The second Austrian benchmark study for blood use in elective surgery: results and practice change

Hospital variation in quality indicators for patient blood management in total knee and hip arthroplasty: a retrospective cohort study

BACKGROUND

Anaemia, blood loss, and blood transfusion are critical aspects of patient care in major orthopaedic surgery. We assessed hospital adherence to guideline-recommended Patient Blood Management (PBM) care, analysed variations between hospitals, and validated two composite indicators of hospital PBM performance in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).

METHODS

This retrospective cohort study included all primary TKA and THA procedures performed during 2021 across 39 hospitals in Spain. We assessed hospital adherence to key guideline-recommended PBM interventions using nine individual quality indicators and two types of composite quality indicators (cQIs): opportunity-based (cQI1) and all-or-none (cQI2). We validated these cQIs by analysing their associations with the adjusted total transfusion index using linear regression.

RESULTS

We included 8561 patient episodes from 33 hospitals in the analysis. Delivery of PBM care was similar for TKA and THA. Patients received 62% of the analysed PBM interventions and only 12% of patients underwent the full PBM pathway. Higher hospital cQIs scores were associated with a lower adjusted total transfusion index, both in TKA and THA. The greatest association was found for cQI1 in THA patients (β=-1.18 [95% confidence interval -2.00 to -0.36]; P=0.007).

CONCLUSIONS

Hospital adherence to guideline-recommended patient blood management care in total hip and knee arthroplasty was suboptimal and varied across centres. Using data that are widely available in hospitals, quality indicators and composite scores could become valuable tools for patient blood management monitoring and comparisons between healthcare organisations.

Bloodless Cardiac Surgery in Jehovah's Witness: A Comprehensive Review

This article explores the major challenges and specialized strategies involved in managing cardiovascular surgery patients who are Jehovah's Witnesses and refuse blood transfusions due to their religious beliefs. It delves into preoperative, intraoperative, and postoperative approaches aimed at minimizing blood loss and optimizing patient outcomes while respecting their autonomy. Preoperative measures focus on correcting anemia and coagulopathy through targeted interventions, such as iron supplementation and erythropoietin therapy, and meticulous screening for bleeding disorders. Intraoperative techniques include the use of vasoconstrictors, hemostatic agents, and innovative blood conservation methods like acute normovolemic hemodilution and cell salvage. Postoperative care emphasizes infection control, hemostasis, and judicious monitoring to prevent anemia and facilitate recovery. Through a multidisciplinary approach and adherence to evidence-based practices, healthcare providers can effectively meet the needs of Jehovah's Witness patients, ensuring safe and successful cardiovascular surgery outcomes without the use of blood transfusions.

Allogeneic Blood Transfusion and Risk of Postoperative Complications in Patients with Mild and Moderate Anemia of Any Cause? A Retrospective Cohort Study in Total Revision Hip Surgery

Introduction

Patients undergoing revision total hip surgery (RTHS) have a high prevalence of mild and moderate preoperative anemia, associated with adverse outcomes. The aim of this study was to investigate the association of perioperative allogeneic blood transfusions (ABT) and postoperative complications in preoperatively mild compared to moderate anemic patients undergoing RTHS who did not receive a diagnostic anemia workup and treatment before surgery.

Methods

We included 1,765 patients between 2007 and 2019 at a university hospital. Patients were categorized according to their severity of anemia using the WHO criteria of mild, moderate, and severe anemia in the first Hb level of the case. Patients were grouped as having received no ABT, 1-2 units of ABT, or more than 2 units of ABT. Need for intraoperative ABT was assessed in accordance with institutional standards. Primary endpoint was the compound incidence of postoperative complications. Secondary outcomes included major/minor complications and length of hospital and ICU stay.

Results

Of the 1,765 patients, 31.0% were anemic of any cause before surgery. Transfusion rates were 81% in anemic patients and 41.2% in nonanemic patients. The adjusted risks for compound postoperative complication were significantly higher in patients with moderate anemia (OR 4.88, 95% CI: 1.54-13.15, p = 0.003) but not for patients with mild anemia (OR 1.93, 95% CI: 0.85-3.94, p < 0.090). Perioperative ABT was associated with significantly higher risks for complications in nonanemic patients and showed an increased risk for complications in all anemic patients. In RTHS, perioperative ABT as a treatment for moderate preoperative anemia of any cause was associated with a negative compound effect on postoperative complications, compared to anemia or ABT alone.

Discussion

ABT is associated with adverse outcomes of patients with moderate preoperative anemia before RTHS. For this reason, medical treatment of moderate preoperative anemia may be considered.

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.

Less (Transfusion) Is More-Enhancing Recovery through Implementation of Patient Blood Management in Cardiac Surgery: A Retrospective, Single-Centre Study of 1174 Patients

Introduction: The implementation of Patient Blood Management (PBM) in cardiac surgery has been shown to be effective in reducing blood transfusions and associated complications, as well as improving patient outcomes. Despite the potential benefits of PBM in cardiac surgery, there are several barriers to its successful implementation. Objectives: The main objectives of this study were to ascertain the impact of the national Romanian PBM recommendations on allogeneic blood product transfusion in cardiac surgery and identify predictors of perioperative packed red blood cell transfusion. Methods: As part of the Romanian national pilot programme of PBM, we performed a single-centre, retrospective study in a tertiary centre of cardiovascular surgery, including patients from two time periods, before and after the implementation of the national recommendations. Using coarsened exact matching, from a total of 1174 patients, 157 patients from the before group were matched to 169 patients in the after group. Finally, we built a multivariate regression model from the entire cohort to analyse independent predictors of PRBC transfusion in the perioperative period. Results: Although there was a trend towards a lower proportion of patients requiring PRBC transfusion in the "after" group compared to the "before" group (44.9%vs. 50.3%), it was not statistically significant. There was a significant difference between the "after" group and the "before" group in terms of fresh-frozen plasma (FFP) transfusion rates, with a lower percentage of patients requiring FFP transfusion in the "after" group compared to "before" (14.2%, vs. 22.9%, p = 0.04). This difference was also seen in the total perioperative FFP transfusion (mean transfusion 0.7 units in the "before" group, SD 1.73 vs. 0.38 units in the "after" group, SD 1.05, p = 0.04). In the multivariate regression analysis, age > 64 years (OR 1.652, 95% CI 1.17-2.331, p = 0.004), female sex (OR 2.404, 95% CI 1.655-3.492, p < 0.001), surgery time (OR 1.295, 95% CI 1.126-1.488, p < 0.001), Hb < 13 g/dl (OR 3.611, 95% CI 2.528-5.158, p < 0.001), re-exploration for bleeding (OR 3.988, 95% CI 1.248-12.738, p = 0.020), viscoelastic test use (OR 2.18, 95% CI 1.34-3.544, p < 0.001), FFP transfusion (OR 4.023, 95% CI 2.426-6.671, p < 0.001), and use of a standardized pretransfusion checklist (OR 8.875, 95% CI 5.496-14.332, p < 0.001) remained significantly associated with PRBC transfusion. The use of a preoperative standardized haemostasis questionnaire was independently associated with a decreased risk of perioperative PRBC transfusion (0.565, 95% CI 0.371-0.861, p = 0.008). Conclusions: Implementation of national PBM recommendations led to a reduction in FFP transfusion in a cardiac surgery centre. The use of a preoperative standardized haemostasis questionnaire is an independent predictor of a lower risk for PRBC transfusion in this setting.

