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Huang X, Du P, Jia H, Wang A, Hua Y, Liu X, Wu K, Li B, Zhao H. Methodologic Quality and Pharmacotherapy Recommendations for Patient Blood Management Guidelines for Cardiac Surgery on Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024; 38:1569-1576. [PMID: 38594156 DOI: 10.1053/j.jvca.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Patient blood management (PBM) guidelines for patients undergoing cardiac surgery under cardiopulmonary bypass (CPB) have increased during the past decade, and pharmacotherapy plays an important role in PBM. In the face of the undefined consistency in the methodologic quality and pharmacotherapy recommendations across multiple guidelines, this study exclusively evaluated methodologies of the related guideline development process, and compiled medication recommendations of PBM for cardiac surgery patients. PBM guidelines for cardiac surgery under CPB were searched through some mainstream literature and guideline databases from database establishment to May 15, 2023. Nine guidelines meeting inclusion criteria were included in this study. The quality of the guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. "Stakeholder involvement" received the lowest mean score of 49.38% in the AGREE II scoring among the guidelines. PBM for cardiac surgery patients spans the perioperative phase. Drug therapy strategies of PBM for cardiac surgery patients involve anemia therapy, perioperative administration of antithrombotic drugs, intraoperative anticoagulation, and the use of hemostatic drugs. Unlike for adults, there is less evidence about the management of antithrombotic drugs and hemostatic drugs for pediatric cardiac surgery patients. Recombinant activated factor VII (rFVIIa) and desmopressin (DDAVP) are not recommended after pediatric cardiac surgery, whereas prothrombin complex concentrate could be considered in clinical trials. As for the controversies regarding the administration of rFVIIa and DDAVP after adult cardiac surgery by different societies, clinicians should exercise their clinical judgment based on individual patient features.
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Affiliation(s)
- Xiaojing Huang
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Pengqiang Du
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Haipan Jia
- Department of Pharmacy, Henan Provincial People's Hospital, Zhengzhou, China
| | - Aifeng Wang
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Ying Hua
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Xuelan Liu
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Kaiyuan Wu
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Bin Li
- Children's Heart Center Intensive Care Unit, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
| | - Hongwei Zhao
- Department of Pharmacy, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China.
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2
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Czarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, Bourgain C, Caron M, Kiss G, Larghi M, Lebard C, Mellano V, Larson J, Megroian B, Lefrançois A, Fox S, Pollet A, Bourgoin P, Biland G, Braunberger E, Maccio G, Delmas B. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth 2024; 38:73-79. [PMID: 37953174 DOI: 10.1053/j.jvca.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/12/2023] [Accepted: 10/16/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVES Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. DESIGN Before-and-after observational study. SETTING Single-center French university teaching hospital. PARTICIPANTS Adult patients scheduled for cardiac surgery. INTERVENTIONS Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. MEASUREMENTS AND MAIN RESULTS Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p = 0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p = 0.025). These effects persisted at day 30 after surgery (p = 0.029). CONCLUSION A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.
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Affiliation(s)
- Jeremie Czarnecka
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arthur Neuschwander
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France.
| | - Thomas Aujoulat
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Adrien Balmier
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Dominique Belcour
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Boris Boulanger
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Caroline Bourgain
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Margot Caron
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Gabor Kiss
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Mathilde Larghi
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Christophe Lebard
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Vincent Mellano
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Jonathan Larson
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Blandine Megroian
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Anaelle Lefrançois
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Sylvain Fox
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Arnaud Pollet
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Pierre Bourgoin
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France; Department of anesthesiology, University Hospital, Nantes, France
| | - Guillaume Biland
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Eric Braunberger
- Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Guillaume Maccio
- French Blood Establishment, Felix Guyon University Hospital, Saint-Denis, Reunion, France
| | - Benjamin Delmas
- Department of Anaesthesia and Critical Care for Cardiovascular and Thoracic Surgery, Felix Guyon University Hospital, Saint-Denis, Reunion, France
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3
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Friedman T, Dann EJ, Bitton-Worms K, Makhoul M, Glam R, Weis A, Tam DY, Bolotin G. Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia. Br J Anaesth 2023; 131:981-988. [PMID: 37838604 DOI: 10.1016/j.bja.2023.09.007] [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: 05/15/2023] [Revised: 09/02/2023] [Accepted: 09/14/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Reducing the need for blood transfusion among patients undergoing cardiac surgery FLA reduce postoperative complications and mortality. Our study aimed to assess the effects of administering preoperative i.v. ferric carboxymaltose on postoperative red cell transfusion requirements in patients without anaemia undergoing on-pump cardiac surgery. METHODS This double-blind, randomised, placebo-controlled trial was conducted between October 2016 and November 2019, with a follow-up period of up to 6 weeks after surgery. Patients without anaemia who underwent on-pump cardiac surgery were included as participants and administered i.v. iron in the form of ferric carboxymaltose or placebo once, 24-72 h before surgery. The primary outcome was the number of red cell units transfused during the first four postoperative days, and the secondary outcome measures were blood haemoglobin concentrations at 4 days and 6 weeks after surgery. RESULTS The 200 patients included were randomly assigned to the ferric carboxymaltose (n=102) and placebo (n=98) groups. By postoperative Day 4, a significantly lower mean number of red cell units were transfused in the ferric carboxymaltose than in the placebo group, 0.3 (0.8) vs 1.6 (4.4), respectively; P=0.007. The mean haemoglobin concentrations on postoperative Day 4 were 9.7 (1) g dl-1 and 9.3 (1) g dl-1, respectively (P=0.03). Corresponding values at 6 weeks after surgery were 12.6 (1.4) g dl-1 and 11.8 (1.5) g dl-1, respectively (P=0.012). CONCLUSIONS In patients without anaemia undergoing on-pump cardiac surgery, treatment with a single dose of 1000 mg ferric carboxymaltose i.v. 1-3 days before surgery significantly reduced the need for red cell transfusions and increased the postoperative haemoglobin concentration. CLINICAL TRIAL REGISTRATION NCT02939794.
