤36%), major liver resection (≥4 segments) and primary liver malignancy. Concordance index was used to assess the discrimination. The Hosmer-Lemeshow test for goodness of fit and calibration curves were used to assess calibration.

RESULTS

Of 2854 hepatectomies, 18.9% received RBCT. The TRS stratified patients from low (8.5% risk of RBCT) to very high risk (40.6%) of RBCT. The concordance was 0.68 (95% CI 0.66-0.70). Hosmer-Lemeshow test and calibration curves supported good predictive performance of the model.

CONCLUSION

The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify patients at high transfusion risk. It can be used to tailor patient blood management initiatives and reduce the use of RBCT.

The impact of intra-operative cell salvage during open nephrectomy

Objective

To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy.

Methods

A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost.

Results

Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient).

Conclusion

ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.

Cost-effectiveness Analysis of Intraoperative Cell Salvage for Obstetric Hemorrhage

BACKGROUND

Cost-effectiveness analyses on cell salvage for cesarean delivery to inform national and societal guidelines on obstetric blood management are lacking. This study examined the cost-effectiveness of cell salvage strategies in obstetric hemorrhage from a societal perspective.

METHODS

Markov decision analysis modeling compared the cost-effectiveness of three strategies: use of cell salvage for every cesarean delivery, cell salvage use for high-risk cases, and no cell salvage. A societal perspective and lifetime horizon was assumed for the base case of a 26-yr-old primiparous woman presenting for cesarean delivery. Each strategy integrated probabilities of hemorrhage, hysterectomy, transfusion reactions, emergency procedures, and cell salvage utilization; utilities for quality of life; and costs at the societal level. One-way and Monte Carlo probabilistic sensitivity analyses were performed. A threshold of $100,000 per quality-adjusted life-year gained was used as a cost-effectiveness criterion.

RESULTS

Cell salvage use for cases at high risk for hemorrhage was cost-effective (incremental cost-effectiveness ratio, $34,881 per quality-adjusted life-year gained). Routine cell salvage use for all cesarean deliveries was not cost-effective, costing $415,488 per quality-adjusted life-year gained. Results were not sensitive to individual variation of other model parameters. The probabilistic sensitivity analysis showed that at the $100,000 per quality-adjusted life-year gained threshold, there is more than 85% likelihood that cell salvage use for cases at high risk for hemorrhage is favorable.

CONCLUSIONS

The use of cell salvage for cases at high risk for obstetric hemorrhage is economically reasonable; routine cell salvage use for all cesarean deliveries is not. These findings can inform the development of public policies such as guidelines on management of obstetric hemorrhage.

Blood Product Administration in the Critical Care and Perioperative Settings

The critical care and perioperative settings are high consumers of blood products, with multiple units and different products often given to an individual patient. The recommendation of this review is always to consider the risks and benefits for a specific blood product for a specific patient in a specific clinical setting. Optimize patient status by treating anemia and preventing the need for red blood cell transfusion. Consider other options for correction of anemia and coagulation disorders and use an imperative non-overtransfusion policy for all blood products.

The role of intraoperative cell salvage system on blood management in major orthopedic surgeries: a cost-benefit analysis

INTRODUCTION

The aim of this study was to compare the efficiency and cost of cell salvage systems with allogeneic blood transfusions in patients who had major elective orthopedic surgeries.

MATERIALS AND METHODS

Consecutive 108 patients who had intraoperative cell saver (CS) performed routinely constitute the study group. In control group, consecutive 112 patients who were operated without intraoperative CS were investigated. Hemoglobin (Hb) level less than 8 mg/dL was regarded as the absolute transfusion indication. The patients were evaluated for age, gender, body mass index, operation period, mean intraoperative estimated blood loss (EBL), postoperative hemovac drainage volume; preoperative, postoperative first day and discharge Hb levels, allogeneic blood transfusion (ABT) volume, hospitalization and cost parameters.

RESULTS

The mean intraoperative EBL was 507 mL in the study group and 576 mL in control group. The mean ABT was 300 mL in the study group and 715 mL in control group. In the study group, intraoperative EBL, ABT usage and hospitalization period were significantly lower compared with the control group (p = 0.009, p = 0.000 and p = 0.000; p < 0.05, respectively). The mean cost was 771 Turkish liras (TL) in the study group and 224 TL in control group. In the study group, the cost was significantly higher than the control group (p = 0.000). The postoperative first day Hb level was significantly higher in the study group (p = 0.010).

CONCLUSION

Although CS usage was determined to increase the costs in this study, it significantly decreases intraoperative and postoperative ABT requirements. We believe that the increase in cost may be neglected when the complications and prolonged hospitalization due to ABT usage were regarded.

Cell salvage and donor blood transfusion during cesarean section: A pragmatic, multicentre randomised controlled trial (SALVO)

BACKGROUND

Excessive haemorrhage at cesarean section requires donor (allogeneic) blood transfusion. Cell salvage may reduce this requirement.

METHODS AND FINDINGS

We conducted a pragmatic randomised controlled trial (at 26 obstetric units; participants recruited from 4 June 2013 to 17 April 2016) of routine cell salvage use (intervention) versus current standard of care without routine salvage use (control) in cesarean section among women at risk of haemorrhage. Randomisation was stratified, using random permuted blocks of variable sizes. In an intention-to-treat analysis, we used multivariable models, adjusting for stratification variables and prognostic factors identified a priori, to compare rates of donor blood transfusion (primary outcome) and fetomaternal haemorrhage ≥2 ml in RhD-negative women with RhD-positive babies (a secondary outcome) between groups. Among 3,028 women randomised (2,990 analysed), 95.6% of 1,498 assigned to intervention had cell salvage deployed (50.8% had salvaged blood returned; mean 259.9 ml) versus 3.9% of 1,492 assigned to control. Donor blood transfusion rate was 3.5% in the control group versus 2.5% in the intervention group (adjusted odds ratio [OR] 0.65, 95% confidence interval [CI] 0.42 to 1.01, p = 0.056; adjusted risk difference -1.03, 95% CI -2.13 to 0.06). In a planned subgroup analysis, the transfusion rate was 4.6% in women assigned to control versus 3.0% in the intervention group among emergency cesareans (adjusted OR 0.58, 95% CI 0.34 to 0.99), whereas it was 2.2% versus 1.8% among elective cesareans (adjusted OR 0.83, 95% CI 0.38 to 1.83) (interaction p = 0.46). No case of amniotic fluid embolism was observed. The rate of fetomaternal haemorrhage was higher with the intervention (10.5% in the control group versus 25.6% in the intervention group, adjusted OR 5.63, 95% CI 1.43 to 22.14, p = 0.013). We are unable to comment on long-term antibody sensitisation effects.

