Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery

Reduction of red blood cell transfusion with a patient blood management protocol in urological and visceral surgery: a before-after study

BACKGROUND

Although Patient Blood Management (PBM) is recommended by international guidelines, little evidence of its effectiveness exists in abdominal surgery. The aim of this study was to evaluate the benefits of the implementation of a PBM protocol on transfusion incidence and anaemia-related outcomes in major urological and visceral surgery.

METHODS

In this before-after study, a three-pillar PBM protocol was implemented in 2020-2021 in a tertiary care centre, including preoperative correction of iron-deficiency anaemia, intraoperative tranexamic acid administration, and postoperative restrictive transfusion. A historical cohort (2019) was compared to a prospective cohort (2022) after the implementation of the PBM protocol. The primary outcome was the incidence of red blood cell transfusion intraoperatively or within 7 days after surgery.

RESULTS

Data from 488 patients in the historical cohort were compared to 499 patients in the prospective cohort. Between 2019 and 2022, screening for iron deficiency increased from 13.9% to 69.8% (p < 0.01), tranexamic acid administration increased from 9.5% to 84.6% (p < 0.01), and median haemoglobin concentration before transfusion decreased from 77 g.L-1 to 71 g.L-1 (p = 0.02). The incidence of red blood cell transfusion decreased from 11.5% in 2019 to 6.6% in 2022 (relative risk 0.58, 95% CI 0.38-0.87, p = 0.01). The incidence of haemoglobin concentration lower than 100 g.L-1 at discharge was 24.2% in 2019 and 21.8% in 2022 (p =  0.41). The incidence of medical complications was comparable between the groups.

CONCLUSION

The implementation of a PBM protocol over a two-year period was associated with a reduction of transfusion in major urological and visceral surgery.

Perfusion Measures and Outcomes (PERForm) registry: First annual report

BACKGROUND

The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology.

METHODS

This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported.

RESULTS

A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%).

CONCLUSION

Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain.

Activated clotting time value as an independent predictor of postoperative bleeding and transfusion

OBJECTIVES

Activated clotting time (ACT) is commonly used to monitor anticoagulation during cardiac surgeries. Final ACT values may be essential to predict postoperative bleeding and transfusions, although ideal values remain unknown. Our aim was to evaluate the utility of ACT as a predictor of postoperative bleeding and transfusion use.

METHODS

Retrospective study (722 patients) submitted to surgery between July 2018-October 2021. We compared patients with final ACT < basal ACT and final ACT ≥ basal ACT and final ACT < 140 s with ≥140 s. Continuous variables were analysed with the Wilcoxon rank-sum test; categorical variables using Chi-square or Fisher's exact test. A linear mixed regression model was used to analyse bleeding in patients with final ACT < 140 and ≥140. Independent variables were analysed with binary logistic regression models to investigate their association with bleeding and transfusion.

RESULTS

Patients with final ACT ≥ 140 s presented higher postoperative bleeding than final ACT < 140 s at 12 h (P = 0.006) and 24 h (**P = 0.004). Cardiopulmonary bypass (CPB) time [odds ratio (OR) 1.009, 1.002-1.015, 95% confidence interval (CI)] and masculine sex (OR 2.842,1.721-4.821, 95% CI) were significant predictors of bleeding. Patients with final ACT ≥ 140 s had higher risk of UT (OR 1.81, 1.13-2.89, 95% CI; P = 0.0104), compared to final ACT < 140 s. CPB time (OR 1.019,1.012-1.026, 95% CI) and final ACT (OR 1.021,1.010-1.032, 95% CI) were significant predictors of transfusion. Female sex was a predictor of use of transfusion, with a probability for use of 27.23% (21.84-33.39%, 95% CI) in elective surgeries, and 60.38% (37.65-79.36%, 95% CI) in urgent surgeries, higher than in males.

CONCLUSIONS

Final ACT has a good predictive value for the use of transfusion. Final ACT ≥ 140 s correlates with higher risk of transfusion and increased bleeding. The risk of bleeding and transfusion is higher with longer periods of CPB. Males have a higher risk of bleeding, but females have a higher risk of transfusion.

Bloodless Gynecological Surgery in Blood Products Refusing Patients: Experience of a Single Institution

Propose

This pilot study aimed to apply the central tenets of bloodless surgery and to analyze the effectiveness of specific preoperative, intraoperative, and postoperative strategies to minimize the risk for blood transfusion after gynecological surgery in a specific group of patients who refused blood products.

Methods

A total of 83 patients undergoing gynecological surgery were included in the study. Forty-two patients received preoperatively oral iron, acid folic, and vitamin B12 supplementation in the 30 days before surgery, and 41 patients did not receive therapy.

Results

No significant differences were found when comparing the two study groups. The implementation of all procedures to maintain a bloodless surgery has been helpful, in association with the other available procedures, in achieving optimal management and maintenance of hemoglobin levels, even in the most critical situations.

Conclusion

In conclusion, implementing the bloodless approach as much as possible could guarantee the patient better and safer clinical and care management. Furthermore, well-designed research is required to clarify further the effects of bloodless surgery in gynecological patients.

Institutional Variability in Red Blood Cell Transfusion With Coronary Bypass in a Statewide Database

BACKGROUND

The decision to perform transfusion is common but varies among centers and surgeons. This study looked at variables associated with red blood cell (RBC) transfusion in a statewide database. The study aimed to understand discrepancies in transfusion rates among hospitals and to establish whether the hospital itself was a significant variable in transfusion, independent of variables known to affect transfusion in patients undergoing cardiac surgical procedures.

METHODS

The Maryland Cardiac Surgery Quality Initiative is a consortium of centers in the state. Patients undergoing isolated coronary artery bypass grafting from January 2018 to June 2020 from 10 centers in Maryland were included. Multivariable logistic regression was used to determine probability of RBC transfusion with covariates, including age, preoperative hemoglobin value, The Society of Thoracic Surgeons predicted risk of mortality, emergency status, preoperative adenosine diphosphate receptor blocker use, sex, body mass index, and off-pump status.

RESULTS

A total of 5343 patients were included and had an overall RBC transfusion rate of 30.3% (range, 11.3%-55.8%). There was significant variability in the incidence of RBC transfusion among hospitals (χ2 = 604.7; P < .001). After covariate adjustment, a significant effect of hospital on transfusion remained (Wald = 547.3; P < .001). Hospital variation in RBC transfusion was not correlated with hospital variation in median age (P = .467), hemoglobin (P 0 855), The Society of Thoracic Surgeons predicted risk of mortality (P = .855), or sex (P = .726).

