Risk-adjusted clinical outcomes in patients enrolled in a bloodless program

Bloodless Gynecological Surgery in Blood Products Refusing Patients: Experience of a Single Institution

Propose

This pilot study aimed to apply the central tenets of bloodless surgery and to analyze the effectiveness of specific preoperative, intraoperative, and postoperative strategies to minimize the risk for blood transfusion after gynecological surgery in a specific group of patients who refused blood products.

Methods

A total of 83 patients undergoing gynecological surgery were included in the study. Forty-two patients received preoperatively oral iron, acid folic, and vitamin B12 supplementation in the 30 days before surgery, and 41 patients did not receive therapy.

Results

No significant differences were found when comparing the two study groups. The implementation of all procedures to maintain a bloodless surgery has been helpful, in association with the other available procedures, in achieving optimal management and maintenance of hemoglobin levels, even in the most critical situations.

Conclusion

In conclusion, implementing the bloodless approach as much as possible could guarantee the patient better and safer clinical and care management. Furthermore, well-designed research is required to clarify further the effects of bloodless surgery in gynecological patients.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Anemia tolerance mechanisms

Understanding the physiological concepts of oxygen delivery is essential to discern the mechanisms that influence its increase, reduction or maintenance in the body. This text explores the different mechanisms that help maintain oxygen delivery even in the face of reduced hemoglobin levels. Adequate oxygen delivery ensures tissue and metabolic balance, which is crucial to avoid harmful consequences such as metabolic acidosis and cellular dysoxia. The complex interaction between variables such as cardiac output, hemoglobin and heart rate (HR) plays a fundamental role in maintaining oxygen delivery, allowing the body to temporarily adjust to situations of anemia or high metabolic demand. It is important to emphasize that blood transfusions should not be based on fixed values, but rather on individual metabolic needs. Strategies to reduce myocardial consumption and monitor macro and micro hemodynamics help in making rational decisions. Individualizing treatment and considering factors such as blood viscosity in relation to the benefits of transfusion are increasingly relevant to optimize therapy and minimize risks, especially in complex clinical scenarios, such as neurocritical patients and trauma victims.

Effectiveness, safety and indications of acute normovolemic haemodilution in total knee arthroplasty

Total knee arthroplasty (TKA) is the most cost-effective, and potent method for the treatment of end-stage knee osteoarthritis. Acute normovolemic haemodilution (ANH) can effectively replace the need for allogeneic transfusions due to the high amount of bleeding during TKA. However, more studies are needed to prove the efficacy and safety of ANH and to clarify its indications in the field of knee replacement. Medical records from June 1, 2019 to June 1, 2021 were searched and grouped according to inclusion and exclusion criteria.

PART I

58 patients with ANH during TKA were selected as the ANH group (n = 58), and 58 patients with allogeneic transfusion were chosen as the control group (n = 58).

PART II

Patients with anaemia were divided into the ANH group (n = 18) and the control group (n = 12).

PART I

The postoperative inflammatory index and serum albumin in the ANH group were significantly lower than those in the control group. No significant difference was observed in the theoretical loss of red blood cells, postoperative renal function, liver function, cardiac function and biochemical ion index between the two groups. The effective rate of ANH in the normal haemoglobin group was significantly lower than that in the anaemia group.

PART II

In patients with anaemia, the theoretical loss of red blood cells in patients with ANH was less than that in the control group. The postoperative inflammation, renal function, liver function and cardiac function in the ANH group were better than those in the control group, and no significant difference was noted in biochemical ions and nutritional status indicators. This paper shows that ANH not only can replace allogeneic transfusion in TKA, especially in patients with anaemia, but also has lower inflammatory indicators than allogeneic transfusion. From a security perspective, the body's tolerance to ANH is within the body's compensation range.

Clinical Outcomes, Blood Utilization, and Ethical Considerations for Pediatric Patients in a Bloodless Medicine and Surgery Program

BACKGROUND

Pediatric patients requesting bloodless care represent a challenging clinical situation, as parents cannot legally refuse lifesaving or optimal interventions for their children. Here, we report clinical outcomes for the largest series of pediatric inpatients requesting bloodless care and also discuss the ethical considerations.

