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Abdolalian M, Khalaf-Adeli E, Yari F, Hosseini S, Kiaeefar P. Presurgical circulating platelet-derived microparticles level as a risk factor of blood transfusion in patients with valve heart disease undergoing cardiac surgery. Transfus Clin Biol 2024; 31:19-25. [PMID: 38029957 DOI: 10.1016/j.tracli.2023.11.004] [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: 07/23/2023] [Revised: 11/17/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Cell-derived microparticles (MPs) are membrane vesicles that have emerged as a potential biomarker for various diseases and their clinical complications. This study investigates the role of MPs as a risk factor for blood transfusion in patients with valve heart disease undergoing cardiac surgery. METHODS Forty adult patients undergoing heart valve surgery with cardiopulmonary bypass (CPB) were enrolled, and venous blood samples were collected prior to surgical incision. Plasma rich in MPs was prepared by double centrifugation, and the concentration of MPs was determined using the Bradford method. Flow cytometry analysis was performed to determine MPs count and phenotype. Patients were divided into "with transfusion" (n = 18) and "without transfusion" (n = 22) groups based on red blood cell (RBC) transfusion. RESULTS There was no significant difference in MPs concentration between the "with transfusion" and "without transfusion" groups. Although the count of preoperative platelet-derived MPs (PMPs), monocyte-derived MPs (MMPs), and red cell-derived MPs (RMPs) was higher in "without transfusion" group, these differences were not statistically significant. The preoperative PMPs count was negatively correlated with RBC transfusion (P = 0.005, r = -0.65). Multivariate logistic regression analysis revealed that the count of CD41+ PMPs, Hemoglobin (Hb), and RBC count were risk factors for RBC transfusion. CONCLUSION This study suggests that the presurgical levels of PMPs, Hb, and RBC count can serve as risk factors of RBC transfusion in patients with valve heart disease undergoing cardiac surgery. The findings provide insights into the potential use of MPs as biomarkers for blood transfusion prediction in cardiac surgery.
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Affiliation(s)
- Mehrnaz Abdolalian
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Elham Khalaf-Adeli
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran; Department of Hematology, Faculty of Paramedical Sciences, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.
| | - Fatemeh Yari
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Schneider AB, Adams U, Gallaher J, Purcell LN, Raff L, Eckert M, Charles A. Blood Utilization and Thresholds for Mortality Following Major Trauma. J Surg Res 2023; 281:82-88. [PMID: 36122473 DOI: 10.1016/j.jss.2022.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/18/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Blood loss is a hallmark of traumatic injury. Massive transfusion, historically defined as the replacement by transfusion of 10 units of packed red blood cells (PRBCs) in 4 h, is a response to uncontrolled hemorrhage. We sought to identify blood transfusion thresholds in which predicted mortality exceeds 50%. METHODS We analyzed the 2017-2019 National Trauma Database. Inclusion criteria included patients ≥18 y who received ≥1 unit of PRBCs. Statistical analysis included bivariate analysis, logistic regression for mortality, and adjusted predicted probability modeling was utilized. RESULTS We identified 61,676 patients for analysis. The 50% predicted mortality for all patients was 31 PRBC units. The 50% predicted mortality was 6 units of PRBCs for elderly trauma patients 80 y and older. CONCLUSIONS Blood remains as scarce resource in hospitals especially with trauma. Patients receiving a massive transfusion over a short period of time may exhaust blood bank supply with diminishing survival benefit. Surgeons should be judicious regarding continued blood usage once the 50% predicted mortality threshold is reached.
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Affiliation(s)
- Andrew B Schneider
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Ursula Adams
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jared Gallaher
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Raff
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew Eckert
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.
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Farzanegan G, Ahmadpour F, Khoshmohabbat H, Khadivi M, Rasouli HR, Eslamian M. The Effect of Topical Tranexamic Acid on Intraoperative Blood Loss in Patients Undergoing Posterior Lumbar Laminectomy and Discectomy: A Randomized, Double-Blind, Controlled Trial Study. Asian Spine J 2022; 16:857-864. [PMID: 35184518 PMCID: PMC9827208 DOI: 10.31616/asj.2021.0285] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Randomized, double-blind, controlled trial study. PURPOSE This study aimed to evaluate the safety and efficacy of topical tranexamic acid (TXA) on intraoperative blood loss (IBL) in patients that have degenerative lumbar canal stenosis and undergo posterior lumbar laminectomy and discectomy. OVERVIEW OF LITERATURE The volume of IBL is directly proportional to potential surgical complications. Recent reports have shown that the topical use of antifibrinolytic drugs, such as TXA, during surgery might decrease IBL and improve patient outcomes. METHODS A total of 104 patients with lumbar canal stenosis were enrolled in this randomized, double blinded clinical trial. Participants were randomized and divided into two groups: TXA (54 cases) and control (50 cases). In the TXA group, a TXA solution was used for washing and soaking, whereas, in the control group, irrigation of wound was with normal saline. IBL, pre- and postoperative coagulative studies, operation time, conventional hemostatic agent usage, systemic complications, and length of hospitalization were consecutively recorded. All participants were followed for an additional two months to gather data on their recovery status and time to return to work (RTW). RESULTS At baseline, there was no difference in clinical or lab findings, between the groups. IBL and use of hemostatic agents were significantly decreased in TXA group, as compared to the control group (p=0.001 and p=0.011, respectively). Systemic complications, length of hospitalization, and RTW were not significantly different between groups (p=0.47, p=0.38, and p=0.08, respectively). CONCLUSIONS This study showed that topical use of TXA during surgery may decrease IBL and minimize the use of hemostatic materials during posterior midline-approach laminectomy and discectomy, without increasing the potential for complications seen with intravenous TXA usage.
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Affiliation(s)
| | - Fathollah Ahmadpour
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Hadi Khoshmohabbat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Masoud Khadivi
- Spine Center of Excellence, Yas Hospital, Tehran University of Medical Sciences, Tehran,
Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran,
Iran
| | - Mohammad Eslamian
- Department of Neurosurgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran
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Tatar M, Alkış N, Yıldırım Güçlü Ç, Bermede O, Erdemli B, Günaydın S. Cost-Effectiveness and Budget Impact of Comprehensive Anemia Management, The First Pillar of Patient Blood Management, on the Turkish Healthcare System. CLINICOECONOMICS AND OUTCOMES RESEARCH 2022; 14:415-426. [PMID: 35669886 PMCID: PMC9166278 DOI: 10.2147/ceor.s360944] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/07/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Methods Results Conclusion
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Affiliation(s)
- Mehtap Tatar
- Polar Health Economics and Policy, Ankara, Turkey
- Correspondence: Mehtap Tatar, Polar Health Economics and Policy, Mustafa Kemal Mah. Dumlupınar Bulvarı No:266 Tepe Prime İş Merkezi A Blok No 18, 06800 Çankaya, Ankara, Turkey, Tel +90 532 5538324, Email
| | - Neslihan Alkış
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Çiğdem Yıldırım Güçlü
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Onat Bermede
- Department of Anesthesiology and Intensive Care Unit, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Bülent Erdemli
- Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Serdar Günaydın
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital Campus, Ankara, Turkey
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Oral Is as Effective as Intravenous Tranexamic Acid at Reducing Blood Loss in Thoracolumbar Spinal Fusions: A Prospective Randomized Trial. Spine (Phila Pa 1976) 2022; 47:91-98. [PMID: 34224510 DOI: 10.1097/brs.0000000000004157] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A prospective randomized trial at a university affiliated tertiary medical center between February 2017 and March 2020. OBJECTIVE The aim of this study was to compare perioperative blood loss in patients undergoing elective posterior thoracolumbar fusion who were treated with IV versus PO TXA. SUMMARY OF BACKGROUND DATA The use of antifibrinolytic agents such as tranexamic acid (TXA) to decrease operative blood loss and allogenic blood transfusions is well documented in the literature. Although evidence supports the use of intravenous (IV) and topical formulations of TXA in spine surgery, the use of oral (PO) TXA has not been studied. METHODS A total of 261 patients undergoing thoracolumbar fusion were randomized to receive 1.95 g of PO TXA 2 hours preoperatively or 2 g IV TXA (1 g before incision and 1 g before wound closure) intraoperatively. The sample was further stratified into three categories based on number of levels fused (one-to two-level fusions, three to five, and more than five). The primary outcome was the reduction of hemoglobin. Secondary outcomes included calculated blood loss, drain output, postoperative transfusion, complications, and length of hospital stay. Equivalence analysis was performed with a two one-sided test. RESULTS One hundred thirty-seven patients received IV and 124 received PO TXA. The average age was 62 ± 13 years (mean ± SD), including 141 females and 120 males. Revision cases comprised of 67% of the total sample. Patient demographic factors were similar between groups except for weight, BMI, and preoperative platelet count. The mean reduction of hemoglobin was similar between IV and PO groups (3.56 vs. 3.28 g/dL, respectively; P = 0.002, equivalence). IV TXA group had a higher transfusion rate compared to PO TXA group (22 patients [19%] vs. 12 patients [10%]; P = 0.03). In addition, IV group had longer length of stay (LOS) than PO group (4.4 vs. 3.7 days; P = 0.02). CONCLUSION Patients treated with IV and PO TXA experienced the same perioperative blood loss after small and large spinal fusions. In subgroup analysis, the intermediate (three to five level) spinal fusions had less blood loss with PO TXA than IV TXA. Given its lower cost, PO TXA represents a superior alternative to IV TXA in patients undergoing elective posterior thoracolumbar fusion and may improve health care cost-efficiency in the studied population.Level of Evidence: 1.
