Transfusion triggers

Changing red blood cell transfusion practice in obstetrics and gynaecology: A before and after study of hospital-wide education

OBJECTIVES

To assess transfusion practices at a Canadian tertiary care center before and after a hospital-wide blood management educational campaign based on the Choosing Wisely toolkit.

BACKGROUND

Red blood cell (RBC) transfusions are an essential intervention in obstetrics and gynaec ology (O&G). However, with limited guidelines outlining the appropriate use of RBC transfusions, clinicians routinely transfuse based on haemoglobin values and habits.

METHODS/MATERIALS

We conducted a retrospective chart review of all patients who received a RBC transfusion while admitted under an O&G provider in two 12-month periods-before and after the intervention. The campaign consisted of Grand Rounds, formal and informal teaching, and posters placed within the hospital. We judged appropriateness from a set of criteria guided by the status of ongoing bleeding, pre-transfusion haemoglobin, and the number of units ordered simultaneously.

RESULTS

Transfusion appropriateness was poor in pre- and post-intervention periods (46% vs. 51%, p = 0.59). The overall rate of RBC transfusion was reduced from 1.8% to 1.2% (83/4610 vs. 55/4618, p = 0.02) after the intervention. There was a 52% reduction in the total number of RBC units of transfused (229 vs. 111, p < 0.001), a 33% reduction in the number of patients transfused (83 vs. 55, p = 0.016), and fewer multiple-unit transfusions without reassessment (39 vs. 13, p = 0.005).

CONCLUSION

RBC transfusion appropriateness remained low after a hospital-wide educational campaign. However, there was a marked decrease in overall transfusion use, reflecting the adoption of more restrictive transfusion practices. The low rate of transfusion appropriateness represents an opportunity for further improvement.

The impact of blood component transfusion practices on patient survival after abdominal aortic aneurysm surgery

BACKGROUND

The aim of the present study was to investigate the blood transfusion practice in patients operated for abdominal aortic aneurysm (AAA) with special emphasis on massive transfusion in cases with rupture.

MATERIAL AND METHODS

From a database, 504 patients operated for AAA were stratified into 2 groups; an early transfusion period (1992-1999) and a late transfusion period (2000-2008) to evaluate the changes in transfusion practices over the course of time.

RESULTS

Patients operated for nonruptured AAA (n = 330) showed a decreased mortality rate from 4% (early transfusion period) to 1% (late transfusion period) without significant changes in the transfusion practices. In patients operated for ruptured AAA (n = 174) an unexpected low mortality rate was found compared to the 30-day mortality reported in earlier studies. The transfusion practices in ruptured AAA surgery showed a significant increase in platelet use and change of fresh frozen plasma: red blood cell ratio from 0.8 to 0.9 between the early and the late transfusion period.

CONCLUSION

The present database study shows that the operating mortality for AAA surgery has declined during the past decades. The cause of the decline in mortality in patients with ruptured AAA was interpreted as partly due to a modern blood component therapy.

Clopidogrel loading dose and bleeding outcomes in patients undergoing urgent coronary artery bypass grafting

BACKGROUND

Coronary artery bypass grafting (CABG) performed within 5 days of clopidogrel administration is associated with increased bleeding. The impact of clopidogrel loading dose is unknown. We examined the effect of clopidogrel loading dose on bleeding outcomes in patients undergoing urgent CABG.

METHODS

Clinical outcomes were examined retrospectively for 196 consecutive patients undergoing urgent CABG within 5 days of a clopidogrel loading dose between January 2003 and June 2009. Major bleeding was defined as a fall in hemoglobin > 5 g/dL, fatal or intracranial bleeding, or cardiac tamponade.

RESULTS

One hundred forty-eight patients received 300 mg and 48 patients received ≥ 600 mg clopidogrel loading. Patients were predominantly male (78%) with a mean age of 66 ± 10 years. Mean duration from clopidogrel loading to CABG was 3.0 ± 1.5 and 3.0 ± 1.6 days for the 300 and 600 mg loading doses, respectively. Major bleeding occurred in 47% of patients receiving 300 mg and 73% of patients receiving ≥ 600 mg clopidogrel loading (P = .002). Compared with 300 mg, patients receiving ≥ 600 mg had greater 24-hour chest tube output (391 ± 251 vs 536 ± 354 mL, P = .01), stayed longer in surgical intensive care (4.3 ± 4.1 vs 5.0 ± 3.1 days, P = .0001), and trended toward greater reoperation for bleeding (5% vs 12%, P = .09). Following multivariate analysis, clopidogrel loading dose ≥ 600 mg (odds ratio 2.8, CI 1.2-6.6), preoperative hemoglobin (3.4, 2.7-5.0 per 1 g/dL increase), and female gender (2.9, 1.1-7.4) predicted major bleeding.

CONCLUSIONS

Higher clopidogrel loading doses are associated with increased bleeding when administered within 5 days of CABG. The development of shorter-acting, reversible, oral antiplatelet agents may reduce perioperative bleeding in this population.

Why an alternative to blood transfusion?

Allogeneic blood transfusions have been associated with several risks and complications and with worse outcomes in a substantial number of patient populations and clinical scenarios. Allogeneic blood is costly and difficult to procure, transport, and store. Global and local shortages are imminent. Alternatives to transfusion provide many advantages, and their use is likely to improve outcomes as safer and more effective agents are developed.