METHODS

We performed a single-institution retrospective cohort study assessing 196 pediatric inpatients (<18 years of age) who requested bloodless care between June 2012 and June 2016. Patient characteristics, transfusion rates, and clinical outcomes were compared between pediatric patients receiving bloodless care and those receiving standard care (including transfusions if considered necessary by the clinical team) (n = 37,271). Families were informed that all available measures would be undertaken to avoid blood transfusions, although we were legally obligated to transfuse blood if the child's life was threatened. The primary outcome was composite morbidity or mortality. Secondary outcomes included percentage of patients transfused, individual morbid events, length of stay, total hospital charges, and total costs. Subgroup analyses were performed after stratification into medical and surgical patients.

RESULTS

Of the 196 pediatric patients that requested bloodless care, 6.1% (n = 12) received an allogeneic blood component, compared to 9.1% (n = 3392) for standard care patients ( P = .14). The most common indications for transfusion were perioperative bleeding and anemia of prematurity. None of the transfusions were administered under a court order. Overall, pediatric patients receiving bloodless care exhibited lower rates of composite morbidity compared to patients receiving standard care (2.6% vs 6.2%; P = .035). There were no deaths in the bloodless cohort. Individual morbid events, length of stay, and total hospital charges/costs were not significantly different between the 2 groups. After multivariable analysis, bloodless care was not associated with a significant difference in composite morbidity or mortality (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.12-1.11; P = .077).

CONCLUSIONS

Pediatric patients receiving bloodless care exhibited similar clinical outcomes compared to patients receiving standard care, although larger studies with adequate power are needed to confirm this finding. There were no mortalities among the pediatric bloodless cohort. Although a subset of our pediatric bloodless patients received an allogeneic transfusion, no patients required a court order. When delivered in a collaborative and patient-centered manner, blood transfusions can be safely limited among pediatric patients.

Management and clinical outcomes for patients with gastrointestinal bleeding who decline transfusion

BACKGROUND

The national blood shortage and growing patient population who decline blood transfusions have created the need for bloodless medicine initiatives. This case series describes the management of gastrointestinal bleed patients who declined allogeneic blood transfusion. Understanding the effectiveness of bloodless techniques may improve treatment for future patients while avoiding the risks and cost associated with transfusion.

STUDY DESIGN AND METHODS

A retrospective chart review identified 30 inpatient encounters admitted between 2016 to 2022 for gastrointestinal hemorrhage who declined transfusion due to religious or personal reasons. Clinical characteristics and patient blood management methods utilized during hospitalization were analyzed. Hemoglobin concentrations and clinical outcomes are reported.

RESULTS

The most common therapy was intravenous iron (n = 25, 83.3%), followed by erythropoietin (n = 18, 60.0%). Endoscopy was the most common procedure performed (n = 23, 76.7%), and surgical intervention was less common (n = 4, 13.3%). Pre-procedure hemoglobin was <6 g/dL in 7 patients, and <5 g/dL in 4 patients. The median nadir hemoglobin was 5.6 (IQR 4.5, 7.0) g/dL, which increased post-treatment to 7.3 (IQR 6.2, 8.4) g/dL upon discharge. One patient (3.3%) with a nadir Hb of 3.7 g/dL died during hospitalization from sepsis. Nine other patients with nadir Hb <5 g/dL survived hospitalization.

CONCLUSIONS

Gastrointestinal bleed patients can be successfully managed with optimal bloodless medicine techniques. Even patients with a nadir Hb <5-6 g/dL can be stabilized with aggressive anemia treatment and may safely undergo anesthesia and endoscopy or surgery for diagnostic or therapeutic purposes. Methods used for treating bloodless medicine patients may be used to improve clinical care for all patients.

Methods of Bloodless Care, Clinical Outcomes, and Costs for Adult Patients Who Decline Allogeneic Transfusions

BACKGROUND

Providing bloodless medical care for patients who wish to avoid allogeneic transfusion can be challenging; however, previous studies have demonstrated favorable outcomes when appropriate methods are used. Here, we report one of the largest series of patients receiving bloodless care, along with the methods used to provide such care, and the resulting outcomes.

METHODS

In a retrospective cohort study, 1111 adult inpatients (age ≥18 years) at a single institution who declined allogeneic transfusion for religious or personal reasons between June 2012 and June 2016 were included, and the patient blood management methods are described. Patient characteristics, laboratory data, and transfusion rates, as well as clinical outcomes (morbidity, mortality, and length of stay) were compared to all other patients in the hospital who received standard care, including transfusions if needed (n = 137,009). Medical and surgical patients were analyzed as subgroups. The primary outcome was composite morbidity (any morbid event: infectious, thrombotic, ischemic, renal, or respiratory). Secondary outcomes included individual morbid events, in-hospital mortality, length of stay, total hospital charges, and costs.

