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Leff J, Romano CA, Gilbert S, Nair S. Validation Study of the Transfusion Risk and Clinical Knowledge (TRACK) Tool in Cardiac Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2019; 33:2669-2675. [DOI: 10.1053/j.jvca.2019.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/21/2019] [Accepted: 05/25/2019] [Indexed: 11/11/2022]
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Brady JS, Desai SV, Crippen MM, Eloy JA, Gubenko Y, Baredes S, Park RCW. Association of Anesthesia Duration With Complications After Microvascular Reconstruction of the Head and Neck. JAMA FACIAL PLAST SU 2019; 20:188-195. [PMID: 28983575 DOI: 10.1001/jamafacial.2017.1607] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Prolonged anesthesia and operative times have deleterious effects on surgical outcomes in a variety of procedures. However, data regarding the influence of anesthesia duration on microvascular reconstruction of the head and neck are lacking. Objective To examine the association of anesthesia duration with complications after microvascular reconstruction of the head and neck. Design, Setting, and Participants The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to collect data. In total, 630 patients who underwent head and neck microvascular reconstruction were recorded in the NSQIP registry from January 1, 2005, through December 31, 2013. Patients who underwent microvascular reconstructive surgery performed by otolaryngologists or plastic surgeons were included in this study. Data analysis was performed from October 15, 2015, to January 15, 2016. Exposures Microvascular reconstructive surgery of the head and neck. Main Outcomes and Measures Patients were stratified into 5 quintiles based on mean anesthesia duration and analyzed for patient characteristics and operative variables (mean [SD] anesthesia time: group 1, 358.1 [175.6] minutes; group 2, 563.2 [27.3] minutes; group 3, 648.9 [24.0] minutes; group 4, 736.5 [26.3] minutes; and group 5, 922.1 [128.1] minutes). Main outcomes include rates of postoperative medical and surgical complications and mortality. Results A total of 630 patients undergoing head and neck free flap surgery had available data on anesthesia duration and were included (mean [SD] age, 61.6 [13.8] years; 436 [69.3%] male). Bivariate analysis revealed that increasing anesthesia duration was associated with increased 30-day complications overall (55 [43.7%] in group 1 vs 80 [63.5%] in group 5, P = .006), increased 30-day postoperative surgical complications overall (45 [35.7%] in group 1 vs 78 [61.9%] in group 5, P < .001), increased rates of postoperative transfusion (32 [25.4%] in group 1 vs 70 [55.6%] in group 5, P < .001), and increased rates of wound disruption (0 in group 1 vs 10 [7.9%] in group 5, P = .02). No specific medical complications and no overall medical complication rate (24 [19.0%] in group 1 vs 22 [17.5%] in group 5, P = .80) or mortality (1 [0.8%] in group 1 vs 1 [0.8%] in group 5, P = .75) were associated with increased anesthesia duration. On multivariate analysis accounting for demographics and significant preoperative factors including free flap type, overall complications (group 5: odds ratio [OR], 1.98; 95% CI, 1.10-3.58; P = .02), surgical complications (group 5: OR, 2.46; 95% CI, 1.35-4.46; P = .003), and postoperative transfusion (group 5: OR, 2.31; 95% CI, 1.27-4.20; P = .006) remained significantly associated with increased anesthesia duration; the association of wound disruption and increased anasthesia duration was nonsignificant (group 5: OR, 2.0; 95% CI, 0.75-5.31; P = .16). Conclusions and Relevance Increasing anesthesia duration was associated with significantly increased rates of surgical complications, especially the requirement for postoperative transfusion. Rates of medical complications were not significantly altered, and overall mortality remained unaffected. Avoidance of excessive blood loss and prolonged anesthesia time should be the goal when performing head and neck free flap surgery. Level of Evidence 3.
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Affiliation(s)
- Jacob S Brady
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Stuti V Desai
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Meghan M Crippen
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
| | - Jean Anderson Eloy
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark.,Department of Ophthalmology, Rutgers New Jersey Medical School, Newark
| | - Yuriy Gubenko
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark
| | - Soly Baredes
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.,Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark
| | - Richard Chan Woo Park
- Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark
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Preoperative Epoetin-α with Intravenous or Oral Iron for Major Orthopedic Surgery: A Randomized Controlled Trial. Anesthesiology 2019; 129:710-720. [PMID: 30074935 DOI: 10.1097/aln.0000000000002376] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Preoperative administration of epoetin-α with iron is commonly used in anemic patients undergoing major orthopedic surgery, but the optimal route of iron intake is controversial. The aim of this study was to compare the clinical effects of erythropoietin in combination with oral or intravenous iron supplementation. METHODS This study was a prospective, randomized, single-blinded, parallel arm trial. Patients scheduled for elective hip or knee arthroplasty with hemoglobin 10 to 13 g/dl received preoperative injections of erythropoietin with oral ferrous sulfate or intravenous ferric carboxymaltose. The primary endpoint was the hemoglobin value the day before surgery. RESULTS One hundred patients were included in the analysis. The day before surgery, hemoglobin, increase in hemoglobin, and serum ferritin level were higher in the intravenous group. For the intravenous and oral groups, respectively, hemoglobin was as follows: median, 14.9 g/dl (interquartile range, 14.1 to 15.6) versus 13.9 g/dl (interquartile range, 13.2 to 15.1), group difference, 0.65 g/dl (95% CI, 0.1 to 1.2; P = 0.017); increase in hemoglobin: 2.6 g/dl (interquartile range, 2.1 to 3.2) versus 1.9 g/dl (interquartile range, 1.4 to 2.5), group difference, 0.7 g/dl (95% CI, 0.3 to 1.1; P < 0.001); serum ferritin: 325 µg/l (interquartile range, 217 to 476) versus 64.5 µg/l (interquartile range, 44 to 107), group difference, 257 µg/l (95% CI, 199 to 315; P < 0.001). The percentage of patients with nausea, diarrhea, or constipation was higher in the oral group, 52% versus 2%; group difference, 50% (95% CI, 35 to 64%; P < 0.0001). CONCLUSIONS After preoperative administration of erythropoietin, body iron stores and stimulation of the erythropoiesis were greater with intravenous ferric carboxymaltose than with oral ferrous sulfate supplementation.
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Sert GS, Çavuş M, Kemerci P, Bektaş Ş, Demir ZA, Özgök A, Sert D, Karadeniz Ü. The Results of Cardiac Surgery in Terms of Patient Blood Management in Our Hospital. Turk J Anaesthesiol Reanim 2019; 47:402-406. [PMID: 31572992 DOI: 10.5152/tjar.2019.02058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 10/30/2018] [Indexed: 11/22/2022] Open
Abstract
Objective Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, beginning in 2014, the patient blood management (PBM) protocol is individualised based on patients' comorbidities, and the threshold for transfusion is 7 g dL-1 of haemoglobin for patients without comorbidities and 8-9 g dL-1 for patients with comorbidities. In this study, our aim was to compare patient outcomes, requirement for transfusion and the cost of transfusion between two different periods with and without PBM protocol. Methods 229 and 283 patients who underwent open-heart surgery using cardiopulmonary bypass during the first 4 months of 2012 and the first 4 months of 2017, respectively, were included in this retrospective, cross-sectional study. Results There were no differences between the groups in preoperative data. Blood and blood product usage was observed to be significantly lower at the time of the PBM protocol. The use of packed red blood cells decreased from 2 units to 0and that of fresh frozen plasma decreased from 2 units to 0. In terms of postoperative mortality, there were no differences between the groups. Conclusion According to the results of this study, the transfusion of unnecessary blood and blood products was reduced and the cost decreased with PBM protocol. Blood product usage did not affect 30-day mortality. It will be possible to achieve more valuable results if more patients are assessed, PBM protocol is implemented and postoperative results are evaluated in detail.
