From blood transfusion to patient blood management: a new paradigm for patient care and cost assessment of blood transfusion practice

Incidence and risk factors of blood transfusion after total knee arthroplasty: A retrospective nationwide inpatient sample database study

Introduction

Common postoperative complications of total knee arthroplasty (TKA) include blood transfusion. Although risk factors and incidence of blood transfusion have been studied through national databases, the relative impact of each risk factor needs to be synthesized over a longer time period into a new model need to be revised.

Material and methods

Patient data were extracted from the National Inpatient Sample (NIS), which is the largest hospital care database in the US, and analyse patient data retrospectively from 2010 through 2019. The final data included the patients undergoing TKA. The final analysis assessed the demographics of patients, type of insurance, type of hospital, length of stay (LOS), preoperative comorbidities, total charge, inpatient mortality, medical-surgical postoperative complications.

Results

After extracting data from the NIS database, a total of 1,250,533 patients with TKA were included in the analysis, and the rate of transfusion was 6.60 %. TKA patients who receive blood transfusion had longer LOS (from 2-3 days to 3-4 days), more preoperative comorbidities, higher inpatient mortality rate, and increased total charge (P < 0.001). Moreover, postoperative complications associated with inpatients included sepsis, acute myocardial infarction and shock. Elective admission and private insurance were also regarded as protective factors.

Conclusion

Blood transfusion could bring postoperative complications to patients, which were also linked to health costs and risks. It was also a common preoperative comorbidities for older patients who underwent TKA. Through better blood management strategies, we could reduce patient transfusion rates and improve clinical outcomes.Level of Evidence: Diagnostic Level Ⅲ.

Blood management practices during rapid transfer of urgent trauma patients pre- and post-implementation of ROTEM®-guided transfusion

Objective

The ‘Red Blanket’ protocol fast tracks trauma patients with severe blood loss to the designated trauma operating theatre directly from the hospital helipad or Emergency Department. This study aimed to assess the impact of patient blood management (PBM) strategies on severely injured trauma patients treated under the ‘Red Blanket’ protocol at a quaternary referral hospital.

Methods

This retrospective review was conducted on all urgent trauma cases that were treated under the ‘Red Blanket’ protocol in a ten-year period between January 2007 and December 2017. The use of blood products and patient outcomes was compared between the 3.5-year periods pre- and post-ROTEM® implementation on 30th June 2014 (Jan 2011-June 2014 versus July 2014-Dec 2017).

Results

During the study period, 120 trauma patients were treated under the ‘Red Blanket’ protocol at our institution. Intention to treat analysis showed a reduction in fresh frozen plasma usage following the introduction of ROTEM®-guided transfusion. Furthermore, subgroup analysis suggested reduced blood product usage in patients who survived.

Conclusions

Patient blood management is a coordinated package of systems and tools, including education, patient logistics, anaemia management, intraoperative cell salvage, rotational thromboelastometry and massive transfusion protocols that together conserve blood products and improve outcomes. The implementation of ROTEM®-guided transfusion demonstrated a reduction in fresh frozen plasma usage.

Determination of reference ranges for the ClotPro® thromboelastometry device in paediatric patients

BACKGROUND

A new thromboelastometry analyser (ClotPro®) was developed with advanced diagnostics. The reference ranges of ClotPro® in children ages 0-16 yr have not been reported.

METHODS

In this prospective study, venous blood samples from 321 patients were obtained from children undergoing elective surgery after induction of anaesthesia. Reference ranges were defined by calculating the 2.5% and 97.5% percentiles for each age group (0-3 months, 4-12 months, 13-24 months, 2-5 yr, 6-10 yr, and 11-16 yr).

RESULTS

Reference ranges of the ClotPro® analyser in all age groups demonstrated significant differences in some parameters between age groups. In the first 3 months of life, a significant shortening of the clotting time (CT) in the extrinsically activated test (EX-test) was observed in children aged 0-3 months compared with children of all older age groups (P<0.001), whereas there were no overall differences in the intrinsically activated test (IN-test). In both assays, the clot amplitude 5 and 10 min after CT (A5, A10 value) was significantly higher in the first year of life compared with children older than 1 yr (EX-test and IN-test A5 and A10, respectively; P<0.001). The strength of fibrin polymerisation (FIB-test) was significantly higher in the first 3 months of life (A5 and A10, P<0.003).

CONCLUSIONS

ClotPro® reference ranges were determined for six paediatric age groups, and show age-dependent differences in specific parameters. These values will be helpful in monitoring haemostasis in paediatric patients and for developing tailored bleeding management protocols.

CLINICAL TRIAL REGISTRATION

NCT04190615.

Fresh Frozen Plasma in Cases of Acute Upper Gastrointestinal Bleeding Does Not Improve Outcomes

Background

Blood products are commonly transfused in patients with acute upper gastrointestinal bleeding (UGIB). There exists considerable practice variation and less evidence to guide fresh frozen plasma transfusion in patients with UGIB. The aim of this study was to explore any association between fresh frozen plasma transfusion following acute UGIB and clinical outcomes.

Methods

This was a prospective, observational, multicenter study conducted at 20 tertiary hospitals in China. Patients with acute UGIB with an international normalized ratio ≤ 2.0 at emergency department admission were included. Multivariate logistic regression models were used to examine and quantify any clinical associations.

Results

A total of 976 patients (61.57 ± 15.79 years old, 73.05% male) were included, of whom 17.42% received fresh frozen plasma transfusion. The overall 90-day mortality and rebleeding rates were 10.20 and 12.19%, respectively. After adjusting for confounding factors, transfusion of fresh frozen plasma during hospitalization was associated with higher 90-day mortality [odd ratio (OR), 2.36; 95% confidence interval (CI), 1.36–4.09; p = 0.002] but not rebleeding (OR, 1.5; 95% CI; 0.94-2.54; p = 0.085). In a subgroup analysis, patients with an international normalized ratio <1.5 who were treated with fresh frozen plasma were associated with both significantly higher 90-day mortality (OR, 2.78; 95% CI, 1.49–5.21; p = 0.001) and rebleeding (OR, 2.02; 95% CI, 1.16–3.52; p = 0.013), whereas in patients with an international normalized ratio between 1.5 and 2, we did not find any significant correlation.