RESULTS

The bloodless cohort had more females and a lower case mix index, but more preadmission comorbidities. Mean nadir hemoglobin during hospitalization was lower in the bloodless (9.7 ± 2.6 g/dL) compared to the standard care (10.1 ± 2.4 g/dL) group (P < .0001). Composite morbidity occurred in 14.4% vs 16.0% (P = .16) of the bloodless and standard care patients, respectively. Length of stay and in-hospital mortality were similar between the bloodless and standard care patients. After Bonferroni adjustment for multiple comparisons, hospital-acquired infection occurred less frequently in the bloodless compared to the standard care cohort (4.3% vs 8.3%) (P < .0001) in the medical patient subgroup, but not in the surgical subgroup. After propensity score adjustment in a multivariable model and adjustment for multiple comparisons, bloodless care was associated with less risk of hospital-acquired infection (OR, 0.56; 95% CI, 0.35-0.83; P = .0074) in the medical subgroup, but not in the surgical subgroup. Median total hospital charges (by 8.5%; P = .0017) and costs (by 8.7%; P = .0001) were lower in the bloodless compared to the standard care cohort, when all patients were included.

CONCLUSIONS

Overall, adult patients receiving bloodless care had similar clinical outcomes compared to patients receiving standard care. Medical (but not surgical) bloodless patients may be at less risk for hospital-acquired infection compared to those receiving standard care. Bloodless care is cost-effective and should be considered as high-value practice.

Operating on Jehovah's Witnesses: A Challenging Surgical Issue

Blood transfusion is often utilized in surgery. Greece is the second-highest consumer of blood components in Europe. It has been shown that at least half of all transfusions are unnecessary and could be avoided. Jehovah's Witnesses (JWs) are a Christian religion that do not accept transfusion of whole blood or the four primary components of blood-namely, red blood cells, white blood cells, platelets, and plasma. This a retrospective study from September of 2015 to January of 2018, analyzing all JWs who underwent an elective operation at the Second Department of Propaedeutic Surgery in Laiko University Hospital. Twenty-nine (Rogers et al. in NCCN Guidelines Version 2.2014 Cancer- and Chemotherapy-Induced Anemia. NCCN Clinical Practice Guidelines in Oncology. National Comprehensive Cancer Network, Fort Washington, 2013) JW patients, 23 females (74.1%) and eight males, were operated on during the aforementioned period. The median ASA score was 1 (range 1-3), and only two of the patients needed postoperative monitoring in the ICU. Almost half of the patients (45.1%) needed iron infusion and EPO injection preoperatively. Two patients presented with postoperative complications, with no postoperative deaths. In conclusion, we found that surgery, in our small group of JW patients, was safe and successful despite the lack of blood transfusion. Techniques developed to treat JW patients should be more widely used to improve clinical outcomes and reduce costs to the healthcare system.

A Global Definition of Patient Blood Management

While patient blood management (PBM) initiatives are increasingly adopted across the globe as part of standard of care, there is need for a clear and widely accepted definition of PBM. To address this, an expert group representing PBM organizations, from the International Foundation for Patient Blood Management (IFPBM), the Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), the Society for the Advancement of Patient Blood Management (SABM), the Western Australia Patient Blood Management (WAPBM) Group, and OnTrac (Ontario Nurse Transfusion Coordinators) convened and developed this definition: "Patient blood management is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient's own blood, while promoting patient safety and empowerment." The definition emphasizes the critical role of informed choice. PBM involves the timely, multidisciplinary application of evidence-based medical and surgical concepts aimed at screening for, diagnosing and appropriately treating anemia, minimizing surgical, procedural, and iatrogenic blood losses, managing coagulopathic bleeding throughout the care and supporting the patient while appropriate treatment is initiated. We believe that having a common definition for PBM will assist all those involved including PBM organizations, hospital administrators, individual clinicians and policy makers to focus on the appropriate issues when discussing and implementing PBM. The proposed definition is expected to continue to evolve, making this endeavor a work in progress.

Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.

