Transfusion rates vary significantly amongst Canadian medical centres

Perioperative Transfusion Practices in Adults Having Noncardiac Surgery

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices.

Evaluation of Red Blood Cell Transfusion Practice and Knowledge Among Cancer Surgeons

BACKGROUND

Transfusion of blood products has a negative impact on surgical and cancer outcomes. The objective of the current study was to evaluate surgeons' practice and knowledge of red blood cell transfusion for surgical patients.

METHODS

A survey of residents, fellows, and faculty surgeons at the Ohio State University Wexner Medical Center and surgeons who identified as taking care of cancer patients nationally was conducted. Four domains were addressed including perceived preoperative assessment and management of anemia, perceived use of transfusion alternatives, perceived use of and factors influencing packed red blood cell administration, and transfusion practice knowledge.

RESULTS

Among 158 respondents, 87 (64.5%) were surgeons on faculty at an academic medical center, 26 (19%) were surgeons in private practice, and 24 (15.2%) were surgical residents or fellows. The majority of respondents were surgical oncologists or hepatobiliary surgeons (N = 83, 62.0%) and had been in practice > 10 years (> 10-15 N = 28, 20.6%) and > 15 years N = 59, 43.4%). Only thirteen (N = 13, 8.2%) surgeons reported that they routinely complete a preoperative anemia workup. The majority of providers reported that they rarely or never use alternatives to transfusion such as erythropoietin (N = 135, 91.8%), tranexamic acid (N = 140, 94.6%), autologous blood transfusion (N = 141, 95.3%), or cell saver for benign (N = 107, 72.3%) or malignant cases (N = 133, 90.4%). Provider transfusion knowledge was variable.

CONCLUSIONS

Surgeons varied widely in their transfusion practice and knowledge. Further education of surgeons regarding transfusion medicine and practice, as well as use of transfusion alternatives, could lead to improved patient outcomes. Patient blood management programs may help inform individual surgeon practices.

Implementation of an electronic identification system in the setting of perioperative autologous cell salvage transfusion: Experience at a university hospital

Perioperative autologous cell salvage (PACS) is one of the effective strategies in patient blood management (PBM). However, mistransfusion, in which the wrong blood is transfused to the wrong patient, of PACS units has been reported. In this study, we implemented a bar code-based electronic identification system (EIS) for blood transfusion in the setting of PACS transfusion. Between February 2009 and December 2020, a total of 12341 surgical patients (9% of whom received surgical interventions) received blood transfusion, among whom 6595 (54 %) received autologous blood transfusion alone, 2877 (23 %) both autologous and allogeneic blood transfusions, and 2869 (23 %) allogeneic blood transfusion alone. Among autologous blood conservation techniques, PACS units were transfused to 7873 patients (83 %) without a single mistransfusion. Rates of overall compliance with the electronic pre-transfusion check at the bedside for all autologous units and PACS units were 98.8 and 98.5 %, respectively. Our observations suggest that a bar code-based EIS can be successfully applied to PACS transfusion, as well as allogeneic blood transfusion in operating rooms.

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

BACKGROUND

Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery.

METHODS

We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding.

RESULTS

Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60-78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). After adjusting for patient, procedure, and hospital factors, the most recent time period (2015-2018) was associated with a reduced likelihood of receiving RBC transfusion [relative risk 0.86 (95% confidence interval: 0.83-0.89)] relative to the intermediate time period (2011-2014).

CONCLUSION

Over 11 years, we observed decreased RBC transfusion use and reduced likelihood of transfusion in patients undergoing gastrointestinal cancer resection. This information provides a foundation to further examine transfusion appropriateness or explore if additional transfusion minimization in surgical patients can be achieved.

Inter-hospital variation in use of obstetrical blood transfusion: a population-based cohort study

OBJECTIVE

To identify the extent of hospital-to-hospital variation in use of obstetrical blood transfusion.

DESIGN

Population-based cohort study linking provincial perinatal and blood transfusion registries.

SETTING

British Columbia, Canada, 2004-2015.

POPULATION

All pregnant women delivering at or beyond 20 weeks' gestation at any British Columbia hospital.

METHODS

Mixed-effects regression models were used to estimate hospital-specific transfusion rates after sequentially accounting for (1) the role of random variation, (2) maternal medical and obstetrical characteristics (i.e. patient case mix) and (3) institutional and delivery factors (such as use of instrumental or caesarean delivery).

MAIN OUTCOME MEASURES

Hospital-specific use of obstetrical red blood cell transfusion.

RESULTS

Among 44 hospitals, crude institutional transfusion rates across the study period ranged from 3.7 to 23.6 per 1000, with an average of 8.3 per 1000. After adjusting for maternal characteristics, institution and delivery risk factors, a nearly three-fold difference in rates between the 10th and 90th percentile remained (5.4-14.5 per 1000). Twelve sites had rates significantly higher or lower than the provincial average. Women residing in remote areas were 2.5-fold (95% CI 1.8-3.5] more likely to receive a blood transfusion than were women residing in metropolitan areas.

CONCLUSIONS

Meaningful variation between hospitals in use of blood transfusion during pregnancy was not explained by differences in patient case-mix or institutional factors, suggesting that over- or under-utilisation of this resource may be occurring in obstetrical care.

TWEETABLE ABSTRACT

Use of blood transfusion in pregnant women varied broadly between hospitals in British Columbia, Canada.

Prospective Evaluation of a Blood Transfusion Protocol for Patients Undergoing Cardiac Operations

BACKGROUND

The Society of Thoracic Surgeons clinical practice guidelines recommend the creation of an interdisciplinary blood management team to implement protocols for improved blood transfusion practices. We report our center's prospective evaluation of a blood transfusion protocol.

METHODS

An interdisciplinary blood management team developed protocols for transfusion of packed red blood cells, fresh frozen plasma, platelets, and cryoprecipitate. The protocols were prospectively evaluated by tracking transfusions administered to consecutive patients undergoing cardiac operations, and the primary outcome of interest was the mean number of adjusted units of blood product transfused per patient. Protocol implementation phases were separated by washout phases to control for a potential Hawthorne effect associated with protocol implementation. Protocol compliance was also assessed.