CONCLUSIONS

In a statewide analysis, wide variability in transfusion rates was observed, with hospital-specific management strongly associated with RBC transfusion. This study suggests that RBC transfusion may be affected by the culture and practices of an institution independent of clinical and demographic variables.

Albumin Infusion and Blood Loss After Cardiac Surgery

BACKGROUND

In the recent ALBICS (ALBumin In Cardiac Surgery) trial, 4% albumin used for cardiopulmonary bypass priming and volume replacement increased perioperative bleeding compared with Ringer acetate. In the present exploratory study, albumin-related bleeding was further characterized.

METHODS

Ringer acetate and 4% albumin were compared in a randomized, double-blinded fashion in 1386 on-pump adult cardiac surgery patients. The study end points for bleeding were the Universal Definition of Perioperative Bleeding (UDPB) class and its components.

RESULTS

The UDPB bleeding grades were higher in the albumin group than the Ringer group: "insignificant" (albumin vs Ringer: 47.5% vs 62.9%), "mild" (12.7% vs 8.9%), "moderate" (28.7% vs 24.4%), "severe" (10.2% vs 3.2%), and "massive" (0.9% vs. 0.6%; P < .001). Patients in the albumin group received red blood cells (45.2% vs 31.5%; odds ratio [OR], 1.80; 95% CI, 1.44-2.24; P < .001), platelets (33.3% vs 21.8%; OR, 1.79; 95% CI, 1.41-2.28; P < .001), and fibrinogen (5.6% vs 2.6%; OR, 2.24; 95% CI, 1.27-3.95; P < .05), and underwent resternotomy (5.3% vs 1.9%; OR, 2.95; 95% CI, 1.55-5.60, P < .001) more often than patients in the Ringer group. The strongest predictors of bleeding were albumin group allocation (OR, 2.18; 95% CI, 1.74-2.74) and complex (OR, 2.61; 95% CI, 2.02-3.37) and urgent surgery (OR, 1.63; 95% CI, 1.26-2.13). In interaction analysis, the effect of albumin on the risk of bleeding was stronger in patients on preoperative acetylsalicylic acid.

CONCLUSIONS

Perioperative administration of albumin, compared with Ringer's acetate, resulted in increased blood loss and higher UDBP class. The magnitude of this effect was similar to the complexity and urgency of the surgery.

Cardiac Surgery in Jehovah's Witnesses: 329 Consecutive Cases

OBJECTIVES

This study aimed to describe the outcome of Jehovah's Witnesses (JWs) undergoing cardiac surgery at the authors' center.

DESIGN

A single-center retrospective cohort study.

SETTING

At a cardiovascular center with a tertiary intensive care unit (ICU) and specific experience with cardiac surgery in JWs. The institutional protocol describing all perioperative care in JWs has been applied for 21 years.

PARTICIPANTS

All JWs undergoing cardiac surgery in the Amphia Hospital from January 1, 2001 to January 31, 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The study cohort comprised 329 JWs undergoing cardiac surgery. Twenty-three patients (6.8%) were treated preoperatively for anemia. The mean European System for Cardiac Operative Risk Evaluation score was 5.1 (range 0-18). Coronary artery bypass grafting (53.2%) was performed most frequently, followed by aortic valve replacement (13.4%). Mean preoperative hemoglobin levels were 14.5 g/dL (range 9.8-18.5 g/dL), dropping to 11.6 g/dL (range 6.6-15.6 g/dL) at hospital discharge. Mean blood loss was 439 ± 349 mL in the first 12 hours postsurgery. Maximum mean postoperative troponin levels were 431 ± 424 ng/L. Resternotomy and postoperative myocardial infarction occurred in 3.6% and 4.2% of patients, respectively. On average, patients had an ICU stay of 1.4 ± 1.8 days and a hospital stay of 6.8 ± 4.2 days. Hospital mortality was 0.6% and was related to cardiac failure.

CONCLUSIONS

This study demonstrated that cardiac surgery in JWs is safe when adhering to a strict perioperative patient blood management protocol.

Nomogram and Risk Calculator for Postoperative Tracheostomy after Heart Valve Surgery

Postoperative tracheostomy (POT) is an important indicator of critical illness, associated with poorer prognoses and increased medical burdens. However, studies on POTs after heart valve surgery (HVS) have not been reported. The objectives of this study were first to identify the risk factors and develop a risk prediction model for POTs after HVS, and second to clarify the relationship between POTs and clinical outcomes. Consecutive adults undergoing HVS from January 2016 to December 2019 in a single cardiovascular center were enrolled, and a POT was performed in 1.8% of the included patients (68/3853). Compared to patients without POTs, the patients with POTs had higher rates of readmission to the ICU and in-hospital mortality, as well as longer ICU and hospital stays. Five factors were identified to be significantly associated with POTs after HVS by our multivariate analysis, including age, diabetes mellitus, pulmonary edema, intraoperative transfusion of red blood cells, and surgical types. A nomogram and a risk calculator were constructed based on the five factors, showing excellent discrimination, calibration, and clinical utility. Three risk intervals were defined as low-, medium-, and high-risk groups according to the nomogram and clinical practice. The findings of this study may be helpful for early risk assessment and perioperative management.

Barriers to atrial fibrillation ablation during mitral valve surgery

BACKGROUND

Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

METHODS

Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

RESULTS

Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

CONCLUSIONS

Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.

The use of blood and blood products in aortic surgery is associated with adverse outcomes

OBJECTIVE

To report long-term outcomes after deep hypothermic circulatory arrest (DHCA) with or without perioperative blood or blood products.

METHODS

All patients who underwent proximal aortic surgery with DHCA from 2011 to 2018 were propensity matched according to baseline characteristics. Primary outcomes included short- and long-term mortality. Stratified Cox regression analysis was performed for significant associations with survival.

RESULTS

A total of 824 patients underwent aortic replacement requiring circulatory arrest. After matching, there were 224 patients in each arm (transfusion and no transfusion). All baseline characteristics were well matched, with a standardized mean difference (SMD) <0.1. Preoperative hematocrit (41.0 vs 40.6; SMD = 0.05) and ejection fraction (57.5% vs 57.0%; SMD = 0.08) were similar between the no transfusion and blood product transfusion cohorts. Rate of aortic dissection (42.9% vs 45.1%; SMD = 0.05), hemiarch replacement (70.1% vs 70.1%; SMD = 0.00), and total arch replacement (21.9% vs 23.2%; SMD = 0.03) were not statistically different. Cardiopulmonary bypass and cross-clamp time were higher in the blood product transfusion cohort (P < .001). Operative mortality (9.4% vs 2.7%; P = .003), stroke (7.6% vs 1.3%; P = .001), reoperation rate, pneumonia, prolonged ventilation, and dialysis requirements were significantly higher in the transfusion cohort (P < .001). In stratified Cox regression, transfusion was an independent predictor of mortality (hazard ratio, 2.62 [confidence interval, 1.47-4.67]; P = .001). One- and 5-year survival were significantly reduced for the transfusion cohort (P < .001).