Physician autonomy and patient rights: lessons from an enforced blood transfusion and the role of patient blood management

This article provides an ethical and medico-legal analysis of ruling no. 465 of 30 May 2018 issued by the Court of Termini Imerese (Palermo) and confirmed on appeal on 11 November 2020, which, in the absence of similar historical precedents in Europe, convicted a medical doctor of a crime of violent assault for having ordered the administration of a blood transfusion to a patient specifically declining blood transfusion on religious grounds. We analyse the Court's decision regarding the identification of assault in performing the blood transfusion and its decision not to accept exculpatory urgent 'necessity' as a defence. In addition, we present an updated revision of the current standard of care in transfusion medicine as well as the ethical principles governing the patient's declining of transfusion. In doing so, we highlight that respect for the patient's self-determination in declining transfusions and respect for the professional autonomy of the doctor protecting the safety and life of the patient could be equally satisfied by applying the current peer-reviewed evidence.

Pancreatic resections in patients who refuse blood transfusions. The application of a perioperative protocol for a true bloodless surgery

BACKGROUND

The refusal of blood transfusions compels surgeons to face ethical and clinical issues. A single-institution experience with a dedicated perioperative blood management protocol was reviewed to assess feasibility and short-term outcomes of true bloodless pancreatic surgery.

METHODS

The institutional database was reviewed to identify patients who refused transfusion and were scheduled for elective pancreatic surgery from 2010 through 2018. A protocol to optimize the hemoglobin values by administration of drugs stimulating erythropoiesis was systematically used.

RESULTS

Perioperative outcomes of 32 Jehovah's Witnesses patients were included. Median age was 67 years (range, 31-77). Nineteen (59.4%) patients were treated with preoperative erythropoietin. Twenty-four (75%) patients underwent pylorus-preserving pancreaticoduodenectomy, 4 (12.5%) distal pancreatectomy (DP) with splenectomy, 3 (9.4%) spleen-preserving DP, and 1 (3.1%) total pancreatectomy. Median estimated blood loss and surgical duration were 400 mL (range, 100-1000) and 470 min (range, 290-595), respectively. Median preoperative hemoglobin was 13.9 g/dL (range, 11.7-15.8) while median postoperative nadir hemoglobin was 10.5 g/dL (range, 7.1-14.1). The most common histological diagnosis (n = 15, 46.9%) was pancreatic ductal adenocarcinoma. Clavien-Dindo grade I-II complications occurred in fourteen (43.8%) patients while one (3.1%) patient had a Clavien-Dindo grade IIIa complication wich was an abdominal collection that required percutaneous drainage. Six (18.8%) patients presented biochemical leak or postoperative pancreatic fistula grade B. Median hospital stay was 16 days (range, 8-54) with no patient requiring transfusion or re-operation and no 90-day mortality.

CONCLUSIONS

A multidisciplinary approach and specific perioperative management allowed performing pancreatic resections in patients who refused transfusion with good short-term outcomes.

Proceedings From the Society for Advancement of Blood Management Annual Meeting 2017: Management Dilemmas of the Surgical Patient-When Blood Is Not an Option

Vigilance is essential in the perioperative period. When blood is not an option for the patient, especially in a procedure/surgery that normally holds a risk for blood transfusion, complexity is added to the management. Current technology and knowledge has made avoidance of blood transfusion a realistic option but it does require a concerted patient-centered effort from the perioperative team. In this article, we provide suggestions for a successful, safe, and bloodless journey for patients. The approaches include preoperative optimization as well as intraoperative and postoperative techniques to reduce blood loss, and also introduces current innovative substitutes for transfusions. This article also assists in considering and maneuvering through the legal and ethical systems to respect patients' beliefs and ensuring their safety.

Jehovah's Witness Patients: Interventions for Successful Stem Cell Transplantation Without Blood Product Transfusions for Hematologic Malignancies

BACKGROUND

Jehovah's Witnesses are members of a religion that prohibits them from accepting blood product transfusions. This refusal makes them a particularly compelling population in the context of hematologic malignancies and stem cell transplantation, because blood product transfusions are a mainstay of supportive treatment.

OBJECTIVES

This article presents preventive and supportive measures allowing Jehovah's Witness patients the opportunity to receive a stem cell transplantation without blood product transfusions.

METHODS

A literature review was done that included evidence focusing on optimizing hematopoiesis, blood loss prevention, alterations in chemotherapy regimens, and implications for nursing practice.

FINDINGS

With proper preventive and supportive care measures, Jehovah's Witness patients can receive stem cell transplantations for hematologic malignancies without blood product transfusions.

