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Grant MC, Crisafi C, Alvarez A, Arora RC, Brindle ME, Chatterjee S, Ender J, Fletcher N, Gregory AJ, Gunaydin S, Jahangiri M, Ljungqvist O, Lobdell KW, Morton V, Reddy VS, Salenger R, Sander M, Zarbock A, Engelman DT. Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS). Ann Thorac Surg 2024; 117:669-689. [PMID: 38284956 DOI: 10.1016/j.athoracsur.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/09/2023] [Indexed: 01/30/2024]
Abstract
Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.
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Affiliation(s)
- Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Cheryl Crisafi
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Adrian Alvarez
- Department of Anesthesia, Hospital Italiano, Buenos Aires, Argentina
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mary E Brindle
- Departments of Surgery and Community Health Services, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Joerg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Nick Fletcher
- Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom; St George's University Hospital, London, United Kingdom
| | - Alexander J Gregory
- Department of Anesthesia, Perioperative and Pain Medicine, Cumming School of Medicine University of Calgary, Calgary, Alberta, Canada
| | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Marjan Jahangiri
- Department of Cardiac Surgery, St George's Hospital, London, United Kingdom
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Kevin W Lobdell
- Regional Cardiovascular and Thoracic Quality, Education, and Research, Atrium Health, Charlotte, North Carolina
| | - Vicki Morton
- Clinical and Quality Outcomes, Providence Anesthesiology Associates, Charlotte, North Carolina
| | - V Seenu Reddy
- Centennial Heart & Vascular Center, Nashville, Tennessee
| | - Rawn Salenger
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Michael Sander
- Department of Anaesthesiology, Operative Intensive Care Medicine and Pain Therapy, Justus Liebig University of Giessen, Giessen, Germany
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Daniel T Engelman
- Heart and Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Vitolo M, Mei DA, Cimato P, Bonini N, Imberti JF, Cataldo P, Menozzi M, Filippini T, Vinceti M, Boriani G. Cardiac Surgery in Jehovah's Witnesses Patients and Association With Peri-Operative Outcomes: A Systematic Review and Meta-Analysis. Curr Probl Cardiol 2023; 48:101789. [PMID: 37172869 DOI: 10.1016/j.cpcardiol.2023.101789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/07/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Strategies for blood conservation, coupled with a careful preoperative assessment, may be applied to Jehovah's Witnesses (JW) patients who are candidates for cardiac surgery interventions. There is a need to assess clinical outcomes and safety of bloodless surgery in JW patients undergoing cardiac surgery. METHODS We performed a systematic review and meta-analysis of studies comparing JW patients with controls undergoing cardiac surgery. The primary endpoint was short-term mortality (in-hospital or 30-day mortality). Peri-procedural myocardial infarction, re-exploration for bleeding, pre-and postoperative Hb levels and cardiopulmonary bypass (CPB) time were also analyzed. RESULTS A total of 10 studies including 2,302 patients were included. The pooled analysis showed no substantial differences in terms of short-term mortality among the two groups (OR 1.13, 95% CI 0.74-1.73, I2=0%). There were no differences in peri-operative outcomes among JW patients and controls (OR 0.97, 95% CI 0.39-2.41, I2=18% for myocardial infarction; OR 0.80, 95% CI 0.51-1.25, I2=0% for re-exploration for bleeding). JW patients had a higher level of preoperative Hb (Standardized Mean Difference [SMD] 0.32, 95% CI 0.06-0.57) and a trend toward a higher level of postoperative Hb (SMD 0.44, 95% CI -0.01-0.90). A slightly lower CPB time emerged in JWs compared with controls (SMD -0.11, 95% CI -0.30-0.07). CONCLUSIONS JW patients undergoing cardiac surgery, with avoidance of blood transfusions, did not have substantially different peri-operative outcomes compared with controls, with specific reference to mortality, myocardial infarction, and re-exploration for bleeding. Our results support the safety and feasibility of bloodless cardiac surgery, applying patient blood management strategies.
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Affiliation(s)
- Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide A Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Paolo Cimato
- Department of Cardiac Surgery, Villa Torri Hospital, GVM Care & Research, Bologna, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Paolo Cataldo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Matteo Menozzi
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tommaso Filippini
- Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia Modena Italy; School of Public Health, University of California Berkeley, Berkeley, CA, USA
| | - Marco Vinceti
- Environmental, Genetic and Nutritional Epidemiology Research Center, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia Modena Italy; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.