RESULTS

A total of 1441 patients underwent cardiac operations during the 16-month study period. Although there was no statistically significant reduction in transfusions with an unadjusted analysis, there was a significant trend toward a reduction of the mean adjusted total units transfused per patient over the course of the study period (P < .001). The mean adjusted total units transfused per patient were significantly less during the second washout phase (2.8 units; 95% confidence interval [CI], 2.3-3.3) and second protocol phase (2.8 units; 95% CI, 2.32-3.27) compared with the initial baseline survey phase (3.6 units, 95% CI, 3.1-4.1; P < .05 for both comparisons). Only 55.2% of all units were transfused in compliance to the implemented protocols: platelets, 46.8%; cryoprecipitate, 32.1%; packed red blood cells, 60.7%; and fresh frozen plasma, 53.6%.

CONCLUSIONS

During a prospective evaluation of blood transfusion protocols, a risk-adjusted analysis demonstrated a reduction in transfusions despite poor protocol compliance.

Patient blood management for liver resection: consensus statements using Delphi methodology

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.

Anticoagulation, bleeding and blood transfusion practices in Australasian cardiac surgical practice

We surveyed contemporary Australasian cardiac surgical and anaesthetic practice, focusing on antiplatelet and antifibrinolytic therapies and blood transfusion practices. The cohort included 499 sequential adult cardiac surgical patients in 12 Australasian teaching hospitals. A total of 282 (57%) patients received red cell or component transfusion. The median (IQR) red cell transfusion threshold haemogloblin levels were 66 (61-73) g/l intraoperative^ and 79 (74-85) g/l postoperatively. Many (40%) patients had aspirin within five days of surgery but this was not associated with blood loss or transfusion; 15% had Clopidogrel within seven days of surgery. In all, 30 patients (6%) required surgical re-exploration for bleeding. Factors associated with transfusion and excessive bleeding include pre-existing renal impairment, preoperative Clopidogrel therapy, and complex or emergency surgery. Despite frequent (67%) use of antifibrinolytic therapy, there was a marked variability in red cell transfusion rates between centres (range 17 to 79%, P <0.001). This suggests opportunities for improvement in implementation of guidelines and effective blood-sparing interventions. Many patients presenting for surgery receive antiplatelet and/or antifibrinolytic therapy, yet the subsequent benefits and risks remain unclear.

Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005-2016

BACKGROUND

Do prescription drugs with anti-inflammatory properties such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins increase the risk of postoperative bleeding measured with RBC transfusion in elderly hip fracture surgery patients?

STUDY DESIGN AND METHODS

Using the Danish Multidisciplinary Hip Fracture Database, 74,791 patients aged 65 years or older with surgery-treated hip fracture were identified during 2005-2016, and their use of NSAIDs, corticosteroids, and statins was ascertained. For each drug, patients were categorized as nonusers (no prescription ≤365 days prior to surgery), former users (one prescription 91-365 days), and current users (one prescription ≤90 days). Information on surgical treatment, transfusion, other medication and comorbidities were collected using Danish nationwide registries. A log-binomial model was used to estimate relative risks for RBC transfusion within 7 days of surgery and corresponding 95% confidence intervals. Adjustments were made for patient- and surgery-related factors.

RESULTS

Former and current users of NSAIDs, corticosteroids, and statins accounted for 22%, 10%, and 24%, respectively. Current users of NSAIDs had an increased adjusted relative risk of transfusion (1.07; confidence interval, 1.04-1.10) compared to nonusers. There was no association between current users of corticosteroids and statins and risk of transfusion.

CONCLUSION

NSAID use within 90 days of a hip fracture surgery was associated with an increased risk of RBC transfusion. Thus, current use of NSAIDs can be associated with an increased risk of postoperative bleeding, but we cannot rule out the influence of confounding.

Transfusion Practices Among General Surgeons at a Tertiary Care Center: a Survey Based Study

INTRODUCTION

Blood transfusion practices affect both patient's outcomes and utilization of institutional resources. Evidence shows that liberal blood transfusion has a detrimental effect on patient's outcome. A restrictive approach of blood transfusion is recommended by current clinical guidelines.

AIM

The aim of this study was to evaluate the attitudes, knowledge, and practices of general surgery (GS) staff and residents regarding peri-operative blood transfusion and anemia management.

MATERIAL AND METHODS

A self-administered, web-based questionnaire was developed, and its link was sent to the emails of all general surgeons at King Abdul-Aziz University Hospital (KAUH), Jeddah city, Saudi Arabia. The questionnaire included four parts: 1) background of surgeons; 2) preoperative assessment and management of anemia; 3) post-operative blood transfusion and alternatives; and 4) enablers and barriers.

RESULTS

56 surgeons responded to the questionnaire. We found variations in blood transfusion practices, notably the hemoglobin threshold. For stable non-cardiac cases, 7 g/dL was considered the threshold by 50% of respondents. For stable patients with past cardiac disease, a higher threshold was chosen by most (9 g/dL by 43% and 10 gm/dL by 21%). Most respondents believed that transfusion had no effect on the risk of survival (73%) and on the risk of cancer recurrence (55%) after oncologic surgical resection. Recognized facilitators were the availability of scientific evidence (84%), medicolegal concerns (57%), preference (52%), and institutional protocols (50%).

CONCLUSION

Although current clinical guidelines recommend a restrictive transfusion practice, most respondents tended to over-order blood for elective procedures and were not aware of the potential complications of liberal blood transfusion. To implement the restrictive transfusion policies, health institutions should improve the awareness of surgeons and incorporate a strong supporting evidence in formulating local institutional guidelines.

Risks of restrictive red blood cell transfusion strategies in patients with cardiovascular disease (CVD): a meta-analysis

AIM

To evaluate the risks of restrictive red blood cell transfusion strategies (haemoglobin 7-8 g dL^-1 ) in patients with and without known cardiovascular disease (CVD).