CONCLUSIONS

In patients who underwent aortic surgery with DHCA, perioperative transfusions were associated with poor outcomes despite matching for preoperative baseline characteristics.

Evaluating variation in perioperative red blood cell transfusion for patients undergoing elective gastrointestinal cancer surgery

BACKGROUND

Patients undergoing gastrointestinal cancer surgery often receive packed red blood cell transfusions. Understanding practice variation is critical to support efforts working toward responsible transfusion use. We measured the extent and importance of variation in perioperative packed red blood cell transfusion use across physicians and hospitals among gastrointestinal cancer surgery patients.

METHODS

We identified patients who underwent elective gastrointestinal cancer resection between 2007 and 2019 using linked administrative health data sets in Ontario, Canada. We used funnel plots to describe variation in transfusion use, adjusted for patient case mix. Hierarchical regression models quantified patient-level, between-physician, and between-hospital variation in transfusion use with R² measures, variance partition coefficients, and median odds ratios.

RESULTS

Of 59,964 included patients (median age 69 years; 43.2% female; 75.8% colorectal resections), 18.0% received perioperative packed red blood cell transfusions. Funnel plots showed variation in transfusion use among physicians and hospitals. Patient characteristics, such as age, comorbidity, and procedure type, combined to explain 12.8% of the variation. After adjusting for case mix, systematic between-physician and between-hospital differences were responsible for 2.8% and 2.1% of the variation, respectively. This translated to an approximately 30% difference in the odds of transfusion for 2 similar patients treated by distinct physicians (median odds ratio: 1.35, 95% confidence interval 1.30-1.40) and hospitals (median odds ratio: 1.30, 95% confidence interval 1.23-1.42). We observed comparable effects across procedure-type subgroups.

CONCLUSION

Transfusion provision is highly driven by patient factors. Yet the impact of the treating physician and hospital on variation relative to other factors is important and reflects opportunities to target modifiable processes of care to standardize perioperative packed red blood cell transfusion practice.

Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement

There is no definitive consensus about the cost-effectiveness of minimally invasive aortic valve replacement (AVR) (MI-AVR) compared to conventional AVR (C-AVR). The aim of this study was to compare the rate of postoperative complications and total hospital costs of MI-AVR versus C-AVR overall and by the type of aortic prosthesis (biological or mechanical). Our single-center retrospective study included 324 patients over 18 years old who underwent elective isolated primary AVR with standard stented AV prosthesis at the Institute for Cardiovascular Diseases "Dedinje" between January 2019 and December 2019. Reintervention, emergencies, combined surgical interventions, and patients with sutureless valves were excluded. In both MI-AVR and C-AVR, mechanical valve implantation contributed to overall reduction of hospital costs with equal efficacy. The cost-effectiveness ratio indicated that C-AVR is cheaper and yielded a better clinical outcome with mechanical valve implantation (67.17 vs. 69.5). In biological valve implantation, MI-AVR was superior. MI-AVR patients had statistically significantly higher LVEF and a lower Euro SCORE than C-AVR patients (Mann-Whitney U-test, p = 0.002 and p = 0.002, respectively). There is a slight advantage to MI-AVR vs. C-AVR, since it costs EUR 9.44 more to address complications that may arise. Complications (mortality, early reoperation, cerebrovascular insult, pacemaker implantation, atrial fibrillation, AV block, systemic inflammatory response syndrome, wound infection) were less frequent in the MI-AVR, making MI-AVR more economically justified than C-AVR (18% vs. 22.1%).

[The costs of preoperative anemia in hip joint revision surgery]

BACKGROUND

Anemia is highly prevalent in patients before hip joint revision surgery (HJRS) and is associated with an increased complication rate. This paper is the first to investigate costs, real diagnosis-related group (DRG) revenues and case coverage of preoperative anemia in elective HJRS.

METHODS

Medical data, transfusions, costs, and revenues of all patients undergoing HJRS at two campuses of the Charité -Universitätsmedizin Berlin between 2010 and 2017 were used for subgroup analyses and linear regressions.

RESULTS

Of 1187 patients included 354 (29.8%) showed preoperative anemia. A total of 565 (47.6%) patients were transfused with a clear predominance of anemic patients (72.6% vs. 37.0%, p < 0.001). Costs (12,318€ [9027;20,044€] vs. 8948€ [7501;11,339€], p < 0.001) and revenues (11,788€ [8992;16,298€] vs. 9611€ [8332;10,719€], p < 0.001) were higher for preoperatively anemic patients and the coverage was deficient (-1170€ [-4467;1238€] vs. 591€ [-1441;2103€], p < 0.001). In anemic patients, case contribution margins decreased with increasing transfusion rates (p ≤ 0.001). Comorbidities had no significant economic impact.

CONCLUSION

Preoperative anemia and perioperative transfusions in HJRS are associated with increased treatment costs and a financial undercoverage for healthcare providers and health insurance companies. Concepts for the treatment of preoperative anemia (e.g. patient blood management) could reduce treatment costs in the medium term.

Role of Omega-6 Fatty Acid Metabolism in Cardiac Surgery Postoperative Bleeding Risk

Cardiac surgery is frequently associated with significant postoperative bleeding. Platelet-dysfunction is the main cardiopulmonary bypass (CPB)-induced hemostatic defect. Not only the number of platelets decreases, but also the remaining are functionally impaired. Although lipid metabolism is crucial for platelet function, little is known regarding platelet metabolic changes associated with CPB-dysfunction. Our aim is to explore possible contribution of metabolic perturbations for platelet dysfunction after cardiac surgery.

DESIGN

Prospective cohort study.

SETTING

Tertiary academic cardiothoracic-surgery ICU.

PATIENTS

Thirty-three patients submitted to elective surgical aortic valve replacement.

INTERVENTIONS

Samples from patients were collected at three time points (preoperative, 6- and 24-hr postoperative). Untargeted metabolic analysis using high-performance liquid chromatography-tandem mass spectrometry was performed to compare patients with significant postoperative bleeding with patients without hemorrhage. Principal component analyses, Wilcoxon matched-pairs signed-rank tests, adjusted to FDR, and pairwise comparison were used to identify pathways of interest. Enrichment and pathway metabolomic complemented the analyses.