Recommendations From the International Consensus Conference on Anemia Management in Surgical Patients (ICCAMS)

BACKGROUND

Perioperative anemia has been associated with increased risk of red blood cell transfusion and increased morbidity and mortality after surgery. The optimal approach to the diagnosis and management of perioperative anemia is not fully established.

OBJECTIVE

To develop consensus recommendations for anemia management in surgical patients.

METHODS

An international expert panel reviewed the current evidence and developed recommendations using modified RAND Delphi methodology.

RESULTS

The panel recommends that all patients except those undergoing minor procedures be screened for anemia before surgery. Appropriate therapy for anemia should be guided by an accurate diagnosis of the etiology. The need to proceed with surgery in some patients with anemia is expected to persist. However, early identification and effective treatment of anemia has the potential to reduce the risks associated with surgery and improve clinical outcomes. As with preoperative anemia, postoperative anemia should be treated in the perioperative period.

CONCLUSIONS

Early identification and effective treatment of anemia has the potential to improve clinical outcomes in surgical patients.

Anemia and formation of deep vein thrombosis before operation in patients with knee osteoarthritis: a cross-sectional study

BACKGROUND

Preoperative anemia is a common complication in knee osteoarthritis (KOA) patients. However, the association between anemia and preoperative deep vein thrombosis (DVT) in osteoarthritis patients remains unknown. The aim of this study was to investigate such association.

METHODS

In this retrospective study, we included 1005 KOA patients undergoing total knee arthroplasty (TKA) in our hospital. According to preoperative hemoglobin levels, the patients were divided into anemia group and non-anemia group. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. A logistic model was established through propensity score matching (PSM), with anemia before TKA as the dependent variable, DVT-related variable as the covariate, and 0.03 as the Caliper value. The anemia group and non-anemia group were matched at a 1:1 ratio and 310 successfully matched. After matching, logistic regression analysis was used to evaluate the correlation between preoperative anemia and DVT in KOA patients.

RESULTS

In this study, 342 cases (33.6%) had preoperative anemia and 73 cases (7.2%) had DVT before TKA. After matching, 46 DVT cases (7.42%) were found. By using binary logistic regression after PSM, we found that the risk for preoperative DVT formation in TKA patients with preoperative anemia increased by 1.97 times [95% (CI 1.05-3.69)], P = 0.035.

CONCLUSION

Preoperative anemia is considered as an independent risk factor for the formation of preoperative DVT in KOA patients.

TRIAL REGISTRATION

ChiCRT2100054844.

Effects of carbazochrome sodium sulfonate combined with tranexamic acid on hemostasis and inflammation during perioperative period of total hip arthroplasty: A randomized controlled trial

BACKGROUND

The hemostatic effect of tranexamic acid (TXA) combined with carbazochrome sodium sulfonate (CSS) in total hip arthroplasty (THA) has not been determined. Therefore we performed a randomized study aiming to evaluate the effects of CSS combined with TXA on perioperative blood loss and inflammatory response of THA.

HYPOTHESIS

CSS combined with TXA can effectively reduce perioperative blood loss and immune response compared to TXA.

MATERIAL AND METHODS

This randomized placebo-controlled trial assigned 150 patients undergoing unilateral primary total hip arthroplasty who underwent direct anterior approach surgery to 3 groups: group A received TXA plus topical CSS; group B received TXA only; and group C received placebo. The main outcome was total blood loss. Secondary outcomes included reduction in hemoglobin concentration, coagulation parameters, inflammatory marker levels, perioperative visual analog scale (VAS) pain score, transfusion rates, postoperative hospital stay, and incidence of thromboembolic events.

RESULTS

Total blood loss in group A (668.84±230.95ml) was lower than in group B (940.96±359.22ml) and C (1166.52±342.85ml, p<0.05). We also found that compared with group B, postoperative hip pain, biomarker level of inflammation, visual analogue score (VAS) pain score in group A were significantly improved. The transfusion rate and unit of group A were significantly lower than group C (8 patients; 17.5 units), but there was no statistical difference between group A (no transfusion) and group B (2 patients; 4 units). No differences were observed in thromboembolic and other outcomes among the groups.

DISCUSSION

The combined application of topic CSS and TXA is more effective than TXA alone following THA in regard of reducing total blood loss. In addition, CSS combined with TXA is better than TXA alone in terms of improving postoperative hip pain and reducing the level of inflammatory factors.

LEVEL OF EVIDENCE

I; randomized controlled study.

Total Knee Arthroplasty: Superiority of Intra-Articular Tranexamic Acid Over Intravenous and Cell Salvage as Blood Sparing Strategy – A Retrospective Study

Purpose

Total knee arthroplasty is associated with considerable perioperative hemorrhage. The decrease in hemoglobin concentration and the need for allogenic blood transfusion are related to increased morbidity and mortality. Strategies for minimizing perioperative bleeding are used, such as tranexamic acid and cell salvage. The study aimed to compare intravenous, intra-articular tranexamic acid and cell salvage protocols regarding perioperative hemoglobin variation. Secondary outcomes included blood loss; allogenic transfusions; complications and in-hospital stay.

Patients and Methods

Patients submitted to unilateral total knee arthroplasty between January and December 2018 were retrospectively evaluated. After excluding 62 patients, 204 were subdivided into 3 groups according to the protocol used. Statistical analysis was performed with SPSS version 26.0. One-way ANOVA and Kruskal–Wallis tests were used. Considered a p-value of <0.05 for statistical significance.