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Affiliation(s)
- Tom Friedman
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Eldad J Dann
- Blood Bank and Apheresis Unit, Rambam Health Care Campus, Haifa, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | | | - Maged Makhoul
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Roi Glam
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Anastasia Weis
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Derrick Y Tam
- Division of Cardiac Surgery, University of Toronto, Toronto, ON, Canada
| | - Gil Bolotin
- Department of Cardiac Surgery, Rambam Health Care Campus, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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4
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Leviner DB, Abraham D, Shiner M, Schwartz N, Lavon O, Sharoni E. Implementation of a Short-term Treatment Protocol in Anemic Patients before Cardiac Surgery. Thorac Cardiovasc Surg 2023. [PMID: 37709298 DOI: 10.1055/a-2176-2218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND We assessed whether implementation of an immediate preoperative treatment in anemic patients could result in fewer perioperative packed red blood cell (PRBC) transfusions and improved outcomes in a real-world setting. METHODS From January 1, 2020, to November 31, 2022, we implemented a perioperative protocol for anemic patients (hemoglobin (Hb) level in women <11.5 g/dL, men <12.5 g/dL), which included subcutaneous erythropoietin α, intravenous Iron, and intramuscular vitamin B12 (all given preoperatively) and per os iron and folic acid given once a day postoperatively. We retrospectively compared all patients receiving the protocol to all eligible patients who were operated upon in the 4 years prior to implementation of the protocol. Primary outcome was amount of PRBC transfusions during surgery and index admission. RESULTS In the months after protocol implementation, 114 patients who received the treatment protocol were compared with 236 anemic patients in the 4 years prior to who did not receive the protocol. The treatment reduced total PRBC use (control group median 4 [2-7] units vs. treatment 2 [1-3] units, p < 0.0001) and the incidence of postoperative blood products transfusions (treatment group 58 patients, 50.88% vs. control group 177 patients, 75%, p < 0.0001). Hb prior to discharge was higher among the protocol group (treatment median 9 g/dL [8.3-9.5 g/dL] vs. control 8.6 g/dL [8.1-9.1 g/dL], p = 0.0081). CONCLUSION Despite some differences compared with previously described protocols, the implementation of a perioperative treatment protocol for anemic patients was associated with a reduction in PRBC transfusion in a real-world setting.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
| | - Dana Abraham
- Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
| | - Maayan Shiner
- Blood Bank Haifa, Carmel Medical Center, Haifa, Israel
| | - Naama Schwartz
- Research Authority, Carmel Medical Center, Haifa, Israel
| | - Ophir Lavon
- Clinical Pharmacology, Carmel Medical Center, Haifa, Israel
| | - Erez Sharoni
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa, Israel
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5
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Gyi R, Cho BC, Hensley NB. Patient Blood Management in Vascular Surgery. Anesthesiol Clin 2022; 40:605-625. [PMID: 36328618 DOI: 10.1016/j.anclin.2022.08.007] [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] [Indexed: 06/16/2023]
Abstract
Patient blood management (PBM) is an evidence-based, multidisciplinary approach aimed at appropriately allocating blood products to patients requiring transfusion while simultaneously minimizing inappropriate transfusions. The 3 pillars of patient blood management are optimizing erythropoiesis, minimizing blood loss, and optimizing physiological reserve of anemia. Benefits seen from PBM include limiting hospital costs and mitigating harm from numerous risks of transfusion.
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Affiliation(s)
- Richard Gyi
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Brian C Cho
- Department of Anesthesiology, Johns Hopkins Hospital, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA; Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA
| | - Nadia B Hensley
- Division of Cardiothoracic Anesthesiology, Johns Hopkins University School of Medicine, 1800 Orleans Avenue, Zayed Tower 6212, Baltimore, MD 21287, USA.
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6
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Hughes K, Jarosz A, Peng DM, Huebschman A. Epoetin alfa in Pediatric Patients With Ventricular Assist Devices: Is It Safe? J Pediatr Pharmacol Ther 2022; 27:384-389. [PMID: 35558345 PMCID: PMC9088434 DOI: 10.5863/1551-6776-27.4.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/09/2021] [Indexed: 09/17/2023]
Abstract
Anemia is a predictor of morbidity and mortality in both pediatric and adult patients with heart failure. This risk is increased in patients who require ventricular assist device (VAD) placement. The most common mechanism suggested for why these patients develop anemia is chronic inflammation caused by the immune system reacting to the VAD components. The inflammatory response that occurs can suppress erythropoiesis by inhibiting production of erythropoietin. Studies have demonstrated that anemic VAD patients have lower-than-expected erythropoietin levels, which leads to the consideration of erythropoiesis-stimulating agents (ESAs) in this population. Therapy with ESAs can increase hemoglobin and hematocrit levels, thereby decreasing the need for transfusions, subsequently reducing the risk of anti-human leukocyte antigen antibody development. Concerns that ESAs may increase the risk of thrombotic complications in a population already plagued with physiologic disturbances due to the VAD device remain a main barrier in routine use of these medications. The goal of this case series is to discuss a single center's experience with epoetin alfa in pediatric VAD patients at an academic children's hospital. A total of 4 patients were included with no evidence of adverse effects during a total of 120 patient-days of epoetin therapy. One patient was able to discontinue ESA therapy secondary to robust improvement in cell line counts at the time of discharge, while the other 3 patients received heart transplant prior to the discontinuation of ESA therapy. An increase in hematocrit of 1% to 5.5% was seen from epoetin initiation to discontinuation.
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Affiliation(s)
- Kaitlynn Hughes
- Department of Pediatric Pharmacy (KH, AJ, AH, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Audrey Jarosz
- Department of Pediatric Pharmacy (KH, AJ, AH, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - David M. Peng
- Department of Pediatric Cardiology (DMP), C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Ashley Huebschman
- Department of Pediatric Pharmacy (KH, AJ, AH, C.S. Mott Children's Hospital, Ann Arbor, MI
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7
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Huang J, Firestone S, Moffatt-Bruce S, Tibi P, Shore-Lesserson L. 2021 Clinical Practice Guidelines for Anesthesiologists on Patient Blood Management in Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3493-3495. [PMID: 34654633 DOI: 10.1053/j.jvca.2021.09.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY; Department of Cardiovascular & Thoracic Surgery, University of Louisville, Louisville, KY; Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY; Department of Pharmacology & Toxicology, University of Louisville, Louisville, KY; Department of Medicine, University of Louisville, Louisville, KY.
| | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, AZ
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, NY
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8
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Hussey P, Onodera Y, Reddy S, Samuelson B, Subramani S, Siddapura Ranganath Y, Jaradat T, Hanada S. Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA. J Anesth 2021; 35:710-722. [PMID: 34338863 DOI: 10.1007/s00540-021-02979-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/21/2021] [Indexed: 12/26/2022]
Abstract
Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.
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Affiliation(s)
- Patrick Hussey
- Department of Anesthesia, School of Medicine, University of Alabama at Birmingham, 619 19th Street S, Birmingham, AL, 35226, USA
| | - Yoshiko Onodera
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.,Surgical Operation Department, Asahikawa Medical University Hospital, Midorigaoka-higashi 2-1-1-1, Asahikawa, Hokkaido, 078-8510, Japan
| | - Sundara Reddy
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Blain Samuelson
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Sudhakar Subramani
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Yatish Siddapura Ranganath
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Tariq Jaradat
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Satoshi Hanada
- Department of Anesthesia, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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9
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STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:97-124. [PMID: 34194077 DOI: 10.1182/ject-2100053] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/16/2022]
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10
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Ann Thorac Surg 2021; 112:981-1004. [PMID: 34217505 DOI: 10.1016/j.athoracsur.2021.03.033] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/01/2021] [Accepted: 03/03/2021] [Indexed: 01/25/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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11
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Tibi P, McClure RS, Huang J, Baker RA, Fitzgerald D, Mazer CD, Stone M, Chu D, Stammers AH, Dickinson T, Shore-Lesserson L, Ferraris V, Firestone S, Kissoon K, Moffatt-Bruce S. STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. J Cardiothorac Vasc Anesth 2021; 35:2569-2591. [PMID: 34217578 DOI: 10.1053/j.jvca.2021.03.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Pierre Tibi
- Department of Cardiovascular Surgery, Yavapai Regional Medical Center, Prescott, Arizona
| | - R Scott McClure
- Division of Cardiac Surgery, Libin Cardiovascular Institute, Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky
| | - Robert A Baker
- Cardiac Surgery Research and Perfusion, Flinders University and Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Fitzgerald
- Division of Cardiovascular Perfusion, Medical University of South Carolina, Charleston, South Carolina
| | - C David Mazer
- Department of Anesthesia, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Marc Stone
- Department of Anesthesia, Mount Sinai Medical Center, New York, New York
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Tim Dickinson
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell Northshore University Hospital, Manhasset, New York
| | - Victor Ferraris
- Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky
| | | | | | - Susan Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada.