BACKGROUND

Recent guidelines recommend restrictive strategies for CVD patients hospitalised for non-CVD indications, patients without known CVD and patients hospitalised for CVD corrective procedures.

METHODS/MATERIALS

Database searches were conducted through December 2017 for randomised clinical trials that enrolled patients with and without known CVD, hospitalised either for CVD-corrective procedures or non-cardiac indications, comparing effects of liberal with restrictive strategies on major adverse coronary events (MACE) and death.

RESULTS

In CVD patients not undergoing cardiac interventions, a liberal strategy decreased (P = 0·01) the relative risk (95% CI) (RR) of MACE [0·50 (0·29-0·86)] (I²  = 0%). Among patients without known CVD, the incidence of MACE was lower (1·7 vs 3·9%), and the effect of a liberal strategy on MACE [0·79, (0·39-1·58)] was smaller and non-significant but not different from CVD patients (P = 0·30). Combining all CVD and non-CVD patients, a liberal strategy decreased MACE [0·59, (0·39-0·91); P = 0·02]. Conversely, among studies reporting mortality, a liberal strategy decreased mortality in CVD patients (11·7% vs·13·3%) but increased mortality (19·2% vs 18·0%) in patients without known CVD [interaction P = 0·05; ratio of RR 0·73, (0·53-1·00)]. A liberal strategy also did not benefit patients undergoing cardiac surgery; data were insufficient for percutaneous cardiac procedures.

CONCLUSIONS

In patients hospitalised for non-cardiac indications, liberal transfusion strategies are associated with a decreased risk of MACE in both those with and without known CVD. However, this only provides a survival benefit to CVD patients not admitted for CVD-corrective procedures.

The impact of perioperative blood transfusions on short-term outcomes following hepatectomy

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.

Extremely Low Transfusion Rates: Contemporary Primary Total Hip and Knee Arthroplasties

BACKGROUND

Considerable blood loss which requires transfusion is frequently reported after total hip and knee arthroplasties (THA and TKA). The purpose of this study is to review the transfusion rates in contemporary THA and TKA with optimized perioperative protocols including minimized surgical trauma and optimal perioperative patient care.

METHODS

This retrospective study included 1442 consecutive patients receiving either a primary THA or a TKA from the same high-volume surgeon between January 2008 and December 2015. Demographics and surgical data were collected from patients' journals. Estimated blood loss, decline in hemoglobin, and use of transfusion were registered.

RESULTS

One (0.0013%) THA and 3 (0.0044%) TKAs required blood transfusion postoperatively. Average measured bleeding was 253 mL ± 142 and 207 mL ± 169 in THA and TKA, respectively. Average decline in hemoglobin was 23.5 g/L ± 11.4 and 22.9 g/L ± 11.6 for THA and TKA, respectively.

CONCLUSION

In contemporary THA and TKA, perioperative protocols and patient optimization can decrease the rate of blood transfusion to near zero.

Long-term audit of the use of fresh frozen plasma in a university hospital

OBJECTIVES

There is universal concern about the inappropriate use of fresh frozen plasma (FFP). This study aimed to determine the extent of the inappropriate use of FFP at a university hospital in KSA.

METHODS

Medical records on the annual use of FFP were analysed from 1986 to 2007. Then, the results of the coagulation screening tests were extracted from the medical records of 531 consecutive patients in various departments of the hospital.

RESULTS

As many as 68,480 FFP units were used during the 22 year study period. Consumption increased and then plateaued in 1995, but dropped dramatically by 30.9% and reached its lowest level in 2000. There was also a concomitant and overlapping drop in both FFP usage and the hospital mortality rate per patient admission. One-thousand-six-hundred-twenty FFP units were issued for 531 patients. Coagulation testing, before and after infusion, was adopted in almost all patients in the Department of Obstetrics and Gynaecology, in 90% of patients in the Department of Surgery and in approximately 70% of patients in other departments.

CONCLUSIONS

Significant inappropriate use of FFP at our institute has been made evident by examining the remarkable drop in use following the universal "HIV scare" of the early 1990s. The resulting drop in the hospital mortality rate, accompanying the simultaneous drop in FFP use, reflects the benefits of resorting to the use of less blood therapy. Coagulation testing was used to a satisfactory extent. Transfusion audits and educational programs could result a better use of FFP.

Long-term audit of platelet consumption in a university hospital

OBJECTIVES

To determine the long-term trend in platelet consumption in a university hospital.

MATERIALS AND METHODS

The annual consumption of platelets concentrate (PC) was analyzed over 23 years (1985-2007) in King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.

RESULTS

The total 23 years consumption was 100,466 units of PC. Consumption went through 3 phases: the first, 1985-1994: the annual consumption increased from 1706 to 5912 which coincided with the increase in the number of patient admissions; the second, 1994-2003:featured a remarkable drop (48.9%) in annual consumption while patient admission remained stable. There was a concurrent decline in platelet consumption and all-cause mortality/patient. Third phase: 2003-2007, the consumption increased to reach 5642 units/year in 2007. The Department of Medicine consumed (52%), followed by Pediatrics (21%), and General Surgery (16%).

CONCLUSION

This audit uncovered evidence of inappropriate platelet consumption that reached 48.9% in the period 1994 to 2003, which coincided with widely publicized HIV scare that dominated blood transfusion during that period. We also found evidence suggesting that reducing platelet transfusion could improve patient outcome.

Additional effects of topical tranexamic acid in on-pump cardiac surgery

Objective

Postoperative bleeding after cardiac surgery is commonly associated with hyperfibrinolysis. This study was designed to evaluate the efficacy of topical tranexamic acid in addition to intravenous tranexamic acid in reducing bleeding in cardiac surgery cases.

Methods

From July 1, 2014 to September 30, 2015, 82 patients who underwent elective on-pump cardiac surgery were randomized into a tranexamic acid group and a placebo group. In the tranexamic acid group, 1 g of tranexamic acid dissolved in 100 mL of normal saline solution was poured into the pericardium during sternal closure; the placebo group had 100 mL of saline only. Two patients were excluded from the study due to obvious surgical bleeding. The primary endpoint was total blood loss 24 h after surgery. Repeated measures with mixed models was used to analyze bleeding over time.