Results

Variation of hemoglobin in the intra-articular tranexamic acid group was significantly lower than that of intravenous (p < 0.001) and cell salvage (p = 0.001) groups. Blood loss, variation of hematocrit, need for blood transfusion and in-hospital stay were also statistically significantly lower in the intra-articular tranexamic acid group. The only related complications were in the intravenous tranexamic acid group. No thromboembolic complications were identified which further solidifies the safety of tranexamic acid administration.

Conclusion

This data shows superiority of the intra-articular administration of tranexamic acid over the other techniques in total knee arthroplasty. We propose this protocol as an efficient, low-risk blood-sparing strategy.

Making patient blood management the new norm(al) as experienced by implementors in diverse countries

BACKGROUND

Patient blood management (PBM) describes a set of evidence-based practices to optimize medical and surgical patient outcomes by clinically managing and preserving a patient's own blood. This concepts aims to detect and treat anemia, minimize the risk for blood loss and the need for blood replacement for each patient through a coordinated multidisciplinary care process. In combination with blood loss, anemia is the main driver for transfusion and all three are independent risk factors for adverse outcomes including morbidity and mortality. Evidence demonstrates that PBM significantly improves outcomes and safety while reducing cost by macroeconomic magnitudes. Despite its huge potential to improve healthcare systems, PBM is not yet adopted broadly. The aim of this study is to analyze the collective experiences of a diverse group of PBM implementors across countries reflecting different healthcare contexts and to use these experiences to develop a guidance for initiating and orchestrating PBM implementation for stakeholders from diverse professional backgrounds.

METHODS

Semi-structured interviews were conducted with 1-4 PBM implementors from 12 countries in Asia, Latin America, Australia, Central and Eastern Europe, the Middle East, and Africa. Responses reflecting the drivers, barriers, measures, and stakeholders regarding the implementation of PBM were summarized per country and underwent qualitative content analysis. Clustering the resulting implementation measures by levels of intervention for PBM implementation informed a PBM implementation framework.

RESULTS

A set of PBM implementation measures were extracted from the interviews with the implementors. Most of these measures relate to one of six levels of implementation including government, healthcare providers, funding, research, training/education, and patients/public. Essential cross-level measures are multi-stakeholder communication and collaboration.

CONCLUSION

The implementation matrix resulting from this research helps to decompose the complexity of PBM implementation into concrete measures on each implementation level. It provides guidance for diverse stakeholders to design, initiate and develop strategies and plans to make PBM a national standard of care, thus closing current practice gaps and matching this unmet public health need.

Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty

AIMS

The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA.

METHODS

This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo).

RESULTS

Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS).

CONCLUSION

The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354-362.

How I treat anemia in the perisurgical setting

Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.

Intravenous iron infusion as an alternative to minimize blood transfusion in peri-operative patients

Despite the reported benefits of intravenous iron therapy (IVIT) for correcting iron deficiency anemia (IDA) before any major surgery and the evidence thereof, perioperative allogenic blood transfusion (ABT) practice is still considered as the only viable option by some clinicians worldwide. As ABT increases the likelihood of infections, cardiac complications, longer hospital stays and mortality among the patients, the practice of ABT should only be reserved for critical cases (Hb level < 7 g/dl). Timely iron studies and iron replenishment (oral/IV) of prospective surgical patients could help decrease the ABT practice, and prove beneficial from both the clinical and economic standpoint. Evidence based patient blood management guidelines should be developed and standardized for use by clinicians worldwide. These guidelines should include specific instructions on timely assessment of surgical patients for correction of their IDA by either oral iron supplementation, if time permits, or by using IVIT such as ferric carboxymaltose (FCM) in emergency surgeries and in patients with functional ID. This study was conducted to explore the clinical benefits of the timely administration of IV-FCM in iron-deficient preoperative patients during 2017-2018 and compare the results thereof with that of the ABT. Based on the IDA treatment plan of 2953 patients, 11.14% cases were administered IV FCM (Group 1), 11.58% cases received ABT (Group 2), while the remaining 77.27% of anemic cases received neither ABT nor IV FCM (Group 3). The results indicate that the IV FCM administration reduces the need for ABT and thus minimizes its associated side effects. The findings of our study concur with the favorable outcomes reported by the other similar studies.

Characteristics of Recipients of Red Blood Cell Concentrates in a German Federal State

BACKGROUND

Annual transfusion rates in many European countries range between 25 and 35 red blood cell concentrates (RBCs)/1,000 population. It is unclear why transfusion rates in Germany are considerably higher (approx. 50-55 RBCs/1,000 population).

METHODS

We assessed the characteristics of transfusion recipients at all hospitals of the German federal state Mecklenburg-Western Pomerania during a 10-year longitudinal study.

RESULTS

Although 75% of patients received ≤4 RBCs/patient in 2015 (1 RBC: 11.3%; 2 RBCs: 42.6%; 3 RBCs: 6.3%; 4 RBCs: 15.0%), the mean transfusion index was 4.6 RBCs due to a minority of patients with a high transfusion demand. Two thirds of all RBCs were transfused to only 25% of RBC recipients. Consistently, male patients received a higher number of RBCs (2005: 54.2%; 2015: 56.8%) and had a higher mean transfusion index than female patients (mean 5.1 ± 7.2; median 2; inter-quartile range [IQR] 2-4 vs. mean 4.0 ± 5.8; median 2; IQR 2-4). The absolute transfusion demand decreased between 2005 and 2015 by 13.5% due to a composite of active reduction (clinical practice change) and population decline in the 65- to 75-year age group (lower birth rate cohort 1940-1950); however, with major differences between hospitals (range from -61.0 to +41.4%).

CONCLUSION

Transfusion demand in a population could largely be driven by patients with high transfusion demand. Different treatment practices in this group of patients probably add to the major differences in transfusion demand per 1,000 individuals between countries. The available data cannot prove this hypothesis. Implementation of a diagnosis-related group-based monitoring system is urgently needed to allow informative monitoring on the population level and meaningful comparisons between transfusion practices.

