1
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Lau FF, Agerskov M, Thusholdt ANW, Højlund J, Meyhoff CS, Jans Ø, Foss NB. Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study. J Clin Anesth 2024; 95:111472. [PMID: 38613938 DOI: 10.1016/j.jclinane.2024.111472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/20/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
STUDY OBJECTIVE Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. DESIGN Multicenter cohort study. SETTING Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. PATIENTS We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. INTERVENTIONS No interventions were carried out. MEASUREMENTS Principal values collected included measurements of peripheral perfusion index and hemoglobin values. METHODS The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. MAIN RESULTS We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62-5.45]) and 90-day mortality (3.13, [1.45-7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57-162.10]). CONCLUSION High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.
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Affiliation(s)
- Frederik F Lau
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Marianne Agerskov
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna N W Thusholdt
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Øivind Jans
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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2
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Song KH, Choi ES, Kim HY, Ahn KH, Kim HJ. Patient blood management to minimize transfusions during the postpartum period. Obstet Gynecol Sci 2023; 66:484-497. [PMID: 37551109 PMCID: PMC10663398 DOI: 10.5468/ogs.22288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 01/11/2023] [Accepted: 07/20/2023] [Indexed: 08/09/2023] Open
Abstract
Patient blood management is an evidence-based concept that seeks to minimize blood loss by maintaining adequate hemoglobin levels and optimizing hemostasis during surgery. Since the coronavirus disease 2019 pandemic, patient blood management has gained significance due to fewer blood donations and reduced amounts of blood stored for transfusion. Recently, the prevalence of postpartum hemorrhage (PPH), as well as the frequency of PPH-associated transfusions, has steadily increased. Therefore, proper blood transfusion is required to minimize PPH-associated complications while saving the patient's life. Several guidelines have attempted to apply this concept to minimize anemia during pregnancy and bleeding during delivery, prevent bleeding after delivery, and optimize recovery methods from anemia. This study systematically reviewed various guidelines to determine blood loss management in pregnant women.
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Affiliation(s)
- Kwan Heup Song
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Eun Saem Choi
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Ho Yeon Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
| | - Ki Hoon Ahn
- Department of Obstetrics and Gynecology, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Hai Joong Kim
- Department of Obstetrics and Gynecology, Korea University Ansan Hospital, Seoul,
Korea
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3
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Ivascu Girardi N, Cushing MM, Evered LA, Benedetto U, Schwann TA, Kurlansky P, Habib RH, Gaudino MFL. Incidence and Impact of a Single-Unit Red Blood Cell Transfusion: Analysis of The Society of Thoracic Surgeons Database 2010-2019. Ann Thorac Surg 2023; 115:1035-1041. [PMID: 36528125 DOI: 10.1016/j.athoracsur.2022.11.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND As the adverse effects of blood transfusions are better understood, recommendations support single-unit red blood cell (RBC) transfusions (SRBCT). However, an isolated SRBCT across the entire index admission suggests even the single unit may be avoidable. We sought to identify the characteristics of cardiac surgery patients receiving an isolated SRBCT and analyze the impact on outcomes. METHODS The Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried for the period between January 1, 2010, and December 31, 2019. Patients aged >18 years undergoing isolated coronary artery bypass grafting or isolated aortic valve replacement were included. A total of 2,151,430 encounters were analyzed. RESULTS Of the 847,442 patients (39.3%) receiving any RBC transfusion during their index admission, 206,555 (24.4%) received only 1 unit. Propensity-matching analysis determined SRBCT patients were significantly older (67.26 vs 64.02 years; odds ratio [OR], 1.02; P < .001), female (39.1% vs 17.8%; OR, 1.57; P < .001), non-White (18.2% vs 13.1%; OR, 0.81; P < .001), and had a smaller body surface area (1.94 vs 2.07 m2; OR, 0.20; P < .001). They also had higher mortality (1.4% vs 1.0%, P < .001), stroke (1.7% vs 1.2%, P < .001), prolonged ventilation (6.4% vs 3.4%, P < .001), renal failure (1.8% vs 0.9%, P < .001), and reoperations (1.3% vs. 0.5%, P < .001) than patients who received 0 RBCs. CONCLUSIONS SRBCT is a common occurrence in adult cardiac surgery. This low-volume transfusion is strongly associated with higher morbidity, even after controlling for preoperative risk factors.
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Affiliation(s)
| | - Melissa M Cushing
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York; Department of Pathology, Weill Cornell Medical College, New York, New York
| | - Lisbeth A Evered
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Umberto Benedetto
- Department of Cardiac Surgery, University "G. d'Annunzio," Pescara, Italy
| | - Thomas A Schwann
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Chan Medical School, Baystate Medical Center, Boston, Massachusetts
| | - Paul Kurlansky
- Department of Surgery, Columbia University College of Physician and Surgeons, New York, New York
| | - Robert H Habib
- The Society of Thoracic Surgeons Research Center, Chicago, Illinois
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medical College, New York, New York
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4
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Delaforce A, Farmer S, Duff J, Munday J, Miller K, Glover L, Corney C, Ansell G, Gutta N, Tuffaha H, Hardy J, Hurst C. Results from a type two hybrid-effectiveness study to implement a preoperative anemia and iron deficiency screening, evaluation, and management pathway. Transfusion 2023; 63:724-736. [PMID: 36807584 DOI: 10.1111/trf.17287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 12/29/2022] [Accepted: 01/13/2023] [Indexed: 02/23/2023]
Abstract
BACKGROUND Implementation of pathways to screen surgical patients for preoperative anemia and iron deficiency remains limited. This study sought to measure the impact of a theoretically informed, bespoke change package on improving the uptake of a Preoperative Anemia and Iron Deficiency Screening, Evaluation, and Management Pathway. STUDY DESIGN AND METHODS Pre-post interventional study using a type two hybrid-effectiveness design evaluated implementation. Four hundred (400) patient medical record reviews provided the dataset (200 pre- and 200-post implementation). The primary outcome measure was compliance with the pathway. Secondary outcome measures (clinical outcomes) were anemia on day of surgery, exposure to a red blood cell (RBC) transfusion, and hospital length of stay. Validated surveys facilitated data collection of implementation measures. Propensity score-adjusted analyses determined the effect of the intervention on clinical outcomes, and a cost analysis determined the economic impact. RESULTS For the primary outcome, compliance improved significantly post-implementation (Odds Ratio 10.6 [95% CI 4.4-25.5] p < .000). In secondary outcomes, adjusted analyses point estimates showed clinical outcomes were slightly improved for anemia on day of surgery (Odds Ratio 0.792 [95% CI 0.5-1.3] p = .32), RBC transfusion (Odds Ratio 0.86 [95% CI 0.41-1.78] p = .69) and hospital length of stay (Hazard Ratio 0.96 [95% CI 0.77-1.18] p = .67), although these were not statistically significant. Cost savings of $13,340 per patient were realized. Implementation outcomes were favorable for acceptability, appropriateness, and feasibility. CONCLUSION The change package significantly improved compliance. The absence of a statistically significant change in clinical outcomes may be because the study was powered to detect an improvement in compliance only. Further prospective studies with larger samples are needed. Cost savings of $13,340 per patient were achieved and the change package was viewed favorably.
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Affiliation(s)
- Alana Delaforce
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, New South Wales, Australia.,Mater Health Services, South Brisbane, Queensland, Australia.,Mater Research Institute-UQ, South Brisbane, Queensland, Australia
| | - Shannon Farmer
- Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia.,Discipline of Surgery, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Jed Duff
- School of Nursing and Midwifery, The University of Newcastle, Callaghan, New South Wales, Australia.,Centre for Healthcare Transformation/ School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Judy Munday
- Centre for Healthcare Transformation/ School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia.,Faculty of Health and Nursing Science, The University of Agder, Kristiansand, Norway
| | - Kristin Miller
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Lynne Glover
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Chris Corney
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Gareth Ansell
- Mater Health Services, South Brisbane, Queensland, Australia.,School of Clinical Medicine-Mater Clinical Unit, The University of Queensland, St Lucia, Queensland, Australia
| | - Naadir Gutta
- Mater Health Services, South Brisbane, Queensland, Australia.,School of Clinical Medicine-Mater Clinical Unit, The University of Queensland, St Lucia, Queensland, Australia
| | - Haitham Tuffaha
- Centre for the Business and Economics of Health, The University of Queensland, St Lucia, Queensland, Australia
| | - Janet Hardy
- Mater Health Services, South Brisbane, Queensland, Australia.,Mater Research Institute-UQ, South Brisbane, Queensland, Australia
| | - Cameron Hurst
- QIMR Berghoffer Medical Research Institute, Brisbane, Queensland, Australia
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5
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Morse B, Anstett T, Mistry N, Porter S, Pincus S, Lin CT, Novins-Montague S, Ho PM. User-Centered Design to Reduce Inappropriate Blood Transfusion Orders. Appl Clin Inform 2023; 14:28-36. [PMID: 36630999 PMCID: PMC9833954 DOI: 10.1055/s-0042-1759866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To improve blood transfusion practices, we applied user-centered design (UCD) to evaluate potential changes to blood transfusion orders. OBJECTIVES The aim of the study is to build effective transfusion orders with different designs to improve guideline adherence. METHODS We developed three different versions of transfusion orders that varied how information was presented to clinicians ordering blood transfusions. We engaged 14 clinicians (residents, advanced practice providers [APPs], and attending physicians) from different specialties. We used the think aloud technique and rapid qualitative analysis to generate themes to incorporate into our modified orders. RESULTS Most end-users who participated in the semi-structured interviews preferred the interruptive alert design plus behavioral nudges (n = 8/14, 57%). The predominant rationale was that the in-line alert was not visually effective in capturing the end-user's attention, while the interruptive alert forced a brief stop in the workflow to consider the guidelines. All users supported the general improvements, though for different reasons, and as a result, the general improvements remained in the designs for the forthcoming trial. CONCLUSION The user experience uncovered through the think aloud approach produced a clear and rich understanding of potentially confounding factors in the initial design of different intervention versions. Input from end-users guided the creation of all three designs so each was addressing human factors with parity, which ensured that the results of our study reflected differences in interruptive properties of the alerts and not differences in design.
