Harms associated with single unit perioperative transfusion: retrospective population based analysis

Perioperative Transfusion Practices in Adults Having Noncardiac Surgery

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices.

Adjusting Current Hemoglobin Thresholds: A Way to Improve Outcome in Women Undergoing Major Surgery

Background/Objective: In the perioperative setting, a suboptimal total hemoglobin (Hb) mass puts women and men at an unreasonable disadvantage. Anemia is an independent risk factor for transfusion, postoperative complications, and mortality. The Hb cut-off value for women was set at <12.0 g/dL by the World Health Organization (WHO) and has been rigorously debated for decades. The aim of this study was to elucidate the risk for postoperative complications in female patients with Hb levels < 12.0, 12.0-12.9, and ≥13.0 g/dL. Material and Methods: Single-center retrospective analysis of female patients undergoing major surgery. Results: In total, 6,516 patients ≥18 years of age had major surgery between 2018 and 2019 and 2,446 female patients were included in analysis. Mean age was 67.4 ± 16.6, 66.4 ± 15.6, and 64.5 ± 15.5 years in female patients with preoperative Hb levels <12.0, 12.0-12.9 and ≥13.0 g/dL, respectively. The transfusion rate of red blood cells (RBCs) was significantly higher in female patients with Hb <12.0 g/dL (53%) and with Hb 12.0-12.9 g/dL (31%) compared to female patients ≥13.0 g/dL (22%). Rates of pneumonia, acute kidney injury, and sepsis were significantly higher in patients with Hb <12.0 and 12.0-12.9 g/dL compared to patients with Hb ≥13.0 g/dL. Total length of hospital stay was significantly longer in female patients with Hb <12.0 g/dL than patients with Hb 12.0-12.9 g/dL and Hb ≥13.0 g/dL (10 days vs. 8 days). Conclusion: Taken together, our data show that Hb values below 12.9 g/dL are associated with increased probability of RBC transfusions and increased risk of postoperative complications. In addition, our results indicate that postoperative outcomes for women might be optimized by increasing cut-off values for anemia. The call to revise the anemia threshold for women by the WHO can no longer be disregarded.

A Cautionary Note on Using Propensity Score Calibration to Control for Unmeasured Confounding Bias When the Surrogacy Assumption Is Absent

Conventional propensity score methods encounter challenges when unmeasured confounding is present, as it becomes impossible to accurately estimate the gold-standard propensity score when data on certain confounders are unavailable. Propensity score calibration (PSC) addresses this issue by constructing a surrogate for the gold-standard propensity score under the surrogacy assumption. This assumption posits that the error-prone propensity score, based on observed confounders, is independent of the outcome when conditioned on the gold-standard propensity score and the exposure. However, this assumption implies that confounders cannot directly impact the outcome and that their effects on the outcome are solely mediated through the propensity score. This raises concerns regarding the applicability of PSC in practical settings where confounders can directly affect the outcome. While PSC aims to target a conditional treatment effect by conditioning on a subject's unobservable propensity score, the causal interest in the latter case lies in a conditional treatment effect conditioned on a subject's baseline characteristics. Our analysis reveals that PSC is generally biased unless the effects of confounders on the outcome and treatment are proportional to each other. Furthermore, we identify 2 sources of bias: 1) the noncollapsibility of effect measures, such as the odds ratio or hazard ratio and 2) residual confounding, as the calibrated propensity score may not possess the properties of a valid propensity score.

Cost-Effectiveness and Budget Impact Analyses of Patient Blood Management in a Cardiovascular Surgery Department at Ankara Bilkent City Hospital in Turkey

INTRODUCTION

Anemia and transfusion of blood products are risk factors associated with poor patient outcomes across all elective surgeries. Patient blood management (PBM) is a patient-centered approach to optimize patient's endogenous red cell mass, to minimize blood loss in patients undergoing surgery, and to harness and optimize patient-specific physiological tolerance to anemia. This study aimed to assess (1) the impact of PBM on blood product usage in cardiovascular surgeries in a state hospital setting, (2) cost-effectiveness of PBM with a model based on transfusion of red blood cells (RBCs) in cardiovascular surgeries, and (3) the budget impact of PBM implementation based on transfusion of RBCs.

METHODS

Cost-effectiveness and budget impact models, based on the numbers of avoided transfusions and avoided complications after implementation of the PBM program, were compared between pre- and post-PBM periods at the cardiovascular surgery department of Ankara Bilkent City Hospital between February 11, 2019 and July 24, 2022. The probabilities of transfusions and complications with and without PBM were taken from recent meta-analyses. Data from the Ankara Bilkent City Hospital transfusion center informed the pre- and post-PBM calculations. Costs were calculated from the Social Security Institution's perspective.

RESULTS

There was a 21% decrease in the use of RBCs and a 23.7% decrease in use of all blood products after the implementation of PBM. The number of RBC packs per patient reduced by 0.88 packs (21%). The cost saving from reduction of RBC transfusions per patient was 518.68 Turkish lira (TRY) and for the hospital it was 1,635,948 TRY. Fewer complications and lower costs in favor of the post-PBM arm were demonstrated in the cost-effectiveness analysis. On the basis of the budget impact model, in 20 months, the hospital's cardiovascular surgery department saved 6,596,934 TRY (€342,302).