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Affiliation(s)
- Gökçe Selçuk Sert
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Mine Çavuş
- Clinic of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Perihan Kemerci
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Şerife Bektaş
- Clinic of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Zeliha Aslı Demir
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Doğan Sert
- Clinic of Cardiovascular Surgery, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ümit Karadeniz
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
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55
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Redfern RE, Fleming K, March RL, Bobulski N, Kuehne M, Chen JT, Moront M. Thromboelastography-Directed Transfusion in Cardiac Surgery: Impact on Postoperative Outcomes. Ann Thorac Surg 2019; 107:1313-1318. [DOI: 10.1016/j.athoracsur.2019.01.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 12/11/2018] [Accepted: 01/07/2019] [Indexed: 01/08/2023]
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Chan CH, Ziyadi GM, Zuhdi MA. Adverse Outcomes of Perioperative Red Blood Cell Transfusions in Coronary Artery Bypass Grafting in Hospital Universiti Sains Malaysia. Malays J Med Sci 2019; 26:49-63. [PMID: 31303850 PMCID: PMC6613466 DOI: 10.21315/mjms2019.26.3.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/03/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Perioperative red blood cell (RBC) transfusion in coronary artery bypass grafting (CABG) has both benefits and harms. Our aim was to study the association between perioperative RBC transfusion and its adverse outcomes. METHODS This was a retrospective study of patients who underwent isolated CABG in Hospital Universiti Sains Malaysia, Kelantan, Malaysia, from 1 January 2013 until 31 December 2017. Data were collected from medical records, and comparisons were made between patients who received perioperative RBC transfusions and those who did not have adverse outcomes after CABG. RESULTS A total of 108 patients who underwent isolated CABG were included in our study, and 78 patients received perioperative RBC transfusions. Patients who received perioperative RBC transfusions compared to those who did not were significantly more likely to develop prolonged ventilatory support (21.8% versus 0%, P = 0.003), cardiac morbidity (14.1% versus 0%, P = 0.032), renal morbidity (28.2% versus 3.3%, P = 0.005) and serious infection (20.5% versus 3.3%, P = 0.037). With each unit of packed RBC transfusions, there was a significantly increased risk of prolonged ventilatory support (adjusted odds ratio [AOR] = 1.45; 95% confidence interval [CI] = 1.20-1.77; P < 0.001), cardiac morbidity (AOR =1.40; 95%CI = 1.01-1.79; P = 0.007), renal morbidity (AOR = 1.23; 95%CI = 1.03-1.45; P = 0.019) and serious infection (AOR = 1.31; 95%CI = 1.07-1.60; P = 0.009). CONCLUSION Perioperative RBC transfusion in isolated CABG patients is associated with increased risks of developing adverse events such as prolonged ventilatory support, cardiac morbidity, renal morbidity and serious infection.
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Affiliation(s)
- Choon Hua Chan
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Ghazali Mohamad Ziyadi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Mamat Ahmad Zuhdi
- Unit of Cardiothoracic Surgery, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
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Saha S, Varghese S, Herr M, Leistner M, Ulrich C, Niehaus H, Ahmad AA, Baraki H, Kutschka I. Minimally invasive versus conventional extracorporeal circulation circuits in patients undergoing coronary artery bypass surgery: a propensity-matched analysis. Perfusion 2019; 34:590-597. [PMID: 30977430 DOI: 10.1177/0267659119842060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Minimally invasive extracorporeal circulation circuits provide several advantages compared to conventional extracorporeal circulation circuits. We compared the results of a minimally invasive extracorporeal circulation system with those of conventional extracorporeal circulation system, in patients undergoing isolated coronary artery bypass grafting. METHODS We identified 753 consecutive patients who underwent coronary artery bypass grafting at our centre between October 2014 and September 2016. These patients were divided into two groups: a minimally invasive extracorporeal circulation group (M, n = 229) and a conventional extracorporeal circulation group (C, n = 524). Baseline parameters, details of cardiac surgery as well as postoperative complications and outcomes were compared by means of a propensity-matched analysis of 180 matched pairs. RESULTS The median EuroSCORE II was 1.3%. Transfusion requirement of packed red blood cells (p = 0.002) was lower in Group M compared to conventional extracorporeal circulation systems. There were no differences in hospital mortality or in rates of adverse events between the matched groups. Total in-hospital mortality of the cohort was 1.7%. CONCLUSION The use of minimally invasive extracorporeal circulation is associated with a significantly lower use of blood products after isolated coronary revascularisation. There were no differences concerning duration of surgery, complication rates and mortality between the groups. Therefore, the application of minimally invasive extracorporeal circulation systems should be considered as preferred technique in isolated coronary artery bypass grafting procedures.
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Affiliation(s)
- Shekhar Saha
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Sam Varghese
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany
| | - Mike Herr
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Marcus Leistner
- Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Christian Ulrich
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Heidi Niehaus
- Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Ammar Al Ahmad
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Hassina Baraki
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
| | - Ingo Kutschka
- Department of Cardiothoracic Surgery, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany.,Department of Thoracic and Cardiovascular Surgery, University Hospital Göttingen, Georg-August-University, Göttingen, Germany
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Patient blood management for liver resection: consensus statements using Delphi methodology. HPB (Oxford) 2019; 21:393-404. [PMID: 30446290 DOI: 10.1016/j.hpb.2018.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/21/2018] [Accepted: 09/27/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.
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Blood Transfusion: Cost, Quality, and Other Considerations for the Surgical Management of the Critically Ill. Crit Care Nurs Q 2019; 42:173-176. [PMID: 30807341 DOI: 10.1097/cnq.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
This article explores the average overall costs of blood transfusion for critically ill surgical patients and in particular explores the evidence supporting reduction of transfusion as part of guideline-based care in cardiothoracic surgical patients. Average cost data compiled from various sources are presented and quality and outcome considerations in blood transfusion in the critically ill are reviewed. Multiple strategies that have a high level of evidence to support their use in this population are noted.
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60
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Lehmann F, Rau J, Malcolm B, Sander M, von Heymann C, Moormann T, Geyer T, Balzer F, Wernecke KD, Kaufner L. Why does a point of care guided transfusion algorithm not improve blood loss and transfusion practice in patients undergoing high-risk cardiac surgery? A prospective randomized controlled pilot study. BMC Anesthesiol 2019; 19:24. [PMID: 30777015 PMCID: PMC6379957 DOI: 10.1186/s12871-019-0689-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background Adult cardiac surgery is often complicated by elevated blood losses that account for elevated transfusion requirements. Perioperative bleeding and transfusion of blood products are major risk factors for morbidity and mortality. Timely diagnostic and goal-directed therapies aim at the reduction of bleeding and need for allogeneic transfusions. Methods Single-centre, prospective, randomized trial assessing blood loss and transfusion requirements of 26 adult patients undergoing elective cardiac surgery at high risk for perioperative bleeding. Primary endpoint was blood loss at 24 h postoperatively. Random assignment to intra- and postoperative haemostatic management following either an algorithm based on conventional coagulation assays (conventional group: platelet count, aPTT, PT, fibrinogen) or based on point-of-care (PoC-group) monitoring, i.e. activated rotational thromboelastometry (ROTEM®) combined with multiple aggregometry (Multiplate®). Differences between groups were analysed using nonparametric tests for independent samples. Results The study was terminated after interim analysis (n = 26). Chest tube drainage volume was 360 ml (IQR 229-599 ml) in the conventional group, and 380 ml (IQR 310-590 ml) in the PoC-group (p = 0.767) after 24 h. Basic patient characteristics, results of PoC coagulation assays, and transfusion requirements of red blood cells and fresh frozen plasma did not differ between groups. Coagulation results were comparable. Platelets were transfused in the PoC group only. Conclusion Blood loss via chest tube drainage and transfusion amounts were not different comparing PoC- and central lab-driven transfusion algorithms in subjects that underwent high-risk cardiac surgery. Routine PoC coagulation diagnostics do not seem to be beneficial when actual blood loss is low. High risk procedures might not suffice as a sole risk factor for increased blood loss. Trial registration NCT01402739, Date of registration July 26, 2011.
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Affiliation(s)
- F Lehmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany.
| | - J Rau
- Division of Medical Biotechnology, Paul-Ehrlich-Institut, Federal Institute for Vaccines and Biomedicines, Langen, Hessen, Germany
| | - B Malcolm
- Department of Internal Medicine, Hegau-Bodensee-Klinikum, Singen, Baden-Württemberg, Germany
| | - M Sander
- Department of Anaesthesiology, Intensive Care Medicine and Pain therapy, University Hospital Gießen UKGM, Justus-Liebig-University Giessen, Giessen, Hessen, Germany
| | - C von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - T Moormann
- Department of Anaesthesiology and Intensive Care Medicine, Martin-Luther-Krankenhaus, Berlin, Germany
| | - T Geyer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - F Balzer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - K D Wernecke
- CRO SOSTANA GmbH and Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - L Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Latchana N, Hirpara DH, Hallet J, Karanicolas PJ. Red blood cell transfusion in liver resection. Langenbecks Arch Surg 2019; 404:1-9. [PMID: 30607533 DOI: 10.1007/s00423-018-1746-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes. PURPOSE Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion. RESULTS Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods. CONCLUSION Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.
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Affiliation(s)
- Nicholas Latchana
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Dhruvin H Hirpara
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul J Karanicolas
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
- Department of Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
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Ge HW, Kong FJ. Letter by Ge and Kong Regarding Article, "High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients: A Randomized Controlled Trial". Circulation 2018; 138:2445-2446. [PMID: 30571582 DOI: 10.1161/circulationaha.118.035995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hong-Wei Ge
- Department of Urology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China (H.W.-G. and F.J.-K.)
| | - Fei-Juan Kong
- Department of Urology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, China (H.W.-G. and F.J.-K.)