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Affiliation(s)
- Brad Morse
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States,Address for correspondence Brad Morse, PhD, MA Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine1890 N Revere Ct, Aurora, CO 80045United States
| | - Tyler Anstett
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Neelam Mistry
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Samuel Porter
- Department of Medicine, Division Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Sharon Pincus
- Adult & Child Center for Outcomes Research & Delivery Science/The NavLab, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Chen-Tan Lin
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Sylvie Novins-Montague
- Adult & Child Center for Outcomes Research & Delivery Science/The NavLab, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - P. Michael Ho
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, United States
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6
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Schneider AB, Adams U, Gallaher J, Purcell LN, Raff L, Eckert M, Charles A. Blood Utilization and Thresholds for Mortality Following Major Trauma. J Surg Res 2023; 281:82-88. [PMID: 36122473 DOI: 10.1016/j.jss.2022.08.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/18/2022] [Accepted: 08/19/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Blood loss is a hallmark of traumatic injury. Massive transfusion, historically defined as the replacement by transfusion of 10 units of packed red blood cells (PRBCs) in 4 h, is a response to uncontrolled hemorrhage. We sought to identify blood transfusion thresholds in which predicted mortality exceeds 50%. METHODS We analyzed the 2017-2019 National Trauma Database. Inclusion criteria included patients ≥18 y who received ≥1 unit of PRBCs. Statistical analysis included bivariate analysis, logistic regression for mortality, and adjusted predicted probability modeling was utilized. RESULTS We identified 61,676 patients for analysis. The 50% predicted mortality for all patients was 31 PRBC units. The 50% predicted mortality was 6 units of PRBCs for elderly trauma patients 80 y and older. CONCLUSIONS Blood remains as scarce resource in hospitals especially with trauma. Patients receiving a massive transfusion over a short period of time may exhaust blood bank supply with diminishing survival benefit. Surgeons should be judicious regarding continued blood usage once the 50% predicted mortality threshold is reached.
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Affiliation(s)
- Andrew B Schneider
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Ursula Adams
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Jared Gallaher
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Laura N Purcell
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Lauren Raff
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Matthew Eckert
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Anthony Charles
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina.
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7
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Leal R, Lança F. Comparison of European recommendations about patient blood management in postpartum haemorrhage. Transfus Med 2022; 33:103-112. [PMID: 36330726 DOI: 10.1111/tme.12927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 09/07/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Abstract
Postpartum haemorrhage (PPH) is the leading cause of maternal mortality and morbidity worldwide. Some documents with practical recommendations for the management of PPH do not include the most updated directives. This review offers a quality comparison of the recommendations stated in Europe since 2015. A literature search was conducted to identify the documents published in Europe from 2015 to 2020 containing recommendations about management of PPH. The search returned 10 publications. A narrative synthesis and a summary of the information about PPH definition and its management were performed. Differences in the definition of PPH were identified: some documents considered the delivery procedure, and many publications included severity criteria. The therapeutic goal for red blood cells transfusion ranged from 6 to 9 g/dl. There were divergences in the need for considering haemostatic results before fresh frozen plasma transfusion. The therapeutic goal of platelet transfusion ranged from 50 x 109 to 100 x 109 μ/L. There was a wide consensus about the therapeutic goal of fibrinogen replacement (>2 g/L), but not about its use in an unmonitored or pre-emptive manner. Most publications included therapeutic approaches such as tranexamic acid and recombinant factor VII activated, but not prothrombin complex concentrate or coagulation factor XIII. The recommendations about PPH management offered in European documents are heterogeneous and have changed over time. The standardisation of all them could be useful to make progress in PPH clinical management and research which, in turn, could strongly impact in patient outcomes.
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Affiliation(s)
| | - Filipa Lança
- Anesthesiology Department Centro Hospitalar Lisboa Norte Lisbon Portugal
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8
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Trentino KM, Leahy MF, Erber WN, Mace H, Symons K, Budgeon CA, Murray K. Hospital-Acquired Infection, Length of Stay, and Readmission in Elective Surgery Patients Transfused 1 Unit of Red Blood Cells: A Retrospective Cohort Study. Anesth Analg 2022; 135:586-591. [PMID: 35977367 DOI: 10.1213/ane.0000000000006133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Most patients transfused red blood cells in elective surgery receive small volumes of blood, which is likely to be discretionary and avoidable. We investigated the outcomes of patients who received a single unit of packed red blood cells during their hospital admission for an elective surgical procedure when compared to those not transfused. METHODS This retrospective cohort study included elective surgical admissions to 4 hospitals in Western Australia over a 6-year period. Participants were included if they were at least 18 years of age and were admitted for elective surgery between July 2014 and June 2020. We compared outcomes of patients who had received 1 unit of red blood cells to patients who had not been transfused. To balance differences in patient characteristics, we weighted our multivariable regression models using the inverse probability of treatment. In addition to propensity score weighting, our multivariable regression models adjusted for hemoglobin level, surgical procedure, patient age, gender, comorbidities, and the transfusion of fresh-frozen plasma or platelets. Outcomes studied were hospital-acquired infection, hospital length of stay, and all-cause emergency readmissions within 28 days. RESULTS Overall, 767 (3.2%) patients received a transfusion of 1 unit of red blood cells throughout their admission. In the propensity score weighted analysis, the transfusion of a single unit of red blood cells was associated with higher odds of hospital-acquired infection (odds ratio, 3.94; 95% confidence interval [CI], 2.99-5.20; P < .001). Patients who received 1 unit of red blood cells throughout their admission were more likely to have a longer hospital stay (rate ratio, 1.57; 95% CI, 1.51-1.63; P < .001) and had 1.42 (95% CI, 1.20-1.69; P < .001) times higher odds of 28-day readmission. CONCLUSIONS These results suggest that avoidance of even small volumes of packed red blood cells may prevent adverse clinical outcomes. This may encourage hospital administrators to implement strategies to avoid the transfusion of even small volumes of red blood cells by applying patient blood management practices.
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Affiliation(s)
- Kevin M Trentino
- From the School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia.,Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology
| | - Wendy N Erber
- School of Biomedical Sciences, The University of Western Australia, Perth, Western Australia, Australia.,PathWest Laboratory Medicine, Nedlands, Western Australia, Australia
| | - Hamish Mace
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Kylie Symons
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Charley A Budgeon
- From the School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Kevin Murray
- From the School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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9
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Saporito A, La Regina D, Hofmann A, Ruinelli L, Merler A, Mongelli F, Trentino KM, Ferrari P. Perioperative inappropriate red blood cell transfusions significantly increase total costs in elective surgical patients, representing an important economic burden for hospitals. Front Med (Lausanne) 2022; 9:956128. [PMID: 36111110 PMCID: PMC9468475 DOI: 10.3389/fmed.2022.956128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 08/12/2022] [Indexed: 01/28/2023] Open
Abstract
Background Red blood cell (RBC) transfusions in surgical patients are associated with increased morbidity a hospital stay. However, little is known about how clinical and economic outcomes differ between appropriately and inappropriately transfused patients. We hypothesized that inappropriate RBC transfusions in elective surgical patients would significantly increase hospital cost. The aim of this study was to quantify the economic burden associated with inappropriate RBC transfusions. Methods We retrospectively included all adult patients admitted for elective non-cardiac surgery between January 2014 and March 2020. Patients were divided into three groups (not transfused, appropriately transfused and inappropriately transfused). The primary outcome was the excess in hospital cost in patients inappropriately transfused compared to non-transfused patients. Costs were calculated using a bottom–up approach and involving cost calculation on a granular level. According to international guidelines, transfusions were considered appropriate if administered with an ASA score of 1–2 and the last hemoglobin level measured before transfusion < 70 g/L, or with an ASA score ≥ 3 and the last hemoglobin level < 80 g/L. Cases where RBC transfusions were deemed necessary regardless of the Hb levels were reviewed by the patient blood management (PBM) board and classified accordingly. Secondary outcomes included total transfusion rate, transfusion index, and length of hospital stay. Statistical analysis was carried out by multivariable regression models. Results During the study period there were 54,922 consecutive surgical admissions, of these 1,997 received an RBC transfusion, with 1,125 considered inappropriate. The adjusted cost of each inappropriate RBC transfusions was estimated in United States dollars (USD) 9,779 (95% CI, 9,358 – 10,199; p < 0.001) and totaled USD 11,001,410 in our series. Inappropriately transfused patients stayed 1.6 times (95% CI, 1.5–1.6; p < 0.001) longer in hospital (10.6 days vs. 6.7 days) than non-transfused patients and a mean 2.35 RBC units per patient were administered. Conclusion Inappropriate RBC transfusions in elective surgical patients seem to be common and may represent a significant economic burden. In our experience, inappropriate transfusions significantly increased hospital costs by an average of USD 9,779 compared to non-transfused patients. Through specific PBM policy, hospitals may improve cost-effectiveness of their elective surgical activity by lowering inappropriate transfusions.