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12
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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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Shehata IM, Odell TD, Elhassan A, Spektor M, Urits I, Viswanath O, Jeha GM, Cornett EM, Kaye AD. Preoperative, Multidisciplinary Clinical Optimization of Patients with Severely Depressed Left Ventricular Ejection Fraction Who Are Undergoing Coronary Artery Bypass Grafting. Cardiol Ther 2020; 10:57-66. [PMID: 33367988 PMCID: PMC8126524 DOI: 10.1007/s40119-020-00207-1] [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: 09/08/2020] [Indexed: 11/30/2022] Open
Abstract
Coronary artery bypass grafting (CABG) remains a routine operation despite major advancements in angioplastic procedures. Around 200,000 CABG procedures are performed annually in the U.S. Patients who are not candidates for angioplasty intervention often have advanced coronary disease and comorbidities that raise the risk of heart failure with decreased ejection fraction to around 25%. Over the years, significant developments in various preoperative interventions have occurred; in this paper, we suggest a multidisciplinary preoperative algorithm that can be included in a regularly scheduled multidisciplinary care plan.
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Affiliation(s)
| | - Tiffany D Odell
- Department of Neurosurgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Amir Elhassan
- Department of Anesthesiology, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Maxim Spektor
- Department of Surgery, Desert Regional Medical Center, Palm Springs, CA, USA
| | - Ivan Urits
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Omar Viswanath
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
- Department of Anesthesiology, University of Arizona College of Medicine, Phoenix, Phoenix, AZ, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, NE, USA
- Valley Anesthesiology and Pain Consultants, Envision Physician Services, Phoenix, AZ, USA
| | - George M Jeha
- Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Shreveport, Shreveport, LA, USA.
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14
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Corwin HL, Shander A, Speiss B, Muñoz M, Faraoni D, Calcaterra D, Welsby I, Ozawa S, Arnofsky A, Goldweit RS, Tibi P. Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study. Ann Thorac Surg 2020; 113:316-323. [PMID: 33345781 DOI: 10.1016/j.athoracsur.2020.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two-thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one-third of non-anemic elective surgical patients are also iron deficient. METHODS Modified-RAND Delphi methodology was employed to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert Scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations. RESULTS The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin stimulating agents may be appropriate for some patients. CONCLUSIONS Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.
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Affiliation(s)
- Howard L Corwin
- Critical Care Medicine, Geisinger Health System Danville, PA.
| | - Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Health, TeamHealth, Englewood, NJ
| | - Bruce Speiss
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry, and Immunology, University of Malaga School of Medicine, Malaga, Spain
| | - David Faraoni
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Domenico Calcaterra
- Department of Cardiothoracic Surgery, Bethesda Heart Hospital, Baptist South Florida, Boynton Beach, FL
| | - Ian Welsby
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - Sherri Ozawa
- Patient Blood Management, Englewood Hospital and Medical Center, Englewood, NJ
| | - Adam Arnofsky
- Cardiothoracic Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Richard S Goldweit
- Interventional Cardiology, Englewood Hospital and Medical Center, Englewood, NJ
| | - Pierre Tibi
- Department of Cardiothoracic and Vascular Diseases, Yavapai Regional Medical Center, Prescott, AZ
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15
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin plus iron versus control treatment including placebo or iron for preoperative anaemic adults undergoing non-cardiac surgery. Cochrane Database Syst Rev 2020; 8:CD012451. [PMID: 32790892 PMCID: PMC8095002 DOI: 10.1002/14651858.cd012451.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Approximately 30% of adults undergoing non-cardiac surgery suffer from preoperative anaemia. Preoperative anaemia is a risk factor for mortality and adverse outcomes in different surgical specialties and is frequently the reason for blood transfusion. The most common causes are renal, chronic diseases, and iron deficiency. International guidelines recommend that the cause of anaemia guide preoperative anaemia treatment. Recombinant human erythropoietin (rHuEPO) with iron supplementation has frequently been used to increase preoperative haemoglobin concentrations in patients in order to avoid the need for perioperative allogeneic red blood cell (RBC) transfusion. OBJECTIVES To evaluate the efficacy of preoperative rHuEPO therapy (subcutaneous or parenteral) with iron (enteral or parenteral) in reducing the need for allogeneic RBC transfusions in preoperatively anaemic adults undergoing non-cardiac surgery. SEARCH METHODS We searched CENTRAL, Ovid MEDLINE(R), Ovid Embase, ISI Web of Science: SCI-EXPANDED and CPCI-S, and clinical trial registries WHO ICTRP and ClinicalTrials.gov on 29 August 2019. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared preoperative rHuEPO + iron therapy to control treatment (placebo, no treatment, or standard of care with or without iron) for preoperatively anaemic adults undergoing non-cardiac surgery. We used the World Health Organization (WHO) definition of anaemia: haemoglobin concentration (g/dL) less than 13 g/dL for males, and 12 g/dL for non-pregnant females (decision of inclusion based on mean haemoglobin concentration). We defined two subgroups of rHuEPO dosage: 'low' for 150 to 300 international units (IU)/kg body weight, and 'high' for 500 to 600 IU/kg body weight. DATA COLLECTION AND ANALYSIS Two review authors collected data from the included studies. Our primary outcome was the need for RBC transfusion (no autologous transfusion, fresh frozen plasma or platelets), measured in transfused participants during surgery (intraoperative) and up to five days after surgery. Secondary outcomes of interest were: haemoglobin concentration (directly before surgery), number of RBC units (where one unit contains 250 to 450 mL) transfused per participant (intraoperative and up to five days after surgery), mortality (within 30 days after surgery), length of hospital stay, and adverse events (e.g. renal dysfunction, thromboembolism, hypertension, allergic reaction, headache, fever, constipation). MAIN RESULTS Most of the included trials were in orthopaedic, gastrointestinal, and gynaecological surgery and included participants with mild and moderate preoperative anaemia (haemoglobin from 10 to 12 g/dL). The duration of preoperative rHuEPO treatment varied across the trials, ranging from once a week to daily or a 5-to-10-day period, and in one trial preoperative rHuEPO was given on the morning of surgery and for five days postoperatively. We included 12 trials (participants = 1880) in the quantitative analysis of the need for RBC transfusion following preoperative treatment with rHuEPO + iron to correct preoperative anaemia in non-cardiac surgery; two studies were multiarmed trials with two different dose regimens. Preoperative rHuEPO + iron given to anaemic adults reduced the need RBC transfusion (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.38 to 0.80; participants = 1880; studies = 12; I2 = 84%; moderate-quality evidence due to inconsistency). This analysis suggests that on average, the combined administration of rHuEPO + iron will mean 231 fewer individuals will need transfusion for every 1000 individuals compared to the control group. Preoperative high-dose rHuEPO + iron given to anaemic adults increased the haemoglobin concentration (mean difference (MD) 1.87 g/dL, 95% CI 1.26 to 2.49; participants = 852; studies = 3; I2 = 89%; low-quality evidence due to inconsistency and risk of bias) but not low-dose rHuEPO + iron (MD 0.11 g/dL, 95% CI -0.46 to 0.69; participants = 334; studies = 4; I2 = 69%; low-quality evidence due to inconsistency and risk of bias). There was probably little or no difference in the number of RBC units when rHuEPO + iron was given preoperatively (MD -0.09, 95% CI -0.23 to 0.05; participants = 1420; studies = 6; I2 = 2%; moderate-quality evidence due to imprecision). There was probably little or no difference in the risk of mortality within 30 days of surgery (RR 1.19, 95% CI 0.39 to 3.63; participants = 230; studies = 2; I2 = 0%; moderate-quality evidence due to imprecision) or of adverse events including local rash, fever, constipation, or transient hypertension (RR 0.93, 95% CI 0.68 to 1.28; participants = 1722; studies = 10; I2 = 0%; moderate-quality evidence due to imprecision). The administration of rHuEPO + iron before non-cardiac surgery did not clearly reduce the length of hospital stay of preoperative anaemic adults (MD -1.07, 95% CI -4.12 to 1.98; participants = 293; studies = 3; I2 = 87%; low-quality evidence due to inconsistency and imprecision). AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that preoperative rHuEPO + iron therapy for anaemic adults prior to non-cardiac surgery reduces the need for RBC transfusion and, when given at higher doses, increases the haemoglobin concentration preoperatively. The administration of rHuEPO + iron treatment did not decrease the mean number of units of RBC transfused per patient. There were no important differences in the risk of adverse events or mortality within 30 days, nor in length of hospital stay. Further, well-designed, adequately powered RCTs are required to estimate the impact of this combined treatment more precisely.
