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Pearse BL, Keogh S, Rickard CM, Fung YL. Barriers and facilitators to implementing evidence based bleeding management in Australian Cardiac Surgery Units: a qualitative interview study analysed with the theoretical domains framework and COM-B model. BMC Health Serv Res 2021; 21:550. [PMID: 34090421 PMCID: PMC8178922 DOI: 10.1186/s12913-021-06269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 03/10/2021] [Indexed: 12/03/2022] Open
Abstract
Background Bleeding during cardiac surgery is a common complication that often requires the transfusion of blood products. The combination of bleeding and blood product transfusion incrementally increases adverse outcomes including infection and mortality. Following bleeding management guideline recommendations could assist with minimising risk but adherence is not high, and the cause for lack of adherence is not well understood. This study aimed to identify barriers and facilitators to practicing and implementing evidenced-based intra-operative, bleeding management in Australian cardiac surgery units. Methods We used a qualitative descriptive design to conduct semi-structured interviews with Australian cardiac surgeons, anaesthetists and perfusionists. The Theoretical Domains Framework (TDF) was utilised to guide interviews and thematically analyse the data. Categorised data were then linked with the three key domains of the COM-B model (capability, opportunity, motivation - behaviour) to explore and understand behaviour. Results Seventeen interviews were completed. Nine of the 14 TDF domains emerged as significant. Analysis revealed key themes to improving capability included, standardisation, monitoring, auditing and feedback of data and cross discipline training. Opportunity for change was improved with interpersonal and interdepartmental collaboration through shared goals, and more efficient and supportive processes allowing clinicians to navigate unfamiliar business and financial models of health care. Results suggest as individuals, clinicians had the motivation to make change and healthcare organisations have an obligation and a responsibility to partner with clinicians to support change and improve goal directed best practice. Conclusion Using a theory-based approach it was possible to identify factors which may be positively or negatively influence clinicians ability to implement best practice bleeding management in Australian cardiac surgical units. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06269-8.
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Affiliation(s)
- Bronwyn L Pearse
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia. .,Departments of Surgery, Anaesthesia and Critical Care, The Prince Charles Hospital, Sippy Downs, QLD, Australia. .,School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia.
| | - Samantha Keogh
- School of Nursing and Centre for Healthcare Transformation, Queensland University of Technology, Kelvin Grove, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Claire M Rickard
- School of Nursing and Midwifery, Griffith University, Brisbane, QLD, Australia.,Alliance for Vascular Access Teaching and Research, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Yoke L Fung
- School of Health & Sports Sciences, University of Sunshine Coast, Sippy Downs, Australia
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2
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Brunet A, N'Guyen Y, Lefebvre A, Poncet A, Robbins A, Bajolet O, Saade Y, Ruggieri VG, Rubin S. Obesity and Preoperative Anaemia as Independent Risk Factors for Sternal Wound Infection After Coronary Artery Bypass Graft Surgery with Pedicled (Non-Skeletonized) Internal Mammary Arteries: The Role of Thoracic Wall Ischemia? Vasc Health Risk Manag 2020; 16:553-559. [PMID: 33364774 PMCID: PMC7751291 DOI: 10.2147/vhrm.s264415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/19/2020] [Indexed: 12/28/2022] Open
Abstract
Purpose Obesity remains statistically associated with coronary artery disease, for which coronary artery bypass graft surgery (CABG) remains the standard of care. However, obesity is also associated with sternal wound infection (SWI) which is a severe complication of CABG despite advances in surgery and in infection prevention and control. Strategies to reduce the incidence of SWI are still being investigated, and we therefore conducted a retrospective study to revisit factors other than obesity associated with SWI after CABG. Patients and Methods Data were extracted from the medical records of 182 patients who underwent elective on-pump CABG using one or both pedicled internal mammary artery grafts in Reims University Hospital between May 2015 and May 2016. All preoperative or perioperative variables with a p value<0.10 in univariate analysis were entered into a stepwise logistic regression model. Results Among the 182 patients (145 male (79.6%), median age 68.0 [45.0-87.0] years), 138 (75.8%) underwent CABG using bilateral internal mammary artery grafts. Median BMI was 27.7 [18.7-50.5] kg/m2, and there were 51 (28.0%) and 79 (43.4%) patients with obesity and overweight, respectively. Twenty-three out of the 182 patients (12.6%) developed SWI. In-hospital mortality was not statistically different between patients with and without SWI but the median length of stay was (6.0 [2.0-38.0] versus 5.0[3.0-21.0] days in the intensive care unit, p=0.03, and 26.0 [9.0-134.0] versus 9.0 [7.0-51.0] days in hospital, p<0.0001). Obesity and preoperative anaemia were independently associated with SWI, as was the number of red blood cell (RBC) units transfused (OR 14.61 [2.64-80.75], OR 4.64 [1.61-13.34] and OR 1.27 [1.02-1.58], respectively). Conclusion The independent association of SWI with the number of RBC units transfused and the existence of preoperative anaemia and obesity suggests a mechanism of thoracic wall ischemia in SWI after CABG, thus leaving insufficient perfusion of the thoracic wall in patients with obesity. Medical strategies are warranted to try to prevent this costly complication.