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Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years. Cardiol Young 2018; 28:1289-1294. [PMID: 30070188 DOI: 10.1017/s1047951118001269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND In Nigeria, access to open heart surgery (OHS) is adversely affected by insufficient blood and blood products, including the challenges because of the lack of patient-focused blood management strategies owing to the absent requisite point-of-care tests in the operating theatre (OR)/ICU. In addition, the limited availability of altruistic blood donors including the detection of transfusion transmitted infections more commonly among non-altruistic blood donors is another burden affecting the management of excessive bleeding during and after open heart surgery in our country. OBJECTIVE The objective of this study was to review our local experience in the use of blood and blood products during open heart surgery and compare the same with the literature.Materials and methodsIn a period of 3 years (March, 2013-February, 2016), we performed a retrospective review of those who had open heart surgery in our institution. The data were obtained from our hospital health information technology department. The data comprised demography, types of operative procedures and units of blood and blood products transfused per procedure, including the details regarding the usage of the cell saver, as well as those who had severe bleeding requiring excessive blood transfusion. RESULTS During the study period, 102 patients had open heart surgery, an average of 34 cases in a year. Among them, there were 75 (73.53%) males and 37 (36.27%) females, giving a ratio of 2:1. The ages of the patients were from 0.6 (7/12) to 74 years. Mitral valve procedure was the most common (n=22, 21.6%) surgery type. Transfusion requirements averaged 1.9 units of fresh frozen plasma, 0.36 units of platelet concentrate, and 1.68 units of packed cells per procedure. The least common surgical procedure was common atrium repair (n=1, 0.01%). CONCLUSION Open heart procedure is a very complex procedure requiring cardiopulmonary bypass with associated severe perioperative bleeding. The attendant blood loss and haemostatic challenges are combated by intricate and selective transfusions of allogeneic blood and or blood products.
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Rich JB, Fonner CE, Quader MA, Ailawadi G, Speir AM. Impact of Regional Collaboration on Quality Improvement and Associated Cost Savings in Coronary Artery Bypass Grafting. Ann Thorac Surg 2018; 106:454-459. [DOI: 10.1016/j.athoracsur.2018.02.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 01/29/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
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St-Onge S, Lemoine É, Bouhout I, Rochon A, El-Hamamsy I, Lamarche Y, Demers P. Evaluation of the real-world impact of rotational thromboelastometry-guided transfusion protocol in patients undergoing proximal aortic surgery. J Thorac Cardiovasc Surg 2018; 157:1045-1054.e4. [PMID: 30195598 DOI: 10.1016/j.jtcvs.2018.07.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 06/12/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Complex aortic procedures are potentially associated with important blood loss and coagulopathy. The aim of this study was to assess the impact of rotational thromboelastometry (ROTEM, Tem International GmBH, Munich, Germany) on transfusion requirements after proximal aortic operations in a real-world setting. METHODS This single-center retrospective analysis based on 385 consecutive patients undergoing cardiac surgeries involving the aortic root, ascending aorta, or aortic arch compared 197 controls managed according to routine transfusion protocol before the introduction of the ROTEM in 2012 with 188 patients operated afterward. With the use of a 1:1 propensity score match, 224 patients were included in paired analysis (112 in each group). The primary end point was erythrocytes transfusion rate. The secondary end points comprised the transfusion of other allogeneic blood products, number of units transfused, postoperative blood loss, massive transfusion rate, and use of other hemostatic products. RESULTS ROTEM implementation was associated with a trend toward reduction in the rate of erythrocytes transfusion (57% vs 46%, P = .08) and a decreased median number of units transfused for erythrocytes (1.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .03) and plasma (0.0 [0.0-4.0] unit vs 0.0 [0.0-2.0] unit, P = .04). After sensitivity analysis, ROTEM displayed a comparable rate of erythrocytes transfusion (58% vs 47%, P = .15). CONCLUSIONS In a real-world setting, ROTEM-based algorithm implementation could help reduce excess erythrocytes transfusion for complex aortic procedures. We advocate for a strict adherence and concerted team effort to maximize the benefits of such addition to patients' management.
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Affiliation(s)
- Samuel St-Onge
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Émile Lemoine
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Ismail Bouhout
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Antoine Rochon
- Department of Anesthesia, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Ismaïl El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Yoan Lamarche
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada
| | - Philippe Demers
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal School of Medicine, Montreal, Quebec, Canada.
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Lo Pinto H, Allyn J, Persichini R, Bouchet B, Brochier G, Martinet O, Brulliard C, Valance D, Delmas B, Braunberger E, Dangers L, Allou N. Predictors of red blood cell transfusion and its association with prognosis in patients undergoing extracorporeal membrane oxygenation. Int J Artif Organs 2018; 41:644-652. [PMID: 29998775 DOI: 10.1177/0391398818785132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE Few data are available on the potential benefits and risks of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation. The aim of this study was to identify the determinants and prognosis of red blood cell transfusion in patients undergoing extracorporeal membrane oxygenation, with a special focus on biological parameters during extracorporeal membrane oxygenation treatment. METHODS We conducted a single-center retrospective cohort study including all consecutive patients who underwent extracorporeal membrane oxygenation between January 2010 and December 2015. RESULTS The 201 evaluated patients received a median of 0.9 [0.5-1.7] units of red blood cell per day. Significant and clinically relevant variables that best correlated with units of red blood cell transfused per day of extracorporeal membrane oxygenation were lower median daily prothrombin time in percentage (Quick) ( t = -0.016, p < 0.0001), higher median daily free bilirubin level ( t = 0.016, p < 0.0001), and lower pH ( t = -2.434, p < 0.0001). In multivariate analysis, red blood cell transfusion was associated with a significantly higher rate of in-intensive care unit mortality (per red blood cell unit increment; adjusted odds ratio: 1.07, 95% confidence interval: 1.02-1.12, p = 0.005). It was also associated with higher rates of acute renal failure ( p = 0.025), thromboembolic complications ( p = 0.0045), and sepsis ( p = 0.015). CONCLUSION This study suggests that red blood cell transfusion may be associated with a higher mortality rate and with severe complications. However, we cannot conclude a direct causal relationship, as red blood cell transfusion may be only a marker of poor outcome. We recommend that physicians correct acidosis and hemolysis in patients undergoing extracorporeal membrane oxygenation whenever possible.
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Affiliation(s)
- Hugo Lo Pinto
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Jérôme Allyn
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Romain Persichini
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Bruno Bouchet
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Gilbert Brochier
- 2 Établissement Français du Sang, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Olivier Martinet
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Caroline Brulliard
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Dorothée Valance
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Benjamin Delmas
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Eric Braunberger
- 3 Chirurgie Cardiaque, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Laurence Dangers
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
| | - Nicolas Allou
- 1 Réanimation Polyvalente, Centre Hospitalier Universitaire Félix Guyon, Saint-Denis, France
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Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP). HPB (Oxford) 2018; 20:669-675. [PMID: 29459001 DOI: 10.1016/j.hpb.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/21/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
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.