Results

There was no significant difference in demographic and intraoperative data except for a significantly lower platelet count preoperatively in the tranexamic acid group ( p = 0.030). There was no significant difference in postoperative drainage volumes at 8, 16, and 24 h, postoperative bleeding over time (coefficient = 0.713, p = 0.709), or blood product transfusion between the groups. There were no serious complications.

Conclusions

Topical tranexamic acid is safe but it adds no additional efficacy to the intravenous application in reducing postoperative blood loss. Intravenous tranexamic acid administration alone is sufficient antifibrinolytic treatment to enhance the hemostatic effects during on-pump cardiac surgery.

Body mass index, risk of allogeneic red blood cell transfusion, and mortality in elderly patients undergoing hip fracture surgery

Despite improvements in preoperative and postoperative treatment, hip fracture surgery may lead to blood transfusion. Little is known about the impact of body mass index on transfusion risk and subsequent mortality. Opposite overweight and obese patients, underweight patients had increased risk of transfusion and death within 1 year of surgery.

INTRODUCTION

Despite improvements in preoperative and postoperative treatment of hip fracture patients, hip fracture surgery may lead to blood loss. We examined the risk of red blood cell transfusion (as an indirect measure of blood loss) and subsequent mortality by body mass index level in patients aged 65 and over undergoing hip fracture surgery.

METHODS

This is a population-based cohort study using medical databases. We included all patients who underwent surgery for hip fracture during 2005-2013. We calculated the cumulative risk of red blood cell transfusion within 7 days of surgery treating death as a competing risk and, among transfused patients, short- (8-30 days postsurgery) and long-term mortality (31-365 days postsurgery).

RESULTS

Among 56,420 patients, 47.7 % received at least one red blood cell transfusion within 7 days of surgery. In patients with normal weight, the risk was 48.8 % compared with 57.0 % in underweight patients (adjusted RR = 1.11; CI 1.08-1.15), 42.1 % in overweight patients (adjusted RR = 0.89; CI 0.86-0.91), and 42.2 % in obese patients (adjusted RR = 0.87; CI 0.84-0.91). Among transfused patients, adjusted HRs for short-term mortality were 1.52 (CI 1.34-1.71), 0.70 (CI 0.61-0.80), and 0.58 (CI 0.43-0.77) for underweight, overweight, and obese patients, respectively, compared with normal-weight patients. The corresponding adjusted HRs for long-term mortality were 1.45 (CI 1.33-1.57), 0.80 (CI 0.74-0.86), and 0.58 (CI 0.50-0.69). Similar association between BMI and mortality was observed also among non-transfused patients.

CONCLUSIONS

Underweight patients had a higher risk of red blood cell transfusion and death in the first year of surgery than normal-weight patients, even when controlling for age and comorbidity. Opposite findings were seen for overweight and obese patients.

The impact of blood transfusion on perioperative outcomes following gastric cancer resection: an analysis of the American College of Surgeons National Surgical Quality Improvement Program database

BACKGROUND

Red blood cell transfusions (RBCT) carry risk of transfusion-related immunodulation that may impact postoperative recovery. This study examined the association between perioperative RBCT and short-term postoperative outcomes following gastrectomy for gastric cancer.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, we compared outcomes of patients (transfused v. nontransfused) undergoing elective gastrectomy for gastric cancer (2007-2012). Outcomes were 30-day major morbidity, mortality and length of stay. The association between perioperative RBCT and outcomes was estimated using modified Poisson, logistic, or negative binomial regression.

RESULTS

Of the 3243 patients in the entire cohort, we included 2884 patients with nonmissing data, of whom 535 (18.6%) received RBCT. Overall 30-day major morbidity and mortality were 20% and 3.5%, respectively. After adjustment for baseline and clinical characteristics, RBCT was independently associated with increased 30-day mortality (relative risk [RR] 3.1, 95% confidence interval [CI] 1.9-5.0), major morbidity (RR 1.4, 95% CI 1.2-1.8), length of stay (RR 1.2, 95% CI 1.1-1.2), infections (RR 1.4, 95% CI 1.1-1.6), cardiac complications (RR 1.8, 95% CI 1.0-3.2) and respiratory failure (RR 2.3, 95% CI 1.6-3.3).

CONCLUSION

Red blood cell transfusions are associated with worse postoperative short-term outcomes in patients with gastric cancer. Blood management strategies are needed to reduce the use of RBCT after gastrectomy for gastric cancer.

Understanding Perioperative Transfusion Practices in Gastrointestinal Surgery-a Practice Survey of General Surgeons

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.

The impact of peri-operative blood transfusions on post-pancreatectomy short-term outcomes: an analysis from the American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Peri-operative red blood cell transfusions (RBCT) may induce transfusion-related immunomodulation and impact post-operative recovery. This study examined the association between RBCT and post-pancreatectomy morbidity.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry, patients undergoing an elective pancreatectomy (2007-2012) were identified. Patients with missing data on key variables were excluded. Primary outcomes were 30-day post-operative major morbidity, mortality, and length of stay (LOS). Unadjusted and adjusted relative risks (RR) with a 95% confidence interval (95%CI) were computed using modified Poisson, logistic, or negative binomial regression, to estimate the association between RBCT and outcomes.

RESULTS

The database included 21 132 patients who had a pancreatectomy during the study period. Seventeen thousand five hundred and twenty-three patients were included, and 4672 (26.7%) received RBCT. After adjustment for baseline and clinical characteristics, including comorbidities, malignant diagnosis, procedure and operative time, RBCT was independently associated with increased major morbidity (RR 1.49; 95% CI: 1.39-1.60), mortality (RR 2.19; 95%CI: 1.76-2.73) and LOS (RR 1.27; 95%CI 1.24-1.29).

CONCLUSION

Peri-operative RBCT for a pancreatectomy was independently associated with worse short-term outcomes and prolonged LOS. Future studies should focus on the impact of interventions to minimize the use of RBCT after an elective pancreatectomy.