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O'Shaughnessy S, Tangel V, Dzotsi S, Jiang S, White R, Hoyler M. Non-White Race/Ethnicity and Female Sex Are Associated with Increased Allogeneic Red Blood Cell Transfusion in Cardiac Surgery Patients: 2007-2018. J Cardiothorac Vasc Anesth 2022; 36:1908-1918. [PMID: 34969561 DOI: 10.1053/j.jvca.2021.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate racial and/or ethnic and sex disparities in allogeneic and autologous red blood cell (RBC) transfusions in cardiac surgery. DESIGN A retrospective observational study. SETTING 2007 to 2018 data from FL, MD, KY, WA, NY, and CA from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. PARTICIPANTS A total of 710,296 inpatients who underwent elective or emergency coronary artery bypass grafting (CABG), cardiac valve surgery,or combination CABG and/or valve surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were cohorted by race and/or ethnicity and sex, as defined by SID-HCUP. Demographic characteristics and comorbidities were compared. Rates and risk-adjusted odds ratios (aOR) were calculated for allogeneic and autologous RBC transfusion (primary outcomes). Additional secondary analyses were conducted for in-hospital mortality, 30-day readmission, 90-day readmission, hospital length of stay, and total charges to examine the effect of RBC transfusion status. Effect modification between race and sex was assessed. When controlling for patient demographics, comorbidities, and hospital characteristics, non-White patients were more likely to receive an allogeneic RBC transfusion during cardiac surgery than White patients (Black: aOR 1.17, 99% CI 1.13-1.20, p < 0.001, Hispanic: aOR 1.22, 99% CI 1.19-1.22, p < 0.001). Women were more likely to receive allogeneic RBC than men (aOR 1.69, 99% CI 1.66-1.72, p < 0.001). In interaction models, non-White women had the highest odds of allogeneic blood transfusion as compared to White men (reference category; Black women: aOR 2.04, 99% CI 1.91-2.17, p < 0.001, Hispanic women: aOR 2.03, 99% CI 1.90-2.16, p < 0.001). CONCLUSION These findings highlighted the differences in the rates of allogeneic RBC transfusion for non-White and female patients undergoing cardiac surgery, which is a well-established marker of poorer outcomes.
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Affiliation(s)
- Sinead O'Shaughnessy
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY.
| | - Virginia Tangel
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Safiya Dzotsi
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Silis Jiang
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Robert White
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
| | - Marguerite Hoyler
- Weill Cornell Medicine, Department of Anesthesiology, 525 East 68th Street, New York City, NY
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Copeland H, Levine D, Morton J, Hayanga JA. Acute respiratory distress syndrome in the cardiothoracic patient: State of the art and use of veno-venous extracorporeal membrane oxygenation. ACTA ACUST UNITED AC 2021; 8:97-103. [PMID: 34723221 PMCID: PMC8541831 DOI: 10.1016/j.xjon.2021.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 10/12/2021] [Indexed: 01/02/2023]
Affiliation(s)
- Hannah Copeland
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
- Indiana University School of Medicine Fort Wayne, Fort Wayne, Ind
- Address for reprints: Hannah Copeland, MD, Indiana University–Fort Wayne School of Medicine, 7910 W Jefferson Blvd, Suite 102, Fort Wayne, IN 46804.
| | - Deborah Levine
- Division of Pulmonary Critical Care and Lung Transplantation, Department of Medicine, University of Texas San Antonio, San Antonio, Tex
| | - John Morton
- Division of Cardiovascular Surgery, Division of Heart Transplantation, Mechanical Circulatory Support and ECMO, Lutheran Hospital, Fort Wayne, Ind
| | - J.W. Awori Hayanga
- Department of Thoracic and Cardiovascular Surgery, West Virginia University, Morgantown, WVa
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Amanvermez Senarslan D, Yildirim F, Kurdal AT, Damar A, Ozturk T, Tetik O. Efficacy and cost-effectiveness of cell saver usage in the repair of thoracic aortic aneurysms and dissections. Perfusion 2021; 37:722-728. [PMID: 34192996 DOI: 10.1177/02676591211028178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION A substantial amount of blood loss occurs during the open repair of aortic aneurysms or dissections. The aim of the present study is to determine the efficacy and cost-effectiveness of cell saver devices in blood conservation during the open repair of thoracic aortic pathologies. METHODS The present study prospectively collected the data pertaining to 25 patients who underwent surgical management of thoracic aortic aneurysms or dissections using a cell saver (Group 1, n = 25). The volume and cost of transfusion and postoperative outcomes were compared with the second group of patients who underwent surgery without the use of cell savers in the previous year (Group 2, n = 25); the data pertaining to the same were retrospectively collected from the hospital records. The patient characteristics and categorical variables were compared using the x2 test and Fisher's exact test. Transfusion volume and costs were compared using the independent samples t-test and Mann-Whitney U test. RESULTS The patients in both the groups displayed similar characteristics and risk factors. The total volume of allogenic red blood cell (p < 0.001) and total blood product (p = 0.01) transfusions were significantly lower in Group 1. The cost of red blood cell (p < 0.001) and total transfusions (p = 0.03) were lower in Group 1. The two groups displayed similar in-hospital morbidity and mortality rates. CONCLUSIONS There was a significant association between the use of cell savers and the decreased need for red blood cell and total blood product transfusions. Considering the cost of the cell saver set, transfusion costs in the two groups were comparable.
