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Hensley NB, Frank SM, Nemergut EC, Neely GA. Pro-Con Debate: Anesthesiologists Should Be Responsible for Treating Preoperative Anemia. Anesth Analg 2024:00000539-990000000-00934. [PMID: 39255043 DOI: 10.1213/ane.0000000000006854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Abstract
In this Pro-Con commentary article, we discuss whether anesthesiologists should be responsible for treating preoperative anemia. This debate was proposed based on the article published in this issue of Anesthesia & Analgesia by Warner et al, which is an advisory on managing preoperative anemia endorsed by both the Society of Cardiovascular Anesthesiologists and the Society for Advancement of Patient Blood Management. All evidence suggests that anemia is not just an innocent "bystander" which can be solved by transfusion. In fact, both anemia and transfusion are independently associated with adverse outcomes, so why not avoid both? It just makes sense that patients show up for surgery with enough red blood cells to avoid needing transfusion with someone else's. Even if we agree that preoperative anemia is worth treating before surgery, the question remains who should be responsible for doing so, and therein lies the reason for this Pro-Con debate. Should it be the responsibility of the anesthesiologist, or not? Let the readers decide.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Steven M Frank
- From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Edward C Nemergut
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia
| | - Grant A Neely
- Department of Anesthesiology, West Virginia University, Morgantown, West Virginia
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Connors JP, Magaldi RJ, Strecker SE, Carangelo RJ, Witmer D. Tranexamic Acid Reduces the Amount of Blood Transfused in Revision Total Hip Arthroplasty for Vancouver B2/B3 Periprosthetic Femur Fractures. Orthopedics 2024; 47:e261-e267. [PMID: 39073044 DOI: 10.3928/01477447-20240718-05] [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] [Indexed: 07/30/2024]
Abstract
BACKGROUND Periprosthetic fractures around total hip arthroplasty (THA) represent a significant source of morbidity and mortality. The use of tranexamic acid (TXA) in arthroplasty is well described, yet little literature supports its role in periprosthetic femur fractures (PFFs). This study investigated the effect of preoperative TXA administration on transfusion rate and volume, length of stay, and 90-day complication rates in patients undergoing revision THA for PFF. MATERIALS AND METHODS All patients undergoing revision THA for PFF (Vancouver B2/B3) at our institution from August 2016 to June 2022 were identified. Routine TXA administration at surgical start was introduced in 2018. Patient demographics, operative time, blood product use, length of stay, and 90-day complications were collected. Patients were divided into those who received TXA preoperatively and those who did not. RESULTS A total of 56 patients were included. There was no difference in age, sex, anesthetic type, fracture classification, or preoperative blood values between cohorts. TXA significantly lowered the amount of blood product required (2.3 units vs 3.2 units, P=.023). Preoperative TXA did not independently reduce length of stay; however, blood transfusion was associated with increased length of stay (7 days vs 4.7 days, P=.003). There were no differences in 90-day complications. CONCLUSION Among patients who underwent revision THA for Vancouver B2/B3 PFF, TXA did not affect transfusion rates but did result in the use of fewer blood products without an increase in complications. We support routine use of TXA in this patient population. Future studies should assess earlier administration of TXA in the emergency department or once patients' conditions have been medically optimized. [Orthopedics. 2024;47(5):e261-e267.].
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Ali AA, Hamwi T, Sikman L, Stana J, Abicht JM, Tsilimparis N, Prendes CF. The Importance of Cell Saver Usage in Complex Endovascular Repair of Thoraco-Abdominal Aortic Aneurysms. Ann Vasc Surg 2024; 109:297-308. [PMID: 39029896 DOI: 10.1016/j.avsg.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 06/10/2024] [Accepted: 06/11/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The use of the cell saver is well-established in open aneurysm repair; however, its role in endovascular repair is yet to be determined. The aim of this study was to analyze the effects of cell saver usage in patients undergoing complex endovascular procedures. MATERIALS AND METHODS Single-center retrospective cohort study, including consecutive patients undergoing fenestrated and/or branched repair for the treatment of thoracoabdominal and complex abdominal aortic aneurysms (CAAAs) between January 2019 and December 2022. The cell saver was a standard part of the intraoperative setup of these procedures, and its use was readily available. The primary endpoint was the percentage of patients, in which autologous blood collected was transfused (cell saver blood transfusion [CSBT]), alongside the useable amount obtained. Secondary endpoints included mean blood loss, postoperative hemoglobin levels, and 30-day mortality. RESULTS A total of 170 patients (77.1% male, mean age 71.2 ± 9.2 years) were included, with a median blood loss of 700 mL (interquartile range [IQR] 400-1,200 mL). A total of 96 patients received some kind of blood transfusion (BT) (56.5%): 35 patients were (20.6%) allogenic BT, 31 patients were (18.2%) CSBT only, and 30 patients were (17.6%) a combination of both. In total, 61 patients (35.9% or 63.5% of all patients requiring BTs) received CSBT, with a median useable blood volume of 282 mL (IQR, 194.5-508 mL). Thirty-day mortality was similar in both groups. Although the CSBT group had lower intraoperative hemoglobin values (9.25 ± 1.55 vs. 10.36 ± 1.88 mg/dL; P < 0.001), both groups presented similar postoperative hemoglobin (Hb) levels. CONCLUSIONS Blood loss during complex endovascular repair is not insignificant. In this cohort, over 50% of included patients required some kind of BT, 32.3% of which received exclusively CSBT, while 31.3% had supplementary CSBT alongside allogenic BT. This data showcases its potential role in these repairs, paving the way for its standardization in the intraoperative setup of these complex procedures.
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Affiliation(s)
- Ahmed A Ali
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany; Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Mansoura University, Mansoura, Egypt
| | - Tarek Hamwi
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Laura Sikman
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Jan Stana
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Jan-Michael Abicht
- Department of Anesthesiology - University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Nikolaos Tsilimparis
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany
| | - Carlota F Prendes
- Department of Vascular Surgery - Vascular and Endovascular Surgery, University Hospital, Ludwig Maximilian University Munich, Munich, Germany.
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Borsinger TM, Chandi SK, Puri S, Debbi EM, Gausden EB, Chalmers BP. The Efficacy and Safety of Tranexamic Acid in Total Hip and Knee Arthroplasty: A Literature Review. HSS J 2024; 20:10-17. [PMID: 38356752 PMCID: PMC10863588 DOI: 10.1177/15563316231208716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/03/2023] [Indexed: 02/16/2024]
Abstract
Historically, total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been associated with significant perioperative blood loss and a relatively high rate of allogeneic blood transfusions. However, in recent years, tranexamic acid (TXA), a competitive inhibitor of tissue plasminogen activator, inhibiting fibrinolysis of existing thrombi, has substantially decreased the need for blood transfusion in THA and TKA. Various administration strategies have been studied, but there remains a lack of consensus on an optimal route and dosing regimen, with intravenous and topical regimens being widely used. A growing body of literature has demonstrated the safety and efficacy of TXA in primary and revision THA and TKA to reduce blood loss, allogeneic transfusions, and complications; it is associated with lowered lengths of stay, costs, and readmission rates.
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Affiliation(s)
- Tracy M Borsinger
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Sonia K Chandi
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Simarjeet Puri
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Eytan M Debbi
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Elizabeth B Gausden
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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Ahn H(S, Lenet T, Gilbert RWD, Mallick R, Shaw JLV, Fergusson DA, McIsaac DI, Martel G. Accuracy of point-of-care testing devices for haemoglobin in the operating room: meta-analysis. BJS Open 2024; 8:zrad148. [PMID: 38266123 PMCID: PMC10807999 DOI: 10.1093/bjsopen/zrad148] [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: 07/21/2023] [Revised: 09/24/2023] [Accepted: 10/29/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Point-of-care tests (POCT) for haemoglobin are increasingly used to guide intraoperative transfusion. However, their accuracy compared to central laboratory tests is unknown. The objective was to perform a systematic review and meta-analysis of method comparison studies assessing the accuracy of POCT versus central laboratory haemoglobin tests in patients undergoing surgery. METHODS Electronic databases were searched from inception to April 2020 (updated August 2023). Any methodological approach comparing haemoglobin measurements between POCT and central laboratory in patients undergoing surgery under anaesthesia in the operating room were included. Data abstraction was guided by PRISMA and risk of bias was assessed by QUADAS-2. Data were extracted independently and in duplicate by two reviewers. Outcomes included mean differences between POCT and central laboratory haemoglobin with associated standard deviations and 95% limits of agreement (LOA). RESULTS Of 3057 citations, 34 studies were included (n = 2427, 6857 paired measurements). Several devices were compared (pulse co-oximetry, n = 25; HemoCue, n = 10; iSTAT, n = 6; blood gas analysers, n = 10; haematology analyser, n = 2). Median sample size was 41 patients, and 11 studies were funded by device manufacturers. Fifteen of 34 studies had low risk of bias. Pooled mean differences (95% LOA) were: pulse co-oximeters 2.3 g/l (-25.2-29.8), HemoCue -0.3 g/l (-11.1-10.5), iSTAT -0.3 g/l (-8.4-7.8) and blood gas analysers -2.6 g/l (-17.8-12.7). CONCLUSION All POCT examining intraoperative haemoglobin measurement yielded pooled mean difference LOAs larger than the allowable limit difference of ±4 g/dl. Intraoperative haemoglobin measured by POCT should not be considered interchangeable with central laboratory values and caution is necessary when using these tests to guide intraoperative transfusion.