MEASUREMENTS AND MAIN RESULTS

We identified a platelet-related signature based on an overrepresentation of changes in known fatty acid metabolism pathways involved in platelet function. We observed that arachidonic acid (AA) levels and other metabolites from the pathway were reduced at 6 and 24 hours, independently from antiagreggation therapy and platelet count. Concentrations of preoperative AA were inversely correlated with postoperative chest tube blood loss but were not correlated with platelet count in the preoperative, at 6 or at 24 hours. Patients with significant postoperative blood-loss had considerably lower values of AA and higher transfusion rates. Values of postoperative interleukin-6 were strongly correlated with AA variability.

CONCLUSIONS AND RELEVANCE

Our observations suggest that an inflammatory-related perturbation of AA metabolism is a signature of cardiac surgery with CPB and that preoperative levels of AA may be more relevant than platelet count to anticipate and prevent postoperative blood loss in patients submitted to cardiac surgery with CPB.

Citrate does not change viscoelastic haemostatic assays after cardiopulmonary bypass

CONTEXT

Viscoelastic hemostatic assays (VHA) are commonly used to identify specific cellular and humoral causes for bleeding in cardiac surgery patients. Cardiopulmonary bypass (CPB) alterations to coagulation are observable on VHA. Citrated VHA can approximate fresh whole blood VHA when kaolin is used as the activator in healthy volunteers. Some have suggested that noncitrated blood is more optimal than citrated blood for point-of-care analysis in some populations.

AIMS

To determine if storage of blood samples in citrate after CPB alters kaolin activated VHA results.

SETTINGS AND DESIGN

This was a prospective observational cohort study at a single tertiary care teaching hospital.

METHODS AND MATERIAL

Blood samples were subjected to VHA immediately after collection and compared to samples drawn at the same time and stored in citrate for 30, 90, and 150 min prior to kaolin activated VHA both before and after CPB.

STATISTICAL ANALYSIS USED

VHA results were compared using paired T-tests and Bland-Altman analysis.

RESULTS

Maximum clot strength and time to clot initiation were not considerably different before or after CPB using paired T-tests or Bland-Altman Analysis.

CONCLUSIONS

Citrated samples appear to be a clinically reliable substitute for fresh samples for maximum clot strength and time to VHA clot initiation after CPB. Concerns about the role of citrate in altering the validity of the VHA samples in the cardiac surgery population seem unfounded.

Nosocomial Extracardiac Infections After Cardiac Surgery

Purpose of Review

Nosocomial extracardiac infections after cardiac surgery are a major public health issue affecting 3–8.2% of patients within 30–60 days following the intervention.

Recent Findings

Here, we have considered the most important postoperative infective complications that, in order of frequency, are pneumonia, surgical site infection, urinary tract infection, and bloodstream infection. The overall picture that emerges shows that they cause a greater perioperative morbidity and mortality with a longer hospitalization time and excess costs. Preventive interventions and corrective measures, diminishing the burden of nosocomial extracardiac infections, may reduce the global costs. A multidisciplinary team may assure a more appropriate management of nosocomial extracardiac infections leading to a reduction of hospitalization time and mortality rate.

Summary

The main and most current data on epidemiology, prevention, microbiology, diagnosis, and management for each one of the most important postoperative infective complications are reported. The establishment of an antimicrobial stewardship in each hospital seems to be, at the moment, the more valid strategy to counteract the challenging problems.

Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions

Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.

Development and validation of a nomogram model for pneumonia after redo cardiac surgery

AIMS

Postoperative pneumonia (POP) after redo cardiac surgery is prevalent, associated with poor outcome. The aim of this study was to identify independent risk factors for POP after redo cardiac surgery and to develop and validate a prediction model.

METHODS

Adults undergoing redo cardiac surgery from 2016 to 2019 were identified in a single-institution database. Using a 2: 1 ratio, the patients were randomly divided into training and validation sets. Univariate and multivariate analyses were applied to identify independent predictors for POP in the training set. A nomogram model was constructed for clinical utility and was validated in the validation set.

RESULTS

POP developed in 72 of the 376 patients (19.1%). Four independent risk factors were identified, including age, chronic obstructive pulmonary disease, serum creatinine level and intraoperative blood transfusion volume. A nomogram based on the four predictors was constructed, with good discrimination in both the training (c-index: 0.86) and validation sets (c-index: 0.78). The model was well calibrated, with a Hosmer-Lemeshow χ 2 -value of 7.31 ( P   =  0.50) in the training set and 7.41 ( P   =  0.49) in the validation set. The calibration was also good by visual inspection. The decision and clinical impact curves of the nomogram indicated good clinical utility. Three risk intervals were identified based on the nomogram for better risk stratification.

CONCLUSION

We developed and validated a nomogram model for POP after redo cardiac surgery. The model may have good clinical utility in risk evaluation and individualized treatment to reduce adverse events. Graphical abstract Incidence, risk factor, and outcomes of postoperative pneumonia after redo cardiac surgery: http://links.lww.com/JCM/A445 .

Development and validation of a risk prediction model for postoperative pneumonia in adult patients undergoing Stanford type A acute aortic dissection surgery: a case control study

Background

Pneumonia is a common complication after Stanford type A acute aortic dissection surgery (AADS) and contributes significantly to morbidity, mortality, and length of stay. The purpose of this study was to identify independent risk factors associated with pneumonia after AADS and to develop and validate a risk prediction model.

Methods

Adults undergoing AADS between 2016 and 2019 were identified in a single-institution database. Patients were randomly divided into training and validation sets at a ratio of 2:1. Preoperative and intraoperative variables were included for analysis. A multivariate logistic regression model was constructed using significant variables from univariate analysis in the training set. A nomogram was constructed for clinical utility and the model was validated in an independent dataset.

Results

Postoperative pneumonia developed in 170 of 492 patients (34.6%). In the training set, multivariate analysis identified seven independent predictors for pneumonia after AADS including age, smoking history, chronic obstructive pulmonary disease, renal insufficiency, leucocytosis, low platelet count, and intraoperative transfusion of red blood cells. The model demonstrated good calibration (Hosmer–Lemeshow χ² = 3.31, P = 0.91) and discrimination (C-index = 0.77) in the training set. The model was also well calibrated (Hosmer–Lemeshow χ² = 5.73, P = 0.68) and showed reliable discriminatory ability (C-index = 0.78) in the validation set. By visual inspection, the calibrations were good in both the training and validation sets.