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Affiliation(s)
- Andrea Saporito
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Division of Anesthesiology, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Davide La Regina
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Department of Surgery, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Axel Hofmann
- Institute of Anesthesiology, University Hospital of Zurich, Zurich, Switzerland
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Lorenzo Ruinelli
- Information and Communications Technology Unit, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Alessandro Merler
- Information and Communications Technology Unit, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Francesco Mongelli
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Department of Surgery, Bellinzona e Valli Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- *Correspondence: Francesco Mongelli,
| | - Kevin M. Trentino
- Medical School, University of Western Australia, Perth, WA, Australia
| | - Paolo Ferrari
- Faculty of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
- Division of Nephrology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Clinical School, University of New South Wales, Sydney, NSW, Australia
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10
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Knowledge from the Noise: A Regression Discontinuity Design to Inform Optimal Transfusion Thresholds for Critically Ill Patients. Ann Am Thorac Soc 2022; 19:1099-1101. [PMID: 35772100 PMCID: PMC9278634 DOI: 10.1513/annalsats.202203-259ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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11
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Hofmann A, Aapro M, Fedorova TA, Zhiburt YB, Snegovoy AV, Kaganov OI, Ognerubov NA, Lyadov VK, Moiseenko VM, Trofimova OP, Ashrafyan LA, Khasanov RS, Poddubnaya IV. Patient blood management in oncology in the Russian Federation: Resolution to improve oncology care. J Cancer Policy 2022; 31:100315. [DOI: 10.1016/j.jcpo.2021.100315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/31/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022]
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12
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Shander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, Kor DJ, Faraoni D, Freedman J. A Global Definition of Patient Blood Management. Anesth Analg 2022; 135:476-488. [PMID: 35147598 DOI: 10.1213/ane.0000000000005873] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Aryeh Shander
- From the Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey
| | - Jean-Francois Hardy
- Department of Anaesthesiology and Pain Medicine, Université de Montréal, Montréal, Quebec, Canada.,Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France
| | - Sherri Ozawa
- Society for the Advancement of Patient Blood Management (SABM), Mount Royal, New Jersey.,Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Health, Englewood, New Jersey
| | - Shannon L Farmer
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,The Western Australia Patient Blood Management Group, The University of Western Australia, Perth, Western Australia, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, Faculty of Medicine and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia.,International Foundation for Patient Blood Management, Basel, Switzerland.,Department of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Steven M Frank
- Department of Anesthesiology, Critical Care Medicine, Johns Hopkins Health System Patient Blood Management Program, The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland
| | - Daryl J Kor
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Michigan.,Patient Blood Management Program, Mayo Clinic, Rochester, Michigan
| | - David Faraoni
- Network for the Advancement of Patient Blood Management, Haemostasis and Thrombosis (NATA), Paris, France.,Department of Anesthesiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - John Freedman
- Ontario Nurse Transfusion Coordinators Program (ONTraC), Ontario, Canada.,The Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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13
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Rambiritch V, Verburgh E, Louw VJ. Patient blood management and blood conservation - Complimentary concepts and solutions for blood establishments and clinical services in South Africa and beyond. Transfus Apher Sci 2021; 60:103207. [PMID: 34353706 PMCID: PMC10399285 DOI: 10.1016/j.transci.2021.103207] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.
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Affiliation(s)
| | - Estelle Verburgh
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Vernon Johan Louw
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa
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14
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Hofmann A, Spahn DR, Holtorf AP. Making patient blood management the new norm(al) as experienced by implementors in diverse countries. BMC Health Serv Res 2021; 21:634. [PMID: 34215251 PMCID: PMC8249439 DOI: 10.1186/s12913-021-06484-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 05/06/2021] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Axel Hofmann
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
- University of Western Australia Faculty of Health and Medical Sciences, Perth, Australia
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Anke-Peggy Holtorf
- Health Outcomes Strategies GmbH, Colmarerstrasse 58, CH4055 Basel, Switzerland
- Faculty of the College of Pharmacy, University of Utah, Salt Lake City, UT USA
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15
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Ikoma S, Furukawa M, Busuttil A, Ward D, Baldwin K, Mayne J, Clarke R, Ziman A. Optimizing Inpatient Blood Utilization Using Real-Time Clinical Decision Support. Appl Clin Inform 2021; 12:49-56. [PMID: 33506477 DOI: 10.1055/s-0040-1721779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Red blood cell (RBC) transfusion is a common medical procedure. While it offers clinical benefits for many, hemodynamically stable patients are often subjected to unwarranted transfusions, with the potential to lead to adverse consequences. We created a real-time clinical decision support (CDS) tool in the electronic health record system to address this problem and optimize transfusion practice as part of an institutional multidisciplinary, team-based patient blood management program. METHODS The real-time CDS tool incorporated the transfusion guidelines published by the AABB. The tool was deployed as a dynamic order set within the computerized provider order entry interface. Prior to implementation, extensive education and outreach to increase provider engagement were provided. The CDS tool was launched in September 2015. RESULTS The percentage of guideline-indicated RBC transfusions increased from a baseline of 43.6 to 54.2% while the percentage of multiunit (≥ 2 units) RBC transfusions decreased from 31.3 to 22.7% between September 2014 and July 2019. The estimated minimum cost saving over the entire study period was $36,519.36. CONCLUSION Our intervention increased guideline-indicated transfusions by 10.6% and reduced multiunit transfusions by 8.6%. The adoption of a dynamic order set for the CDS tool, as opposed to an interruptive alert that displays static alert messages, allowed for more customized and tighter control of RBC orders, leading to a sustained improvement in our transfusion practice.
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Affiliation(s)
- Shohei Ikoma
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California, United States
| | - Meg Furukawa
- Health Information Technology, University of California, Los Angeles, California, United States
| | - Ashley Busuttil
- Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Dawn Ward
- Department of Pathology and Laboratory Medicine, Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, David Geffen School of Medicine, University of California, Los Angeles, California, United States
| | - Kevin Baldwin
- Health Information Technology, University of California, Los Angeles, California, United States
| | - Jeffrey Mayne
- Division of Hospital Medicine, Department of Medicine, Nuvance Health, Rhinebeck, New York, United States
| | - Robin Clarke
- Ursa Health, Nashville, Tennessee, United States
| | - Alyssa Ziman
- Department of Pathology and Laboratory Medicine, Wing-Kwai and Alice Lee-Tsing Chung Transfusion Service, David Geffen School of Medicine, University of California, Los Angeles, California, United States
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16
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Tankard KA, Park B, Brovman EY, Bader AM, Urman RD. The Impact of Preoperative Intravenous Iron Therapy on Perioperative Outcomes in Cardiac Surgery: A Systematic Review. J Hematol 2020; 9:97-108. [PMID: 33224389 PMCID: PMC7665859 DOI: 10.14740/jh696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/18/2020] [Indexed: 01/05/2023] Open
Abstract
Background Anemia is common in cardiac surgery affecting 25-40% of patients and associated with increased blood transfusions, morbidity, mortality, and higher hospital costs. Higher rates of stroke, acute renal injury, and total number of adverse postoperative outcomes have also been reported to be associated with preoperative anemia. This systematic review assessed the current evidence for preoperative intravenous iron on major outcomes following cardiac surgery. Methods Outcome measures included postoperative hemoglobin, transfusion rates, major adverse events, and mortality. The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and articles were identified using PubMed, Cochrane, CLINAHL, WOS, and EMBASE databases. Articles were included if they compared patients with and without preoperative anemia based on treatment with intravenous iron. Quality was assessed using Cochrane Risk of Bias Tool and Newcastle-Ottawa scale, and strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results Of the articles reviewed, six met inclusion criteria. These included four randomized double-blind prospective cohort studies, one randomized non-blinded prospective study, and one non-randomized non-blinded prospective study with historical control. Across studies, 1,038 patients were enrolled. Two studies showed higher hemoglobin with iron therapy, and only one study showed significant differences in multiple outcomes such as transfusion and morbidity. Conclusions Given the paucity of studies and biases within them, the current evidence for treatment with intravenous iron prior to cardiac surgery is weak. More evidence is needed to support the administration of preoperative intravenous iron in cardiac surgery patients.
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Affiliation(s)
- Kelly A Tankard
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Brian Park
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Ethan Y Brovman
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Tufts University School of Medicine, 800 Washington St, Boston, MA 02111, USA
| | - Angela M Bader
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA 02115, USA
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17
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Trentino KM, Mace HS, Symons K, Sanfilippo FM, Leahy MF, Farmer SL, Hofmann A, Watts RD, Wallace MH, Murray K. Screening and treating pre-operative anaemia and suboptimal iron stores in elective colorectal surgery: a cost effectiveness analysis. Anaesthesia 2020; 76:357-365. [PMID: 32851648 PMCID: PMC7891607 DOI: 10.1111/anae.15240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2020] [Indexed: 01/28/2023]
Abstract
Our study investigated whether pre-operative screening and treatment for anaemia and suboptimal iron stores in a patient blood management clinic is cost effective. We used outcome data from a retrospective cohort study comparing colorectal surgery patients admitted pre- and post-implementation of a pre-operative screening programme. We applied propensity score weighting techniques with multivariable regression models to adjust for differences in baseline characteristics between groups. Episode-level hospitalisation costs were sourced from the health service clinical costing data system; the economic evaluation was conducted from a Western Australia Health System perspective. The primary outcome measure was the incremental cost per unit of red cell transfusion avoided. We compared 441 patients screened in the pre-operative anaemia programme with 239 patients not screened; of the patients screened, 180 (40.8%) received intravenous iron for anaemia and suboptimal iron stores. The estimated mean cost of screening and treating pre-operative anaemia was AU$332 (£183; US$231; €204) per screened patient. In the propensity score weighted analysis, screened patients were transfused 52% less red cell units when compared with those not screened (rate ratio = 0.48, 95%CI 0.36-0.63, p < 0.001). The mean difference in total screening, treatment and hospitalisation cost between groups was AU$3776 lower in the group screened (£2080; US$2629; €2325) (95%CI AU$1604-5947, p < 0.001). Screening elective patients pre-operatively for anaemia and suboptimal iron stores reduced the number of red cell units transfused. It also resulted in lower total costs than not screening patients, thus demonstrating cost effectiveness.
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Affiliation(s)
- K M Trentino
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - H S Mace
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - K Symons
- Department of Anaesthesia and Pain Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - F M Sanfilippo
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - M F Leahy
- Department of Haematology, PathWest Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - S L Farmer
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - A Hofmann
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - R D Watts
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - M H Wallace
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
| | - K Murray
- School of Population and Global Health, University of Western Australia, Perth, Western Australia, Australia
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18
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Liu J, Lin J, Guan X, Liu L, Pan X, Zhou L, Luo Y, Wang D. Risks associated with perioperative anaemia and perioperative blood transfusion in patients undergoing neurosurgical operation. Transfus Med 2020; 30:343-351. [PMID: 32754991 DOI: 10.1111/tme.12708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/19/2020] [Accepted: 07/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate the prevalence of preoperative anaemia and the risks associated with perioperative anaemia and blood transfusion in patients who underwent neurological surgery. BACKGROUND Perioperative anaemia has an important impact on neurosurgery patients. The prevalence and risks of perioperative anaemia and blood transfusion in Chinese patients are still unknown. METHODS Logistic regression was used to predict adverse outcomes of red blood cell (RBC) transfusion and different levels of anaemia. Anaemia and transfusion were compared as independent variables by using a 1:1 match on propensity score. RESULTS The prevalence of preoperative anaemia in neurosurgical patients was 20.05%; 10.33% patients received RBC transfusion. Perioperative RBC and plasma transfusion rates (P < .001) and average hospital costs (P = .0365) were higher in preoperative moderate-to-severe anaemia patients than in no anaemia patients. Perioperative RBC transfusion patients had longer hospital length of stay (LOS) (P < .001) and higher average hospital costs (P < .001) than no-transfusion patients. The rates of return to the operating room (OR) within 30 days and intensive care unit stay did not demonstrate any significant difference in anaemia and transfusion cohorts, respectively. CONCLUSION The status of preoperative anaemia in Chinese neurosurgical patients is associated with increased transfusion rates and hospital costs. Perioperative RBC transfusion is associated with increased length and cost of hospitalisation.