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Gharib Bidgoli J, Madani F, Hassan Matini S, Akbari H. Investigation into changes in blood transfusion indicators and returning blood products along with the cause of returning and cost calculation. ARCHIVES OF TRAUMA RESEARCH 2022. [DOI: 10.4103/atr.atr_26_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Hofmann A, Spahn DR, Holtorf AP. Making patient blood management the new norm(al) as experienced by implementors in diverse countries. BMC Health Serv Res 2021; 21:634. [PMID: 34215251 PMCID: PMC8249439 DOI: 10.1186/s12913-021-06484-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/06/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds. METHODS Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework. RESULTS A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration. CONCLUSION The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.
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Affiliation(s)
- Axel Hofmann
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
- University of Western Australia Faculty of Health and Medical Sciences, Perth, Australia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies GmbH, Colmarerstrasse 58, CH4055 Basel, Switzerland
- Faculty of the College of Pharmacy, University of Utah, Salt Lake City, UT USA
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Abstract
Background: Resuscitation from hemorrhagic shock (HS) by blood transfusion restores oxygen (O2) delivery and provides hemodynamic stability. Current regulations allow red blood cells (RBCs) to be stored and used for up to 42 days. During storage, RBCs undergo many structural and functional changes. These storage lesions have been associated with adverse events and increased mortality after transfusion, increasing the need for improved RBC storage protocols. This study evaluates the efficacy of anaerobically stored RBCs to resuscitate rats from severe HS compared with conventionally stored RBCs. Methods and results: Rat RBCs were stored under anaerobic, anaerobic/hypercapnic, or conventional conditions for a period of 3 weeks. Hemorrhage was induced by controlled bleeding, shock was maintained for 30 min, and RBCs were transfused to restore and maintain blood pressure near the prhemorrhage level. All storage conditions met current regulatory 24-h posttransfusion recovery requirements. Transfusion of anaerobically stored RBCs required significantly less RBC volume to restore and maintain hemodynamics. Anaerobic or anaerobic/hypercapnic RBCs restored hemodynamics better than conventionally stored RBCs. Resuscitation with conventionally stored RBCs impaired indices of left ventricular cardiac function, increased hypoxic tissue staining and inflammatory markers, and affected organ function compared with anaerobically stored RBCs. Conclusions: Resuscitation from HS via transfusion of anaerobically stored RBCs recovered cardiac function, restored hemodynamic stability, and improved outcomes.
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [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: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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Jones JJ, Mundy LM, Blackman N, Shwarz M. Ferric Carboxymaltose for Anemic Perioperative Populations: A Systematic Literature Review of Randomized Controlled Trials. J Blood Med 2021; 12:337-359. [PMID: 34079413 PMCID: PMC8165212 DOI: 10.2147/jbm.s295041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/29/2021] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE Perioperative anemia is a common comorbid condition associated with increased risk of morbidity and mortality in patients undergoing elective surgical procedures. OBJECTIVE We conducted a systematic literature review (SLR) to determine the efficacy and safety of the use of intravenous ferric carboxymaltose (FCM) for the treatment of perioperative anemia in preoperative, intraoperative, and postoperative elective surgical care. EVIDENCE REVIEW Studies meeting inclusion criteria for the SLR reported on treatment efficacy in an adult study population randomly allocated to FCM for the treatment of perioperative anemia during the perioperative period. After screening, 10 of 181 identified studies from searches in MEDLINE and EMBASE databases were identified for inclusion in this review. FINDINGS Preoperative treatment was reported in six studies, intraoperative treatment in one study, postoperative treatment in two studies, and both pre- and postoperative treatment in one study. Together, 1975 patients were studied, of whom 943 were randomized to FCM, of whom 914 received FCM treatment. The 10 studies reported elective surgical populations for colorectal, gastric, orthopedic, abdominal, urologic, plastic, neck, gynecologic, and otolaryngologic procedures. Given the clinical and methodological heterogeneity of the studies, the analyses were limited to qualitative assessments without meta-analyses. All 10 studies reported statistically greater changes in hemoglobin concentration, serum ferritin, and/or transferrin saturation with FCM treatment compared with comparators (placebo, oral iron, standard care, or a combination of these). Two studies reported statistically significant differences in transfusion rate and 2 studies reported significant differences in length of hospital stay between FCM and its comparator(s). CONCLUSIONS AND RELEVANCE This SLR adds to existing data that administration of FCM in preoperative and postoperative settings improves hematologic parameters. Several studies in the review supported the beneficial effects of FCM in reducing transfusion rate and length of stay. Larger, well-designed, longer-term studies may be needed to further establish the efficacy and safety of FCM in elective surgery patients with perioperative anemia.
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Affiliation(s)
- John Jeffrey Jones
- College of Pharmacy and Health Sciences, St. John’s University, Queens, NY, USA
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11
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The cost of one unit blood transfusion components and cost-effectiveness analysis results of transfusion improvement program. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:150-157. [PMID: 34104508 PMCID: PMC8167483 DOI: 10.5606/tgkdc.dergisi.2021.20886] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/20/2021] [Indexed: 11/21/2022]
Abstract
Background This study aims to analyze the cost of the entire transfusion process in Turkey including evaluation of the cost of transfusion from the perspective of hospital management and determination of savings achieved with the transfusion improvement program. Methods Invoices, labor, material costs were calculated with micro-costing method, while general production expenses were calculated with gross costing method between January 2018 and December 2019. Unit costs for each blood product were calculated separately by collecting unit acquisition costs, material costs, labor costs, and general production expenses and, then, distributed into six different blood products as follows: erythrocyte suspension, fresh frozen plasma, pooled platelet, apheresis platelet, cryoprecipitate, fresh whole blood. The total costs for 2018 and 2019 were calculated and the savings achieved were estimated. The Turkish Lira was converted into the United States Dollar ($) currency using the purchasing power parity. Results In 2018/2019, the blood component transfusion cost was $240.90/251.18 for erythrocyte suspension, $120.00/128.67 for fresh frozen plasma, $313.50/322.19 for pooled platelet, $314.24/325.73 for apheresis platelet, $104.95/113.99 for cryoprecipitate, and $189.91/209.09 for fresh whole blood. The total transfusion cost was $6,224,208.33 in 2108 and $5,308,148.43 in 2019. As a result of the transfusion improvement program launched in 2019, the amount of blood components decreased by 23.24%, compared to the previous year, and a saving of $916,059.9 was achieved. Conclusion The transfusion is a burden for both the hospital management systems and the country's economy. To accurately calculate and manage this economic burden is important for sustainable healthcare services.
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Hanada K, Ahmad A, Shadi H, Wajdi A, Haitham S, Wesam K, Lamees A, Qamar M, Rami A. Castigating intraoperative bleeding: Tranexamic acid, a new ally. Asian J Neurosurg 2021; 16:51-55. [PMID: 34211866 PMCID: PMC8202383 DOI: 10.4103/ajns.ajns_339_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/28/2020] [Accepted: 10/15/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction: The field of instrumented spinal procedures is associated with substantial blood volume losses, which is one of the major hazards we encounter; this would lead to a greater need for blood products transfusions. The frequent use of these products can have negative consequences due to body fluid shifting, and donor-host rejection. Thus, it has become mandatory to establish strategies to maintain blood volume and minimize losses. Several strategies have been approved to control the disproportionate blood loss. Objective: This study aims to assess the effectiveness of tranexamic acid in reducing intraoperative bleeding during our spine instrumented surgeries, while addressing complications associated. Methods: In this retrospective analysis was steered of 153- consecutive patients treated in the neurosurgical- spine unit of King Hussein hospital, King Hussein Medical Center (KHMC), between April 2017 to January 2020, patients who underwent instrumented surgery for different spinal pathologies at our institute were reviewed. Results: During the analysis period, 153-patients who underwent interbody fusion, were allocated into two groups. The mean instrumented segments were 2.8 level (range 1-5 levels). The demographical data of patients of both groups analyzed. The mean span of operating time was (212.74 ± 41.85 min) for group I, while for the control group mean length was (208.09min ±42.03). Study showed that the mean drop in the hemoglobin concentration postoperatively was statistically significant comparing the two groups. Analysis of blood volume in suction container showed that group I had: 470 ml ±153.06 ml; while in control group volume was: 1560 ml ± 567.59 ml, which showed significant difference (p = 0.002). Comparing the drainage volumes at 12 hours postoperatively displayed no statistically significant differences (p = 0.69) concerning the two groups. Minor adverse effects allied with the tranexamic acid administration. Conclusions: In summary, perioperative bleeding deemed one of the most important threat for patients. Tranexamic acid is proved excellent in controlling perioperative bleeding, harboring few contraindications. Future large studies are still needed to elaborate on unanswered issues.