Conclusion

We developed and validated a risk prediction model for pneumonia after AADS. The model may have clinical utility in individualized risk evaluation and perioperative management.

Development and Validation of Nomogram Models for Postoperative Pneumonia in Adult Patients Undergoing Elective Cardiac Surgery

Background: Postoperative pneumonia (POP) is a frequent complication following cardiac surgery, related to increased morbidity, mortality and healthcare costs. The objectives of this study were to investigate the risk factors associated with POP in adults undergoing elective cardiac surgery and to develop and validate nomogram models.

Methods: We conducted a multicenter retrospective study in four cardiac centers in China. Adults operated with elective open-heart surgery from 2016 to 2020 were included. Patients were randomly allocated to training and validation sets by 7:3 ratio. Demographics, comorbidities, laboratory data, surgical factors, and postoperative outcomes were collected and analyzed. Risk factors for POP were identified by univariate and multivariate analysis. Nomograms were constructed based on the multivariate logistic regression models and were evaluated with calibration, discrimination and decision curve analysis.

Results: A total of 13,380 patients meeting the criteria were included and POP developed in 882 patients (6.6%). The mortality was 2.0%, but it increased significantly in patients with POP (25.1 vs. 0.4%, P < 0.001). Using preoperative and intraoperative variables, we constructed a full nomogram model based on ten independent risk factors and a preoperative nomogram model based on eight preoperative factors. Both nomograms demonstrated good calibration, discrimination, and were well validated. The decision curves indicated significant clinical usefulness. Finally, four risk intervals were defined for better clinical application.

Conclusions: We developed and validated two nomogram models for POP following elective cardiac surgery using preoperative and intraoperative factors, which may be helpful for individualized risk evaluation and prevention decisions.

Impact of early massive transfusion and blood component ratios in patients undergoing left ventricular assist device implantation

BACKGROUND

This study evaluates the impact of early massive transfusion and blood component ratios on outcomes following left ventricular assist device (LVAD) implantation.

METHODS

Adults undergoing LVAD implantation between 2009 and 2018 at a single institution were included. Transfusions were analyzed during the intraoperative and the initial 24-h postoperative period. Patients were stratified into massive and nonmassive transfusion groups. The primary outcome was survival, and secondary outcomes included postoperative complications. Sub-analyses were performed to evaluate the impact of balanced transfusion.

RESULTS

A total of 278 patients were included. A total of 45.3% (n = 126) required massive transfusions. The massive transfusion group experienced significantly higher rates of postimplant adverse events, including reoperation, renal failure, and hepatic dysfunction (all, p ≤ .05). Furthermore, the massive transfusion group had significantly lower 30-day, 90-day, 1-year, 2-year, and overall survival rates following LVAD implantation (all, p < .05). In multivariable analysis, massive transfusion significantly impacted overall risk-adjusted mortality rate (hazard ratio: 2.402, 95% confidence Interval: 1.677-3.442, p < .001). In the sub-analyses evaluating the impact of balanced massive transfusion, balanced fresh frozen plasma to packed red blood cell (pRBC) transfusion did not provide any survival benefit (all, p > .05). However, balanced platelet to pRBC massive transfusion did improve 2-year and overall mortality rates in the massive transfusion cohort (both, p ≤ .05).

CONCLUSIONS

This study demonstrates a significant association between early massive transfusion and adverse outcomes following LVAD implantation. Balancing platelet to pRBC transfusion in the early postoperative period may help mitigate some of these detrimental effects of massive transfusion on subsequent survival.

Clinical risk score for postoperative pneumonia following heart valve surgery

Background:

Postoperative pneumonia (POP) is one of the most common infections following heart valve surgery (HVS) and is associated with a significant increase in morbidity, mortality, and health care costs. This study aimed to identify the major risk factors associated with the occurrence of POP following HVS and to derive and validate a clinical risk score.

Methods:

Adults undergoing open HVS between January 2016 and December 2019 at a single institution were enrolled in this study. Patients were randomly assigned to the derivation and validation sets at 1:1 ratio. A prediction model was developed with multivariable logistic regression analysis in the derivation set. Points were assigned to independent risk factors based on their regression coefficients.

Results:

POP occurred in 316 of the 3853 patients (8.2%). Multivariable analysis identified ten significant predictors for POP in the derivation set, including older age, smoking history, chronic obstructive pulmonary disease, diabetes mellitus, renal insufficiency, poor cardiac function, heart surgery history, longer cardiopulmonary bypass, blood transfusion, and concomitant coronary and/or aortic surgery. A 22-point risk score based on the multivariable model was then generated, demonstrating good discrimination (C-statistic: 0.81), and calibration (Hosmer-Lemeshow χ² = 8.234, P = 0.312). The prediction rule also showed adequate discriminative power (C-statistic: 0.83) and calibration (Hosmer-Lemeshow χ² = 5.606, P = 0.691) in the validation set. Three risk intervals were defined as low-, medium-, and high-risk groups.

Conclusion:

We derived and validated a 22-point risk score for POP following HVS, which may be useful in preventive interventions and risk management.

Trial Registration:

Chictr.org, ChiCTR1900028127; http://www.chictr.org.cn/showproj.aspx?proj=46932

Number and Type of Blood Products are Negatively Associated With Outcomes Following Cardiac Surgery

BACKGROUND

The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with type and number of blood product units transfused.

METHODS

Statewide data from adult cardiac surgery patients were included (N=24,082). Relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC+non-RBC). Multivariable logistic regressions examined these associations.

RESULTS

Median age was 66 years (30% female) with 51% of patients transfused (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity (all P<0.001). Odds for 30-day mortality were 13% greater with each RBC unit (P<0.001) and 6% greater for each non-RBC unit (P<0.001). Each unit of fresh frozen plasma (P<0.001) and platelets (P<0.001) increased odds for 30-day mortality, but no effect for cryoprecipitate (P=0.725). Odds for 30-day mortality were lower for non-RBC only (OR=0.52, P=0.030) and greater for RBC+non-RBC (OR=2.98, P<0.001) compared to RBC only transfusion.

CONCLUSIONS

Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared to non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event following cardiac surgery.

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines

BACKGROUND

Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap.

METHODS

Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018.

RESULTS

Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria.

CONCLUSIONS

The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.

Risk Factors for Prolonged Mechanical Ventilation After Pulmonary Endarterectomy: 7 Years' Experience From an Experienced Hospital in China

Background: Prolonged mechanical ventilation (PMV) is common after cardiothoracic surgery, whereas the mechanical ventilation strategy after pulmonary endarterectomy (PEA) has not yet been reported. We aim to identify the incidence and risk factors for PMV and the relationship between PMV and short-term outcomes.