CONCLUSIONS

The overall reduction observed in donor blood transfusion associated with the routine use of cell salvage during cesarean section was not statistically significant.

TRIAL REGISTRATION

This trial was prospectively registered on ISRCTN as trial number 66118656 and can be viewed on http://www.isrctn.com/ISRCTN66118656.

Perioperative comparison of blood loss and complications between simultaneous bilateral and unilateral total knee arthroplasty for knee osteoarthritis

OBJECTIVE

This study aimed to compare the blood loss and complications between simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral total knee arthroplasty (UTKA).

METHODS

This study included 54 SBTKAs and 70 UTKAs performed between 2013 and 2014. Groups were compared with respect to blood loss, hemoglobin, hematocrit, D-dimer, blood transfusion, and complications.

RESULTS

Hemoglobin between the groups was not significantly different (P>0.05). In the SBTKA group, the hematocrit on the 3rd postoperative day was lower (P<0.05), and the D-dimer on the 1st postoperative day was higher (P<0.05) than in the UTKA group. The total drain output of the UTKA group was not significantly different from any unilateral side of the SBTKA group (P<0.05). The mean autologous red blood cell (RBC) transfusion requirements were not significantly different between the two groups. However, the mean allogeneic RBC transfusion requirement was higher in the SBTKA group than in the UTKA group (P<0.001). The total drainage of the SBTKA group was significantly more than the UTKA group, but the total drain output of the UTKA group was not significantly different from any unilateral side of the SBTKA group (P>0.05). Also, the mean allogeneic RBC transfusion requirement was higher in the SBTKA group than in the UTKA group (P<0.001).

CONCLUSION

This study demonstrates that the rate of complication between SBTKA and UTKA is similar. The total drainage and transfusion of SBTKA are not twice that of UTKA, and after treatment, hemoglobin could be increased to a similar level. Thus, SBTKA is an effective and safe option.

Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management

BACKGROUND

Relative to first-time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era.

STUDY DESIGN AND METHODS

Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components.

RESULTS

Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two- to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion.

CONCLUSIONS

In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre-PBM era.

Anemia and Red Blood Cell Transfusion: Advances in Critical Care

Anemia is common in the intensive care unit (ICU), resulting in frequent administration of red blood cell (RBC) transfusions. Significant advances have been made in understanding the pathophysiology of anemia in the ICU, which is anemia of inflammation. This anemia is related to high hepcidin concentrations resulting in iron-restricted erythropoiesis, and decreased erythropoietin concentrations. A new hormone (erythroferrone) has been identified, which mediates hepcidin suppression to allow increased iron absorption and mobilization from iron stores. RBC transfusions are most commonly administered to ICU patients for treatment of anemia. All strategies to reduce anemia in the ICU should be implemented.

Allogenic Blood Transfusion Is an Independent Predictor of Poorer Peri-operative Outcomes and Reduced Long-Term Survival after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: a Review of 936 Cases

INTRODUCTION

There is a paucity of data on the impact of allogenic blood transfusion (ABT) on morbidity and survival outcomes after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC).

METHODS

Nine hundred and thirty-five consecutive CRS/HIPEC procedures were performed between 1996 and 2016 at a high-volume institution in Sydney, Australia. Of these, 337(36%) patients required massive ABT (MABT) (≥5 units). Peri-operative complications were graded according to the Clavien-Dindo classification. The association of concomitant MABT with 21 peri-operative outcomes and overall survival (OS) was assessed using univariate and multivariate analyses.

RESULTS

In-hospital mortality was 1.8%. Patients requiring MABT had more extensive disease as reflected by a higher peritoneal cancer index (≥17) (70 vs. 29%, p < 0.001) and longer operative times (≥9 h) (82 vs. 35%, p < 0.001). After accounting for confounding factors, MABT was associated with in-hospital mortality (relative risk (RR), 7.72; 95% confidence interval (CI), 1.35-10.11; p = 0.021) and grade III/IV morbidity (RR, 2.05; 95% CI, 1.42-2.95; p < 0.001). MABT was associated with an increased incidence of prolonged hospital stay (≥28 days) (RR, 1.86; 95% CI, 1.26-2.74; p = 0.002) and intensive care unit stay (≥4 days) (RR, 1.83; 95% CI, 1.24-2.70, p = 0.002). It was also associated with a significant OS in patients with colorectal cancer peritoneal carcinomatosis (RR 4.49; p < 0.001) and pseudomyxoma peritonei (RR, 4.37; p = 0.026), but not appendiceal cancer (p = 0.160).

CONCLUSION

MABT is an independent predictor for poorer peri-operative outcomes including in-hospital mortality and grade III/IV morbidity. It may also compromise long-term survival, particularly in patients with colorectal cancer peritoneal carcinomatosis.