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Affiliation(s)
- Krashan Hanada
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alhasan Ahmad
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Hammadeen Shadi
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alnajada Wajdi
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Saraireh Haitham
- Department of Radiation Oncology, Queen Alia Military Hospital, Royal Medical Services, Amman, Jordan
| | - Khresat Wesam
- Department of Anesthesia, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Arabiyat Lamees
- Department of Plastic Surgery, Farah Medical Center, Royal Medical Services, Amman, Jordan
| | - Malabeh Qamar
- Department of Radiology, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
| | - Alqroom Rami
- Department of Neurosurgery, King Hussein Medical Center, Royal Medical Services, Amman, Jordan
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Ducrocq G, Calvo G, González-Juanatey JR, Durand-Zaleski I, Avendano-Sola C, Puymirat E, Lemesle G, Arnaiz JA, Martínez-Sellés M, Rousseau A, Cachanado M, Vicaut E, Silvain J, Karam C, Danchin N, Simon T, Steg PG. Restrictive vs liberal red blood cell transfusion strategies in patients with acute myocardial infarction and anemia: Rationale and design of the REALITY trial. Clin Cardiol 2021; 44:143-150. [PMID: 33405291 PMCID: PMC7852166 DOI: 10.1002/clc.23453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/10/2020] [Indexed: 01/28/2023] Open
Abstract
Background Anemia is common in patients with acute myocardial infarction (AMI), and is an independent predictor of mortality. The optimal transfusion strategy in these patients is unclear. Hypothesis We hypothesized that a “restrictive” transfusion strategy (triggered by hemoglobin ≤8 g/dL) is clinically noninferior to a “liberal” transfusion strategy (triggered by hemoglobin ≤10 g/dL), but is less costly. Methods REALITY is an international, randomized, multicenter, open‐label trial comparing a restrictive vs a liberal transfusion strategy in patients with AMI and anemia. The primary outcome is the incremental cost‐effectiveness ratio (ICER) at 30 days, using the primary composite clinical outcome of major adverse cardiovascular events (MACE; comprising all‐cause death, nonfatal stroke, nonfatal recurrent myocardial infarction, or emergency revascularization prompted by ischemia) as the effectiveness criterion. Secondary outcomes include the ICER at 1 year, and MACE (and its components) at 30 days and at 1 year. Results The trial aimed to enroll 630 patients. Based on estimated event rates of 11% in the restrictive group and 15% in the liberal group, this number will provide 80% power to demonstrate clinical noninferiority of the restrictive group, with a noninferiority margin corresponding to a relative risk equal to 1.25. The sample size will also provide 80% power to show the cost‐effectiveness of the restrictive strategy at a threshold of €50 000 per quality‐adjusted life year. Conclusions REALITY will provide important guidance on the management of patients with AMI and anemia.
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Affiliation(s)
- Gregory Ducrocq
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France
| | - Gonzalo Calvo
- Àrea del Medicament Hospital Clínic of Barcelona, University of Barcelona, Barcelona, Spain
| | - José Ramón González-Juanatey
- Cardiology Department, University Hospital, IDIS, CIBERCV, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Isabelle Durand-Zaleski
- AP-HP Health Economics Research Unit, Hotel Dieu Hospital, INSERM UMR 1153 CRESS, Paris, France
| | - Cristina Avendano-Sola
- Clinical Pharmacology Service, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Etienne Puymirat
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Gilles Lemesle
- Institut Cœur Poumon, Centre Hospitalier Universitaire de Lille, Faculté de Médecine de Lille, Université de Lille, Institut Pasteur de Lille, Inserm U1011, F-59000 Lille, France; French Alliance for Cardiovascular Trials (FACT), Paris, France
| | - Joan Albert Arnaiz
- Clinical Trials Unit, Clinical Pharmacology Department, Hospital Clinic, Barcelona, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV; Universidad Europea, Universidad Complutense, Madrid, Spain
| | - Alexandra Rousseau
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Marine Cachanado
- Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, Paris, France
| | - Eric Vicaut
- AP-HP, Department of Biostatistics, Université Paris-Diderot, Sorbonne-Paris Cité, Fernand Widal Hospital, France
| | - Johanne Silvain
- Sorbonne Université, ACTION Study Group, Institut de Cardiologie, Hôpital Pitié-Salpêtrière, AP-HP, INSERM UMRS 1166, Paris, France
| | - Carma Karam
- Cardiology Department, Ambroise Paré Hospital, AP-HP, Boulogne, University of Versailles-Saint Quentin en Yvelines, Boulogne-Billancourt, France
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou, AP-HP, French Alliance for Cardiovascular Trials (FACT), and Université de Paris, Paris, France
| | - Tabassome Simon
- Department of Clinical Pharmacology-Clinical Research Platform (URCEST-CRB-CRCEST), AP-HP, Hôpital Saint Antoine, French Alliance for Cardiovascular Trials (FACT), Sorbonne-Université, Paris, France
| | - Philippe Gabriel Steg
- Université de Paris, AP-HP, French Alliance for Cardiovascular Trials (FACT), INSERM U1148, Paris, France.,Royal Brompton Hospital, Imperial College, London, UK
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14
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Trentino KM, Mace HS, Symons K, Sanfilippo FM, Leahy MF, Farmer SL, Hofmann A, Watts RD, Wallace MH, Murray K. Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis. Anaesthesia 2020; 76:357-365. [PMID: 32851648 PMCID: PMC7891607 DOI: 10.1111/anae.15240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 01/28/2023]
Abstract
Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36-0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604-5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.
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Affiliation(s)
- K M Trentino
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - H S Mace
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - K Symons
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - F M Sanfilippo
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - M F Leahy
- Department of Haematology, PathWest Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - S L Farmer
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - A Hofmann
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - R D Watts
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - M H Wallace
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - K Murray
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
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15
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Rigal JC, Riche VP, Tching-Sin M, Fronteau C, Huon JF, Cadiet J, Boukhari R, Vourc'h M, Rozec B. Cost of red blood cell transfusion; evaluation in a French academic hospital. Transfus Clin Biol 2020; 27:222-228. [PMID: 32810606 DOI: 10.1016/j.tracli.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The economic impact of Patient blood management (PBM) must be assessed beyond the acquisition cost of blood products alone. The estimate of indirect costs may vary depending on the organization and the elements taken into account. The transposition of data from the literature into a specific local context is therefore delicate. The objective of this work was to evaluate the overall cost of red blood cell concentrate (RBC) transfusion from a French healthcare establishment point of view. METHODS We carried out an activity based costing analysis in our hospital for the year 2018. The steps of the transfusion process and additional costs were detailed and cumulated (resource consumption, labor time, frequency) to populate the ABC model. Several scenarios were developed focusing either on RBC, all blood products or the surgical activity, and a univariate sensitivity analysis was conducted. RESULTS The average total cost of transfusion, including acquisition cost, was 339,64 euros per RBC transfused. The cost of administration was 138.41 euros/RBC. Focusing only on surgical activities increased this cost (152.43 euros) while taking all blood products into account reduced it (92.49 euros). CONCLUSION The difference in our results with the literature confirms the local variability in the cost of transfusion, which may affect the economic impact of PBM. Our study related to the specific context of a single French institution has limitations that a multicenter study would clarify in order to carry out economic modelling of transfusion optimization and alternatives and to guide the choice of PBM strategies at the national level.
