Clinical predictors of postoperative hemoglobin drift

Association of hemoglobin drift and outcomes in patients with aneurysmal subarachnoid hemorrhage

The relationship between in-hospital hemoglobin (Hb) drift and outcomes in patients undergoing surgical clipping for aneurysmal subarachnoid hemorrhage (aSAH) is not well studied. This study aims to investigate the association between Hb drift and mortality in this patient population. We conducted a cohort study encompassing adult patients diagnosed with aSAH who were admitted to a university hospital. These patients were stratified into distinct groups based on their Hb drift levels. We employed logistic and Cox proportional hazard models to assess the relationship between Hb drift and outcomes. Additionally, propensity score matching (PSM) was utilized to ensure comparability between patient groups. The discriminative performance of different models was evaluated using C-statistics, integrated discrimination improvement (IDI), and net reclassification improvement (NRI). Overall, our cohort comprised 671 patients, of whom 165 (24.6%) demonstrated an in-hospital Hb drift exceeding 25%. The analyses revealed elevated Hb drift was independently associated with higher likelihood of follow-up mortality (aOR: 3.29, 95% CI: 1.65 to 6.56; P = 0.001) and in-hospital mortality (aOR: 3.44, 95% CI: 1.55 to 7.63; P = 0.002). PSM analysis yielded similar results. Additionally, patients with Hb drift exhibited a notable decrease in survival rate compared to those without Hb drift (aHR: 3.99, 95% CI 2.30 to 6.70; P < 0.001). Furthermore, the inclusion of Hb drift significantly improved the C-statistic (P = 0.037), IDI (2.78%; P = 0.004) and NRI metrics (41.86%; P < 0.001) for mortality prediction. In summary, our results highlight that an in-hospital Hb drift exceeding 25% serves as an independent predictor of mortality in patients who have undergone surgical clipping for aSAH.

Robotic surgery versus conventional laparoscopy in sigmoid colectomy for diverticular disease-a comparison of operative trauma and cost-effectiveness: retrospective, single-center analysis

PURPOSE

Robotic assisted surgery is an alternative, fast evolving technique for performing colorectal surgery. The primary aim of this single center analysis is to compare elective laparoscopic and robotic sigmoid colectomies for diverticular disease on the extent of operative trauma and the costs.

METHODS

Retrospective analysis from our prospective clinical database to identify all consecutive patients aged ≥ 18 years who underwent elective minimally invasive left sided colectomy for diverticular disease from January 2016 until December 2020 at our tertiary referral institution.

RESULTS

In total, 83 patients (31 female and 52 male) with sigmoid diverticulitis underwent elective minimally invasive sigmoid colectomy, of which 42 underwent conventional laparoscopic surgery (LS) and 41 robotic assisted surgery (RS). The mean C-reactive protein difference between the preoperative and postoperative value was significantly lower in the robotic assisted group (4,03 mg/dL) than in the laparoscopic group (7.32 mg/dL) (p = 0.030). Similarly, the robotic´s hemoglobin difference was significantly lower (p = 0.039). The first postoperative bowel movement in the LS group occurred after a mean of 2.19 days, later than after a mean of 1.63 days in the RS group (p = 0.011). An overview of overall charge revealed significantly lower total costs per operation and postoperative hospital stay for the robotic approach, 6058 € vs. 6142 € (p = 0,014) not including the acquisition and maintenance costs for both systems.

CONCLUSION

Robotic colon resection for diverticular disease is cost-effective and delivers reduced intraoperative trauma with significantly lower postoperative C-reactive protein and hemoglobin drift compared to conventional laparoscopy.

Mechanism-Based Modeling of Perioperative Variations in Hemoglobin Concentration in Patients Undergoing Laparoscopic Surgery

BACKGROUND

Hemoglobin concentration ([Hb]) in the perioperative setting should be interpreted in the context of the variables and processes that may affect it to differentiate the dilution effects caused by changes in intravascular volume. However, it is unclear what variables and processes affect [Hb]. Here, we modeled the perioperative variations in [Hb] to identify the variables and processes that govern [Hb] and to describe their effects.

METHODS

We first constructed a mechanistic framework based on the main variables and processes related to the perioperative [Hb] variations. We then prospectively studied patients undergoing laparoscopic surgery, divided into 2 consecutive cohorts for the development and validation of the model. The study protocol consisted of serial measurements of [Hb] along with recordings of hemoglobin mass loss, blood volume loss, fluid infusion, urine volume, and inflammatory biomarkers measurements, up to 96 hours postoperatively. Mathematical fitting was performed using nonlinear mixed-effects. Additionally, we performed simulations to explore the effects of blood loss and fluid therapy protocols on [Hb].