Conclusion

This study found an association between fresh frozen plasma transfusion following acute UGIB and elevated 90-day mortality. Both 90-day mortality and rebleeding risk were significantly higher in patients with an international normalized ratio < 1.5. Fresh frozen plasma transfusion in acute UGIB does not improve the poor outcomes (Chinese Clinical Trial registry, Number ChiCTR1900028676).

Focused educational intervention improves intern knowledge of perioperative patient blood management principles

A perioperative patient blood management (PBM) educational intervention was implemented for first year postgraduate doctors (interns) at the Royal Brisbane and Women’s Hospital (RBWH) following identification of a perioperative PBM training requirement. This quality improvement activity evaluated the effectiveness of this educational intervention in improving intern knowledge of perioperative PBM principles.

A 15-question perioperative PBM focused multiple choice questionnaire developed from information attained from comprehensive, evidence and consensus-based guidelines regarding PBM practice was distributed to interns immediately before a compulsory perioperative PBM educational intervention and then again 5 weeks later. The perioperative PBM educational intervention was delivered every 10 weeks (five interventions in total) to a different group of interns each time. Statistical analysis determined significance between mean questionnaire score before and after the intervention.

The mean pre-intervention score for correctly answered questions was 7/15 (SD 2.73) and mean post-intervention score was 9/15 (SD 2.99) (p=0.02). Categorisation of questions into core domains of perioperative PBM demonstrated intern scores for correctly answered questions improved in all domains following the educational intervention.

Perioperative PBM education delivered through a dedicated intervention aimed to improve knowledge is associated with objective evidence of educational benefits for interns at RBWH. It is an effective strategy to enact PBM governance and bestow clinical guideline knowledge. This is important given the global health sector’s challenge to improve patient outcomes despite increasingly restricted funding and pressure on doctors to devote more time to service and less to teaching.

Patient blood management and blood conservation - Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond

Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.

A Theoretically Informed Approach to Support the Implementation of Pre-Operative Anemia and Iron Deficiency Screening, Evaluation, and Management Pathways: Protocol for a Type Two Hybrid-Effectiveness Study

Introduction

Blood transfusions are a risk factor for increased morbidity, mortality, and length of hospital stay. Patient blood management guidelines provide guidance to reduce risk and improve patient outcomes. They outline steps to help prevent transfusions and considerations for when deciding to transfuse. One recommendation to prevent unnecessary transfusion is to optimize patients using Pre-operative Anemia and Iron Deficiency Screening, Evaluation and Management Pathways (PAIDSEM-P). The uptake of these recommendations is highly variable, and an effective approach to implementing them in a tailored and context-specific manner remains elusive.

Method and Design

A mixed-methods, interventional study, using a type two-hybrid effectiveness-implementation design, will evaluate the impact of a change package to improve the uptake of PAIDSEM-P. The change package consists of the intervention (PAIDSEM-P) supported by theoretically informed implementation strategies. Pre- and post-implementation, retrospective health record reviews will determine the effect of the change package on provider outcomes, including compliance with guideline recommendations as measured by the proportion of patients who have the appropriate tests performed, and, if required, appropriate treatment and/or referrals. Patient outcomes will be measured by checking for any difference in the proportion of patients with anemia on the day of surgery and the proportion of patients who receive a blood transfusion during the peri-operative period. An economic evaluation will be conducted to compare health outcomes and costs. The feasibility, acceptability and appropriateness of the PAIDSEM-P will be assessed using a quantitative, validated survey to measure implementation outcomes.

Discussion

Testing of implementation theory is required to advance understanding of what works, in what context, and the impact on implementation success. This study aims to evaluate the impact of a theoretically informed change package on improving the uptake of PAIDSEM-P. If successful, it will also provide a framework for health care facilities to follow when addressing other evidence-practice gaps.

Safety, efficacy and cost of intra-operative cell salvage during open radical prostatectomy

BACKGROUND

We aim to examine the safety and efficacy of intra-operative cell salvage (ICS) in radical prostatectomy.

METHODS

A retrospective cohort study was performed, enrolling consecutive patients undergoing open radical prostatectomy at two institutions during 01/01/18-31/12/19. Patients were grouped by ICS use. Primary outcomes were allogeneic transfusion rates, and biochemical recurrence (prostate specific antigen >0.2 mg/mL). Secondary outcomes were use of adjuvant therapies, Clavien-Dindo complications and transfusion-related cost (allogeneic transfusion + ICS setup + ICS reinfusion).

RESULTS

In total, 168 men were enrolled. Patients were grouped based on whether they received no blood conservation technique (126 men) or ICS (42 men). Groups were similar in median age, pre- and post-operative haemoglobin and length of stay. They also had similar post-operative tumour Gleason score, TNM-stage and positive surgical margin rates. Compared with controls, the ICS group had shorter follow up (336 vs. 225 days; P=0.003). The groups had similar rates of biochemical recurrence (17% vs. 14%; P=0.90), adjuvant therapy use (30% vs. 29%; P=0.85) and complications (14% vs. 19% patients; P=0.46). There was no metastatic progression or cancer-specific mortality in either group. Although a similar proportion of patients received allogenic transfusion (2.4% vs. 4.8%; P=0.33) and units of packed red blood cells (PRBC) (9 vs. 5 units), transfusion-related costs were higher amongst the ICS group (AUD $11,422 vs. $43,227).

CONCLUSIONS

ICS use in radical prostatectomy was not associated with altered rates of allogeneic transfusion, complications, biochemical recurrence or adjuvant or salvage therapies. Transfusion related costs were higher in the ICS group.

Global survey of transfusion medicine curricula in medical schools: Challenges and opportunities

BACKGROUND

Physician's knowledge in transfusion medicine (TM) is critical for patient safety. Therefore, ensuring that medical schools provide adequate education in TM is important. The aim of this study was to assess the status of TM education at a global level.

STUDY DESIGN AND METHODS

A comprehensive anonymous survey to assess TM education in existing medical school curricula was developed. The survey was distributed to deans and educational leads of medical schools in a range of low-, medium-, high-, and very high-human development index (HDI) countries. It included 20 questions designed to assess specific domains including structure of TM curriculum and teaching faculty.