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Affiliation(s)
- J-C Rigal
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - V P Riche
- Département recherche clinique partenariat et innovation, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - M Tching-Sin
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - C Fronteau
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - J-F Huon
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - J Cadiet
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - R Boukhari
- Unité de sécurité transfusionnelle et d'hémovigilance, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - M Vourc'h
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - B Rozec
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France; CNRS, Inserm, l'institut du thorax, université de Nantes, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
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16
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Rigal JC. WITHDRAWN: Évaluation du coût de la transfusion de concentrés de globules rouges dans un établissement de soins français. Transfus Clin Biol 2020:S1246-7820(20)30080-X. [PMID: 32593713 DOI: 10.1016/j.tracli.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Affiliation(s)
- J-C Rigal
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, centre hospitalier universitaire de Nantes, 5, allée de l'Île-Gloriette, 44093 Nantes cedex 1, France
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17
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Newcomb AE, Dignan R, McElduff P, Pearse EJ, Bannon P. Bleeding After Cardiac Surgery Is Associated With an Increase in the Total Cost of the Hospital Stay. Ann Thorac Surg 2020; 109:1069-1078. [DOI: 10.1016/j.athoracsur.2019.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/24/2019] [Accepted: 11/15/2019] [Indexed: 11/29/2022]
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18
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Silverstein A, Reddy K, Smith V, Foster JH, Russell HV, Whittle SB. Blood product administration during high risk neuroblastoma therapy. Pediatr Hematol Oncol 2020; 37:5-14. [PMID: 31829069 PMCID: PMC6942619 DOI: 10.1080/08880018.2019.1668095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The increasing intensity of high-risk neuroblastoma (HR NB) treatment over the last decades has resulted in improved survival at the expense of prolonging therapy and exposure to additional potentially toxic agents. Anemia and thrombocytopenia requiring transfusion are common during therapy for HR NB. Risks of cumulative red blood cell and platelet transfusions are incompletely defined in pediatric oncology patients, however, risks of transfusional iron overload are well described in other populations. This study aimed to determine the number of packed red blood cell (pRBC) and platelet transfusions throughout treatment for HR NB and how these numbers have changed with modern therapy. We performed a retrospective review of 92 patients with HR NB from June 2002 until September 2017. Patients received a median of 20 pRBC and 32 platelet transfusions. Our results demonstrated large numbers of transfusions with significantly increased blood product exposures among patients who received intensified therapy, either with additional induction chemotherapy, tandem autologous stem cell transplants, or dinutuximab plus cytokines with isotretinoin. Similar volumes of pRBC transfusions have been associated with iron overload in other populations and warrant further discussion of guidelines for long-term follow up of HR NB patients.
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Affiliation(s)
- Allison Silverstein
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Kiranmye Reddy
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Valeria Smith
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Jennifer H. Foster
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Heidi V. Russell
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Sarah B. Whittle
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
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19
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Steinmetzer T, Pilgram O, Wenzel BM, Wiedemeyer SJA. Fibrinolysis Inhibitors: Potential Drugs for the Treatment and Prevention of Bleeding. J Med Chem 2019; 63:1445-1472. [PMID: 31658420 DOI: 10.1021/acs.jmedchem.9b01060] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hyperfibrinolytic situations can lead to life-threatening bleeding, especially during cardiac surgery. The approved antifibrinolytic agents such as tranexamic acid, ε-aminocaproic acid, 4-aminomethylbenzoic acid, and aprotinin were developed in the 1960s without the structural insight of their respective targets. Crystal structures of the main antifibrinolytic targets, the lysine binding sites on plasminogen's kringle domains, and plasmin's serine protease domain greatly contributed to the structure-based drug design of novel inhibitor classes. Two series of ligands targeting the lysine binding sites have been recently described, which are more potent than the most-widely used antifibrinolytic agent, tranexamic acid. Furthermore, four types of promising active site inhibitors of plasmin have been developed: tranexamic acid conjugates targeting the S1 pocket and primed sites, substrate-analogue linear homopiperidylalanine-containing 4-amidinobenzylamide derivatives, macrocyclic inhibitors addressing nonprimed binding regions, and bicyclic 14-mer SFTI-1 analogues blocking both, primed and nonprimed binding sites of plasmin. Furthermore, several allosteric plasmin inhibitors based on heparin mimetics have been developed.
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Affiliation(s)
- Torsten Steinmetzer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Oliver Pilgram
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Benjamin M Wenzel
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
| | - Simon J A Wiedemeyer
- Department of Pharmacy, Institute of Pharmaceutical Chemistry , Philipps University Marburg , Marbacher Weg 6 , D-35032 Marburg , Germany
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20
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Yoo JS, Ahn J, Karmarkar SS, Lamoutte EH, Singh K. The use of tranexamic acid in spine surgery. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:S172. [PMID: 31624738 PMCID: PMC6778277 DOI: 10.21037/atm.2019.05.36] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/13/2019] [Indexed: 11/06/2022]
Abstract
Patients undergoing surgical procedures of the spine with associated large volume blood loss often require perioperative blood conservation strategies. Synthetic antifibrinolytic medications such as tranexamic acid (TXA) may reduce blood transfusion requirements and postoperative complications following spinal procedures. Studies investigating the role of TXA in spine surgery have presented promising results and have proven its safety and efficacy. However, further investigation is needed to determine the optimal dosing regimen of TXA. In this article, we provide an overview of the basic science and pharmacology of TXA. A comprehensive summary of the findings from clinical trials and a review of the literature that demonstrate the risks and benefits of TXA in spine surgery are also presented.
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Affiliation(s)
- Joon S Yoo
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Junyoung Ahn
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sailee S Karmarkar
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Eric H Lamoutte
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Kern Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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21
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Chai KL, Cole-Sinclair M. Review of available evidence supporting different transfusion thresholds in different patient groups with anemia. Ann N Y Acad Sci 2019; 1450:221-238. [PMID: 31359453 DOI: 10.1111/nyas.14203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 05/16/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
In patients with anemia, transfusion of red blood cells (RBCs) can save lives and improve quality of life. The choice to transfuse should be cautiously made owing to risks of transfusion, economic costs, and limitations on the blood supply. Until the 1980s, the decision for RBC transfusion was guided by Hb threshold, with the aim of maintaining the patient's blood Hb level over 100 grams per liter. Since then, multiple randomized controlled trials and key systematic reviews have provided evidence-based guidelines as to appropriate transfusion thresholds in a number of clinical settings. Here, we aimed to address the outcome of defining different anemia criteria in specific clinical populations exclusively on the basis of the need for RBC transfusion based on Hb concentration. We focused on the patient populations, where there were the most available data on differing transfusion thresholds, which looked at transfusing to a higher or liberal transfusion threshold in comparison with a lower or restrictive transfusion threshold. These included patients in intensive care with or without septic shock, hip fracture surgery, cardiovascular surgery, and upper gastrointestinal bleeding, the pediatric population, and also those with malaria, by reviewing key randomized controlled trials and systematic reviews. Twenty-four randomized controlled studies and 12 systematic reviews have been included, and these are discussed below.
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Affiliation(s)
- Khai Li Chai
- Department of Haematology, St Vincent's Hospital, Melbourne, Victoria, Australia
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22
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Okorie CO, Pisters LL. Evolution of Bloodless Surgery: A Case for Bloodless Suprapubic Prostatectomy. Niger Med J 2019; 60:169-174. [PMID: 31831934 PMCID: PMC6892331 DOI: 10.4103/nmj.nmj_121_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 08/06/2019] [Accepted: 08/11/2019] [Indexed: 11/04/2022] Open
Abstract
Allogeneic blood transfusion is commonly prescribed to patients undergoing suprapubic prostatectomy for benign prostatic hyperplasia as a treatment option to replace blood loss. Historically, suprapubic prostatectomy has been perceived as an extremely high hemorrhagic surgery, and this has led to the association of suprapubic prostatectomy with a high rate of allogeneic blood transfusion. However, the outcome of suprapubic prostatectomy has significantly improved over the years and has become less hemorrhagic in many hands - creating the opportunity to consistently avoid allogeneic blood transfusion. On the other hand, the efficacy of blood transfusion has come under more stringent scrutiny as many clinical studies have reported inconsistent effects of blood transfusion on patient outcome. In contemporary practice, a more conservative/bloodless approach in the perioperative management of anemia in surgical patients is strongly being advocated with convincing evidence that many surgical patients can be routinely and safely managed without allogeneic blood transfusion. There is no large-scale discussion on bloodless surgery in urology in the contemporary literature, especially in the area of suprapubic prostatectomy that has been historically associated with a high rate of blood transfusion. This review article will discuss the evolution of bloodless surgery including the ongoing controversies surrounding blood transfusion in general, and then the relatively small but ongoing penetration of bloodless surgical approach in the field of suprapubic prostatectomy. Furthermore, the authors' approach to bloodless suprapubic prostatectomy will be highlighted, and in doing so, it can be emphasized that suprapubic prostatectomy is no more as hemorrhagic as was historically perceived, but rather a routine bloodless suprapubic prostatectomy is now possible in many hands.