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Affiliation(s)
- Lutz Kaufner
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Anne Henkelmann
- Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Berlin, Germany
| | - Nathan L Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Weibel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Ravi Gill
- Department of Anaesthetics, Southampton University Hospital NHS Trust, Southampton, UK
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16
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Muller Moran HR, Arora RC. Commentary: Thrombosis and hemorrhage, yin and yang. JTCVS Tech 2020; 4:156-157. [PMID: 34317995 PMCID: PMC8303075 DOI: 10.1016/j.xjtc.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Hellmuth R Muller Moran
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba.,Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba.,Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada
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17
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Warner MA, Shore-Lesserson L, Shander A, Patel SY, Perelman SI, Guinn NR. Perioperative Anemia. Anesth Analg 2020; 130:1364-1380. [DOI: 10.1213/ane.0000000000004727] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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18
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Kwak J, Wilkey AL, Abdalla M, Joshi R, Roman PEF, Greilich PE. Perioperative Blood Conservation: Guidelines to Practice. Adv Anesth 2019; 37:1-34. [PMID: 31677651 DOI: 10.1016/j.aan.2019.08.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Jenny Kwak
- Department of Anesthesiology and Perioperative Medicine, Loyola University Medical Center, 2160 South First Avenue, Maywood, IL 60153, USA
| | - Andrew L Wilkey
- Department of Anesthesia, Abbott Northwestern Hospital, 800 East 28th Street, Minneapolis, MN 55407, USA
| | - Mohamed Abdalla
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Lerner College of Medicine, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue/J4-331, Cleveland, OH 44196, USA
| | - Ravi Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center - Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-8894, USA
| | - Philip E F Roman
- Department of Anesthesiology, Centura St. Anthony Hospital, United States Anesthesia Partners, 11600 West 2nd Place, Lakewood, CO 80228, USA
| | - Philip E Greilich
- Cardiac Anesthesiology, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center - Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-8894, USA
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Prevalence and Clinical Impact of Iron Deficiency in Patients With Severe Aortic Stenosis Referred for Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 124:1442-1448. [PMID: 31474326 DOI: 10.1016/j.amjcard.2019.07.051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/18/2019] [Accepted: 07/23/2019] [Indexed: 11/20/2022]
Abstract
Patients referred for transcatheter aortic valve implantation (TAVI) are typically elderly with several co-morbidities, which might limit prognosis despite successful procedural outcome. To date, the prevalence and clinical impact of iron deficiency (ID) in patients with severe aortic stenosis who underwent TAVI remains poorly defined. This study included 495 patients who underwent transfemoral TAVI for severe symptomatic aortic stenosis. ID was defined as ferritin <100 ng/ml or ferritin 100 to 300 ng/ml, when transferrin saturation was <20%. The primary end point of the study was a composite of all-cause mortality, unplanned readmission for worsening heart failure or red blood cell transfusions during the first year after TAVI, which occurred in 22% (109 of 495) of the population. ID was present in 54% (268 of 495) of the entire cohort and was associated with a higher rate of the primary end point (27.6% [74 of 268] vs 15.4% [35 of 227]; p = 0.001). After multivariable adjustment, the association of ID with the primary end point remained significant (hazard ratio 1.64, 95% confidence interval [1.08 to 2.48]; p = 0.019). In a subgroup of ferropenic patients (n = 56), treatment with intravenous iron before TAVI was feasible, resulting in a considerable improvement of ferritin, transferrin saturation and symptoms at 30-day follow-up. In conclusion, ID is common in TAVI patients and is associated with adverse clinical outcome after TAVI. Correction of ID with intravenous iron seems feasible in contemporary TAVI patients. Whether this reduces transfusion rates and impacts clinical outcome after TAVI remains to be investigated in future prospective trials.
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20
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Leff J, Romano CA, Gilbert S, Nair S. Validation Study of the Transfusion Risk and Clinical Knowledge (TRACK) Tool in Cardiac Surgery Patients: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2019; 33:2669-2675. [DOI: 10.1053/j.jvca.2019.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/21/2019] [Accepted: 05/25/2019] [Indexed: 11/11/2022]
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21
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Terwindt L, Karlas A, Eberl S, Wijnberge M, Driessen A, Veelo D, Geerts B, Hollmann M, Vlaar A. Patient blood management in the cardiac surgical setting: An updated overview. Transfus Apher Sci 2019; 58:397-407. [DOI: 10.1016/j.transci.2019.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Miller RJH, Gregory AJ, Kent W, Banerjee D, Hiesinger W, Clarke B. Predicting Transfusions During Left Ventricular Assist Device Implant. Semin Thorac Cardiovasc Surg 2019; 32:747-755. [PMID: 31128255 DOI: 10.1053/j.semtcvs.2019.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/17/2019] [Indexed: 01/28/2023]
Abstract
Perioperative bleeding and transfusion cause morbidity and mortality in patients receiving left ventricular assist devices (LVADs). We assessed factors associated with transfusions within 30 days of durable LVAD implantation and the clinical outcomes associated with transfusions. A retrospective cohort study of patients undergoing initial durable LVAD implantation between 2014 and 2016 was performed. Rates of packed red blood cell (PRBC) or other blood product transfusions (platelets or fresh frozen plasma) were assessed. Ordinal multivariable regression analysis was performed to determine factors independently associated with transfusion. Analysis included 156 patients, mean age 54.6 years and 74.4% male, who received a mean of 11.7 units of PRBC and 10.0 units of other products within 30 days. Preimplant mechanical ventilation, dialysis, higher INR, previous sternotomy, higher model for end-stage liver disease score, and lower hemoglobin were associated with increased PRBC transfusion rates. Higher preoperative central venous pressure, mechanical ventilation, concomitant surgical procedures, previous sternotomy, and lower hemoglobin were associated with increased PRBC transfusion rates within 48 hours of implant (adjusted odds ratio [OR] 1.46, P = 0.013 per 5 mm Hg). There were no significant associations with ferritin (adjusted OR 1.00, P = 0.236) or transferrin saturation (adjusted OR 1.17, P = 0.068). Transfusions were associated with an increase in ventilation duration, intensive care unit length of stay, reoperation for bleeding, and all-cause mortality. In patients undergoing LVAD implantation, perioperative blood product exposure is common and associated with increased morbidity and mortality. Elevated central venous pressure and anemia are potentially modifiable factors associated with increased early PRBC transfusion rates.