RESULTS

The response rate was 53%. The majority of responding schools from very-high-HDI countries offered a 6-year curriculum after high school or a 4-year curriculum after college education, whereas most schools from medium-HDI countries offered a 5-year medical curriculum. A formal teaching program was available in only 42% of these schools in contrast to 94% of medical schools from very high-HDI. Overall, 25% of all medical schools did not offer structured TM teaching. When offered, most TM teaching was mandatory (95%) and integrated within the third and fourth year of medical school. Formal assessment of TM knowledge was done in 72% of all responding medical schools. More than half of the deans considered the TM education in their medical schools as inadequate.

CONCLUSION

Despite its limitations, the current survey highlights significant gaps and opportunities of TM education at a global scale.

A review of blood usage and wastage in a tertiary heart center

Background/Objectives: Blood is a vital resource that its utilization is ever increasing throughout the world and blood wastage is a global challenge that needs to be controlled. Most blood resources are used during complications of pregnancy, trauma, severe childhood anemia, gynecology, cancers, surgery, hematology disorders, and chronic diseases. Units that are expired, broken bags, returning the blood unit after 30 min, blood clotted units, etc., which are due to lack of awareness may result in the wastage of blood products. The objective of this study is to analyze the usage and wastage of blood and its products in Mazandaran heart center.Methods: In this retrospective study, the survey was carried out on the data that were obtained from Mazandaran heart center of Sari, Iran during 2012-2017. Data included details of usage and wastage on blood and its product units. MS Excel 2016 and SPSS 16.0 were used in analysis and diagrams.Results: A total of 35,686 blood units were consumed, which included 55.7% packed red blood cells (PRBCs), 33.9% platelets (Plts), 8.9% fresh-frozen-plasma (FFP), and 8.9% cryoprecipitates. Moreover, 823 blood units including 41.4% FFP, 37.2% PRBCs, and 21.4% Plts were wasted mostly because of inappropriate order (70.6%). Cross-match to transfusion ratio was 1.13. The intensive care unit reported the highest level of blood intake by 45.0%. The blood group O+ was the most frequent by 34.8%. In addition, blood wastage has decreased over study period by approximately 10.0%.Conclusion: Our study showed not only the increasing pattern of blood usage but also the dropping pattern of blood wastage due to hemovigilance performance and additional training in our healthcare center. We found that the main reason for the blood wastage in this center is an excessive order of blood units.

Improving blood product utilization at an ambulatory surgery center: a retrospective cohort study on 50 patients with lumbar disc replacement

Background

There is minimal literature discussing anterior lumbar spine surgery in ambulatory surgery centers (ASCs). The main concern with the anterior approach to the lumbar spine is the potential for injury to great vessels. In our facility, there are two units of crossmatched blood available in addition to cell saver during the procedure. We retrospectively looked at 50 cases of lumbar total disc arthroplasty (TDA) in our ASC to determine utilization of blood products.

Methods

Medical records of 50 consecutive patients who underwent a lumbar TDA at a single ASC were reviewed. Surgeries completed at the ASC were all transferred from the post anesthesia care unit to an attached convalescence care center which allows up to 3 days of observation. Patients who had either a 1 or 2 level lumbar TDA were included in the study. Data consisting of demographics, American Society of Anesthesiologist Physical Status Classification System, length of stay, estimated blood loss, cell saver volume, transfusion, perioperative and postoperative complications were recorded. Preoperative, perioperative and postoperative medical records were reviewed.

Results

Medical records of 50 consecutive patients were reviewed. The mean age was 40.86 ± 9.45. Of these, 48 (96%) had a 1-level lumbar TDA, 1(2%) had a 2-level lumbar TDA, 1 (2%) had a lumbar TDA at L4/5 and an anterior lumbar interbody fusion at L5/S1. There were no mortalities; no patient had recorded perioperative complications. No patients received allogeneic blood transfusion, 4 (8%) were re-transfused with cell saver (2 receiving approximately 400 ml and 2 receiving approximately 200 ml of re-transfused blood). All 50 (100%) were discharged home in stable condition. We had 30-day follow-up data on 35 of 50 patients. Of the 35 patients reviewed, three (8.5%) of the patients were readmitted to the hospital. One additional patient was seen in the emergency department and discharged home after negative testing. No patient was readmitted for post-operative anemia.

Conclusion

The routine use of both cell saver and crossmatched blood in the operating suite for lumbar TDA may be an over-utilization of healthcare resources. In our review of 50 patients, we had no need for transfusion of allogeneic packed red blood cells (PRBCs) and only four of the 50 patients had enough blood output for re-transfusion from the cell saver. This opens the conversation for alternatives to crossmatched PRBCs being held in the operating room. Such alternatives may be the use of cell salvage, only type O blood in a cooler for each patient or keeping type O blood on constant hold in ASCs.

The Extremity/Mechanism/Shock Index/GCS (EMS-G) score: A novel pre-hospital scoring system for early and appropriate MTP activation

BACKGROUND

Numerous in-hospital scoring systems to activate massive transfusion protocols (MTP) have been proposed; however, to date, pre-hospital scoring systems have not been robustly validated. Many trauma centers do not have blood or pre-thawed plasma available in the trauma bay, leading to delays in balanced transfusion. This study aims to assess pre-hospital injury and physiologic parameters to develop a pre-hospital scoring system predictive of need for massive transfusion (MT) prior to patient arrival.

METHODS

A retrospective review of all adult full and partial trauma team activations from July 2014-July 2018 from an urban level 2 trauma center was performed utilizing our trauma registry. Stepwise logistic regression analysis was performed to develop a new scoring system, with point totals assigned proportional to the odds ratios of requiring MT for each variable. Internal validation of the EMS-G score was performed using a subset of the data which was not utilized for development of the scoring system, and sensitivity and specificity were compared to previously validated in-hospital scoring systems applied in the pre-hospital setting.