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Affiliation(s)
- Aurélie Brunet
- Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France
| | - Yohan N'Guyen
- Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France
| | - Annick Lefebvre
- Operational Hygiene Team, Robert Debré University Hospital, Reims, France
| | - Anne Poncet
- Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
| | - Ailsa Robbins
- Internal Medicine, Infectious Diseases and Clinical Immunology, Robert Debré University Hospital, Reims, France
| | - Odile Bajolet
- Operational Hygiene Team, Robert Debré University Hospital, Reims, France
| | - Yves Saade
- Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
| | | | - Sylvain Rubin
- Thoracic and Cardiovascular Surgery, Robert Debré University Hospital, Reims, France
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3
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Did blood transfusion increase mortality in patients with diabetes undergoing isolated coronary artery bypass graft surgery? A propensity score-matched analysis of 816 patients. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:586-592. [PMID: 33403130 PMCID: PMC7759041 DOI: 10.5606/tgkdc.dergisi.2020.19814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/30/2020] [Indexed: 12/22/2022]
Abstract
Background
The aim of this study was to compare clinical outcomes of blood transfusion in patients with diabetes mellitus undergoing isolated on-pump coronary artery bypass grafting.
Methods
The medical records of a total of 1,912 patients (1,300 males, 612 females; mean age 60.7±10.0) with diabetes who underwent isolated on-pump coronary artery bypass grafting between January 1999 and June 2019 were retrospectively analyzed. The patients were divided into two groups as patients with and without blood transfusions. The mortality rates were compared between the two groups.
Results
The mortality rate was 14 times higher in the patients receiving blood transfusion (odds ratio: 14.80; 95% confidence interval 5.05 to 43.34; p<0.001). However, in the multivariate logistic regression analysis, there were no statistically significant difference in mortality between the patient groups, when diabetes mellitus was a covariate factor (Odds ratio: 8.34; 95% confidence interval 3.94 to 17.66 vs. odds ratio 8.36; 95% confidence interval 3.95 to 17.70).
Conclusion
The propensity score-matched analysis of patients with diabetes showed that clinical outcomes were more severely affected by blood transfusion.
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Vranken NP, Babar ZU, Montoya JA, Weerwind PW. Retrograde autologous priming to reduce allogeneic blood transfusion requirements: a systematic review. Perfusion 2020; 35:574-586. [PMID: 32009539 PMCID: PMC7536507 DOI: 10.1177/0267659119895474] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Efforts have been made to minimize transfusion of packed red blood cells in
patients undergoing cardiac surgery with cardiopulmonary bypass. One method
concerns retrograde autologous priming. Although the technique has been used
for decades, results remain contradictory in terms of transfusion
requirements. Objective: This systematic literature review aimed to summarize the evidence for the
efficacy of retrograde autologous priming in terms of decreasing
perioperative packed red blood cell requirements in adults. Methods: Two researchers independently searched PubMed for articles published in the
past 10 years. The modified Cochrane collaboration Risk of Bias Tool and the
Research Triangle Institute Item Bank were used to assess bias. Results: Eight studies were included, of which two randomized and six observational
studies. Five studies, including one randomized study, report a significant
decrease in packed red blood cell use in the retrograde autologous priming
group compared to no retrograde autologous priming used. All studies are
flawed by at least a high risk bias of bias score on one item of the bias
assessment. Conclusion: Although most studies reported significantly fewer packed red blood cell
transfusions in the retrograde autologous priming group, it is important to
note that relatively few articles are available which are flawed by several
types of bias. Prospective, randomized multi-center trials are warranted to
conclude decisively on the benefits of retrograde autologous priming.