RESULTS

We studied 154 patients: 118 enrolled in the development group and 36 in the validation group. We characterized the perioperative course of [Hb] using a mass balance model that accounted for hemoglobin losses during surgery, and a 2-compartment model that estimated fluid kinetics and intravascular volume changes. During model development, we found that urinary fluid elimination represented only 24% of the total fluid elimination, and that total fluid elimination was inhibited after surgery in a time-dependent manner and influenced by age. Also, covariate evaluation showed a significant association between the type of surgery and proportion of fluid eliminated via urine. In contrast, neither the type of infused solution, blood volume loss nor inflammatory biomarkers were found to correlate with model parameters. In the validation analysis, the model demonstrated a considerable predictive capacity, with 95% of the predicted [Hb] within -4.4 and +5.5 g/L. Simulations demonstrated that hemoglobin mass loss determined most of the postoperative changes in [Hb], while intravascular volume changes due to fluid infusion, distribution, and elimination induced smaller but clinically relevant variations. Simulated patients receiving standard fluid therapy protocols exhibited a hemodilution effect that resulted in a [Hb] decrease between 7 and 15 g/L at the end of surgery, and which was responsible for the lowest [Hb] value during the perioperative period.

CONCLUSIONS

Our model provides a mechanistic and quantitative understanding of the causes underlying the perioperative [Hb] variations.

Prediction of hematocrit decline and the impact of peri-operative fluid use in lumbar spinal fusion surgery

PURPOSE

Peri-operative blood loss unaccounted for and post-operative hematocrit decline could have a significant impact on the outcome of elective spinal surgery patients. The study assesses the accuracy of predictive models of hematocrit decline and blood loss in spinal surgery and determines the impact of peri-operative fluid administration on hematocrit levels of patients undergoing first-time single level lumbar fusion surgery for degenerative spine disease and the trend thereof in the first 24 h post-operatively.

METHODS

Clinical and biochemical parameters were prospectively collected in patients undergoing single level lumbar spinal surgery. Predictive models were applied to assess their accuracy in intra-operative blood loss and post-operative hematocrit decline.

RESULTS

High correlation (0.98 Pearson correlation coefficient) occurred between calculated (predicted) and recorded hematocrit from hours 2 to 6 post-operatively. Predictive accuracy declined thereafter yet remained moderate. Patients received an average intra-operative fluid volume of 545.45 ml per hour (47% of estimated total blood volume). A significant hematocrit decline occurred post-induction (43.47-39.78%, p < 0.001) with total fluid volume received being the significant contributing variable (p < 0.001). Hypertensive patients were the only subgroup to drop below the safe hematocrit threshold of 30%.

CONCLUSION

Iatrogenic hemodilution can accurately be predicted for the first six hours post-operatively, with high risk patients identifiable. Fluid therapy should be goal directed rather than generic, and good communication between the surgeon and anesthesiologist remains the cornerstone to manage physiological changes secondary to blood loss. Although helpful, predictive formulas are not universally applicable to all phenotypes.

Longer Operative Time and the Use of Anticoagulants Are Associated With Increased Blood Loss in Elderly Patients Undergoing Arthroscopic Rotator Cuff Repair

Purpose

To study the effects of rotator cuff tear size, operation time, and the use of anticoagulant on blood loss in elderly patients undergoing arthroscopic rotator cuff surgery.

Methods

Patients aged older than 65 years who underwent arthroscopic rotator cuff repair with subacromial decompression at our hospital from January 2015 to December 2021 were identified. We measured hemoglobin levels preoperatively, postoperatively, and 7 days after surgery. First, subjects were divided according to the operation time (group I, <90 minutes; group II, <120 minutes; group III <150 minutes; and group IV, >150 minutes). Second, we classified the subjects by the size of the rotator cuff tear (group A, <3 cm; group B, <5 cm; and group C, >5 cm). Lastly, we categorized the subjects into 2 groups according to the use of anticoagulant medication.