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LaPar DJ, Hawkins RB, McMurry TL, Isbell JM, Rich JB, Speir AM, Quader MA, Kron IL, Kern JA, Ailawadi G. Preoperative anemia versus blood transfusion: Which is the culprit for worse outcomes in cardiac surgery? J Thorac Cardiovasc Surg 2018; 156:66-74.e2. [PMID: 29706372 DOI: 10.1016/j.jtcvs.2018.03.109] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Revised: 02/05/2018] [Accepted: 03/02/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Reducing blood product utilization after cardiac surgery has become a focus of perioperative care as studies have suggested improved outcomes. The relative impact of preoperative anemia versus packed red blood cells (PRBC) transfusion on outcomes remains poorly understood, however. In this study, we investigated the relative association between preoperative hematocrit (Hct) level and PRBC transfusion on postoperative outcomes after coronary artery bypass grafting (CABG) surgery. METHODS Patient records for primary, isolated CABG operations performed between January 2007 and December 2017 at 19 cardiac surgery centers were evaluated. Hierarchical logistic regression modeling was used to estimate the relationship between baseline preoperative Hct level as well as PRBC transfusion and the likelihoods of postoperative mortality and morbidity, adjusted for baseline patient risk. Variable and model performance characteristics were compared to determine the relative strength of association between Hct level and PRBC transfusion and primary outcomes. RESULTS A total of 33,411 patients (median patient age, 65 years; interquartile range [IQR], 57-72 years; 26% females) were evaluated. The median preoperative Hct value was 39% (IQR, 36%-42%), and the mean Society of Thoracic Surgeons (STS) predicted risk of mortality was 1.8 ± 3.1%. Complications included PRBC transfusion in 31% of patients, renal failure in 2.8%, stroke in 1.3%, and operative mortality in 2.0%. A strong association was observed between preoperative Hct value and the likelihood of PRBC transfusion (P < .001). After risk adjustment, PRBC transfusion, but not Hct value, demonstrated stronger associations with postoperative mortality (odds ratio [OR], 4.3; P < .0001), renal failure (OR 6.3; P < .0001), and stroke (OR, 2.4; P < .0001). A 1-point increase in preoperative Hct was associated with decreased probabilities of mortality (OR, 0.97; P = .0001) and renal failure (OR, 0.94; P < .0001). The models with PRBC had superior predictive power, with a larger area under the curve, compared with Hct for all outcomes (all P < .01). Preoperative anemia was associated with up to a 4-fold increase in the probability of PRBC transfusion, a 3-fold increase in renal failure, and almost double the mortality. CONCLUSIONS PRBC transfusion appears to be more closely associated with risk-adjusted morbidity and mortality compared with preoperative Hct level alone, supporting efforts to reduce unnecessary PRBC transfusions. Preoperative anemia independently increases the risk of postoperative morbidity and mortality. These data suggest that preoperative Hct should be included in the STS risk calculators. Finally, efforts to optimize preoperative hematocrit should be investigated as a potentially modifiable risk factor for mortality and morbidity.
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Affiliation(s)
| | | | | | | | | | - Alan M Speir
- Inova Heart and Vascular Institute, Falls Church, Va
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Anemia, transfusion, and outcome: Both are bad…does it really matter which is worse? J Thorac Cardiovasc Surg 2018; 156:75-76. [PMID: 29655536 DOI: 10.1016/j.jtcvs.2018.03.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 03/19/2018] [Indexed: 11/21/2022]
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70
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Bobbitt J, Petro K, Martin M. Evaluating the effectiveness of pre-operative platelet inhibition testing to reduce costs and pre-operative length of stay. Appl Nurs Res 2018; 39:241-243. [DOI: 10.1016/j.apnr.2017.11.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 11/02/2017] [Accepted: 11/19/2017] [Indexed: 10/18/2022]
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71
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Hallet J, Mahar AL, Nathens AB, Tsang ME, Beyfuss KA, Lin Y, Coburn NG, Karanicolas PJ. The impact of perioperative blood transfusions on short-term outcomes following hepatectomy. Hepatobiliary Surg Nutr 2018. [PMID: 29531938 DOI: 10.21037/hbsn.2017.05.07] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Bleeding and need for red blood cell transfusions (RBCT) remain a significant concern with hepatectomy. RBCT carry risk of transfusion-related immunomodulation that may impact post-operative recovery. This study soughs to assess the association between RBCT and post-hepatectomy morbidity. Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, we identified all adult patients undergoing elective hepatectomy over 2007-2012. Two exposure groups were created based on RBCT. Primary outcomes were 30-day major morbidity and mortality. Secondary outcomes included 30-day system-specific morbidity and length of stay (LOS). Relative risks (RR) with 95% confidence interval (95% CI) were computed using regression analyses. Sensitivity analyses were conducted to understand how missing data might have impacted the results. Results A total of 12,180 patients were identified. Of those, 11,712 met inclusion criteria, 2,951 (25.2%) of whom received RBCT. Major morbidity occurred in 14.9% of patients and was strongly associated with RBCT (25.3% vs. 11.3%; P<0.001). Transfused patients had higher rates of 30-day mortality (5.6% vs. 1.0%; P<0.0001). After adjustment for baseline and clinical characteristics, RBCT was independently associated with increased major morbidity (RR 1.80; 95% CI: 1.61-1.99), mortality (RR 3.62; 95% CI: 2.68-4.89), and 1.29 times greater LOS (RR 1.29; 95% CI: 1.25-1.32). Results were robust to a number of sensitivity analyses for missing data. Conclusions Perioperative RBCT for hepatectomy was independently associated with worse short-term outcomes and prolonged LOS. These findings further the rationale to focus on minimizing RBCT for hepatectomy, when they can be avoided.
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Affiliation(s)
- Julie Hallet
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alyson L Mahar
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - Avery B Nathens
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Melanie E Tsang
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kaitlyn A Beyfuss
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Yulia Lin
- Division of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Natalie G Coburn
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
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Less Is More: Results of a Statewide Analysis of the Impact of Blood Transfusion on Coronary Artery Bypass Grafting Outcomes. Ann Thorac Surg 2018; 105:129-136. [DOI: 10.1016/j.athoracsur.2017.06.062] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 06/16/2017] [Accepted: 06/21/2017] [Indexed: 01/16/2023]
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73
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Inohara T, Numasawa Y, Higashi T, Ueda I, Suzuki M, Hayashida K, Yuasa S, Maekawa Y, Fukuda K, Kohsaka S. Predictors of high cost after percutaneous coronary intervention: A review from Japanese multicenter registry overviewing the influence of procedural complications. Am Heart J 2017; 194:61-72. [PMID: 29223436 DOI: 10.1016/j.ahj.2017.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 08/15/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is widely used; however, factors of high-cost care after PCI have not been thoroughly investigated. We sought to evaluate the in-hospital costs related to PCI and identify predictors of high costs. METHODS We extracted 2,354 consecutive PCI cases (1,243 acute cases, 52.8%) from 3 Japanese cardiovascular centers from 2011 to 2015. In-hospital complications were predefined under consensus definitions (eg, acute kidney injury [AKI]). We extracted the facility cost data for each patient's resource under the universal Japanese insurance system. We classified the patients into total cost quartiles and identified predictors for the highest quartile ("high-cost" group). In addition, incremental costs for procedure-related complications were calculated. RESULTS During the study period, a total of 401 cases (17.0%) experienced procedure-related complications. The in-hospital acute and elective PCI costs per case were US $14,840 (interquartile range [IQR] 11,370-20,070) and US $11,030 (IQR 8929-14,670), respectively. After adjusting for baseline differences, any of the procedure-related complications remained an independent predictor of high costs (acute: odds ratio 1.66, 95% CIs 1.13-2.43; elective: odds ratio 3.73, 95% CIs 1.96-7.11). Notably, incremental costs were mainly attributed to AKI, which accounted for 37.5% of all incremental costs; it increased by US $9,840 for each AKI event, and the total cost increase reached US $2,588,035. CONCLUSIONS Procedure-related complications, particularly postprocedural AKI, were associated with higher costs in PCI. Further studies are required to evaluate prospectively whether the preventive strategy with a personalized risk stratification for AKI could save costs.
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Abstract
High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.
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Craver C, Belk KW, Myers GJ. Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis. Perfusion 2017; 33:44-52. [PMID: 28816101 PMCID: PMC5734379 DOI: 10.1177/0267659117723698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. Methods: A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. Results: The study population included 18,169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs 8.9%, p=0.0069). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, CI 1.15-1.38, p<0.0001), longer LOS (IRR=1.08, p<0.0001) and higher costs (IRR=1.15, p<0.0001) than tHb-monitored patients. RBC transfusions were a significant driver of LOS (IRR=1.25, p<0.0001) and cost (IRR=1.22, p<0.0001). Conclusions: tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.