Methods: We studied a retrospective cohort of 171 who undergoing PEA surgery from 2014 to 2020. Cox regression with restricted cubic splines was performed to identify the cutoff value for PMV. The Least absolute shrinkage and selection operator regression and logistic regressions were applied to identify risk factors for PMV. The impacts of PMV on the short-term outcomes were evaluated.

Results: PMV was defined as the duration of mechanical ventilation exceeding 48 h. Independent risk factors for PMV included female sex (OR 2.911; 95% CI 1.303–6.501; P = 0.009), prolonged deep hypothermic circulatory arrest (DHCA) time (OR 1.027; 95% CI 1.002–1.053; P = 0.036), increased postoperative blood product use (OR 3.542; 95% CI 1.203–10.423; P = 0.022), elevated postoperative total bilirubin levels (OR 1.021; 95% CI 1.007–1.034; P = 0.002), increased preoperative pulmonary artery pressure (PAP) (OR 1.031; 95% CI 1.014–1.048; P < 0.001) and elongated postoperative right ventricular anteroposterior dimension (RVAD) (OR 1.119; 95% CI 1.026–1.221; P = 0.011). Patients with PMV had longer intensive care unit stays, higher incidences of postoperative complications, and higher in-hospital medical expenses.

Conclusions: Female sex, prolonged DHCA time, increased postoperative blood product use, elevated postoperative total bilirubin levels, increased preoperative PAP, and elongated postoperative RVAD were independent risk factors for PMV. Identification of risk factors associated with PMV in patients undergoing PEA may facilitate timely diagnosis and re-intervention for some of these modifiable factors to decrease ventilation time and improve patient outcomes.

Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.

Associations between preoperative anaemia and hospital costs following major abdominal surgery: cohort study

Background

Determining the cost-effectiveness and sustainability of patient blood management programmes relies on quantifying the economic burden of preoperative anaemia. This retrospective cohort study aimed to evaluate the hospital costs attributable to preoperative anaemia in patients undergoing major abdominal surgery.

Methods

Patients who underwent major abdominal surgery between 2010 and 2018 were included. The association between preoperative patient haemoglobin (Hb) concentration and hospital costs was evaluated by curve estimation based on the least-square method. The in-hospital cost of index admission was calculated using an activity-based costing methodology. Multivariable regression analysis and propensity score matching were used to estimate the effects of Hb concentration on variables related directly to hospital costs.

Results

A total of 1286 patients were included. The median overall cost was US $18 476 (i.q.r.13 784–27 880), and 568 patients (44.2 per cent) had a Hb level below 13.0 g/dl. Patients with a preoperative Hb level below 9.0 g/dl had total hospital costs that were 50.6 (95 per cent c.i. 14.1 to 98.9) per cent higher than those for patients with a preoperative Hb level of 9.0–13.0 g/dl (P < 0.001), 72.5 (30.6 to 128.0) per cent higher than costs for patients with a Hb concentration of 13.1–15.0 g/dl (P < 0.001), and 62.4 (21.8 to 116.7) per cent higher than those for patients with a Hb level greater than 15.0 g/dl (P < 0.001). Multivariable general linear modelling showed that packed red blood cell (PRBC) transfusions were a principal cost driver in patients with a Hb concentration below 9.0 g/dl.

Conclusion

Patients with the lowest Hb concentration incurred the highest hospital costs, which were strongly associated with increased PRBC transfusions. Costs and possible complications may be decreased by treating preoperative anaemia, particularly more severe anaemia.

Risk factors for postoperative pneumonia after cardiac surgery: a prediction model

Background

Postoperative pneumonia is the main infectious complication following cardiac surgery and is associated with significant increases in morbidity, mortality and health care costs. The aim of this study was to identify potential risk factors related to the occurrence of postoperative pneumonia in adult patients undergoing cardiac surgery and to develop a predictive system.

Methods

Adult patients who underwent open heart surgery in our institution between 2016 and 2019 were enrolled in this study. Preoperative and intraoperative variables were collected and analyzed. A multivariate prediction model for evaluating the risk of postoperative pneumonia was established using logistic regression analysis via forward stepwise selection, and points were assigned to significant risk factors based on their regression coefficient values.

Results

Postoperative pneumonia occurred in 530 of the 5,323 patients (9.96%). Prolonged stays in the postoperative intensive care unit (ICU) and hospital, as well as higher mortality (25.66% versus 0.65%), were observed in patients with postoperative pneumonia. Multivariate analysis identified 13 independent risk factors including patient demographics, comorbidities, cardiac function, cardiopulmonary bypass (CPB) duration, and blood transfusion. The prediction model showed good discrimination (C-statistic: 0.80) and was well calibrated (Hosmer-Lemeshow χ²=7.907, P value =0.443). A 32-point risk score was generated, and then three risk intervals were defined.

Conclusions

We derived and validated a prediction model for postoperative pneumonia after cardiac surgery incorporating 13 easily discernible risk factors. The scoring system may be helpful for individualized risk estimations and clinical decision-making.

Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation

OBJECTIVES

Extracorporeal membrane oxygenation is a life-sustaining therapy for severe respiratory failure. Extracorporeal membrane oxygenation circuits require systemic anticoagulation that creates a delicate balance between circuit-related thrombosis and bleeding-related complications. Although unfractionated heparin is most widely used anticoagulant, alternative agents such as bivalirudin have been used. We sought to compare extracorporeal membrane oxygenation circuit thrombosis and bleeding-related outcomes in respiratory failure patients receiving either unfractionated heparin or bivalirudin for anticoagulation on venovenous extracorporeal membrane oxygenation support.

DESIGN

Retrospective cohort study.

SETTING

Single-center, cardiothoracic ICU.

PATIENTS

Consecutive patients requiring venovenous extracorporeal membrane oxygenation who were maintained on anticoagulation between 2013 and 2020.

INTERNVENTIONS

IV bivalirudin or IV unfractionated heparin.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the presence of extracorporeal membrane oxygenation in-circuit-related thrombotic complications and volume of blood products administered during extracorporeal membrane oxygenation duration. One hundred sixty-two patients receiving unfractionated heparin were compared with 133 patients receiving bivalirudin for anticoagulation on venovenous extracorporeal membrane oxygenation. In patients receiving bivalirudin, there was an overall decrease in the number of extracorporeal membrane oxygenation circuit thrombotic complications (p < 0.005) and a significant increase in time to circuit thrombosis (p = 0.007). Multivariable Cox regression found that heparin was associated with a significant increase in risk of clots (Exp[B] = 2.31, p = 0.001). Patients who received bivalirudin received significantly less volume of packed RBCs, fresh frozen plasma, and platelet transfusion (p < 0.001 for each). There was a significant decrease in the number major bleeding events in patients receiving bivalirudin, 40.7% versus 11.7%, p < 0.001.

