A survey of physicians' attitudes toward blood transfusion in patients undergoing cesarean section

Nonclinical factors affecting intraoperative red blood cell transfusion: a systematic review

PURPOSE

There is significant variability in intraoperative red blood cell (RBC) transfusion practice. We aimed to use the theoretical domains framework (TDF) to categorize nonclinical and behavioural factors driving intraoperative RBC transfusion practice in a systematic review of the literature.

SOURCE

We searched electronic databases from inception until August 2021 to identify studies evaluating nonclinical factors affecting intraoperative RBC transfusion. Using the Mixed Methods Appraisal Tool, we assessed the quality of included studies and identified relevant nonclinical factors, which were coded into TDF domains by two independent reviewers using NVivo (Lumivero, QSR International, Burlington, MA, USA). We identified common themes within domains and sorted domains based on the frequency of reported factors.

PRINCIPAL FINDINGS

Our systematic review identified 18 studies: nine retrospective cohort studies, six cross-sectional surveys, and three before-and-after studies. Factors related to the social influences, behavioural regulation, environmental context/resources, and beliefs about consequences domains of the TDF were the most reported factors. Key factors underlying the observed variability in transfusion practice included the social effects of peers, patients, and institutional culture on decision-making (social influences), and characteristics of the practice environment including case volume, geographic location, and case start time (environmental context/resources). Studies reported variable beliefs about the consequences of both intraoperative transfusion and anemia (beliefs about consequences). Provider- and institutional-level audits, educational sessions, and increased communication between surgeons/anesthesiologists were identified as strategies to optimize intraoperative transfusion decision-making (behavioural regulation).

CONCLUSION

Our systematic review has synthesized the literature on nonclinical and behavioural factors impacting intraoperative transfusion decision-making, categorized using the TDF. These findings can inform evidence-based interventions to reduce intraoperative RBC transfusion variability.

STUDY REGISTRATION

Open Science Framework ( https://osf.io/pm8zs/?view_only=166299ed28964804b9360c429b1218c1 ; first posted, 3 August 2022).

Severity of shock, rate of physiological stabilization and organ failure in healthy women admitted to the intensive care unit following major peripartum hemorrhage: A retrospective, descriptive study

PURPOSE

To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH).

MATERIALS AND METHODS

Retrospective, descriptive, single center study.

RESULTS

Twenty-nine women median age 33 years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23 mmol/L to 1.54 mmol/L within 24 h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48 h and that of mechanical ventilation was <24 h. Increased transfusion rates correlated with lengthier ICU admission (p ≤ 0.01 regardless of blood product).

CONCLUSIONS

Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.

The effect of perioperative blood transfusion on kidney functions in total knee Arthroplasty

Objective:

Various studies have examined the effects of perioperative blood transfusion on kidney functions. In this study, we investigated the effects of blood transfusion on the kidney functions of patients undergoing total knee arthroplasty.

Methods:

: This retrospective study was carried out on 216 patients who had undergone total knee arthroplasty between January 2016 and January 2017. The patients were divided into two groups according to the level of blood transfusion used during surgery. Group-1 comprised 157 patients (72.7%) needing a blood transfusion of less than three units, while the 59 (27.3) patients in Group-2 required three or more than three units.

Results:

No statistical difference was found between the two groups regarding hypertension before surgery, diabetes mellitus, chronic kidney failure, smoking habits or lung disease (p> 0.05). Likewise, there was no significant difference related to pulmonary and other complications or mortality (p> 0.05). When the groups were compared according to their blood parameters, no statistical differences in postoperative renal or other system functions were found (p> 0.05).

Conclusions:

Blood transfusion does not have a negative effect on postoperative blood urea nitrogen (BUN) and creatinine levels, or glomerular filtration rate in total knee arthroplasty.

Caesarean delivery-related blood transfusion: correlates in a tertiary hospital in Southwest Nigeria

BACKGROUND

Caesarean delivery carries a risk of major intra-operative blood loss and its performance is often delayed by non-availability of blood and blood products. Unnecessary cross-matching and reservation of blood lead to apparent scarcity in centres with limited supply. This study set out to identify the risk factors for blood transfusion in women who underwent caesarean delivery at a tertiary obstetric unit with a view to ensuring efficient blood utilization.

METHODS

A prospective cohort analysis of 906 women who had caesarean deliveries at the Lagos State University Teaching Hospital, Nigeria between January and December, 2011. A comparison was made between 188 women who underwent blood transfusion and 718 who did not. Data were obtained on a daily basis by investigators from patients, clinical notes and referral letters using structured pre-tested data collecting form. Socio-demographic characteristics; antenatal, perioperative and intraoperative details; blood loss; transfusion; and puerperal observations were recorded. EPI-Info statistical software version 3.5.3 was used for multivariable analysis to determine independent risk factors for blood transfusion.