RESULTS

763 patients were included with 94 patients (12.3%) receiving early MT, defined as 4 units pRBC in 4 h or ED death. In-hospital models for predicting MT such as Assessment of Blood Consumption (ABC) or Shock Index (SI) have sensitivities and specificities of 46/85% and 94/79% respectively for early MTP utilization based on pre-hospital data. Pre-hospital variables found to be predictive of MT were used to develop the EMS-G (Extremity, Mechanism, Shock Index, GCS) score. This system assigns obvious extremity injury-1-point, penetrating mechanism -2 points, shock index ≥0.9-2 points, GCS ≤8-3 points. A score of 3 or greater was chosen to maximize sensitivity and specificity for pre-hospital MT activation. EMS-G score based on pre-hospital report is 89% sensitive, 84% specific, with a PPV of 44% and NPV of 98% for early MT. Using this system, 25% of full and partial trauma team activations met criteria for pre-hospital MTP activation.

CONCLUSION

The EMS-G Score has increased sensitivity and specificity compared to the ABC Score in the pre-hospital setting and appears more appropriate than shock index alone at predicting massive transfusion. This scoring system allows trauma centers to activate MTP prior to patient arrival to ensure early and appropriate blood product administration without blood product wastage.

The impact of intra-operative cell salvage during open nephrectomy

OBJECTIVE

To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy.

METHODS

A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost.

RESULTS

Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient).

CONCLUSION

ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.

Implementation of a patient blood management program in hematopoietic stem cell transplantation (Editorial, p. 2763)

BACKGROUND

Recipients of hematopoietic stem cell transplantation (HSCT) are among the highest consumers of allogeneic red blood cell (RBC) and platelet (PLT) components. The impact of patient blood management (PBM) efforts on HSCT recipients is poorly understood.

STUDY DESIGN AND METHODS

This observational study assessed changes in blood product use and patient-centered outcomes before and after implementing a multidisciplinary PBM program for patients undergoing HSCT at a large academic medical center. The pre-PBM cohort was treated from January 1 through September 31, 2013; the post-PBM cohort was treated from January 1 through September 31, 2015.

RESULTS

We identified 708 patients; 284 of 352 (80.7%) in the pre-PBM group and 225 of 356 (63.2%) in the post-PBM group received allogeneic RBCs (p < 0.001). Median (interquartile range [IQR]) RBC volumes were higher before PBM than after PBM (3 [2-4] units vs. 2 [1-4] units; p = 0.004). A total of 259 of 284 pre-PBM patients (91.2%) and 57 of 225 (25.3%) post-PBM patients received RBC transfusions when hemoglobin levels were more than 7 g/dL (p < 0.001). The median (IQR) PLT transfusion quantities was 3 (2-5) units for pre-PBM patients and 2 (1-4) units for post-PBM patients (p < 0.001). For patients with PLT counts of more than 10 × 10⁹ /L, a total of 1219 PLT units (73.4%) were transfused before PBM and 691 units (48.8%) were transfused after PBM (p < 0.001). Estimated transfusion expenditures were reduced by $617,152 (18.3%). We noted no differences in clinical outcomes or transfusion-related adverse events.

CONCLUSION

Patient blood management implementation for HSCT recipients was associated with marked reductions in allogeneic RBC and PLT transfusions and decreased transfusion-related costs with no detrimental impact on clinical outcomes.

Transfusion knowledge of medical and surgical specialty board residents: a cohort study

OBJECTIVES

This study was conducted to assess transfusion knowledge between different specialty board residents and to identify areas of need for further education.

BACKGROUND

Physicians' knowledge of transfusion medicine (TM) is critical for patients' safety. Many clinicians who are involved in day-to-day transfusion practice have little or no formal training in TM. There are no studies to assess physician's TM knowledge locally.

METHODS

A comprehensive anonymous survey was developed to assess baseline TM knowledge of all the residents. The survey is composed of different sections, including a questionnaire on resident's demographics, resident's self-reflection on their TM knowledge and 30 multiple choice questions addressing basic and clinical TM knowledge in two major domains: component selection and transfusion practice and transfusion safety and transfusion reactions. Finally, the residents' opinion on educational needs was assessed.

RESULTS

A total of 130 residents were surveyed. The lowest score obtained among the two major domains assessed was in the transfusion safety and transfusion reaction domain, with a mean score of 4·34 of 15 (SD ± 3·27). The mean score obtained on component selection and transfusion practice was 7·1 of 15 (SD ± 3·74). A substantial proportion of the residents (74·7%) admitted minimal baseline knowledge in the field of TM. Finally, 94·5% of the residents admitted the need for more education during residency, whereas 49·5% thought additional education is required during the first year of practice.

CONCLUSION

This survey shows serious TM knowledge deficiency and indicates the need for additional education among all physicians during training.

The effect of a novel turbulence-controlled suction system in the prevention of hemolysis and platelet dysfunction in autologous surgery blood

Background:

Re-transfusion of autologous blood is an important aspect of intraoperative blood management. Hemolysis and platelet dysfunction due to turbulence in the blood suction system strongly impede later usage of suction blood for re-transfusion. The aim of this study was to analyze the effects of a novel surgical-blood suction system with an automatic control setup for minimization of turbulence in the blood flow.

Methods:

We compared the turbulence-controlled suction system (TCSS) with a conventional suction system and untreated control blood in vitro. Blood cell counts, hemolysis levels according to free hemoglobin (fHb) and platelet function were analyzed to determine the integrity of the suction blood.

Results:

In the conventional suction system, we found a strong increase of the fHb levels. In contrast, erythrocyte integrity was almost completely preserved when using the TCSS. We obtained similar results regarding platelet function. The expression of platelet glycoproteins, such as GP IIb/IIIa and P-selectin, native or after stimulation with ADP, were markedly impaired by the conventional system, but not by the TCSS. In addition, platelet aggregometry revealed significant platelet dysfunction in conventional suction blood, but less aggregation impairments were present in blood samples from the TCSS.

Conclusion:

Our findings on an in vitro assessment show major improvements in red blood cell integrity and platelet function of suction blood when using the TCSS compared to a conventional suction system. These results reflect a significant benefit for autologous re-transfusion. We suggest testing the TCSS in surgery for clinical evaluation.

Implementation of a patient blood management program in an Australian private hospital orthopedic unit

Background

Preoperative anemia in surgical patients has been linked to increased rates of allogeneic blood transfusion (ABT) and associated adverse patient outcomes such as prolonged ventilation in intensive care, increased length of hospital stay, and infections. We conducted a multifaceted implementation for orthopedic surgeons to improve preoperative patient assessment of anemia and iron deficiency to reduce perioperative blood transfusions.