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Affiliation(s)
- Hilalion (San) Ahn
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Richard W D Gilbert
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Julie L V Shaw
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Anesthesiology & Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Kougias P, Mi Z, Zhan M, Carson JL, Dosluoglu H, Nelson P, Sarosi GA, Arya S, Norman LE, Sharath S, Scrymgeour A, Ollison J, Calais LA, Biswas K. Transfusion trigger after operations in high cardiac risk patients (TOP) trial protocol. Protocol for a multicenter randomized controlled transfusion strategy trial. Contemp Clin Trials 2023; 126:107095. [PMID: 36690072 DOI: 10.1016/j.cct.2023.107095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is substantial uncertainty regarding the effects of restrictive postoperative transfusion among patients who have underlying cardiovascular disease. The TOP Trial's objective is to compare adverse outcomes between liberal and restrictive transfusion strategies in patients undergoing vascular and general surgery operations, and with a high risk of postoperative cardiac events. METHODS A two-arm, single-blinded, randomized controlled superiority trial will be used across 15 Veterans Affairs hospitals with expected enrollment of 1520 participants. Postoperative transfusions in the liberal arm commence when Hb is <10 g/ dL and continue until Hb is greater than or equal to 10 g/dL. In the restrictive arm, transfusions begin when Hb is <7 g/dL and continue until Hb is greater than or equal to 7 g/dL. Study duration is estimated to be 5 years including a 3-month start-up period and 4 years of recruitment. Each randomized participant will be followed for 90 days after randomization with a mortality assessment at 1 year. RESULTS The primary outcome is a composite endpoint of all-cause mortality, myocardial infarction (MI), coronary revascularization, acute renal failure, or stroke occurring up to 90-days after randomization. Events rates will be compared between restrictive and liberal transfusion groups. CONCLUSIONS The TOP Trial is uniquely positioned to provide high quality evidence comparing transfusion strategies among patients with high cardiac risk. Results will clarify the effect of postoperative transfusion strategies on adverse outcomes and inform postoperative management algorithms. TRIAL REGISTRATION http://clinicaltrials.gov identifier: NCT03229941.
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Affiliation(s)
- Panos Kougias
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America.
| | - Zhibao Mi
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Min Zhan
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Jeffrey L Carson
- Division of General Internal Medicine, Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Hasan Dosluoglu
- Division of Vascular Surgery, Department of Surgery, SUNY at Buffalo/VA Western NY Healthcare System, Buffalo, NY, United States of America
| | - Peter Nelson
- Division of Vascular Surgery, Department of Surgery, University of Oklahoma School of Community Medicine, Tulsa, OK, United States of America
| | - George A Sarosi
- Department of Surgery, University of Florida College of Medicine, General Surgery Section, Department of Surgery, Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL, United States of America
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Vascular Section, Surgery Service Line, Palo Alto Veterans Affairs Medical Center, Palo Alto, CA, United States of America
| | - L Erin Norman
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
| | - Sherene Sharath
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Alexandra Scrymgeour
- Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, United States of America
| | - Jade Ollison
- Department of Surgery, State University of New York (SUNY) Downstate Health Sciences University, VA New York Harbor Healthcare System, Brooklyn, NY 11203, United States of America
| | - Lawrence A Calais
- Cooperative Studies Program Site Monitoring, Auditing, and Resource Team (SMART), Albuquerque, NM, United States of America
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Perry Point, MD, United States of America
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The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial. Pediatr Crit Care Med 2023; 24:84-92. [PMID: 36661416 DOI: 10.1097/pcc.0000000000003128] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Guidelines recommend against RBC transfusion in hemodynamically stable (HDS) children without cardiac disease, if hemoglobin is greater than or equal to 7 g/dL. We sought to assess the clinical and economic impact of compliance with RBC transfusion guidelines. DESIGN A nonprespecified secondary analysis of noncardiac, HDS patients in the randomized trial Age of Blood in Children (NCT01977547) in PICUs. Costs analyzed included ICU stay and physician fees. Stabilized inverse propensity for treatment weighting was used to create a cohort balanced with respect to potential confounding variables. Weighted regression models were fit to evaluate outcomes based on guideline compliance. SETTING Fifty international tertiary care centers. PATIENTS Critically ill children 3 days to 16 years old transfused RBCs at less than or equal to 7 days of ICU admission. Six-hundred eighty-seven subjects who met eligibility criteria were included in the analysis. INTERVENTIONS Initial RBC transfusions administered when hemoglobin was less than 7 g/dL were considered "compliant" or "non-compliant" if hemoglobin was greater than or equal to 7 g/dL. MEASUREMENTS AND MAIN RESULTS Frequency of new or progressive multiple organ system dysfunction (NPMODS), ICU survival, and associated costs. The hypothesis was formulated after data collection but exposure groups were masked until completion of planned analyses. Forty-nine percent of patients (338/687) received a noncompliant initial transfusion. Weighted cohorts were balanced with respect to confounding variables (absolute standardized differences < 0.1). No differences were noted in NPMODS frequency (relative risk, 0.86; 95% CI, 0.61-1.22; p = 0.4). Patients receiving compliant transfusions had more ICU-free days (mean difference, 1.73; 95% CI, 0.57-2.88; p = 0.003). Compliance reduced mean costs in ICU by $38,845 U.S. dollars per patient (95% CI, $65,048-$12,641). CONCLUSIONS Deferring transfusion until hemoglobin is less than 7 g/dL is not associated with increased organ dysfunction in this population but is independently associated with increased likelihood of live ICU discharge and lower ICU costs.
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Jadwin DF, Fenderson PG, Friedman MT, Jenkins I, Shander A, Waters JH, Friedman A, Tesoriero E, Refaai MA, Shih AW, Awan T, Ngo AL, Perez JA, Reynolds JD. Determination of Unnecessary Blood Transfusion by Comprehensive 15-Hospital Record Review. Jt Comm J Qual Patient Saf 2023; 49:42-52. [PMID: 36494267 DOI: 10.1016/j.jcjq.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Although unnecessary blood component transfusions are costly and pose substantial patient risks, the extent of unnecessary blood use in a community hospital setting has not been systematically measured. METHODS A 15-hospital observational analysis was performed using comprehensive retrospective review. Approximately 100 encounters (x¯ = 103.9, standard deviation [SD] ± 7.6) per hospital (6,696 total component transfusion events) were reviewed between 2012 and 2018. Review was performed by two medical directors. Findings were supported by blind intra- and inter-reviewer double review and blind external review by 10 independent reviewers. RESULTS Patients received an average of 4.3 (± 1.3) units. Only 8.2% (± 6.7) of patient encounters did not receive unnecessary units. Fifty-five percent (54.6% ± 13.5) could have been managed without at least one component type, while 44.6% (± 14.9) could have been managed completely without transfusion. Forty-five percent (45.4% ± 17.0) of red blood cell, 54.9% (± 19.3) of plasma-cryoprecipitate, and 38.0% (± 15.6) of plateletpheresis encounters could likely have been managed without transfusion. Between 2,713 units (40.5%) and 3,306 units (49.4%) were likely unnecessary. In patients who could have been managed without transfusion of at least one component type, unnecessary blood use was associated with a 0.38 (± 0.11)-day increase in length of hospital stay for each additional unnecessary unit received (p < 0.001). CONCLUSION Substantial unnecessary blood use was identified, all of which was unrecognized by hospitals prior to review. Unnecessary blood use was attributed to overreliance on laboratory transfusion criteria and failure to follow common blood management principles, which resulted in potential harm to patients and avoidable cost.
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ONTraC: A 20-Year History of a Successfully Coordinated Provincewide Patient Blood Management Program: Lessons Learned and Goals Achieved. Anesth Analg 2022; 135:448-458. [PMID: 35977355 DOI: 10.1213/ane.0000000000006065] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Our understanding of the risks associated with perioperative anemia and transfusion, in terms of increased morbidity and mortality, has evolved over the past 2 decades. By contrast, our understanding of the potential mechanisms of injury and optimal treatment strategies remains incomplete. As such, the important role of effective patient blood management (PBM) programs, which address both the effective treatment of anemia and minimizes the need for red blood cell (RBC) transfusion, is of central importance to optimizing patient care and improving patient outcomes. We report on important clinical outcomes of the Ontario Transfusion Coordinator (ONTraC Program), a network of 25 hospital sites, working in coordination over the past 20 years. Transfusion nurse coordinators were assigned to apply multimodal best practice in PBM (including recommended changes in surgical approach; diagnosis, assessment, and treatment of anemia; and adherence to more restrictive RBC transfusion thresholds). Data were collected on various clinical parameters. We further described lessons learned and difficulties encountered in this multisite PBM initiative. A significant reduction in RBC transfusions was observed for numerous indexed surgeries. For example, RBC transfusion rates for knee arthroplasty decreased from 25% in 2002 to 0.4% in 2020. For coronary artery bypass graft (CABG) surgery, transfusion rates decreased from 60% in 2002 to 27% in 2020. We also observed a decrease in RBC units utilized per transfused patient for knee (2.1 ± 0.5 [2002] vs 1.0 ± 0.6 [2020] units per patient) and CABG surgery (3.3 ± 0.6 [2002] vs 2.3 ± 1.9 [2020] units per patient). These reductions were associated with favorable clinical outcomes, including reduced length of hospital stay (P = .00003) and a reduced rate of perioperative infections (P < .001) for nontransfused versus transfused patients. These advances have been achieved with estimated savings in the tens of millions of dollars annually. Our experience and data support the hypothesis that instituting an integrated network of transfusion nurse coordinators can provide an effective provincewide PBM program, reduce RBC transfusions, improve some patient outcomes, and reduce health care costs, as an example of a "win-win-win" medical program.
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Núñez JH, Bosch-García D, Escudero B, Martínez-Peñas J, Omiste I, Alonzo-González F, García de Frutos A, Ramírez M. Is routine blood typing and screening necessary for degenerative cervical spine surgery patients in specialty surgical hospitals? Transfusion 2022; 62:1199-1207. [PMID: 35460279 DOI: 10.1111/trf.16889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/22/2022] [Accepted: 03/27/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Blood loss warranting transfusion is a relatively rare requirement for degenerative cervical spine surgery. Despite this rarity, pretransfusion testing (blood typing, screening, and cross-matching) has become routine in most parts of the world. We sought to determine if such routine testing is necessary for patients who undergo degenerative cervical spine surgery patients in specialty surgical hospitals by (1) measuring the current rate of intraoperative transfusions in degenerative cervical spine surgery and (2) identifying risk factors for transfusions. STUDY METHODS Retrospective review was performed on patients who underwent degenerative cervical spine surgery in two institutions. Demographic and baseline clinical and laboratory data were collected and analyzed to identify predictors of transfusion. Bivariate and multivariate logistic regression analysis was performed to identify perioperative transfusion risk factors. RESULTS Overall transfusion rate was 1.9% (7/372), with no emergent transfusions. Decreases between preoperative and postoperative hemoglobin and hematocrit were 1.4 (SD 1.1) g/dL and 7.2 (SD 4.1) %, respectively. Multivariate logistic regression identified preoperative Hgb lower than 12 gr/dl (OR 27.62; 95% CI 4.31-176.96; p < 0.001) as significant independent transfusion risk factor. The receiver operating characteristic (ROC) curve for the model showed a very good discriminatory power with an area under the curve of 0.91. DISCUSSION Our study suggests that pretransfusion testing for all patients undergoing degenerative cervical spine surgery is unnecessary. We recommend that only patients with preoperative Hgb lower than 12 gr/dl would routinely need pretransfusion testing.