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Affiliation(s)
- Robert J H Miller
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada; Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Alexander J Gregory
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - William Kent
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada
| | - Dipanjan Banerjee
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - William Hiesinger
- Section of Heart Failure, Cardiac Transplant, and Mechanical Circulatory Support, and Department of Medicine, Stanford University, Stanford, California
| | - Brian Clarke
- Division of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Canada.
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23
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Cho BC, Serini J, Zorrilla-Vaca A, Scott MJ, Gehrie EA, Frank SM, Grant MC. Impact of Preoperative Erythropoietin on Allogeneic Blood Transfusions in Surgical Patients. Anesth Analg 2019; 128:981-992. [DOI: 10.1213/ane.0000000000004005] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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24
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Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, Fergusson D, Folléa G, French C, Frey KP, Gammon R, Levy JH, Murphy MF, Ozier Y, Pavenski K, So-Osman C, Tiberghien P, Volmink J, Waters JH, Wood EM, Seifried E. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019; 321:983-997. [PMID: 30860564 DOI: 10.1001/jama.2019.0554] [Citation(s) in RCA: 345] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEW The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCE The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.
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Affiliation(s)
- Markus M Mueller
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
| | - Hans Van Remoortel
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kari Aranko
- European Blood Alliance (EBA), Amsterdam, the Netherlands
| | - Cécile Aubron
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Jeffrey L Carson
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | | | - Emmy De Buck
- Centre for Evidence-Based Practice (CEBaP), Belgian Red Cross, Mechelen, Belgium
- Department of Public Health and Primary Care, Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Dana Devine
- Canadian Blood Services, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Departments of Medicine, Surgery, Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Gilles Folléa
- Société Française de Transfusion Sanguine (SFTS), Paris, France
| | - Craig French
- Intensive Care, Western Health, Melbourne, Australia
| | | | | | - Jerrold H Levy
- Department of Cardiothoracic Intensive Care Medicine, Duke University Medical Centre, Durham, North Carolina
| | - Michael F Murphy
- National Health Service Blood and Transplant and University of Oxford, Oxford, United Kingdom
| | - Yves Ozier
- Departments of Intensive Care and of Anesthesia, University Hospital of Brest, Brest, France
| | | | - Cynthia So-Osman
- Sanquin Blood Bank, Leiden and Department of Haematology, Groene Hart Hospital, Gouda, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
| | | | - Jimmy Volmink
- Department of Clinical Epidemiology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Jonathan H Waters
- Departments of Anesthesiology and Bioengineering, University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania
| | - Erica M Wood
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erhard Seifried
- German Red Cross Blood Transfusion Service and Goethe University Clinics, Frankfurt/Main, Germany
- European Blood Alliance (EBA), Amsterdam, the Netherlands
- International Society of Blood Transfusion (ISBT), Amsterdam, the Netherlands
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Khalili M, Morano WF, Marconcini L, Shaikh MF, Gleeson EM, Styler M, Zebrower M, Bowne WB. Multidisciplinary strategies in bloodless medicine and surgery for patients undergoing pancreatectomy. J Surg Res 2018; 229:208-215. [DOI: 10.1016/j.jss.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 01/05/2023]
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26
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Boer C, Meesters MI, Milojevic M, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk AB, Wahba A, Pagano D. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. J Cardiothorac Vasc Anesth 2018; 32:88-120. [DOI: 10.1053/j.jvca.2017.06.026] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Indexed: 01/28/2023]
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27
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Lee H, Yuh YJ. A Paradigm Shift: Perioperative Iron and Erythropoietin Therapy for Patient Blood Management. ACTA ACUST UNITED AC 2018. [DOI: 10.7599/hmr.2018.38.1.16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Hyesun Lee
- Department of Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Jin Yuh
- Department of Internal Medicine, Inje University Paik Hospital, Seoul, Korea
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Pagano D, Milojevic M, Meesters MI, Benedetto U, Bolliger D, von Heymann C, Jeppsson A, Koster A, Osnabrugge RL, Ranucci M, Ravn HB, Vonk ABA, Wahba A, Boer C. 2017 EACTS/EACTA Guidelines on patient blood management for adult cardiac surgery. Eur J Cardiothorac Surg 2017; 53:79-111. [DOI: 10.1093/ejcts/ezx325] [Citation(s) in RCA: 192] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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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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Urena M, del Trigo M, Altisent O, Campelo-Prada F, Regueiro A, DeLarochellière R, Doyle D, Mohammadi S, Paradis JM, Dagenais F, Dumont E, Puri R, Laroche V, Rodés-Cabau J. Combined erythropoietin and iron therapy for anaemic patients undergoing transcatheter aortic valve implantation: the EPICURE randomised clinical trial. EUROINTERVENTION 2017; 13:44-52. [DOI: 10.4244/eij-d-16-00591] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
Heart surgery patients have a high prevalence of anemia. Its etiology is multifactorial, and iron deficiency is one of the most common correctable causes. Anemia is an independent risk factor for postsurgical morbidity and mortality. It also predisposes patients to a greater need for transfusions, which increases the associated complications and the use of resources. The etiological diagnosis of anemia is no different from that of other surgical procedures, but the time available for correcting it before surgery is shorter. Studies have been conducted on therapeutic regimens with iron deficiency replenishment with total dose and erythropoiesis-stimulating agents, which enable the rapid correction of anemia and reduce transfusion requirements. There is considerable variability in terms of dosage, adverse effects, administration time and routes, drug combinations and results. New studies are needed to investigate the most ideal regimens for correcting anemia in these patients.
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Affiliation(s)
- G J Yanes Vidal
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen del Rocío, Sevilla, España.
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Kaufner L, von Heymann C, Henkelmann A, Pace NL, Weibel S, Kranke P, Meerpohl JJ, Gill R. Erythropoietin with iron supplementation for preoperative anaemia in non‐cardiac surgery. Cochrane Database Syst Rev 2016; 2016:CD012451. [PMCID: PMC6463842 DOI: 10.1002/14651858.cd012451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2024]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: We aim to evaluate the efficacy and safety of preoperative erythropoietin (rHuEPO) with supplemental iron (parenteral or oral) in reducing perioperative allogeneic red blood cell transfusions in preoperatively anaemic people undergoing non‐cardiac surgery.