A 23 years audit of packed red blood cell consumption in a university hospital in a developing country

BACKGROUND

There is paucity of information on the blood transfusion practice in developing countries. The current audit aims to find out the long term trend in the consumption of packed red blood cells (PRBCs) in a large Saudi teaching hospital in Riyadh

MATERIALS AND METHODS

We analyzed the annual consumption of PRBCs from 1985 to 2007 in seven major hospital divisions (Medicine, General Surgery, Pediatrics, Obstetrics and Gynecology, Cardiac Surgery, Accident and Emergency and Renal Dialysis Unit) at the 850-bed King Khalid University Hospital (KKUH), Riyadh.

RESULTS

Grand total consumption of PRBCs was 345,642 units. The consumption increased gradually and peaked in the year 1994, dropped to 30.4% 6 years later and then increased gradually thereafter, due to the expansion in the number of patients cared for in the Departments of Medicine, Cardiac Surgery and Accident and Emergency, while in the Department of Pediatrics the drop in consumption continued unabated. In the Renal Dialysis Unit consumption was minimal with the use of erythropoietin therapy. The crossmatch:transfusion ratio uncovered gross over-ordering of PRBCs and wastage of blood bank resources in most hospital divisions most notably in the Department of Obstetrics and Gynecology.

CONCLUSION

The results obtained indicate clearly that there has been overuse of blood products that dropped markedly in years coinciding with the worldwide apprehension about the safety of transfusion therapy particularly HIV transmission. This factor in addition to the current implementation of strict guidelines is gradually improving transfusion practices in our institute.

Red blood cell transfusion for people undergoing hip fracture surgery

BACKGROUND

The incidence of hip fracture is increasing and it is more common with increasing age. Surgery is used for almost all hip fractures. Blood loss occurs as a consequence of both the fracture and the surgery and thus red blood cell transfusion is frequently used. However, red blood cell transfusion is not without risks. Therefore, it is important to identify the evidence for the effective and safe use of red blood cell transfusion in people with hip fracture.

OBJECTIVES

To assess the effects (benefits and harms) of red blood cell transfusion in people undergoing surgery for hip fracture.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (31 October 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014, Issue 10), MEDLINE (January 1946 to 20 November 2014), EMBASE (January 1974 to 20 November 2014), CINAHL (January 1982 to 20 November 2014), British Nursing Index Database (January 1992 to 20 November 2014), the Systematic Review Initiative's Transfusion Evidence Library, PubMed for e-publications, various other databases and ongoing trial registers.

SELECTION CRITERIA

Randomised controlled trials comparing red blood cell transfusion versus no transfusion or an alternative to transfusion, different transfusion protocols or different transfusion thresholds in people undergoing surgery for hip fracture.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed each study's risk of bias and extracted data using a study-specific form. We pooled data where there was homogeneity in the trial comparisons and the timing of outcome measurement. We used GRADE criteria to assess the quality (low, moderate or high) of the evidence for each outcome.

MAIN RESULTS

We included six trials (2722 participants): all compared two thresholds for red blood cell transfusion: a 'liberal' strategy to maintain a haemoglobin concentration of usually 10 g/dL versus a more 'restrictive' strategy based on symptoms of anaemia or a lower haemoglobin concentration, usually 8 g/dL. The exact nature of the transfusion interventions, types of surgery and participants varied between trials. The mean age of participants ranged from 81 to 87 years and approximately 24% of participants were men. The largest trial enrolled 2016 participants, over 60% of whom had a history of cardiovascular disease. The percentage of participants receiving a red blood cell transfusion ranged from 74% to 100% in the liberal transfusion threshold group and from 11% to 45% in the restrictive transfusion threshold group. There were no results available for the smallest trial (18 participants). All studies were at some risk of bias, in particular performance bias relating to the absence of blinding of personnel. We judged the evidence for all outcomes, except myocardial infarction, was low quality reflecting risk of bias primarily from imbalances in protocol violations in the largest trial and imprecision, often because of insufficient events. Thus, further research is likely to have an important impact on these results.There was no evidence of a difference between a liberal versus restricted threshold transfusion in mortality, at 30 days post hip fracture surgery (risk ratio (RR) 0.92, 95% confidence interval (CI) 0.67 to 1.26; five trials; 2683 participants; low quality evidence) or at 60 days post surgery (RR 1.08, 95% CI 0.80 to 1.44; three trials; 2283 participants; low quality evidence). Assuming an illustrative baseline risk of 50 deaths per 1000 participants in the restricted threshold group at 30 days, these data equate to four fewer (95% CI 17 fewer to 14 more) deaths per 1000 in the liberal threshold group at 30 days.There was no evidence of a difference between a liberal versus restricted threshold transfusion in functional recovery at 60 days, assessed in terms of the inability to walk 10 feet (3 m) without human assistance (RR 1.00, 95% CI 0.87 to 1.15; two trials; 2083 participants; low quality evidence).There was low quality evidence of no difference between the transfusion thresholds in postoperative morbidity for the following complications: thromboembolism (RR 1.15 favouring a restrictive threshold, 95% CI 0.56 to 2.37; four trials; 2416 participants), stroke (RR 2.40 favouring a restrictive threshold, 95% CI 0.85 to 6.79; four trials; 2416 participants), wound infection (RR 1.61 favouring a restrictive threshold, 95% CI 0.77 to 3.35; three trials; 2332 participants), respiratory infection (pneumonia) (RR 1.35 favouring a restrictive threshold, 95% CI 0.95 to 1.92; four trials; 2416 participants) and new diagnosis of congestive heart failure (RR 0.77 favouring a liberal threshold, 95% CI 0.48 to 1.23; three trials; 2332 participants). There was very low quality evidence of a lower risk of myocardial infarction in the liberal compared with the restrictive transfusion threshold group (RR 0.59, 95% CI 0.36 to 0.96; three trials; 2217 participants). Assuming an illustrative baseline risk of myocardial infarction of 24 per 1000 participants in the restricted threshold group, this result was compatible with between one and 15 fewer myocardial infarctions in the liberal threshold group.