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Affiliation(s)
- Jorge H Núñez
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - David Bosch-García
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Berta Escudero
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Judith Martínez-Peñas
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Irene Omiste
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Mutua Terrasa, Barcelona, Spain
| | - Francisco Alonzo-González
- Spine Unit. Department of Orthopedic Surgery, Hospital General de Accidentes Ceibal Del Instituto Guatemalteco de Seguridad Social, Sacatepéquez, Guatemala
| | - Ana García de Frutos
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Vall d' Hebron, Barcelona, Spain
| | - Manuel Ramírez
- Spine Unit. Department of Orthopedic Surgery, University Hospital of Vall d' Hebron, Barcelona, Spain
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BASILGAN S, POLAT A, BUYUKKUSCU MO, DİNÇEL YM, YAĞMURLU F. Tranexamic acid in knee arthroplasty: the effect of preoperative intravenous administration of together with postoperative intravenous maintenance and periarticular administration on bleeding, transfusion, and hospitalization time – a retrospective cohort study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1024881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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12
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Chen L, Zhao C, Luo Y, Wang Q, Li Q, Kang P. Different Doses of Intravenous Tranexamic Acid in Revision Total Knee Arthroplasty: A Retrospective Study. J Knee Surg 2021; 36:652-657. [PMID: 34952545 DOI: 10.1055/s-0041-1740585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE This article assessed the efficacy and safety of different doses of intravenous tranexamic acid (TXA) in revision total knee arthroplasty (TKA). METHODS We retrospectively identified 122 patients in our institution who underwent revision TKA with a history of perioperative intravenous TXA utilization. According to the sum of intravenous TXA documented, all patients were divided into three groups: 1 g intravenous TXA, 2 g intravenous TXA, and equal or greater than 3 g intravenous TXA. The primary outcomes included total blood loss (TBL), hidden blood loss (HBL), transfusion rate, and the incidence of symptomatic venous thromboembolism among the three groups. A correlation analysis was conducted to analyze the correlation between the dose of TXA and the blood loss. RESULTS In total, there was no significance difference in TBL and revised HBL (rHBL) between the first two groups (1 g/dL for intravenous TXA, 2 g/dL for intravenous TXA; p = 0.486; p = 0.525). Equal or greater than 3 g intravenous TXA (≥3 g/dL for intravenous TXA) reached a significant reduction in TBL, rHBL, and length of stay compared with the first two groups (p = 0.01; p = 0.01; p = 0.01). The rate of transfusion between the three groups did not differ significantly (p = 0.21). Due to the limitations in sample size, only one symptomatic venous thromboembolism was reported in the 1 g intravenous TXA group. CONCLUSION Applying the dose of intravenous TXA equal or greater than 3 g in revision TKA might further reduce the blood loss and shorten the length of stay.
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Affiliation(s)
- Liyile Chen
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chenchen Zhao
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yue Luo
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiuru Wang
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qianhao Li
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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13
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Osemwengie D, Lagerberg JW, Vlaar R, Gouwerok E, Go M, Nierich AP, de Korte D. Recovery of platelet-rich red blood cells and acquisition of convalescent plasma with a novel gravity-driven blood separation device. Transfus Med 2021; 32:53-63. [PMID: 34761451 PMCID: PMC9298860 DOI: 10.1111/tme.12830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/15/2021] [Accepted: 10/10/2021] [Indexed: 12/26/2022]
Abstract
Objectives Our objectives were to determine the separation characteristics and blood product quality of a gravity‐driven microfiltration blood separation system (HemoClear, The Netherlands). Background A range of centrifugal blood separation devices, including intraoperative cell salvage devices (cell savers) and apheresis machines, are available to assist in preparing both allogenic and autologous blood products. These devices are expensive to operate and require extensive training. Methods and Materials Nine whole blood units were collected under standard conditions and analysed for haematological parameters, thromboelastographic properties, platelet morphology and activation, and red blood cell (RBC) deformability and morphology. Three whole blood units were separated by means of the HemoClear device, into a liquid and cellular component. The cellular component was diluted with SAGM and cold stored for 14 days. To simulate cell salvage six whole blood units were diluted with isotonic saline, followed by multiple HemoClear separation rounds. Results The recovery of both RBCs (100 ± 1.6%) and white blood cells (99 ± 4.5%) after undiluted filtration were very high, while platelet recovery was high (83 ± 3.0%). During the filtration, and cold storage after filtration storage both the non‐deformable RBC fraction and the RBC maximum elongation remained stable. Parameters of thromboelastography indicated that platelets remain functional after filtration and after 7 days of cold storage. In the cell salvage simulation the total protein load in the cellular fraction was reduced by 65 ± 4.1% after one washing round and 84 ± 1.9% after two consecutive washing rounds. Conclusion The novel blood filter studied effectively separates whole blood into diluted plasma and platelet‐rich RBCs. Moreover, the device effectively washed diluted whole blood, driving over 80% of proteins to the liquid component.
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Affiliation(s)
| | - Johan W Lagerberg
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Richard Vlaar
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Gouwerok
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mya Go
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arno P Nierich
- Clinical Department, HemoClear BV, Zwolle, The Netherlands.,Department of Anesthesiology and Intensive Care, Isala, Zwolle, The Netherlands
| | - Dirk de Korte
- Department of Blood Cell Research, Sanquin Research, Amsterdam, The Netherlands.,Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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14
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Winter A, Zacharowski K, Meybohm P, Schnitzbauer A, Ruf P, Kellermann C, Lindhofer H. Removal of EpCAM-positive tumor cells from blood collected during major oncological surgery using the Catuvab device- a pilot study. BMC Anesthesiol 2021; 21:261. [PMID: 34715784 PMCID: PMC8555247 DOI: 10.1186/s12871-021-01479-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Intraoperative blood salvage (IBS) is regarded as an alternative to allogeneic blood transfusion excluding the risks associated with allogeneic blood. Currently, IBS is generally avoided in tumor surgeries due to concern for potential metastasis caused by residual tumor cells in the erythrocyte concentrate. METHODS The feasibility, efficacy and safety aspects of the new developed Catuvab procedure using the bispecific trifunctional antibody Catumaxomab was investigated in an ex-vivo pilot study in order to remove residual EpCAM positive tumor cells from the autologous erythrocyte concentrates (EC) from various cancer patients, generated by a IBS device. RESULTS Tumor cells in intraoperative blood were detected in 10 of 16 patient samples in the range of 69-2.6 × 105 but no residual malignant cells in the final erythrocyte concentrates after Catuvab procedure. IL-6 and IL-8 as pro-inflammatory cytokines released during surgery, were lowered in mean 28-fold and 52-fold during the Catuvab procedure, respectively, whereas Catumaxomab antibody was detected in 8 of 16 of the final EC products at a considerable decreased and uncritical residual amount (37 ng in mean). CONCLUSION The preliminary study results indicate efficacy and feasibility of the new medical device Catuvab allowing potentially the reinfusion of autologous erythrocyte concentrates (EC) produced by IBS device during oncological high blood loss surgery. An open-label, multicenter clinical study on the removal of EpCAM-positive tumor cells from blood collected during tumor surgery using the Catuvab device is initiated to validate these encouraging results.
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Affiliation(s)
- Andreas Winter
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, 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
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
- Department of Anaesthesiology, University Hospital Wuerzburg, Oberdürrbacher Straße 6, 97080, Wuerzburg, Germany
| | - Andreas Schnitzbauer
- Department of General and Visceral Surgery, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Peter Ruf
- Trion Research GmbH, Am Klopferspitz 19, 82152, Martinsried, Germany
| | | | - Horst Lindhofer
- Trion Research GmbH, Am Klopferspitz 19, 82152, Martinsried, Germany
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15
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Anesthesia preoperative clinics: redefining the value proposition. Int Anesthesiol Clin 2021; 59:59-72. [PMID: 34433183 DOI: 10.1097/aia.0000000000000341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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16
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Justo I, Marcacuzco A, Caso O, García-Conde M, Manrique A, Calvo J, García-Sesma A, Cambra F, García A, Cortés M, Loinaz C, Jiménez-Romero C. Hemoderivative Transfusion in Liver Transplantation: Comparison Between Recipients of Grafts From Brain Death Donors and Recipients of Uncontrolled Donors After Circulatory Death. Transplant Proc 2021; 53:2298-2304. [PMID: 34419255 DOI: 10.1016/j.transproceed.2021.07.009] [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: 03/17/2021] [Revised: 06/07/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Intraoperative bleeding during liver transplantation has been correlated with a higher risk of morbidity and mortality and decrease in patient and graft survival. MATERIALS AND METHODS Between January 2006 and December 2016 we performed 783 orthotopic liver transplants. After applying exclusion criteria, we found liver grafts from donors after circulatory death (DCD, group A) were used in 69 patients and liver grafts from donors after brain death (group B) were used in 265 patients. RESULTS No difference was found in terms of sex, body mass index, Model for End-Stage Liver Disease score, indication for transplantation, intensive care unit stay, and Child-Pugh score. The mean transfusion of hemoderivates was as follows: red blood cell 9 (0-28) units in group A vs 6 (0-20) units in group B (P = .004) and fresh frozen plasma 10 (0-29) units in group A vs 9.5 (0-23) in group B (P = .000). The only 2 factors related to massive blood transfusion (>6 units of red blood cell) were uncontrolled DCD condition (odds ratio = 2.38; 95% confidence interval, 1.32-4.31; P = .004), and higher Model for End-Stage Liver Disease score (odds ratio = 2.63; 95% confidence interval, 1.53-4.55; P = .001). Survival at 1, 3, and 5 years was 81.3%, 70.2%, and 68.9% in group A vs 89%, 83.7%, and 78% in group B (P = .070). CONCLUSION The use of liver grafts from DCDs is associated with increased necessity of transfusion of hemoderivates in comparison with the use of liver grafts from donors after brain death.