CONCLUSION

This hospital-based study demonstrated that PBM is a budget-saving and cost-effective option in Turkey.

Evaluation of Anemia and Iron Deficiency in French Surgical Departments: The National Multicenter Observational PERIOPES Study

BACKGROUND

Assessment of anemia and iron deficiency before surgery is pivotal for patient blood management (PBM), but few data on current practices are available in the French context. The objective of this study was to describe anemia and iron deficiency management and blood transfusion use in surgical departments in France.

METHODS

This was a national multicenter cross-sectional study in 13 public hospitals and 3 private ones (all with an interest for PBM). Data of consecutive surgical patients from different specialties were retrieved from their chart between July 30, 2019, and December 31, 2021. Data included hemoglobin, iron workup, treatment with oral/intravenous iron or erythropoiesis-stimulating agent, and transfusions.

RESULTS

Data from 2345 patients (median age, 68 years; women, 50.9%; American Society of Anesthesiologists [ASA] physical status III-IV, 35.4%) were obtained. Only 5 centers had a formalized PBM program. At preoperative anesthesia visit, hemoglobin (Hb) level was assessed in 2112 (90.1%) patients and anemia diagnosed in 722 of them (34.2%). Complete iron workup was performed in 715 (30.5%) of the 2345 patients. Iron deficiency anemia was present in 219 (30.3%) of the 722 anemic patients. Among patients with anemia, only 217 (30.1%) of them were treated. A total of 479 perioperative blood transfusions were reported in 315 patients. Restrictive transfusion was not applied in 50% of transfusion episodes, and the single-unit red blood cell transfusion was also not frequent (37.2%).

CONCLUSIONS

Our observational study showed that preoperative anemia was frequent, but iron deficiency was often not assessed and few patients were treated. There is an urgent need for PBM implementation in these centers.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022

BACKGROUND

Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management.

DESIGN

A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline.

RESULTS

These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%.

DISCUSSION

Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality.

CONCLUSION

All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

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

BACKGROUND

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

OBJECTIVE

To develop consensus recommendations for anemia management in surgical patients.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Anemia is associated with higher mortality and morbidity after thoracic endovascular aortic repair

BACKGROUND

It is uncertain whether preoperative anemia is independently associated with thoracic endovascular aortic repair (TEVAR) outcomes. Using a national vascular surgery database, we evaluated the associations between preoperative anemia and 30-day mortality, postoperative complications, and 1-year survival for patients undergoing TEVAR.

METHODS

We retrospectively analyzed all patients in the Vascular Quality Initiative who had undergone TEVAR for aortic dissection, aortic aneurysm, penetrating aortic ulcer, hematoma, or thrombus between January 2011 and December 2019. We excluded patients with a ruptured aneurysm, traumatic dissection, emergent repair, treated aorta distal to zone 5, polycythemia, transfusion of >4 U of packed red blood cells intraoperatively or postoperatively, and missing data on hemoglobin level or surgical indications. The final study cohort was dichotomized into two groups: normal/mild anemia (women, ≥10 g/dL; men, ≥12 g/dL) and moderate/severe anemia (women, <10 g/dL; male, <12 g/dL). Propensity scores by stratification were used to control for confounding in the analysis of the association between the outcomes of 30-day mortality, postoperative complications, and 1-year survival and a binary indicator variable of moderate/severe anemia vs normal/mild anemia. Kaplan-Meier analysis and log-rank tests were used to compare the 1-year survival between the two groups. A Cox regression model was fitted to assess the associations between anemia and survival outcomes.

RESULTS

A total of 3391 patients were analyzed, 958 (28.3%) of whom had had moderate/severe anemia. After adjustment for multiple clinical factors using propensity score stratification, moderate/severe anemia was associated with a 141% increased odds of 30-day mortality (adjusted odds ratio [aOR], 2.41; 95% confidence interval [CI], 1.15-5.05; P = .019), 58% increased odds of any in-hospital complication (aOR, 1.58; 95% CI, 1.17-2.13; P = .003), 281% increased odds of intraoperative transfusion (aOR, 3.81; 95% CI, 2.68-5.53; P < .001). In addition, moderate/severe anemia was associated with significantly worse survival within the first year after TEVAR (log-rank P < .001; 1-year survival rate using Kaplan-Meier estimates, 86.4% ± 1.3% standard error vs 92.5% ± 0.6% standard error) and with an increased risk of mortality in the first postoperative year (adjusted hazard ratio, 1.81; 95% CI, 1.16-2.82; P = .009).

CONCLUSIONS

We found that moderate or severe anemia is associated with significantly increased odds of mortality, postoperative complications, and worse 1-year survival after TEVAR. Future studies are needed to evaluate the effect of anemia correction on the outcomes of TEVAR.

Current concepts in evaluation and management of preoperative anaemia in patients undergoing thoracic surgery

PURPOSE OF REVIEW

The purpose of this review is to evaluate the current recommendations for management of perioperative anaemia in patients undergoing thoracic surgery, present the impact of anaemia on outcomes in this patient population and suggest an algorithm for evaluating and treating anaemia preoperatively.