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Affiliation(s)
| | - Funda Yildirim
- Department of Cardiovascular Surgery, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Adnan Taner Kurdal
- Department of Cardiovascular Surgery, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Abdulkerim Damar
- Department of Cardiovascular Surgery, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Tulun Ozturk
- Department of Anesthesiology and Reanimation, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Omer Tetik
- Department of Cardiovascular Surgery, Manisa Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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Delaforce A, Duff J, Munday J, Hardy J. Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management: Barrier Identification and Implementation Strategy Mapping. J Multidiscip Healthc 2020; 13:1759-1770. [PMID: 33293819 PMCID: PMC7718960 DOI: 10.2147/jmdh.s282308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/04/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction and aims Patients undergoing major surgery risk significant blood loss and transfusion, which increases substantially if they have pre-existing anemia. Preoperative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P) outline recommended blood tests and treatment to optimize patients before surgery. Documented success using PAIDSEM-P to reduce transfusions and improve patient outcomes exists, but the reporting quality of such studies is suboptimal. It remains unclear what implementation strategies best support the implementation of PAIDSEM-P. Method Maximum variation, purposive sampling was used to recruit a total of 15 participants, including a range of health professionals and patients for semi-structured interviews. Data analysis utilized a deductive approach informed by the Consolidated Framework for Implementation Research (CFIR) for barrier identification and the Expert Recommendations for Implementing Change (ERIC) for reporting recommended implementation strategies. A modified version of the Action, Actor, Context, Target and Time (AACTT) framework assisted with conceptualisation and targeted strategy selection. Results The analysis revealed five barriers: access to knowledge and information, patient needs and resources, knowledge and beliefs about the intervention, available resources, and networks and communications, which had strong ERIC recommendations, including conduct educational meetings, develop educational materials, distribute educational materials, obtain and use patients/consumers family feedback, involve patients/consumers/family members, conduct a local needs assessment, access new funding, promote network weaving, and organize clinician implementation team meetings. Conclusions Mapping the barriers and strategies using the ERIC framework on the basis of individual actor categories proved to be useful in identifying a pragmatic number of implementation strategies that may help in supporting the utilisation of the PAIDSEM-P and other evidence-based healthcare implementation problems more broadly.
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Affiliation(s)
- Alana Delaforce
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia.,Mater Health Services, South Brisbane, QLD 4101, Australia
| | - Jed Duff
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, NSW, Australia.,School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - Judy Munday
- School of Nursing/Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,School of Nursing, The University of Agder, Kristiansand, Norway
| | - Janet Hardy
- Mater Health Services, South Brisbane, QLD 4101, Australia
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Akhrass R, Bakaeen FG, Akras Z, Houghtaling PL, Soltesz EG, Gillinov AM, Svensson LG. Primary isolated CABG restrictive blood transfusion protocol reduces transfusions and length of stay. J Card Surg 2020; 35:2506-2511. [PMID: 33043652 DOI: 10.1111/jocs.14718] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG). METHODS Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared. RESULTS CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity. CONCLUSIONS A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG.
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Affiliation(s)
- Rami Akhrass
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Cardiothoracic Surgery, Lake Health System, Willoughby, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zade Akras
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Irving AH, Harris A, Petrie D, Higgins A, Smith J, McQuilten ZK. Impact of patient blood management guidelines on blood transfusions and patient outcomes during cardiac surgery. J Thorac Cardiovasc Surg 2020; 160:437-445.e20. [DOI: 10.1016/j.jtcvs.2019.08.102] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/27/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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Worrall N, Brevig J, Jin R, Gluckman T, Hunter R, Ducsik M, Batkoff B, Grunkemeier G. Reduction in coronary artery bypass grafting surgery mortality and morbidity during a 3-year multicenter quality improvement project. J Thorac Cardiovasc Surg 2020; 159:1779-1791. [DOI: 10.1016/j.jtcvs.2019.04.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 04/17/2019] [Accepted: 04/20/2019] [Indexed: 10/26/2022]
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Delaforce A, Duff J, Munday J, Hardy J. Overcoming barriers to evidence-based patient blood management: a restricted review. Implement Sci 2020; 15:6. [PMID: 31952514 PMCID: PMC6969479 DOI: 10.1186/s13012-020-0965-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/06/2020] [Indexed: 01/31/2023] Open
Abstract
Background Blood transfusions are associated with a range of adverse patient outcomes, including coagulopathy, immunomodulation and haemolysis, which increase the risk of morbidity and mortality. Consideration of these risks and potential benefits are necessary when deciding to transfuse. Patient blood management (PBM) guidelines exist to assist in clinical decision-making, but they are underutilised. Exploration of barriers to the implementation and utilisation of the PBM guidelines is required. This study aimed to identify common barriers and implementation strategies used to implement PBM guidelines, with a comparison against current expert opinion. Methods A restricted review approach was used to identify the barriers to PBM guideline implementation as reported by health professionals and to review which implementation strategies have been used. Searches were undertaken in MEDLINE/PubMed, CINAHL, Embase, Scopus and the Cochrane library. The Consolidated Framework for Implementation Research (CFIR) was used to code barriers. The Expert Recommendations for Implementing Change (ERIC) tool was used to code implementation strategies, and subsequently, develop recommendations based on expert opinion. Results We identified 14 studies suitable for inclusion. There was a cluster of barriers commonly reported: access to knowledge and information (n = 7), knowledge and beliefs about the intervention ( = 7) and tension for change (n = 6). Implementation strategies used varied widely (n = 25). Only one study reported the use of an implementation theory, model or framework. Most studies (n = 11) had at least 50% agreement with the ERIC recommendations. Conclusions There are common barriers experienced by health professionals when trying to implement PBM guidelines. There is currently no conclusive evidence to suggest which implementation strategies are most effective. Further research using validated implementation approaches and improved reporting is required.