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Affiliation(s)
- Iago Justo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain.
| | - Alberto Marcacuzco
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Oscar Caso
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - María García-Conde
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alejandro Manrique
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Jorge Calvo
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Alvaro García-Sesma
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Félix Cambra
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Adolfo García
- Department of Anesthesiology, Perioperative and Pain Medicine, "Doce de Octubre" University Hospital, Madrid, Spain
| | - Manuel Cortés
- Department of Anesthesiology, Perioperative and Pain Medicine, "Doce de Octubre" University Hospital, Madrid, Spain
| | - Carmelo Loinaz
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
| | - Carlos Jiménez-Romero
- Unit of HPB Surgery and Abdominal Organ Transplantation, Department of General Surgery, "Doce de Octubre" University Hospital, Instituto de Investigación (Imas12), Faculty of Medicine, Complutense University, Madrid, Spain
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17
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Rambiritch V, Verburgh E, Louw VJ. Patient blood management and blood conservation - Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond. Transfus Apher Sci 2021; 60:103207. [PMID: 34353706 PMCID: PMC10399285 DOI: 10.1016/j.transci.2021.103207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.
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Affiliation(s)
| | - Estelle Verburgh
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Vernon Johan Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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18
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Hensley NB, Mazzeffi MA. Pro-Con Debate: Fibrinogen Concentrate or Cryoprecipitate for Treatment of Acquired Hypofibrinogenemia in Cardiac Surgical Patients. Anesth Analg 2021; 133:19-28. [PMID: 34127586 DOI: 10.1213/ane.0000000000005513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cryoprecipitate has been the gold standard for treating acquired hypofibrinogenemia in cardiac surgery for nearly 50 years. More recently, fibrinogen concentrate has been used off-label in the United States and is the standard in European countries and Canada to treat the acquired hypofibrinogenemia during cardiac surgery. Fibrinogen concentrate has multiple potential advantages including rapid reconstitution, greater dose predictability, viral inactivation during processing, and reduced transfusion-related adverse events. However, because fibrinogen concentrate lacks the other components contained in the cryoprecipitate, it may not be the "ideal" product for replacing fibrinogen in all cardiac surgical patients, particularly those with longer cardiopulmonary bypass duration. In this Pro-Con commentary article, we discuss the advantages and disadvantages of using fibrinogen concentrate and cryoprecipitate to treat acquired hypofibrinogenemia in cardiac surgical patients.
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Affiliation(s)
- Nadia B Hensley
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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19
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Roets M, Sturgess DJ, Obeysekera MP, Tran TV, Wyssusek KH, Punnasseril JEJ, da Silva D, van Zundert A, Perros AJ, Tung JP, Flower RLP, Dean MM. Intraoperative Cell Salvage as an Alternative to Allogeneic (Donated) Blood Transfusion: A Prospective Observational Evaluation of the Immune Response Profile. Cell Transplant 2021; 29:963689720966265. [PMID: 33076681 PMCID: PMC7784599 DOI: 10.1177/0963689720966265] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Allogeneic blood transfusion (ABT) is associated with transfusion-related immune modulation (TRIM) and subsequent poorer patient outcomes including perioperative infection, multiple organ failure, and mortality. The precise mechanism(s) underlying TRIM remain largely unknown. During intraoperative cell salvage (ICS) a patient's own (autologous) blood is collected, anticoagulated, processed, and reinfused. One impediment to understanding the influence of the immune system on transfusion-related adverse outcomes has been the inability to characterize immune profile changes induced by blood transfusion, including ICS. Dendritic cells and monocytes play a central role in regulation of immune responses, and dysfunction may contribute to adverse outcomes. During a prospective observational study (n = 19), an in vitro model was used to assess dendritic cell and monocyte immune responses and the overall immune response following ABT or ICS exposure. Exposure to both ABT and ICS suppressed dendritic cell and monocyte function. This suppression was, however, significantly less marked following ICS. ICS presented an improved immune competence. This assessment of immune competence through the study of intracellular cytokine production, co-stimulatory and adhesion molecules expressed on dendritic cells and monocytes, and modulation of the overall leukocyte response may predict a reduction of adverse outcomes ( i.e., infection) following ICS.
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Affiliation(s)
- Michelle Roets
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - David John Sturgess
- Faculty of Medicine, the University of Queensland, Queensland, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | | | - Thu Vinh Tran
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | - Kerstin Hildegard Wyssusek
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - Diana da Silva
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | - Andre van Zundert
- Department of Anaesthesia, the Royal Brisbane and Women's Hospital, Herston, Queensland, Australia.,Faculty of Medicine, the University of Queensland, Queensland, Australia
| | | | - John Paul Tung
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia
| | | | - Melinda Margaret Dean
- Australian Red Cross Lifeblood, Kelvin Grove, Queensland, Australia.,School of Health and Sport Sciences, University of the Sunshine Coast, Petrie, Queensland, Australia
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20
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Qi Q, Qian X, Zhu X, Cai J, Xia R, Zhang Q. Perioperative Transfusion is Related to the Length of Hospital Stays in Primary Liver Cancer Patients. Cancer Manag Res 2021; 13:4947-4954. [PMID: 34188547 PMCID: PMC8233480 DOI: 10.2147/cmar.s296022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Blood loss may be corrected with red blood cell transfusion, but may ultimately contribute to negative impacts. This study was a retrospective analysis to assess the impact of perioperative blood transfusion on hospital stay days in liver cancer patients. Methods We retrospectively examined data from patients with primary liver cancer who underwent curative resection. Patients were divided into perioperative blood transfusion (PBT) and non-PBT groups. Data were given as means and SDs for continuous variables and as counts and percentage for categorical variables. The correlation between blood transfusion and hospital stay days was analyzed by Fisher's exact test. Multivariable logistic regression analyses were used to identify independent predictors of length of hospital stays. Results Totally 206/1031 patients (20.3%) were given perioperative transfusion. The mean length of hospital stay was 17.8 days in PBT and 13.9 days in non-PBT groups. Our multivariable logistic regression showed transfusion, total bilirubin, indirect bilirubin, and the ratio of albumin to bilirubin were all indicators of the length of hospital stay days. Perioperative transfusion was also associated with prolonged length of hospital stays (95% CI: 0.395-0.811, p = 0.002). Transfusion also affected intrinsic coagulation factors (activated partial thromboplastin time, fibrinogen, platelet), inflammatory index (neutrocyte to lymphocyte ratio, monocyte), albumin and bilirubin levels. Conclusion Perioperative transfusion of blood was associated with a significantly increased length of hospital stays probably via changing intrinsic coagulation and inflammatory factors and bilirubin levels in plasma.
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Affiliation(s)
- Qi Qi
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Xuemeng Qian
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Xinfang Zhu
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Jiajing Cai
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Rong Xia
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
| | - Qi Zhang
- Department of Transfusion Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, People's Republic of China
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21
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Sood SB, Walker LA, Ramanujam R, Hardison D, Andrews J, Smith AH, Bridges BC. The Use of Antifactor Xa Assays in a Comprehensive Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol is Associated with Increased Survival and Significant Blood Product Cost-Savings. J Pediatr Intensive Care 2021; 11:341-348. [DOI: 10.1055/s-0041-1726455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/17/2021] [Indexed: 10/21/2022] Open
Abstract
AbstractWe augmented our standard extracorporeal membrane oxygenation laboratory protocol to include antifactor Xa assays, thromboelastography, and antithrombin measurements. We performed a retrospective chart review to determine outcomes for patients placed on extracorporeal membrane oxygenation (ECMO) prior to and after the initiation of our anticoagulation laboratory protocol. A total of 663 consecutive ECMO runs were evaluated from January 1, 2007 to June 30, 2018. Of these patients, 252 were on ECMO prior to initiation of the anticoagulation laboratory protocol on September 1, 2011, and 411 patients were on ECMO after initiation of the protocol. There were no major changes to our extracorporeal membrane oxygenation circuit or changes to our transfusion threshold during this continuous study period. Transfusion utilization data revealed statistically significant decreases in almost all blood components, and a savings in blood component inflation-adjusted acquisition costs of 31% bringing total blood product cost-savings to $309,905 per year. In addition, there was an increase in survival to hospital discharge from 45 to 56% associated with the initiation of the protocol (p = 0.004). Our data indicate that implementation of a standardized ECMO anticoagulation protocol, which titrates unfractionated heparin infusions based on antifactor Xa assays, is associated with reduced blood product utilization, significant blood product cost savings, and increased patient survival. Future prospective evaluation is needed to establish an antifactor Xa assay-driven ECMO anticoagulation strategy as both clinically superior and cost-effective.
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Affiliation(s)
- Shawn B. Sood
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States
| | - Louisa Anne Walker
- Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States
| | - Rangaraj Ramanujam
- Owen Graduate School of Management, Vanderbilt University, Tennessee, United States
| | - Daphne Hardison
- Monroe Carell Jr. Children's Hospital, Vanderbilt University, Tennessee, United States
| | - Jennifer Andrews
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States
- Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Tennessee, United States
| | - Andrew H. Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States
- Thomas P. Graham Jr. Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University School of Medicine, Tennessee, United States
| | - Brian C. Bridges
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Tennessee, United States
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22
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Warner MA, Goobie SM. Preoperative Anemia Screening and Treatment: Is It Worth the Return on Investment? Anesth Analg 2021; 132:341-343. [PMID: 33449557 DOI: 10.1213/ane.0000000000005313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew A Warner
- From the Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care & Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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23
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Braester A, Akria L, Yakir O, Shelev L, Barhoum M. Blood Myths and Ethnic-Cultural Background as Impediments in Patient Blood Management Education. JOURNAL OF RELIGION AND HEALTH 2020; 59:2918-2927. [PMID: 32285248 DOI: 10.1007/s10943-020-01015-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
A significant percentage of red blood cell transfusions (RBCTs) are the result of overuse. The implementation of patient blood management (PBM) is challenging. We examined whether blood-linked myths and ethnic-cultural background factors are impediments to PBM education and implementation. Data about the influence of blood myths and diverse ethnic-cultural communities were collected from physicians in our medical center via an anonymous questionnaire which contained questions about myths as well as knowledge of blood transfusion. No statistical differences were found between ethnic and cultural groups regarding blood myths and cultural background influence, although the Jewish participants were less influenced by myths than their Arab colleagues. The influence of blood myths concerning the decision to transfuse exists in both studied ethnic groups. With regard to the association between knowledge and myths influence, we found that the greater the knowledge of the participant, the lower was the myths influence. In a significant proportion of our physician cohort, blood myths and cultural-ethnic status influenced their approach toward RBCT and can be considered an impediment in PBM education. A high knowledge level is associated with less myths influence. The myths and cultural-ethnic background may play a role in PBM education.