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Affiliation(s)
- Junting Liu
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Jie Lin
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiaozhen Guan
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Li Liu
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xue Pan
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lingling Zhou
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yuanyuan Luo
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Deqing Wang
- Department of Transfusion Medicine, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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19
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Abbruzzese L, Agostini V, Livraghi A, Manzini PM, Marmifero M, Tirindelli CM. How to implement of patient blood management pillar 1: An Italian expert opinion based on a "bundles" approach. Transfus Apher Sci 2020; 59:102874. [PMID: 32713628 DOI: 10.1016/j.transci.2020.102874] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022]
Abstract
Worldwide iron anemia is a common disorder with a significant economic burden on health-care systems. Red blood cell transfusion is the mainstay to correct anemia in surgical settings, but it is also an overused procedure and recent data support its possible role in worsening patient outcomes. Patient Blood Management (PBM) is a multidisciplinary approach to optimize hemostasis, manage anemia, minimize iatrogenic blood loss, and improve tolerance to anemia. The present paper aims to provide a "bundles" approach, based on several preoperative anemia management measures, to implement PBM Pillar 1 in clinical practice.
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Affiliation(s)
- Luciano Abbruzzese
- Transfusion Medicine, Azienda Ospedaliera "Card. G. Panico", Tricase, Lecce, Italy
| | - Vanessa Agostini
- Transfusion Medicine, Ospedale Policlinico San Martino, Genova, Italy
| | - Alessandra Livraghi
- Immunohematology and Transfusion Medicine Service, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Paola Maria Manzini
- Blood Bank and Transfusion Medicine, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Melania Marmifero
- Transfusion Medicine, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Via Venezia 16, Alessandria, Italy.
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20
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Yang XX, Dai XC, Liu CX, Lu JH, Lin SY. Restrictive versus liberal transfusion strategies in patients with malignant neoplasm -a meta-analysis of randomized controlled trials. Transfus Apher Sci 2020; 59:102825. [PMID: 32616366 DOI: 10.1016/j.transci.2020.102825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/13/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Transfusion strategies are involving the survival and prognosis of patients with malignant neoplasm and the rational utilization of medical resources, but there are still controversy between different transfusion strategies. The aim of this article is to compare the benefit and harm of restrictive and liberal red blood cell(RBC) transfusion strategies in patients with malignant tumors. METHODS We searched articles in the databases of PubMed, Cochrane Library, Web of Science, Embase and major conference proceedings, identified all randomized controlled trials (RCTs) and compared restrictive transfusion strategies with those that are liberal until MARCH 18, 2019. We used risk ratio (RR) and and 95 % confidence interval (95 %CI) to calculate the results of dichotomous variables, and the study heterogeneity was assessed by using the I2 statistics. Also, we did sensitivity analysis and quality assessment. RESULTS Restrictive transfusion policies appear to have no effect on all-cause mortality (RR 1.33; 95 % CI 0.74-2.38; P = 0.34), compared with liberal policies. 2 trials including 498 patients were included of renal replacement therapy (RR 1.38; 95 % CI, 0.73-2.59; P = 0.32; I2 = 0%). Myocardial infarction (RR 1.17; 95 % CI, 0.33-4.1; P = 0.81; I2 = 0%) and ICU readmission were also mentioned in these articles (RR 1.19; 95 % CI, 0.7-2.04; P = 0.52; I2 = 0%). However, the RR of hospital length can't be evaluated. CONCLUSION Restrictive transfusion strategies were not associated with all-cause mortality and other clinical outcomes in malignant tumors, and may be more suitable for patients' quality of life and medical economy than liberal.
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Affiliation(s)
- Xin-Xin Yang
- 54 youdian road, shangcheng district, Hangzhou, China
| | - Xiao-Ce Dai
- 54 youdian road, shangcheng district, Hangzhou, China
| | - Chen-Xin Liu
- 54 youdian road, shangcheng district, Hangzhou, China
| | - Jia-Hong Lu
- 54 youdian road, shangcheng district, Hangzhou, China
| | - Sheng-Yun Lin
- 54 youdian road, shangcheng district, Hangzhou, China.
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21
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Trentino KM, Farmer SL, Leahy MF, Sanfilippo FM, Isbister JP, Mayberry R, Hofmann A, Shander A, French C, Murray K. Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: an overview of systematic reviews. BMC Med 2020; 18:154. [PMID: 32576194 PMCID: PMC7313211 DOI: 10.1186/s12916-020-01614-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 04/30/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There are no overviews of systematic reviews investigating haemoglobin thresholds for transfusion. This is important as the literature on transfusion thresholds has grown considerably in recent years. Our aim was to synthesise evidence from systematic reviews and meta-analyses of the effects of restrictive and liberal transfusion strategies on mortality. METHODS This was a systematic review of systematic reviews (overview). We searched MEDLINE, Embase, Web of Science Core Collection, PubMed, Google Scholar, and the Joanna Briggs Institute EBP Database, from 2008 to 2018. We included systematic reviews and meta-analyses of randomised controlled trials comparing mortality in patients assigned to red cell transfusion strategies based on haemoglobin thresholds. Two independent reviewers extracted data and assessed methodological quality. We assessed the methodological quality of included reviews using AMSTAR 2 and the quality of evidence pooled using an algorithm to assign GRADE levels. RESULTS We included 19 systematic reviews reporting 33 meta-analyses of mortality outcomes from 53 unique randomised controlled trials. Of the 33 meta-analyses, one was graded as high quality, 15 were moderate, and 17 were low. Of the meta-analyses presenting high- to moderate-quality evidence, 12 (75.0%) reported no statistically significant difference in mortality between restrictive and liberal transfusion groups and four (25.0%) reported significantly lower mortality for patients assigned to a restrictive transfusion strategy. We found few systematic reviews addressed clinical differences between included studies: variation was observed in haemoglobin threshold concentrations, the absolute between group difference in haemoglobin threshold concentration, time to randomisation (resulting in transfusions administered prior to randomisation), and transfusion dosing regimens. CONCLUSIONS Meta-analyses graded as high to moderate quality indicate that in most patient populations no difference in mortality exists between patients assigned to a restrictive or liberal transfusion strategy. TRIAL REGISTRATION PROSPERO CRD42019120503.
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Affiliation(s)
- Kevin M. Trentino
- School of Population and Global Health, The University of Western Australia, Perth, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Australia
| | - Shannon L. Farmer
- Medical School and Division of Surgery, The University of Western Australia, Perth, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Bentley, Australia
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia
| | - Michael F. Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia
- Medical School, The University of Western Australia, Perth, Australia
| | - Frank M. Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Australia
| | | | - Rhonda Mayberry
- Library and Information Service, South Metropolitan Health Service, Murdoch, Australia
| | - Axel Hofmann
- School of Health Sciences and Graduate Studies, Curtin University, Bentley, Australia
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, TeamHealth Research Institute New Jersey, Englewood, USA
| | - Craig French
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Perth, Australia
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22
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Abstract
OBJECTIVES To critically assess available high-level clinical studies regarding RBC transfusion strategies, with a focus on hemoglobin transfusion thresholds in the ICU. DATA SOURCES Source data were obtained from a PubMed literature review. STUDY SELECTION English language studies addressing RBC transfusions in the ICU with a focus on the most recent relevant studies. DATA EXTRACTION Relevant studies were reviewed and the following aspects of each study were identified, abstracted, and analyzed: study design, methods, results, and implications for critical care practice. DATA SYNTHESIS Approximately 30-50% of ICU patients receive a transfusion during their hospitalization with anemia being the indication for 75% of transfusions. A significant body of clinical research evidence supports using a restrictive transfusion strategy (e.g., hemoglobin threshold < 7 g/dL) compared with a more liberal approach (e.g., hemoglobin threshold < 10 g/dL). A restrictive strategy (hemoglobin < 7 g/dL) is recommended in patients with sepsis and gastrointestinal bleeds. A slightly higher restrictive threshold is recommended in cardiac surgery (hemoglobin < 7.5 g/dL) and stable cardiovascular disease (hemoglobin < 8 g/dL). Although restrictive strategies are generally supported in hematologic malignancies, acute neurologic injury, and burns, more definitive studies are needed, including acute coronary syndrome. Massive transfusion protocols are the mainstay of treatment for hemorrhagic shock; however, the exact RBC to fresh frozen plasma ratio is still unclear. There are also emerging complimentary practices including nontransfusion strategies to avoid and treat anemia and the reemergence of whole blood transfusion. CONCLUSIONS The current literature supports the use of restrictive transfusion strategies in the majority of critically ill populations. Continued studies of optimal transfusion strategies in various patient populations, coupled with the integration of novel complementary ICU practices, will continue to enhance our ability to treat critically ill patients.
