Laboratory evaluation of hemostasis before cardiac operations

Prospective monitoring of plasma and platelet transfusions in a large teaching hospital results in significant cost reduction

BACKGROUND

Plasma and platelets (PLTs) are often transfused to correct mild to moderately abnormal laboratory values. Our objective was to reduce unnecessary plasma and PLT transfusions to nonbleeding patients by prospective triage and education of end users in evidence-based hemostasis and transfusion medicine practices.

STUDY DESIGN AND METHODS

Using the Parkland Memorial Hospital's transfusion service and admission database as the data source, this study comprises the comparison of transfusion data on plasma and PLT use between pre- (2000-2002) and posttriage (2003-2006) periods. Yearly transfusion and wastage data on red blood cells (RBCs), plasma, and PLTs and yearly hospital admissions, trauma visits, and surgical procedures were extracted retrospectively for the study.

RESULTS

The study revealed that implementation of triage resulted in a significant reduction of plasma (60%) and PLT (25%) transfusions, saving more than $3,000,000 over 4 years.

CONCLUSIONS

Prospective triage and evidence-based transfusion practice education reduced unnecessary plasma and PLT transfusions and health care costs.

Bleeding in Cardiac Surgery: Its Prevention and Treatment—an Evidence-Based Review

Expected and unexpected bleeding occur frequently in patients undergoing cardiac surgery. Bleeding after cardiac surgery can be broadly divided into two groups: surgical (unrecognized bleeding vessel, anastomosis, or other suture line) or nonsurgical bleeding (caused by coagulopathy). Factors influencing both surgical and nonsurgical bleeding can be further broken down into those occurring preoperatively and those that occur intraoperatively and postoperatively. A thorough understanding of these factors is necessary to reduce bleeding. This is a desirable clinical goal, because excessive bleeding is associated with adverse outcomes.

[Preoperative evaluation of hemorrhagic risk]

Should we consider that haemostasis tests may help guide the anaesthesiologist's therapeutic choices when the patients is on the operating table and bleeds without evident explanation? The response is yes, provided that the results will be available rapidly. Haemostasis tests that are performed in laboratory wards distant from the surgery room often prove to be unuseful in emergency situations as haemostasis abnormalities usually occur in a shorter time than is required to get biological test results. Devices located in the vicinity of the surgery room should therefore be available to the anaesthesiologist. Furthermore, these devices should be able to perform not only platelet counts and haematocrit determination, but other blood tests that may be useful to get further insights in the patient's haemostasis function. Such devices are already available, allowing rapid haemostasis tests in the surgery room and prompt decision with regard to appropriate transfusion policy. However, the haemostasis laboratory is still useful, as it permits to refine coagulation profile and also offers quality controls for those tests that were done in the surgery room.

Preoperative clinical assessment of hemostatic function in patients scheduled for a cardiac operation

BACKGROUND

Bleeding during and after cardiac operations is usually attributed to inadequate surgical hemostasis or cardiopulmonary bypass-induced disorders of hemostasis. Patient-related factors often are neglected.

METHODS

Articles published between 1976 and 1996 on the preoperative assessment of surgical patients were reviewed to determine the clinical elements most likely to predict increased perioperative blood requirements.

RESULTS

Preoperative assessment is based on a carefully conducted interview (history of bruising, petechiae, recent or excessive bleeding after operation, chronic drug therapy) and physical examination. A standardized questionnaire to enhance the reliability of the assessment is presented. Thus, patients at high risk of being transfused can be identified early on and may be enrolled in various programs designed to decrease bleeding and the need for allogeneic blood transfusions.

CONCLUSIONS

Clinical assessment of hemostatic function before cardiac operations is both effective and efficient. It obviates the need for routine laboratory testing and favors the introduction of blood conservation strategies early on during the process of care.