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Affiliation(s)
- Andrei Braester
- Galilee Medical Center, Nahariya, Israel.
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.
- Hematology Institute, Galilee Medical Center, POB 21, 22100, Nahariya, Israel.
| | - Luiza Akria
- Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
| | - Orly Yakir
- Galilee Medical Center, Nahariya, Israel
| | | | - Masad Barhoum
- Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel
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24
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Gammon RR, Rosenbaum L, Cooke R, Friedman M, Rockwood L, Nichols T, Vossoughi S. Maintaining adequate donations and a sustainable blood supply: Lessons learned. Transfusion 2020; 61:294-302. [PMID: 33206404 PMCID: PMC7753343 DOI: 10.1111/trf.16145] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/10/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023]
Abstract
Background The availability of a safe blood supply is a key component of transfusion medicine. A decade of decreased blood use, decreased payment for products, and a dwindling donor base have placed the sustainability of the US blood supply at risk. Study Design and Methods A literature review was performed for blood center (BC) and hospital disaster management, chronically transfusion‐dependent diseases, and appropriate use of group O‐negative red blood cells (RBCs), and the Choosing Wisely campaign. The aim was to identify current practice and to make recommendations for BC and hospital actions. Results While BCs are better prepared to handle disasters than after the 9/11 attacks, messaging to the public remains difficult, as donors often do not realize that blood transfused during a disaster was likely collected before the event. BCs and transfusion services should participate in drafting disaster response plans. Hospitals should maintain inventories adequate for patients in the event supply is disrupted. Providing specialty products for transfusion‐dependent patients can strain collections, lead to increased use of group O RBCs, and create logistical inventory challenges for hospitals. The AABB Choosing Wisely initiative addresses overuse of blood components to optimally use this precious resource. Group O‐negative RBCs should be transfused only to patients who truly need them. Conclusions Collecting and maintaining a blood supply robust enough to handle disasters and transfusion‐dependent patients in need of specialty products is challenging. Collaboration of all parties should help to optimize resources, ensure appropriate collections, improve patient care, and ultimately result in a robust, sustainable blood supply.
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Affiliation(s)
- Richard R Gammon
- Scientific Medical and Technical Direction, OneBlood, Inc., Orlando, Florida, USA
| | | | - Rhonda Cooke
- Missouri Baptist Medical Center, St. Louis, Missouri, USA
| | - Mark Friedman
- Transfusion Service, NYU Winthrop Hospital, Mineola, New York, USA
| | - Linda Rockwood
- New England Baptist Hospital, Boston, Massachusetts, USA
| | - Tracie Nichols
- Blood Bank, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Sarah Vossoughi
- Department of Pathology & Cell Biology, Columbia University, New York, New York, USA
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Al-Riyami AZ, Louw VJ, Indrikovs AJ, Nedelcu E, Bakhtary S, Eichbaum QG, Smit Sibinga CT. Global survey of transfusion medicine curricula in medical schools: Challenges and opportunities. Transfusion 2020; 61:617-626. [PMID: 33091965 PMCID: PMC7894143 DOI: 10.1111/trf.16147] [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: 07/02/2020] [Revised: 09/13/2020] [Accepted: 09/20/2020] [Indexed: 01/28/2023]
Abstract
BACKGROUND Physician's knowledge in transfusion medicine (TM) is critical for patient safety. Therefore, ensuring that medical schools provide adequate education in TM is important. The aim of this study was to assess the status of TM education at a global level. STUDY DESIGN AND METHODS A comprehensive anonymous survey to assess TM education in existing medical school curricula was developed. The survey was distributed to deans and educational leads of medical schools in a range of low-, medium-, high-, and very high-human development index (HDI) countries. It included 20 questions designed to assess specific domains including structure of TM curriculum and teaching faculty. RESULTS The response rate was 53%. The majority of responding schools from very-high-HDI countries offered a 6-year curriculum after high school or a 4-year curriculum after college education, whereas most schools from medium-HDI countries offered a 5-year medical curriculum. A formal teaching program was available in only 42% of these schools in contrast to 94% of medical schools from very high-HDI. Overall, 25% of all medical schools did not offer structured TM teaching. When offered, most TM teaching was mandatory (95%) and integrated within the third and fourth year of medical school. Formal assessment of TM knowledge was done in 72% of all responding medical schools. More than half of the deans considered the TM education in their medical schools as inadequate. CONCLUSION Despite its limitations, the current survey highlights significant gaps and opportunities of TM education at a global scale.
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Affiliation(s)
- Arwa Z Al-Riyami
- Department of Haematology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Vernon J Louw
- Division of Clinical Haematology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Alexander J Indrikovs
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Elena Nedelcu
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Sara Bakhtary
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of California San Francisco, San Francisco, California, USA
| | - Quentin G Eichbaum
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Retrospective Analysis of Thromboelastography-Directed Transfusion in Isolated CABG: Impact on Blood Product Use, Cost, and Outcomes. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:103-111. [PMID: 32669736 DOI: 10.1182/ject-2000007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/30/2020] [Indexed: 11/20/2022]
Abstract
Cardiac surgeries account for approximately 20% of blood use in the United States. Allogeneic transfusion has been associated with increased risk of morbidity and mortality, further justifying the need to reduce blood use. This study aimed at determining whether a point-of-care coagulation test, thromboelastography (TEG), impacted blood product administration and outcomes. Patients undergoing isolated coronary artery bypass grafting (CABG) were retrospectively reviewed before the use of TEG (2008-2009) (n = 640) and after implementation (2011-2012) (n = 458). Blood product use was compared between time frames. Logistic regression and generalized linear models were created to estimate the impact on outcomes including the reoperation rate, mortality, and cost. The mean use of each blood product was significantly reduced in the perioperative period. Overall blood product use was decreased by over 40%. Mediastinal re-exploration of bleeding was significantly reduced with TEG (4.8 vs. 1.5%). Six-month mortality was not impacted in this cohort nor was the readmission rate or hospital length of stay. However, blood cost and patient charges were significantly lower after TEG was introduced. The use of TEG to guide the administration of blood products during isolated CABG significantly affected the amounts and types of products given intra- and perioperatively. This resulted in less chest tube drainage, fewer returns to the operating room, and more accurate diagnosis of coagulopathic status. Cost savings to the patient and institution were appreciated as a consequence of these improved clinical outcomes.
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Salehi SH, Daniali M, Motaghi P, Momeni M. The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial. Burns 2020; 47:1038-1044. [PMID: 34045114 DOI: 10.1016/j.burns.2020.06.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 06/06/2020] [Accepted: 06/29/2020] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. MATERIAL AND METHODS Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. RESULT The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. CONCLUSION Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. CLINICAL TRIAL REGISTRATION REFERENCE IRCT20190209042660N1.
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Affiliation(s)
- Seyed Hamid Salehi
- Department of General Surgery, Motahari Burn Research Center, Iran University of Medical Sciences, Tehran, Iran.
| | - Maziar Daniali
- Department of General Surgery, Rasoul-e-Akram General Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Paniz Motaghi
- Department of General Surgery, Rasoul-e-Akram General Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Mahnoush Momeni
- Department of General Surgery, Motahari Burn Research Center, Iran University of Medical Sciences, Tehran, Iran.
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Tan WS, Wang Y, Trinh QD, Preston MA, Kelly JD, Hrouda D, Kibel AS, Krasnow RE, Liu JJ, Chung BI, Chang SL, Mossanen M. Delayed blood transfusion is associated with mortality following radical cystectomy. Scand J Urol 2020; 54:290-296. [DOI: 10.1080/21681805.2020.1777195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Wei Shen Tan
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Division of Surgery & Interventional Science, University College London, London, UK
- Department of Urology, Northwick Park Hospital, London, UK
| | - Ye Wang
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mark A. Preston
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - John D. Kelly
- Division of Surgery & Interventional Science, University College London, London, UK
| | - David Hrouda
- Department of Urology, Imperial College Healthcare NHS Trust, London, UK
| | - Adam S. Kibel
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ross E. Krasnow
- Department of Urology, Med Star Washington Hospital Center, Washington, DC, USA
| | - Jen-Jane Liu
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Benjamin I. Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA, USA
| | - Steven L. Chang
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Matthew Mossanen
- Division of Urological Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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Migliorini F, Trivellas A, Eschweiler J, El Mansy Y, Mazzanti MC, Tingart M, Aretini P. Hospitalization length, surgical duration, and blood lost among the approaches for total hip arthroplasty: a Bayesian network meta-analysis. Musculoskelet Surg 2020; 104:257-266. [PMID: 32248344 DOI: 10.1007/s12306-020-00657-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/27/2020] [Indexed: 01/16/2023]
Abstract
Despite the numerous studies, there is no consensus concerning the best approach for total hip arthroplasty (THA), and debates are ongoing. The purpose of this study was to perform a Bayesian network meta-analysis (NMA) comparing several approaches for primary THA. The focus was on peri-operative outcomes: surgical duration, total estimated blood loss, and length of the hospitalization. This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. In October 2019, the main databases were accessed. All the clinical trials comparing two or more different approaches for primary THA were assessed. For the methodology quality assessment, the PEDro score was performed. The Software STATA MP was used for the statistical analyses. The NMA was performed through the routine for Bayesian hierarchical random-effects analysis with the inverse variance statistic method for continuous variables. Data from 4843 procedures was analysed. Between patient's demographic, good baseline comparability was found. The comparison total estimated blood loss detected statistically significant inconsistency (P = 0.01). The posterolateral approach reported the lowest value for the surgical duration. The test for overall inconsistency was statistically significant (P = 0.4). The posterolateral approach reported the shortest hospitalization length. The test for overall inconsistency was statistically significant (P = 0.9). The posterolateral approach reported shorter surgical duration and hospitalization length. Concerning the analysis of total estimated blood loss, no significant result was obtained. Data must be considered in the light of the limitations of the present study.