AUTHORS' CONCLUSIONS

We found low quality evidence of no difference in mortality, functional recovery or postoperative morbidity between 'liberal' versus 'restrictive' thresholds for red blood cell transfusion in people undergoing surgery for hip fracture. Although further research may change the estimates of effect, the currently available evidence does not support the use of liberal red blood cell transfusion thresholds based on a 10 g/dL haemoglobin trigger in preference to more restrictive transfusion thresholds based on lower haemoglobin levels or symptoms of anaemia in these people. Future research needs to address the effectiveness of red blood cell transfusions at different time points in the surgical pathway, whether pre-operative, peri-operative or postoperative. In particular, such research would need to consider people who are symptomatic or haemodynamically unstable who were excluded from most of these trials.

Blood Conservation in Neurosurgery: Erythropoietin and Autologous Donation

Background

Neurosurgery may involve significant blood loss and frequently requires allogeneic red blood cell (RBC) transfusion. Preoperative recombinant erythropoietin (EPO) may be used to improve erythroid status and recovery, and used either alone or in combination with preoperative autologous donation (PAD) it may reduce exposure to allogeneic RBC. We wished to study the use of EPO with and without PAD and the risk of RBC transfusion in neurosurgery.

Methods

Using a retrospective case-control design, 57 patients who received EPO preoperatively were matched 2:1 for age, sex, year of surgery, and International Classification of Diseases code most responsible for surgery (three were excluded because of stringent matching criteria, leaving 54 cases and 108 comparison subjects). Thirty-two cases participated in PAD. Medical and anesthetic records as well as laboratory investigations were reviewed and extracted.

Results

Allogeneic RBC exposure was identical for EPO cases and comparison subjects (18.5%). Concomitant PAD and EPO did not reduce allogeneic RBC exposure (21.9%), and resulted in a greater number of RBC units transfused. Last recorded hemoglobin levels suggested that autologous RBCs were not more liberally used. Patients who engaged in PAD and EPO suffered from iatrogenic anemia. A significant proportion (58.6%) of the autologous RBCs was ultimately not used and discarded.

Conclusion

Further research is needed to determine the efficacy of EPO in neurological surgery. PAD does not appear to reduce the risk of allogeneic RBC transfusion, despite concomitant EPO. Indeed, PAD resulted in iatrogenic anemia and increased transfusion requirements. The cost-effectiveness of blood conservation efforts in neurosurgery deserves additional research.

Trends in red blood cell transfusion and 30-day mortality among hospitalized patients

BACKGROUND

Blood conservation strategies have been shown to be effective in decreasing red blood cell (RBC) utilization in specific patient groups. However, few data exist describing the extent of RBC transfusion reduction or their impact on transfusion practice and mortality in a diverse inpatient population.

STUDY DESIGN AND METHODS

We conducted a retrospective cohort study using comprehensive electronic medical record data from 21 medical facilities in Kaiser Permanente Northern California. We examined unadjusted and risk-adjusted RBC transfusion and 30-day mortality coincident with implementation of RBC conservation strategies.

RESULTS

The inpatient study cohort included 391,958 patients who experienced 685,753 hospitalizations. From 2009 to 2013, the incidence of RBC transfusion decreased from 14.0% to 10.8% of hospitalizations; this change coincided with a decline in pretransfusion hemoglobin (Hb) levels from 8.1 to 7.6 g/dL. Decreased RBC utilization affected broad groups of admission diagnoses and was most pronounced in patients with a nadir Hb level between 8 and 9 g/dL (n = 73,057; 50.8% to 19.3%). During the study period, the standard deviation of risk-adjusted RBC transfusion incidence across hospitals decreased by 44% (p < 0.001). Thirty-day mortality did not change significantly with declines in RBC utilization in patient groups previously studied in clinical trials nor in other subgroups.

CONCLUSIONS

After the implementation of blood conservation strategies, RBC transfusion incidence and pretransfusion Hb levels decreased broadly across medical and surgical patients. Variation in RBC transfusion incidence across hospitals decreased from 2010 to 2013. Consistent with clinical trial data, more restrictive transfusion practice did not appear to impact 30-day mortality.

Concepts of blood transfusion in adults

Recent progress has been made in the identification and implementation of best transfusion practices on the basis of evidence-based clinical trials, published clinical practice guidelines, and process improvements for blood use and clinical patient outcomes. However, substantial variability persists in transfusion outcomes for patients in some clinical settings--eg, patients undergoing cardiothoracic surgery. This variability could be the result of insufficient understanding of published guidelines; different recommendations of medical societies, including the specification of a haemoglobin concentration threshold to use as a transfusion trigger; the value of haemoglobin as a surrogate indicator for transfusion benefit, even though only changes in concentration and not absolute red cell mass of haemoglobin can be identified; and disagreement about the validity of the level 1 evidence for clinical practice guidelines. Nevertheless, institutional experience and national databases suggest that a restrictive blood transfusion approach is being increasingly implemented as best practice.

The effect of a preoperative erythropoietin protocol as part of a multifaceted blood management program in daily clinical practice (CME)

BACKGROUND

The effectiveness of a preoperative erythropoietin (EPO) protocol to reduce allogeneic blood transfusions (ABTs) in daily clinical practice has been insufficiently studied. This study evaluated the effect of such a protocol, as part of a multifaceted blood management program, in patients undergoing total hip arthroplasty (THA).

STUDY DESIGN AND METHODS

This retrospective observational study was designed as an interrupted time series (1999-2010). The intervention was the introduction of an EPO protocol in THA patients in 2003. Patients were classified according to preoperative hemoglobin (Hb) level: 10 to 13 g/dL (eligible patients for EPO) and more than 13 g/dL. The primary outcome was the percentage of patients receiving an ABT. Segmented regression analysis was used to estimate changes in outcome after the intervention.