Influence of autologous blood transfusion in liver transplantation in patients with hepatitis B on the function and hemorheology of red blood cells

The present study aimed to characterize the function and hemorheology of red blood cells (RBCs) recovered during liver transplantation surgery in patients with hepatitis B and decompensation. A total of 15 hepatitis B patients with decompensation who underwent liver transplantation surgery were included in the present study. Blood samples were recovered during the liver transplantation surgery using an Autologous Blood Recovery System. The morphology and structure of RBCs were characterized and compared between pre-operative and recovered blood samples. In addition, the physiological functions of RBCs were measured and compared between pre-operative and recovered blood samples. No significant differences in the morphological score, 2,3-diphosphoglycerate, Na+K+-ATPase, Ca2+-ATPase, Mg2+-ATPase, malondialdehyde and osmotic fragility were identified between RBCs in the pre-operative and recovered blood samples. The level of free hemoglobin in RBCs of the recovered blood samples was significantly higher than in the pre-operative blood samples (P<0.05). Medium- and high-shear blood viscosities in the recovered blood samples were significantly lower than those observed in the pre-operative blood samples (P<0.05). Casson viscosity in the recovered blood samples was significantly higher compared with the pre-operative blood samples. However, no significant differences (P>0.05) in the low-shear blood viscosity, plasma viscosity, relative blood viscosity, erythrocyte aggregation index or Casson yield stress were identified between recovered and pre-operative blood samples. These findings suggested that autologous blood transfusion in liver transplantation surgery in patients with hepatitis B and decompensation had no significant influence on the morphology, structure, function and hemorheology of RBCs.

The safety, efficacy, and cost-effectiveness of intraoperative cell salvage in metastatic spine tumor surgery

BACKGROUND CONTEXT

Metastatic spine tumor surgery (MSTS) is associated with substantial blood loss, therefore leading to high morbidity and mortality. Although intraoperative cell salvage with leukocyte depletion filter (IOCS-LDF) has been studied as an effective means of reducing blood loss in other surgical settings, including the spine, no study has yet analyzed the efficacy of reinfusion of salvaged blood in reducing the need for allogenic blood transfusion in patients who have had surgery for MSTS.

PURPOSE

This study aimed to analyze the efficacy, safety, and cost-effectiveness of using IOCS-LDF in MSTS.

STUDY DESIGN

This is a retrospective controlled study.

PATIENT SAMPLE

A total of 176 patients undergoing MSTS were included in the study.

METHODS

All patients undergoing MSTS at a single center between February 2010 and December 2014 were included in the study. The primary outcome measure was the use of autologous blood transfusion. Secondary outcome measures included hospital stay, survival time, complications, and procedural costs. The key predictor variable was whether IOCS-LDF was used during surgery. Logistic and linear regression analyses were conducted by controlling variables such as tumor type, number of diseased vertebrae, approach, number and site of stabilized segments, operation time, preoperative anemia, American Society of Anesthesiologists (ASA) grade, age, gender, and body mass index (BMI). No funding was obtained and there are no conflicts of interest to be declared.

RESULTS

Data included 63 cases (IOCS-LDF) and 113 controls (non-IOCS-LDF). Intraoperative cell salvage with LDF utilization was substantively and significantly associated with a lower likelihood of allogenic blood transfusion (OR=0.407, p=.03). Intraoperative cell salvage with LDF was cost neutral (p=.88). Average hospital stay was 3.76 days shorter among IOCS-LDF patients (p=.03). Patient survival and complication rates were comparable in both groups.

CONCLUSIONS

We have demonstrated that the use of IOCS-LDF in MSTS reduces the need for postoperative allogenic blood transfusion while maintaining satisfactory postoperative hemoglobin. We recommend routine use of IOCS-LDF in MSTS for its safety, efficacy, and potential cost benefit.

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.

"Simplified International Recommendations for the Implementation of Patient Blood Management" (SIR4PBM)

BACKGROUND

More than 30% of the world's population are anemic with serious medical and economic consequences. Red blood cell transfusion is the mainstay to correct anemia, but it is also one of the top five overused procedures and carries its own risk and cost burden. Patient blood management (PBM) is a patient-centered and multidisciplinary approach to manage anemia, minimize iatrogenic blood loss, and harness tolerance to anemia in an effort to improve patient outcome. Despite resolution 63.12 of the World Health Organization in 2010 endorsing PBM and current guidelines which include evidence-based recommendations on the use of diagnostic/therapeutic resources to provide better health care, many hospitals have yet to implement PBM in routine clinical practice.

METHOD AND RESULTS

A number of experienced clinicians developed the following "Simplified International Recommendations for Patient Blood Management." We propose a series of simple, cost-effective, best-practice, feasible, and evidence-based measures that will enable any hospital to reduce both anemia prevalence on the day of intervention/surgery and anemia-related unnecessary transfusion in surgical and medical patients, including obstetrics and gynecology.

Anesthesia for Patients with Anemia

Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.

The use of intraoperative cell salvage in urologic oncology

Intraoperative cell salvage (IOCS) has been used in urologic surgery for over 20 years to manage intraoperative blood loss and effectively minimize the need for allogenic blood transfusion. Concerns about viability of transfused erythrocytes and potential dissemination of malignant cells have been addressed in the urologic literature. We present a comprehensive review of the use of IOCS in urologic oncologic surgery. IOCS has been shown to preserve the integrity of erythrocytes during processing and effectively provides cell filtration to mitigate the risk of tumor dissemination. Its use is associated with reduction in the overall need for allogenic blood transfusion, which clinically reduces the risk of hypersensitivity reactions and disease transmission, and may have important implications on overall oncologic outcomes. In the context of a variety of urologic malignancies, including prostate, urothelial, and renal cancer, the use of IOCS appears to be safe, without risk of tumor spread leading to metastatic disease or differences in cancer-specific and overall survival. IOCS has been shown to be an effective intraoperative blood management strategy that appears safe for use in urologic oncology surgery. The ability to reduce the need for additional allogenic blood transfusion may have significant impact on immune-mediated oncologic outcomes.

Point-of-Care Hemostatic Testing in Cardiac Surgery: A Stepped-Wedge Clustered Randomized Controlled Trial

BACKGROUND

Cardiac surgery is frequently complicated by coagulopathic bleeding that is difficult to optimally manage using standard hemostatic testing. We hypothesized that point-of-care hemostatic testing within the context of an integrated transfusion algorithm would improve the management of coagulopathy in cardiac surgery and thereby reduce blood transfusions.