RECENT FINDINGS

Anaemia is a common medical issue noted preoperatively in patients presenting for thoracic surgery and carries significant morbidity. Preoperative anaemia increases the likelihood of receiving a perioperative transfusion, which represents a significant risk factor for morbidity and reduced disease-free survival in lung cancer patients presenting for thoracic surgery. It is also associated with longer hospital lengths of stay and increased risk for reoperation following lung transplantation. An algorithm-based approach to management of anaemia is beneficial and treatment with iron has been shown to reduce transfusions.

SUMMARY

Patients undergoing thoracic surgery have a high incidence of preoperative anaemia that increases the risk of transfusion and postoperative morbidity. Preoperative evaluation and tailored treatment based on the underlying cause of anaemia reduces the incidence of anaemia prior to surgery and decreases transfusion rates.

Association of anaemia, co-morbidities and red blood cell transfusion according to age groups: multicentre sub-analysis of the German Patient Blood Management Network Registry

Background

Blood transfusions are common medical procedures and every age group requires detailed insights and treatment bundles. The aim of this study was to examine the association of anaemia, co-morbidities, complications, in-hospital mortality, and transfusion according to age groups to identify patient groups who are particularly at risk when undergoing surgery.

Methods

Data from 21 Hospitals of the Patient Blood Management Network Registry were analysed. Patients were divided into age subgroups. The incidence of preoperative anaemia, co-morbidities, surgical disciplines, hospital length of stay, complications, in-hospital mortality rate, and transfusions were analysed by descriptive and multivariate regression analysis.

Results

A total of 1 117 919 patients aged 18–108 years were included. With increasing age, the number of co-morbidities and incidence of preoperative anaemia increased. Complications, hospital length of stay, and in-hospital mortality increased with age and were higher in patients with preoperative anaemia. The mean number of transfused red blood cells (RBCs) peaked, whereas the transfusion rate increased continuously. Multivariate regression analysis showed that increasing age, co-morbidities, and preoperative anaemia were independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion.

Conclusion

Increasing age, co-morbidities, and preoperative anaemia are independent risk factors for complications, longer hospital length of stay, in-hospital mortality, and the need for RBC transfusion. Anaemia diagnosis and treatment should be established in all patients.

Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up?

Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.

Expanding restrictive transfusion evidence in surgical practice: a multicentre, prospective cohort study

BACKGROUND

Findings of observational studies investigating the impact of transfusions are at odds with those of randomised controlled trials, raising concern that observational studies may be inappropriate to inform transfusion decisions. We examined whether observational data could replicate evidence from randomised controlled trials on restrictive transfusion in cardiac and orthopaedic surgery, and be generalised to broader specialties as well as to a lower haemoglobin transfusion threshold (7 g/dL).

MATERIAL AND METHODS

A multicentre, prospective cohort study was performed at three representative regional hospitals in China between 2015 and 2016. Participants were surgical inpatients (≥18 years; hospital stay ≥24 h) in six specialties: cardiac, cerebral, vascular (CCV), and orthopaedic, general, thoracic (non-CCV). Patients with a stable haemoglobin (7-10 g/dL) constituted the primary analytic sample, while patients with ≥500 mL intra-operative bleeding were analysed separately to avoid haemoglobin instability. The association of transfusion with surgical outcomes (death, in-hospital complications) was evaluated.

RESULTS

The transfusion rate was 10.7% in 36,607 patients (mean age, 52.5±14.3 years; 52.3% female). After restriction, stratification, and propensity score matching to reduce patients' heterogeneity, transfusion was unrelated to death (CCV: odds ratio [OR]=0.74, 95% confidence interval [CI]: 0.16-3.39; non-CCV: OR 0.83, 95% CI: 0.36-1.94) and the composite complication (CCV: OR 1.31, 95% CI: 0.63-2.72; non-CCV: OR=1.24, 95% CI: 0.81-1.90). The results were consistent in subgroups (elderly, coronary heart disease, malignant tumour, severe illness) and applicable to patients with significant bleeding after restoration of a stable haemoglobin.

DISCUSSION

Transfusion at a stable haemoglobin concentration of 7-10 g/dL did not alter surgical outcomes. Our results show the feasibility of observational data to expand restrictive transfusion to broader specialties and a lower transfusion threshold in surgical practice.

Factors Associated with Rebound Pain After Patient-controlled Epidural Analgesia in Patients Undergoing Major Abdominal Surgery: A Retrospective Study

OBJECTIVES

Although patient-controlled epidural analgesia (PCEA) is an effective form of regional analgesia for abdominal surgery, some patients experience significant rebound pain after the discontinuation of PCEA. However, risk factors for rebound pain associated with PCEA in major abdominal surgery remain unknown. This study evaluated the incidence of rebound pain related to PCEA and explored potential associated risk factors.

METHODS

We performed a retrospective review of 236 patients using PCEA following hepatobiliary and pancreas surgery between 2018 and 2020 in a tertiary hospital in South Korea. Rebound pain was defined as an increase from well-controlled pain (numeric rating scale <4) during epidural analgesia to severe pain (numeric rating scale ≥7) within 24 hours of discontinuation of PCEA. Logistic regression analysis was performed to determine the factors associated with rebound pain.