[Health policy strategies for Patient Blood Management implementation throughout the Spanish health systems]

Los programas de Patient Blood Management (PBM) permiten reducir intervenciones sanitarias innecesarias e incorporar prácticas clínicas de alto valor que mejoran los resultados en salud y la eficiencia. Su adopción en España es todavía limitada y con una alta variabilidad entre hospitales. Las recientes guías de la Unión Europea sobre cómo implementar el PBM, así como las recomendaciones de expertos, indican que para conseguir un avance en este campo se requiere, no solo de la implicación de los profesionales, sino también de las autoridades sanitarias y direcciones hospitalarias. Este artículo proporciona algunas propuestas en materia de gestión y política sanitaria para promover el desarrollo del PBM en los sistemas de salud en España.

Peri-operative blood transfusion in elective major surgery: incidence, indications and outcome - an observational multicentre study

BACKGROUND

Patients' demographic and epidemiological characteristics, local variations in clinicians' knowledge and experience and types of surgery can influence peri-operative transfusion practices. Sharing data on transfusion practices and recipients may improve patients' care and implementation of Patient Blood Management (PBM).

MATERIALS AND METHODS

This was a multicentre, prospective, observational, cross-sectional study that included 61 centres. Clinical and transfusion data of patients undergoing major elective surgery were collected; transfusion predictors and patients' outcomes were analysed.

RESULTS

Of 6,121 patients, 1,579 (25.8%) received a peri-operative transfusion. A total of 5,812 blood components were transfused: red blood cells (RBC), fresh-frozen plasma and platelets in 1,425 (23.3%), 762 (12.4%) and 88 (1.4%) cases, respectively). Pre-operative anaemia was identified in 2,019 (33%) patients. Half of the RBC units were used by patients in the age group 45-69 years. Specific procedures with the highest RBC use were coronary artery bypass grafting (16.9% of all units) and hip arthroplasty (14.9%). Low haemoglobin concentration was the most common indication for intra-operative RBC transfusion (57%) and plasma and platelet transfusions were mostly initiated for acute bleeding (61.3% and 61.1%, respectively). The RBC transfusion rate in study centres varied from 2% to 72%. RBC transfusion was inappropriate in 99% (n=150/151) of pre-operative, 23% (n=211/926) of intra-operative and 43% (n=308/716) of post-operative RBC transfusion episodes. Pre-operative haemoglobin, increased blood loss, open surgery and duration of surgery were the main independent predictors of intra-operative RBC transfusion. Low pre-operative haemoglobin concentration was independently associated with post-operative pulmonary complications.

CONCLUSIONS

These findings identified areas for improvement in peri-operative transfusion practice and PBM implementation in Turkey.

Patient Blood Management for primary hip and knee replacement. A survey among POWER.2 study researchers

BACKGROUND

Implementation of Patient Blood Management programs remain variable in Europe, and even in centres with well-established PBM programs variability exists in transfusion practices.

OBJECTIVES AND METHODS

We conducted a survey in order to assess current practice in perioperative Patient Blood Management in patients undergoing total hip and knee replacement among researchers involved in POWER.2 Study in Spain (an observational prospective study evaluating enhanced recovery pathways in orthopaedic surgery).

RESULTS

A total of 322 responses were obtained (37.8%). Half of responders check Haemoglobin levels in patients at least 4 weeks before surgery; 35% treat all anaemic patients, although 99.7% consider detection and treatment of preoperative anaemia could influence the postoperative outcomes. Lack of infrastructure (76%) and lack of time (51%) are the main stated reasons not to treat anaemic patients. Iron status is routinely checked by 19% before surgery, and 36% evaluate it solely in the anaemic patient. Hb<9.9 g/dl is the threshold to delay surgery for 61% of clinicians, and 22% would consider transfusing preoperatively clinically stable patients without active bleeding. The threshold to transfuse patients without cardiovascular disease is 8 g/dl for 43%, and 7 g/dl for 34% of the responders; 75% of clinicians consider they use "restrictive thresholds", and 90% follow the single unit transfusion policy.

CONCLUSIONS

The results of our survey show variability in clinical practice in Patient Blood Management in major orthopaedic surgery, despite being the surgery with the greatest tradition in these programs.

Hemostatic and Anti-Inflammatory Effects of Carbazochrome Sodium Sulfonate in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Postoperative recovery after total knee arthroplasty (TKA) is associated with postoperative anemia, allogeneic transfusion, and stress immune responses to surgery. Carbazochrome sodium sulfonate (CSS) reduces bleeding through several mechanisms. We assessed the effect of CSS combined with tranexamic acid (TXA) on postoperative anemia, blood transfusion, and inflammatory responses.

METHODS

This study was designed as a randomized, placebo-controlled trial of 200 patients undergoing unilateral primary TKA. Patients were divided into 4 groups: group A received TXA plus topical and intravenous CSS; group B received TXA plus topical CSS only; group C received TXA plus intravenous CSS only; group D received TXA only.

RESULTS

Total blood loss in groups A (609.92 ± 221.24 mL), B (753.16 ± 247.67 mL), and C (829.23 ± 297.45 mL) was lower than in group D (1158.26 ± 334.13 mL, P < .05). There was no difference in total blood loss between groups B and C. We also found that compared with group D, the postoperative swelling rate, biomarker level of inflammation, visual analog scale pain score, and range of motion at discharge in groups A, B, and C were significantly improved (P < .05). No thromboembolic complications occurred. There were no differences in transfusion rate, intraoperative blood loss, platelet count, or average length of stay among the 4 groups (P > .05).

CONCLUSION

CSS combined with TXA was more effective than TXA alone in reducing perioperative blood loss and inflammatory response and did not increase the incidence of thromboembolism complications.

Liberal transfusion strategy to prevent mortality and anaemia-associated, ischaemic events in elderly non-cardiac surgical patients - the study design of the LIBERAL-Trial

Background

Perioperative anaemia leads to impaired oxygen supply with a risk of vital organ ischaemia. In healthy and fit individuals, anaemia can be compensated by several mechanisms. Elderly patients, however, have less compensatory mechanisms because of multiple co-morbidities and age-related decline of functional reserves. The purpose of the study is to evaluate whether elderly surgical patients may benefit from a liberal red blood cell (RBC) transfusion strategy compared to a restrictive transfusion strategy.