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Affiliation(s)
- Christopher Craver
- 1 Vizient Inc., Health Data analytics, Irving, TX, USA.,2 University of North Carolina-Charlotte, College of Health and Human Services, Charlotte, NC, USA
| | - Kathy W Belk
- 1 Vizient Inc., Health Data analytics, Irving, TX, USA
| | - Gerard J Myers
- 3 Eastern Perfusion International, Dartmouth, Nova Scotia, Canada
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Fabbro M, Gutsche JT, Miano TA, Augoustides JG, Patel PA. Comparison of Thrombelastography-Derived Fibrinogen Values at Rewarming and Following Cardiopulmonary Bypass in Cardiac Surgery Patients. Anesth Analg 2017; 123:570-7. [PMID: 27541720 DOI: 10.1213/ane.0000000000001465] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The inflated costs and documented deleterious effects of excess perioperative transfusion have led to the investigation of targeted coagulation factor replacement strategies. One particular coagulation factor of interest is factor I (fibrinogen). Hypofibrinogenemia is typically tested for using time-consuming standard laboratory assays. The thrombelastography (TEG)-based functional fibrinogen level (FLEV) provides an assessment of whole blood clot under platelet inhibition to report calculated fibrinogen levels in significantly less time. If FLEV values obtained on cardiopulmonary bypass (CPB) during rewarming are similar to values obtained immediately after the discontinuation of CPB, then rewarming values could be used for preemptive ordering of appropriate blood product therapy. METHODS Fifty-one cardiac surgery patients were enrolled into this prospective nonrandomized study to compare rewarming fibrinogen values with postbypass values using TEG FLEV assays. Baseline, rewarming, and postbypass fibrinogen values were recorded for all patients using both standard laboratory assay (Clauss method) and FLEV. Mixed-effects regression models were used to examine the change in TEG FLEV values over time. Bland-Altman analysis was used to examine bias and the limits of agreement (LOA) between the standard laboratory assay and FLEVs. RESULTS Forty-nine patients were included in the analysis. The mean FLEV value during rewarming was 333.9 mg/dL compared with 332.8 mg/dL after protamine, corresponding to an estimated difference of -1.1 mg/dL (95% confidence interval [CI], -25.8 to 23.6; P = 0.917). Rewarming values were available on average 47 minutes before postprotamine values. Bland-Altman analysis showed poor agreement between FLEV and standard assays: mean difference at baseline was 92.5 mg/dL (95% CI, 71.1 to 114.9), with a lower LOA of -56.5 mg/dL (95% CI, -94.4 to -18.6) and upper LOA of 242.4 mg/dL (95% CI, 204.5 to 280.3). The difference between assays increased after CPB and persisted after protamine administration. CONCLUSIONS Our results revealed negligible change in FLEV values from the rewarming to postbypass periods, with a CI that does not include clinically meaningful differences. These findings suggest that rewarming samples could be utilized for ordering fibrinogen-specific therapies before discontinuation of CPB. Mean FLEV values were consistently higher than the reference standard at each time point. Moreover, bias was highly heterogeneous among samples, implying a large range of potential differences between assays for any 1 patient.
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Affiliation(s)
- Michael Fabbro
- From the *Department of Anesthesiology, University of Miami, Miami, Florida; †Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania; and ‡Department of Biostatistics and Epidemiology, Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
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Johnston LE, Downs EA, Hawkins RB, Quader MA, Speir AM, Rich JB, Ghanta RK, Yarboro LT, Ailawadi G. Outcomes for Low-Risk Surgical Aortic Valve Replacement: A Benchmark for Aortic Valve Technology. Ann Thorac Surg 2017; 104:1282-1288. [PMID: 28610884 DOI: 10.1016/j.athoracsur.2017.03.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 03/14/2017] [Accepted: 03/27/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Two large, randomized trials are underway evaluating transcatheter aortic valve replacement (AVR) against conventional surgical AVR. We analyzed contemporary, real-world outcomes of surgical AVR in low-risk patients to provide a practical benchmark of outcomes and cost for evaluating current and future transapical AVR technology. METHODS From 2010 to 2015, 2,505 isolated AVR operations were performed for severe aortic stenosis at 18 statewide cardiac institutions. Of these, 2,138 patients had a Society of Thoracic Surgeons predicted risk of mortality of less than 4%, and 1,119 met other clinical and hemodynamic criteria as outlined in the PARTNER 3 (The Placement of Transcatheter Aortic Valves) protocol. Patients with endocarditis, end-stage renal disease, ejection fraction of less than 0.45, bicuspid valves, and previous valve replacements were excluded. Outcomes of interest included operative death and postoperative adverse events. RESULTS The median Society of Thoracic Surgeons predicted risk of mortality for the study-eligible patients was 1.44%, with a median age of 72 years (interquartile range [IQR], 65 to 78 years). Operative mortality was 1.3%, permanent stroke was 1.3%, and pacemaker requirement was 4.2%. The most common adverse events were transfusion of 2 or more units of red blood cells (18%) and atrial fibrillation (28%). The median length of stay was 6 days (IQR, 5 to 8 days). Median total hospital cost was $37,999 (IQR, $30,671 to $46,138). Examination of complications by age younger than 65 vs 65 or older demonstrated a significantly lower need for transfusion (11.2%, p < 0.001) and incidence of atrial fibrillation (17.1%, p < 0.001) but no difference in operative mortality (2.2% vs 0.9%, p = 0.1), major morbidity (10.4% vs 12.6%, p = 0.3), or total hospital costs. CONCLUSIONS Low-risk patients undergoing surgical AVR in the current era have excellent results. The most common complications were atrial fibrillation and bleeding. These real-world results should provide additional context for upcoming transcatheter clinical trial data.
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Affiliation(s)
- Lily E Johnston
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Emily A Downs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Alan M Speir
- Inova Heart and Vascular Institute, Inova Fairfax Hospital, Fairfax, Virginia
| | | | - Ravi K Ghanta
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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Chang E, Gatling JW, Bode S, Herrmann PC, Bull BS, Applegate RL. Extreme Plasma Dilution Decreases Heparin and Protamine Cardiopulmonary Bypass Requirements: A Case Report on a Jehovah's Witness Patient. ACTA ACUST UNITED AC 2017; 8:291-293. [PMID: 28328588 DOI: 10.1213/xaa.0000000000000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The primary focus of cardiopulmonary bypass management in Jehovah's Witness patients is the need to conserve blood. A consequence of these strategies inevitably results in hemodilution that is frequently extreme enough to dilute clotting factors and potentially impair coagulation. The purpose of this case report is to demonstrate that a hemodiluted patient requires less heparin to sustain anticoagulation and less protamine to reverse heparin at cardiopulmonary bypass termination. Patient harm may ensue unless the effects of extreme hemodilution are recognized.
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Affiliation(s)
- Emilie Chang
- From the *Department of Anesthesiology, Loma Linda University School of Medicine, Loma Linda, California; and †Department of Pathology & Human Anatomy, Loma Linda University School of Medicine, Loma Linda, California
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79
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Malhotra A, Garg P, Bishnoi AK, Sharma P, Wadhawa V, Shah K, Patel S, Ahirwar UK, Rodricks D, Pandya H. Dialyzer-based cell salvage system: a superior alternative to conventional cell salvage in off-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2017; 24:489-497. [PMID: 28062681 DOI: 10.1093/icvts/ivw371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/19/2016] [Indexed: 11/13/2022] Open
Abstract
Objectives Our goal was to test the hypothesis that the use of a dialyzer-based cell salvage system during off-pump coronary artery bypass grafting (OPCABG) reduces requirements for homologous blood transfusions (HBT) and improves postoperative haemtochemical parameters. Methods Data were prospectively collected for 222 patients who had OPCABG using 3 different cell salvage techniques: (1) dialyzer-based cell salvage (DBCS) ( n = 75), (2) conventional cell salvage (CCS) ( n = 73) and (3) without cell salvage (WCS) ( n = 74). Salvaged blood was transfused at the end of the operation. The primary outcome of the study was the amount of homologous blood transfused. Secondary outcomes were changes in haemtochemical parameters, postoperative bleeding, need for non-invasive ventilation (NIV), postoperative complications, renal dysfunction, clotting derangement, duration of intensive care unit (ICU) and hospital stay and mortality rates. Results There were no deaths. In patients with >1000 ml blood loss, there was a significant reduction in HBT in the DBCS group (300 ± 161 ml) compared with the WCS group (550 ± 85 ml) ( P < 0.0001). Postoperative changes in haemtochemical parameters were significantly fewer in the DBCS group compared with the other 2 groups. The incidence of NIV ( P = 0.002), renal dysfunction ( P = 0.009) and postoperative complications ( P = 0.003) was least in the DBCS group and highest in the WCS group. Mean ICU stays were comparable ( P = 0.208); however, the mean hospital stay was significantly shorter in the DBCS group (6.08 ± 3.12 days) compared with the WCS group (7.54 ± 4.46 days) ( P = 0.022). There was no significant increase in coagulopathy in any group as suggested by comparable chest tube drainage ( P = 0.285) and comparable prothrombin time. Conclusions The use of the DBCS system in OPCABG resulted in a significant reduction in HBT, improvement in postoperative levels of haemoglobin, platelets and albumin and reduction in complications without increased risk of coagulopathy.