RESULTS

A total of 4568 THA patients were included. The absolute reductions in ABTs after the intervention were 17% (95% confidence interval [CI], 6%-29%) for the total study population and 25% (95% CI, 11%-39%) and 8% (95% CI, -5% to 21%) for the Hb groups 10 to 13 and more than 13 g/dL, respectively. In the postintervention period, 46% of the eligible patients (Hb level, 10-13 g/dL) actually received EPO. The transfusion rate in the EPO group was lower compared to the non-EPO group: 14 and 50%, respectively (p < 0.01).

CONCLUSION

Introduction of a preoperative EPO protocol reduced the transfusion rate in THA patients in daily clinical practice. The reduction must be seen as part of a multifaceted blood management program, in which increased awareness of blood transfusion contributes simultaneously and substantially to the reduction in transfusion rate.

Effect of hospital culture on blood transfusion in cardiac procedures

BACKGROUND

In our effort to reduce the use of blood products in cardiac operations in a health care system, we noted variations in transfusion practices among facilities. Interestingly, surgeons practicing at the same hospital had similar transfusion rates. We sought to quantitate the contribution of hospital influence on individual surgeons' transfusion practices.

METHODS

Blood transfusion data for coronary artery bypass graft operations at 12 Providence Health & Services facilities between January 2008 and June 2011 were reviewed. Frequency of perioperative blood transfusion, amount of transfusion, components transfused, and timing of transfusions were compared. Variation among surgeons at the same institution vs between institutions was computed based on multilevel mixed-effect logistic and linear regression models. Intraclass correlation coefficients were calculated.

RESULTS

A total of 5,744 nonemergency first-time coronary artery bypass graft procedures were performed by 42 not-low volume (n>30 in 2.5 years) surgeons at 12 Providence Health & Services hospitals during the 3.5-year study period. Frequency, amount, timing, and blood component usage were different among facilities but relatively similar for surgeons within a facility. The variance of red blood cell transfusion rate among hospitals (.82) is more than two times that among surgeons practicing within the same hospital (.35). Thus, surgeons contribute 30% to the variation, and 70% of the total variation can be explained by the hospital effect.

CONCLUSIONS

In our multihospital system, the hospital that a surgeon practices at plays a larger role in determining blood utilization than the individual surgeon's preference.

A cross-country comparison of intensive care physicians' beliefs about their transfusion behaviour: a qualitative study using the Theoretical Domains Framework

BACKGROUND

Evidence of variations in red blood cell transfusion practices have been reported in a wide range of clinical settings. Parallel studies in Canada and the United Kingdom were designed to explore transfusion behaviour in intensive care physicians. The aim of this paper is three-fold: first, to explore beliefs that influence Canadian intensive care physicians' transfusion behaviour; second, to systematically select relevant theories and models using the Theoretical Domains Framework (TDF) to inform a future predictive study; and third, to compare its results with the UK study.

METHODS

Ten intensive care unit (ICU) physicians throughout Canada were interviewed. Physicians' responses were coded into theoretical domains, and specific beliefs were generated for each response. Theoretical domains relevant to behaviour change were identified, and specific constructs from the relevant domains were used to select psychological theories. The results from Canada and the United Kingdom were compared.

RESULTS

Seven theoretical domains populated by 31 specific beliefs were identified as relevant to the target behaviour. The domains Beliefs about capabilities (confident to not transfuse if patients' clinical condition is stable), Beliefs about consequences (positive beliefs of reducing infection and saving resources and negative beliefs about risking patients' clinical outcome and potentially more work), Social influences (transfusion decision is influenced by team members and patients' relatives), and Behavioural regulation (wide range of approaches to encourage restrictive transfusion) that were identified in the UK study were also relevant in the Canadian context. Three additional domains, Knowledge (it requires more evidence to support restrictive transfusion), Social/professional role and identity (conflicting beliefs about not adhering to guidelines, referring to evidence, believing restrictive transfusion as professional standard, and believing that guideline is important for other professionals), and Motivation and goals (opposing beliefs about the importance of restrictive transfusion and compatibility with other goals), were also identified in this study. Similar to the UK study, the Theory of Planned Behaviour, Social Cognitive Theory, Operant Learning Theory, Action Planning, and Knowledge-Attitude-Behaviour model were identified as potentially relevant theories and models for further study. Personal project analysis was added to the Canadian study to explore the Motivation and goals domain in further detail.

CONCLUSIONS

A wide range of beliefs was identified by the Canadian ICU physicians as likely to influence their transfusion behaviour. We were able to demonstrate similar though not identical results in a cross-country comparison. Designing targeted behaviour-change interventions based on unique beliefs identified by physicians from two countries are more likely to encourage restrictive transfusion in ICU physicians in respective countries. This needs to be tested in future prospective clinical trials.

Drug, Devices, Technologies, and Techniques for Blood Management in Minimally Invasive and Conventional Cardiothoracic Surgery a Consensus Statement from the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) 2011

Objective

The objectives of this consensus conference were to evaluate the evidence for the efficacy and safety of perioperative drugs, technologies, and techniques in reducing allogeneic blood transfusion for adults undergoing cardiac surgery and to develop evidence-based recommendations for comprehensive perioperative blood management in cardiac surgery, with emphasis on minimally invasive cardiac surgery.

Methods

The consensus panel short-listed the potential topics for review from a comprehensive list of potential drugs, devices, technologies, and techniques. The process of short-listing was based on the need to prioritize and focus on the areas of highest importance to surgeons, anesthesiologists, perfusionists, hematologists, and allied health care involved in the management of patients who undergo cardiac surgery whether through the conventional or minimally invasive approach. MEDLINE, Cochrane Library, and Embase databases were searched from their date of inception to May 2011, and supplemental hand searches were also performed. Detailed methodology and search strategies are outlined in each of the subsequently published systematic reviews. In general, all relevant synonyms for drugs (antifibrinolytic, aprotinin, ∊-aminocaproic acid, tranexamic acid [TA], desmopressin, anticoagulants, heparin, antiplatelets, anti-Xa agents, adenosine diphosphate inhibitors, acetylsalicylic acid [ASA], factor VIIa [FVIIa]), technologies (cell salvage, miniaturized cardiopulmonary bypass (CPB) circuits, biocompatible circuits, ultrafiltration), and techniques (transfusion thresholds, minimally invasive cardiac or aortic surgery) were searched and combined with terms for blood, red blood cells, fresh-frozen plasma, platelets, transfusion, and allogeneic exposure. The American Heart Association/American College of Cardiology system was used to label the level of evidence and class of each recommendation.