METHODS

We conducted a pragmatic multicenter stepped-wedge cluster randomized controlled trial of a point-of-care-based transfusion algorithm in consecutive patients undergoing cardiac surgery with cardiopulmonary bypass at 12 hospitals from October 6, 2014, to May 1, 2015. Following a 1-month data collection at all participating hospitals, a transfusion algorithm incorporating point-of-care hemostatic testing was sequentially implemented at 2 hospitals at a time in 1-month intervals, with the implementation order randomly assigned. No other aspects of care were modified. The primary outcome was red blood cell transfusion from surgery to postoperative day 7. Other outcomes included transfusion of other blood products, major bleeding, and major complications. The analysis adjusted for secular time trends, within-hospital clustering, and patient-level risk factors. All outcomes and analyses were prespecified before study initiation.

RESULTS

Among the 7402 patients studied, 3555 underwent surgery during the control phase and 3847 during the intervention phase. Overall, 3329 (45.0%) received red blood cells, 1863 (25.2%) received platelets, 1645 (22.2%) received plasma, and 394 (5.3%) received cryoprecipitate. Major bleeding occurred in 1773 (24.1%) patients, and major complications occurred in 740 (10.2%) patients. The trial intervention reduced rates of red blood cell transfusion (adjusted relative risk, 0.91; 95% confidence interval, 0.85-0.98; P=0.02; number needed to treat, 24.7), platelet transfusion (relative risk, 0.77; 95% confidence interval, 0.68-0.87; P<0.001; number needed to treat, 16.7), and major bleeding (relative risk, 0.83; 95% confidence interval, 0.72-0.94; P=0.004; number needed to treat, 22.6), but had no effect on other blood product transfusions or major complications.

CONCLUSIONS

Implementation of point-of-care hemostatic testing within the context of an integrated transfusion algorithm reduces red blood cell transfusions, platelet transfusions, and major bleeding following cardiac surgery. Our findings support the broader adoption of point-of-care hemostatic testing into clinical practice.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT02200419.

Washed cell salvage in surgical patients: A review and meta-analysis of prospective randomized trials under PRISMA

BACKGROUND

Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage.

METHODS

We performed a meta-analysis of randomized controlled trials in which patients, scheduled for all types of surgery, were randomized to washed cell salvage or to a control group with no cell salvage. Data were independently extracted, risk ratio (RR), and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary endpoint was the number of patients exposed to allogeneic red blood cell (RBC) transfusion.

RESULTS

Out of 1140 search results, a total of 47 trials were included. Overall, the use of washed cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 39% (RR = 0.61; 95% CI 0.57 to 0.65; P < 0.001), resulting in an average saving of 0.20 units of allogeneic RBC per patient (weighted mean differences [WMD] = -0.20; 95% CI -0.22 to -0.18; P < 0.001), reduced risk of infection by 28% (RR = 0.72; 95% CI 0.54 to 0.97; P = 0.03), reduced length of hospital stay by 2.31 days (WMD = -2.31; 95% CI -2.50 to -2.11; P < 0.001), but did not significantly affect risk of mortality (RR = 0.92; 95% CI 0.63 to 1.34; P = 0.66). No statistical difference could be observed in the number of patients exposed to re-operation, plasma, platelets, or rate of myocardial infarction and stroke.

CONCLUSIONS

Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery.

Argatroban for anticoagulation of a blood salvage system - an ex-vivo study

BACKGROUND

Blood salvage systems help to minimize intraoperative transfusion of allogenic blood. So far no data is available on the use of argatroban for anticoagulation of such systems. We conducted an ex-vivo trial to evaluate the effectiveness of three different argatroban doses as compared to heparin and to assess potential residual anticoagulant in the red cell concentrates.

METHODS

With ethical approval and individual informed consent, blood of 23 patients with contraindications for use of blood salvage systems during surgery was processed by the Continuous-Auto-Transfusion-System (C.A.T.S. ® Cell Saver System, Fresenius Kabi, Bad Homburg, Germany) using 5,50 or 250 mg of argatroban or 25.000 U of heparin in 1000 ml saline for anticoagulation of the system. Emergency and high-quality washing modes were applied in random order. Patency of the system and residual amount of anticoagulants in the re-transfusion bag were measured. The collected blood was not re-infused, but only used for analysis of hematocrit, heparin and argatroban concentrations.

RESULTS

Patency of the system was provided by all anticoagulants except for 3/8 cases with 5 mg of argatroban. Residual anticoagulant was found in 2/10 (20 %) heparin samples in two different patients (1 emergency and 1 high-quality washing) and in all argatroban samples. High quality washing eliminated 89-95 % and emergency washing 60-90 % of the initial argatroban concentration. Residual argatroban concentrations ranged from 55 ng ml(-1) to 6810 ng ml(-1), with initial argatroban concentrations of 5 and 250 mg, respectively.

CONCLUSION

The C.A.T.S. does not reliably remove heparin and should therefore not be used in HIT patients. Anticoagulation with 50 and 250 mg argatroban, maintains the systems patency and is significantly removed during washing. In this ex-vivo study a concentration of 50 μg ml(-1) argatroban provided the best ratio of system patency and residual argatroban concentration. Additional dose-finding studies with different blood salvage systems are needed to evaluate the optimal argatroban concentration.