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Affiliation(s)
- Alana Delaforce
- The University of Newcastle, School of Nursing and Midwifery, University Drive, Callaghan, NSW, 2302, Australia. .,Mater Health Services, Level 6, Duncombe Building, Raymond Terrace, QLD, 4101, Australia.
| | - Jed Duff
- The University of Newcastle, School of Nursing and Midwifery, University Drive, Callaghan, NSW, 2302, Australia
| | - Judy Munday
- School of Nursing/Institute for Health and Biomedical Innovation, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD, 4059, Australia.,Faculty of Health and Sports Sciences, The University of Agder, Grimstad, Norway
| | - Janet Hardy
- Mater Health Services, Level 6, Duncombe Building, Raymond Terrace, QLD, 4101, Australia
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11
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Squiers JJ, Baumgarten H, Filardo G, Sass D, Pollock B, Edgerton J, Marcel R, DiMaio JM, Smith RL. Prospective Evaluation of a Blood Transfusion Protocol for Patients Undergoing Cardiac Operations. Ann Thorac Surg 2019; 110:144-151. [PMID: 31770507 DOI: 10.1016/j.athoracsur.2019.09.099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/08/2019] [Accepted: 09/27/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- John J Squiers
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Heike Baumgarten
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas; Department of Cardiac Surgery, Kerckhoff Heart Center, Bad Nauheim, Germany
| | - Giovanni Filardo
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Texas
| | - Danielle Sass
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Texas
| | - Benjamin Pollock
- Department of Epidemiology, Baylor Scott & White Health, Dallas, Texas
| | - James Edgerton
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - Randy Marcel
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - Robert L Smith
- Department of Cardiothoracic Surgery, The Heart Hospital Baylor Plano, Plano, Texas.
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Kataruka A, Doll JA, Hira RS. Public Reporting for Cardiac Procedures: Is the Juice Worth the Squeeze? J Am Coll Cardiol 2019; 74:2218. [PMID: 31648716 DOI: 10.1016/j.jacc.2019.07.086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 10/25/2022]
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Derzon JH, Clarke N, Alford A, Gross I, Shander A, Thurer R. Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse. Am J Clin Pathol 2019; 152:544-557. [PMID: 31305890 DOI: 10.1093/ajcp/aqz070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Assess support for the effectiveness of two separate practices, restrictive transfusion strategy and computerized physician order entry/clinical decision support (CPOE/CDS) tools, in decreasing RBC transfusions in adult surgical and nonsurgical patients. METHODS Following the Centers for Disease Control and Prevention Laboratory Medicine Best Practice (LMBP) Systematic Review (A-6) method, studies were assessed for quality and evidence of effectiveness in reducing the percentage of patients transfused and/or units of blood transfused. RESULTS Twenty-five studies on restrictive transfusion practice and seven studies on CPOE/CDS practice met LMBP inclusion criteria. The overall strength of the body of evidence of effectiveness for restrictive transfusion strategy and CPOE/CDS was rated as high. CONCLUSIONS Based on these procedures, adherence to an institutional restrictive transfusion strategy and use of CPOE/CDS tools for hemoglobin alerts or reminders of the institution's restrictive transfusion policies are effective in reducing RBC transfusion overuse.