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.

Evolution of Bloodless Surgery: A Case for Bloodless Suprapubic Prostatectomy

Allogeneic blood transfusion is commonly prescribed to patients undergoing suprapubic prostatectomy for benign prostatic hyperplasia as a treatment option to replace blood loss. Historically, suprapubic prostatectomy has been perceived as an extremely high hemorrhagic surgery, and this has led to the association of suprapubic prostatectomy with a high rate of allogeneic blood transfusion. However, the outcome of suprapubic prostatectomy has significantly improved over the years and has become less hemorrhagic in many hands - creating the opportunity to consistently avoid allogeneic blood transfusion. On the other hand, the efficacy of blood transfusion has come under more stringent scrutiny as many clinical studies have reported inconsistent effects of blood transfusion on patient outcome. In contemporary practice, a more conservative/bloodless approach in the perioperative management of anemia in surgical patients is strongly being advocated with convincing evidence that many surgical patients can be routinely and safely managed without allogeneic blood transfusion. There is no large-scale discussion on bloodless surgery in urology in the contemporary literature, especially in the area of suprapubic prostatectomy that has been historically associated with a high rate of blood transfusion. This review article will discuss the evolution of bloodless surgery including the ongoing controversies surrounding blood transfusion in general, and then the relatively small but ongoing penetration of bloodless surgical approach in the field of suprapubic prostatectomy. Furthermore, the authors' approach to bloodless suprapubic prostatectomy will be highlighted, and in doing so, it can be emphasized that suprapubic prostatectomy is no more as hemorrhagic as was historically perceived, but rather a routine bloodless suprapubic prostatectomy is now possible in many hands.

Cost-equivalence and Pluralism in Publicly-funded Health-care Systems

Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients' right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence (CE), as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to (or cheaper than) the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment.

Transfusion of Red Blood Cells Stored More Than 28 Days is Associated With Increased Morbidity Following Spine Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to describe the association between storage duration of packed red blood cells (PRBCs) and perioperative adverse events in patients undergoing spine surgery at a tertiary care center.

SUMMARY OF BACKGROUND DATA

Despite retrospective studies that have shown that longer PRBC storage duration worsens patient outcomes, randomized clinical trials have found no difference in outcomes. However, no studies have examined the impact of giving the oldest blood (28 days old or more) on morbidity within spine surgery.

METHODS

The surgical administrative database at our institution was queried for patients transfused with PRBCs who underwent spine surgery between December 4, 2008, and June 26, 2015. Patients undergoing spinal fusion, tumor-related surgeries, and other identified spine surgeries were included. Patients were divided into two groups on the basis of storage duration of blood transfused: exclusively ≤28 days' storage or exclusively >28 days' storage. The primary outcome was composite in-hospital morbidity, which included (1) infection, (2) thrombotic event, (3) renal injury, (4) respiratory event, and/or (5) ischemic event.

RESULTS

In total, 1141 patients who received a transfusion were included for analysis in this retrospective study; 710 were transfused exclusively with PRBCs ≤28 days' storage and 431 exclusively with PRBCs >28 days' storage. Perioperative complications occurred in 119 patients (10.4%). Patients who received blood stored for >28 days had higher odds of developing any one complication [odds ratio (OR) = 1.82; 95% confidence interval (95% CI), 1.20-2.74; P = 0.005] even after adjusting for competing perioperative risk factors.

CONCLUSION

Blood stored for >28 days is independently associated with higher odds of developing perioperative complications in patients transfused during spinal surgery. Our results suggest that blood storage duration may be an appropriate parameter to consider when developing institutional transfusion guidelines that seek to optimize patient outcomes.

LEVEL OF EVIDENCE

3.