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Affiliation(s)
- Amber Malhotra
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Arvind Kumar Bishnoi
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Pranav Sharma
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Vivek Wadhawa
- Department of Cardiovascular and Thoracic Surgery, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Komal Shah
- Department of Research, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Sanjay Patel
- Department of Research, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Umesh Kumar Ahirwar
- Department of Perfusion, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Dayesh Rodricks
- Department of Perfusion, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
| | - Himani Pandya
- Department of Research, U.N. Mehta Institute of Cardiology and Research Center (Affiliated to BJ Medical College, Ahmedabad), Ahmedabad, Gujarat, India
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80
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Ghanta RK, LaPar DJ, Zhang Q, Devarkonda V, Isbell JM, Yarboro LT, Kern JA, Kron IL, Speir AM, Fonner CE, Ailawadi G. Obesity Increases Risk-Adjusted Morbidity, Mortality, and Cost Following Cardiac Surgery. J Am Heart Assoc 2017; 6:JAHA.116.003831. [PMID: 28275064 PMCID: PMC5523989 DOI: 10.1161/jaha.116.003831] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Despite the epidemic rise in obesity, few studies have evaluated the effect of obesity on cost following cardiac surgery. We hypothesized that increasing body mass index (BMI) is associated with worse risk-adjusted outcomes and higher cost. METHODS AND RESULTS Medical records for 13 637 consecutive patients who underwent coronary artery bypass grafting (9702), aortic (1535) or mitral (837) valve surgery, and combined valve-coronary artery bypass grafting (1663) procedures were extracted from a regional Society of Thoracic Surgeons certified database. Patients were stratified by BMI: normal to overweight (BMI 18.5-30), obese (BMI 30-40), and morbidly obese (BMI >40). Differences in outcomes and cost were compared between BMI strata and also modeled as a continuous function of BMI with adjustment for preoperative risk using Society of Thoracic Surgeons predictive risk indices. Morbidly obese patients incurred nearly 60% greater observed mortality than normal weight patients. Moreover, morbidly obese patients had greater than 2-fold increase in renal failure and 6.5-fold increase in deep sternal wound infection. After risk adjustment, a significant association was found between BMI and mortality (P<0.001) and major morbidity (P<0.001). The risk-adjusted odds ratio for mortality for morbidly obese patients was 1.57 (P=0.02) compared to normal patients. Importantly, risk-adjusted total hospital cost increased with BMI, with 17.2% higher costs in morbidly obese patients. CONCLUSIONS Higher BMI is associated with increased mortality, major morbidity, and cost for hospital care. As such, BMI should be more strongly considered in risk assessment and resource allocation.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alan M Speir
- Inova Heart and Vascular Institute, Falls Church, VA
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81
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Ad N, Holmes SD, Patel J, Shuman DJ, Massimiano PS, Choi E, Fitzgerald D, Halpin L, Fornaresio LM. The impact of a multidisciplinary blood conservation protocol on patient outcomes and cost after cardiac surgery. J Thorac Cardiovasc Surg 2017; 153:597-605.e1. [DOI: 10.1016/j.jtcvs.2016.10.083] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 09/15/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
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Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, Hamdorf J, Gallagher T, Koay A, Geelhoed GC, Farmer SL. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 2017; 57:1347-1358. [DOI: 10.1111/trf.14006] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Michael F. Leahy
- School of Medicine and Pharmacology; The University of Western Australia
- Department of Haematology; Royal Perth Hospital
- PathWest Laboratory Medicine; Royal Perth Hospital; Perth, Western Australia Australia
| | - Axel Hofmann
- Department of Anesthesiology; University Hospital Zurich; Zurich Switzerland
- School of Surgery; University of Western Australia
- Centre for Population Health Research; Curtin University; Perth Western Australia Australia
| | - Simon Towler
- Service 4, Fiona Stanley Hospital; Murdoch Western Australia Australia
| | | | - Sally A. Burrows
- School of Medicine and Pharmacology; The University of Western Australia
| | - Stuart G. Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | - Jeffrey Hamdorf
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences; The University of Western Australia
- Clinical Training and Evaluation Centre (CTEC); University of Western Australia; Perth Western Australia Australia
| | - Trudi Gallagher
- Department of Health; Western Australia Australia
- Accumen LLC; San Diego California
| | - Audrey Koay
- Department of Health; Western Australia Australia
| | - Gary C. Geelhoed
- Department of Health; Western Australia Australia
- School of Paediatrics and Child Health and School of Primary and Aboriginal and Rural Health; The University of Western Australia; Perth Western Australia Australia
| | - Shannon L. Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences; The University of Western Australia
- Centre for Population Health Research, Faculty of Health Sciences; Curtin University; Perth Western Australia Australia
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83
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Magruder JT, Blasco-Colmenares E, Crawford T, Alejo D, Conte JV, Salenger R, Fonner CE, Kwon CC, Bobbitt J, Brown JM, Nelson MG, Horvath KA, Whitman GR. Variation in Red Blood Cell Transfusion Practices During Cardiac Operations Among Centers in Maryland: Results From a State Quality-Improvement Collaborative. Ann Thorac Surg 2017; 103:152-160. [DOI: 10.1016/j.athoracsur.2016.05.109] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/19/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022]
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84
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Henke PK, Park YJ, Hans S, Bove P, Cuff R, Kazmers A, Schreiber T, Gurm HS, Grossman PM. The Association of Peri-Procedural Blood Transfusion with Morbidity and Mortality in Patients Undergoing Percutaneous Lower Extremity Vascular Interventions: Insights from BMC2 VIC. PLoS One 2016; 11:e0165796. [PMID: 27835656 PMCID: PMC5106007 DOI: 10.1371/journal.pone.0165796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 10/18/2016] [Indexed: 01/28/2023] Open
Abstract
Objective To determine the predictors of periprocedural blood transfusion and the association of transfusion on outcomes in high risk patients undergoing endoluminal percutaneous vascular interventions (PVI) for peripheral arterial disease. Methods/Results Between 2010–2014 at 47 hospitals participating in a statewide quality registry, 4.2% (n = 985) of 23,273 patients received a periprocedural blood transfusion. Transfusion rates varied from 0 to 15% amongst the hospitals in the registry. Using multiple logistic regression, factors associated with increased transfusion included female gender (OR = 1.9; 95% CI: 1.6–2.1), low creatinine clearance (1.3; 1.1–1.6), pre-procedural anemia (4.7; 3.9–5.7), family history of CAD (1.2; 1.1–1.5), CHF (1.4; 1.2–1.6), COPD (1.2; 1.1–1.4), CVD or TIA (1.2; 1.1–1.4), renal failure CRD (1.5; 1.2–1.9), pre-procedural heparin use (1.8; 1.4–2.3), warfarin use (1.2; 1.0–1.5), critical limb ischemia (1.7; 1.5–2.1), aorta-iliac procedure (1.9; 1.5–2.5), below knee procedure (1.3; 1.1–1.5), urgent procedure (1.7; 1.3–2.2), and emergent procedure (8.3; 5.6–12.4). Using inverse weighted propensity matching to adjust for confounders, transfusion was a significant risk factor for death (15.4; 7.5–31), MI (67; 29–150), TIA/stroke (24; 8–73) and ARF (19; 6.2–57). A focused QI program was associated with a 28% decrease in administration of blood transfusion (p = 0.001) over 4 years. Conclusion In a large statewide PVI registry, post procedure transfusion was highly correlated with a specific set of clinical risk factors, and with in-hospital major morbidity and mortality. However, using a focused QI program, a significant reduction in transfusion is possible.
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Affiliation(s)
- Peter K. Henke
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States of America
- * E-mail:
| | - Yeo Jung Park
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Sachinder Hans
- Henry Ford Malcomb Hospital, Wyndott, MI, United States of America
| | - Paul Bove
- Beaumont Health System, Royal Oak, MI, United States of America
| | - Robert Cuff
- Spectrum Health System, Grand Rapids, MI, United States of America
| | - Andris Kazmers
- McLaren Northern Michigan Health System, Traverse City, MI, United States of America
| | | | - Hitinder S. Gurm
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - P. Michael Grossman
- Department of Medicine, University of Michigan, Ann Arbor, MI, United States of America
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85
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Belk KW, Laposata M, Craver C. A comparison of red blood cell transfusion utilization between anti-activated factor X and activated partial thromboplastin monitoring in patients receiving unfractionated heparin. J Thromb Haemost 2016; 14:2148-2157. [PMID: 27543785 DOI: 10.1111/jth.13476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 07/14/2016] [Indexed: 11/28/2022]
Abstract
Essentials Anti-activated factor X (Anti-Xa) monitoring is more precise than activated partial thromboplastin (aPTT). 20 804 hospitalized cardiovascular patients monitored with Anti-Xa or aPTT were analyzed. Adjusted transfusion rates were significantly lower for patients monitored with Anti-Xa. Adoption of Anti-Xa protocols could reduce transfusions among cardiovascular patients in the US. SUMMARY Background Anticoagulant activated factor X protein (Anti-Xa) has been shown to be a more precise monitoring tool than activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin (UFH) anticoagulation therapy. Objectives To compare red blood cell (RBC) transfusions between patients receiving UFH who are monitored with Anti-Xa and those monitored with aPTT. Patients/Methods A retrospective cohort study was conducted on patients diagnosed with acute coronary syndrome (ACS) (N = 14 822), diagnosed with ischemic stroke (STK) (N = 1568) or with a principal diagnosis of venous thromboembolism (VTE) (N = 4414) in the MedAssets data from January 2009 to December 2013. Anti-Xa and aPTT groups were identified from hospital billing details, with both brand and generic name as search criteria. Propensity score techniques were used to match Anti-Xa cases to aPTT controls. RBC transfusions were identified from hospital billing data. Multivariable logistic regression was used to identify significant drivers of transfusions. Results Anti-Xa patients had fewer RBC transfusions than aPTT patients in the ACS population (difference 17.5%; 95% confidence interval [CI] 16.4-18.7%), the STK population (difference 8.2%; 95% CI 4.4-11.9%), and the VTE population (difference 4.7%; 95% CI 3.3-6.1%). After controlling for patient age and gender, diagnostic risks (e.g. anemia, renal insufficiency, and trauma), and invasive procedures (e.g. cardiac catheterization, hemodialysis, and coronary artery bypass graft), Anti-Xa patients were less likely to have a transfusion while hospitalized for ACS (odds ratio [OR] 0.16, 95% CI 0.14-0.18), STK (OR 0.41, 95% CI 0.29-0.57), and VTE (OR 0.35, 95% CI 0.26-0.48). Conclusion Anti-Xa monitoring was associated with a significant reduction in RBC transfusions as compared with aPTT monitoring alone.