RESULTS

A total of 236 patients were included in this study. Patients were categorized into the non-rebound pain group (170 patients; 72%) and the rebound pain group (66 patients; 28%). Multivariable logistic regression analysis revealed that preoperative prognostic nutritional index (PNI) below 45 (odds ratio [OR]=2.080, 95% confidential interval [CI]=1.061-4.079, P=0.033) and intraoperative transfusion (OR=4.190, 95% CI=1.436-12.226, P=0.009) were independently associated with rebound pain after PCEA discontinuation.

DISCUSSION

Rebound pain after PCEA occurred in approximately 30% of patients who underwent major abdominal surgery, resulting in insufficient postoperative pain management. Preoperative low PNI and intraoperative transfusion may be associated with rebound pain after PCEA discontinuation.

Predictive Factors for Acute Postoperative Pain After Open Radical Gastrectomy for Gastric Cancer

Background

Pain has become an important factor in evaluating patients' quality of life and clinical treatment. For gastric cancer (GC) patients, open radical gastrectomy (OG) causes significant trauma to the body, increases patients' pain after operation, and delays early recovery. The aim of this study was to investigate the predictive factors of acute pain after OG within postoperative 72 h.

Methods

From March 2020 to September 2021, 307 patients who underwent OG were included in the study in Nanjing Drum Tower Hospital. The predictors included demographic predictors, pathological data, surgical predictors, and intraoperative predictors. The pain scores at 12, 24, 48, and 72 h after operation were evaluated by numeric rating scale (NRS). The predictors of acute pain were determined by univariate and multivariate analysis.

Results

The average pain score (NRS) of patients showed a downward trend over time within 72 h after OG. Multivariate analysis indicated that total gastrectomy (OR 1.823, 95% CI 1.094–3.040, P < 0.05), AJCC TNM stage (II) (OR.232, 95% CI 0.062–0.872, P < 0.05), AJCC TNM stage(III) (OR.185, 95% CI 0.049–0.698, P < 0.05), BMI (kg/m²) (OR 1.75, 95% CI 1.029–2.976, P < 0.05), distant metastasis (OR 3.054, 95% CI 1.019–9.155, P < 0.05), intraoperative transfusion (OR 2.246, 95% CI 1.267–3.982, P < 0.01) were significant predictive factors for acute pain after OG.

Conclusion

Reasonable postoperative acute pain control was the prerequisite for accelerating the postoperative rehabilitation of patients. In order to reduce the occurrence of excessive or insufficient analgesia, it was necessary for patients who underwent OG to formulate appropriate analgesics according to risk factors.

Recovery of organ-specific tissue oxygen delivery at restrictive transfusion thresholds after fluid treatment in ovine haemorrhagic shock

Background

Fluid resuscitation is the standard treatment to restore circulating blood volume and pressure after massive haemorrhage and shock. Packed red blood cells (PRBC) are transfused to restore haemoglobin levels. Restoration of microcirculatory flow and tissue oxygen delivery is critical for organ and patient survival, but these parameters are infrequently measured. Patient Blood Management is a multidisciplinary approach to manage and conserve a patient’s own blood, directing treatment options based on broad clinical assessment beyond haemoglobin alone, for which tissue perfusion and oxygenation could be useful. Our aim was to assess utility of non-invasive tissue-specific measures to compare PRBC transfusion with novel crystalloid treatments for haemorrhagic shock.

Methods

A model of severe haemorrhagic shock was developed in an intensive care setting, with controlled haemorrhage in sheep according to pressure (mean arterial pressure 30–40 mmHg) and oxygen debt (lactate > 4 mM) targets. We compared PRBC transfusion to fluid resuscitation with either PlasmaLyte or a novel crystalloid. Efficacy was assessed according to recovery of haemodynamic parameters and non-invasive measures of sublingual microcirculatory flow, regional tissue oxygen saturation, repayment of oxygen debt (arterial lactate), and a panel of inflammatory and organ function markers. Invasive measurements of tissue perfusion, oxygen tension and lactate levels were performed in brain, kidney, liver, and skeletal muscle. Outcomes were assessed during 4 h treatment and post-mortem, and analysed by one- and two-way ANOVA.

Results

Each treatment restored haemodynamic and tissue oxygen delivery parameters equivalently (p > 0.05), despite haemodilution after crystalloid infusion to haemoglobin concentrations below 70 g/L (p < 0.001). Recovery of vital organ-specific perfusion and oxygen tension commenced shortly before non-invasive measures improved. Lactate declined in all tissues and correlated with arterial lactate levels (p < 0.0001). The novel crystalloid supported rapid peripheral vasodilation (p = 0.014) and tended to achieve tissue oxygen delivery targets earlier. PRBC supported earlier renal oxygen delivery (p = 0.012) but delayed peripheral perfusion (p = 0.034).

Conclusions

Crystalloids supported vital organ oxygen delivery after massive haemorrhage, despite haemodilution to < 70 g/L, confirming that restrictive transfusion thresholds are appropriate to support oxygen delivery. Non-invasive tissue perfusion and oximetry technologies merit further clinical appraisal to guide treatment for massive haemorrhage in the context of Patient Blood Management.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40635-022-00439-6.