Pharmacotherapy in Acutely Anemic Jehovah’s Witnesses: An Evidence-Based Review

Objective: To determine the pharmacological treatment methods available to anemic Jehovah’s Witnesses (JW). Data Sources: MEDLINE and PubMed were searched from inception through February 2018 using the search terms Jehovah’s Witnesses, treatment, erythropoietin, hemoglobin-based oxygen carrier, Sanguinate, Hemopure, bleeding, and anemia. Study Selection and Data Extraction: All clinical trials, cohort studies, case-control studies, and observational trials involving pharmacotherapy in anemic JW patients were evaluated. Case reports and bibliographies were also analyzed for inclusion. Data Synthesis: Two studies involving the use of erythropoietin (EPO) and one study involving recombinant factor VIIa were included. Information was also included from other pharmacotherapeutic modalities that had case report data only. Current published evidence is limited with regard to evidence-based management of JW patients. High-dose EPO, intravenous iron supplementation, and hemostatic agents have demonstrated good clinical outcomes in case reports. EPO doses as high as 40 000 units daily have been advocated by some experts; however, pharmacokinetic studies do not support dose-dependent effects. Hemoglobin-based oxygen carriers (HBOCs) are currently not Food and Drug Administration approved. They are available through expanded access programs and may represent a lifesaving modality in the setting of severe anemia. Conclusions: There are currently not enough data to make definitive recommendations on the use of pharmacological agents to treat severe anemia in the JW population. Further evidence utilizing EPO and HBOCs will be beneficial to guide therapy.

High-dose Versus Low-dose Tranexamic Acid to Reduce Transfusion Requirements in Pediatric Scoliosis Surgery

BACKGROUND

Our objective was to quantify blood loss and transfusion requirements for high-dose and low-dose tranexamic acid (TXA) dosing regimens in pediatric patients undergoing spinal fusion for correction of idiopathic scoliosis. Previous investigators have established the efficacy of TXA in pediatric scoliosis surgery; however, the dosing regimens vary widely and the optimal dose has not been established.

METHODS

We retrospectively analyzed electronic medical records for 116 patients who underwent spinal fusion surgery for idiopathic scoliosis by a single surgeon and were treated with TXA. In total, 72 patients received a 10 mg/kg loading dose with a 1 mg/kg/h maintenance dose (low-dose) and 44 patients received 50 mg/kg loading dose with a 5 mg/kg/h maintenance dose (high-dose). Estimated blood loss and transfusion requirements were compared between dosing groups.

RESULTS

Patient characteristics were nearly identical between the 2 groups. Compared with the low-dose TXA group, the high-dose TXA group had decreased estimated blood loss (695 vs. 968 mL, P=0.01), and a decrease in both intraoperative (0.3 vs. 0.9 units, P=0.01) and whole hospitalization (0.4 vs. 1.0 units, P=0.04) red blood cell transfusion requirements. The higher-dose TXA was associated with decreased intraoperative (P=0.01), and whole hospital transfusion (P=0.01) requirements, even after risk-adjustment for potential confounding variables.

CONCLUSIONS

High-dose TXA is more effective than low-dose TXA in reducing blood loss and transfusion requirements in pediatric idiopathic scoliosis patients undergoing surgery.

LEVEL OF EVIDENCE

Level-III, retrospective cohort study.

Treatment of individuals who cannot receive blood products for religious or other reasons

By virtue of their religious principles, Jehovah's Witnesses (JWs) generally object to receiving blood products, raising numerous ethical, legal, and medical challenges for providers who care for these patients, especially in the emergent setting. In this review, we discuss several areas relevant to the care of JWs, including the current literature on "bloodless" medical care in the setting of perioperative and intraoperative management, acute blood loss, trauma, pregnancy, and malignancy. We have found that medical and administrative efforts in the form of bloodless medicine and surgery programs can be instrumental in helping to reduce risks of morbidity and mortality in these patients. Planning prior to an anticipated event associated with blood loss or anemia (such as elective surgery, pregnancy, and chemotherapy) is critical. Specifically, bloodless medicine programs should prioritize vigilant early screening and management of anemias, early establishment of patient wishes regarding transfusion, and the incorporation of those wishes into multidisciplinary medical and surgical care. Although there are now a variety of human-based and nonhuman-based products available as transfusion alternatives, the degree and quality of evidence to support their use varies significantly between products and is also largely dependent on the clinical setting.

Thrombotic and Infectious Morbidity Are Associated with Transfusion in Posterior Spine Fusion

BACKGROUND

Although previous investigators have established an association between blood transfusion and adverse outcomes, the relative frequency of different morbid events and the association with transfusion dose are not well understood.

QUESTIONS/PURPOSES

The purpose of the study is to characterize the relationship between blood transfusion and different types of morbidity after posterior spine fusion.

METHODS

We retrospectively analyzed electronic medical records for 963 patients who underwent posterior spinal fusion surgery at a single institution, of which 603 (62.6%) received an allogeneic blood transfusion. Then, we assessed patient and surgical characteristics in a risk-adjusted fashion to identify various morbid event rates and independent predictors in these adverse outcomes.