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Affiliation(s)
- F Migliorini
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - A Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Suite 755, Los Angeles, CA, 90095, USA
| | - J Eschweiler
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Y El Mansy
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.,Department of Orthopedics and Traumatology, University of Alexandria, Alexandria, Egypt
| | - M C Mazzanti
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini 13, 56017, Pisa, Italy
| | - M Tingart
- Department of Orthopaedics, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - P Aretini
- Fondazione Pisana per la Scienza, Via Ferruccio Giovannini 13, 56017, Pisa, Italy
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Hines JT, Petis SM, Amundson AW, Pagnano MW, Sierra RJ, Abdel MP. Intravenous Tranexamic Acid Safely and Effectively Reduces Transfusion Rates in Revision Total Knee Arthroplasties. J Bone Joint Surg Am 2020; 102:381-387. [PMID: 31977819 DOI: 10.2106/jbjs.19.00857] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The efficacy and safety of tranexamic acid (TXA) in primary total knee arthroplasty (TKA) have been well established. However, there have been limited data for revision TKAs. The primary aim was to assess the impact of intravenous TXA on transfusion rates and symptomatic venous thromboembolic events (VTEs) in a large revision TKA cohort with or without intravenous TXA utilization. METHODS A retrospective review of revision TKAs performed from 2005 to 2014 was performed, identifying 2,951 procedures (2,219 patients), in which TXA was utilized in 1,144 procedures (39%). The mean age was 65 years with 52% female patients in the TXA revision group and 67 years with 52% female patients in the non-TXA revision group. Transfusion rates and symptomatic VTEs were the primary outcomes assessed. Comparisons were performed between cohorts, utilizing a unique propensity model to mitigate bias, on the basis of TXA use and subsequently for aseptic or septic revision etiology. RESULTS Significant reductions in transfusion rates with use of TXA were identified in revision TKAs overall (13% compared with 39%; p < 0.001 [adjusted relative risk, 1.7]), including revisions for both aseptic etiology (6% with TXA compared with 28% without TXA; p < 0.001) and septic etiology (31% with TXA compared with 54% without TXA; p < 0.001). The risk of a postoperative symptomatic VTE was not significantly different (adjusted p = 0.63) with use of TXA at 11 events (1.0%) compared with 24 events (1.3%) in the non-TXA group). CONCLUSIONS Intravenous TXA significantly reduced transfusion rates in revision TKAs by approximately twofold, including cohorts revised for aseptic and septic etiologies. There was a very low rate of VTEs (1.2%) with no significant difference in the number of VTEs between groups after adjusting risk utilizing propensity modeling. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeremy T Hines
- Departments of Orthopedic Surgery (J.T.H., S.M.P., M.W.P., R.J.S., and M.P.A.) and Anesthesiology and Perioperative Medicine (A.W.A), Mayo Clinic, Rochester, Minnesota
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Kaserer A, Rössler J, Braun J, Farokhzad F, Pape H, Dutkowski P, Plass A, Horisberger T, Volbracht J, Manz MG, Spahn DR. Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs. Anaesthesia 2019; 74:1534-1541. [DOI: 10.1111/anae.14816] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 11/27/2022]
Affiliation(s)
- A. Kaserer
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Rössler
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Braun
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute University of Zurich Switzerland
| | - F. Farokhzad
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - H.‐C. Pape
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - P. Dutkowski
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - A. Plass
- Department of Surgery University of Zurich and University Hospital Zurich Switzerland
| | - T. Horisberger
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
| | - J. Volbracht
- Medical Directorate University of Zurich and University Hospital Zurich Switzerland
| | - M. G. Manz
- Department of Medical Oncology and Haematology University of Zurich and University Hospital Zurich Switzerland
| | - D. R. Spahn
- Institute of Anaesthesiology University of Zurich and University Hospital Zurich Switzerland
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Abstract
To improve quality and outcomes, a preoperative anemia clinic (PAC) was established to screen, evaluate, and manage preoperative anemia. A retrospective review of primary and revision hip and knee arthroplasty patients from August 2013 to September 2017 was conducted. Patients at "high risk" for transfusion were referred to PAC for treatment with iron, erythropoietin, or both based on anemia type. Preoperative anemia clinic referred patients were compared with a 1:3 historic propensity-matched control set of patients to help determine impact of PAC. Forty PAC patients were compared with 120 control patients. Among PAC patients, 26 (63.41%) received iron only, 3 (7.32%) received erythropoietin (EPO) only, and 12 (29.27%) received both. Preoperative hemoglobin significantly increased in the treatment group (median [interquartile range] 10.9 g/dl [10.3-11.2] vs. 12.0 g/dl [11.2-12.7]; p < .001). Four PAC patients (10.00%) received red blood cell transfusions compared with 29 (24.17%) from matched controls (p = .055). In addition, the PAC cohort had higher postoperative nadir hemoglobin levels (mean [SD] 9.7 g/dl [1.31] vs. 8.7 g/dl [1.25]; p < .001). High-risk patients appropriately treated with iron and/or EPO before surgery demonstrate a significant increase in preoperative hemoglobin, trend toward decrease perioperative transfusion, and increased hemoglobin levels postoperatively compared with matched controls.
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Baker L, Park L, Gilbert R, Martel A, Ahn H, Davies A, McIsaac DI, Saidenberg E, Tinmouth A, Fergusson DA, Martel G. Guidelines on the intraoperative transfusion of red blood cells: a protocol for systematic review. BMJ Open 2019; 9:e029684. [PMID: 31213453 PMCID: PMC6586075 DOI: 10.1136/bmjopen-2019-029684] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/22/2019] [Accepted: 05/09/2019] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION A significant proportion of red blood cell (RBC) transfusions are administered intraoperatively; yet there is limited evidence to guide transfusion decisions in this setting. The objective of this systematic review is to explore the availability, quality and content of clinical practice guidelines (CPGs) reporting on the indication for allogenic RBC transfusion during surgery. METHODS Major electronic databases (MEDLINE, EMBASE and CINAHL), guideline clearinghouses and Google Scholar, will be systematically searched from inception to January 2019 for CPGs pertaining to indications for intraoperative allogenic RBC transfusion. Characteristics of eligible guidelines will be reported in a summary table. The AGREE II instrument will be used to appraise the quality of identified guidelines. Recommendations advising on indications for intraoperative RBC transfusion will be manually extracted and presented to allow for comparison of similarities and/or discrepancies in the literature. ETHICS AND DISSEMINATION The results of this systematic review will be disseminated through relevant conferences and peer-reviewed journals. TRIAL REGISTRATION NUMBER CRD42018111487.
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Affiliation(s)
- Laura Baker
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Lily Park
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Gilbert
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Andre Martel
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Hilalion Ahn
- Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Alexandra Davies
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Departments of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Elianna Saidenberg
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
- Division of Hematology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Programme, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, The University of Ottawa, Ottawa, Ontario, Canada
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Hines JT, Hernandez NM, Amundson AW, Pagnano MW, Sierra RJ, Abdel MP. Intravenous tranexamic acid safely and effectively reduces transfusion rates in revision total hip arthroplasty. Bone Joint J 2019; 101-B:104-109. [PMID: 31146563 DOI: 10.1302/0301-620x.101b6.bjj-2018-1376.r1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
AIMS Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA. PATIENTS AND METHODS We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery. RESULTS Tranexamic acid significantly and substantially reduced the rate of blood transfusions after revision THA overall from 54% to 26% (p < 0.001; adjusted relative risk (RR) 1.6; 95% confidence interval (CI) 1.3 to 1.9), with a significant reduction in both aseptic (49% to 18%; p < 0.001) and septic (73% to 53%; p = 0.04) revisions. The rate of VTE was minimal overall, with three events (0.3%) in the TXA group and four events (0.2%) in the non-TXA group. There were no significant differences in VTE rates based on TXA use or aetiology of revision. CONCLUSION Intravenous TXA significantly reduced transfusion rates during all-cause revision THAs, including a subgroup analysis of both aseptic and septic cohorts. Adjusted risk using propensity modelling showed no statistical difference in rates of VTEs between either group. Cite this article: Bone Joint J 2019;100-B(6 Supple B):104-109.
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Affiliation(s)
- J T Hines
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - N M Hernandez
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - A W Amundson
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota, USA
| | - M W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - R J Sierra
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - M P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Hemoglobin Optimization for Coronary Bypass: A 10-Year Canadian Multicenter Experience. Ann Thorac Surg 2019; 107:711-717. [DOI: 10.1016/j.athoracsur.2018.10.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 11/23/2022]
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Abstract
Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.
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Ackroyd SA, Brown J, Houck K, Chu C, Mantia-Smaldone G, Rubin S, Hernandez E. A preoperative risk score to predict red blood cell transfusion in patients undergoing hysterectomy for ovarian cancer. Am J Obstet Gynecol 2018; 219:598.e1-598.e10. [PMID: 30240655 DOI: 10.1016/j.ajog.2018.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 09/04/2018] [Accepted: 09/10/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Patients with ovarian cancer experience a high rate of anemia throughout their treatment course, with rates that range from 19-95%. Blood transfusions offer symptom relief but may be costly, are limited in supply, and have been associated with worse 30-day surgical morbidity and mortality rates. OBJECTIVE The purpose of this study was to identify risk factors for blood transfusion with packed red blood cell and to develop a transfusion risk score to identify patients who undergo surgery for ovarian cancer and who are at lowest risk for a blood transfusion. Our aim was to help clinicians identify those patients who may not require a crossmatch to encourage resource use and cost-savings. STUDY DESIGN This is a retrospective database cohort study of 3470 patients who underwent hysterectomy for ovarian cancer with the use the National Surgical Quality Improvement Program database from 2014-2016. The association between risk factors with respect to 30-day postoperative blood transfusion was modeled with the use of logistic regression. A risk score to predict blood transfusion was created. RESULTS Eight hundred ninety-one (25.7%) patients received a blood transfusion. In multivariate analysis, blood transfusion was associated independently with age (odds ratio, 1.90, P<.01), African American race (odds ratio, 2.30; P<.01), ascites (odds ratio, 1.89; P=.02), preoperative hematocrit level <30% (odds ratio, 10.70; P<.01), preoperative platelet count >400×109/L (odds ratio, 1.75; P<.01), occurrence of disseminated cancer (odds ratio, 1.71; P<.01), open surgical approach (odds ratio, 7.88; P<.01), operative time >3 hours (odds ratio, 2.19; P<.01), and additional surgical procedures that included large bowel resection (odds ratio, 4.23; P<.01), bladder/ureter resection (odds ratio, 1.69; P=.02), and pelvic exenteration (P=.02). A preoperative risk score that used age, race, ascites, preoperative hematocrit level, platelets, presence of disseminated cancer, planned hysterectomy approach, and procedures accurately predicted blood transfusion with good discriminatory ability (C-statistic=0.80 [P<.001]; C-statistic=0.69 [P<.001] for derivation and validation datasets, respectively) and calibration (Hosmer-Lemeshow goodness-of-fit, P=.081; P=.56 for derivation and validation datasets, respectively). CONCLUSION Patients who undergo hysterectomy for ovarian cancer experience a high incidence of blood transfusions in the perioperative period. Preoperative risk factors and planned surgical procedures can be used in our transfusion risk score to help predict anticipated blood requirements.