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Affiliation(s)
- Chukwudi Ogonnaya Okorie
- Department of Surgery, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- Department of Surgery, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
| | - Louis L. Pisters
- Department of Urology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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23
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Abstract
Background: Significant blood loss is still one of the most frequent complications in spinal surgery, which often necessitates blood transfusion. Massive perioperative blood loss and blood transfusion can create additional risks. Aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The aim of this study was to evaluate the efficacy and safety of aprotinin, EACA, and low/high doses of TXA in spinal surgery, and assess the use of which agent is the most optimal intervention using the network meta-analysis (NMA) method. Methods: Five electronic databases were searched, including PubMed, Cochrane Library, ScienceDirect, Embase, and Web of Science, from the inception to March 1, 2018. Trials that were randomized and compared results between TXA, EACA, and placebo were identified. The NMA was conducted with software R 3.3.2 and STATA 14.0. Results: Thirty randomized controlled trial (RCT) studies were analyzed. Aprotinin (standardized mean difference [SMD]=−0.65, 95% credibility intervals [CrI;−1.25, −0.06]), low-dose TXA (SMD = −0.58, 95% CrI [−0.92, −0.25]), and high-dose TXA (SMD = −0.70, 95% CrI [−1.04, −0.36]) were more effective than the respective placebos in reducing intraoperative blood loss. Low-dose TXA (SMD = −1.90, 95% CrI [−3.32, −0.48]) and high-dose TXA (SMD = −2.31, 95% CrI [−3.75, −0.87]) had less postoperative blood loss. Low-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) and high-dose TXA (SMD = −1.07, 95% CrI [−1.82, −0.31]) significantly reduced total blood loss. However, only high-dose TXA (SMD = −2.07, 95% CrI [−3.26, −0.87]) was more effective in reducing the amount of transfusion, and was significantly superior to low-dose TXA in this regard (SMD = −1.67, 95% CrI [−3.20, −0.13]). Furthermore, aprotinin (odds ratio [OR] = 0.16, 95% CrI [0.05, 0.54]), EACA (OR = 0.46, 95% CrI [0.22, 0.97]) and high dose of TXA (OR = 0.34, 95% CrI [0.19, 0.58]) had a significant reduction in transfusion rates. Antifibrinolytics did not show a significantly increased risk of postoperative thrombosis. Results of ranking probabilities indicated that high-dose TXA had the greatest efficacy and a relatively high safety level. Conclusions: The antifibrinolytic agents are able to reduce perioperative blood loss and transfusion requirement during spine surgery. And the high-dose TXA administration might be used as the optimal treatment to reduce blood loss and transfusion.
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24
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Lam JH, Ng O. Monitoring clinical decision support in the electronic health record. Am J Health Syst Pharm 2019; 74:1130-1133. [PMID: 28743777 DOI: 10.2146/ajhp160819] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Jason H Lam
- UCSD Skaggs School of Pharmacy and Pharmaceutical SciencesLa Jolla, CASharp HealthcareSan Diego,
| | - Olivia Ng
- University of San DiegoSan Diego, CA
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25
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Abdullah HR, Ang AL, Froessler B, Hofmann A, Jang JH, Kim YW, Lasocki S, Lee JJ, Lee SY, Lim KKC, Singh G, Spahn DR, Um TH. Getting patient blood management Pillar 1 right in the Asia-Pacific: a call for action. Singapore Med J 2019; 61:287-296. [PMID: 31044255 DOI: 10.11622/smedj.2019037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Preoperative anaemia is common in the Asia-Pacific. Iron deficiency anaemia (IDA) is a risk factor that can be addressed under patient blood management (PBM) Pillar 1, leading to reduced morbidity and mortality. We examined PBM implementation under four different healthcare systems, identified challenges and proposed several measures: (a) Test for anaemia once patients are scheduled for surgery. (b) Inform patients about risks of preoperative anaemia and benefits of treatment. (c) Treat IDA and replenish iron stores before surgery, using intravenous iron when oral treatment is ineffective, not tolerated or when rapid iron replenishment is needed; transfusion should not be the default management. (d) Harness support from multiple medical disciplines and relevant bodies to promote PBM implementation. (e) Demonstrate better outcomes and cost savings from reduced mortality and morbidity. Although PBM implementation may seem complex and daunting, it is feasible to start small. Implementing PBM Pillar 1, particularly in preoperative patients, is a sensible first step regardless of the healthcare setting.
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Affiliation(s)
| | - Ai Leen Ang
- Department of Haematology, Singapore General Hospital, Singapore
| | - Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, Discipline of Acute Care Medicine, University of Adelaide, Australia
| | - Axel Hofmann
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland.,Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Australia.,Faculty of Health Sciences, Curtin University Western Australia, Australia
| | - Jun Ho Jang
- Division of Hematology-Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Woo Kim
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, South Korea
| | - Sigismond Lasocki
- Department of Anesthesiology, Critical Care and Emergency, Angers University Hospital, France
| | - Jeong Jae Lee
- Department of Obstetrics and Gynecology, Soonchunhyang University, South Korea
| | - Shir Ying Lee
- Department of Laboratory Medicine, Haematology Division, National University Hospital, Singapore
| | - Kar Koong Carol Lim
- Department of Obstetrics and Gynaecology, Hospital Sultan Haji Ahmad Shah, Pahang, Malaysia
| | - Gurpal Singh
- Division of Hip and Knee Surgery, National University Hospital, Singapore.,Division of Musculoskeletal Oncology, National University Hospital, Singapore
| | - Donat R Spahn
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Tae Hyun Um
- Department of Laboratory Medicine, Inje University Ilsan Paik Hospital, South Korea
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26
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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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Sudprasert W, Tanaviriyachai T, Choovongkomol K, Jongkittanakul S, Piyapromdee U. A Randomized Controlled Trial of Topical Application of Tranexamic Acid in Patients with Thoracolumbar Spine Trauma Undergoing Long-Segment Instrumented Posterior Spinal Fusion. Asian Spine J 2018; 13:146-154. [PMID: 30347526 PMCID: PMC6365782 DOI: 10.31616/asj.2018.0125] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 07/25/2018] [Indexed: 12/31/2022] Open
Abstract
Study Design Prospective, randomized controlled trial. Purpose To evaluate the effect of topically applied tranexamic acid (TXA) on postoperative blood loss of neurologically intact patients with thoracolumbar spine trauma. Overview of Literature Few articles exist regarding the use of topical TXA for postoperative bleeding and blood transfusion in spinal surgery. Methods A total of 57 patients were operated on with long-segment instrumented fusion without decompression. In 29 patients, a solution containing 1 g of TXA (20 mL) was applied to the site of surgery via a drain tube after the spinal fascia was closed, and then the drain was clamped for 2 hours. The 28 patients in the control group received the same volume of normal saline, and clamping was performed using the same technique. The groups were compared for postoperative packed red cells (PRC) transfusion rate and drainage volume. Results The rate of postoperative PRC transfusion was significantly lower in the topical TXA group than in the control group (13.8% vs. 39.3%; relative risk, 0.35; 95% confidence interval, 0.13 to 0.97; p=0.03). The mean total drainage volume was significantly lower in the topical TXA group than in the control group (246.7±125 mL vs. 445.7±211.1 mL, p<0.01). No adverse events or complications were recorded in any patient during treatment over a mean follow-up period of 27.5 months. Conclusions The use of topically administered 1 g TXA in thoracic and lumbar spinal trauma cases effectively decreased postoperative transfusion requirements and minimized postoperative blood loss, as determined by the total drainage volume.
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Affiliation(s)
- Weera Sudprasert
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Terdpong Tanaviriyachai
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Kongtush Choovongkomol
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Sarut Jongkittanakul
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
| | - Urawit Piyapromdee
- Department of Orthopedic Surgery, Maharat Nakhon Ratchasima Hospital, Nakhon Ratchasima, Thailand
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Basora M, Pereira A, Coca M, Tió M, Lozano L. Cost-effectiveness analysis of ferric carboxymaltose in pre-operative haemoglobin optimisation in patients undergoing primary knee arthroplasty. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 16:438-442. [PMID: 30036177 PMCID: PMC6125239 DOI: 10.2450/2018.0031-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 06/05/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND An analytic-decision model was built to estimate the cost-effectiveness of using ferric carboxymaltose for pre-operative haemoglobin optimisation in patients with iron deficiency anaemia undergoing primary knee arthroplasty. MATERIALS AND METHODS We simulated 20,000 patients who were randomly assigned to the haemoglobin optimisation arm or the non-optimisation control arm in a strict 1:1 ratio. The main outcomes were cost per patient transfusion avoided and red blood cell units spared. The analyses were performed from the hospital perspective with length of stay as the time horizon. RESULTS In the reference case scenario, pre-operative haemoglobin optimisation led to fewer patients being exposed to allogeneic red blood cell transfusion (2,212 vs 6,595 out of 10,000 patients) and a relevant decrease in the number of red blood cell units transfused (4.342 vs 13.336). The costs of avoiding one patient transfusion and sparing one red blood cell unit were € 831 and € 405, respectively. Increased costs in the optimisation arm were mostly associated with the outpatient day hospital visit (54%) and ferric carboxymaltose treatment (40%). DISCUSSION In primary knee arthroplasty, pre-operative haemoglobin optimisation with intravenous ferric carboxymaltose is less expensive than other reported patient blood management modalities and must be considered in patients with iron deficiency anaemia.