Results

A total of 566 patients were included. The mean hemoglobin (Hgb) levels were 13.8 ± 1.4 g/dL preoperatively, 13.2 ± 1.4 g/dL postoperatively, and 12.8 ± 1.3 g/dL 7 days after surgery, and the differences among them were statistically significant (P < .001). The Hgb level changes 7 days after surgery showed a significant decrease in the group with a longer operation time, and the Hgb loss increased from group 1 to group 4 (P < .001). They did not show any difference in the Hgb levels among the groups according to the size of a cuff tear preoperatively, postoperatively, and 7 days after surgery. The subjects with anticoagulant use showed more decrease in Hgb levels between immediately after the surgery and 7 days after the surgery (P = .031). Still, both groups did not show a statistical difference in the Hgb level 7 days after surgery (P = .115).

Conclusions

In this study, blood loss after arthroscopic rotator cuff repair in elderly patients was greater than expected. Bleeding increased in elderly patients who had longer surgical times or were taking anticoagulant medications after surgery. Tear size was not associated with a decrease in Hgb levels.

Level of Evidence

Level III, retrospective comparative study.

Association of Postoperative Drift in Hemoglobin With Mortality After Brain Tumor Craniotomy

BACKGROUND

Postoperative downward drift in hemoglobin (Hb) concentration may be associated with complications and death, even if nadir Hb remains more than the red blood cell transfusion threshold of 7 g/dL.

OBJECTIVE

To assess whether postoperative Hb drift in patients undergoing brain tumor craniotomy influences mortality in the immediate perioperative period.

METHODS

This retrospective cohort study included patients undergoing craniotomy for brain tumors. We defined no postoperative Hb decrease, mild decrease, moderate decrease, and severe decrease as postoperative Hb drift of ≤25%, 26% to 50%, 51% to 75%, and >75%, respectively. The primary outcome was 30-day mortality after craniotomy.

RESULTS

This study included 8159 patients who underwent a craniotomy for brain tumors. Compared with patients with no postoperative Hb drift, the odds of postoperative mortality at 30 days increased in patients with mild postoperative Hb drift (adjusted odds ratio [OR] 2.47, 95% CI 1.72-3.56), moderate drift (adjusted OR 6.56, 95% CI 3.42-12.59), and severe drift (adjusted OR 12.33, 95% CI 3.48-43.62). When postoperative Hb drift was analyzed as a continuous variable, for each 10% increase in Hb drift, the adjusted OR of postoperative mortality at 30 days was 1.46 (95% CI 1.31-1.63).

CONCLUSION

In patients undergoing brain tumor craniotomy, a small postoperative Hb drift was associated with increased odds of postoperative mortality at 30 days, even if the nadir Hb level remained greater than the red blood cell transfusion threshold of 7 g/dL. Future randomized clinical trials of perioperative transfusion practices may examine the effect of both nadir Hb and Hb drift.

Haemoglobin drift in patients following Whipple's procedure

BACKGROUNDS

This study aims to identify the objective findings of haemoglobin (Hb) drift in patients that had a Whipple's procedure in the last 10 years, their transfusion status intraoperatively and post-operatively, the potential factors affecting Hb drift, and the outcomes following Hb drift.

METHODS

A retrospective study was conducted at Northern Health, Melbourne. All adult patients who were admitted for a Whipple's procedure from 2010 to 2020 were included and information collected retrospectively for demographics, pre-operative, operative and post-operative details.

RESULTS

A total of 103 patients were identified. The median Hb drift calculated from a Hb level at the end of operation was 27.0 g/L (IQR 18.0-34.0), and 21.4% of patients received a packed red blood cell (PRBC) transfusion during the post-operative period. Patients received a large amount of intraoperative fluid with a median of 4500 mL (IQR 3400-5600). Hb drift was statistically associated with intraoperative and post-operative fluid infusion leading to concurrent issues with electrolyte imbalance and diuresis.

CONCLUSION

Hb drift is a phenomenon that does happen in major operations such as a Whipple's procedure, likely secondary to fluid over-resuscitation. Considering the risk of fluid overload and blood transfusion, Hb drift in the setting of fluid over-resuscitation needs to be kept in mind prior to blood transfusion to avoid unnecessary complications and wasting of other precious resources.

Post-Embolization Hemoglobin Changes: When to Consider Re-intervention

PURPOSE

Decline in hemoglobin (Hgb) levels is common post-embolization, but there is no consensus on the classification of patients based on risk for re-bleeding or re-intervention. The current study evaluated post-embolization Hgb level trends with the goal of understanding the factors predictive of re-bleeding and re-intervention.