A Global Definition of Patient Blood Management

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

Emergency Blood Transfusion for Trauma and Perioperative Resuscitation: Standard of Care

Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting.

[Preoperative anemia in patients with rheumatic diseases]

A preoperative anemia is an independent risk factor for the occurrence of complications during and after surgical interventions. It is associated with an increased length of hospital stay, higher mortality and an increased use of blood transfusions. Anemia affects some 30-70% of patients suffering from inflammatory rheumatic diseases, mostly caused by iron deficiency and/or chronic inflammation. The possibilities to treat anemia in rheumatic patients were extremely limited for a long period of time as older studies showed life-threatening side effects, the need of high doses of iron supplements or the occurrence of many nonresponders. Further development of the supplements, new dosage schemes and the combination of supplements increased the efficacy and reduced the occurrence of side effects to a minimum. In addition to orthopedic surgical interventions for rheumatism that despite new therapeutic options in some cases still represent the only way to alleviate the complaints, more and more patients with inflammatory rheumatic diseases also need surgical interventions due to comorbidities. Therefore, anemia should be clarified and preoperatively treated in accordance with the new study situation, to minimize additional complications due to anemia and to increase patient safety.

Complication Risk in Ventral Skull Base Surgery Based on Preoperative Hematocrit

OBJECTIVES/HYPOTHESIS

Preoperative anemia has been shown to be a predictor of complications in different surgeries. This has not been exclusively studied in skull base surgery. This study investigates the impact of preoperative hematocrit on complications following ventral skull base (VSB) surgery.

STUDY DESIGN

Retrospective database review.

METHODS

The National Surgical Quality Improvement Program was queried for all cases of VSB surgery from 2005 to 2015. Univariate and multivariate analyses were performed to investigate the impact of preoperative anemia on complications following VSB procedures.

RESULTS

3,053 patients meeting inclusion criteria were identified. On univariate analysis, low hematocrit was found in 39.7% of patients and was associated with increased mean age (55.71 vs. 53.25 years), male gender (63.6% vs. 36.4%), and Black race (18.5% vs. 10.9%). Preoperative anemia was also associated with increased incidences of postoperative pneumonia, blood transfusions, sepsis, medical complications, surgical complications, extended length of hospital stay (LOS), and mortality. On multivariate analysis, associations between low preoperative hematocrit and perioperative transfusions (odds ratio [OR] 2.57, 95% confidence interval [CI] 1.88-3.50, P < .001), total surgical complications (OR 2.12, 95% CI 1.60-2.80, P < .001), and extended LOS (OR 1.29, 95% CI 1.05-1.57, P = .013) remained significant.

CONCLUSIONS

Low preoperative hematocrit is associated with increased risk of postoperative complications and extended LOS in patients undergoing VSB surgery. This study highlights the importance of careful preoperative assessment and management of anemia in these patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

Perioperative Blood Management of Preoperative Anemia Determines Long-Term Outcome in Patients with Pancreatic Surgery

BACKGROUND/PURPOSE

Anemia affects the postoperative course of patients undergoing a major surgical procedure. However, it remains unclear whether anemia has a different impact on the long-term outcome of patients with malignant or benign pancreatic disease.

METHODS

A retrospective analysis of patients undergoing pancreatic surgery for pancreatic malignancies or chronic pancreatitis was conducted between January 2012 and June 2018 at the University Hospital Dresden, Germany. The occurrence of preoperative anemia and the administration of pre-, intra-, and postoperative blood transfusions were correlated with postoperative complications and survival data by uni- and multivariate analysis.

RESULTS

A total of 682 patients were included with 482 (70.7%) undergoing surgical procedures for pancreatic malignancies. Univariate regression analysis confirmed preoperative anemia as a risk factor for postoperative complications > grade 2 according to the Clavien-Dindo classification. Multivariate regression analyses indicated postoperative blood transfusion as an independent risk factor for postoperative complications in patients with a benign (OR 20.5; p value < 0.001) and a malignant pancreatic lesion (OR 4.7; p value < 0.01). Univariate and multivariate analysis revealed preoperative anemia and pre-, intra-, and postoperative blood transfusions as independent prognostic factors for shorter overall survival in benign and malignant patients (p value < 0.001-0.01).

CONCLUSION

Preoperative anemia is a prevalent, independent, and adjustable factor in pancreatic surgery, which poses a significant risk for postoperative complications irrespective of the entity of the underlying disease. It should therefore be understood as an adjustable factor rather than an indicator of underlying disease severity.

Perioperative Care of Patients at High Risk for Stroke During or After Non-cardiac, Non-neurological Surgery: 2020 Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

Perioperative stroke is associated with considerable morbidity and mortality. Stroke recognition and diagnosis are challenging perioperatively, and surgical patients receive therapeutic interventions less frequently compared with stroke patients in the outpatient setting. These updated guidelines from the Society for Neuroscience in Anesthesiology and Critical Care provide evidence-based recommendations regarding perioperative care of patients at high risk for stroke. Recommended areas for future investigation are also proposed.

Incidence, aetiology and outcomes of major postoperative haemorrhage after pulmonary lobectomy

OBJECTIVES

Post-lobectomy bleeding is uncommon and rarely studied. In this study, we aimed to determine the incidence of post-lobectomy haemorrhage and compare the outcomes of reoperation and non-operative management.