Methods

The LIBERAL Trial is a prospective, randomized, multicentre, controlled clinical phase IV trial randomising 2470 elderly (≥ 70 years) patients undergoing intermediate- or high-risk non-cardiac surgery. Registered patients will be randomised only if Haemoglobin (Hb) reaches ≤9 g/dl during surgery or within 3 days after surgery either to the LIBERAL group (transfusion of a single RBC unit when Hb ≤ 9 g/dl with a target range for the post-transfusion Hb level of 9–10.5 g/dl) or the RESTRICTIVE group (transfusion of a single RBC unit when Hb ≤ 7.5 g/dl with a target range for the post-transfusion Hb level of 7.5–9 g/dl). The intervention per patient will be followed until hospital discharge or up to 30 days after surgery, whichever occurs first. The primary efficacy outcome is defined as a composite of all-cause mortality, acute myocardial infarction, acute ischaemic stroke, acute kidney injury (stage III), acute mesenteric ischaemia and acute peripheral vascular ischaemia within 90 days after surgery. Infections requiring iv antibiotics with re-hospitalisation are assessed as important secondary endpoint. The primary endpoint will be analysed by logistic regression adjusting for age, cancer surgery (y/n), type of surgery (intermediate- or high-risk), and incorporating centres as random effect.

Discussion

The LIBERAL-Trial will evaluate whether a liberal transfusion strategy reduces the occurrence of major adverse events after non-cardiac surgery in the geriatric population compared to a restrictive strategy within 90 days after surgery.

Trial registration

ClinicalTrials.gov (identifier: NCT03369210).

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3200-3) contains supplementary material, which is available to authorized users.

Evaluation of the use of blood in surgeries as a tool to change patterns for requesting blood product reserves

OBJECTIVES

Thirty to sixty percent of prepared blood products are not transfused. Blood reserves for surgeries lead to many unused blood products, which increases hospital costs. The aim of this study is to identify the request and use profiles of blood products for elective surgeries in different surgical specialties, the influence of surgery time and demographic, clinical, and laboratory variables on the number of red blood cells (RBCs) used and to calculate the rate of transfused patients (RTP) and cross-matched and transfused (C/T) RBCs.

METHODS

Observational and prospective studies. Sociodemographic, clinical and quantitative data on the request and use of blood products were collected. The influence of the data on the use of RBCs was examined by binary logistic regression. Chi-square, one-way ANOVA and Kruskal-Wallis tests were utilized to compare the data among the specialties.

RESULTS

In total, 822 procedures were included. Most of the requested blood products were not used, even 24 hours postoperatively. Of the 2,483 RBC units, 314 were transfused, leaving 87.6% unused; however, cardiac, digestive tract, vascular, gynecologic, urologic and thoracic surgery procedures transfused 50%, 25%, 16.5%, 11%, 9.5% and 8.1% of requested RBCs, respectively. The factors that influenced the transfusions were age, time of surgery and cardiac surgeries. The RTP was >10% in 22 surgical types and <1% in 24 surgical types, and 88% of samples presented a C/T ratio >2.5.

CONCLUSION

The RTP and C/T ratios can guide RBC requests in the preoperative period. Knowing the standard of use of blood products and developing protocols enables the optimization of reserves, reduction of costs and improvement of care.

Tranexamic Acid Prophylaxis in Hip and Knee Joint Replacement

BACKGROUND

The antifibrinolytic agent tranexamic acid (TXA) is widely used for the prevention and treatment of hyperfibrinolytic states, such as in severe polytrauma. It can also be used for the systemic prevention of hemorrhage in elective orthopedic procedures. In this review, we assess the efficacy and risks of the prophylactic administration of tranexamic acid before major endoprosthetic surgery of the hip and knee.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in the PubMed and Cochrane Library databases.

RESULTS

Endoprosthetic surgery of the hip and knee is often associated with perioperative blood losses exceeding 500 mL. The prophylactic administration of tranexamic acid immediately before such procedures has been shown in randomized, controlled trials to lessen the quantity of intra- and postoperative bleeding and to reduce the likelihood of blood transfusion (number needed to treat [NNT] 3.7-5.7 for knee replacement and 4.1-8.2 for hip replacement). The rate of thromboembolic events did not differ significantly from the rate in the placebo groups. No reliable data are available on the frequency of epileptic seizures as a complication of TXA use in knee and hip endoprosthetic surgery. On the basis of data from other types of surgery, one may reasonably conclude that the doses of TXA used for knee and hip endoprosthetic procedures are unlikely to cause this problem.

CONCLUSION

The prophylactic intravenous administration of tranexamic acid lessens the amount of bleeding in endoprosthetic knee and hip procedures and reduces the likelihood of blood transfusion. According to the current state of the evidence, complications are rare. Nonetheless, consideration of the risks and benefits implies that tranexamic acid should not be given for this purpose to patients who have recently had urogenital bleeding, pulmonary embolism, or a myocardial infarction, who have recently undergone percutaneous transluminal coronary angioplasty or stenting, or who are known to have epilepsy.

Efficacy of topical tranexamic acid within a blood-saving programme for primary total hip arthroplasty: a pragmatic, open-label randomised study

BACKGROUND

Total hip arthroplasty entails considerable peri-operative blood loss, which may lead to acute post-operative anaemia and red blood cell transfusion. This study was aimed at assessing whether the addition of topical tranexamic acid to our ongoing blood-saving protocol for total hip arthroplasty was effective and safe.

MATERIALS AND METHODS

A pragmatic, prospective, open-label randomised study of patients scheduled for total hip arthroplasty at a single centre was conducted. Consecutive patients were randomly assigned to receive topical tranexamic acid (2 g) at the end of surgery (tranexamic group, n=125) or not (control group, n=129). A restrictive transfusion protocol was applied. Outcome measures were red blood cell loss at 24 hours after surgery, in-hospital transfusion rate, and incidence of thromboembolic complications.

RESULTS

Topical tranexamic acid was effective in reducing both red cell loss (mean difference: 138 mL [95% CI 87-189 mL]; p<0.001) in the 24h after surgery and in-hospital transfusion rates (12 vs 32.6%, for the tranexamic acid and control groups, respectively; p<0.001; relative risk=0.37 [95% CI 0.22-0.63]). However, relative red cell loss and transfusion rates were higher in females than in males, irrespectively of tranexamic acid use. The beneficial effect of tranexamic acid on transfusion was restricted to patients with pre-operative haemoglobin ≥13 g/dL (5.1 vs 24.8%; p<0.001). Topical tranexamic acid was well tolerated and no clinically apparent thromboembolic complications were witnessed.