RESULTS

Of the 2134 deliveries during the study period, 906 (42.5%) had caesarean deliveries and of which 188 (20.8%) were transfused. The modal unit of blood transfused was 3 pints (41.3%). The most common indication for caesarean section was cephalo-pelvic disproportion (25.7%).The independent risk factors for blood transfusion at caesarean section were second stage Caesarean Section (aOR = 76.14, 95% CI = 1.25-4622.06, p = 0.04), placenta previa (aOR = 32.57, 95% CI = 2.22-476.26, p = 0.01), placental abruption (aOR = 25.35, 95% CI = 3.06-211.02, p < 0.001), pre-operative anaemia (aOR = 12.15, 95% = CI 4.02-36.71, p < 0.001), prolonged operation time (aOR = 10.72 95% CI = 1.37-36.02, p < 0.001), co-morbidities like previous uterine scar (aOR = 7.02, 95% CI = 1.37-36.02, p = 0.02) and hypertensive disorders in pregnancy (aOR = 5.19, 95% CI = 1.84-14.68, p < 0.001). Obesity reduced the risk for blood transfusion (aOR = 0.24, 95% CI = 0.09-0.61, p = 0.0024).

CONCLUSION

The overall risk of blood transfusion in cesarean delivery is high. Paturients with the second stage Caesarean section, placenta previa, abruptio placentae and preoperative maternal anaemia have an increased risk of blood transfusion. Hence, adequate peri-operative preparations for blood transfusion are essential in these situations. Optimizing maternal hemoglobin concentration during antenatal period may reduce the incidence of caesarean-associated blood transfusion.

A survey of resident physicians' knowledge concerning transfusion medicine in Shiraz, Iran

OBJECTIVE

The knowledge of physicians concerning blood transfusion has a significant impact on the optimal use of blood and blood products. The aim was to survey their knowledge regarding this area and identify whether additional training is required.

MATERIAL AND METHODS

This cross-sectional study was conducted on all 1(st) year resident physicians at Shiraz University of Medical Sciences, Iran in 2011. The questionnaire solicited information on demographic variables, knowledge regarding transfusion medicine, education and experience regarding blood transfusion.

RESULTS

The mean total knowledge score regarding transfusion medicine was 15.44 ± 3.3 (7-25) out of 29. Only about one-fourth (27.4%) replied correctly to over 60% of questions. The mean score of knowledge was higher among residents who stated that they received special training regarding blood transfusion in their medical courses (P < 0.01). Seventy-five percent of residents believed that they had received insufficient education and 97.8% believed that they need additional training.

CONCLUSION

The results reflect the uncertainties among resident physicians regarding blood transfusion. It has been suggested that a special transfusion medicine educational program should be added to the medical education curriculum.

Risk factors for blood transfusion at delivery in Finland

OBJECTIVE

To examine the prevalence and risk factors for blood transfusion during delivery.

DESIGN

Register-based retrospective cohort study from Finland.

SETTING

National Medical Birth Register data during 2006-2008.

SAMPLE

A total of 171 731 women having singleton deliveries, of whom 3394 (1.98%) received blood transfusion.

METHODS

We calculated odds ratios (ORs) with 95% confidence intervals (CIs) by multivariate logistic regression to adjust for confounders related to maternal background and mode of delivery.

MAIN OUTCOME MEASURES

Blood transfusion rates by risk factors.

RESULTS

Blood transfusion rate during labor increased slightly, from 1.83% in 2006 to 2.27% in 2008 (p < 0.001), during the study period. The highest rate, almost 4%, was reported in central hospitals. Advanced maternal age and primiparity predisposed to blood transfusion. A previous cesarean section increased these rates also in subsequent vaginal delivery (2.64%) compared with women who had vaginal deliveries only (0.86%, OR 3.14, 95% CI 2.65-3.72). Induction of labor almost doubled the risk for blood transfusion (adjusted OR 1.74, 95% CI 1.60-1.89). All instrumental vaginal deliveries (adjusted OR 2.46, 95% CI 2.25-2.69) and any cesarean sections (adjusted OR 1.80, 95% CI 1.66-1.96) increased this risk. Delivery of a large-for-gestational age newborn increased the blood transfusion risk over twofold.

CONCLUSIONS

As previous cesarean section includes an increased risk for blood transfusion, even in subsequent deliveries, it is essential to consider the mode of labor carefully. The blood transfusion rate was the highest in central hospitals, suggesting differences in blood transfusion practice.

Evaluation of blood reservation and use for caesarean sections in a tertiary maternity unit in south western Nigeria

BACKGROUND

Haemorrhage from obstetric causes is the most common cause of maternal mortality in the developing world. Prevention of mortality from haemorrhage will necessarily involve prompt blood transfusions among other life saving measures. There are however limited stocks of fresh or stored blood in many health care facilities in Sub Saharan Africa. Caesarean section has been identified as a common indication for blood transfusion in obstetrics practice and its performance is often delayed by non availability of blood in our centre. An evaluation of blood reservation and use at caesarean sections in a tertiary maternity unit in Lagos, south western Nigeria should therefore assist in formulating the most rational blood transfusion policies.

METHODS

Case records of 327 patients who had elective and emergency caesarian sections at the Lagos State University Teaching Hospital between 1st October and 31st December 2007 were reviewed. Data pertaining to age, parity, booking status, type and indication for Caesarean section, pre- and post-operative packed cell volume, blood loss at surgery, units of blood reserved in the blood bank, unit(s) of blood transfused and duration of hospital stay was extracted and the data analysed.