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Affiliation(s)
| | - Arturo Pereira
- Department of Haemotherapy and Haemostasis, Hospital Clinic Barcelona, Barcelona, Spain
| | - Miquel Coca
- Department of Anaesthesiology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Montse Tió
- Department of Anaesthesiology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Lluís Lozano
- Department of Orthopaedic Surgery, Hospital Clinic Barcelona, Barcelona, Spain
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Muniz Castro J, Burton K, Thurer RL, Bernal NP. How does blood loss relate to the extent of surgical wound excision? Burns 2018; 44:1130-1134. [DOI: 10.1016/j.burns.2018.04.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/22/2018] [Accepted: 04/10/2018] [Indexed: 12/31/2022]
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Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP). HPB (Oxford) 2018; 20:669-675. [PMID: 29459001 DOI: 10.1016/j.hpb.2018.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/21/2017] [Accepted: 01/07/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Risk of red blood cell transfusion (RBCT) in partial hepatectomy is 17-27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database. METHODS TRIPOD guidelines were followed. A validation cohort was created with the ACS-NSQIP dataset. Risk groups for RBCT were created using the TRS: anemia (hematocrit ≤36%), major liver resection (≥4 segments) and primary liver malignancy. Concordance index was used to assess the discrimination. The Hosmer-Lemeshow test for goodness of fit and calibration curves were used to assess calibration. RESULTS Of 2854 hepatectomies, 18.9% received RBCT. The TRS stratified patients from low (8.5% risk of RBCT) to very high risk (40.6%) of RBCT. The concordance was 0.68 (95% CI 0.66-0.70). Hosmer-Lemeshow test and calibration curves supported good predictive performance of the model. CONCLUSION The TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify patients at high transfusion risk. It can be used to tailor patient blood management initiatives and reduce the use of RBCT.
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Blaudszun G, Butchart A, Klein AA. Blood conservation in cardiac surgery. Transfus Med 2017; 28:168-180. [DOI: 10.1111/tme.12475] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 12/30/2022]
Affiliation(s)
- G. Blaudszun
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
| | - A. Butchart
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
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Leahy MF, Trentino KM, May C, Swain SG, Chuah H, Farmer SL. Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program. Transfusion 2017; 57:2189-2196. [PMID: 28671296 DOI: 10.1111/trf.14191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. STUDY DESIGN AND METHODS A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality. RESULTS Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study. CONCLUSION The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.
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Affiliation(s)
- Michael F Leahy
- School of Medicine and Pharmacology
- Department of Haematology
- PathWest Laboratory Medicine, Royal Perth Hospital
| | | | | | - Stuart G Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | | | - Shannon L Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia
- Centre for Population Health Research, Faculty of Health, Sciences, Curtin University, Perth, Western Australia, Australia
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Ngwenya LB, Suen CG, Tarapore PE, Manley GT, Huang MC. Safety and cost efficiency of a restrictive transfusion protocol in patients with traumatic brain injury. J Neurosurg 2017. [PMID: 28644101 DOI: 10.3171/2017.1.jns162234] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Blood loss and moderate anemia are common in patients with traumatic brain injury (TBI). However, despite evidence of the ill effects and expense of the transfusion of packed red blood cells, restrictive transfusion practices have not been universally adopted for patients with TBI. At a Level I trauma center, the authors compared patients with TBI who were managed with a restrictive (target hemoglobin level > 7 g/dl) versus a liberal (target hemoglobin level > 10 g/dl) transfusion protocol. This study evaluated the safety and cost-efficiency of a hospital-wide change to a restrictive transfusion protocol. METHODS A retrospective analysis of patients with TBI who were admitted to the intensive care unit (ICU) between January 2011 and September 2015 was performed. Patients < 16 years of age and those who died within 24 hours of admission were excluded. Demographic data and injury characteristics were compared between groups. Multivariable regression analyses were used to assess hospital outcome measures and mortality rates. Estimates from an activity-based cost analysis model were used to detect changes in cost with transfusion protocol. RESULTS A total of 1565 patients with TBI admitted to the ICU were included in the study. Multivariable analysis showed that a restrictive transfusion strategy was associated with fewer days of fever (p = 0.01) and that patients who received a transfusion had a larger fever burden. ICU length of stay, ventilator days, incidence of lung injury, thromboembolic events, and mortality rates were not significantly different between transfusion protocol groups. A restrictive transfusion protocol saved approximately $115,000 annually in hospital direct and indirect costs. CONCLUSIONS To the authors' knowledge, this is the largest study to date to compare transfusion protocols in patients with TBI. The results demonstrate that a hospital-wide change to a restrictive transfusion protocol is safe and cost-effective in patients with TBI.
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Affiliation(s)
- Laura B Ngwenya
- 1Department of Neurological Surgery and.,2Brain and Spinal Injury Center, University of California, San Francisco, California
| | - Catherine G Suen
- 1Department of Neurological Surgery and.,2Brain and Spinal Injury Center, University of California, San Francisco, California
| | - Phiroz E Tarapore
- 1Department of Neurological Surgery and.,2Brain and Spinal Injury Center, University of California, San Francisco, California
| | - Geoffrey T Manley
- 1Department of Neurological Surgery and.,2Brain and Spinal Injury Center, University of California, San Francisco, California
| | - Michael C Huang
- 1Department of Neurological Surgery and.,2Brain and Spinal Injury Center, University of California, San Francisco, California
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Lagerquist O, Poseluzny D, Werstiuk G, Slomp J, Maier M, Nahirniak S, Clarke G. The cost of transfusing a unit of red blood cells: a costing model for Canadian hospital use. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/voxs.12355] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- O. Lagerquist
- Northern Alberta Institute of Technology; Edmonton AB Canada
| | | | - G. Werstiuk
- Northern Alberta Institute of Technology; Edmonton AB Canada
| | - J. Slomp
- Northern Alberta Institute of Technology; Edmonton AB Canada
| | - M. Maier
- University of Alberta; Edmonton AB Canada
| | - S. Nahirniak
- Alberta Health Services; Edmonton AB Canada
- University of Alberta; Edmonton AB Canada
| | - G. Clarke
- Alberta Health Services; Edmonton AB Canada
- University of Alberta; Edmonton AB Canada
- Canadian Blood Services
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Smith I, Pearse BL, Faulke DJ, Naidoo R, Nicotra L, Hopkins P, Ryan EG. Targeted Bleeding Management Reduces the Requirements for Blood Component Therapy in Lung Transplant Recipients. J Cardiothorac Vasc Anesth 2017; 31:426-433. [DOI: 10.1053/j.jvca.2016.06.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Indexed: 11/11/2022]
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Peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 15:296-306. [PMID: 28151388 DOI: 10.2450/2017.0177-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/31/2016] [Indexed: 12/16/2022]
Abstract
In patients undergoing major orthopaedic surgery, pre-operative anaemia, peri-operative bleeding and a liberal transfusion policy are the main risk factors for requiring red blood cell transfusion (RBCT). The clinical and economic disadvantages of RBCT have led to the development and implementation of multidisciplinary, multimodal, individualised strategies, collectively termed patient blood management, which aim to reduce RBCT and improve patients' clinical outcome and safety. Within a patient blood management programme, low pre-operative haemoglobin is one of the few modifiable risk factors for RBCT. However, a survey among Anaesthesia Departments in Spain revealed that, although pre-operative assessment was performed in the vast majority of hospitals, optimisation of haemoglobin concentration was attempted in <40% of patients who may have benefitted from it, despite there being enough time prior to surgery. This indicates that haemoglobin optimisation takes planning and forethought to be implemented in an effective manner. This review, based on available clinical evidence and our experience, is intended to provide clinicians with a practical tool to optimise pre-operative haemoglobin levels, in order to minimise the risk of patients requiring RBCT. To this purpose, after reviewing the diagnostic value and limitations of available laboratory parameters, we developed an algorithm for the detection, classification and treatment of pre-operative anaemia, with a patient-tailored approach that facilitates decision-making in the pre-operative assessment. We also reviewed the efficacy of the different pharmacological options for pre-operative and post-operative management of anaemia. We consider that such an institutional pathway for anaemia management could be a viable, cost-effective strategy that is beneficial to both patients and healthcare systems.
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Abstract
BACKGROUND Preoperative anemia has a prevalence of approximately 30% and is one of the strongest predictors of perioperative red blood cell (RBC) transfusion. It is rarely treated although it is an independent risk factor for the occurrence of postoperative complications. Additionally, the high variability in the worldwide usage of RBC transfusions is alarming. Due to these serious deficits in patient care, in 2011 the World Health Organization recommended the implementation of a patient blood management (PBM). OBJECTIVES This article provides information about PBM as a multidimensional and interdisciplinary approach. MATERIAL AND METHODS A selective literature search was carried out in the Medline and Cochrane library databases including consideration of national and international guidelines. RESULTS A PBM promotes the medically and ethically appropriate use of all available resources, techniques and materials in favor of an optimized perioperative patient care. Patients' own resources should be specifically protected, strengthened and used and include (i) diagnosis and therapy of preoperative anemia, (ii) minimizing perioperative blood loss, (iii) blood-conserving surgical techniques, (iv) restriction of diagnostic blood sampling, (v) utilization of individual anemia tolerance, (vi) optimal coagulation and hemotherapy concepts and (vii) guideline-based, rational indications for the use of RBC transfusions. CONCLUSION A PBM should be advocated as an incentive to evaluate and critically optimize local conditions. An individual, interdisciplinarily structured bundle of different PBM measures has great potential to optimize the quality of patient care and to make it safer.