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Affiliation(s)
- Lutz Kaufner
- Charité ‐ University Medicine BerlinDepartment of Anaesthesiology and Intensive Care MedicineAugustenburger Platz 1BerlinGermany13353
| | - Christian von Heymann
- Vivantes Klinikum im FriedrichshainDepartment of Anaesthesiology, Intensive Care Medicine, Emergency Care Medicine and Pain TherapyLandsberger Allee 49BerlinGermany10249
| | - Anne Henkelmann
- Charité ‐ University Medicine BerlinDepartment of Anaesthesiology and Intensive Care MedicineAugustenburger Platz 1BerlinGermany13353
| | - Nathan Leon Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUSA84132‐2304
| | - Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Joerg J Meerpohl
- Medical Center ‐ University of FreiburgCochrane GermanyBreisacher Straße 153FreiburgGermany79110
| | - Ravi Gill
- Southampton University Hospital NHS TrustDepartment of AnaestheticsTremona RoadSouthamptonUKSO16 6YD
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Deepak B, Balaji A, Pramod A, Sujit K, Savani F, Bapu K, Manish P, Yogesh B, Shreedhar J, Antony G. The Prevalence and Impact of Preoperative Anemia in Patients Undergoing Cardiac Surgery for Rheumatic Heart Disease. J Cardiothorac Vasc Anesth 2016; 30:896-900. [DOI: 10.1053/j.jvca.2015.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Indexed: 12/20/2022]
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Ogami T, Matsue Y, Kawasumi R, Tanabe H. Prognostic implications of preoperative chronic kidney disease and anemia in patients undergoing coronary artery bypass graft surgery. Surg Today 2016; 47:245-251. [DOI: 10.1007/s00595-016-1368-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 05/16/2016] [Indexed: 01/12/2023]
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The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:157-64. [DOI: 10.1097/imi.0000000000000280] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Limiting blood transfusion in cardiac operations is a well-meaning goal of perioperative care. Potential benefits include decreasing morbidity and limiting procedural costs. It is difficult to identify transfusion as the cause of adverse outcomes. The need for transfusion may identify a sicker patient population at greater risk for a worse outcome that may or may not be related to the transfusion. We reviewed the indications for and adverse effects of blood transfusion in patients undergoing cardiac procedures to provide a balanced approach to management of blood resources in this population. We reviewed current literature, including systematic reviews and practice guidelines, to synthesize a practice management plan in patients having cardiac operations. Several prospective randomized studies and large population cohort studies compared a postoperative restrictive transfusion policy to a more liberal policy and found very little difference in outcomes but decreased costs with a restrictive policy. Evidence-based practice guidelines and implementation standards provide robust intervention plans that can limit harmful effects of transfusion and provide safe and effective procedure outcomes. A restrictive transfusion policy seems to be safe and effective but does not necessarily provide better outcome in most patient cohorts. The implications of these findings suggest that many discretionary transfusions could be avoided. A subset of high-risk patients could undoubtedly benefit from a more liberal transfusion policy, but the definition of high risk is ill defined.
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Gunn T, Paone G, Emery RW, Ferraris VA. The Case for a Conservative Approach to Blood Transfusion Management in Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Tyler Gunn
- Department of Surgery, University of Kentucky, Lexington, KY USA
| | - Gaetano Paone
- Cardiac Surgery, Henry Ford Hospital, Detroit, MI USA
| | | | - Victor A. Ferraris
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY USA
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Lindenfeld J, Keebler ME. Left ventricular assist device thrombosis: another piece of the puzzle? JACC-HEART FAILURE 2016; 3:154-8. [PMID: 25660840 DOI: 10.1016/j.jchf.2014.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 12/01/2014] [Indexed: 01/17/2023]
Affiliation(s)
| | - Mary E Keebler
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
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Abstract
Blood transfusion is the most common procedure in cardiac surgery. Increasing evidence exists that excess transfusions are harmful to patients. Transfusion reactions and complications, including infection, immune modulation, and lung injury, are known complications but underreported; hence, their significance is often disregarded. Furthermore, a number of randomized trials have shown that a restrictive transfusion strategy is equal to if not better than a liberal transfusion strategy. Despite the evidence for the use of restrictive transfusion triggers, its dissemination in the cardiac surgical community has met with resistance. In this review, we outline the risks of transfusion, compare restrictive and liberal transfusion strategies in cardiac surgery, and finally outline perioperative interventions to minimize transfusion in the cardiac surgical patient.
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Kotzé A, Harris A, Baker C, Iqbal T, Lavies N, Richards T, Ryan K, Taylor C, Thomas D. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol 2015; 171:322-31. [PMID: 26343392 DOI: 10.1111/bjh.13623] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 01/28/2023]
Affiliation(s)
- Alwyn Kotzé
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Charles Baker
- University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tariq Iqbal
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nick Lavies
- Western Sussex Hospitals NHS Trust, Pre-Operative Association Representative, Sussex, UK
| | - Toby Richards
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kate Ryan
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Craig Taylor
- Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | - Dafydd Thomas
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
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Goldfarb M, Drudi L, Almohammadi M, Langlois Y, Noiseux N, Perrault L, Piazza N, Afilalo J. Outcome Reporting in Cardiac Surgery Trials: Systematic Review and Critical Appraisal. J Am Heart Assoc 2015; 4:e002204. [PMID: 26282561 PMCID: PMC4599473 DOI: 10.1161/jaha.115.002204] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background There is currently no accepted standard for reporting outcomes following cardiac surgery. The objective of this paper was to systematically review the literature to evaluate the current use and definition of perioperative outcomes reported in cardiac surgery trials. Methods and Results We reviewed 5 prominent medical and surgical journals on Medline from January 1, 2010, to June 30, 2014, for randomized controlled trials involving coronary artery bypass grafting and/or valve surgery. We identified 34 trials meeting inclusion criteria. Sample sizes ranged from 57 to 4752 participants (median 351). Composite end points were used as a primary outcome in 56% (n=19) of the randomized controlled trials and as a secondary outcome in 12% (n=4). There were 14 different composite end points. Mortality at any time (all-cause and/or cardiovascular) was reported as an individual end point or as part of a combined end point in 82% (n=28), myocardial infarction was reported in 68% (n=23), and bleeding was reported in 24% (n=8). Patient-centered outcomes, such as quality of life and functional classification, were reported in 29% (n=10). Definition of clinical events such as myocardial infarction, stroke, renal failure, and bleeding varied considerably among trials, particularly for postoperative myocardial infarction and bleeding, for which 8 different definitions were used for each. Conclusions Outcome reporting in the cardiac surgery literature is heterogeneous, and efforts should be made to standardize the outcomes reported and the definitions used to ascertain them. The development of standardizing outcome reporting is an essential step toward strengthening the process of evidence-based care in cardiac surgery.