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Desai N, Schofield N, Richards T. Perioperative Patient Blood Management to Improve Outcomes. Anesth Analg 2018; 127:1211-1220. [DOI: 10.1213/ane.0000000000002549] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Baker CE, Marvi T, Austin TM, Payne S, Mignemi ME, Gailani D, Wheeler AP, Nguyen TT, Lovejoy SA, Martus JE, Mencio GA, Schoenecker JG. Dilutional coagulopathy in pediatric scoliosis surgery: A single center report. Paediatr Anaesth 2018; 28:974-981. [PMID: 30295357 DOI: 10.1111/pan.13488] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 08/09/2018] [Accepted: 08/13/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Children undergoing posterior spinal fusion experience high blood loss often necessitating transfusion. An appropriately activated coagulation system provides hemostasis during surgery, but pathologic dysregulation can cause progressive bleeding and increased transfusions. Despite receiving antifibrinolytics for clot stabilization, many patients still require transfusions. AIMS We sought to examine the association of dilutional coagulopathy with blood loss and blood transfusion in posterior spinal fusion for pediatric scoliosis patients. METHODS A retrospective, single institution study of children undergoing posterior spinal fusion >6 levels with a standardized, prospective anesthetic protocol utilizing antifibrinolytics. Blood loss was evaluated using a hematocrit-based calculation. To evaluate transfusions, a normalized Blood Product Transfusion calculation was developed. Factors associated with blood loss and blood transfusions were determined by univariate analysis and multivariate regression modeling with multicollinearity and mediation analysis. RESULTS Patients received 73.7 mL/kg (standard deviation ±30.8) of fluid poor in coagulation factors. Estimated blood loss was 42.6 mL/kg (standard deviation ±18.0). There was a significant association between estimated blood loss and total fluids delivered (Spearman's rho = 0.51, 95% confidence interval 0.33-0.65, P < 0.001). Factors significantly associated with normalized Blood Product Transfusion in this cohort included age, weight, scoliosis type, levels fused, total osteotomies, pelvic fixation, total fluid, maximum prothrombin time, and minimum fibrinogen. Regression modeling showed the best combination of variables for modeling normalized Blood Product Transfusion included patient weight, number of levels fused, total fluid administered, and maximum prothrombin time. CONCLUSION Blood product transfusion remains a frustrating problem in pediatric scoliosis. Identifying and controlling dilutional coagulopathy in these patients may reduce blood loss and the need for blood transfusion.
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Affiliation(s)
- Courtney E Baker
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Tanya Marvi
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Thomas M Austin
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Shelby Payne
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Megan E Mignemi
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Thanh T Nguyen
- University of Colorado School of Medicine, Aurora, Colorado
| | - Steven A Lovejoy
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey E Martus
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory A Mencio
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan G Schoenecker
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University, Nashville, Tennessee
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Barnett CL, Mladsi D, Vredenburg M, Aggarwal K. Cost estimate of platelet transfusion in the United States for patients with chronic liver disease and associated thrombocytopenia undergoing elective procedures. J Med Econ 2018; 21:827-834. [PMID: 29912593 DOI: 10.1080/13696998.2018.1490301] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS This study aimed to estimate the cost of platelet transfusion in patients with chronic liver disease (CLD)-associated thrombocytopenia undergoing an elective procedure in the United States. MATERIALS AND METHODS The study was conducted in two parts: development of a conceptual framework identifying direct, indirect and intangible costs of platelet transfusion, followed by the estimation of the total cost of platelet transfusion in patients with CLD-associated thrombocytopenia before an elective procedure in the United States using the conceptual framework and cost data obtained from a literature search. The cost of the entire care required to raise a patient's platelet count before the procedure was considered. RESULTS The final conceptual framework included the costs of generating the supply of platelets, the platelet transfusion itself, adverse events associated with platelet transfusion and refractoriness to platelet transfusion. When costs were accounted for in all the framework cost categories, the total direct cost of a platelet transfusion in a patient with CLD and associated thrombocytopenia was estimated to be in the range of $5258 to $13,117 (2017 US dollars) in the United States. The largest portion of costs was incurred by the transfusion event itself ($3723 to $4436) and the cost of refractoriness ($874 to $7578), which included the opportunity cost of a delayed procedure and subsequent platelet transfusions with human leukocyte antigen-matched platelets. LIMITATIONS AND CONCLUSIONS Although we were unable to include all cost components identified in the conceptual framework in our total cost estimate, thus likely underestimating the true total cost, and despite the data gaps and challenges limiting our estimate of the full cost of a platelet transfusion in patients with CLD-associated thrombocytopenia undergoing an elective procedure in the United States, this study outlines a comprehensive conceptual framework for estimating the cost elements of a platelet transfusion in these patients.
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Affiliation(s)
| | - Deirdre Mladsi
- a RTI Health Solutions, Research Triangle Park , NC , USA
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Soril LJJ, Noseworthy TW, Dowsett LE, Memedovich K, Holitzki HM, Lorenzetti DL, Stelfox HT, Zygun DA, Clement FM. Behaviour modification interventions to optimise red blood cell transfusion practices: a systematic review and meta-analysis. BMJ Open 2018; 8:e019912. [PMID: 29776919 PMCID: PMC5961610 DOI: 10.1136/bmjopen-2017-019912] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To assess the impact of behaviour modification interventions to promote restrictive red blood cell (RBC) transfusion practices. DESIGN Systematic review and meta-analysis. SETTING, PARTICIPANTS, INTERVENTIONS Seven electronic databases were searched to January 2018. Published randomised controlled trials (RCTs) or non-randomised studies examining an intervention to modify healthcare providers' RBC transfusion practice in any healthcare setting were included. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the proportion of patients transfused. Secondary outcomes included the proportion of inappropriate transfusions, RBC units transfused per patient, in-hospital mortality, length of stay (LOS), pretransfusion haemoglobin and healthcare costs. Meta-analysis was conducted using a random-effects model and meta-regression was performed in cases of heterogeneity. Publication bias was assessed by Begg's funnel plot. RESULTS Eighty-four low to moderate quality studies were included: 3 were RCTs and 81 were non-randomised studies. Thirty-one studies evaluated a single intervention, 44 examined a multimodal intervention. The comparator in all studies was standard of care or historical control. In 33 non-randomised studies, use of an intervention was associated with reduced odds of transfusion (OR 0.63 (95% CI 0.56 to 0.71)), odds of inappropriate transfusion (OR 0.46 (95% CI 0.36 to 0.59)), RBC units/patient weighted mean difference (WMD: -0.50 units (95% CI -0.85 to -0.16)), LOS (WMD: -1.14 days (95% CI -2.12 to -0.16)) and pretransfusion haemoglobin (-0.28 g/dL (95% CI -0.48 to -0.08)). There was no difference in odds of mortality (OR 0.90 (95% CI 0.80 to 1.02)). Protocol/algorithm and multimodal interventions were associated with the greatest decreases in the primary outcome. There was high heterogeneity among estimates and evidence for publication bias. CONCLUSIONS The literature examining the impact of interventions on RBC transfusions is extensive, although most studies are non-randomised. Despite this, pooled analysis of 33 studies revealed improvement in the primary outcome. Future work needs to shift from asking, 'does it work?' to 'what works best and at what cost?' PROSPERO REGISTRATION NUMBER CRD42015024757.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Thomas W Noseworthy
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Laura E Dowsett
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Katherine Memedovich
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Hannah M Holitzki
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Diane L Lorenzetti
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
| | - Henry Thomas Stelfox
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, Alberta, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - David A Zygun
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, Alberta Health Services and Faculty of Medicine and Dentistry, University of Alberta, Calgary, Alberta, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, The University of Calgary, Calgary, Alberta, Canada
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Garraud O, Sut C, Haddad A, Tariket S, Aloui C, Laradi S, Hamzeh-Cognasse H, Bourlet T, Zeni F, Aubron C, Ozier Y, Laperche S, Peyrard T, Buffet P, Guyotat D, Tavernier E, Cognasse F, Pozzetto B, Andreu G. Transfusion-associated hazards: A revisit of their presentation. Transfus Clin Biol 2018; 25:118-135. [PMID: 29625790 DOI: 10.1016/j.tracli.2018.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
As a therapy or a support to other therapies, despite being largely beneficial to patients in general, transfusion it is not devoid of some risks. In a moderate number of cases, patients may manifest adverse reactions, otherwise referred to as transfusion-associated hazards (TAHs). The latest French 2016 haemovigilance report indicates that 93% of TAHs are minor (grade 1), 5.5% are moderate (grade 2) and 1.6% are severe (grade 3), with only five deaths (grade 4) being attributed to transfusion with relative certainty (imputability of level [or grade] 1 to 3). Health-care providers need to be well aware of the benefits and potential risks (to best evaluate and discuss the benefit-risk ratio), how to prevent TAHs, the overall costs and the availability of alternative therapeutic options. In high-income countries, most blood establishments (BEs) and hospital blood banks (HBBs) have developed tools for reporting and analysing at least severe transfusion reactions. With nearly two decades of haemovigilance, transfusion reaction databases should be quite informative, though there are four main caveats that prevent it from being fully efficient: (ai) reporting is mainly declarative and is thus barely exhaustive even in countries where it is mandatory by law; (aii) it is often difficult to differentiate between the different complications related to transfusion, diseases, comorbidities and other types of therapies in patients suffering from debilitating conditions; (aiii) there is a lack of consistency in the definitions used to describe and report some transfusion reactions, their severity and their likelihood of being related to transfusion; and (aiv) it is difficult to assess the imputability of a particular BC given to a patient who has previously received many BCs over a relatively short period of time. When compiling all available information published so far, it appears that TAHs can be analysed using different approaches: (bi) their pathophysiological nature; (bii) their severity; (biii) the onset scheme; (biv) a quality assessment (preventable or non-preventable); (bv) their impact on ongoing therapy. Moreover, TAHs can be reported either in a non-integrative or in an integrative way; in the latter case, presentation may also differ when issued by a blood establishment or a treating ward. At some point, a recapitulative document would be useful to gain a better understanding of TAHs in order to decrease their occurrence and severity and allow decision makers to determine action plans: this is what this review attempts to make. This review attempts to merge the different aspects, with a focus on the hospital side, i.e., how the most frequent TAHs can be avoided or mitigated.