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Affiliation(s)
| | | | - Aaron Alford
- National Network of Public Health Institutes, Washington, DC
| | | | - Aryeh Shander
- Englewood Hospital and Medical Center, Englewood, NJ
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Hira RS, Ring M, Dunbar P. Public Reporting of Percutaneous Coronary Intervention Outcomes Done Differently-Leading From Washington. JAMA Cardiol 2018; 3:1126-1127. [PMID: 30267059 DOI: 10.1001/jamacardio.2018.3000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ravi S Hira
- Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington.,Division of Cardiology, University of Washington, Seattle
| | - Michael Ring
- Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington.,Providence Sacred Heart Medical Center, Spokane, Washington
| | - Peter Dunbar
- Clinical Outcomes Assessment Program, Foundation for Health Care Quality, Seattle, Washington
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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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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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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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Gunn T, Paone G, Emery RW, Ferraris VA. The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Tyler Gunn
- Department of Surgery, University of Kentucky, Lexington, KY USA
| | - Gaetano Paone
- Cardiac Surgery, Henry Ford Hospital, Detroit, MI USA
| | | | - Victor A. Ferraris
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY USA
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Sharma AD, Al-Achi A, Behrend D, Seccombe JF. Adult cardiac surgery blood/blood product utilization in the post aprotinin era: an 855 patient, community hospital, retrospective experience. Indian J Thorac Cardiovasc Surg 2016. [DOI: 10.1007/s12055-015-0413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
OBJECTIVE AND BACKGROUND Minimally invasive breast biopsy (MIBB) rates remain well below guideline recommendations of more than 90% and vary across geographic areas. Our aim was to determine the variation in use attributable to the surgeon and facility and determine the patient, surgeon, and facility characteristics associated with the use of MIBB. METHODS We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years with a breast biopsy (open or minimally invasive) and subsequent breast cancer diagnosis/operation within 1 year. The percentage of patients undergoing MIBB as the first diagnostic modality was estimated for each surgeon and facility. Three-level hierarchical generalized linear models (patients clustered within surgeons within facilities) were used to evaluate variation in MIBB use. RESULTS A total of 22,711 patients underwent a breast cancer operation by 1226 surgeons at 525 facilities. MIBB was the initial diagnostic modality in 62.4% of cases. Only 7.0% of facilities and 12.9% of surgeons used MIBB for more than 90% of patients. In 3-level models adjusted for patient characteristics, the percentage of patients who received MIBB ranged from 7.5% to 96.0% across facilities (mean = 50.1%, median = 49.2%) and from 8.0% to 87.0% across surgeons (mean = 50.3%, median = 50.9%). The variance in MIBB use was attributable to facility (8.8%) and surgeon (15.4%) characteristics. Lower surgeon and facility volume, longer surgeon years in practice, and smaller facility bed size were associated with lower rates of MIBB use. CONCLUSIONS Identification of surgeon and facility characteristics associated with low use of MIBB provides potential targets for interventions to improve MIBB rates and decrease variation in use. TYPE OF STUDY Retrospective cohort.
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Meybohm P, Fischer DP, Geisen C, Müller MM, Weber CF, Herrmann E, Steffen B, Seifried E, Zacharowski K. Safety and effectiveness of a Patient Blood Management (PBM) program in surgical patients--the study design for a multi-centre prospective epidemiologic non-inferiority trial. BMC Health Serv Res 2014; 14:576. [PMID: 25927460 PMCID: PMC4261241 DOI: 10.1186/s12913-014-0576-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 11/03/2014] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Preoperative and hospital-acquired anaemia is common among surgical patients. It is associated with an increased risk of morbidity and mortality and a strong risk factor for allogeneic blood transfusions with their own inherent risks. Patient Blood Management (PBM) concepts aim to increase and preserve autologous erythrocyte volume and to optimise haemotherapy. They thus have great potential to benefit patients. METHODS/DESIGN This prospective, multi-centre clinical trial tests the hypothesis that PBM programs are safe and effective in the care of adult surgical patients. Primary outcome is a composite endpoint of adverse events and in-hospital mortality. DISCUSSION This trial will determine whether the implementation of a PBM program is safe and effective in terms of clinical outcome compared to a pre-implementation cohort. This trial is registered at www.clinicaltrials.gov (NCT01820949).
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Affiliation(s)
- Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Dania Patricia Fischer
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Christof Geisen
- German Red Cross Blood Transfusion Service Baden-Wuerttemberg - Hessen, Institute of Transfusion Medicine and Immunohematology, Sandhofstrasse 1, Frankfurt am Main, Germany.
| | - Markus Matthias Müller
- German Red Cross Blood Transfusion Service Baden-Wuerttemberg - Hessen, Institute of Transfusion Medicine and Immunohematology, Sandhofstrasse 1, Frankfurt am Main, Germany.
| | - Christian Friedrich Weber
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | - Björn Steffen
- Department of Haematooncology, University Hospital Frankfurt, Frankfurt am Main, Germany.
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service Baden-Wuerttemberg - Hessen, Institute of Transfusion Medicine and Immunohematology, Sandhofstrasse 1, Frankfurt am Main, Germany.