METHODS

We conducted a single-institution review of lobectomy cases from 2009 to 2018. The patients were divided into two groups based on the treatment for postoperative bleeding: reoperation or transfusion of packed red blood cells with observation. Transfusion correcting intraoperative blood loss was excluded. One or more criteria defined postoperative bleeding: (i) drop in haematocrit ≥10 or (ii) frank, sustained chest tube bleeding with or without associated hypotension. Covariates included demographics, comorbidities and operative characteristics. Outcomes were operative mortality, complications, length of hospital stay and readmission within 30 days.

RESULTS

Following 1960 lobectomies (92% malignant disease, 8% non-malignant), haemorrhage occurred in 42 cases (2.1%), leading to reoperation in 27 (1.4%), and non-operative management in 15 (0.8%). The median time to reoperation was 17 h. No source of bleeding was identified in 44% of re-explorations. Patients with postoperative haemorrhage were more often male (64.3% vs 41.2%; P < 0.01) and more likely to have preoperative anaemia (45.2% vs 26.5%; P = 0.01), prior median sternotomy (14.3% vs 6.0%; P = 0.04), an infectious indication (7.1% vs 1.8%; P = 0.01) and operative adhesiolysis (45.2% vs 25.8%; P = 0.01). Compared with non-operative management, reoperation was associated with fewer units of packed red blood cells transfusion (0.4 vs 1.9; P < 0.001), while complication rates were similar and 30-day mortality was absent in either group.

CONCLUSIONS

Haemorrhage after lobectomy is associated with multiple risk factors. Reoperation may avoid transfusion. A prospective study should optimize timing and selection of operative and non-operative management.

Current concepts in the evaluation and management of preoperative anemia

PURPOSE OF REVIEW

In the past years, patient blood management (PBM) has evolved to improve patient's care and safety. Anemia is one of the most common medical diseases in the world and is an independent risk factor for morbidity and mortality. Iron deficiency is the main cause for anemia and constitutes a potentially preventable condition with a great impact on surgical outcome. However, preoperative anemia management is not yet established in most hospitals. Changing workflows and re-thinking is challenging. Numerous published studies confirmed the positive effect of preoperative anemia diagnosis and treatment recently.

RECENT FINDINGS

Iron supplementation in iron-deficient anemic (IDA) patients reduce the need for allogenic blood transfusion thereby improving perioperative outcome.

SUMMARY

Since the introduction of PBM programs, important movements towards early detection and therapy of preoperative anemia have been observed. However, preoperative anemia management is not implemented on a large scale as many healthcare professionals are not aware of the most recent findings in the field. Preoperative anemia management, particularly iron supplementation in IDA patients, has proven to be highly effective and has a tremendous effect on patient safety and outcome.

Impact of anaemia in oesophago-gastric cancer patients undergoing curative treatment by means of neoadjuvant chemotherapy and surgery

BACKGROUND

The present study investigated factors associated with pre-neoadjuvant chemotherapy (NAC), and pre-operative anaemia, and examined their impact on outcomes in patients with oesophago-gastric cancer treated with curative intent.

METHODS

Patients diagnosed with oesophago-gastric cancer (January 2010 to December 2015) and treated with curative intent by NAC then surgery at a tertiary centre were included. Patients were grouped by the presence of anaemia (haemoglobin <130 mg/L in males and <120 mg/L in females) and into microcytic (MCV <80 fL), normocytic (80-100 fL) and macrocytic (>100 fL) subgroups. Categorical data were analysed by chi-squared test and overall survival by univariate and multivariate Cox regression.

RESULTS

99/295 (34%) patients who received NAC were diagnosed with pre-NAC anaemia, and 157/268 (59%) of patients who subsequently underwent surgery were diagnosed with pre-operative anaemia. Normocytic anaemia was the most common, with 76 (26%) in pre-NAC and 107 (40%) in pre-operative groups. Pre-NAC anaemia was associated with increasing clinical N stage (p = 0.022), higher modified Glasgow Prognostic Score (mGPS) (p = 0.006), and a higher rate of intra-operative transfusion (p = 0.030). Pre-operative anaemia was associated with pre-NAC anaemia (p = 0.004), increasing age (p = 0.026), higher pre-operative mGPS (p = 0.021), and a higher rate of intra-operative transfusion (p = 0.021). Anaemia before NAC and surgery was associated with poorer overall survival in patient following R0 resection, independent of stage (HR 1.26, 95% CI 1.02-1.54, p = 0.030).

CONCLUSION

Anaemia was associated with poorer overall survival and greater requirement for intra-operative blood transfusion in oesophago-gastric cancer patients undergoing treatment with curative intent.

Real-world results of the implementation of preoperative anaemia clinic with intravenous iron therapy for treating iron-deficiency anaemia: a propensity-matched case-control study

Background

Preoperative anaemia is associated with blood transfusion and longer hospital length of stay. Preoperative iron deficiency anaemia (IDA) can be treated with oral or intravenous (IV) iron. IV iron can raise haemoglobin faster compared with oral iron. However, its ability to reduce blood transfusion and length of stay in clinical trials is inconclusive. This study aims to compare blood transfusion and hospital length of stay between anemic patients who received preoperative IV iron versus standard care, after implementation of a protocol in 2017 to screen patients for preoperative IDA, and its treatment with IV iron.