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Affiliation(s)
- K W Belk
- MedAssets, Inc., Health Data Analytics, Charlotte, NC, USA
| | - M Laposata
- Department of Pathology, University of Texas Medical Branch-Galveston, Galveston, TX, USA
| | - C Craver
- MedAssets, Inc., Health Data Analytics, Charlotte, NC, USA
- College of Health and Human Services, University of North Carolina-Charlotte, Charlotte, NC, USA
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86
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Zheng J, Chen L, Qian L, Jiang J, Chen Y, Xie J, Shi L, Ni Y, Zhao H. Blood conservation strategies in cardiac valve replacement: A retrospective analysis of 1645 patients. Medicine (Baltimore) 2016; 95:e5160. [PMID: 27741149 PMCID: PMC5072976 DOI: 10.1097/md.0000000000005160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We aimed to evaluate whether blood conservation strategies including intraoperative autologous donation (IAD) could reduce perioperative blood transfusion for patients undergoing cardiac valve replacement including mitral valve replacement, aortic valve replacement (AVR), and double valve replacement (DVR).A total of 726 patients were studied over a 3-year period (2011-2013) after the implementation of IAD and were compared with 919 patients during the previous 36-month period (January 2008-December 2010). The method of small-volume retrograde autologous priming, strict blood transfusion standard together with IAD constituted a progressive blood-saving strategy.Baseline characteristics and preoperative information showed no statistically significant difference between IAD group and non-IAD group. Most of the postoperative morbidities are statistically the same in the 2 groups. Chest tube output (415.2 vs 1029.8 mL, P < 0.001) and postoperative respiratory failure (5.9% vs 8.6%, P = 0.039) favored the IAD group, whereas hematocrit levels were more favorable in the non-IAD group (30.3% vs 33.0% at the end of the operation, P < 0.001; 30.4% vs 31.5% at the time of discharge). The use of blood product transfusion was higher in the non-IAD group (22.6% vs 43.3%, P < 0.001). Binary multivariate logistic regression analysis showed that high age, non-IAD, DVR surgery, and absent smoking history are associated with a higher risk of intra-/postoperative blood transfusion.Blood conservation is effective and safe in cardiac valve replacement surgeries. The use of intraoperative autologous donation can lead to improved outcomes including a significantly lower rate of intra-/postoperative blood transfusion and postoperative complications.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Haige Zhao
- Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
- Correspondence: Haige Zhao, Department of Cardiothoracic Surgery, The First Affiliated Hospital of Zhejiang University, 79 Qingchun Road, 310003 Hangzhou, China (e-mail: )
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87
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Corral M, Ferko N, Hogan A, Hollmann SS, Gangoli G, Jamous N, Batiller J, Kocharian R. A hospital cost analysis of a fibrin sealant patch in soft tissue and hepatic surgical bleeding. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:507-519. [PMID: 27703386 PMCID: PMC5036832 DOI: 10.2147/ceor.s112762] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Despite hemostat use, uncontrolled surgical bleeding is prevalent. Drawbacks of current hemostats include limitations with efficacy on first attempt and suboptimal ease-of-use. Evarrest® is a novel fibrin sealant patch that has demonstrated high hemostatic efficacy compared with standard of care across bleeding severities. The objective of this study was to conduct a hospital cost analysis of the fibrin sealant patch versus standard of care in soft tissue and hepatic surgical bleeding. Methods The analysis quantified the 30-day costs of each comparator from a hospital perspective. Published US unit costs were applied to resource use (ie, initial treatment, retreatment, operating time, hospitalization, transfusion, and ventilator) reported in four trials. A “surgical” analysis included resources clinically related to the hemostatic benefit of the fibrin sealant patch, whereas a “hospital” analysis included all resources reported in the trials. An exploratory subgroup analysis focused solely on coagulopathic patients defined by abnormal blood test results. Results The surgical analysis predicted cost savings of $54 per patient with the fibrin sealant patch compared with standard of care (net cost impact: −$54 per patient; sensitivity range: −$1,320 to $1,213). The hospital analysis predicted further cost savings with the fibrin sealant patch (net cost impact of −$2,846 per patient; sensitivity range: −$1,483 to −$5,575). Subgroup analyses suggest that the fibrin sealant patch may provide dramatic cost savings in the coagulopathic subgroup of $3,233 (surgical) and $9,287 (hospital) per patient. Results were most sensitive to operating time and product units. Conclusion In soft tissue and hepatic problematic surgical bleeding, the fibrin sealant patch may result in important hospital cost savings.
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Affiliation(s)
| | - Nicole Ferko
- Cornerstone Research Group, Burlington, ON, Canada
| | - Andrew Hogan
- Cornerstone Research Group, Burlington, ON, Canada
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88
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Pack QR, Priya A, Lagu T, Pekow PS, Engelman R, Kent DM, Lindenauer PK. Development and Validation of a Predictive Model for Short- and Medium-Term Hospital Readmission Following Heart Valve Surgery. J Am Heart Assoc 2016; 5:JAHA.116.003544. [PMID: 27581171 PMCID: PMC5079019 DOI: 10.1161/jaha.116.003544] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Although models exist for predicting hospital readmission after coronary artery bypass surgery, no such models exist for predicting readmission after heart valve surgery (HVS). Methods and Results Using a geographically and structurally diverse sample of US hospitals (Premier Inpatient Database, January 2007–June 2011), we examined patient, hospital, and clinical factors predictive of short‐ and medium‐term hospital readmission post‐HVS. We set aside 20% of hospitals for model validation. A generalized estimating equation model accounted for clustering within hospitals. At 219 hospitals, we identified 38 532 patients (67 years, 56% male, 62% aortic valve surgery) who underwent HVS. A total of 3125 (7.8%) and 4943 (12.8%) patients were readmitted to the index hospital within 1 and 3 months, respectively. Our 3‐month model predicted readmission rates between 3% and 61% with fair discrimination (C‐statistic, 0.67) and good calibration (predicted vs observed differences in validation cohort averaged 1.9% across all deciles of predicted readmission risk). Results were similar for our 1‐month model and our simplified 3‐month model (suitable for clinical use), which used the 5 strongest predictors of readmission: transfused units of packed Red blood cells, presence of End‐stage renal disease, type of Valve surgery, Emergency hospital admission, and hospital Length of stay (REVEaL). Conclusions We described and validated key factors that predict short‐ and medium‐term hospital readmission post‐HVS. These models should enable clinicians to identify individuals with HVS who are at increased risk for hospital readmission and are most likely to benefit from improved postdischarge care and follow‐up.