Effect of Point-of-care Hemoglobin/Hematocrit Devices and Autologous Blood Salvage on Reduction of Perioperative Allogeneic Blood Transfusion

Objective To evaluate the effect of point-of-care hemoglobin/hematocrit (POC HGB/HCT) devices and intraoperative blood salvage on the amount of perioperative allogeneic blood transfusion and blood conservation in clinical practice.Methods A total of 46 378 medical records of 22 selected hospitals were reviewed. The volume of allogeneic red blood cell and plasma, number of patients transfused, number of intraoperative autologous blood salvage, total volume of autologous blood transfusion, and amount of surgery in the year of 2011 and 2013 were tracked. Paired t-test was used in intra-group comparison, while t-test of two isolated samples carried out in inter-group comparison. P<0.05 was defined as statistically significant difference.Results In the hospitals where POC HGB/HCT device was used (n=9), the average allogeneic blood transfusion volume per 100 surgical cases in 2013 was significantly lower than that in 2011 (39.86±20.20 vs. 30.49±17.50 Units, t=3.522, P=0.008). In the hospitals without POC HGB/HCT meter, the index was not significantly different between 2013 and 2011. The average allogeneic blood transfusion volume was significantly reduced in 2013 than in 2011 in the hospitals where intraoperative autologous blood salvage ratio [autologous transfusion volume/(autologous transfusion volume+allogeneic transfusion volume)] was increased (n=12, t=2.290, P=0.042). No significant difference of the above index was found in the hospitals whose autologous transfusion ratio did not grow.Conclusion Intraoperative usage of POC HGB/HCT devices and increasing autologous transfusion ratio could reduce perioperative allogeneic blood transfusion.

Experience of Intraoperative Cell Salvage in Surgical Correction of Spinal Deformity: A Retrospective Review of 124 Patients

The effect of intraoperative cell salvage (ICS) in surgical correction of spinal deformity remained controversial. This study was to quantitatively demonstrate its effect. In all, 124 patients having ICS in surgical correction of spinal deformity were included. These patients would be divided into 3 groups. Group 1-blood loss less than 15 mL/kg; group 2-between 15 and 37.5 mL/kg; and group 3-more than 37.5 mL/kg. The mean blood loss was 37.2 mL/kg and patients received 872.2 mL salvaged blood on average. The prevalence of intraoperative transfusion of allogenic RBC was 62.9% and the amount averaged 3.4 U. In groups 1 to 3, the prevalence of intraoperative allogenic transfusion was 23.5%, 66.7%, and 100%, respectively. Logistic analysis showed blood loss minus autotransfusion was of significance in predicting intraoperative transfusion, whereas the blood loss or autotransfusion alone was not, implicating an important role of ICS in saving allogenic RBC. The maximum decrease of hemoglobin after operation occurred in the third day, and the magnitude was 45.7 g/L. No severe complications related to ICS were observed. In summary, ICS could decrease the amount of allogenic transfusion in surgical correction of spinal deformity. However, in terms of reducing prevalence of allogenic transfusion, it had a protective effect only in patients with small blood loss.

A decision model and cost analysis of intra-operative cell salvage during hepatic resection

BACKGROUND

Intraoperative cell salvage (ICS) can reduce allogeneic transfusions but with notable direct costs. This study assessed whether routine use of ICS is cost minimizing in hepatectomy and defines a subpopulation of patients where ICS is most cost minimizing based on patient transfusion risk.

METHODS

A decision model from a health systems perspective was developed to examine adoption and non-adoption of ICS use for hepatectomy. A prospectively maintained database of hepatectomy patients provided data to populate the model. Probabilistic sensitivity analysis was used to determine the probability of ICS being cost-minimizing at specified transfusion risks. One-way sensitivity analysis was used to identify factors most relevant to institutions considering adoption of ICS for hepatectomies.

RESULTS

In the base case analysis (transfusion risk of 28.8%) the probability that routine utilization of ICS is cost-minimizing is 64%. The probability that ICS is cost-minimizing exceeds 50% if the patient transfusion risk exceeds 25%. The model was most sensitive to patient transfusion risk, variation in costs of allogeneic blood, and number of appropriate cases the device could be used for.

CONCLUSIONS

ICS is cost-minimizing for routine use in liver resection, particularly when used for patients with a risk of transfusion of 25% or greater.

Post-operative retransfusion of unwashed filtered shed blood reduces allogenic blood demand in hip hemiarthroplasty in traumatic femoral neck fractures-a prospective randomized trial

PURPOSE

Patients who undergo hip hemiarthroplasty (HHA) due to traumatic femoral neck fracture frequently require red blood cell (RBC) transfusion. Although post-operative autologous blood transfusion (ABT) is well established in elective arthroplasty, its role in trauma patients remains unclear.

METHODS

Two hundred twenty-nine patients with a traumatic femoral neck fracture that underwent HHA at our level-I trauma centre between 2005 and 2009 were prospectively randomized to a high-vacuum drainage or an ABT device. In this single-institution analysis, the number of RBC units as well as the amount of retransfused shed blood were recorded and compared according to study groups. Additionally, the significance of confounding factors for allogenic blood demand such as age, gender, pre-operative Hb level, surgical approach, type of prosthesis and amount of intra-operative RBC units were evaluated using multivariate analysis.

RESULTS

One hundred thirty-five patients were randomized in the high-vacuum group while 94 patients received an ABT device. Intention to treat analysis revealed no significant difference in post-operative RBC demand (ABT: 0.87 RBC, high-vacuum drainage: 1.01 RBC; P = 0.374). However, patients that actually received retransfusion (N = 35) had a reduced post-operative RBC demand (0.49 RBC units, P = 0.014).

CONCLUSION

While only one third of trauma patients treated with an ABT device during HHA actually receive retransfusion, retransfused patients seem to significantly benefit from this treatment as reflected by a reduced pos-toperative RBC demand.

Hemostasis and Hepatic Surgery

Operative blood loss is a major source of morbidity and even mortality for patients undergoing hepatic resection. This review discusses strategies to minimize blood loss and the utilization of allogeneic blood transfusion pertaining to oncologic hepatic surgery.

Coagulopathy and transfusion therapy in pediatric liver transplantation

Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.

Oxygen carrying capacity of salvaged blood in patients undergoing off-pump coronary artery bypass grafting surgery: a prospective observational study

BACKGROUND

Intraoperative cell salvage (ICS), hereby referred to 'mechanical red cell salvage', has been widely used and proven to be an effective way to reduce or avoid the need for allogeneic red blood cells (RBCs)transfusion and its associated complications in surgeries involving major blood loss. However, little is known about the influence of this technique on the functional state of salvaged RBCs. Furthermore, there are no articles that describe the change of free hemoglobin (fHb) in salvage blood during storage, which is a key index of the quality control of salvaged blood. Therefore, in this study, the influence of ICS on the function of salvaged RBCs and the changes of salvaged RBCs during storage were studied with respect to the presence of oxyhemoglobin affinity (recorded as a P50 value) and the level of 2, 3-diphosphoglycerate (2, 3-DPG) and fHb by comparing salvaged RBCs with self-venous RBCs and 2-week-old packed RBCs.