Materials and methods

Using a before-and-after study design of independent samples, we recruited a convenience sample of surgeons who performed primary total hip arthroplasty at 1 Australian private hospital. Our implementation intervention consisted of: executive support, interactive education, and peer-to-peer support to encourage adherence to the National Blood Authority’s Patient Blood Management Program (PBMP) guidelines. We also used monthly reminders, e-learning access, and posters. Pre and post medical record audits evaluated preoperative blood tests, preoperative anemia, and number of blood units transfused between day of surgery until discharge. The primary outcome was an increase in the proportion of patients with preoperative blood tests undertaken prior to total hip arthroplasty surgery as recommended by the PBMP guidelines.

Results

Audits from 239 pre- and 263 postimplementation patients from 3 surgeons were conducted. Our primary outcome showed a significantly increased proportion of patients who had all the required preoperative tests postimplementation (0% to 94.6%; P<0.0001). Administration of ABT significantly decreased (pre: 9.2%, n=22; post: 2.3%, n=6; P=0.001) as well as the standard 2 blood units transfused (pre: 73%, n=16; post: 17%, n=1; P=0.022). The time between preoperative tests and day of surgery increased from 16 to 20 days (P<0.0001), allowing more time for physician’s review of test results.

Conclusion

Our results demonstrated successful implementation of a targeted PBMP to improve preoperative assessment to diagnose and treat anemia and/or iron deficiency prior to orthopedic surgery. This avoided unnecessary ABT and therefore mitigated potential risk to the patient.

Intra-operative cell salvage in urological surgery: a systematic review and meta-analysis of comparative studies

OBJECTIVE

To evaluate systematically the safety and efficacy of intra-operative cell salvage (ICS) in urology.

METHODS

A search of Medline, Embase and Cochrane Library to August 2017 was performed using methods pre-published on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible titles were comparative studies published in English that used ICS in urology. Primary outcomes were allogeneic transfusion rates (ATRs) and tumour recurrence. Secondary outcomes were complications and cost.

RESULTS

Fourteen observational studies were identified, with a total of 4 536 patients. ICS was compared with no the blood conservation technique (seven studies), preoperative autologous donation (PAD; five studies) or both (two studies). Cohorts underwent open prostatectomy (11 studies), open cystectomy (two studies) or open partial nephrectomy (one study). Meta-analysis was possible only for ATRs within prostatectomy studies. In this setting, ICS reduced ATR compared with no the blood conservation technique (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.15-0.76) but not PAD (OR 0.76, 95% CI 0.39-1.31). In the non-prostatectomy setting, ATRs amongst patients who underwent ICS were significantly higher or similar in one and two studies, respectively. Tumour recurrence was found to be significantly less common (two studies), similar (eight studies) or not measured (four studies). All six studies reporting complications found no difference in their ICS cohorts. Regarding cost, one study from 1995 found ICS more expensive than PAD, while two more recent studies found ICS to be cheaper than no blood conservation technique. As a result of inter-study heterogeneity, meta-analyses were not possible for recurrence, complications or cost.

CONCLUSION

Low-level evidence exists that, compared with other blood conservation techniques, ICS reduces ATR and cost while not affecting complications. It does not appear to increase tumour recurrence post-prostatectomy, although follow-up durations were short. Small study sizes and short follow-ups mean conclusions cannot be drawn with regard to recurrence after nephrectomy or cystectomy. Randomized trials with long-term follow-up evaluating ICS in urology are required.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013

BACKGROUND

Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013.

METHODS

A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges.

RESULTS

There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size.

CONCLUSION

Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

The impact of intra-operative cell salvage during open radical prostatectomy

Background

To examine the effect of intra-operative cell salvage (ICS) in open radical prostatectomy.

Methods

In this retrospective cohort study, all patients undergoing open radical prostatectomy for malignancy at our institution between 10/04/2013 and 10/04/2017 were enrolled. Patients were grouped and compared based on whether they received ICS. Primary outcomes were allogeneic transfusion rates, and disease recurrence. Secondary outcomes were complications and transfusion-related cost.

Results

Fifty-nine men were enrolled; 30 used no blood conservation technique, while 29 employed ICS. There were no significant differences between groups in age, pre- or post-operative haemoglobin, Charlson comorbidity index, operation duration or length of stay. Tumour characteristics were also similar between groups, including pre-operative prostate specific antigen, post-operative Gleason score, T-stage, nodal status and rates of margin positivity. Compared with controls, the ICS group had longer follow up (945 vs. 989 days; P=0.0016). The control and ICS groups were not significantly different in rates of tumour recurrence (6 vs. 3 patients; P=0.30) or complications (10 vs. 5 patients; P=0.16). While the proportion of patients receiving allogenic transfusion was similar (9 vs. 6 patients; P=0.41), fewer red blood products transfused (40 vs. 12 units) meant transfusion related costs were lower in ICS patients (AUD $47,666 vs. $37,429).

Conclusions

ICS reduced transfusion related costs, without affecting allogeneic transfusion rates, tumour recurrence or complication rates. These findings extend the literature supporting ICS in oncological surgery. Prospective randomised studies are needed to confirm the existing level III evidence.

Factors affecting patient-reported outcomes after red blood cell transfusion in medical patients

BACKGROUND

Physical variables like mortality or cardiac events were used to evaluate the requirement of red blood cell (RBC) transfusion. However, patient-reported outcomes (PROs) of blood transfusion recipients were seldom assessed. The health-related quality of life (HRQoL) of patients before and after RBC transfusion was compared in this study.

STUDY DESIGN AND METHODS

The study period was February to June 2016. Standardized generic and anemia symptom-specific HRQoL instruments were administered to patients receiving RBC transfusion in the medical unit of a single center. The primary outcome was the change in HRQoL scores on Days 1 and 7 posttransfusion from baseline values on the day of transfusion (Day 0). Multiple linear regression analysis was performed to study the effect of transfusion strategy and other factors on PRO.