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Affiliation(s)
- Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada (M.G., J.A.)
| | - Laura Drudi
- Division of Vascular Surgery, McGill University, Montreal, Quebec, Canada (L.D.)
| | - Mohammad Almohammadi
- Division of Medicine, McGill University Health Center, McGill University, Montreal, Quebec, Canada (M.A.)
| | - Yves Langlois
- Division of Cardiac Surgery, Jewish General Hospital, McGill University, Montreal, Quebec, Canada (Y.L.)
| | - Nicolas Noiseux
- Division of Cardiac Surgery, Centre Hospitalier de L'Université de Montréal, Montreal, Quebec, Canada (N.N.)
| | - Louis Perrault
- Division of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada (L.P.)
| | - Nicolo Piazza
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Quebec, Canada (N.P.)
| | - Jonathan Afilalo
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada (M.G., J.A.) Centre for Clinical Epidemiology, Lady Davis Institute, McGill University, Montreal, Quebec, Canada (J.A.)
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White MJ, Hazard SW, Frank SM, Boyd JS, Wick EC, Ness PM, Tobian AAR. The evolution of perioperative transfusion testing and blood ordering. Anesth Analg 2015; 120:1196-203. [PMID: 25988630 DOI: 10.1213/ane.0000000000000619] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The evolution of modern anesthesia and surgical practices has been accompanied by enhanced supportive procedures in blood banking and transfusion medicine. There is increased focus on the preparation and the use of blood components including, but not limited to, preventing unnecessary type and screen/crossmatch orders, decreasing the time required to provide compatible red blood cells (RBCs), and reducing the waste of limited blood and personnel resources. The aim of this review is to help the anesthesiologist and surgical staff identify patients at highest risk for surgical bleeding. In addition, this review examines how anesthesia and transfusion medicine can efficiently and safely allocate blood components for surgical patients who require transfusions. The following databases were searched: PubMed, EMBASE, Google Scholar, and the Cochrane Library from January 1970 through March 2014. Subsequent reference searches of retrieved articles were also assessed. Several innovations have drastically changed the procedures by which blood is ordered, inventoried, and the speed in which blood is delivered for patient care. Before entering an operating room, patient blood management provides guidance to clinicians about when and how to treat preoperative anemia and intra- and postoperative strategies to limit the patient's exposure to blood components. Timely updates of the recommendations for blood orders (maximum surgical blood ordering schedule) have enhanced preoperative decision making regarding the appropriateness of the type and screen versus the type and crossmatch order. The updated maximum surgical blood ordering schedule reflects modern practices, such as laparoscopy, improved surgical techniques, and use of hemostatic agents resulting in a more streamlined process for ordering and obtaining RBCs. The electronic (computer) crossmatch and electronic remote blood issue have also dramatically reduced the amount of time required to obtain crossmatch-compatible RBCs when compared with the more traditional serologic crossmatch methods. These changes in blood banking methods have resulted in more efficient delivery of blood to surgical patients.
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Affiliation(s)
- Marissa J White
- From the *Department of Pathology, Division of Transfusion Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; †Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; ‡Department of Anesthesiology, Penn State College of Medicine, Hershey, Pennsylvania; and §Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Pre-operative anaemia: prevalence, consequences and approaches to management. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:370-9. [PMID: 26192787 DOI: 10.2450/2015.0014-15] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/24/2015] [Indexed: 01/28/2023]
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Weltert L, Rondinelli B, Bello R, Falco M, Bellisario A, Maselli D, Turani F, De Paulis R, Pierelli L. A single dose of erythropoietin reduces perioperative transfusions in cardiac surgery: results of a prospective single-blind randomized controlled trial. Transfusion 2015; 55:1644-54. [DOI: 10.1111/trf.13027] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 12/21/2014] [Accepted: 12/23/2014] [Indexed: 12/21/2022]
Affiliation(s)
| | | | - Ricardo Bello
- Montefiore-Einstein Heart Center; Albert Einstein College of Medicine; Bronx New York
| | - Mauro Falco
- Anaesthesiology Department; European Hospital
| | | | | | | | | | - Luca Pierelli
- Transfusion Medicine Department; San Camillo-Forlanini Hospital; Rome Italy
- Department of Experimental Medicine; Sapienza University; Rome Italy
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Nassif ME, Patel JS, Shuster JE, Raymer DS, Jackups R, Novak E, Gage BF, Prasad S, Silvestry SC, Ewald GA, LaRue SJ. Clinical outcomes with use of erythropoiesis stimulating agents in patients with the HeartMate II left ventricular assist device. JACC. HEART FAILURE 2015; 3:146-53. [PMID: 25660839 PMCID: PMC4766587 DOI: 10.1016/j.jchf.2014.08.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 08/05/2014] [Accepted: 08/08/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study evaluated clinical outcomes associated with erythropoiesis stimulating agent (ESA) use in left ventricular assist devices (LVAD)-supported patients. BACKGROUND Use of ESAs in patients with LVADs may minimize blood transfusions and decrease allosensitization. ESAs increase thrombotic events, which is concerning because LVADs are sensitive to pump thrombosis (PT). METHODS We retrospectively reviewed 221 patients at our center who received a HeartMate II (Thoratec Corp., Pleasanton, California) LVAD between January 1, 2009 and June 6, 2013. Patients were divided into those who received ESAs during index admission (n = 121) and those who did not (n = 100). Suspected PT was defined as evidence of thrombus in the LVAD or severe hemolysis (lactate dehydrogenase >1,000 mg/dl or plasma-free hemoglobin >40 mg/dl). Outcomes were compared between cohorts using inverse probability-weighted analyses. RESULTS During a mean follow-up of 14.2 ± 11.9 months, suspected PT occurred in 37 patients (ESA 23%, no ESA 12%; p =0.03). The ESA cohort received ESAs 13.9 ± 60.9 days after LVAD implantation. At 180 days, event-free rates for suspected PT were ESA 78.6% versus no ESA 94.5% (p < 0.001). ESA use had higher rates of suspected PT (hazard ratio [HR]: 2.35; 95% confidence interval [CI]: 1.38 to 4.00; p = 0.002). For every 100-unit increase in cumulative ESA dosage, the hazard of suspected PT increased by 10% (HR: 1.10; 95% CI: 1.04 to 1.16; p < 0.001). After inverse probability weighting, ESA use was associated with a significantly higher rate of all-cause mortality (HR: 1.62; 95% CI: 1.12 to 2.33; p = 0.01). CONCLUSIONS ESA use in LVAD patients is associated with higher rates of suspected PT.
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Affiliation(s)
- Michael E Nassif
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jayendrakumar S Patel
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jerrica E Shuster
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - David S Raymer
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ronald Jackups
- Division of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri
| | - Eric Novak
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Brian F Gage
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Sunil Prasad
- Division of Cardiovascular Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Scott C Silvestry
- Division of Cardiovascular Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gregory A Ewald
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Shane J LaRue
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri.