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Affiliation(s)
- Nousjka Pa Vranken
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Zaheer Ud Babar
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jesse A Montoya
- Perfusion Sciences Program, Department of Pharmacology, The University of Arizona, Tucson, AZ, USA
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Shin JI, Kim JS, Steinberger J, DiCapua J, Cho SK. Patient Factors Contributing to Prolonged Postoperative Length of Stay and Increased Rate of Readmission After Elective Posterior Cervical Fusion. Clin Spine Surg 2018; 31:E55-E61. [PMID: 28234774 DOI: 10.1097/bsd.0000000000000512] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
STUDY DESIGN This is retrospective study of prospectively collected data. OBJECTIVE To identify patient factors that are independently associated with prolonged length of stay (LOS) and readmission after posterior cervical fusion (PCF) utilizing a large national database. SUMMARY OF BACKGROUND DATA A number of studies have investigated the morbidity and mortality after PCF; however, little is known about the factors that are associated with prolonged LOS and readmission, both of which incur increased costs for patients and hospitals. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2011 to 2014. Current Procedural Terminology code 22600 was used to identify patients who underwent PCF. All patient factors were assessed for association with LOS and readmission rate using bivariate and multivariate logistic regressions. RESULTS A total of 2667 patients who underwent PCF met the inclusion criteria for LOS analysis. Average (±SD) LOS was 3.92 (±3.24) days, and median LOS was 3 days (interquartile range, 2-5 d). On multivariate analysis, increased LOS was found to be significantly associated with dependent functional status (P<0.001), diabetes mellitus (P=0.021), preoperative anemia (P=0.001), American Society of Anesthesiologists class 3 or 4 (P<0.001), and number of fused levels (P<0.001). A total of 2591 patients met criteria (LOS≤11 d) for analysis of readmission. Readmission rate among these patients was 7.1%. Average (±SD) LOS of the patients not readmitted within 30 days of operation was 3.89 (±3.25), whereas the average (±SD) LOS of the patients readmitted was 4.24 (±3.08). On multivariate analysis, readmission was found to be significantly associated with only dependent functional status (P=0.019) and increased number of fused levels (P=0.032). CONCLUSIONS The current study provides valuable information on patient factors that are associated with prolonged LOS and readmission, which would be useful in enhanced informed consent before surgery, surgical planning, discharge planning, and optimizing postoperative care. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- John I Shin
- Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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6
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Smith I, Pearse BL, Faulke DJ, Naidoo R, Nicotra L, Hopkins P, Ryan EG. Targeted Bleeding Management Reduces the Requirements for Blood Component Therapy in Lung Transplant Recipients. J Cardiothorac Vasc Anesth 2017; 31:426-433. [DOI: 10.1053/j.jvca.2016.06.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Indexed: 11/11/2022]
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Abstract
Transfusion-transmitted infections remain among the most-feared complications of allogeneic blood transfusion. Thanks to several strategies including donor screening and deferral, blood testing and pathogen inactivation, their risks have reached all-time low levels, particularly in developed nations. Nonetheless, new and emerging infections remain a threat that is likely to exacerbate in the coming years with continued globalization and climate change. More effective strategies of pathogen inactivation and more vigilant horizon screening are hoped to abate the risk. Additionally, allogeneic transfusion has repeatedly been shown to be associated with worsening of outcomes in patients, including the documented increased risk of infections (often nosocomial) in recipients of transfusions. The underlying mechanism is likely to be related to immunosuppressive effects of allogeneic blood, iron content, and bacterial contamination. This issue is best addressed by more judicious and evidence-based use of allogeneic blood components to ensure the potential benefits outweigh the risks.