RESULTS

The analysis included 99 general medical patients. The median (interquartile range) pretransfusion hemoglobin level was 72 (66-78) g/L. Two or more units of RBCs were prescribed to 45 patients (45%) on Day 0. Functional Assessment of Cancer Therapy-Anemia Subscale improved significantly on Days 1 and 7 by effect sizes of 0.41 and 0.38, respectively (p < 0.001). Regression analysis showed that lower baseline HRQoL scores were associated with better PRO on both Day 1 and Day 7 (p < 0.001). Transfusion trigger and number of RBC units transfused did not affect the change in HRQoL.

CONCLUSION

Worse pretransfusion HRQoL is a predictor of improvement in PRO after blood transfusion. There is no evidence that a restrictive transfusion or single-unit policy jeopardizes PRO.

Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program

BACKGROUND

Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.

STUDY DESIGN AND METHODS

A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality.

RESULTS

Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study.

CONCLUSION

The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.

Effect of Repeated Whole Blood Donations on Aerobic Capacity and Hemoglobin Mass in Moderately Trained Male Subjects: A Randomized Controlled Trial

Background

The aims of the present study were to investigate the impact of three whole blood donations on endurance capacity and hematological parameters and to determine the duration to fully recover initial endurance capacity and hematological parameters after each donation.

Methods

Twenty-four moderately trained subjects were randomly divided in a donation (n = 16) and a placebo (n = 8) group. Each of the three donations was interspersed by 3 months, and the recovery of endurance capacity and hematological parameters was monitored up to 1 month after donation.

Results

Maximal power output, peak oxygen consumption, and hemoglobin mass decreased (p < 0.001) up to 4 weeks after a single blood donation with a maximal decrease of 4, 10, and 7%, respectively. Hematocrit, hemoglobin concentration, ferritin, and red blood cell count (RBC), all key hematological parameters for oxygen transport, were lowered by a single donation (p < 0.001) and cumulatively further affected by the repetition of the donations (p < 0.001). The maximal decrease after a blood donation was 11% for hematocrit, 10% for hemoglobin concentration, 50% for ferritin, and 12% for RBC (p < 0.001). Maximal power output cumulatively increased in the placebo group as the maximal exercise tests were repeated (p < 0.001), which indicates positive training adaptations. This increase in maximal power output over the whole duration of the study was not observed in the donation group.

Conclusions

Maximal, but not submaximal, endurance capacity was altered after blood donation in moderately trained people and the expected increase in capacity after multiple maximal exercise tests was not present when repeating whole blood donations.

Electronic supplementary material

The online version of this article (doi:10.1186/s40798-016-0067-7) contains supplementary material, which is available to authorized users.

The Incremental Hospital Cost and Length-of-Stay Associated With Treating Adverse Events Among Medicare Beneficiaries Undergoing THA During Fiscal Year 2013

This paper estimates the incremental hospital resource consumption associated with treating selected adverse events experienced by Medicare beneficiaries (MBs) undergoing total hip arthroplasty (THA). This retrospective study, using the Medicare Provider Analysis and Review file, identified 174,167 MBs who underwent THA in 2013. Overall, 20.16% of MB undergoing THA experienced at least one adverse event. MB experiencing any adverse event consumed significantly higher hospital cost ($3429) and had longer length of stays (1.0 day). The risk-adjusted incremental cost of treating adverse events ranged from a high of $27,116 (pneumonia) to a low of $2626 (hemorrhage or post-operative shock requiring transfusion). Most major adverse events occurred infrequently, however when adverse events occurred, they add substantially to the hospital resource costs of treating MB.

Red blood cell transfusion is associated with further bleeding and fresh-frozen plasma with mortality in nonvariceal upper gastrointestinal bleeding

BACKGROUND

Blood products are commonly transfused for patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). While concerns exist about further bleeding and mortality in subsets of patients receiving red blood cell (RBC) transfusion, the impact of non-RBC blood products has not previously been systematically investigated. The aim of the study was to investigate the associations between blood products transfusion, further bleeding, and mortality after acute NVUGIB.

STUDY DESIGN AND METHODS

A retrospective cohort study examined further bleeding and 30-day and 1-year mortality in adult patients who underwent gastroscopy for suspected acute NVUGIB between 2008 and 2010 in three tertiary hospitals in Western Australia. Survival analysis was performed.

RESULTS

A total of 2228 adults (63% male) with 2360 hospital admissions for NVUGIB met the inclusion criteria. Median age at presentation was 70 years (range, 19-99 years). Thirty-day mortality was 4.9% and 1-year mortality was 13.9%. Transfusion of 4 or more units of RBCs was associated with greater than 10 times the odds of further bleeding in patients with a hemoglobin level of more than 90 g/L (odds ratio, 11.9; 95% confidence interval [CI], 3.1-45.7; p ≤ 0.001), but was not associated with mortality. Administration of 5 or more units of fresh-frozen plasma (FFP) was associated with increased 30-day (hazard ratio, 2.8; 95% CI, 1.3-5.9; p = 0.008) and 1-year (hazard ratio, 2.6; 95% CI, 1.3-5.0; p = 0.005) mortality after adjusting for coagulopathy, comorbidity, Rockall score, and other covariates.

CONCLUSION

In this large, multicenter study of NVUGIB, RBC transfusion was associated with further bleeding but not mortality, while FFP transfusion was associated with increased mortality in a subset of patients.

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009

BACKGROUND

Total shoulder arthroplasty (TSA) may be associated with substantial blood loss, and some patients require perioperative blood transfusion. Possible blood transfusion methods include predonated autologous blood transfusion, perioperative autologous blood transfusion, and allogeneic blood transfusion (ALBT). The purposes of the present study were to assess the incidence and recent trends over time of blood transfusion in TSA and analyze patient and hospital characteristics that affect the risk of ALBT.

METHODS

This study used national hospital discharge data from the National Inpatient Sample between 2000 and 2009. The data were used to generate the overall blood transfusion rate, and linear regression was used to assess trends in transfusion patterns over time. Logistic regression analysis was performed to analyze which patient and hospital characteristics independently influence the likelihood that a given patient undergoes ALBT.

RESULTS

The overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001). Risk factors associated with ALBT included age, gender, race, insurance status, hospital region, and hospital annual caseload.