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Affiliation(s)
- O Garraud
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Institut National de la Transfusion Sanguine, 75017 Paris, France.
| | - C Sut
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France
| | - A Haddad
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Sacré-Cœur University Hospital, Beirut, Lebanon
| | - S Tariket
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France
| | - C Aloui
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France
| | - S Laradi
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Sacré-Cœur University Hospital, Beirut, Lebanon
| | | | - T Bourlet
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Department of Microbiology, University Hospital, 42023 Saint-Etienne, France
| | - F Zeni
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Department of Critical Care, University Hospital, 29200 Saint-Etienne, France
| | - C Aubron
- Université de Bretagne Occidentale, 29200 Brest, France; Department of Critical Care, University Hospital, 75005 Brest, France
| | - Y Ozier
- Université de Bretagne Occidentale, 29200 Brest, France; Department of Critical Care, University Hospital, 75005 Brest, France
| | - S Laperche
- Institut National de la Transfusion Sanguine, 75017 Paris, France
| | - T Peyrard
- Institut National de la Transfusion Sanguine, 75017 Paris, France; Inserm S_1134, 75015 Paris, France
| | - P Buffet
- Institut National de la Transfusion Sanguine, 75017 Paris, France; Inserm S_1134, 75015 Paris, France; University Paris-Descartes, Paris, France
| | - D Guyotat
- UMR_5229, University of Lyon, 69675 Lyon, France; Institut du Cancer Lucien Neuwirth, 42023 Saint-Etienne, France
| | - E Tavernier
- UMR_5229, University of Lyon, 69675 Lyon, France; Institut du Cancer Lucien Neuwirth, 42023 Saint-Etienne, France
| | - F Cognasse
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Sacré-Cœur University Hospital, Beirut, Lebanon
| | - B Pozzetto
- EA3064, University of Lyon/Saint-Etienne, Saint-Etienne, France; Department of Microbiology, University Hospital, 42023 Saint-Etienne, France
| | - G Andreu
- Institut National de la Transfusion Sanguine, 75017 Paris, France
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Implementation of a Standardized Transfusion Protocol for Cardiac Patients Treated With Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Decreased Blood Component Utilization and May Improve Clinical Outcome. Anesth Analg 2018; 126:1262-1267. [DOI: 10.1213/ane.0000000000002238] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Slezak P, Heher P, Monforte X, Keibl C, Redl H, Spazierer D, Gulle H. Efficacy of Topical Hemostatic Agents: A Comparative Evaluation of Two Gelatin/Thrombin-Based Hemostatic Matrices in a Porcine Kidney Surgical Model. J INVEST SURG 2018; 32:646-653. [PMID: 29561208 DOI: 10.1080/08941939.2018.1447619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Purpose: Topical hemostatic agents are an important means of controlling or preventing bleeding. This study was performed to compare gelatin-thrombin matrix with smooth particles (SmGM) versus gelatin-thrombin matrix with stellate particles (StGM) in a porcine kidney bleeding model. Materials and methods: In male pigs, reproducible lesions (diameter and depth ∼10 mm) were created in the renal cortex. Each lesion was treated topically using either SmGM or StGM. Blood loss was quantified before and 2, 5 and 10 minutes after treatment. Dry mass, ultrastructural and histologic analyses were also performed. Results: Thirty-two lesions were treated with SmGM and 32 with StGM; median initial bleeding rates were 27.6 and 29.1 mL/min, respectively. Two minutes post-application, SmGM was associated with significantly less bleeding than StGM (0.574 vs 0.920 mL/min; p < .0001). This difference stemmed principally from lesions with initial blood loss >29 mL/min, where bleeding rates at 2 minutes were ∼3-fold higher with StGM (1.636 vs 0.567 mL/min; p ≥ 0.040). Dry mass per unit volume of hemostatic agent was significantly higher with SmGM versus StGM. SmGM formed discrete, smooth particles, while StGM particles were stellate and tended to coalesce. Histologic analysis showed more solid mass, larger particles and less intervening space with SmGM versus StGM. Conclusions: In a severe, high-volume bleeding model, residual bleeding at 2 minutes was significantly lower with SmGM versus StGM, and SmGM showed greater consistency across bleeding intensities. These findings may be attributable to dry mass per unit volume and/or ultrastructural differences between the two agents.
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Affiliation(s)
- Paul Slezak
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology , Vienna , Austria
| | - Philipp Heher
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology , Vienna , Austria
| | - Xavier Monforte
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology , Vienna , Austria
| | - Claudia Keibl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology , Vienna , Austria
| | - Heinz Redl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology , Vienna , Austria
| | | | - Heinz Gulle
- Baxter Medical Products GmbH , Vienna , Austria
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de Lange N, Schol P, Lancé M, Woiski M, Langenveld J, Rijnders R, Smits L, Wassen M, Henskens Y, Scheepers H. Restrictive Versus Massive Fluid Resuscitation Strategy (REFILL study), influence on blood loss and hemostatic parameters in obstetric hemorrhage: study protocol for a randomized controlled trial. Trials 2018; 19:166. [PMID: 29510717 PMCID: PMC5838856 DOI: 10.1186/s13063-018-2512-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 01/30/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is associated with maternal morbidity and mortality and has an increasing incidence in high-resource countries, despite dissemination of guidelines, introduction of skills training, and correction for risk factors. Current guidelines advise the administration, as fluid resuscitation, of almost twice the amount of blood lost. This advice is not evidence-based and could potentially harm patients. METHODS All women attending the outpatient clinic who are eligible will be informed of the study; oral and written informed consent will be obtained. Where there is more than 500 ml blood loss and ongoing bleeding, patients will be randomized to care as usual, fluid resuscitation with 1.5-2 times the amount of blood loss or fluid resuscitation with 0.75-1.0 times the blood loss. Blood loss will be assessed by weighing all draping. A blood sample, for determining hemoglobin concentration, hematocrit, thrombocyte concentration, and conventional coagulation parameters will be taken at the start of the study, after 60 min, and 12-18 h after delivery. In a subgroup of women, additional thromboelastometric parameters will be obtained. DISCUSSION Our hypothesis is that massive fluid administration might lead to a progression of bleeding due to secondary coagulation disorders. In non-pregnant individuals with massive blood loss, restrictive fluid management has been shown to prevent a progression to dilution coagulopathy. These data, however, cannot be extrapolated to women in labor. Our objective is to compare both resuscitation protocols in women with early, mild PPH (blood loss 500-750 ml) and ongoing bleeding, taking as primary outcome measure the progression to severe PPH (blood loss > 1000 ml). TRIAL REGISTRATION Netherlands Trial Register, NTR 3789 . Registered on 11 January 2013.
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Affiliation(s)
- Natascha de Lange
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, P.O. 11120, 9700 CC Groningen, the Netherlands
| | - Pim Schol
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Marcus Lancé
- Department of Anesthesiology and Pain Treatment, Department of Intensive Care, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Mallory Woiski
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Robbert Rijnders
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, P.O. 90153, 5200 ME ‘s-Hertogenbosch, the Netherlands
| | - Luc Smits
- Department of Epidemiology, Caphri School for Public Health and Primary Care, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Martine Wassen
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Yvonne Henskens
- Central Diagnostics Laboratory, Maastricht University Medical Centre, P.O. 5500, 6202 AZ Maastricht, the Netherlands
| | - Hubertina Scheepers
- GROW: School for Oncology and Developmental Biology and Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
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O'Donnell TFX, Shean KE, Deery SE, Bodewes TCF, Wyers MC, O'Brien KL, Matyal R, Schermerhorn ML. A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross. J Vasc Surg 2018; 67:442-448. [PMID: 28756046 PMCID: PMC5785583 DOI: 10.1016/j.jvs.2017.05.108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/12/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Preoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. METHODS We queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. RESULTS Between 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. CONCLUSIONS Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Thomas C F Bodewes
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mark C Wyers
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Kerry L O'Brien
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Robina Matyal
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Anani H, Baluchi I, Ghazizadeh M, Mardani Valandani H, Mirzaee Khalilabadi R. Evaluating the effect of tariff on wastage and return of blood products in Kerman province. Transfus Clin Biol 2018; 25:44-48. [DOI: 10.1016/j.tracli.2017.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
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Lindman IS, Carlsson LV. Extremely Low Transfusion Rates: Contemporary Primary Total Hip and Knee Arthroplasties. J Arthroplasty 2018; 33:51-54. [PMID: 28844765 DOI: 10.1016/j.arth.2017.07.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/14/2017] [Accepted: 07/20/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Considerable blood loss which requires transfusion is frequently reported after total hip and knee arthroplasties (THA and TKA). The purpose of this study is to review the transfusion rates in contemporary THA and TKA with optimized perioperative protocols including minimized surgical trauma and optimal perioperative patient care. METHODS This retrospective study included 1442 consecutive patients receiving either a primary THA or a TKA from the same high-volume surgeon between January 2008 and December 2015. Demographics and surgical data were collected from patients' journals. Estimated blood loss, decline in hemoglobin, and use of transfusion were registered. RESULTS One (0.0013%) THA and 3 (0.0044%) TKAs required blood transfusion postoperatively. Average measured bleeding was 253 mL ± 142 and 207 mL ± 169 in THA and TKA, respectively. Average decline in hemoglobin was 23.5 g/L ± 11.4 and 22.9 g/L ± 11.6 for THA and TKA, respectively. CONCLUSION In contemporary THA and TKA, perioperative protocols and patient optimization can decrease the rate of blood transfusion to near zero.
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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