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Supra-plasma expanders: the future of treating blood loss and anemia without red cell transfusions? JOURNAL OF INFUSION NURSING 2016; 38:217-22. [PMID: 25871869 DOI: 10.1097/nan.0000000000000103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oxygen delivery capacity during profoundly anemic conditions depends on blood's oxygen-carrying capacity and cardiac output. Oxygen-carrying blood substitutes and blood transfusion augment oxygen-carrying capacity, but both have given rise to safety concerns, and their efficacy remains unresolved. Anemia decreases oxygen-carrying capacity and blood viscosity. Present studies show that correcting the decrease of blood viscosity by increasing plasma viscosity with newly developed plasma expanders significantly improves tissue perfusion. These new plasma expanders promote tissue perfusion, increasing oxygen delivery capacity without increasing blood oxygen-carrying capacity, thus treating the effects of anemia while avoiding the transfusion of blood.
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Baron D, Metnitz P, Fellinger T, Metnitz B, Rhodes A, Kozek-Langenecker S. Evaluation of clinical practice in perioperative patient blood management. Br J Anaesth 2016; 117:610-616. [DOI: 10.1093/bja/aew308] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2016] [Indexed: 01/07/2023] Open
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Kleinerüschkamp AG, Zacharowski K, Ettwein C, Müller MM, Geisen C, Weber CF, Meybohm P. [Cost analysis of patient blood management]. Anaesthesist 2016; 65:438-48. [PMID: 27160419 DOI: 10.1007/s00101-016-0152-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 01/21/2016] [Accepted: 02/18/2016] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patient blood management (PBM) is a multidisciplinary approach focusing on the diagnosis and treatment of preoperative anaemia, the minimisation of blood loss, and the optimisation of the patient-specific anaemia reserve to improve clinical outcomes. Economic aspects of PBM have not yet been sufficiently analysed. OBJECTIVES The aim of this study is to analyse the costs associated with the clinical principles of PBM and the project costs associated with the implementation of a PBM program from an institutional perspective. MATERIALS AND METHODS Patient-related costs of materials and services were analysed at the University Hospital Frankfurt for 2013. Personnel costs of all major processes were quantified based on the time required to perform each step. Furthermore, general project costs of the implementation phase were determined. RESULTS Direct costs of transfusing a single unit of red blood cells can be calculated to a minimum of €147.43. PBM-associated costs varied depending on individual patient requirements. The following costs per patient were calculated: diagnosis of preoperative anaemia €48.69-123.88; treatment of preoperative anaemia (including iron-deficiency anaemia and megaloblastic anaemia) €12.61-127.99; minimising perioperative blood loss (including point-of-care diagnostics, coagulation management and cell salvage) €3.39-1,901.81; and costs associated with the optimisation of the tolerance to anaemia (including patient monitoring and volume therapy) €28.62. General project costs associated with the implementation of PBM were €24,998.24. CONCLUSIONS PBM combines various alternatives to the transfusion of red blood cells and improves clinical outcome. Costs of PBM vary from institution to institution and depend on the extent to which different aspects of PBM have been implemented. The quantification of costs associated with PBM is essential in order to assess the economic impact of PBM, and thereby, to efficiently re-allocate health care resources. Costs were determined at a single university hospital. Thus, further analyses of both the costs of transfusion and the costs of PBM-principles will be necessary to evaluate the cost-effectiveness of PBM.
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Affiliation(s)
- A G Kleinerüschkamp
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - C Ettwein
- Dezernat 1, Finanz- und Rechnungswesen, Abteilung Operatives Controlling, Universitätsklinikum Frankfurt, Frankfurt am Main, Deutschland
| | - M M Müller
- DRK Blutspendedienst Baden-Württemberg Hessen, Institut für Transfusionsmedizin und Immunhämatologie, Frankfurt am Main, Deutschland
| | - C Geisen
- DRK Blutspendedienst Baden-Württemberg Hessen, Institut für Transfusionsmedizin und Immunhämatologie, Frankfurt am Main, Deutschland
| | - C F Weber
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - P Meybohm
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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Winter SF, Santaguida C, Wong J, Fehlings MG. Systemic and Topical Use of Tranexamic Acid in Spinal Surgery: A Systematic Review. Global Spine J 2016; 6:284-95. [PMID: 27099820 PMCID: PMC4836933 DOI: 10.1055/s-0035-1563609] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 07/13/2015] [Indexed: 01/17/2023] Open
Abstract
Study Design Combination of narrative and systematic literature reviews. Objectives Massive perioperative blood loss in complex spinal surgery often requires blood transfusions and can negatively affect patient outcome. Systemic use of the antifibrinolytic agent tranexamic acid (TXA) has become widely used in the management of surgical bleeding. We review the clinical evidence for the use of intravenous TXA as a hemostatic agent in spinal surgery and discuss the emerging role for its complementary use as a topical agent to reduce perioperative blood loss from the surgical site. Through a systematic review of published and ongoing investigations on topical TXA for spinal surgery, we wish to make spine practitioners aware of this option and to suggest opportunities for further investigation in the field. Methods A narrative review of systemic TXA in spinal surgery and topical TXA in surgery was conducted. Furthermore, a systematic search (using PRISMA guidelines) of PubMed (MEDLINE), EMBASE, and Cochrane CENTRAL databases as well as World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov (National Institutes of Health), and International Standard Randomized Controlled Trial Number registries was conducted to identify both published literature and ongoing clinical trials on topical TXA in spinal surgery. Results Of 1,631 preliminary search results, 2 published studies were included in the systematic review. Out of 285 ongoing clinical trials matching the search criteria, a total of 4 relevant studies were included and reviewed. Conclusion Intravenous TXA is established as an efficacious hemostatic agent in spinal surgery. Use of topical TXA in surgery suggests similar hemostatic efficacy and potentially improved safety as compared with intravenous TXA. For spinal surgery, the literature on topical TXA is sparse but promising, warranting further clinical investigation and consideration as a clinical option in cases with significant anticipated surgical site blood loss.
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Affiliation(s)
| | - Carlo Santaguida
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada,Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada,Address for correspondence Michael G. Fehlings, MD Suite 4W449, Toronto Western Hospital399 Bathurst Street, Toronto M5T 2S8, OntarioCanada
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Prescott LS, Taylor JS, Lopez-Olivo MA, Munsell MF, VonVille HM, Lairson DR, Bodurka DC. How low should we go: A systematic review and meta-analysis of the impact of restrictive red blood cell transfusion strategies in oncology. Cancer Treat Rev 2016; 46:1-8. [PMID: 27046422 PMCID: PMC4884540 DOI: 10.1016/j.ctrv.2016.03.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 03/16/2016] [Accepted: 03/21/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Most non-oncologic clinical practice guidelines recommend restrictive allogeneic blood transfusion practices; however, there is a lack of consensus regarding the best transfusion practice in oncology. We conducted a systematic review of the literature to compare the efficacy and safety of restrictive versus liberal transfusion strategies in patients with cancer. METHODS A literature search using MEDLINE, PUBMED and EMBASE identified all controlled studies comparing the use of restrictive with liberal transfusion in adult oncology participants up to August 10, 2015. Two review authors independently assessed studies for inclusion, extracted data and appraised the quality of the included studies. The primary outcomes of interest were blood utilization and all-cause mortality. RESULTS Out of 4241 citations, six studies (3 randomized and 3 non-randomized) involving a total of 983 patients were included in the final review. The clinical context of the studies varied with 3 chemotherapy and 3 surgical studies. The overall risk of bias in all studies was moderate to high. Restrictive transfusion strategies were associated with a 36% reduced risk of receiving a perioperative transfusion (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.49-0.83). There was no difference in mortality between the strategies (RR 1.00, 95% CI 0.32-3.18). There were no differences in adverse events reported between the restrictive and liberal transfusion strategies. CONCLUSION Restrictive strategy appears to decrease blood utilization without increasing morbidity or mortality in oncology. This review is limited by a paucity of high quality studies on this topic. Better designed studies are warranted.