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Affiliation(s)
- Quinn R Pack
- Division of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA Department of Internal Medicine, Baystate Medical Center, Springfield, MA Center for Quality of Care Research, Baystate Medical Center, Springfield, MA Tufts University School of Medicine, Boston, MA
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA
| | - Tara Lagu
- Department of Internal Medicine, Baystate Medical Center, Springfield, MA Center for Quality of Care Research, Baystate Medical Center, Springfield, MA Tufts University School of Medicine, Boston, MA
| | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, MA School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA
| | | | - David M Kent
- Tufts University School of Medicine, Boston, MA Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies (ICRHPS), Tufts Medical Center, Boston, MA
| | - Peter K Lindenauer
- Department of Internal Medicine, Baystate Medical Center, Springfield, MA Center for Quality of Care Research, Baystate Medical Center, Springfield, MA Tufts University School of Medicine, Boston, MA
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Halpin LS, Gallardo BE, Speir AM, Ad N. Outcome Management in Cardiac Surgery Using the Society of Thoracic Surgeons National Database. AORN J 2016; 104:198-205. [PMID: 27568532 DOI: 10.1016/j.aorn.2016.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 10/30/2015] [Accepted: 06/28/2016] [Indexed: 11/16/2022]
Abstract
Health care reform has helped streamline patient care and reimbursement by encouraging providers to provide the best outcome for the best value. Institutions with cardiac surgery programs need a methodology to monitor and improve outcomes linked to reimbursement. The Society of Thoracic Surgeons National Database (STSND) is a tool for monitoring outcomes and improving care. This article identifies the purpose, goals, and reporting system of the STSND and ways these data can be used for benchmarking, linking outcomes to the effectiveness of treatment, and identifying factors associated with mortality and complications. We explain the methodology used at Inova Heart and Vascular Institute, Falls Church, Virginia, to perform outcome management by using the STSND and address our performance-improvement cycle through discussion of data collection, analysis, and outcome reporting. We focus on the revision of clinical practice and offer examples of how patient outcomes have been improved using this methodology.
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90
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The Dilemma of Blood Transfusion: Strict or Liberal? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:155-6. [PMID: 27513217 DOI: 10.1097/imi.0000000000000284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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91
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Patient Blood Management is Associated With a Substantial Reduction of Red Blood Cell Utilization and Safe for Patient's Outcome. Ann Surg 2016; 264:203-11. [DOI: 10.1097/sla.0000000000001747] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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92
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A Preoperative Risk Model for Postoperative Pneumonia After Coronary Artery Bypass Grafting. Ann Thorac Surg 2016; 102:1213-9. [PMID: 27261082 DOI: 10.1016/j.athoracsur.2016.03.074] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/24/2016] [Accepted: 03/24/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative pneumonia is the most prevalent of all hospital-acquired infections after isolated coronary artery bypass graft surgery (CABG). Accurate prediction of a patient's risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision making and quality improvement, we developed a preoperative prediction model for postoperative pneumonia after CABG. METHODS We undertook an observational study of 16,084 patients undergoing CABG between the third quarter of 2011 and the second quarter of 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy, and the institution performing the procedure were investigated. Logistic regression through forward stepwise selection (p < 0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were used to assess the model's performance. RESULTS Postoperative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 preoperative factors, including demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed through sensitivity analyses by center and clinically important subgroups. CONCLUSIONS We identified 17 readily obtainable preoperative variables associated with postoperative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient's preoperative risk of pneumonia through prehabilitation.
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93
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Preprocedure Anemia Management Decreases Transfusion Rates in Patients Undergoing Transcatheter Aortic Valve Implantation. Can J Cardiol 2016; 32:732-8. [DOI: 10.1016/j.cjca.2015.08.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 08/19/2015] [Accepted: 08/19/2015] [Indexed: 11/19/2022] Open
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94
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Yohanathan L, Coburn NG, McLeod RS, Kagedan DJ, Pearsall E, Zih FSW, Callum J, Lin Y, McCluskey S, Hallet J. Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons. J Gastrointest Surg 2016; 20:1106-22. [PMID: 27025709 DOI: 10.1007/s11605-016-3111-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 02/15/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite guidelines recommending restrictive red blood cell transfusion (RBCT) strategies, perioperative transfusion practices still vary significantly. To understand the underlying mechanisms that lead to gaps in practice, we sought to assess the attitudes of surgeons regarding the perioperative management of anemia and use of RBCT in patients having gastrointestinal surgery. METHODS We conducted a self-administered Web-based survey of general surgery staff and residents, in a network of eight academic institutions at the University of Toronto. We developed a questionnaire using a systematic approach of items generation and reduction. We tested face and content validity and test-retest reliability. We administered the survey via emails, with planned reminders. RESULTS Total response rate was 48.1 % (62/125). Half (51.0 %) of respondents stated that they were unlikely to conduct a preoperative anemia work-up. About 54.0 % reported ordering preoperative oral iron supplementation for anemia. Most respondents indicated using a 70 g/L hemoglobin trigger (92.0 %) for transfusion. Factors increasing thresholds above 70 g/L included cardiac comorbidity (58.0 %), acute cardiac disease (94.0 %), symptomatic anemia (68.0 %), and suspected bleeding (58.0 %). With those factors, the transfusion threshold often increased above 90 g/L. Respondents perceived RBCTs to increase the postoperative morbidity (62 %), but not to impact the mortality (48 %) and cancer recurrence (52 %). Institutional protocols (68.0 %), blood conservation clinics (44.0 %), and clinical practice guidelines (84.0 %) were believed to encourage restrictive use of RBCTs. CONCLUSION Self-reported perioperative transfusion practices for GI surgery are heterogeneous. Few respondents investigated preoperative anemia. Stated use of RBCT indications varied from recommendations in published guidelines for patients with symptomatic anemia. Establishing team consensus and implementing local blood management guidelines appear necessary to improve uptake of evidence-based recommendations.
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Affiliation(s)
| | - Natalie G Coburn
- Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robin S McLeod
- Division of General Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Daniel J Kagedan
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Emily Pearsall
- Division of General Surgery, Mount Sinai Hospital, Toronto, ON, Canada
| | - Francis S W Zih
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Yulia Lin
- Department of Clinical Pathology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Stuart McCluskey
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Julie Hallet
- Division of General Surgery, University of Toronto, Toronto, ON, Canada. .,Division of General Surgery, Odette Cancer Centre-Sunnybrook Health Sciences Centre, Toronto, ON, Canada. .,Odette Cancer Centre-Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, T2-063, Toronto, M4N3M5, ON, Canada.
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95
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Hallet J, Kulyk I, Cheng ES, Truong J, Hanna SS, Law CH, Coburn NG, Tarshis J, Lin Y, Karanicolas PJ. The impact of red blood cell transfusions on perioperative outcomes in the contemporary era of liver resection. Surgery 2016; 159:1591-1599. [DOI: 10.1016/j.surg.2015.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 12/02/2015] [Accepted: 12/17/2015] [Indexed: 01/10/2023]
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96
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Blood Product Utilization with Left Ventricular Assist Device Implantation: A Decade of Statewide Data. ASAIO J 2016; 62:268-73. [DOI: 10.1097/mat.0000000000000345] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
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97
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The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:157-64. [DOI: 10.1097/imi.0000000000000280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limiting blood transfusion in cardiac operations is a well-meaning goal of perioperative care. Potential benefits include decreasing morbidity and limiting procedural costs. It is difficult to identify transfusion as the cause of adverse outcomes. The need for transfusion may identify a sicker patient population at greater risk for a worse outcome that may or may not be related to the transfusion. We reviewed the indications for and adverse effects of blood transfusion in patients undergoing cardiac procedures to provide a balanced approach to management of blood resources in this population. We reviewed current literature, including systematic reviews and practice guidelines, to synthesize a practice management plan in patients having cardiac operations. Several prospective randomized studies and large population cohort studies compared a postoperative restrictive transfusion policy to a more liberal policy and found very little difference in outcomes but decreased costs with a restrictive policy. Evidence-based practice guidelines and implementation standards provide robust intervention plans that can limit harmful effects of transfusion and provide safe and effective procedure outcomes. A restrictive transfusion policy seems to be safe and effective but does not necessarily provide better outcome in most patient cohorts. The implications of these findings suggest that many discretionary transfusions could be avoided. A subset of high-risk patients could undoubtedly benefit from a more liberal transfusion policy, but the definition of high risk is ill defined.
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98
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Patient Blood Management: por onde começar? Braz J Anesthesiol 2016; 66:333-4. [DOI: 10.1016/j.bjan.2015.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 12/23/2014] [Indexed: 01/28/2023] Open
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Azi LMTDA, Garcia LV. Patient Blood Management: where to start? BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2016; 66:333-334. [PMID: 27108835 DOI: 10.1016/j.bjane.2014.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/02/2014] [Accepted: 12/23/2014] [Indexed: 06/05/2023]
Affiliation(s)
- Liana Maria Torres de Araujo Azi
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil; Hospital Universitário Professor Edgard Santos (UFBA), Salvador, BA, Brazil.
| | - Luis Vicente Garcia
- Departamento de Biomecânica, Medicina e Reabilitação do Aparelho Locomotor, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil
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100
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Ad N, Fornaresio L. The Dilemma of Blood Transfusion: Strict or Liberal? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Niv Ad
- Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA USA
| | - Lisa Fornaresio
- Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA USA
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