RESULTS

There were 1056 deliveries out of which 327 (31%) were by Caesarean section. During the study period, a total of 654 units of blood were reserved in the blood bank and subsequently made available in theatre. Out of this number, only 89 (13.6%) were transfused to 41 patients. Amongst those transfused, twenty-six (54%) were booked and 31 (75.6%) had primary caesarian section. About 81% of those transfused had emergency caesarean section. The most common indication for surgery among those transfused were placenta praevia (9 patients with 21 units of blood) and cephalo-pelvic disproportion (8 patients with 13 units).

CONCLUSION

Even though a large number of units of blood was reserved and made available in the theatre at the time of operation, majority of the patients operated did not need blood transfusion. Provision of a mini- blood bank within the obstetric unit and careful patient categorization will ensure timely availability of blood for surgery without necessarily tying down stock in the central blood bank.

Blood component therapy in obstetrics

Hemorrhage is the leading cause of intensive care unit admission and one of the leading causes of death in the obstetric population. This emphasizes the importance of a working knowledge of the indications for and complications associated with blood product replacement in obstetric practice. This article provides current information regarding preparation for and administration of blood products, discusses alternatives to banked blood in the obstetric population, and introduces pharmacological strategies for treatment of hemorrhage.

Attitudes to blood transfusion post arthroplasty surgery in the United Kingdom: a national survey

Five hundred orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty surgery. Seventy-two percent of surgeons and 73% of anaesthetists responded to the survey. In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below a haemoglobin (Hb) level of 8 g/dL. Surgeons tended to be more aggressive in their attitudes, with a mean transfusion threshold of 8.3 g/dL compared to 7.9 g/dL for anaesthetists (p<0.01), and with 97% of surgeons transfusing two or more units compared to 78% of anaesthetists (p<0.01). This threshold Hb increased if the patient was symptomatic (surgeons 9.3 g/dL, anaesthetists 8.8 g/dL, p<0.05) or was known to have pre-existing ischaemic heart disease (surgeons 9.0 g/dL, anaesthetists 9.2 g/dL, p<0.05). A wide variability in attitudes and practices is demonstrated, and the development and adoption of consensus guidelines needs to be encouraged if efforts to reduce the use of blood products are to succeed.

Red blood cell transfusion practices amongst Canadian anesthesiologists: a survey

PURPOSE

To assess red blood cell transfusion practices among Canadian anesthesiologists.

METHODS

A survey depicting three realistic clinical scenarios of elective surgical procedures with different risks of bleeding was administered to all Canadian practicing members (n = 2,100) of the Canadian Anesthesiologists' Society. Respondents were requested to choose hemoglobin thresholds for which they would transfuse red blood cells under various conditions within each scenario.

RESULTS

We obtained a response rate of 47% (719/1,512). Transfusion thresholds differed significantly between baseline scenarios. A threshold above 70 g x L(-1) was chosen by 48% of respondents in the general surgery scenario compared to 56% in the orthopedic surgery scenario and 79% in the vascular surgery scenario (P < 0.001). A history of coronary artery disease was associated with a transfusion threshold >or= 100 g x L(-1) in a significant proportion of respondents ranging from 20% in the orthopedic surgery scenario to 31% in the general surgery scenario and to 49% in the vascular surgery scenario (P < 0.001). Conversely, changing the patient's age from 60 to 20 yr resulted in the adoption of a transfusion threshold <or= 60 g x L(-1) by > 30% of respondents in two scenarios (P < 0.001). The year of respondent graduation was strongly associated with these findings.

CONCLUSION

There was significant variation in transfusion practices among Canadian anesthesiologists. The type of surgical procedure, patient's age and a history of coronary artery disease influenced reported transfusion threshold. Practice variation in specific subgroups would support the need for further research to identify optimal transfusion thresholds.

Postpartum hemorrhage and transfusion of blood and blood components

Postpartum hemorrhage (PPH) is one of the top 5 causes of maternal mortality in developed and developing countries. The incidence of PPH is 40% after vaginal delivery and 30% after cesarean section. Criteria for PPH are based on the amount of blood loss. In clinical obstetrics, exact measurement of blood loss is often difficult. The most important treatment of PPH is red blood cell (RBC) transfusion. In the past few years, increasing concern has arisen about this treatment. Despite the introduction of several new guidelines, transfusion criteria still vary widely between clinicians. The decision whether to prescribe RBC transfusion is mostly based on postpartum hemoglobin (Hb) values. RBC transfusion should be aimed to reduce morbidity and especially to improve health-related quality of life (HRQoL). In this review, etiology, epidemiology, treatment, and prevention of postpartum hemorrhage are described. Special attention is given to the role of RBC transfusion in the treatment of PPH and the effects of RBC transfusion on HRQoL.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize the new guidelines related to transfusion criteria, explain the importance of reducing morbidity related to improving quality of life issues, and list infectious and noninfectious complications of a red blood cell transfusion.