CONCLUSIONS

Patients receiving bivalirudin for systemic anticoagulation on venovenous extracorporeal membrane oxygenation experienced a decrease in the number of extracorporeal membrane oxygenation circuit-related thrombotic events as well as a significant decrease in volume of blood products administered.

The impact of tranexamic acid on administration of red blood cell transfusions for resection of colorectal liver metastases

BACKGROUND

Red blood cell transfusions (RBCT) remain a concern for patients undergoing hepatectomy. The effect of tranexamic acid (TXA), an anti-fibrinolytic, on receipt of RBCT in colorectal liver metastases (CRLM) resection was examined.

METHODS

Hepatectomies for CRLM over 2009-2014 were included. Primary outcome was 30-day receipt of RBCT. Secondary outcomes were 30-day major morbidity (Clavien-Dindo III-V) and 90-day mortality. Multivariable modelling examined the adjusted association between TXA and outcomes.

RESULTS

Of 433 included patients, 146 (34%) received TXA. TXA patients were more likely to have inflow occlusion (41.8% vs. 23.1%; p < 0.01) and major hepatectomies (56.1% vs. 45.6%; p = 0.0193). TXA was independently associated with lower risk of RBCT (Relative risk (RR) 0.59; 95% confidence interval (95%CI): 0.42-0.85), but not with 30-day major morbidity (adjusted RR 1.02; 95%CI: 0.64-1.60) and 90-day mortality (univariable RR 0.99; 95%CI: 0.95-1.03).

CONCLUSION

Intraoperative TXA was associated with a 41% reduction in risk of 30 -day receipt of RBCT after hepatectomy for CRLM. This finding is important to potentially improve healthcare resource allocation and patient outcomes. Pending further evidence, intraoperative TXA may be an effective method of reducing RBCT in hepatectomy for CRLM.

Declining Use of Red Blood Cell Transfusions for Gastrointestinal Cancer Surgery: A Population-Based Analysis

BACKGROUND

Gastrointestinal cancer surgery patients often develop perioperative anemia commonly treated with red blood cell (RBC) transfusions. Given the potential associated risks, evidence published over the past 10 years supports restrictive transfusion practices and blood conservation programs. Whether transfusion practices have changed remains unclear. We describe temporal RBC transfusion trends in a large North American population who underwent gastrointestinal cancer surgery.

METHODS

We conducted a population-based retrospective cohort study of patients who underwent gastrointestinal cancer resection between 2007 and 2018 using health administrative datasets. The outcome was RBC transfusion during hospitalization. Temporal transfusion trends were analyzed with Cochran-Armitage tests. Multivariable regression assessed the association between year of diagnosis and likelihood of RBC transfusion while controlling for confounding.

RESULTS

Of 79,764 patients undergoing gastrointestinal cancer resection, the median age was 69 years old (interquartile range (IQR) 60-78 years) and 55.5% were male. The most frequent procedures were colectomy (52.8%) and proctectomy (23.0%). A total of 18,175 patients (23%) received RBC transfusion. The proportion of patients transfused decreased from 26.5% in 2007 to 18.9% in 2018 (p < 0.001). After adjusting for patient, procedure, and hospital factors, the most recent time period (2015-2018) was associated with a reduced likelihood of receiving RBC transfusion [relative risk 0.86 (95% confidence interval: 0.83-0.89)] relative to the intermediate time period (2011-2014).

CONCLUSION

Over 11 years, we observed decreased RBC transfusion use and reduced likelihood of transfusion in patients undergoing gastrointestinal cancer resection. This information provides a foundation to further examine transfusion appropriateness or explore if additional transfusion minimization in surgical patients can be achieved.

Retrospective Analysis of Thromboelastography-Directed Transfusion in Isolated CABG: Impact on Blood Product Use, Cost, and Outcomes

Cardiac surgeries account for approximately 20% of blood use in the United States. Allogeneic transfusion has been associated with increased risk of morbidity and mortality, further justifying the need to reduce blood use. This study aimed at determining whether a point-of-care coagulation test, thromboelastography (TEG), impacted blood product administration and outcomes. Patients undergoing isolated coronary artery bypass grafting (CABG) were retrospectively reviewed before the use of TEG (2008-2009) (n = 640) and after implementation (2011-2012) (n = 458). Blood product use was compared between time frames. Logistic regression and generalized linear models were created to estimate the impact on outcomes including the reoperation rate, mortality, and cost. The mean use of each blood product was significantly reduced in the perioperative period. Overall blood product use was decreased by over 40%. Mediastinal re-exploration of bleeding was significantly reduced with TEG (4.8 vs. 1.5%). Six-month mortality was not impacted in this cohort nor was the readmission rate or hospital length of stay. However, blood cost and patient charges were significantly lower after TEG was introduced. The use of TEG to guide the administration of blood products during isolated CABG significantly affected the amounts and types of products given intra- and perioperatively. This resulted in less chest tube drainage, fewer returns to the operating room, and more accurate diagnosis of coagulopathic status. Cost savings to the patient and institution were appreciated as a consequence of these improved clinical outcomes.

The Use of Hemostatic Blood Products in Children Following Cardiopulmonary Bypass and Associated Outcomes

To describe the use of hemostatic transfusions in children following cardiac surgery with cardiopulmonary bypass and the association of hemostatic transfusions postoperatively with clinical outcomes.

Preoperative erythropoietin within a patient blood management program decreases both blood transfusion and postoperative anemia: a prospective observational study

BACKGROUND

In orthopedic surgery, a patient blood management program (PBM) has been proposed to reduce blood transfusion. The aim of this observational study was to assess, within a PBM, the specific efficacy of preoperative erythropoietin (EPO).

STUDY DESIGN AND METHODS

In a single hospital, 723 patients undergoing elective primary hip or knee arthroplasty were prospectively studied. The PBM included EPO if preoperative hemoglobin was lower than 13 g/dL, intraoperative administration of tranexamic acid, use of recommended transfusion thresholds, and postoperative infusion of iron. Blood transfusion and hemoglobin were noted until discharge. Major thromboembolic or cardiovascular events were assessed during admission and 1 month after discharge.