DISCUSSION

The use of topical tranexamic acid after hip arthroplasty reduced red cell loss and transfusion rates; the efficacy of this strategy may be improved by reinforcing both pre-operative haemoglobin optimisation and adherence to the practice of transfusing single units of red cells.

Cost-effectiveness analysis of ferric carboxymaltose in pre-operative haemoglobin optimisation in patients undergoing primary knee arthroplasty

BACKGROUND

An analytic-decision model was built to estimate the cost-effectiveness of using ferric carboxymaltose for pre-operative haemoglobin optimisation in patients with iron deficiency anaemia undergoing primary knee arthroplasty.

MATERIALS AND METHODS

We simulated 20,000 patients who were randomly assigned to the haemoglobin optimisation arm or the non-optimisation control arm in a strict 1:1 ratio. The main outcomes were cost per patient transfusion avoided and red blood cell units spared. The analyses were performed from the hospital perspective with length of stay as the time horizon.

RESULTS

In the reference case scenario, pre-operative haemoglobin optimisation led to fewer patients being exposed to allogeneic red blood cell transfusion (2,212 vs 6,595 out of 10,000 patients) and a relevant decrease in the number of red blood cell units transfused (4.342 vs 13.336). The costs of avoiding one patient transfusion and sparing one red blood cell unit were € 831 and € 405, respectively. Increased costs in the optimisation arm were mostly associated with the outpatient day hospital visit (54%) and ferric carboxymaltose treatment (40%).

DISCUSSION

In primary knee arthroplasty, pre-operative haemoglobin optimisation with intravenous ferric carboxymaltose is less expensive than other reported patient blood management modalities and must be considered in patients with iron deficiency anaemia.

Red blood cell transfusion probability and associated costs in neurosurgical procedures

BACKGROUND

The extent of red blood cell units (RBC) needed for different neurosurgical procedures and the time point of their administration are widely unknown, which results in generously cross-matching prior to surgery. However, RBC are increasingly requested in the aging western populations, and blood donations are significantly reduced. Therefore, the knowledge of the extent and time point of administration of RBC is of major importance.

METHODS

This is a retrospective single center analysis. The incidence of RBC transfusion during surgery or within 48 h after surgery was analyzed for all neurosurgical patients within 3 years. Costs for cross-matched and transfused RBC were calculated and risk factors for RBC transfusion analyzed.

RESULTS

The risk of intraoperative RBC administration was low for spinal and intracranial tumor resections (1.87%) and exceeded 10% only in spinal fusion procedures. This was dependent on the number of fused segments with an intraoperative transfusion risk of > 12.5% with fusion of more than three levels. Multiple logistic regression analysis showed a significantly increased risk for RBC transfusion for female gender (p = 0.006; OR 1.655), higher age (N = 4812; p < 0.0001; OR 1.028), and number of fused segments (N = 737; p < 0.0001; OR 1.433). Annual costs for cross-matching were 783,820.88 USD and for intraoperative RBC administration 121,322.13 USD.

CONCLUSIONS

Neurosurgical procedures are associated with a low number of RBC needed intraoperatively. Only elective spine fusion procedures with ≥ 3 levels involved and AVM resections seem to require cross-matching of RBC. The present data may allow changing the preoperative algorithm of RBC cross-matching in neurosurgical procedures and help to save resources and costs.

Perioperative Blood Management Strategies for Total Knee Arthroplasty

Total knee arthroplasty (TKA) often causes a significant amount of blood loss with an accompanying decline in hemoglobin and may increase the frequency of allogeneic blood transfusion rates. Unfortunately, allogeneic blood transfusions have associated risks including postoperative confusion, infection, cardiac arrhythmia, fluid overload, increased length of hospital stay, and increased mortality. Other than reducing the need for blood transfusions, reducing perioperative blood loss in TKA may also minimize intra-articular hemorrhage, limb swelling, and postoperative pain, and increase the range of motion during the early postoperative period. These benefits improve rehabilitation success and increase patients' postoperative satisfaction. Preoperative anemia, coupled with intraoperative and postoperative blood loss, is a major factor associated with higher rates of blood transfusion in TKA. Thus, treatment of preoperative anemia and prevention of perioperative blood loss are the primary strategies for perioperative blood management in TKA. This review, combined with current evidence, analyzes various methods of blood conservation, including preoperative, intraoperative, and postoperative methods, in terms of their effectiveness, safety, and cost. Because many factors can be controlled to reduce blood loss and transfusion rates in TKA, a highly efficient, safe, and cost-effective blood management strategy can be constructed to eliminate the need for transfusions associated with TKA.

Age and blood transfusion: relationship and prognostic implications in cardiac surgery

Background

Red blood cell (RBC) transfusion is a well-known predictor of acute kidney injury (AKI) and death after cardiac surgery. This study aimed to define the relationship between age and the need for RBC.

Methods

Study population included 1,765 consecutive patients undergoing on-pump procedures from 2013 to 2015. The relationship between RBC transfusion and both survival and AKI, and any interaction with age was estimated. A propensity score for the likelihood to receive RBC transfusion was calculated using multivariate logistic regression analysis to adjust for the effect of confounding factors. A logistic estimation curve was developed to investigate the interaction between this score and age.

Results

Patients receiving RBC transfusions had more comorbidities irrespective of age. Elderly patients underwent transfusion more often than younger patients with a 1.3-fold increase in the relative risk for transfusion. Age did not independently predict the need for RBC. AKI and mortality rates were significantly higher in transfused subsets irrespective of age.

Conclusions

Comorbidity profile and not age per se confers an increased risk of transfusion.

Development of Multivariable Models to Predict and Benchmark Transfusion in Elective Surgery Supporting Patient Blood Management

BACKGROUND

Blood transfusion is a highly prevalent procedure in hospitalized patients and in some clinical scenarios it has lifesaving potential. However, in most cases transfusion is administered to hemodynamically stable patients with no benefit, but increased odds of adverse patient outcomes and substantial direct and indirect cost. Therefore, the concept of Patient Blood Management has increasingly gained importance to pre-empt and reduce transfusion and to identify the optimal transfusion volume for an individual patient when transfusion is indicated.

OBJECTIVES

It was our aim to describe, how predictive modeling and machine learning tools applied on pre-operative data can be used to predict the amount of red blood cells to be transfused during surgery and to prospectively optimize blood ordering schedules. In addition, the data derived from the predictive models should be used to benchmark different hospitals concerning their blood transfusion patterns.