Methods

Retrospective before-after cohort study comparing 89 patients who received IV iron preoperatively in 2017, with historic patients who received oral iron therapy (selected by propensity score matching (PSM) from historic cohort of 7,542 patients who underwent surgery in 2016). Propensity score was calculated using ASA status, age, gender, surgical discipline, surgical risk and preoperative haemoglobin concentration. Both 1:1 and 1:2 matching were performed as sensitivity analysis.

Results

After PSM, there was no statistically significant difference in distribution of preoperative clinical variables. There was no significant difference in proportion of cases requiring transfusion nor a difference in average units transfused per patient. IV iron cohort stayed in hospital on average 8.0 days compared to non-IV iron cohort 14.1–15.1 days (P=0.006, P=0.013 respectively). Average time from IV iron therapy to surgery was 10.5 days.

Conclusions

Preoperative IV iron therapy for patients with IDA undergoing elective surgery may not reduce perioperative blood transfusion, but this could be due to the short time between therapy and surgery. Implementation of IV iron therapy may reduce hospital length of stay compared to standard care for anemic patients, although this may be enhanced by concomitant improvement in perioperative care.

Improving preoperative haemoglobin using a quality improvement approach to treat iron deficiency anaemia

Optimising preoperative haemoglobin (Hb) before elective surgery is recommended by the National Institute of Clinical Excellence. We have used a quality improvement (QI) approach to treat iron deficiency anaemia in patients presenting to the preoperative assessment clinic (PAC) before major elective oesophagogastric surgery. Through a series of three QI cycles, we have treated iron deficiency, improved preoperative haemoglobin (Hb) and reduced the rate of postoperative blood transfusion. Our methods have included the early diagnosis of iron deficiency at the PAC attendance, the development and implementation of a new clinical guideline on the treatment of preoperative anaemia and the introduction of a one-stop clinic facilitating same-day treatment with intravenous iron, where appropriate, in conjunction with comprehensive preoperative assessment. The incidence of severe preoperative anaemia (Hb<100 g/L) has fallen from 10% in 2014 to 1.6% in 2018. The overall incidence of preoperative anaemia (defined as Hb<130 g/L by international consensus statement) has reduced from 57.9% in 2014 to 43.9% in 2018. Blood transfusion rate has declined from 16% to 6.5% of patients between 2014 and 2018. In 2018, none of the patients who required a postoperative blood transfusion presented to theatre with preoperative anaemia, a significant change from prior to the interventions. There has been a reduction of 63% in the number of units transfused. The project has successfully optimised these patients, leading to improved preoperative Hb and reduced use of blood transfusion.

Prescriptive analytics for reducing 30-day hospital readmissions after general surgery

INTRODUCTION

New financial incentives, such as reduced Medicare reimbursements, have led hospitals to closely monitor their readmission rates and initiate efforts aimed at reducing them. In this context, many surgical departments participate in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), which collects detailed demographic, laboratory, clinical, procedure and perioperative occurrence data. The availability of such data enables the development of data science methods which predict readmissions and, as done in this paper, offer specific recommendations aimed at preventing readmissions.

MATERIALS AND METHODS

This study leverages NSQIP data for 722,101 surgeries to develop predictive and prescriptive models, predicting readmissions and offering real-time, personalized treatment recommendations for surgical patients during their hospital stay, aimed at reducing the risk of a 30-day readmission. We applied a variety of classification methods to predict 30-day readmissions and developed two prescriptive methods to recommend pre-operative blood transfusions to increase the patient's hematocrit with the objective of preventing readmissions. The effect of these interventions was evaluated using several predictive models.

RESULTS

Predictions of 30-day readmissions based on the entire collection of NSQIP variables achieve an out-of-sample accuracy of 87% (Area Under the Curve-AUC). Predictions based only on pre-operative variables have an accuracy of 74% AUC, out-of-sample. Personalized interventions, in the form of pre-operative blood transfusions identified by the prescriptive methods, reduce readmissions by 12%, on average, for patients considered as candidates for pre-operative transfusion (pre-operative hematoctic <30). The prediction accuracy of the proposed models exceeds results in the literature.

CONCLUSIONS

This study is among the first to develop a methodology for making specific, data-driven, personalized treatment recommendations to reduce the 30-day readmission rate. The reported predicted reduction in readmissions can lead to more than $20 million in savings in the U.S. annually.

Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study establishing diagnostic criteria and prognostic importance

BACKGROUND

We aimed to establish diagnostic criteria for bleeding independently associated with mortality after noncardiac surgery (BIMS) defined as bleeding during or within 30 days after noncardiac surgery that is independently associated with mortality within 30 days of surgery, and to estimate the proportion of 30-day postoperative mortality potentially attributable to BIMS.

METHODS

This was a prospective cohort study of participants ≥45 yr old having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011. Cox proportional hazards models evaluated the adjusted relationship between candidate diagnostic criteria for BIMS and all-cause mortality within 30 days of surgery.