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
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Robich MP, Koch CG, Johnston DR, Schiltz N, Chandran Pillai A, Hussain ST, Soltesz EG. Trends in blood utilization in United States cardiac surgical patients. Transfusion 2014; 55:805-14. [DOI: 10.1111/trf.12903] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Revised: 08/29/2014] [Accepted: 08/30/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Michael P. Robich
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Colleen G. Koch
- Department of Cardiothoracic Anesthesia; Cleveland Clinic; Cleveland Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Nicholas Schiltz
- Department of Epidemiology and Biostatistics; Case Western Reserve University; Cleveland Ohio
| | | | - Syed T. Hussain
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Clinic; Cleveland Ohio
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Roubinian NH, Escobar GJ, Liu V, Swain BE, Gardner MN, Kipnis P, Triulzi DJ, Gottschall JL, Wu Y, Carson JL, Kleinman SH, Murphy EL. Trends in red blood cell transfusion and 30-day mortality among hospitalized patients. Transfusion 2014; 54:2678-86. [PMID: 25135770 DOI: 10.1111/trf.12825] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/15/2014] [Accepted: 07/16/2014] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Nareg H Roubinian
- Blood Systems Research Institute, San Francisco, California; Kaiser Permanente Northern California Division of Research, Oakland, California; University of California at San Francisco, San Francisco, California
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Mulaj M, Faraoni D, Willems A, Sanchez Torres C, Van der Linden P. Predictive Factors for Red Blood Cell Transfusion in Children Undergoing Noncomplex Cardiac Surgery. Ann Thorac Surg 2014; 98:662-7. [DOI: 10.1016/j.athoracsur.2014.04.089] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/07/2014] [Accepted: 04/21/2014] [Indexed: 10/25/2022]
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Tran MH, Lin DM, Wilcox T, Schiro D, Cannesson M, Milliken J. Effects of a multimodality blood conservation schema toward improvement of intraoperative hemoglobin levels and off-pump transfusions in coronary artery bypass graft surgery. Transfusion 2014; 54:2769-74. [DOI: 10.1111/trf.12745] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/25/2014] [Accepted: 04/28/2014] [Indexed: 01/12/2023]
Affiliation(s)
- Minh-Ha Tran
- Department of Pathology and Laboratory Medicine; UC Irvine School of Medicine; Irvine California
| | - David M. Lin
- Department of Internal Medicine; UC Irvine School of Medicine; Irvine California
| | | | - Dana Schiro
- Perioperative Services; UC Irvine Medical Center; Irvine California
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Services; UC Irvine School of Medicine; Irvine California
| | - Jeffrey Milliken
- Department of Surgery; UC Irvine School of Medicine; Irvine California
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Vonk AB, Meesters MI, van Dijk WB, Eijsman L, Romijn JW, Jansen EK, Loer SA, Boer C. Ten-year patterns in blood product utilization during cardiothoracic surgery with cardiopulmonary bypass in a tertiary hospital. Transfusion 2013; 54:2608-16. [DOI: 10.1111/trf.12522] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 12/21/2022]
Affiliation(s)
- Alexander B.A. Vonk
- Department of Cardio-thoracic Surgery; VU University Medical Center; Amsterdam the Netherlands
| | - Michael I. Meesters
- Department of Cardio-thoracic Surgery; VU University Medical Center; Amsterdam the Netherlands
- Department of Anesthesiology, Institute for Cardiovascular Research; VU University Medical Center; Amsterdam the Netherlands
| | - Wouter B. van Dijk
- Department of Anesthesiology, Institute for Cardiovascular Research; VU University Medical Center; Amsterdam the Netherlands
| | - Leon Eijsman
- Department of Cardio-thoracic Surgery; VU University Medical Center; Amsterdam the Netherlands
| | - Johannes W.A. Romijn
- Department of Anesthesiology, Institute for Cardiovascular Research; VU University Medical Center; Amsterdam the Netherlands
| | - Evert K. Jansen
- Department of Cardio-thoracic Surgery; VU University Medical Center; Amsterdam the Netherlands
| | - Stephan A. Loer
- Department of Anesthesiology, Institute for Cardiovascular Research; VU University Medical Center; Amsterdam the Netherlands
| | - Christa Boer
- Department of Anesthesiology, Institute for Cardiovascular Research; VU University Medical Center; Amsterdam the Netherlands
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Paone G, Brewer R, Likosky DS, Theurer PF, Bell GF, Cogan CM, Prager RL. Transfusion Rate as a Quality Metric: Is Blood Conservation a Learnable Skill? Ann Thorac Surg 2013; 96:1279-1286. [DOI: 10.1016/j.athoracsur.2013.05.045] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/08/2013] [Accepted: 05/10/2013] [Indexed: 11/30/2022]
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Bilecen S, de Groot JA, Kalkman CJ, Spanjersberg AJ, Moons KG, Nierich AP. Effectiveness of a cardiac surgery-specific transfusion protocol. Transfusion 2013; 54:708-16. [DOI: 10.1111/trf.12346] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2012] [Revised: 05/29/2013] [Accepted: 05/30/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Süleyman Bilecen
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Joris A.H. de Groot
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Cor J. Kalkman
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Alexander J. Spanjersberg
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Karel G.M. Moons
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
| | - Arno P. Nierich
- Department of Cardiothoracic Anaesthesia and Intensive Care; Isala Clinics Zwolle; Zwolle The Netherlands
- Department of Anesthesiology; Julius Center for Health Sciences and Primary Care; University Medical Center Utrecht; Utrecht The Netherlands
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Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg 2013; 145:796-803; discussion 803-4. [DOI: 10.1016/j.jtcvs.2012.12.041] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 11/26/2012] [Accepted: 12/11/2012] [Indexed: 11/24/2022]