METHODS

6,530 case records obtained for elective surgeries from 16 centers taking part in two studies conducted in 2004-2005 and 2009-2010 were analyzed. Transfused red blood cell volume was predicted using random forests. Separate models were trained for overall data, for each center and for each of the two studies. Important characteristics of different models were compared with one another.

RESULTS

Our results indicate that predictive modeling applied prior surgery can predict the transfused volume of red blood cells more accurately (correlation coefficient cc = 0.61) than state of the art algorithms (cc = 0.39). We found significantly different patterns of feature importance a) in different hospitals and b) between study 1 and study 2.

CONCLUSION

We conclude that predictive modeling can be used to benchmark the importance of different features on the models derived with data from different hospitals. This might help to optimize crucial processes in a specific hospital, even in other scenarios beyond Patient Blood Management.

The efficacy and safety of epinephrine for postoperative bleeding in total joint arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

Total joint arthroplasty (TJA) usually results in postoperative bleeding. Some randomized controlled trials (RCTs) and nonrandomized controlled trials (non-RCTs) have been performed to evaluate the effects of epinephrine on postoperative bleeding after TJA. However, this remained controversial about the efficacy and safety of epinephrine for postoperative bleeding in TJA. The objective of our meta-analysis was to compare the overall effect and safety of epinephrine and placebo for postoperative bleeding in TJA.

METHODS

PubMed, Embase, and the Cochrane Library were searched to identify potentially relevant articles. RCTs or non-RCTs involving epinephrine and placebo for blood loss in total knee arthroplasty or total hip arthroplasty were included. Our study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RevMan v5.3 was used to analyze the relevant data.

RESULTS

Four RCTs and 1 non-RCT involving 646 participants met the inclusion criteria. The overall pooled results from meta-analysis demonstrated that compared with control groups, epinephrine groups could significantly reduce the postoperative bleeding volume (mean difference [MD] = -168.42, 95% confidence interval [CI]: -272.37 to -64.47, P = 0.001). There was no significant difference in intraoperative bleeding volume between epinephrine and control groups (MD = -12.89, 95% CI: -53.45 to 27.69, P = 0.53). No significant difference was found between 2 groups in terms of postoperative hemoglobin loss (MD = -0.28, 95% CI: -0.66 to 0.10, P = 0.15). Compared with the control groups, no statistically significant difference was found in terms of postoperative transfusion rate in epinephrine groups (relative risk [RR] 0.86, 95% CI: 0.64-1.15, P = 0.31). In addition, the results of the meta-analysis also indicated no significant difference in terms of the incidence rate of deep venous thrombosis (DVT) between 2 groups (RR 0.28, 95% CI: 0.05-1.64, P = 0.16).

CONCLUSION

The meta-analysis showed that epinephrine could significantly reduce postoperative bleeding volume in TJA without increasing the incidence of DVT. However, there was no significant reduction in intraoperative bleeding volume, postoperative hemoglobin loss, and transfusion rate after the administration of epinephrine.

LIMITATIONS

In this study, a higher heterogeneity and a risk of selection bias may be present in postoperative hemoglobin loss. In addition, the sample size of the included studies was too small, so our findings need to be further validated with more high-quality and larger scale RCTs in the future.

SYSTEMATIC REVIEW REGISTRATION NUMBER

None.

Anesthesia for Patients with Anemia

Anemia is a common and often ignored condition in surgical patients. Anemia is usually multifactorial and iron deficiency and inflammation are commonly involved. An exacerbating factor in surgical patients is iatrogenic blood loss. Anemia has been repeatedly shown to be an independent predictor of worse outcomes. Patient blood management (PBM) provides a multimodality framework for prevention and management of anemia and related risk factors. The key strategies in PBM include support of hematopoiesis and improving hemoglobin level, optimizing coagulation and hemostasis, use of interdisciplinary blood conservation modalities, and patient-centered decision making throughout the course of care.

Peri-operative treatment of anaemia in major orthopaedic surgery: a practical approach from Spain

In patients undergoing major orthopaedic surgery, pre-operative anaemia, peri-operative bleeding and a liberal transfusion policy are the main risk factors for requiring red blood cell transfusion (RBCT). The clinical and economic disadvantages of RBCT have led to the development and implementation of multidisciplinary, multimodal, individualised strategies, collectively termed patient blood management, which aim to reduce RBCT and improve patients' clinical outcome and safety. Within a patient blood management programme, low pre-operative haemoglobin is one of the few modifiable risk factors for RBCT. However, a survey among Anaesthesia Departments in Spain revealed that, although pre-operative assessment was performed in the vast majority of hospitals, optimisation of haemoglobin concentration was attempted in <40% of patients who may have benefitted from it, despite there being enough time prior to surgery. This indicates that haemoglobin optimisation takes planning and forethought to be implemented in an effective manner. This review, based on available clinical evidence and our experience, is intended to provide clinicians with a practical tool to optimise pre-operative haemoglobin levels, in order to minimise the risk of patients requiring RBCT. To this purpose, after reviewing the diagnostic value and limitations of available laboratory parameters, we developed an algorithm for the detection, classification and treatment of pre-operative anaemia, with a patient-tailored approach that facilitates decision-making in the pre-operative assessment. We also reviewed the efficacy of the different pharmacological options for pre-operative and post-operative management of anaemia. We consider that such an institutional pathway for anaemia management could be a viable, cost-effective strategy that is beneficial to both patients and healthcare systems.

Gender disparities in red blood cell transfusion in elective surgery: a post hoc multicentre cohort study

OBJECTIVES

A post hoc gender comparison of transfusion-related modifiable risk factors among patients undergoing elective surgery.

SETTINGS

23 Austrian centres randomly selected and stratified by region and level of care.

PARTICIPANTS

We consecutively enrolled in total 6530 patients (3465 women and 3065 men); 1491 underwent coronary artery bypass graft (CABG) surgery, 2570 primary unilateral total hip replacement (THR) and 2469 primary unilateral total knee replacement (TKR).

MAIN OUTCOME MEASURES

Primary outcome measures were the number of allogeneic and autologous red blood cell (RBC) units transfused (postoperative day 5 included) and differences in intraoperative and postoperative transfusion rate between men and women. Secondary outcomes included perioperative blood loss in transfused and non-transfused patients, volume of RBCs transfused, perioperative haemoglobin values and circulating red blood volume on postoperative day 5.