MATERIALS AND METHODS

All patients who underwent embolization for gastrointestinal (GI), genitourinary, peripheral, or thoracic arterial hemorrhage from 01/2017 to 01/2022 were reviewed. Data included demographics, periprocedural pRBC transfusion (TF) or pressor requirements, and outcome. Lab data consisted of Hgb values pre-embolization, immediately post-embolization, and daily values on days 1-10 after embolization. Hgb trends were compared between patients across TF and re-bleeding outcomes. Regression model was used to examine factors predictive of re-bleeding and magnitude of Hgb reduction post-embolization.

RESULTS

A total of 199 patients were embolized for active arterial hemorrhage. Perioperative Hgb level trends were similar for all sites and between TF + and TF- patients, showing a decline reaching a nadir within 6 days post-embolization followed by an upward trend. Maximum Hgb drift was predicted by GI embolization (p = 0.018), TF before embolization (p = 0.001), and use of vasopressor (p = 0.000). Patients with Hgb drop  > 15% within the first two days post-embolization had a higher chance of having a re-bleeding episode (p = 0.04).

CONCLUSION

Perioperative Hgb trends showed a consistent downward drift followed by an upward shift, irrespective of TF requirement status or site of embolization. Using a cut-off value of 15% Hgb reduction within the first two days post-embolization may be helpful to assess re-bleeding risk.

Identification of intraoperative management strategies that have a differential effect on patients with reduced left ventricular ejection fraction: a retrospective cohort study

Background

There are few data to guide the intraoperative management of patients with reduced left ventricular ejection fraction (LVEF). This study aimed to describe how patients with reduced LVEF are managed differently and to identify and treatments had a different risk profile in this population.

Methods

We performed a retrospective cohort study of adult patients who underwent general anesthesia for non-cardiac surgery. The effect of anesthesia medications and fluid balance was compared between those with and without a reduced preoperative LVEF. The primary outcome was a composite of acute kidney injury, myocardial injury, pulmonary complications, and 30-day mortality. Multivariable logistic regression was used to adjust for confounders. Treatments that affected patients with reduced LVEF differently were defined as those associated with the primary outcome that also had a significant interaction with LVEF.

Results

A total of 9420 patients were included. Patients with reduced LVEF tended to have a less positive fluid balance. Etomidate, calcium, and phenylephrine were use more frequently, while propofol and remifentanil were used less frequently. Remifentanil affected patients with reduced LVEF differently than those without (interaction term OR 2.71, 95% CI 1.30–5.68, p = 0.008). While the use of remifentanil was associated with fewer complications in patients with normal systolic function (OR 0.54, 95% CI 0.42–0.68, p < 0.001), it was associated with an increase in complications in patients with reduced LVEF (OR = 3.13, 95% CI 3.06–5.98, p = 0.026).

Conclusions

Patients with a reduced preoperative LVEF are treated differently than those with a normal LVEF when undergoing non-cardiac surgery. An association was found between the use of remifentanil and an increase in postoperative adverse events that was unique to this population. Future research is needed to determine if this relationship is secondary to the medication itself or reflects a difference in how remifentanil is used in patients with reduced LVEF.

Posterior Ischemic Optic Neuropathy after Cervical Spine Surgery

Purpose: To describe a patient with posterior ischemic optic neuropathy (PION) after cervical spine surgery who recovered after treatment.Case summary: A 51-year-old woman presented with eye pain and decreased visual acuity in the left eye, which had begun 8 hours after cervical spine surgery in the prone position. Her best-corrected visual acuity (BCVA) was 20/20 in the right eye and hand motion in the left eye; a relative afferent pupillary defect was present in the left eye. Ductions and versions were normal with pain in the left eye. The results of slit lamp examination, fundoscopic examination, fluorescein angiography, and optical coherence tomography were unremarkable in both eyes. Brain and orbital magnetic resonance imaging showed no abnormal findings in the visual pathway, such as brain infarction or intracranial artery stenosis. The patient was diagnosed with PION in the left eye. Because postoperative anemia had developed with a rapid decrease in hemoglobin from 14.7 g/dL to 9.9 g/dL, red blood cell (RBC) transfusion was performed together with intravenous high-dose steroid therapy and subcutaneous epoetin alfa injection. After 3 weeks, the patient’s BCVA improved to 20/22 in the left eye.Conclusions: Unilateral PION developed after cervical spine surgery in the prone position. Visual improvement was observed after RBC transfusion, intravenous high-steroid therapy, and subcutaneous epoetin alfa injection.