CONCLUSIONS

The increase in overall blood transfusion rate in TSA found in the present study may be related to factors specific to TSA, such as the introduction of reverse total shoulder arthroplasty during the study period. A variety of patient and hospital characteristics contribute to the risk of undergoing ALBT.

Increased hospital costs associated with red blood cell transfusion

BACKGROUND

Red blood cell (RBC) transfusion is independently associated in a dose-dependent manner with increased intensive care unit stay, total hospital length of stay, and hospital-acquired complications. Since little is known of the cost of these transfusion-associated adverse outcomes our aim was to determine the total hospital cost associated with RBC transfusion and to assess any dose-dependent relationship.

STUDY DESIGN AND METHODS

A retrospective cohort study of all multiday acute care inpatients discharged from a five hospital health service in Western Australia between July 2011 and June 2012 was conducted. Main outcome measures were incidence of RBC transfusion and mean inpatient hospital costs.

RESULTS

Of 89,996 multiday, acute care inpatient discharges, 4805 (5.3%) were transfused at least 1 unit of RBCs. After potential confounders were adjusted for, the mean inpatient cost was 1.83 times higher in the transfused group compared with the nontransfused group (95% confidence interval, 1.78-1.89; p < 0.001). The estimated total hospital-associated cost of RBC transfusion in this study was AUD $77 million (US $72 million), representing 7.8% of total hospital expenditure on acute care inpatients. There was a significant dose-dependent association between the number of RBC units transfused and increased costs after adjusting for confounders.

CONCLUSION

RBC transfusions were independently associated with significantly higher hospital costs. The financial implication to hospital budgets will assist in prioritizing areas to reduce the rate of RBC transfusions and in implementing patient blood management programs.

Indications and organisational methods for autologous blood transfusion procedures in Italy: results of a national survey

INTRODUCTION

Pre-operative donation of autologous blood is a practice that is now being abandoned. Alternative methods of transfusing autologous blood, other than predeposited blood, do however play a role in limiting the need for transfusion of allogeneic blood. This survey of autologous blood transfusion practices, promoted by the Italian Society of Transfusion Medicine and Immunohaematology more than 2 years after the publication of national recommendations on the subject, was intended to acquire information on the indications for predeposit in Italy and on some organisational aspects of the alternative techniques of autotransfusion.

MATERIALS AND METHODS

A structured questionnaire consisting of 22 questions on the indications and organisational methods of autologous blood transfusion was made available on a web platform from 15 January to 15 March, 2013. The 232 Transfusion Services in Italy were invited by e-mail to complete the online survey.

RESULTS

Of the 232 transfusion structures contacted, 160 (69%) responded to the survey, with the response rate decreasing from the North towards the South and the Islands. The use of predeposit has decreased considerably in Italy and about 50% of the units collected are discarded because of lack of use. Alternative techniques (acute isovolaemic haemodilution and peri-operative blood salvage) are used at different frequencies across the country.

DISCUSSION

The data collected in this survey can be considered representative of national practice; they show that the already very limited indications for predeposit autologous blood transfusion must be adhered to even more scrupulously, also to avoid the notable waste of resources due to unused units.Users of alternative autotransfusion techniques must be involved in order to gain a full picture of the degree of use of such techniques; multidisciplinary agreement on the indications for their use is essential in order for these indications to have an effective role in "patient blood management" programmes.

National trends in the utilization of blood transfusions in total hip and knee arthroplasty

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common surgical procedures that necessitate blood transfusion. The purpose of this study was to examine the trends in the utilization of blood transfusions in THA and TKA in the US from 2000 to 2009 by analyzing the Nationwide Inpatient Sample (NIS). During the last decade, the allogeneic blood transfusion (ALBT) rate increased (THA: 11.2% to 19.1%, TKA: 7.7% to 12.4%), whereas the predonated autologous blood transfusion (PR-ABT) rate decreased (THA: 7.7% to 3.9%, TKA: 6.1% to 2.4%) in primary unilateral THA and TKA patients in US hospitals. Overall blood transfusion rates remained stable over time in primary unilateral THA and TKA patients.

National trends in spinal fusion for pediatric patients with idiopathic scoliosis: demographics, blood transfusions, and in-hospital outcomes

STUDY DESIGN

Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample database.

OBJECTIVE

To analyze trends in spinal fusion for pediatric patients with idiopathic scoliosis on a national level with regard to demographics, blood transfusions, and in-hospital outcomes.

SUMMARY OF BACKGROUND DATA

Spinal fusion for pediatric patients with idiopathic scoliosis is required for rapid curve progression. For such patients and their families, blood transfusions and complications are important aspects of the surgery.

METHODS

The Nationwide Inpatient Sample database was used to identify pediatric patients with idiopathic scoliosis who underwent spinal fusion from 2000 to 2009 using the International Classification of Diseases, Ninth Revision, Clinical Modification codes. Demographics of the patients were retrieved. Trends in demographics, blood transfusion methods, and in-hospital outcomes were analyzed.

RESULTS

The total number of patients included in this study was 43,983. A total of 30.4% of patients received a blood transfusion. Predonated autologous blood transfusions decreased over time, whereas perioperative autologous blood transfusions increased over time (P < 0.05, respectively). The in-hospital overall complication rate was 14.4%. The respiratory complication rate was the highest among complications; however, the rate decreased over time (P = 0.003). In-hospital blood transfusion, complication, and mortality rates were high in certain subgroups of patients, such as those with increased Elixhauser Comorbidity Score and those who underwent anterior and posterior fusion. The mean length of hospital stay decreased over time (P = 0.043).

CONCLUSION

During the last decade, 30% of pediatric patients with idiopathic scoliosis who underwent spinal fusion received some type of blood transfusion; and strategies for blood transfusion methods have changed over the years. A decreasing trend in the respiratory complication rate and reduction in length of hospital stay may indicate better postoperative care.

LEVEL OF EVIDENCE

3.

Trends in the utilization of blood transfusions in spinal fusion in the United States from 2000 to 2009

STUDY DESIGN

Retrospective study.

OBJECTIVE

The purpose of this study was to examine the trends in the utilization of blood transfusions in spinal fusion in the United States from 2000 to 2009.