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Alizadeh-Ghavidel A, Totonchi Z, Hoseini A, Ziyaeifard M, Azarfarin R. Blood transfusion practice in a referral cardiovascular center in tehran, iran: a critical point of view. Res Cardiovasc Med 2014; 3:e21772. [PMID: 25780781 PMCID: PMC4347724 DOI: 10.5812/cardiovascmed.21772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Revised: 08/25/2014] [Accepted: 09/04/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Unnecessary perioperative transfusions are likely to be related to increased morbidity and additional costs in cardiac surgery. OBJECTIVES The aim of this study was to evaluate the blood transfusion practice during and after adult cardiac surgery in a referral university hospital in Iran. PATIENTS AND METHODS In a descriptive study, we collected data from 153 adult patients underwent cardiac surgery at Rajaie Cardiovascular Medical and Research Center, Tehran, Iran from January to March 2013. The variables were patients' demographic, operative and post-operative data and the numbers of transfused packed red blood cell (PC) units and fresh frozen plasma (FFP) during and after cardiac surgery. Then we evaluated patients' and physicians' related causes of relatively increased transfusion rate in our patients and compared them with literature. RESULTS Of 153 patients, 96.8% received PC and 54.9% transfused FFP during or after surgery. Most of the transfusions were done after operation in intensive care unit (ICU). Also, 20% and 17% of the patients underwent transfusion of more than 6 units of PC and FFP, respectively. The mean left ventricular ejection fraction of the patients was 42.5 ± 10.9%. A significant number of patients had anemia (especially women) or received anticoagulants or antiplatelet agents preoperatively. Thirteen percent of the patients underwent emergency operations and 12.3% had re-exploration. CONCLUSIONS The results of this study demonstrate that the cardiac surgery patients receive a relatively greater number of PC or FFP units during and after the operation in our center. This finding may be explained to some extent by the fact that the sicker and more co-morbid patients referred to our center and such patients are more anemic and undergoing more emergent and complex procedures. Moreover, Transfusion strategy or protocol should be updated, especially after the operation in ICU.
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Affiliation(s)
- Alireza Alizadeh-Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Ziae Totonchi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Abedin Hoseini
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Mohsen Ziyaeifard
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
| | - Rasoul Azarfarin
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Rasoul Azarfarin, Rajaie Cardiovascular Medical and Research Center, Vali-Asr St., Niayesh Blvd, Tehran, IR Iran. Tel: +98-2123922017, Fax: +98-2122663293, E-mail:
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dos Santos AA, da Silva JP, da Silva LDF, de Sousa AG, Piotto RF, Baumgratz JF. Therapeutic options to minimize allogeneic blood transfusions and their adverse effects in cardiac surgery: a systematic review. Braz J Cardiovasc Surg 2014; 29:606-21. [PMID: 25714216 PMCID: PMC4408825 DOI: 10.5935/1678-9741.20140114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 09/30/2014] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Allogeneic blood is an exhaustible therapeutic resource. New evidence indicates that blood consumption is excessive and that donations have decreased, resulting in reduced blood supplies worldwide. Blood transfusions are associated with increased morbidity and mortality, as well as higher hospital costs. This makes it necessary to seek out new treatment options. Such options exist but are still virtually unknown and are rarely utilized. OBJECTIVE To gather and describe in a systematic, objective, and practical way all clinical and surgical strategies as effective therapeutic options to minimize or avoid allogeneic blood transfusions and their adverse effects in surgical cardiac patients. METHODS A bibliographic search was conducted using the MeSH term "Blood Transfusion" and the terms "Cardiac Surgery" and "Blood Management." Studies with titles not directly related to this research or that did not contain information related to it in their abstracts as well as older studies reporting on the same strategies were not included. RESULTS Treating anemia and thrombocytopenia, suspending anticoagulants and antiplatelet agents, reducing routine phlebotomies, utilizing less traumatic surgical techniques with moderate hypothermia and hypotension, meticulous hemostasis, use of topical and systemic hemostatic agents, acute normovolemic hemodilution, cell salvage, anemia tolerance (supplementary oxygen and normothermia), as well as various other therapeutic options have proved to be effective strategies for reducing allogeneic blood transfusions. CONCLUSION There are a number of clinical and surgical strategies that can be used to optimize erythrocyte mass and coagulation status, minimize blood loss, and improve anemia tolerance. In order to decrease the consumption of blood components, diminish morbidity and mortality, and reduce hospital costs, these treatment strategies should be incorporated into medical practice worldwide.
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Affiliation(s)
| | - José Pedro da Silva
- Real e Benemérita Associação Portuguesa de Beneficência
de São Paulo, São Paulo, SP, Brasil
| | | | | | - Raquel Ferrari Piotto
- Real e Benemérita Associação Portuguesa de Beneficência
de São Paulo, São Paulo, SP, Brasil
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Kim CJ, Connell H, McGeorge AD, Hu R. Prevalence of preoperative anaemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study. Perfusion 2014; 30:277-83. [DOI: 10.1177/0267659114542457] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The prevalence of anaemia is increasing globally. It has a close association with perioperative blood transfusion which, in turn, results in an increased risk of postoperative complications. Undesirable effects are not only limited to short-term, but also have long-term implications. Despite this, many patients undergo cardiac surgery with undiagnosed and untreated anaemia. We designed a retrospective, observational study to estimate the prevalence of anaemia in patients having cardiac surgery in Auckland District Health Board, blood transfusion rates and associated clinical outcome. Two hundred of seven hundred and twelve (28.1%) patients were anaemic. Red blood cell (RBC) transfusion rates were significantly higher in the anaemic group compared to the non-anaemic group (160 (80%) vs. 192 (38%), p-value <0.0001, RR (CI 95%) 2.133 (1.870-2.433)). Transfusion rates for fresh frozen plasma (FFP), cryoprecipitate and platelets were also higher in the anaemic group. Anaemia was significantly associated with the development of new infection (14 (7%) vs. 15 (2.9%), p-value 0.0193, RR (CI 95%) 2.389 (1.175-4.859)), prolonged ventilation time (47.01 hours vs. 23.59 hours, p-value 0.0076) and prolonged intensive care unit (ICU) stay (80.23 hours vs. 50.27, p-value 0.0011). Preoperative anaemia is highly prevalent and showed a clear link with significantly higher transfusion rates and postoperative morbidity. It is vital that a preoperative management plan for the correction of anaemia should be sought to improve patient safety and outcome.
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Affiliation(s)
- CJ Kim
- Department of Anaesthesia. Auckland District Health Board (ADHB), Auckland, New Zealand
| | - H Connell
- Department of Anaesthesia and Cardiothoracic and Vascular Intensive Care Unit (CVICU). ADHB, Auckland, New Zealand
| | - AD McGeorge
- Department of Anaesthesia and Cardiothoracic and Vascular Intensive Care Unit (CVICU). ADHB, Auckland, New Zealand
| | - R Hu
- ADHB Research Office. Auckland District Health Board, Auckland, New Zealand
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McCartney S, Guinn N, Roberson R, Broomer B, White W, Hill S. Jehovah's Witnesses and cardiac surgery: a single institution's experience. Transfusion 2014; 54:2745-52. [DOI: 10.1111/trf.12696] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 03/14/2014] [Accepted: 03/14/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Sharon McCartney
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina
| | - Nicole Guinn
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina
| | - Russell Roberson
- Department of Anesthesiology; University of Texas-Southwestern; Dallas Texas
| | - Bob Broomer
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina
| | - William White
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina
| | - Steven Hill
- Department of Anesthesiology; University of Texas-Southwestern; Dallas Texas
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Tran DHD, Wong GTC, Chee YE, Irwin MG. Effectiveness and safety of erythropoiesis-stimulating agent use in the perioperative period. Expert Opin Biol Ther 2013; 14:51-61. [DOI: 10.1517/14712598.2014.858116] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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