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Meybohm P, Westphal S, Ravn HB, Ranucci M, Agarwal S, Choorapoikayil S, Spahn DR, Ahmed AB, Froessler B, Zacharowski K. Perioperative Anemia Management as Part of PBM in Cardiac Surgery – A Narrative Updated Review. J Cardiothorac Vasc Anesth 2020; 34:1060-1073. [DOI: 10.1053/j.jvca.2019.06.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 06/18/2019] [Accepted: 06/29/2019] [Indexed: 12/18/2022]
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Malinowski EA, Matias JEF, Percicote AP, Nakadomari T, Robes R, Petterle RR, Noronha LD, Godoy JLD. Conservation of both hematocrit and liver regeneration in hepatectomies: a vascular occlusion approach in rats. ACTA ACUST UNITED AC 2020; 33:e1484. [PMID: 32236290 PMCID: PMC7099868 DOI: 10.1590/0102-672020190001e1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/19/2019] [Indexed: 02/08/2023]
Abstract
Background: Hepatectomies promote considerable amount of blood loss and the need to
administrate blood products, which are directly linked to higher
morbimortality rates. The blood-conserving hepatectomy (BCH) is a
modification of the selective vascular occlusion technique. It could be a
surgical maneuver in order to avoid or to reduce the blood products
utilization in the perioperative period. Aim: To evaluate in rats the BCH effects on the hematocrit (HT) variation,
hemoglobin serum concentration (HB), and on liver regeneration. Methods: Twelve Wistar rats were divided into two groups: control (n=6) and
intervention (n=6). The ones in the control group had their livers partially
removed according to the Higgins and Anderson technique, while the rats in
the treatment group were submitted to BCH technique. HT and HB levels were
measured at day D0, D1 and D7. The rate between the liver and rat weights
was calculated in D0 and D7. Liver regeneration was quantitatively and
qualitatively evaluated. Results: The HT and HB levels were lower in the control group as of D1 onwards,
reaching an 18% gap at D7 (p=0.01 and p=0.008, respectively); BCH resulted
in the preservation of HT and HB levels to the intervention group rats. BCH
did not alter liver regeneration in rats. Conclusion: The BCH led to beneficial effects over the postoperative HT and serum HB
levels with no setbacks to liver regeneration. These data are the necessary
proof of evidence for translational research into the surgical practice. Abstract: A) Unresected liver; B) liver appearance after the partial hepatectomy
(1=vena cava; 2=portal vein; 3=hepatic vein; 4=biliary drainage; 5=hepatic
artery)
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Surbek D, Vial Y, Girard T, Breymann C, Bencaiova GA, Baud D, Hornung R, Taleghani BM, Hösli I. Patient blood management (PBM) in pregnancy and childbirth: literature review and expert opinion. Arch Gynecol Obstet 2020; 301:627-641. [PMID: 31728665 PMCID: PMC7033066 DOI: 10.1007/s00404-019-05374-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/31/2019] [Indexed: 12/24/2022]
Abstract
PURPOSE Patient blood management [PBM] has been acknowledged and successfully introduced in a wide range of medical specialities, where blood transfusions are an important issue, including anaesthesiology, orthopaedic surgery, cardiac surgery, or traumatology. Although pregnancy and obstetrics have been recognized as a major field of potential haemorrhage and necessity of blood transfusions, there is still little awareness among obstetricians regarding the importance of PBM in this area. This review, therefore, summarizes the importance of PBM in obstetrics and the current evidence on this topic. METHOD We review the current literature and summarize the current evidence of PBM in pregnant women and postpartum with a focus on postpartum haemorrhage (PPH) using PubMed as literature source. The literature was reviewed and analysed and conclusions were made by the Swiss PBM in obstetrics working group of experts in a consensus meeting. RESULTS PBM comprises a series of measures to maintain an adequate haemoglobin level, improve haemostasis and reduce bleeding, aiming to improve patient outcomes. Despite the fact that the WHO has recommended PBM early 2010, the majority of hospitals are in need of guidelines to apply PBM in daily practice. PBM demonstrated a reduction in morbidity, mortality, and costs for patients undergoing surgery or medical interventions with a high bleeding potential. All pregnant women have a significant risk for PPH. Risk factors do exist; however, 60% of women who experience PPH do not have a pre-existing risk factor. Patient blood management in obstetrics must, therefore, not only be focused on women with identified risk factor for PPH, but on all pregnant women. Due to the risk of PPH, which is inherent to every pregnancy, PBM is of particular importance in obstetrics. Although so far, there is no clear guideline how to implement PBM in obstetrics, there are some simple, effective measures to reduce anaemia and the necessity of transfusions in women giving birth and thereby improving clinical outcome and avoiding complications. CONCLUSION PBM in obstetrics is based on three main pillars: diagnostic and/or therapeutic interventions during pregnancy, during delivery and in the postpartum phase. These three main pillars should be kept in mind by all professionals taking care of pregnant women, including obstetricians, general practitioners, midwifes, and anaesthesiologists, to improve pregnancy outcome and optimize resources.
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Affiliation(s)
- Daniel Surbek
- Department of Obstetrics and Gynaecology, Bern University Hospital, Insel Hospital, University of Bern, Friedbühlstrasse 19, 3010, Bern, Switzerland.
| | - Yvan Vial
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - Thierry Girard
- Department of Anaesthesiology, University Hospital Basel, Basel, Switzerland
| | - Christian Breymann
- Obstetric Research-Feto Maternal Haematology Unit, University Hospital Zurich, Zurich, Switzerland
| | | | - David Baud
- Service of Obstetrics, Department Woman-Mother-Child, University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
| | - René Hornung
- Department of Obstetrics and Gynaecology, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
| | | | - Irene Hösli
- Clinic of Obstetrics and Gynaecology, University Hospital Basel, Basel, Switzerland
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Silverstein A, Reddy K, Smith V, Foster JH, Russell HV, Whittle SB. Blood product administration during high risk neuroblastoma therapy. Pediatr Hematol Oncol 2020; 37:5-14. [PMID: 31829069 PMCID: PMC6942619 DOI: 10.1080/08880018.2019.1668095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The increasing intensity of high-risk neuroblastoma (HR NB) treatment over the last decades has resulted in improved survival at the expense of prolonging therapy and exposure to additional potentially toxic agents. Anemia and thrombocytopenia requiring transfusion are common during therapy for HR NB. Risks of cumulative red blood cell and platelet transfusions are incompletely defined in pediatric oncology patients, however, risks of transfusional iron overload are well described in other populations. This study aimed to determine the number of packed red blood cell (pRBC) and platelet transfusions throughout treatment for HR NB and how these numbers have changed with modern therapy. We performed a retrospective review of 92 patients with HR NB from June 2002 until September 2017. Patients received a median of 20 pRBC and 32 platelet transfusions. Our results demonstrated large numbers of transfusions with significantly increased blood product exposures among patients who received intensified therapy, either with additional induction chemotherapy, tandem autologous stem cell transplants, or dinutuximab plus cytokines with isotretinoin. Similar volumes of pRBC transfusions have been associated with iron overload in other populations and warrant further discussion of guidelines for long-term follow up of HR NB patients.
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Affiliation(s)
- Allison Silverstein
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Kiranmye Reddy
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Valeria Smith
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Jennifer H. Foster
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Heidi V. Russell
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX,Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Sarah B. Whittle
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
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Beverina I, Brando B. Prevalence of anemia and therapeutic behavior in the emergency department at a tertiary care Hospital: Are patient blood management principles applied? Transfus Apher Sci 2019; 58:688-692. [DOI: 10.1016/j.transci.2019.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 06/26/2019] [Accepted: 07/05/2019] [Indexed: 01/28/2023]
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Bielby L, Moss R, Mo A, McQuilten Z, Wood E. The role of the transfusion practitioner in the management of anaemia. ACTA ACUST UNITED AC 2019. [DOI: 10.1111/voxs.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Linley Bielby
- Department of Health and Human Services Victoria and the Australian Red Cross Blood Service Melbourne VIC Australia
| | - Rachel Moss
- Department of Laboratory Medicine Great Ormond Street Hospital for Children NHS Foundation Trust London UK
| | - Allison Mo
- Transfusion Research Unit School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia
- Department of Haematology Monash Health Clayton VIC Australia
- Austin Pathology and Department of Clinical Haematology Austin Health Heidelburg VIC Australia
| | - Zoe McQuilten
- Transfusion Research Unit School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia
- Department of Haematology Monash Health Clayton VIC Australia
| | - Erica Wood
- Transfusion Research Unit School of Public Health and Preventive Medicine Monash University Melbourne VIC Australia
- Department of Haematology Monash Health Clayton VIC Australia
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Trentino KM, Farmer SL, Sanfilippo FM, Leahy MF, Isbister J, Mayberry R, Hofmann A, Murray K. Systematic reviews and meta-analyses comparing mortality in restrictive and liberal haemoglobin thresholds for red cell transfusion: protocol for an overview of systematic reviews. BMJ Open 2019; 9:e029828. [PMID: 31446415 PMCID: PMC6719757 DOI: 10.1136/bmjopen-2019-029828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION There has been a significant increase in the number of systematic reviews and meta-analyses of randomised controlled trials investigating thresholds for red blood cell transfusion. To systematically collate, appraise and synthesise the results of these systematic reviews and meta-analyses, we will conduct an overview of systematic reviews. METHODS AND ANALYSIS This is a protocol for an overview of systematic reviews. We will search five databases: MEDLINE, Embase, Web of Science Core Collection, PubMed (for prepublication, in process and non-Medline records) and Google Scholar. We will consider systematic reviews and meta-analyses of randomised controlled trials evaluating the effect of haemoglobin thresholds for red blood cell transfusion on mortality. Two authors will independently screen titles and abstracts retrieved in the literature search and select studies meeting the eligibility criteria for full-text review. We will extract data onto a predefined form designed to summarise the key characteristics of each review. We will assess the methodological quality of included reviews and the quality of evidence in included reviews. ETHICS AND DISSEMINATION Formal ethics approval is not required for this overview as we will only analyse published literature. The findings of this study will be presented at relevant conferences and submitted for peer-review publication. The results are likely to be used by clinicians, policy makers and developers of clinical guidelines and will inform suggestions for future systematic reviews and randomised controlled trials. PROSPERO REGISTRATION NUMBER CRD42019120503.