METHODS

Fifteen patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery were enrolled. Blood was collected and processed using a Dideco Electa device. The level of P50, 2, 3-DPG and fHB from salvaged RBCs, venous RBCs and 2-week-old packed RBCs was measured. We also measured the changes of these indicators among salvaged RBCs at 4 h (storage at 21-24 °C) and at 24 h (storage at 1-6 °C).

RESULTS

The P50 value of salvaged RBCs at 0 h (28.77 ± 0.27 mmHg) was significantly higher than the value of venous RBCs (27.07 ± 0.23 mmHg, p=0.000) and the value of the 2-week-old packed RBCs (16.26 ± 0.62 mmHg, p=0.000). P50 value did not change obviously at 4 h (p=0.121) and 24 h (p=0.384) compared with the value at 0 h. The 2, 3-DPG value of salvaged RBCs at 0 h (17.94 ± 6.91 μmol/g Hb) was significantly higher than the value of venous RBCs (12.73 ± 6.52 mmHg, p = 0.007) and the value of the 2-week-old packed RBCs (2.62 ± 3.13 mmHg, p=0.000). The level of 2, 3-DPG slightly decreased at 4 h (p=0.380) and 24 h (p=0.425) compared with the value at 0 h. Percentage of hemolysis of the salvaged blood at 0 h(0.51 ± 0.27 %) was significantly higher than the level of venous blood (0.07 ± 0.05 %, p=0.000) and the value of 2-week-old packed RBCs (0.07 ± 0.05 %, p=0.000), and reached 1.11 ± 0.42 % at 4 h (p=0.002) and 1.83 ± 0.77 % at 24 h (p=0.000).

CONCLUSIONS

The oxygen transport function of salvaged RBCs at 0 h was not influenced by the cell salvage process and was better than that of the venous RBCs and 2-week-old packed RBCs. At the end of storage, the oxygen transport function of salvaged RBCs did not change obviously, but percentage of hemolysis significantly increased.

Patient blood management to reduce surgical risk

BACKGROUND

Preoperative anaemia and perioperative blood transfusion are both identifiable and preventable surgical risks. Patient blood management is a multimodal approach to address this issue. It focuses on three pillars of care: the detection and treatment of preoperative anaemia; the reduction of perioperative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anaemia, including restrictive haemoglobin transfusion triggers. This article reviews why patient blood management is needed and strategies for its incorporation into surgical pathways.

METHODS

Studies investigating the three pillars of patient blood management were identified using PubMed, focusing on recent evidence-based guidance for perioperative management.

RESULTS

Anaemia is common in surgical practice. Both anaemia and blood transfusion are independently associated with adverse outcomes. Functional iron deficiency (iron restriction due to increased levels of hepcidin) is the most common cause of preoperative anaemia, and should be treated with intravenous iron. Intraoperative blood loss can be reduced with antifibrinolytic drugs such as tranexamic acid, and cell salvage should be used. A restrictive transfusion practice should be the standard of care after surgery.

CONCLUSION

The significance of preoperative anaemia appears underappreciated, and its detection should lead to routine investigation and treatment before elective surgery. The risks of unnecessary blood transfusion are increasingly being recognized. Strategic adoption of patient blood management in surgical practice is recommended, and will reduce costs and improve outcomes in surgery.

Implementation of an obstetric cell salvage service in a tertiary women's hospital

INTRODUCTION

Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage.

METHODS

With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent.

RESULTS

A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL.

CONCLUSION

The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.

Impact of perioperative blood transfusion on immune function and prognosis in colorectal cancer patients

OBJECTIVE

To investigate the impacts of perioperative blood transfusion on the immune function and prognosis in colorectal cancer (CC) patients.

METHODS

A retrospective analysis was conducted in 1404 CC patients, including 1223 sporadic colorectal cancer (SCC) patients and 181 hereditary colorectal cancer (HCC) patients. Among them, 701 SCC and 102 HCC patients received perioperative blood transfusion. The amount of T lymphocyte subsets and natural killer (NK) cells was measured. All patients received a 10-year follow-up and relapse, metastasis and curative conditions were recorded.

RESULTS

In SCC group, mortality, local recurrence and distant metastasis rate of transfused patients were significantly higher than non-transfused patients (all P <0.05). In HCC group, mortality was apparently higher in transfused patients than non-transfused patients (P = 0.002). SCC patients transfused with ≥3 U of blood had significantly higher mortality than patients transfused with <3 U (P = 0.006). The amount of T lymphocyte subsets and NK cells showed statistical differences before and after perioperative blood transfusion in SCC and HCC patients (all P <0.05). Also, there existed statistical differences in CD4+/CD8+ ratio among SCC patients before and after the perioperative blood transfusion (P <0.05). CC patients who received perioperative blood transfusion had markedly lower 10-year survival rates as compared with those who did not receive (both P <0.05). SCC patients transfused with ≥3 U of blood had remarkably lower survival rates compared with SCC patients transfused with <3 U (P = 0.002).

CONCLUSIONS

Perioperative blood transfusion could impact immune function, increased postoperative mortality, local recurrence rate and distant metastasis rate in CC patients; and survival rate of CC patients is negatively related to blood transfusion volume.

Dynamic changes in clot formation determined using thromboelastometry after reinfusion of unwashed anticoagulated cell-salvaged whole blood in total hip arthroplasty

BACKGROUND

Cell salvage is a key part of patient blood management. Different techniques are available for salvaging blood. A new intra-operative autotransfusion filter system became available for reinfusion of unwashed whole blood. Concern exists regarding whether this technique induces coagulation disturbances, offsetting the benefits of the reinfusion of autologous blood. This study was designed to investigate the content of intra-operatively salvaged filtered blood and its impact after reinfusion on clot formation in patients undergoing primary hip arthroplasty.