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Chu MWA, Losenno KL, Moore K, Berta D, Hewitt J, Ralley F. Blood conservation strategies reduce the need for transfusions in ascending and aortic arch surgery. Perfusion 2013; 28:315-21. [DOI: 10.1177/0267659113479816] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Ascending and aortic arch surgery is associated with higher levels of blood loss and subsequent need for allogeneic blood transfusions. We hypothesized that aggressive, comprehensive blood conservation strategies may limit the need for transfusions and, subsequently, improve postoperative outcomes. Methods: Over a five-year period, 189 patients underwent proximal aortic surgery at our institution. Fifty-one patients underwent surgery using a comprehensive blood conservation strategy (BCS), including preoperative hemoglobin optimization, antifibrinolytic therapy, intraoperative acute normovolemic hemodilution, cell salvage and meticulous surgical technique. The remaining 138 patients underwent surgery using conventional techniques (CONV). Results: Patients in the BCS group required fewer transfusions during their hospital stay compared to the conventional group (56.9% vs. 72.5%, p=0.041). When examining elective cases, this trend widens, with 40.0% of BCS patients requiring any transfusions compared to 72.9% patients in the conventional group (p=0.001). Red cell (47.1% vs. 62.3%, p=0.06), plasma (43.1% vs. 61.6%, p=0.02) and platelets (27.5% vs. 47.8%, p=0.01) were also less frequently required in the BCS group than the conventional group, respectively. When a transfusion was required, patients in the BCS group received significantly fewer units of red blood cells (2.8 ± 7.0 units) than the conventional group (5.81 ± 9.5 units; p=0.039). Mortality was similar in both groups (BCS 7.8%, conventional 10.9%, p=0.54); however, there was significantly less morbidity in the BCS group, using a composite of any of 10 major postoperative complications (23.5% vs. 39.1%; p=0.046). Median intensive care unit (ICU) and hospital lengths of stay were 2 and 7 days in the BCS group and 2 and 8 days in the CONV group (p=0.15), respectively. Conclusions: The aggressive use of a comprehensive blood conservation strategy in ascending and aortic arch surgery can significantly reduce the need for blood transfusions and is associated with less postoperative morbidity. Further evaluation with a randomized, controlled trial is warranted.
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Affiliation(s)
- MWA Chu
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario & Lawson Health Research Institute, Ontario, Canada
| | - KL Losenno
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario & Lawson Health Research Institute, Ontario, Canada
| | - K Moore
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario & Lawson Health Research Institute, Ontario, Canada
| | - D Berta
- Perioperative Blood Conservation Program, London Health Sciences Centre, London, Ontario, Canada
| | - J Hewitt
- Division of Cardiac Surgery, Department of Surgery, University of Western Ontario & Lawson Health Research Institute, Ontario, Canada
| | - F Ralley
- Perioperative Blood Conservation Program, London Health Sciences Centre, London, Ontario, Canada
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Abstract
In the tradition of Dr Arom, who had many interests in his clinical and research career, I will touch on three things that will impact the practice of clinical cardiac surgery over the next several years: use of bilateral internal mammary arteries, use of external mesh support to improve saphenous vein graft patency, and anticoagulation of mechanical heart valves. The remainder of the presentation goes into depth on the development of a bloodless heart surgery program, which is contemporary and timely as it encompasses some thoughts of this society.
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Risks of packed red blood cell transfusion in patients undergoing cardiac surgery. J Crit Care 2012; 27:737.e1-9. [DOI: 10.1016/j.jcrc.2012.05.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 05/09/2012] [Accepted: 05/13/2012] [Indexed: 01/29/2023]
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Étude de deux cohortes de patients opérés pour pontages des coronaires en 2008 et 2011. Transfus Clin Biol 2012. [DOI: 10.1016/j.tracli.2012.08.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rigal JC, Cinotti R, Rozec B, Fernandez M, Bruckler M, Miguet B, Dang Van H, Blanloeil Y. Étude de deux cohortes de patients opérés pour remplacements valvulaires aortiques en 2008 et 2011. Transfus Clin Biol 2012. [DOI: 10.1016/j.tracli.2012.08.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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2012 Update to The Society of Thoracic Surgeons Guideline on Use of Antiplatelet Drugs in Patients Having Cardiac and Noncardiac Operations. Ann Thorac Surg 2012; 94:1761-81. [DOI: 10.1016/j.athoracsur.2012.07.086] [Citation(s) in RCA: 228] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 06/19/2012] [Accepted: 07/10/2012] [Indexed: 12/31/2022]
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Jin R, Zelinka ES, McDonald J, Byrnes T, Grunkemeier GL, Brevig J. Effect of hospital culture on blood transfusion in cardiac procedures. Ann Thorac Surg 2012; 95:1269-74. [PMID: 23040823 DOI: 10.1016/j.athoracsur.2012.08.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 07/29/2012] [Accepted: 08/01/2012] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Ruyun Jin
- Medical Data Research Center, Providence Health & Services, Portland, Oregon 97225, USA.
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Shander A, Puzio T, Javidroozi M. Variability in Transfusion Practice and Effectiveness of Strategies to Improve It. J Cardiothorac Vasc Anesth 2012; 26:541-4. [DOI: 10.1053/j.jvca.2012.04.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Indexed: 11/11/2022]
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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. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 7:229-41. [DOI: 10.1097/imi.0b013e3182747699] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
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.