Results and Recommendations

Database search identified more than 6900 articles, with 4423 full-text randomized controlled trials assessed for eligibility, and the final 125 systematic reviews and meta-analyses were used in the consensus conference. The results of the consensus conference, including the evidence-based statements and the recommendations, are outlined in the text, with references given for the relevant evidence that formed the basis for the statements and recommendations.

Transfusion-related acute lung injury: Current understanding and preventive strategies

Transfusion-related acute lung injury (TRALI) is the most serious complication of transfusion medicine. TRALI is defined as the onset of acute hypoxia within 6 hours of a blood transfusion in the absence of hydrostatic pulmonary oedema. The past decades have resulted in a better understanding of the pathogenesis of this potentially life-threating syndrome. The present notion is that the onset of TRALI follows a threshold model in which both patient and transfusion factors are essential. The transfusion factors can be divided into immune and non-immune mediated TRALI. Immune-mediated TRALI is caused by the passive transfer of human neutrophil antibodies (HNA) or human leukocyte antibodies (HLA) present in the blood product reacting with a matching antigen in the recipient. Non-immune mediated TRALI is caused by the transfusion of stored cell-containing blood products. Although the mechanisms behind immune-mediated TRALI are reasonably well understood, this is not the case for non-immune mediated TRALI. The increased understanding of pathways involved in the onset of immune-mediated TRALI has led to the design of preventive strategies. Preventive strategies are aimed at reducing the risk to exposure of HLA and HNA to the recipient of the transfusion. These strategies include exclusion of "at risk" donors and pooling of high plasma volume products and have shown to reduce the TRALI incidence effectively. This review discusses the current understanding of TRALI and preventive strategies available.

Using theories of behaviour to understand transfusion prescribing in three clinical contexts in two countries: development work for an implementation trial

BACKGROUND

Blood transfusion is an essential part of healthcare and can improve patient outcomes. However, like most therapies, it is also associated with significant clinical risks. In addition, there is some evidence of overuse. Understanding the potential barriers and enablers to reduced prescribing of blood products will facilitate the selection of intervention components likely to be effective, thereby reducing the number of costly trials evaluating different implementation strategies. Using a theoretical basis to understand behaviours targeted for change will contribute to a 'basic science' relating to determinants of professional behaviour and how these inform the selection of techniques for changing behaviour. However, it is not clear which theories of behaviour are relevant to clinicians' transfusing behaviour. The aim of this study is to use a theoretical domains framework to identify relevant theories, and to use these theories to identify factors that predict the decision to transfuse.

METHODS

The study involves two steps: interview study and questionnaire study. Using a previously identified framework, we will conduct semi-structured interviews with clinicians to elicit their views about which factors are associated with waiting and further monitoring the patient rather than transfusing red blood cells. Interviews will cover the following theoretical domains: knowledge; skills; social/professional role and identity; beliefs about capabilities; beliefs about consequences; motivation and goals; memory, attention, and decision processes; environmental context and resources; social influences; emotion; behavioural regulation; nature of the behaviour. The interviews will take place independently in Canada and the UK and involve two groups of physicians in each country (UK: adult and neonatal intensive care physicians; Canada: intensive care physicians and orthopaedic surgeons). We will: analyse interview transcript content to select relevant theoretical domains; use consensus processes to map these domains on to theories of behaviour; develop questionnaires based on these theories; and mail them to each group of physicians in the two countries. From our previous work, it is likely that the theories will include: theory of planned behaviour, social cognitive theory and the evidence-based strategy, implementation intention. The questionnaire data will measure predictor variables (theoretical constructs) and outcome variables (intention and clinical decision), and will be analysed using multiple regression analysis. We aim to achieve 150 respondents in each of the four groups for each postal survey.

Patient blood management - a new paradigm for transfusion medicine?

The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropriate transfusion is still not sufficiently tangible for the public and many clinicians. This has to change. The medical, ethical, legal and economic evidence cannot be ignored. Patient blood management needs to be implemented as the standard of care for all patients.

Determinants of transfusion decisions in a mixed medical-surgical intensive care unit: a prospective cohort study

BACKGROUND

For reasons unknown, a restrictive transfusion policy of red blood cells (RBC) is only gradually being implemented by Intensive Care Unit (ICU) physicians, resulting in a large variation in transfusion practice. Insight into physicians' transfusion decisions may aid efforts to restrict transfusion practice.

STUDY DESIGN AND METHODS

In a prospective cohort study, transfusion triggers were determined in patients consecutively admitted to an ICU during a 10-week period. Using a questionnaire, the reasons why ICU physicians transfused RBC were evaluated.

RESULTS

Among 310 admissions, 90 patients (29%) received a RBC transfusion. Eighty-one of these 90 patients were included in this analysis. RBC were transfused at a mean haemoglobin (Hb) level of 7.4+/-1.1 g/dL. Residents transfused RBC at a higher Hb level compared to senior staff (7.7+/-1.0 versus 6.9+/-1.3, respectively; p<0.05). The most important reason for physicians to transfuse RBC was the suspicion of bleeding. Age and coronary ischaemia were the predominant reasons for transfusing RBC in 4% and 12% of cases, respectively. The average order for RBC transfusion was four units. Of each order, 38% of the units were not administered.

CONCLUSION

RBC transfusion decisions are predominantly based on Hb levels rather than on patients' characteristics. Residents transfuse at a higher Hb level compared to more experienced physicians. The major determinant for physicians to transfuse RBC is bleeding. However, the majority of patients were transfused in the absence of bleeding, and many of these patients received multiple units. The need for RBC may be overestimated, resulting in wasted orders.