MATERIALS AND METHODS

Twenty-five patients scheduled for primary total hip arthroplasty were enrolled in the study. Cell salvage was performed using a new intra-operative autotransfusion filter system. Before surgery and within 1 hour of reinfusion of 300 mL or more of salvaged whole blood, blood samples were taken to assess clot formation by thromboelastometry and standard laboratory-based coagulation profiling. Cytokine content of the salvaged blood was assessed by enzyme-linked immunosorbent assays.

RESULTS

Following reinfusion of 460 mL (median) of salvaged blood, thromboelastometry showed normal clot formation and did not indicate a coagulopathy. Clotting time, clot formation time, maximum firmness and maximum lysis all remained within the normal range. Standard laboratory coagulation tests were also normal in all patients before surgery and after reinfusion. Although monocyte chemoattractant protein-1 levels were higher than normal, all other measured cytokines were either undetectable or within the normal range. No adverse events were seen following cell salvage.

DISCUSSION

Reinfusion of unwashed salvaged whole blood did not alter clot formation in our patients. The results add to the knowledge about this approach and contribute to the growing body of evidence regarding the lack of adverse events when reinfusing unwashed shed blood in major orthopaedic procedures.

Cell Salvage in Hip and Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Cell salvage is used to reduce allogeneic red blood-cell (RBC) transfusions in total hip arthroplasty (THA) and total knee arthroplasty (TKA). We performed a meta-analysis to assess the effectiveness of cell salvage to reduce transfusions in THA and TKA separately, and to examine whether recent trials change the conclusions from previous meta-analyses.

METHODS

We searched MEDLINE through January 2013 for randomized clinical trials evaluating the effects of cell salvage in THA and TKA. Trial results were extracted using standardized forms and pooled using a random-effects model. Methodological quality of the trials was evaluated using the Cochrane Collaboration's tool for risk-of-bias assessment.

RESULTS

Forty-three trials (5631 patients) were included. Overall, cell salvage reduced the exposure to allogeneic RBC transfusion in THA (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.51 to 0.85) and TKA (RR, 0.51; 95% CI, 0.39 to 0.68). However, trials published in 2010 to 2012, with a lower risk of bias, showed no significant effect of cell salvage in THA (RR, 0.82; 95% CI, 0.66 to 1.02) and TKA (RR, 0.91; 95% CI, 0.63 to 1.31), suggesting that the treatment policy regarding transfusion may have changed over time.

CONCLUSIONS

Looking at all trials, cell salvage still significantly reduced the RBC exposure rate and the volume of RBCs transfused in both THA and TKA. However, in trials published more recently (2010 to 2012), cell salvage reduced neither the exposure rate nor the volume of RBCs transfused in THA and TKA, most likely explained by changes in blood transfusion management.

Use of tranexamic acid in craniosynostosis surgery

BACKGROUND

Intraoperative tranexamic acid (TXA) administration has been used to abate blood loss in a variety of surgical procedures. Several recent studies have supported its efficacy in reducing transfusion requirements in pediatric cranial vault reconstruction (CVR).

OBJECTIVE

To conduct a retrospective chart review to determine whether a significant reduction in packed red blood cell (PRBC) and fresh frozen plasma (FFP) transfusions exists when TXA is used.

METHODS

A retrospective cohort study of 28 patients who underwent CVR for sagittal craniosynostosis was performed. Transfusion requirements for 14 patients who did not receive TXA were compared with 14 patients who did. Predictors of increased blood product transfusion were also studied.

RESULTS

Total volume of PRBC transfusion was reduced by 50% with the use of TXA (P=0.004) with a 34% reduction in intraoperative PRBC transfusion (P=0.017) and a 67% reduction in postoperative PRBC transfusion (P<0.001). Total volume of FFP transfusion was reduced by 46% (P=0.002) and postoperative FFP transfusion was reduced by 100% (P=0.001). The use of TXA was associated with a lower total volume of PRBC (P=0.003) and FFP (P=0.003) transfusions. Older patient age was associated with lower total volume of PRBC transfused (P=0.046 and P=0.002), but not with FFP (P=0.183 and P=0.099) transfusion volumes. Increasing patient weight was associated with lower PRBC (P=0.010 and P=0.020) and FFP (P=0.045 and P=0.016) transfusion volumes.

CONCLUSION

TXA decreased blood product transfusion requirements in patients undergoing CVR for sagittal craniosynostosis, and should be a routine part of the strategy to reduce blood loss in these procedures.

Perioperative blood management

Perioperative anaemia and allogenic blood transfusion (ABT) are known to increase the risk of adverse clinical outcomes. The quality, cost and availability of blood components are also major limitations with regard to ABT. Perioperative patient blood management (PBM) strategies should be aimed at minimizing and improving utilization of blood components. The goals of PBM are adequate preoperative evaluation and optimization of haemoglobin and bleeding parameters, techniques to minimize blood loss, blood conservation technologies and use of transfusion guidelines with targeted therapy. Attention to these details can help in cost reduction and improved patient outcome.