RESULTS

Transfusion was noted in 2.5% patients with EPO. Transfusion rate was higher in patient for whom EPO was not indicated (13.6% transfusion rate; odds ratio [OR], 13.7; 95% confidence interval [CI], 2.6-66; p = 10^-3 ) or if erythropoietin was indicated but not administrated (36.8% transfusion rate; OR, 18.2; 95% CI, 3.9-84.5; p < 10^-3 ). Hemoglobin was significantly higher during the postoperative period in patients with erythropoietin. At hospital discharge, 57% of patients were anemic if EPO was used compared to 88% when EPO was not indicated and 87% when EPO was indicated but not administered (p < 10^-6 ). There were no significant differences in the odds of major complications between patients with or without EPO.

CONCLUSIONS

Within a PBM, preoperative treatment of anemia with EPO decreased both the rate of blood transfusion and postoperative anemia. Further studies are necessary to confirm these results.

Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgery

OBJECTIVE

To identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery.

METHODS

Observational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation.

RESULTS

Of the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P < .001), were women (41.5% vs 15.9%; P < .001), and had a lower body surface area (1.93 m² vs 2.07 m²; P < .001), respectively. Among the models explaining center-level transfusion variability, the intraclass correlation coefficients were 0.07 for model 1 (random intercepts), 0.12 for model 2 (patient factors), 0.14 for model 3 (intraoperative factors), and 0.11 for model 4 (combined). The coefficient of variation for center-level transfusion rates were 0.31, 0.29, 0.40, and 0.30 for models 1 through 4, respectively. The majority of center-level variation could not be explained through models containing both patient and intraoperative factors.

CONCLUSIONS

The results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.

Society of Cardiovascular Anesthesiologists Clinical Practice Improvement Advisory for Management of Perioperative Bleeding and Hemostasis in Cardiac Surgery Patients

Bleeding after cardiac surgery is a common and serious complication leading to transfusion of multiple blood products and resulting in increased morbidity and mortality. Despite the publication of numerous guidelines and consensus statements for patient blood management in cardiac surgery, research has revealed that adherence to these guidelines is poor, and as a result, a significant variability in patient transfusion practices among practitioners still remains. In addition, although utilization of point-of-care (POC) coagulation monitors and the use of novel therapeutic strategies for perioperative hemostasis, such as the use of coagulation factor concentrates, have increased significantly over the last decade, they are still not widely available in every institution. Therefore, despite continuous efforts, blood transfusion in cardiac surgery has only modestly declined over the last decade, remaining at ≥50% in high-risk patients. Given these limitations, and in response to new regulatory and legislature requirements, the Society of Cardiovascular Anesthesiologists (SCA) has formed the Blood Conservation in Cardiac Surgery Working Group to organize, summarize, and disseminate the available best-practice knowledge in patient blood management in cardiac surgery. The current publication includes the summary statements and algorithms designed by the working group, after collection and review of the existing guidelines, consensus statements, and recommendations for patient blood management practices in cardiac surgery patients. The overall goal is creating a dynamic resource of easily accessible educational material that will help to increase and improve compliance with the existing evidence-based best practices of patient blood management by cardiac surgery care teams.

Collaborative Quality Improvement Reduces Postoperative Pneumonia After Isolated Coronary Artery Bypass Grafting Surgery

BACKGROUND

To date, studies evaluating outcome improvements associated with participation in physician-led collaboratives have been limited by the absence of a contemporaneous control group. We examined post cardiac surgery pneumonia rates associated with participation in a statewide, quality improvement collaborative relative to a national physician reporting program.

METHODS AND RESULTS

We evaluated 911 754 coronary artery bypass operations (July 1, 2011, to June 30, 2017) performed across 1198 hospitals participating in a voluntary national physician reporting program (Society of Thoracic Surgeons [STS]), including 33 that participated in a Michigan-based collaborative (MI-Collaborative). Unlike STS hospitals not participating in the MI-Collaborative (i.e., STSnonMI) that solely received blinded reports, MI-Collaborative hospitals received a multi-faceted intervention starting November 2012 (quarterly in-person meetings showcasing unblinded data, webinars, site visits). Eighteen of the MI-Collaborative hospitals received additional support to implement recommended pneumonia prevention practices ("MI-CollaborativePlus"), whereas 15 did not ("MI-CollaborativeOnly"). We evaluated rates of postoperative pneumonia, adjusting for patient mix and hospital effects. Baseline patient characteristics were qualitatively similar between groups and time. During the preintervention period (Q3/2011 through Q3/2012), there was no statistically significant difference in the adjusted odds of pneumonia for STS hospitals participating in the MI-Collaborative compared to the STS non-MI hospitals. However, during the intervention period (Q4/2012 through Q2/2017), there was a significant 2% reduction per quarter in the adjusted odds of pneumonia for MI-Collaborative hospitals (n=33) relative to the STS-nonMI hospitals. There was a significant 3% per quarter reduction in the adjusted odds of pneumonia for the MI-CollaborativeOnly (n=15) hospitals relative to the STS-nonMI hospitals. Over the course of the overall study period, the STS-nonMI hospitals had a 1.96% reduction in risk-adjusted pneumonia (pre- vs. intervention periods), which was less than the MI-Collaborative (3.23%, P=0.011). Over the same time period, the MI-CollaborativePlus (n=18) reduced adjusted pneumonia rates by 10.29%, P=0.001.

CONCLUSIONS

Participation in a physician-led collaborative was associated with significant reductions in pneumonia relative to a national quality reporting program. Interventions including collaborative learning may yield superior outcomes relative to solely using physician feedback reporting.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02068716.

Restrictive Transfusion Strategy and Clinical Decision Support Practices for Reducing RBC Transfusion Overuse

OBJECTIVES

Assess support for the effectiveness of two separate practices, restrictive transfusion strategy and computerized physician order entry/clinical decision support (CPOE/CDS) tools, in decreasing RBC transfusions in adult surgical and nonsurgical patients.

METHODS

Following the Centers for Disease Control and Prevention Laboratory Medicine Best Practice (LMBP) Systematic Review (A-6) method, studies were assessed for quality and evidence of effectiveness in reducing the percentage of patients transfused and/or units of blood transfused.

RESULTS

Twenty-five studies on restrictive transfusion practice and seven studies on CPOE/CDS practice met LMBP inclusion criteria. The overall strength of the body of evidence of effectiveness for restrictive transfusion strategy and CPOE/CDS was rated as high.

CONCLUSIONS

Based on these procedures, adherence to an institutional restrictive transfusion strategy and use of CPOE/CDS tools for hemoglobin alerts or reminders of the institution's restrictive transfusion policies are effective in reducing RBC transfusion overuse.