RESULTS

Compared to the non-transfused patients, transfused patients had a higher incidence of any morbid event (9.1 vs. 2.5%. P < 0.0001), thrombotic events (4.6 vs. 1.1%, P = 0.0025), and hospital-acquired infections (2.3 vs. 0.6%, P = 0.039). Renal, respiratory, and ischemic morbidity occurred less frequently and were not more common in transfused patients. Risk-adjusted analysis revealed a dose-response effect, whereby for each unit of allogeneic blood transfused, the risks of any morbid event (OR 1.183; 95% CI 1.103-1.274; P < 0.0001), thrombotic complication (OR 1.104; 95% CI 1.032-1.194; P = 0.0035), and infectious complication (OR 1.182; 95% CI 1.077-1.332; P = 0.0002) were increased.

CONCLUSION

Our data demonstrate risk-adjusted and transfusion dose-related increases in perioperative morbidity, with thrombotic and infectious events being the most common.

Outcomes of Protocol-Driven Care of Critically Ill Severely Anemic Patients for Whom Blood Transfusion Is Not an Option

OBJECTIVE

To compare the outcomes of severely anemic critically ill patients for whom transfusion is not an option ("bloodless" patients) with transfused patients.

DESIGN

Cohort study with propensity score matching.

SETTING

ICU of a referral center.

PATIENTS

One hundred seventy-eight bloodless and 441 transfused consecutive severely anemic, critically ill patients, admitted between May 1996 and April 2011, and having at least one hemoglobin level less than or equal to 8 g/dL within 24 hours of ICU admission. Patients with diagnosis of brain injury, acute myocardial infarction, or status postcardiac surgery were excluded.

INTERVENTIONS

Allogeneic RBC transfusion during ICU stay.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was in-hospital mortality. Other outcomes were ICU mortality, readmission to ICU, new electrocardiographic or cardiac enzyme changes suggestive of cardiac ischemia or injury, and new positive blood culture result. Transfused patients were older, had higher hemoglobin level at admission, and had higher Acute Physiology and Chronic Health Evaluation II score. Hospital mortality rates were 24.7% in bloodless and 24.5% in transfused patients (odds ratio, 1.01; 95% CI, 0.68-1.52; p = 0.95). Adjusted odds ratio of hospital mortality was 1.52 (95% CI, 0.95-2.43; p = 0.08). No significant difference in ICU readmission or positive blood culture results was observed. Analysis of propensity score-matched cohorts provided similar results.

CONCLUSIONS

Overall risk of mortality in severely anemic critically ill bloodless patients appeared to be comparable with transfused patients, albeit the latter group had older age and higher Acute Physiology and Chronic Health Evaluation II score. Use of a protocol to manage anemia in these patients in a center with established patient blood management and bloodless medicine and surgery programs is feasible and likely to contribute to improved outcome, whereas more studies are needed to better delineate the impact of such programs.

Longer average blood storage duration is associated with increased risk of infection and overall morbidity following radical cystectomy

BACKGROUND

Patients with bladder cancer undergoing radical cystectomy (RC) experience high rates of perioperative blood transfusions (PBTs) and morbidity. The aim of this study was to evaluate the effect of blood storage duration on the risk of adverse perioperative outcomes in this high-risk patient population.

MATERIALS AND METHODS

In a retrospective review of RC patients from 2010 to 2014 who received PBTs, the average storage duration for all units transfused was used to classify patients as receiving older blood using 3 different definitions (≥21 days,≥28 days, and≥35 days). Multivariable Poisson regression models were used to determine the adjusted relative risk of perioperative infections and overall morbidity in those given older blood compared to fresher blood.

RESULTS

Of the 451 patients undergoing RC, 205 (45%) received nonirradiated PBTs. In multivariable modeling, increasing average blood storage duration, as a continuous variable, was associated with an increased risk of infections (risk ratio [RR] = 1.08 per day, 95% CI: 1.01-1.17) and overall morbidity (RR = 1.08 per day, 95% CI: 1.01-1.15). Furthermore, ≥28-day blood storage (vs.<28) was associated with increased infections (RR = 2.69, 95% CI: 1.18-6.14) and morbidity (RR = 2.54, 95% CI: 1.31-4.95), and ≥35-day blood storage (vs.<35) was also associated with increased infections (RR = 2.83, 95% CI: 1.42-5.66) and morbidity (RR = 3.35, 95% CI: 1.95-5.77).