The impact of perioperative iron on the use of red blood cell transfusions in gastrointestinal surgery: a systematic review and meta-analysis

Perioperative anemia is common, yet detrimental, in surgical patients. However, red blood cell transfusions (RBCTs) used to treat anemia are associated with significant postoperative risks and worse oncologic outcomes. Perioperative iron has been suggested to mitigate perioperative anemia. This meta-analysis examined the impact of perioperative iron compared to no intervention on the need for RBCT in gastrointestinal surgery. We systematically searched Medline, Embase, Web of Science, Cochrane Central, and Scopus to identify relevant randomized controlled trials (RCTs) and nonrandomized studies (NRSs). We excluded studies investigating autologous RBCT or erythropoietin. Two independent reviewers selected the studies, extracted data, and assessed the risk of bias using the Cochrane tool and Newcastle-Ottawa scale. Primary outcomes were proportion of patients getting allogeneic RBCT and number of transfused patient. Secondary outcomes were hemoglobin change, 30-day postoperative morbidity and mortality, length of stay, and oncologic outcomes. A meta-analysis using random effects models was performed. The review was registered in PROSPERO (CRD42013004805). From 883 citations, we included 2 RCTs and 2 NRSs (n = 325 patients), all pertaining to colorectal cancer surgery. Randomized controlled trials were at high risk for bias and underpowered. One RCT and 1 NRS using preoperative oral iron reported a decreased proportion of patients needing RBCT. One RCT on preoperative intravenous iron and 1 NRS on postoperative PO iron did not observe a difference. Only 1 study revealed a difference in number of transfused patients. One RCT reported significantly increased postintervention hemoglobin. Among 3 studies reporting length of stay, none observed a difference. Other secondary outcomes were not reported. Meta-analysis revealed a trend toward fewer patients requiring RBCT with iron supplementation (risk ratio, 0.66 [0.42, 1.02]), but no benefit on the number of RBCT per patient (weighted mean difference, -0.91 [-1.61, -0.18]). Although preliminary evidence suggests that it may be a promising strategy, there is insufficient evidence to support the routine use of perioperative iron to decrease the need for RBCT in colorectal cancer surgery. Well-designed RCTs focusing on the need for RBCT and including long-term outcomes are warranted.

Quick biochemical markers for assessment of quality control of intraoperative cell salvage: a prospective observational study

BACKGROUND

Intraoperative Cell Salvage (ICS), hereby referred to 'mechanical red cell salvage', has been widely used in adult elective major surgeries to reduce requirement for homologous red blood cell transfusion and its associated complications. However, amount of free haemoglobin (fHb) from ICS has been shown related to incidence of renal failure. fHb is the most important indicator of quality control of cell salvaged blood, thus monitoring the fHb concentration is imperative to minimise renal injury. However, currently there has been lacking quick biochemical markers to monitor the levels of fHb during ICS. The aim of this study was to screen quick biochemical markers for evaluating the amount of fHb during use of intraoperative cell salvage.

METHODS

Twenty patients undergoing elective cardiovascular surgery were enrolled. Blood was collected and processed using a Fresenius continuous auto-transfusion system device. The concentration of fHb, albumin (Alb), and calcium (Ca) in three washing modes were measured, and their clearance rates were calculated. The correlations among the clearances and concentrations of fHb, albumin, and calcium were analysed.

RESULTS

In three washing modes, concentrations of albumin and calcium are significantly associated with amount of fHb:fHb(g/L) = 0.111 Alb(g/L) -0.108, R = 0.638, p = 0.000; fHb(g/L) = 1.721 Ca(mmol/L) +0.091, R = 0.514, p = 0.000. Furthermore, the clearance rates of albumin and calcium significantly predict clearance of fHb, CR(fHb) = 0.310 CR(ALB) + 0.686, R = 0.753, p = 0.000, CR(fHb) = 0.073 CR(Ca) + 0.913, R = 0.497, p = 0.000.

CONCLUSIONS

In clinic practice, clearance rates of albumin, or calcium can be used to evaluate the quality of salvaged blood, fHb. Bed-side measurement of calcium could offer a more feasible means for clinicians to undertake a real-time assessment of fHb.

Perceived barriers among physicians for stopping non-cost-effective blood-saving measures in total hip and total knee arthroplasties

BACKGROUND

Despite evidence that the blood-saving measures (BSMs) erythropoietin (EPO) and intra- and postoperative blood salvage are not (cost-)effective in primary elective total hip and knee arthroplasties, they are used frequently in Dutch hospitals. This study aims to assess the impact of barriers associated with the intention of physicians to stop BSMs.

STUDY DESIGN AND METHODS

A survey among 400 orthopedic surgeons and 400 anesthesiologists within the Netherlands was performed. Multivariate logistic regression was used to identify barriers associated with intention to stop BSMs.

RESULTS

A total of 153 (40%) orthopedic surgeons and 100 (27%) anesthesiologists responded. Of all responders 67% used EPO, perioperative blood salvage, or a combination. After reading the evidence on non-cost-effective BSMs, 50% of respondents intended to stop EPO and 53% to stop perioperative blood salvage. In general, barriers perceived most frequently were lack of attention for blood management (90% of respondents), department priority to prevent transfusions (88%), and patient characteristics such as comorbidity (81%). Barriers significantly associated with intention to stop EPO were lack of interest to save money and the impact of other involved parties. Barriers significantly associated with intention to stop perioperative blood salvage were concerns about patient safety, lack of alternatives, losing experience with the technique, and lack of interest to save money.

CONCLUSION

Physicians experience barriers to stop using BSMs, related to their own technical skills, patient safety, current blood management policy, and lack of interest to save money. These barriers should be targeted in strategies to make BSM use cost-effective.

[Patient Blood Management : three pillar strategy to improve outcome through avoidance of allogeneic blood products]

Blood transfusions are commonly viewed as life-saving interventions; however, current evidence shows that blood transfusions are associated with a significant increase of morbidity and mortality in a dose-dependent relationship. Not only explanatory models of basic research but also the results from randomized controlled trials suggest a causal relationship between blood transfusion and adverse outcome. Therefore, it can be claimed that the current state of science debunks the long held belief in the so-called life-saving blood transfusion by exposing the potential for promoting disease and death. Adherence to the precautionary principle and also the fact that blood transfusions are more costly than previously assumed require novel approaches in the treatment of anemia and bleeding. Patient Blood Management (PBM) allows transfusion rates to be dramatically reduced through correcting anemia by stimulating erythropoiesis, minimization of perioperative blood loss and harnessing and optimizing the physiological tolerance of anemia. A resolution of the World Health Assembly has endorsed PBM and therefore morbidity and mortality should be significantly reduced by lowering of the currently high blood utilization rate of allogeneic blood products in Austria, Germany and Switzerland.