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Affiliation(s)
- Kevin M Trentino
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
- Data and Digital Innovation, East Metropolitan Health Service, Perth, Western Australia, Australia
| | - Shannon L Farmer
- Medical School and Division of Surgery, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Curtin, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, The University of Western Australia, Crawley, Western Australia, Australia
| | - James Isbister
- Northern Clinical School, Sydney Medical School, St Leonards, New South Wales, Australia
| | - Rhonda Mayberry
- Library and Information Service, South Metropolitan Health Service, Murdoch, Western Australia, Australia
| | - Axel Hofmann
- Medical School and Division of Surgery, The University of Western Australia, Crawley, Western Australia, Australia
- School of Health Sciences and Graduate Studies, Curtin University, Curtin, Western Australia, Australia
- Institute of Anesthesiology, Universitat Zurich, Zurich, Switzerland
| | - Kevin Murray
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
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Alfonso AR, Hutzler L, Lajam C, Bosco J, Goldstein J. Institution-Wide Blood Management Protocol Reduces Transfusion Rates Following Spine Surgery. Int J Spine Surg 2019; 13:270-274. [PMID: 31328091 DOI: 10.14444/6036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background Spine surgery is associated with significant intraoperative blood loss, often leading to transfusion. Patients who receive transfusions have an increased length of stay and risk of perioperative complications. To decrease the transfusion rate, we implemented an evidence-based institution-wide restrictive transfusion blood management guideline. The goal of this study is to describe the impact of this guideline on our spine surgery patients. Methods We analyzed the incidence of transfusion following 3709 single-institution, inpatient spine procedures before and after implementation of a revised blood transfusion protocol. The baseline period (1742 patients) from January 2014 to March 2015 was compared to the study period (1967 patients) of April 2015 to July 2016. One patient was excluded because of incomplete medical records. The revised protocol included establishing a postoperative blood transfusion trigger at hemoglobin < 7g/dL, instituting a computerized provider order entry, and appointing a physician champion to monitor and report progress. Results Transfusion rate decreased from 16.2% to 9.7% from baseline to study period, respectively (P < .001). The number of transfusions in patients with hemoglobin > 7g/dL decreased to 4.9% from 6.1% (P = .09). The rate of transfusions with a prior hemoglobin test increased from 42.0% to 59.1% (P < .001). Length of stay was reduced from 3.67 to 3.46 days (P = .04), and postsurgical infection rate was reduced from 1.5% to 0.6% (P = .01). There was no significant difference in total hospital costs following protocol implementation. Conclusions Implementation of a restrictive transfusion protocol through use of a computerized provider order entry and a physician champion to oversee clinician compliance led to a 40.1% reduction in blood transfusion following spine surgery. Behavior changes were visible with a 40.7% increase in hemoglobin documentation before transfusion, and patients benefited from a reduction in length of stay and postsurgical infection rate. Future study is encouraged to understand the long-term impact of this intervention and its role in hospital expenditure.
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Affiliation(s)
| | | | | | - Joseph Bosco
- NYU Langone Orthopedic Hospital, New York, New York
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31
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Gastecki K, Shanley R, Welbig J, Cohn C, Brunstein CG. Red blood cell product utilization in patients undergoing allogeneic stem cell transplantation. Transfusion 2019; 59:2301-2307. [PMID: 30957250 DOI: 10.1111/trf.15285] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/28/2019] [Accepted: 03/03/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The risk of transfusion reactions (TR) and the cost of blood has led to efforts to reduce blood use. We changed our practice to transfuse just one instead of two units of red blood cells (RBC) when hemoglobin ≤8 g/dL due to patient blood management (PBM) recommendations. METHODS AND MATERIALS We compared RBC utilization in patients receiving allogeneic HCT in the 10 months before (control arm) and 13 months after implementation of this new practice (intervention arm). We used regression models to estimate the independent effect of transfusion practice, length of hospitalization, the conditioning regimen, and donor type for patients who received at least one RBC unit. The outcome variable was total number of inpatient transfusions. In addition, a survey assessed the impact of this. RESULTS Cohorts were matched for age, primary diagnosis, graft source, and conditioning regimen. The median number of RBC units transfused/patient was identical in both arms (4; interquartile range 19 units/patient). Using the regression model, only length of stay (relative increase of 1.035 units/day; 95%CI, 1.0271.043) was an independent predictor of the number of RBC units a patient received. When data were normalized/1000 patient days, the control arm received 240 units vs the intervention arm, which received 193 units, resulting in a reduction of 47 units transfused/1000-patient-days, which was not statistically significant (p-value = 0.32). The survey of RNs showed that it positively affected the workflow. CONCLUSIONS There was a modest reduction in RBC utilization based on units transfused/1000-patient-days. There was a positive impact on RN workflow.
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Affiliation(s)
- Karen Gastecki
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Ryan Shanley
- Masonic Cancer Center Biostatistics Core, University of Minnesota, Minneapolis, Minnesota
| | - Julie Welbig
- Blood Bank Transfusion Safety Officer, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Claudia Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Claudio G Brunstein
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, Minnesota.,Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
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Hollis C, Rice AN, Gupta DK, Goode V. Laboratory Monitoring and Transfusion Guidelines to Influence Care in Patients Undergoing Multilevel Spinal Fusion Surgery. J Perianesth Nurs 2019; 34:691-700. [PMID: 30853328 DOI: 10.1016/j.jopan.2018.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 11/10/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this project was to determine whether the use of the modified Northwestern high risk spine protocol in patients undergoing multilevel spinal fusion surgery would result in improved transfusion practices. DESIGN Preimplementation and postimplementation design. METHODS A laboratory monitoring and transfusion guideline protocol was implemented in patients undergoing multilevel spinal fusions. Data were collected via a manual retrospective chart review of the electronic medical record before and after implementation of the protocol. FINDINGS Laboratory values were monitored at guided intervals. There was a statistically significant (P = .004) decrease in the mean hemoglobin value at which a packed red blood cell transfusion was initiated. CONCLUSIONS Through the use of the protocol, laboratory value monitoring provided quantitative data to aid and improve clinical decision making for practitioners in the perioperative period.
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Shih AW, Liu A, Elsharawi R, Crowther MA, Cook RJ, Heddle NM. Systematic reviews of guidelines and studies for single versus multiple unit transfusion strategies. Transfusion 2018; 58:2841-2860. [DOI: 10.1111/trf.14952] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/27/2018] [Accepted: 08/01/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Andrew W. Shih
- Department of Pathology and Laboratory Medicine; University of British Columbia; Vancouver British Columbia Canada
- Department of Pathology, Vancouver Coastal Health Authority; Vancouver British Columbia Canada
| | - Aixin Liu
- Department of Medicine; Queens University; Kingston Ontario Canada
| | - Radwa Elsharawi
- Department of Medicine, School of Medicine; Wayne State University; Detroit Michigan
| | - Mark A. Crowther
- Department of Medicine; McMaster University; Hamilton Ontario Canada
| | - Richard J. Cook
- Department of Health Research, Methods and Impact; McMaster University; Hamilton Ontario Canada
- McMaster Centre for Transfusion Research; McMaster University; Hamilton Ontario Canada
| | - Nancy M. Heddle
- Department of Medicine; McMaster University; Hamilton Ontario Canada
- McMaster Centre for Transfusion Research; McMaster University; Hamilton Ontario Canada
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Krishnasivam D, Trentino KM, Burrows S, Farmer SL, Picardo S, Leahy MF, Halder A, Chamberlain J, Swain S, Muthucumarana K, Waterer G. Anemia in hospitalized patients: an overlooked risk in medical care. Transfusion 2018; 58:2522-2528. [PMID: 30276822 DOI: 10.1111/trf.14877] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 06/18/2018] [Accepted: 06/18/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study investigated the association between nadir anemia and mortality and length of stay (LOS) in a general population of hospitalized patients. STUDY DESIGN AND METHODS A retrospective cohort study of tertiary hospital admissions in Western Australia between July 2010 and June 2015. Outcome measures were in-hospital mortality and LOS. RESULTS Of 80,765 inpatients, 45,675 (56.55%) had anemia during admission. Mild and moderate/severe anemia were independently associated with increased in-hospital mortality (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.36-1.86, p = 0.001; OR 2.77, 95% CI 2.32-3.30, p < 0.001, respectively). Anemia was also associated with increased LOS, demonstrating a larger effect in emergency (mild anemia-incident rate ratio [IRR] 1.52, 95% CI 1.48-1.56, p < 0.001; moderate/severe anemia-IRR 2.18, 95% CI 2.11-2.26, p < 0.001) compared to elective admissions (mild anemia-IRR 1.30, 95% CI 1.21-1.41, p < 0.001; moderate/severe anemia-IRR 1.69, 95% CI 1.55-1.83, p < 0.001). LOS was longer in patients who developed anemia during admission compared to those who had anemia on admission (IRR 1.13, 95% CI 1.10-1.17, p < 0.001). Red cell transfusion was independently associated with 2.23 times higher odds of in-hospital mortality (95% CI 1.89-2.64, p < 0.001) and 1.31 times longer LOS (95% CI 1.25-1.37, p < 0.001). CONCLUSION More than one-third of patients not anemic on admission developed anemia during admission. Even mild anemia is independently associated with increased mortality and LOS; however, transfusion to treat anemia is an independent and additive risk factor.
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Affiliation(s)
| | - Kevin M Trentino
- Business Intelligence Unit, East Metropolitan Health Service, Perth, Australia.,Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia
| | | | - Shannon L Farmer
- Medical School, Faculty of Health and Medical Sciences, The University of Western Australia, Perth, Australia.,School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Australia
| | | | - Michael F Leahy
- Department of Haematology, PathWest Laboratory Medicine, Royal Perth Hospital, Perth, Australia.,School of Medicine and Pharmacology, School of Laboratory Medicine, University of Western Australia, Perth, Australia
| | - Abir Halder
- Department of General Medicine, Perth, Australia
| | | | | | | | - Grant Waterer
- Faculty of Medicine, The University of Western Australia, Perth, Australia
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Rizwan M, Hashmi M, Zafar H. A Six-month Retrospective Study of Resources Burden by Trauma Victims in the Surgical Intensive Care Unit of a University Hospital in Pakistan. Cureus 2018; 10:e3236. [PMID: 30410842 PMCID: PMC6207497 DOI: 10.7759/cureus.3236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction Trauma is the fourth leading cause of death globally and constitutes a huge burden on limited critical care resources. Aim This study aimed to identify the trauma patient burden in terms of resources used in the surgical intensive care unit (SICU) of Aga Khan University Hospital in Pakistan which also included characteristics and outcomes of trauma and non-trauma patients. Methods We retrospectively reviewed all patient data for adult patients (>16 years old) admitted to the SICU from July through December 2014. Results Of 141 SICU cases included in our study period, 32 (22.7%) trauma patients were identified. On further stratification of trauma patients, road traffic injuries (43.8%), gunshot injuries (43.8%), and blast injuries (6.3%) were the most common, and about 73% of all trauma patients underwent emergency surgical interventions, comprising a huge burden on all resources. The average age of the trauma patients was significantly lower than non-trauma patients (36 years ± 13 vs. 49 years ± 19; p < 0.01). The male-to-female ratio was 7:1 in trauma cases and 2:1 in non-trauma cases (p = 0.019). There was no statistically significant difference in mortality (31.3% vs. 42.2% p > 0.05) and median length of stay [Median (interquartile range), 5(8) vs. 4(7); p > 0.05] between trauma and non-trauma patients. Conclusions Trauma constitutes a significant burden in terms of resources used for the SICU of the Aga Khan University, Pakistan. Trauma victims are predominantly young men in whom gunshot injuries are as common as road traffic injuries. Emergency surgical interventions comprise the largest draw on resources, followed by use of blood products, radiological, and laboratory investigations.