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Affiliation(s)
- Lauren S Prescott
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Maria A Lopez-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mark F Munsell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Helena M VonVille
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - David R Lairson
- The University of Texas School of Public Health, Houston, TX 77030, USA
| | - Diane C Bodurka
- Department of Clinical Education, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Shander A, Ozawa S, Hofmann A. Activity-based costs of plasma transfusions in medical and surgical inpatients at a US hospital. Vox Sang 2016; 111:55-61. [DOI: 10.1111/vox.12386] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 12/17/2015] [Accepted: 01/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- A. Shander
- Department of Anesthesiology; Critical Care and Hyperbaric Medicine; Englewood Hospital and Medical Center; Englewood NJ USA
- Clinical Professor of Anesthesiology; Medicine and Surgery; Icahn School of Medicine at Mount Sinai; New York NY USA
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - S. Ozawa
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
| | - A. Hofmann
- School of Surgery; Faculty of Medicine Dentistry and Health Sciences; University of Western Australia; Perth WA Australia
- Centre for Population Health Research; Curtin Health Innovation Research Institute; Curtin University; Perth WA Australia
- Institute of Anaesthesiology; University Hospital and University of Zurich; Zurich Switzerland
- Institute for Bloodless Medicine and Patient Blood Management; Englewood Hospital & Medical Center; Englewood NJ USA
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45
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Ranucci M. Outcome measures and quality markers for perioperative blood loss and transfusion in cardiac surgery. Can J Anaesth 2015; 63:169-75. [DOI: 10.1007/s12630-015-0515-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2015] [Revised: 09/16/2015] [Accepted: 10/14/2015] [Indexed: 11/24/2022] Open
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Abstract
The liberal use of transfusions is not only a risk for patients but also represents a significant healthcare expenditure. The rational use of allogeneic blood transfusions and the use of transfusion alternatives, such as the optimization of preoperative hemoglobin levels, can offer substantial savings to health departments by reducing the cost of transfusions and the morbidity related to the transfusions.
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47
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Clevenger B, Mallett SV, Klein AA, Richards T. Patient blood management to reduce surgical risk. Br J Surg 2015; 102:1325-37; discussion 1324. [PMID: 26313653 DOI: 10.1002/bjs.9898] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND Preoperative anaemia and perioperative blood transfusion are both identifiable and preventable surgical risks. Patient blood management is a multimodal approach to address this issue. It focuses on three pillars of care: the detection and treatment of preoperative anaemia; the reduction of perioperative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anaemia, including restrictive haemoglobin transfusion triggers. This article reviews why patient blood management is needed and strategies for its incorporation into surgical pathways. METHODS Studies investigating the three pillars of patient blood management were identified using PubMed, focusing on recent evidence-based guidance for perioperative management. RESULTS Anaemia is common in surgical practice. Both anaemia and blood transfusion are independently associated with adverse outcomes. Functional iron deficiency (iron restriction due to increased levels of hepcidin) is the most common cause of preoperative anaemia, and should be treated with intravenous iron. Intraoperative blood loss can be reduced with antifibrinolytic drugs such as tranexamic acid, and cell salvage should be used. A restrictive transfusion practice should be the standard of care after surgery. CONCLUSION The significance of preoperative anaemia appears underappreciated, and its detection should lead to routine investigation and treatment before elective surgery. The risks of unnecessary blood transfusion are increasingly being recognized. Strategic adoption of patient blood management in surgical practice is recommended, and will reduce costs and improve outcomes in surgery.
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Affiliation(s)
- B Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - S V Mallett
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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48
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Orbe J, Rodríguez JA, Sánchez-Arias JA, Salicio A, Belzunce M, Ugarte A, Chang HCY, Rabal O, Oyarzabal J, Páramo JA. Discovery and safety profiling of a potent preclinical candidate, (4-[4-[[(3R)-3-(hydroxycarbamoyl)-8-azaspiro[4.5]decan-3-yl]sulfonyl]phenoxy]-N-methylbenzamide) (CM-352), for the prevention and treatment of hemorrhage. J Med Chem 2015; 58:2941-57. [PMID: 25686022 DOI: 10.1021/jm501939z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Discovery of potent and safe therapeutics that improve upon currently available antifibrinolytics, e.g., tranexamic acid (TXA, 1) and aprotinin, has been challenging. Matrix metalloproteinases (MMPs) participate in thrombus dissolution. Then we designed a novel series of optimized MMP inhibitors that went through phenotypic screening consisting of thromboelastometry and mouse tail bleeding. Our optimized lead compound, CM-352 (2), inhibited fibrinolysis in human whole blood functional assays and was more effective than the current standard of care, 1, in the tail-bleeding model using a 30 000 times lower dose. Moreover, 2 reduced blood loss during liver hepatectomy, while 1 and aprotinin had no effect. Molecule 2 displayed optimal pharmacokinetic and safety profiles with no evidence of thrombosis or coagulation impairment. This novel mechanism of action, targeting MMP, defines a new class of antihemorrhagic agents without interfering with normal hemostatic function. Furthermore, 2 represents a preclinical candidate for the acute treatment of bleeding.
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Affiliation(s)
- Josune Orbe
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - José A Rodríguez
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Juan A Sánchez-Arias
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Agustina Salicio
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Miriam Belzunce
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Ana Ugarte
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Haisul C Y Chang
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Obdulia Rabal
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - Julen Oyarzabal
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
| | - José A Páramo
- †Atherosclerosis Research Laboratory, ‡Small Molecule Discovery Platform, Molecular Therapeutics Program, §Experimental Hepathology, Center for Applied Medical Research (CIMA), and ∥Hematology Service, Clínica Universidad de Navarra, University of Navarra, Pamplona, 31008, Spain
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Fayed N, Mourad W, Yassen K, Görlinger K. Preoperative Thromboelastometry as a Predictor of Transfusion Requirements during Adult Living Donor Liver Transplantation. Transfus Med Hemother 2015; 42:99-108. [PMID: 26019705 DOI: 10.1159/000381733] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 03/20/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The ability to predict transfusion requirements may improve perioperative bleeding management as an integral part of a patient blood management program. Therefore, the aim of our study was to evaluate preoperative thromboelastometry as a predictor of transfusion requirements for adult living donor liver transplant recipients. METHODS The correlation between preoperative thromboelastometry variables in 100 adult living donor liver transplant recipients and intraoperative blood transfusion requirements was examined by univariate and multivariate linear regression analysis. Thresholds of thromboelastometric parameters for prediction of packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate transfusion requirements were determined with receiver operating characteristics analysis. The attending anesthetists were blinded to the preoperative thromboelastometric analysis. However, a thromboelastometry-guided transfusion algorithm with predefined trigger values was used intraoperatively. The transfusion triggers in this algorithm did not change during the study period. RESULTS Univariate analysis confirmed significant correlations between PRBCs, FFP, platelets or cryoprecipitate transfusion requirements and most thromboelastometric variables. Backward stepwise logistic regression indicated that EXTEM coagulation time (CT), maximum clot firmness (MCF) and INTEM CT, clot formation time (CFT) and MCF are independent predictors for PRBC transfusion. EXTEM CT, CFT and FIBTEM MCF are independent predictors for FFP transfusion. Only EXTEM and INTEM MCF were independent predictors of platelet transfusion. EXTEM CFT and MCF, INTEM CT, CFT and MCF as well as FIBTEM MCF are independent predictors for cryoprecipitate transfusion. Thromboelastometry-based regression equation accounted for 63% of PRBC, 83% of FFP, 61% of cryoprecipitate, and 44% of platelet transfusion requirements. CONCLUSION Preoperative thromboelastometric analysis is helpful to predict transfusion requirements in adult living donor liver transplant recipients. This may allow for better preparation and less cross-matching prior to surgery. The findings of our study need to be re-validated in a second prospective patient population.
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Affiliation(s)
- Nirmeen Fayed
- Department of Anesthesia, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Wessam Mourad
- Department of Public Health, Community Medicine and Statistics, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Khaled Yassen
- Department of Anesthesia, National Liver Institute, Menoufiya University, Shebeen El Kom City, Egypt
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany ; Tem International GmbH, Munich, Germany
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50
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Trentino KM, Farmer SL, Swain SG, Burrows SA, Hofmann A, Ienco R, Pavey W, Daly FFS, Van Niekerk A, Webb SAR, Towler S, Leahy MF. Increased hospital costs associated with red blood cell transfusion. Transfusion 2014; 55:1082-9. [PMID: 25488623 DOI: 10.1111/trf.12958] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 08/26/2014] [Accepted: 10/17/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship. STUDY DESIGN AND METHODS A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs. RESULTS Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders. CONCLUSION RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.
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Affiliation(s)
- Kevin M Trentino
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Shannon L Farmer
- School of Surgery, University of Western Australia, Perth, Western Australia.,Centre for Population Health Research, Curtin University, Perth, Western Australia
| | - Stuart G Swain
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Sally A Burrows
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - Axel Hofmann
- School of Surgery, University of Western Australia, Perth, Western Australia.,Centre for Population Health Research, Curtin University, Perth, Western Australia
| | - Rinaldo Ienco
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia
| | - Warren Pavey
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia
| | - Frank F S Daly
- Royal Perth Group, South Metropolitan Health Service, Perth, Western Australia.,Center for Clinical Research in Emergency Medicine, University of Western Australia, Perth, Western Australia
| | - Anton Van Niekerk
- Department of Anaesthesiology, Fremantle Hospital, Fremantle, Western Australia
| | - Steven A R Webb
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria
| | - Simon Towler
- Department of Intensive Care, Royal Perth Hospital, Perth, Western Australia.,Service 4, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Michael F Leahy
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia.,Department of Haematology, PathWest, Fremantle Hospital, Fremantle, Western Australia
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