SUMMARY OF BACKGROUND DATA

Spinal fusion is among the most common surgical procedures that necessitate blood transfusion. Blood transfusion methods include predonated autologous blood transfusion (PR-ABT), perioperative autologous blood transfusion (PE-ABT) (intraoperative and postoperative blood collection), and allogeneic blood transfusion (ALBT). The trends in the utilization of these blood transfusion methods in spinal fusion during the past decade are uncertain.

METHODS

The Nationwide Inpatient Sample was used to identify patients who underwent spinal fusion from 2000 to 2009, using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Patients who received PR-ABT, PE-ABT, and ALBT were identified using the appropriate ICD-9-CM codes. Patient demographics, surgical variables, and hospital characteristics data were retrieved. Trends in the utilization of blood transfusions were analyzed.

RESULTS

From 2000 to 2009, there was an increasing trend in the ALBT rate (4.3%-8.0%, P < 0.001) and a decreasing trend in the PR-ABT rate (2.6%-0.7%, P < 0.001) in patients who underwent spinal fusion. The overall blood transfusion and PE-ABT rates remained stable. The ALBT rate was high in the subgroups of patients, such as pediatric and elderly patients, female patients, patients with increased Elixhauser Comorbidity Score, Medicare patients, and patients who underwent thoracolumbar, posterior, and anterior and posterior fusion.

CONCLUSION

During the past decade, the ALBT rate increased, whereas the PR-ABT rate decreased in patients who underwent spinal fusion in US hospitals. The overall blood transfusion rate remained stable; however, it may be reduced by using a patient blood management program, targeting the subgroups of patients with the high ALBT rate.

LEVEL OF EVIDENCE

3.

Economic considerations on transfusion medicine and patient blood management

In times of escalating health-care cost, it is of great importance to carefully assess the cost-effectiveness and appropriateness of the most resource-consuming health interventions. A long-standing and common clinical practice that has been underestimated in cost and overestimated in effectiveness is the transfusion of allogeneic blood products. Studies show that this intervention comes with largely underestimated service cost and unacceptably high utilisation variability for matched patients, thus adding billions of unnecessary dollars to the health-care expenditure each year. Moreover, a large and increasing body of literature points to a dose-dependent increase of morbidity and mortality and adverse long-term outcomes associated with transfusion whereas published evidence for benefit is extremely limited. This means that transfusion may be a generator for increased hospital stay and possible re-admissions, resulting in additional billions in unnecessary expenditure for the health system. In contrast to this, there are evidence-based and cost-effective treatment options available to pre-empt and reduce allogeneic transfusions. The patient-specific rather than a product-centred application of these multiple modalities is termed patient blood management (PBM). From a health-economic perspective, the expeditious implementation of PBM programmes is clearly indicated. Both patients and payers could benefit from this concept that has recently been endorsed through the World Health Assembly resolution WHA63.12.

Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions

OBJECTIVE

We previously described a method for reducing early phlebotomy losses from very low birth weight (VLBW) neonates by obtaining the initial blood tests from otherwise discarded fetal blood from the placenta. In the present study we sought to; (1) measure the feasibility of performing this method in actual practice, (2) test the hypothesis that this method would result in higher hemoglobin concentrations and lower erythrocyte transfusion rates in the first week after birth.

METHODS

We conducted two studies in three Intermountain Healthcare NICUs. The first was a feasibility analysis involving 96 VLBW neonates, measuring the success of obtaining the NICU admission laboratory blood tests this way. The second study used case-control methodology to test the hypothesis that this method would result in a higher blood hemoglobin 12 to 24 h after birth, and a lower proportion receiving an erythrocyte transfusion in the first week.

RESULT

In 91 of 96 VLBW neonates (95%) the initial blood tests were successfully obtained with this method. The success rate was not diminished by delayed cord clamping or cord milking, as it was successful in 35 of 36 (97%) such instances. Cases and controls were well matched on demographic and level of illness comparisons. Among cases the hemoglobin generally increased between birth and 12 to 24 h later, but among controls the hemoglobin generally decreased (P<0.05). In the week following birth fewer cases received vasopressors (P<0.01) and erythrocyte transfusions (P<0.001).

CONCLUSION

We judge that it is feasible to collect the initial blood tests of VLBW neonates using otherwise discarded umbilical cord/placental blood, in that this can be accomplished in about 95% of VLBW deliveries. This method, which can be used in addition to either delayed clamping of the umbilical cord or cord milking, results in higher hemoglobin concentrations, less vasopressor use and fewer transfusions in the first week.

Blood Transfusion Policies in Elective General Surgery: How to Optimise Cross-Match-to-Transfusion Ratios

OBJECTIVE

Preoperative over-ordering of blood is common and leads to the wastage of blood bank resources. The preoperative blood ordering and transfusion practices for common elective general surgical procedures were evaluated in our university hospital to formulate a maximum surgical blood order schedule (MSBOS) for those procedures where a cross-match appears necessary.

METHODS

We evaluated blood ordering practices retrospectively in all elective general surgical procedures in our institution over a 6-month period. Cross-match-to-transfusion ratios (C:T) were calculated and compared to current trust and the British Society of Haematology (BSH) guidelines. The adjusted C:T ratio was also calculated and was defined as the C:T ratio when only cross-matched blood used intraoperatively was included in the calculation.

RESULTS

541 patients were identified during the 6-month period. There were 314 minor and 227 major surgeries carried out. 99.6% (n = 226) of the patients who underwent major surgery and 95.5% (n = 300) of the patients having minor surgery had at least a group and save (G and S) test preoperatively. A total of 507 units of blood were cross-matched and 238 units were used. The overall C:T ratio was therefore 2.1:1, which corresponds to a 46.9% red cell usage. There was considerable variation in the C:T ratio, depending on the type of surgery performed. The adjusted C:T ratio varied between 3.75 and 37.

CONCLUSIONS

Compliance with transfusion policies is poor and over-ordering of blood products commonplace. Implementation of the updated recommended MSBOS and introduction of G and S for eligible surgical procedures is a safe, effective and cost-effective method to prevent preoperative over-ordering of blood in elective general surgery. Savings of GBP 8,596.00 per annum are achievable with the incorporation of updated evidence-based guidelines in our university hospital.