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Menkis AH, Martin J, Cheng DC, Fitzgerald DC, Freedman JJ, Gao C, Koster A, Mackenzie GS, Murphy GJ, Spiess B, Ad N. 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. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012. [DOI: 10.1177/155698451200700401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alan H. Menkis
- WRHA Cardiac Sciences Program, Department of Surgery, University of Manitoba, Winnipeg, MB Canada
| | - Janet Martin
- Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR), Department of Anesthesia and Perioperative Medicine, Western University, London, ON Canada
| | - Davy C.H. Cheng
- Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR), Department of Anesthesia and Perioperative Medicine, Western University, London, ON Canada
| | | | - John J. Freedman
- Division of Hematology, Department of Medicine, St. Michael Hospital, Toronto, ON Canada
| | - Changqing Gao
- Department of Cardiovascular Surgery, Minimally Invasive and Robotic Cardiac Surgery Center, PLA General Hospital, Beijing, China
| | - Andreas Koster
- Heart and Diabetes Center NRW, Bad Oeynhausen, Germany, Ruhr-University Bochum, Germany
| | - G. Scott Mackenzie
- Cardiac Anesthesia, WRHA/SBGH Cardiac Sciences Program, Winnipeg, MB Canada
| | | | - Bruce Spiess
- Department of Anesthesiology, Virginia Commonwealth University/Medical College of Virginia, Richmond VA USA
| | - Niv Ad
- Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA USA
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Emery RW, Cooper MM, Joyce DL. Over the Next Hill. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012. [DOI: 10.1177/155698451200700302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Robert W. Emery
- HealthEast Care System, Saint Joseph's Hospital, St Paul, MN USA
| | | | - David L. Joyce
- HealthEast Care System, Saint Joseph's Hospital, St Paul, MN USA
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Moskowitz D, Shander A. Reply. Ann Thorac Surg 2011. [DOI: 10.1016/j.athoracsur.2011.07.041] [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: 12/01/2022]
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Nalla BP, Freedman J, Hare GMT, Mazer CD. Update on blood conservation for cardiac surgery. J Cardiothorac Vasc Anesth 2011; 26:117-33. [PMID: 22000983 DOI: 10.1053/j.jvca.2011.07.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Bhanu P Nalla
- Department of Anesthesia, Keenan Research Center in the Li Ka Shing Knowledge Translation Institute of St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Role of quality improvement in prevention of inappropriate transfusions. Qual Manag Health Care 2011; 20:298-310. [PMID: 21971027 DOI: 10.1097/qmh.0b013e3182315d22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Many different methods are used to manage surgical bleeding and reduce transfusion. Techniques vary by institution, resulting in inconsistent outcomes. We reviewed the current literature on the quality and costs of transfusions, focusing on prevention and management of transfusions during surgery, and provide recommendations on future directions for quality improvement (QI). DATA SOURCES Ovid, PubMed, and Scopus. STUDY SELECTION Key words included QI, blood loss, transfusion, hemostasis, and costs. Inclusion criteria were English language, publication between 1999 and 2010, and primary end points of blood loss, transfusion, or hemostasis. DATA EXTRACTION A total of 1331 abstracts were reviewed; 43 met the inclusion criteria. RESULTS A variety of bleeding management (BM) techniques were identified, with multiple studies suggesting that algorithms combining pre-, peri-, and postoperative interventions have the greatest potential to minimize transfusions. Most studies assessing the economic impact of BM interventions excluded resources beyond blood acquisition cost and longer-term complications, which may underestimate transfusion costs and bias estimates of the cost-effectiveness of interventions. Despite consensus on avoiding inappropriate transfusions, little agreement exists on optimal use of interventions. CONCLUSIONS Multifaceted algorithms show promising results. Future QI should focus on reducing practice variation via evidence-based guidelines for effective use of BM interventions.
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Milas BL. Con: the practice of cardiac anesthesia has not significantly changed after the withdrawal of aprotinin. J Cardiothorac Vasc Anesth 2011; 24:879-82. [PMID: 20869615 DOI: 10.1053/j.jvca.2010.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Indexed: 11/11/2022]
Affiliation(s)
- Bonnie L Milas
- Department of Anesthesiology and Critical Care Medicine,University of Pennsylvania, Philadelphia, PA 19104, USA.
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Masud F, Larson-Pollock K, Leveque C, Vykoukal D. Establishing a Culture of Blood Management Through Education. Am J Med Qual 2011; 26:349-56. [DOI: 10.1177/1062860611398532] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Faisal Masud
- Methodist DeBakey Heart & Vascular Center, Houston, TX
- Cardiovascular Intensive Care Unit, The Methodist Hospital, Houston, TX
- Weill Cornell Medical College, New York, NY
| | | | | | - Daynene Vykoukal
- Methodist DeBakey Heart & Vascular Center, Houston, TX
- The Methodist Hospital Research Institute, Houston, TX
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Ranucci M, Aronson S, Dietrich W, Dyke CM, Hofmann A, Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, von Heymann C. Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice? J Thorac Cardiovasc Surg 2011; 142:249.e1-32. [DOI: 10.1016/j.jtcvs.2011.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 02/09/2011] [Accepted: 04/08/2011] [Indexed: 12/13/2022]
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 859] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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