CONCLUSIONS

Although blood is stored up to 42 days, storage≥28 days may expose RC patients to increased perioperative infections and overall morbidity compared with storage<28 days. Prospective cohort studies are warranted in cystectomy and other high-risk surgical oncology patients to better determine the effect of blood storage duration.

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.

Major thoracic surgery in Jehovah's witness: A multidisciplinary approach case report

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Bloodless surgery multidisciplinary approach.

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Management of Jehovah's witness patient.

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Patient-centered blood products use.

Introduction

A bloodless surgery can be desirable also for non Jehovah’s witnesses patients, but requires a team approach from the very first assessment to ensure adequate planning.

Presentation of the case

Our patient, a Jehovah’s witnesses, was scheduled for right lower lobectomy due to pulmonary adenocarcinoma. Her firm denies to receive any kind of transfusions, forced clinicians to a bloodless management of the case.

Discussion

Before surgery a meticulous coagulopathy research and hemodynamic optimization are useful to prepare patient to operation. During surgery, controlled hypotension can help to obtain effective hemostasis. After surgery, clinicians monitored any possible active bleeding, using continuous noninvasive hemoglobin monitoring, limiting the blood loss due to serial in vitro testing. The optimization of cardiac index and delivery of oxygen were continued to grant a fast recovery.

Conclusion

Bloodless surgery is likely to gain popularity, and become standard practice for all patients. The need for transfusion should be targeted on individual case, avoiding strictly fixed limit often leading to unnecessary transfusion.

Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery

BACKGROUND

The effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures.

METHODS

Patients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity.

RESULTS

Among 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3-4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98-1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88-1.22; P = 0.65).

CONCLUSIONS

Liberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.

Hemoglobin thresholds for transfusion in pediatric patients at a large academic health center

BACKGROUND

Although prior studies support the use of a hemoglobin (Hb) transfusion trigger of 7 to 8 g/dL for most hospitalized adults, there are few studies in pediatric populations. We therefore investigated transfusion practices and Hb triggers in hospitalized children.

STUDY DESIGN AND METHODS

We performed a historical cohort study comparing transfusion practices in hospitalized children by service within a single academic institution. Blood utilization data from transfused patients (n = 3370) were obtained from electronic records over 4 years. Hb triggers and posttransfusion Hb levels were defined as the lowest and last Hb measured during hospital stay, respectively, in transfused patients. The mean and percentile distribution for Hb triggers were compared to the evidence-based restrictive transfusion threshold of 7 g/dL.

RESULTS

Mean Hb triggers were above the restrictive trigger (7 g/dL) for eight of 12 pediatric services. Among all of the services, there were significant differences between the mean Hb triggers (>2.5 g/dL, p<0.0001) and between the posttransfusion Hb levels (>3 g/dL, p < 0.0001). The variation between the 10th and 90th percentiles for triggers (up to 4 g/dL, p < 0.0001) and posttransfusion Hb levels (up to 6 g/dL, p < 0.0001) were significant. Depending on the service, between 25 and 90% of transfused patients had Hb triggers higher than the restrictive range.

CONCLUSIONS

Red blood cell (RBC) transfusion therapy varies significantly in hospitalized children with mean Hb triggers above a restrictive threshold for most services. Our findings suggest that transfusions may be overused and that implementing a restrictive transfusion strategy could decrease the use of RBC transfusions, thereby reducing the associated risks and costs.

Should we restrict erythrocyte transfusion in early goal directed protocols?

BACKGROUND

Early goal-directed therapy has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy among patients presenting with severe sepsis or septic shock. But more importantly, early goal-directed therapy also became standard care for non-septic critically ill patients and was adopted for high-risk surgical patients.

DISCUSSION

Importantly, transfusion of red blood cells is a central part of many protocols of early goal-directed therapy to indicate the need for use of inotropes and red blood cells, as both central venous saturation and hematocrit are used as transfusion triggers. However, burgeoning data has strongly linked transfusion with worse clinical outcomes. If correct, could these early goal-directed therapy 'bundles' have better outcome if a restrictive transfusion practice is adopted?

SUMMARY

Early goal-directed therapy has evolved as standard care for most of critically ill patients, and many protocols contain transfusion of red blood cells targeting high hemoglobin level as a key element. As red blood cell transfusions are associated with increased morbidity and mortality, transfusion thresholds need to be more individualized.