RESULTS

In all surgical groups, the transfusion rate was significantly higher in women than in men (CABG 81 vs 49%, THR 46 vs 24% and TKR 37 vs 23%). In transfused patients, the absolute blood loss was higher among men in all surgical categories while the relative blood loss was higher among women in the CABG group (52.8 vs 47.8%) but comparable in orthopaedic surgery. The relative RBC volume transfused was significantly higher among women in all categories (CABG 40.0 vs 22.3; TKR 25.2 vs 20.2; THR 26.4 vs 20.8%). On postoperative day 5, the relative haemoglobin values and the relative circulating RBC volume were higher in women in all surgical categories.

CONCLUSIONS

The higher transfusion rate and volume in women when compared with men in elective surgery can be explained by clinicians applying the same absolute transfusion thresholds irrespective of a patient's gender. This, together with the common use of a liberal transfusion strategy, leads to further overtransfusion in women.

Red blood cell use in Switzerland: trends and demographic challenges

BACKGROUND

Several studies have raised concerns that future demand for blood products may not be met. The ageing of the general population and the fact that a large proportion of blood products is transfused to elderly patients has been identified as an important driver of blood shortages. The aim of this study was to collect, for the first time, nationally representative data regarding blood donors and transfusion recipients in order to predict the future evolution of blood donations and red blood cell (RBC) use in Switzerland between 2014 and 2035.

MATERIALS AND METHODS

Blood donor and transfusion recipient data, subdivided by the subjects' age and gender were obtained from Regional Blood Services and nine large, acute-care hospitals in various regions of Switzerland. Generalised additive regression models and time-series models with exponential smoothing were employed to estimate trends of whole blood donations and RBC transfusions.

RESULTS

The trend models employed suggested that RBC demand could equal supply by 2018 and could eventually cause an increasing shortfall of up to 77,000 RBC units by 2035.

DISCUSSION

Our study highlights the need for continuous monitoring of trends of blood donations and blood transfusions in order to take proactive measures aimed at preventing blood shortages in Switzerland. Measures should be taken to improve donor retention in order to prevent a further erosion of the blood donor base.

Protocol for a national blood transfusion data warehouse from donor to recipient

INTRODUCTION

Blood transfusion has health-related, economical and safety implications. In order to optimise the transfusion chain, comprehensive research data are needed. The Dutch Transfusion Data warehouse (DTD) project aims to establish a data warehouse where data from donors and transfusion recipients are linked. This paper describes the design of the data warehouse, challenges and illustrative applications.

STUDY DESIGN AND METHODS

Quantitative data on blood donors (eg, age, blood group, antibodies) and products (type of product, processing, storage time) are obtained from the national blood bank. These are linked to data on the transfusion recipients (eg, transfusions administered, patient diagnosis, surgical procedures, laboratory parameters), which are extracted from hospital electronic health records.

APPLICATIONS

Expected scientific contributions are illustrated for 4 applications: determine risk factors, predict blood use, benchmark blood use and optimise process efficiency. For each application, examples of research questions are given and analyses planned.

CONCLUSIONS

The DTD project aims to build a national, continuously updated transfusion data warehouse. These data have a wide range of applications, on the donor/production side, recipient studies on blood usage and benchmarking and donor-recipient studies, which ultimately can contribute to the efficiency and safety of blood transfusion.

The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial

OBJECTIVE

To determine if preoperative intravenous (IV) iron improves outcomes in abdominal surgery patients.

SUMMARY BACKGROUND DATA

Preoperative iron deficiency anemia (IDA) occurs frequently; however if left untreated, increases the risk of blood transfusion allogeneic blood transfusion (ABT). Limited evidence supports IDA treatment with preoperative IV iron. This randomized controlled trial aimed to determine whether perioperative IV iron reduced the need for ABT.

METHODS

Between August 2011 and November 2014, 72 patients with IDA were assigned to receive either IV iron or usual care. The primary endpoint was incidence of ABT. Secondary endpoints were various hemoglobin (Hb) levels, change in Hb between time points, length of stay, iron status, morbidity, mortality, and quality of life 4 weeks postsurgery.

RESULTS

A 60% reduction in ABT was observed in the IV iron group compared with the usual care group (31.25% vs 12.5%). Hb values, although similar at randomization, improved by 0.8 g/dL with IV iron compared with 0.1 g/dL with usual care (P = 0.01) by the day of admission. The IV iron group had higher Hb 4 weeks after discharge compared with the usual care group (1.9 vs 0.9 g/dL, P = 0.01), and a shorter length of stay (7.0 vs 9.7 d, P = 0.026). There was no difference in discharge Hb levels, morbidity, mortality, or quality of life.

CONCLUSIONS

Administration of perioperative IV iron reduces the need for blood transfusion, and is associated with a shorter hospital stay, enhanced restoration of iron stores, and a higher mean Hb concentration 4 weeks after surgery.

Intraoperative transfusion practices in Europe

BACKGROUND

Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe.

METHODS

We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013.

RESULTS

The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl(-1) and increased to 9.8 (1.8) g dl(-1) after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2).

CONCLUSION

Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl(-1)), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold.

CLINICAL TRIAL REGISTRATION

NCT 01604083.

Reduction of red blood cell transfusions by implementation of a concise pretransfusion checklist

BACKGROUND

This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy.

OBJECTIVES

To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm.

METHODS

To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre- and post-implementation period of 1 year.

RESULTS

Transfusion requests decreased by 17·0%. The proportion of 1-unit and 2-unit transfusions decreased by 5·6% and 29·2%, respectively, corresponding with a total red blood cell units reduction of 22·6% and a yearly direct local cost reduction of 190·000 €. The median length of stay of transfused patients on wards decreased by 1·07 days (P < 0·05). Average pre- and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0·32-0·35 g L(-1) (P < 0·05) for one unit red blood cell transfusions and 0·72-0·87 g L(-1) (P < 0·05) for two units of red blood cell transfusions.

CONCLUSION

Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.

[Treatment of anemia in Patient Blood Management from an economic perspective]

The liberal use of transfusions is not only a risk for patients but also represents a significant healthcare expenditure. The rational use of allogeneic blood transfusions and the use of transfusion alternatives, such as the optimization of preoperative hemoglobin levels, can offer substantial savings to health departments by reducing the cost of transfusions and the morbidity related to the transfusions.