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Affiliation(s)
- Aryeh Shander
- a Department of Anesthesiology and Critical Care Medicine , Englewood Hospital and Medical Center and TeamHealth Research Institute , Englewood , NJ , USA
| | - Gregg P Lobel
- a Department of Anesthesiology and Critical Care Medicine , Englewood Hospital and Medical Center and TeamHealth Research Institute , Englewood , NJ , USA
| | - Mazyar Javidroozi
- a Department of Anesthesiology and Critical Care Medicine , Englewood Hospital and Medical Center and TeamHealth Research Institute , Englewood , NJ , USA
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8
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Patient-, procedure-, and hospital-related risk factors of allogeneic and autologous blood transfusion in pediatric spinal fusion surgery in the United States. Spine (Phila Pa 1976) 2015; 40:560-9. [PMID: 25646747 DOI: 10.1097/brs.0000000000000816] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Cross-sectional study using data from the Health Care Cost and Utilization Project Kids' Inpatient Database. OBJECTIVE Blood loss during spinal fusion surgery may lead to the need for transfusion. Preoperative identification of patient-related, procedure-related, or hospital-related risk factors for blood transfusion would allow for implementation of interventions designed to control excessive bleeding. SUMMARY OF BACKGROUND DATA Several studies have analyzed predictors associated with transfusion in spinal fusion. Identified predictors include age, female sex, anemia, comorbidities, number of fusion levels, osteotomy, and greater hospital volume. There have been few studies examining these predictors in children undergoing spinal fusion. METHODS Using Kids' Inpatient Database data, univariate and multivariate logistic regression was used to calculate unadjusted and adjusted odds ratios (aOR). P values of less than 0.05 were considered statistically significant. RESULTS We identified 9538 pediatric hospitalizations (patients <21 yr) with spinal fusion in 2009. Overall, 25.1% were associated with blood transfusion. The following factors were associated with transfusions: female sex (aOR 1.14, P = 0.023), black race (aOR 1.35, P = 0.005), length of hospital stay (aOR 1.03, P < 0.001), anterior approach/lumbar segment (aOR 2.11, P = 0.011) and posterior approach/lumbar segment (aOR 2.75, P < 0.001) compared with anterior approach/cervical segment, midlength fusion (aOR 1.71, P < 0.001), and long length fusion (aOR 2.85, P < 0.001) compared with short length. Higher transfusion rates were observed in patients with complications of fever and hematoma but not wound infection. CONCLUSION This study showed significant patient-, procedure-, and hospital-related predictors of allogeneic and autologous blood transfusion in spinal fusion in the pediatric age group. Higher health care resource utilization of length of stay and additional procedures are directed toward care of this transfused subgroup. Therapies to reduce blood loss and transfusion requirement are necessary for this pediatric population. LEVEL OF EVIDENCE 4.
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9
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Abstract
Patients in the perioperative period and intensive care unit are commonly exposed to blood transfusion (BT). They are at increased risk of transfusion transmitted bacterial, viral and protozoal diseases. The risk of viral transmission has decreased steadily, but the risk of bacterial transmission remains same. Bacterial contamination is more in platelet concentrates than in red cells and least in plasma. The chances of sepsis, morbidity and mortality depend on the number of transfusions and underlying condition of the patient. Challenges to safe BT continue due to new emerging pathogens and various management problems. Strategies to restrict BT, optimal surgical and anaesthetic techniques to reduce blood loss and efforts to develop transfusion alternatives should be made. Literature search was performed using search words/phrases blood transfusion, transfusion, transfusion transmitted diseases, transfusion transmitted bacterial diseases, transfusion transmitted viral diseases, transfusion transmitted protozoal diseases or combinations, on PubMed and Google Scholar from 1990 to 2014.
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Affiliation(s)
- Rekha Das
- Department of Anaesthesiology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India
| | - Upendra Hansda
- Department of Anaesthesiology, Acharya Harihar Regional Cancer Centre, Cuttack, Odisha, India
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10
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Bockeria LA, Popov DA. eComment re: the role of patient's profile and allogeneic blood transfusion in development of post-cardiac surgery infections: a retrospective study. Interact Cardiovasc Thorac Surg 2014; 19:238. [PMID: 25035504 DOI: 10.1093/icvts/ivu180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Leo A Bockeria
- Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia
| | - Dmitry A Popov
- Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia
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