Coagulation Status and Surgical Approach as Predictors of Postoperative Anemia in Patients Undergoing Thoracic Surgery: A Retrospective Study

Objective: Postoperative anemia is a common complication after a major surgery. Our study aims to identify factors that are associated with higher risk of developing postoperative anemia after thoracic surgery.

Methods: We conducted a retrospective study of 465 patients who underwent pulmonary surgery in 2017 in Shanghai Pulmonary Hospital, China. Of them, 191 patients underwent standard open thoracotomy (OT), and 274 patients underwent video-assisted thoracic surgery (VATS). A total of 350 patients were diagnosed with postoperative anemia, and 115 patients did not have anemia. Multiple logistic regression was used to compute odds ratios for predicting preoperative anemia.

Results: Postoperative anemia was associated with significantly lower weight (p < 0.001) and height (p = 0.022) of the patients, as well as higher prothrombin time (PT), and international normalized ratio (INR) (p = 0.012). Open thoracotomy resulted in a 1.2-fold increase in the incidence of postoperative anemia compared to VATS (p = 0.002). Multiple logistic regression analysis identified INR [OR (95% CI) 24.46 (2.05–292.27; p = 0.012] and surgical approach [OR (95% CI) 0.48 (0.31–0.74); p < 0.001] as predictors of postoperative anemia and postoperative drop in hemoglobin (Hb).

Conclusion: Postoperative coagulation status and surgical approach are statistically significant predictors of postoperative anemia in patients undergoing thoracic surgery. International normalized ratio and surgical approach are specifically associated with Hb drop immediately after the surgery.

Perioperative changes in hemoglobin levels during major hepatopancreatic surgery in transfused and non-transfused patients

Background:

Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations.

Methods:

Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time.

Results:

The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion.

Conclusions:

Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.

Approaches to Bloodless Surgery for Oncology Patients

Providing optimal care to surgical oncology patients who cannot be transfused for religious or other reasons can be challenging. However, with careful planning, using a combination of blood-conserving methods, these "bloodless" patients have clinical outcomes that are similar to other patients who can be transfused. Bloodless surgery can be accomplished safely for most patients, including those undergoing technically challenging oncologic surgery. This article reviews best practices used in a bloodless program during the preoperative, intraoperative, and postoperative periods, with the aim of achieving optimal outcomes when transfusion is not an option for surgical oncology patients.

Clinical standards for patient blood management and perioperative hemostasis and coagulation management. Position Paper of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI)

Patient blood management is currently defined as the application of evidence based medical and surgical concepts designed to maintain hemoglobin (Hb), optimize hemostasis and minimize blood loss to improve patient outcome. Blood management focus on the perioperative management of patients undergoing surgery or other invasive procedures in which significant blood loss occurs or is expected. Preventive strategies are emphasized to identify and manage anemia, reduce iatrogenic blood losses, optimize hemostasis (e.g. pharmacologic therapy, and point of care testing); establish decision thresholds for the appropriate administration of blood therapy. This goal was motivated historically by known blood risks including transmissible infectious disease, transfusion reactions, and potential effects of immunomodulation. Patient blood management has been recognized by the World Health Organization (WHO) as the new standard of care and has urged all 193-member countries of WHO to implement this concept. There is a pressing need for this new "standard of care" so as to reduce blood transfusion and promote the availability of transfusion alternatives. Patient blood management therefore encompasses an evidence-based medical and surgical approach that is multidisciplinary (transfusion medicine specialists, surgeons, anesthesiologists, and critical care specialists) and multiprofessional (physicians, nurses, pump technologists and pharmacists). The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) organized a consensus project involving a Task Force of expert anesthesiologists that reviewing literature provide appropriate levels of care and good clinical practices. Hence, this article focuses on achieving goals of PBM in the perioperative period.

Effect of intraoperative autologous transfusion techniques on perioperative hemoglobin level in idiopathic scoliosis patients undergoing posterior spinal fusion: A prospective randomized trial

BACKGROUND

Massive blood loss during posterior spinal fusion for adolescent idiopathic scoliosis remains a significant risk for patients. There is no consensus on the benefit of acute normovolemic hemodilution (ANH) or intraoperative cell salvage (ICS) in scoliosis surgery.

METHODS

Patients were randomized to one of two groups. Group A received ANH and ICS during operation, while group B received only ICS. Patients' age, sex, height, weight, body blood volume, number of fusion level, Cobb angle, number of screws, duration of surgery, and skin incision length were recorded. Hemoglobin and hematocrit levels were obtained preoperatively and postoperatively (0 h and 24 h).