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Affiliation(s)
- Muhammad Rizwan
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, SAU
| | - Madiha Hashmi
- Anaesthesiology, Aga Khan University Hospital, Karachi, PAK
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Red blood cell transfusion probability and associated costs in neurosurgical procedures. Acta Neurochir (Wien) 2018; 160:1483-1489. [PMID: 29556717 DOI: 10.1007/s00701-018-3516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 03/09/2018] [Indexed: 10/17/2022]
Abstract
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.
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Cost analysis of enhanced recovery after surgery in microvascular breast reconstruction. J Plast Reconstr Aesthet Surg 2018; 71:819-826. [DOI: 10.1016/j.bjps.2018.02.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 02/18/2018] [Indexed: 11/22/2022]
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Connor JP, Raife T, Medow JE, Ehlenfeldt BD, Sipsma K. The blood utilization calculator, a target-based electronic decision support algorithm, increases the use of single-unit transfusions in a large academic medical center. Transfusion 2018; 58:1689-1696. [PMID: 29717482 DOI: 10.1111/trf.14637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/15/2018] [Accepted: 02/15/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Electronic decision support has been used to reduce use of red blood cell (RBC) transfusion. With the goal of reducing transfusions, we modified our RBC orders to default to 1 unit. Next, we created a target-based algorithm, the blood utilization calculator or BUC, to calculate a dose in units, based on initial hemoglobin or hematocrit and weight. STUDY DESIGN AND METHODS RBC orders defaulted to 1 unit in March 2016 and the BUC was implemented in July 2016. This gave three periods to compare old orders (before intervention), new orders (1-unit default), and the BUC period. A hospital dashboard that tracks blood product orders was queried to determine changes in single-unit transfusions between periods. Changes in transfusions were compared by analysis of variance. Acceptance of the BUC dosage recommendation was studied in both medical-based and surgical-based specialties. RESULTS The number of single-unit transfusions showed significant increases after each of the two interventions studied from 247 ± 19 before interventions to 358 ± 19 and then to 445 ± 141-unit transfusions/month (p < 0.0001). The ratio of 1-unit to 2-unit transfusions increased from 0.72 to 1.67 (p < 0.0001) and we observed a 19% overall reduction in units transfused. The BUC recommendation was accepted in 49% of orders. CONCLUSIONS One-unit default orders and implementation of the BUC resulted in a significant increase in the use of single-unit transfusions. Improvement in the rate of acceptance of the BUC recommendation should further increase the use of single-unit transfusions.
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Affiliation(s)
- Joseph P Connor
- Department of Pathology and Laboratory Medicine, Madison, Wisconsin
| | - Thomas Raife
- Department of Pathology and Laboratory Medicine, Madison, Wisconsin
| | - Joshua E Medow
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Stoneham MD, Von Kier S, Harvey L, Murphy M. Effects of a targeted blood management programme on allogeneic blood transfusion in abdominal aortic aneurysm surgery. Transfus Med 2017; 28:290-297. [PMID: 29243334 DOI: 10.1111/tme.12495] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To investigate the impact of a dedicated cell salvage practitioner team on blood loss and allogeneic transfusion in abdominal aortic aneurysm (AAA) surgery. BACKGROUND Cell salvage reduces allogeneic transfusion in AAA surgery, but is commonly performed by the anaesthetic nurse. At our hospital, a dedicated patient blood management practitioner is present for all elective open AAA repairs. METHODS/MATERIALS Data were collected on 171 AAA patients operated on at the John Radcliffe Hospital, Oxford over a 3-year period, looking at the Patient Blood Management processes, including: blood loss, cell salvage, near-patient testing (thrombelastography) and transfusion rates of allogeneic blood products. RESULTS Blood loss ranged from 3-108% of estimated blood volume (EBV) (median 25% = 1500 mL). In seven patients who lost 70-110% of their EBV, none reached the thrombelastography intervention threshold for R time (11 min) or MA (48 mm) despite such massive blood loss. Overall, only 7/171 (4%) patients received intra-operative allogeneic blood, all of whom had a mean baseline haemoglobin concentration < 106 g L-1 (median 98, range 95-105 g L-1 ). In terms of other blood products, only 4/171 (2·3%) received one unit of platelets each intra-operatively. None received FFP or cryoprecipitate. CONCLUSIONS Such low levels of allogeneic transfusion have not been reported previously. We hypothesise that this is due to the additional blood management contributions of the specialised cell salvage practitioners and collaboration with the rest of the vascular surgical team. These results support the development of pre-operative anaemia clinics. Overall the service runs at a profit to the trust.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - S Von Kier
- Haemostasis and Blood Conservation Service, John Radcliffe Hospital, Oxford, UK
| | - L Harvey
- Nuffield Division of Anaesthetics, John Radcliffe Hospital, Oxford, UK
| | - M Murphy
- National Health Service (NHS) Blood and Transplant & Oxford National Institute for Health Research (NIHR) Biomedical Research Centre, Oxford University Hospitals & University of Oxford, Oxford, UK
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Filipescu D, Bănăţeanu R, Beuran M, Burcoş T, Corneci D, Cristian D, Diculescu M, Dobrotă A, Droc G, Isacoff D, Goşa D, Grinţescu I, Lupu A, Mirea L, Posea C, Stanca O, Ştefan M, Tomescu D, Tudor C, Ungureanu D, Mircescu G. Perioperative Patient Blood Management Programme. Multidisciplinary recommendations from the Patient Blood Management Initiative Group. Rom J Anaesth Intensive Care 2017; 24:139-157. [PMID: 29090267 DOI: 10.21454/rjaic.7518.242.fil] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Patients with untreated anaemia or iron deficiency who undergo surgical procedures have an increased risk for mortality and morbidity. Patient Blood Management programmes address this issue worldwide and try to improve patient outcomes through a complex set of measures targeting anaemia correction, minimisation of bleeding and improvement of anaemia tolerance, in all phases of perioperative care. The Patient Blood Management Initiative Group is a multidisciplinary team of physicians from specialties including anaesthesiology, nephrology, surgery, orthopaedics, haematology, gastroenterology and transfusion medicine. The team has elaborated ten recommendations, divided into five categories, in order to implement a Patient Blood Management programme in Romania, using the most recent and relevant evidence. The document was discussed during three meetings which took place during October 2016 and May 2017 and the result was modified and updated via e-mail.
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Leahy MF, Trentino KM, May C, Swain SG, Chuah H, Farmer SL. Blood use in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation: the impact of a health system-wide patient blood management program. Transfusion 2017; 57:2189-2196. [PMID: 28671296 DOI: 10.1111/trf.14191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Little is published on patient blood management (PBM) programs in hematology. In 2008 Western Australia announced a health system-wide PBM program with PBM staff appointments commencing in November 2009. Our aim was to assess the impact this program had on blood utilization and patient outcomes in intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation. STUDY DESIGN AND METHODS A retrospective study of 695 admissions at two tertiary hospitals receiving intensive chemotherapy for acute leukemia or undergoing hematopoietic stem cell transplantation between July 2010 and December 2014 was conducted. Main outcomes included pre-red blood cell (RBC) transfusion hemoglobin (Hb) levels, single-unit RBC transfusions, number of RBC and platelet (PLT) units transfused per admission, subsequent day case transfusions, length of stay, serious bleeding, and in-hospital mortality. RESULTS Over the study period, the mean RBC units transfused per admission decreased 39% from 6.1 to 3.7 (p < 0.001), and the mean PLT units transfused decreased 35% from 6.3 to 4.1 (p < 0.001), with mean RBC and PLT units transfused for follow-up day cases decreasing from 0.6 to 0.4 units (p < 0.001). Mean pre-RBC transfusion Hb level decreased from 8.0 to 6.8 g/dL (p < 0.001), and single-unit RBC transfusions increased 39% to 67% (p < 0.001). This reduction represents blood product cost savings of AU$694,886 (US$654,007). There were no significant changes in unadjusted or adjusted length of stay, serious bleeding events, or in-hospital mortality over the study. CONCLUSION The health system-wide PBM program had a significant impact, reducing blood product use and costs without increased morbidity or mortality in patients receiving intensive chemotherapy for acute leukemia or hematopoietic stem cell transplantation.
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Affiliation(s)
- Michael F Leahy
- School of Medicine and Pharmacology
- Department of Haematology
- PathWest Laboratory Medicine, Royal Perth Hospital
| | | | | | - Stuart G Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | | | - Shannon L Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia
- Centre for Population Health Research, Faculty of Health, Sciences, Curtin University, Perth, Western Australia, Australia
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Meybohm P, Muellenbach RM, Keller H, Fichtlscherer S, Papadopoulos N, Spahn DR, Greinacher A, Zacharowski K. Patient Blood Management in der Herzchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0168-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Mahmoudi R, Novella JL, Jaïdi Y. [Transfusion in elderly: Take account frailty]. Transfus Clin Biol 2017; 24:200-208. [PMID: 28690038 DOI: 10.1016/j.tracli.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 06/12/2017] [Indexed: 10/19/2022]
Abstract
The conjunction of the demographic aging and the increase in the frequency of anemia with the advancing age, mean that the number of globular concentrates delivered each year increases with a consequent heavy pressure on blood collection. The etiologies of anemia in the elderly are often multifactorial and their investigation is an indispensable step and prior to any treatment. Transfusion thresholds, particularly in the elderly, are gradually evolving and a so-called restrictive strategy is now favored. Immediate and delayed complications of transfusion are more frequent in the elderly due to vulnerability factors associated with frailty and the risk of multiple transfusions. The screening of complications related to transfusion of RBCs is essential and makes it possible to avoid their recurrence. The impact of transfusion on the quality of life of elderly patients is not obvious and is a controversial issue. In addition, transfusion of red blood cells (RBCs) is accompanied by an increase in health expenditure and an increase in morbidity and mortality, whose risks can be reduced through alternatives to transfusion. Longitudinal studies, including elderly subjects, would allow a better understanding of the issues involved in the transfusion of RBCs in this population.