RESULTS

There were 22 patients in each group. There was no significant difference in total blood loss. The perioperative decrease in hemoglobin levels between preoperation and postoperation 24 h (group A 2.79 ± 1.15 and group B 2.76 ± 1.00) showed no significant difference ( p = 0.93). Group A observed a larger decrease in hemoglobin levels at postoperative 0 h relative to preoperative level (2.57 ± 0.82 g/dl), followed by a smaller decrease within the next 24 h (0.22 ± 1.33 g/dl). Group B showed a continued drop in hemoglobin levels of similar magnitude at postoperation 0 h (1.60 ± 0.67 g/dl) and within the next 24 h (1.16 ± 0.78 g/dl). One patient from group B received 1 unit of allogenic blood transfusion ( p = 0.33).

CONCLUSIONS

The addition of ANH to ICS in posterior spinal fusion surgery for AIS resulted in a similar decrease in hemoglobin levels between preoperative values and at 24 h postoperatively.

Bloodless medicine: current strategies and emerging treatment paradigms

BACKGROUND

Advances in our understanding of the risks associated with allogeneic blood transfusions (ABTs) and the growing number of patients who wish to avoid ABTs have led to the emergence of new treatment paradigms for "bloodless" medicine and surgery.

STUDY DESIGN AND METHODS

Here, we review prior studies and summarize current strategies for bloodless care used at our institution. We advocate three basic principles: 1) diagnosing and aggressively treating anemia, 2) minimizing blood loss from laboratory testing and invasive procedures, and 3) identifying and managing bleeding diatheses. Anemia is treated with erythropoiesis-stimulating agents as well as iron, folate, and B12 when indicated. Low-volume phlebotomy tubes are used for laboratory testing. Autologous blood salvage is used for childbirth and surgical patients who have the potential for substantial bleeding.

RESULTS

Although there have been few retrospective studies and no prospective studies to guide management, prior studies suggest that outcomes for surgical patients managed without ABTs are comparable to those of historic controls.

CONCLUSIONS

Given the emerging evidence that patients who avoid ABTs do as well if not better than patients who accept ABTs, further efforts are needed to determine whether all patients could benefit from bloodless strategies. Bloodless approaches in selected patients could reduce risks, improve outcomes, and decrease costs for all patients.

2,3-Diphosphoglycerate Concentrations in Autologous Salvaged Versus Stored Red Blood Cells and in Surgical Patients After Transfusion

BACKGROUND

Stored red blood cells (RBCs) are deficient in 2,3-diphosphoglycerate (2,3-DPG), but it is unclear how autologous salvaged blood (ASB) compares with stored blood and how rapidly 2,3-DPG levels return to normal after transfusion. Therefore, we compared levels of 2,3-DPG in stored versus ASB RBCs and in patients' blood after transfusion.

METHODS

Twenty-four patients undergoing multilevel spine fusion surgery were enrolled. We measured 2,3-DPG and the oxyhemoglobin dissociation curve (P50) in samples taken from the ASB and stored blood bags before transfusion and in blood samples drawn from patients before and after transfusion.

RESULTS

The mean storage duration for stored RBCs was 24 ± 8 days. Compared with fresh RBCs, stored RBCs had decreased 2,3-DPG levels (by approximately 90%; P < 0.0001) and a decreased P50 (by approximately 30%; P < 0.0001). However, ASB RBCs did not exhibit these changes. The mean 2,3-DPG concentration decreased by approximately 20% (P < 0.05) in postoperative blood sampled from patients who received 1 to 3 stored RBC units and by approximately 30% (P < 0.01) in those who received ≥4 stored RBC units. 2,3-DPG was unchanged in patients who received no stored blood or ASB alone. After surgery, 2,3-DPG levels recovered gradually over 3 postoperative days in patients who received stored RBCs.

CONCLUSIONS

Stored RBCs, but not ASB RBCs, have decreased levels of 2,3-DPG and a left-shift in the oxyhemoglobin dissociation curve. Postoperatively, 2,3-DPG levels remain below preoperative baseline levels for up to 3 postoperative days in patients who receive stored RBCs but are unchanged in those who receive only ASB RBCs.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization

BACKGROUND

Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions.

STUDY DESIGN AND METHODS

We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs.

RESULTS

For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization.

CONCLUSIONS

Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.