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Affiliation(s)
- R Mahmoudi
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France.
| | - J-L Novella
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France
| | - Y Jaïdi
- Service de médecine interne et gériatrie aiguë, hôpital Maison-Blanche, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 3797, faculté de médecine, université de Reims Champagne Ardenne, 51092 Reims cedex, France
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Improving outcome of trauma patients by implementing patient blood management. Curr Opin Anaesthesiol 2017; 30:243-249. [DOI: 10.1097/aco.0000000000000427] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Meybohm P, Froessler B, Goodnough LT, Klein AA, Muñoz M, Murphy MF, Richards T, Shander A, Spahn DR, Zacharowski K. "Simplified International Recommendations for the Implementation of Patient Blood Management" (SIR4PBM). Perioper Med (Lond) 2017; 6:5. [PMID: 28331607 PMCID: PMC5356305 DOI: 10.1186/s13741-017-0061-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/23/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND More than 30% of the world's population are anemic with serious medical and economic consequences. Red blood cell transfusion is the mainstay to correct anemia, but it is also one of the top five overused procedures and carries its own risk and cost burden. Patient blood management (PBM) is a patient-centered and multidisciplinary approach to manage anemia, minimize iatrogenic blood loss, and harness tolerance to anemia in an effort to improve patient outcome. Despite resolution 63.12 of the World Health Organization in 2010 endorsing PBM and current guidelines which include evidence-based recommendations on the use of diagnostic/therapeutic resources to provide better health care, many hospitals have yet to implement PBM in routine clinical practice. METHOD AND RESULTS A number of experienced clinicians developed the following "Simplified International Recommendations for Patient Blood Management." We propose a series of simple, cost-effective, best-practice, feasible, and evidence-based measures that will enable any hospital to reduce both anemia prevalence on the day of intervention/surgery and anemia-related unnecessary transfusion in surgical and medical patients, including obstetrics and gynecology.
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Affiliation(s)
- Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, South Australia, Australia
| | | | - Andrew A. Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - Manuel Muñoz
- Transfusion Medicine, School of Medicine, University of Málaga, Málaga, Spain
| | - Michael F. Murphy
- NHS Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, University of Oxford, Oxford, UK
| | - Toby Richards
- Centre for CardioVascular and Interventional Research (CAVIAR), University College London, Rockerfellow Building, University Street, London, UK
| | - Aryeh Shander
- Department of Anaesthesiology and Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, TeamHealth Research Institute, Englewood, NJ USA
| | - Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
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Leahy MF, Hofmann A, Towler S, Trentino KM, Burrows SA, Swain SG, Hamdorf J, Gallagher T, Koay A, Geelhoed GC, Farmer SL. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion 2017; 57:1347-1358. [DOI: 10.1111/trf.14006] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 01/28/2023]
Affiliation(s)
- Michael F. Leahy
- School of Medicine and Pharmacology; The University of Western Australia
- Department of Haematology; Royal Perth Hospital
- PathWest Laboratory Medicine; Royal Perth Hospital; Perth, Western Australia Australia
| | - Axel Hofmann
- Department of Anesthesiology; University Hospital Zurich; Zurich Switzerland
- School of Surgery; University of Western Australia
- Centre for Population Health Research; Curtin University; Perth Western Australia Australia
| | - Simon Towler
- Service 4, Fiona Stanley Hospital; Murdoch Western Australia Australia
| | | | - Sally A. Burrows
- School of Medicine and Pharmacology; The University of Western Australia
| | - Stuart G. Swain
- Business Intelligence Unit, South Metropolitan Health Service
| | - Jeffrey Hamdorf
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences; The University of Western Australia
- Clinical Training and Evaluation Centre (CTEC); University of Western Australia; Perth Western Australia Australia
| | - Trudi Gallagher
- Department of Health; Western Australia Australia
- Accumen LLC; San Diego California
| | - Audrey Koay
- Department of Health; Western Australia Australia
| | - Gary C. Geelhoed
- Department of Health; Western Australia Australia
- School of Paediatrics and Child Health and School of Primary and Aboriginal and Rural Health; The University of Western Australia; Perth Western Australia Australia
| | - Shannon L. Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences; The University of Western Australia
- Centre for Population Health Research, Faculty of Health Sciences; Curtin University; Perth Western Australia Australia
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Shander A, Nemeth J, Cruz JE, Javidroozi M. Patient blood management: A role for pharmacists. Am J Health Syst Pharm 2017; 74:e83-e89. [DOI: 10.2146/ajhp151048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, NJ
| | - Jeff Nemeth
- Department of Pharmacy, Englewood Hospital and Medical Center, Englewood, NJ
| | - Joseph E. Cruz
- Department of Pharmacy, Englewood Hospital and Medical Center, Englewood, NJ, and Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, Piscataway, NJ
| | - Mazyar Javidroozi
- Department of Anesthesiology and Critical Care Medicine, Englewood Hospital and Medical Center, Englewood, NJ
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Trentino K, Farmer S, Gross I, Shander A, Isbister J. Observational studies - should we simply ignore them in assessing transfusion outcomes? BMC Anesthesiol 2016; 16:96. [PMID: 27741940 PMCID: PMC5064888 DOI: 10.1186/s12871-016-0264-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/07/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND As defined by evidence-based medicine randomized controlled trials rank higher than observational studies in the hierarchy of clinical research. Accordingly, when assessing the effects of treatments on patient outcomes, there is a tendency to focus on the study method rather than also appraising the key elements of study design. A long-standing debate regarding findings of randomized controlled trials compared with those of observational studies, their strengths and limitations and questions regarding causal inference, has recently come into focus in relation to research assessing patient outcomes in transfusion medicine. DISCUSSION Observational studies are seen to have limitations that are largely avoided with randomized controlled trials, leading to the view that observational studies should not generally be used to inform practice. For example, observational studies examining patient outcomes associated with blood transfusion often present higher estimates of adverse outcomes than randomized controlled trials. Some have explained this difference as being a result of observational studies not properly adjusting for differences between patients transfused and those not transfused. However, one factor often overlooked, likely contributing to these variances between study methods is different exposure criteria. Another common to both study methods is exposure dose, specifically, measuring units transfused during only a part of the patient's hospital stay. When comparing the results of observational studies with randomized controlled trials assessing transfusion outcomes it is important that one consider not only the study method, but also the key elements of study design. Any study, regardless of its method, should focus on accurate measurement of the exposure and outcome variables of interest. Failure to do so may subject the study, regardless of its type, to bias and the need to interpret the results with caution.
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Affiliation(s)
- Kevin Trentino
- Performance Unit, South Metropolitan Health Service, Perth, Western Australia, Australia
| | - Shannon Farmer
- School of Surgery, Faculty of Medicine Dentistry and Health Sciences, The University of Western Australia, Perth, Western Australia, Australia. .,Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
| | | | - Aryeh Shander
- Department of Anesthesiology and Critical Care, Englewood Hospital and Medical Center, Englewood, NJ, USA
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Malkin M, Lenart J, Walsh CA, Woodfin M, Vadi M. Transfusion Ethics in a Pediatric Jehovah's Witness Trauma Patient: Simulation Case. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2016; 12:10450. [PMID: 31008228 PMCID: PMC6464417 DOI: 10.15766/mep_2374-8265.10450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 06/27/2016] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Current ethical practice allows for adult patients with decision-making capacity to refuse blood transfusion, even at the cost of high morbidity or mortality. However, for an adult patient who is of the Jehovah's Witness faith, an unwanted blood transfusion confers a psychospiritual cost to the patient and a financial cost to health care entities. The ethical boundaries are increasingly ambiguous with minors who are members of the Jehovah's Witness faith. This simulation experience intends to identify and address knowledge gaps in the care of minors in an emergent setting using a biomedical ethics framework. METHODS This scenario provides an immersive simulation experience involving a 12-year-old Jehovah's Witness patient requiring emergent laparotomy for splenic hemorrhage. Patient interview (via simulation manikin with instructor voice) and care handoff take place in an operating room setting. The learner ascertains the patient's and family's refusal of blood products. Induction of general anesthesia results in profound patient hypotension secondary to acute blood-loss anemia. Pulseless electrical activity results if packed red blood cells are not administered. Ethical principles require the learner to impose an unwanted lifesaving therapy on a minor patient over the objections of family members. Secondly, the anesthesia provider must advocate for transfusion on these ethical grounds against a well-meaning but ultimately misguided surgeon who opposes transfusion. An included learner evaluation form based on ACGME core competencies facilitates postsimulation debriefing. RESULTS Participants were primarily anesthesia residents and fellows. Anecdotally, the residents said that it "felt good to be an attending" and that the simulation helped them appreciate how important conflict resolution skills are in the OR setting. Additionally, faculty appreciated the ability to assess the development of crucial assertiveness skills, with the option of remediating incorrect behavior during the debriefing. DISCUSSION This simulation experience provides experience in the emergent medical management of a pediatric trauma patient while also incorporating specific ethical consent issues unique to pediatric and trauma patient populations. Furthermore, this experience develops professionalism skills and practice in assertive patient advocacy.
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Affiliation(s)
- Mathew Malkin
- Assistant Professor of Anesthesiology, Loma Linda University School of Medicine
| | - John Lenart
- Associate Professor, Division of Anesthesiology, Loma Linda University School of Medicine
- Assistant Professor of Graduate Nursing, Loma Linda University School of Nursing
| | - Catherine A. Walsh
- Assistant Professor of Plastic and Reconstructive Surgery, Loma Linda University School of Medicine
| | - Michelle Woodfin
- Assistant Professor of Anesthesiology, Loma Linda University School of Medicine
| | - Marissa Vadi
- Assistant Professor of Anesthesiology, Loma Linda University School of Medicine
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