RESULTS

Of 16 079 participants, 2.0% (315) died and 36.1% (5810) met predefined screening criteria for bleeding. Based on independent association with 30-day mortality, BIMS was identified as bleeding leading to a postoperative haemoglobin <70 g L^-1, transfusion of ≥1 unit of red blood cells, or that was judged to be the cause of death. Bleeding independently associated with mortality after noncardiac surgery occurred in 17.3% of patients (2782). Death occurred in 5.8% of patients with BIMS (161/2782), 1.3% (39/3028) who met bleeding screening criteria but not BIMS criteria, and 1.1% (115/10 269) without bleeding. BIMS was associated with mortality (adjusted hazard ratio: 1.87; 95% confidence interval: 1.42-2.47). We estimated the proportion of 30-day postoperative deaths potentially attributable to BIMS to be 20.1-31.9%.

CONCLUSIONS

Bleeding independently associated with mortality after noncardiac surgery (BIMS), defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, blood transfusion, or that is judged to be the cause of death, is common and may account for a quarter of deaths after noncardiac surgery.

CLINICAL TRIAL REGISTRATION

NCT00512109.

Preoperative prediction of Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS): an international prospective cohort study

BACKGROUND

Diagnostic criteria for Bleeding Independently associated with Mortality after noncardiac Surgery (BIMS) have been defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or is judged to be the direct cause of death. Preoperative prediction guides for BIMS can facilitate informed consent and planning of perioperative care.

METHODS

In a prospective cohort study of 16 079 participants aged ≥45 yr having inpatient noncardiac surgery at 12 academic hospitals in eight countries between 2007 and 2011, 17.3% (2782) experienced BIMS. An electronic risk calculator for BIMS was developed and internally validated by logistic regression with bootstrapping, and further simplified to a risk index. Decision curve analysis assessed the potential utility of each prediction guide compared with a strategy of identifying risk of BIMS based on preoperative haemoglobin <120 g L^-1.

RESULTS

With information about the type of surgery, preoperative haemoglobin, age, sex, functional status, kidney function, history of high-risk coronary artery disease, and active cancer, the risk calculator accurately predicted BIMS (bias-corrected C-statistic, 0.84; 95% confidence interval, 0.837-0.852). A simplified index based on preoperative haemoglobin <120 g L^-1, open surgery, and high-risk surgery also predicted BIMS, but less accurately (C-statistic, 0.787; 95% confidence interval, 0.779-0.796). Both prediction guides could improve decision making compared with knowledge of haemoglobin <120 g L^-1 alone.

CONCLUSIONS

BIMS, defined as bleeding that leads to a postoperative haemoglobin <70 g L^-1, leads to blood transfusion, or that is judged to be the direct cause of death, can be predicted by a simple risk index before surgery.

CLINICAL TRIAL REGISTRATION

NCT00512109.

Effect of haemoglobin levels on outcome in intravenous thrombolysis-treated stroke patients

INTRODUCTION

Alterations in haemoglobin levels are frequent in stroke patients. The prognostic meaning of anaemia and polyglobulia on outcomes in patients treated with intravenous thrombolysis is ambiguous.

PATIENTS AND METHODS

In this prospective multicentre, intravenous thrombolysis register-based study, we compared haemoglobin levels on hospital admission with three-month poor outcome (modified Rankin Scale 3-6), mortality and symptomatic intracranial haemorrhage (European Cooperative Acute Stroke Study II-criteria (ECASS-II-criteria)). Haemoglobin level was used as continuous and categorical variable distinguishing anaemia (female: <12 g/dl; male: <13 g/dl) and polyglobulia (female: >15.5 g/dl; male: >17 g/dl). Anaemia was subdivided into mild and moderate/severe (female/male: <11 g/dl). Normal haemoglobin level (female: 12.0-15.5 g/dl, male: 13.0-17.0 g/dl) served as reference group. Unadjusted and adjusted odds ratios with 95% confidence intervals were calculated with logistic regression models.

RESULTS

Among 6866 intravenous thrombolysis-treated stroke patients, 5448 (79.3%) had normal haemoglobin level, 1232 (17.9%) anaemia - of those 903 (13.2%) had mild and 329 (4.8%) moderate/severe anaemia - and 186 (2.7%) polyglobulia. Anaemia was associated with poor outcome (ORadjusted 1.25 (1.05-1.48)) and mortality (ORadjusted 1.58 (1.27-1.95)). In anaemia subgroups, both mild and moderate/severe anaemia independently predicted poor outcome (ORadjusted 1.29 (1.07-1.55) and 1.48 (1.09-2.02)) and mortality (ORadjusted 1.45 (1.15-1.84) and ORadjusted 2.00 (1.46-2.75)). Each haemoglobin level decrease by 1 g/dl independently increased the risk of poor outcome (ORadjusted 1.07 (1.02-1.11)) and mortality (ORadjusted 1.08 (1.02-1.15)). Anaemia was not associated with occurrence of symptomatic intracranial haemorrhage. Polyglobulia did not change any outcome.

DISCUSSION

The more severe the anaemia, the higher the probability of poor outcome and death. Severe anaemia might be a target for interventions in hyperacute stroke.

CONCLUSION

Anaemia on admission, but not polyglobulia, is a strong and independent predictor of poor outcome and mortality in intravenous thrombolysis-treated stroke patients.

Issues in the development of hemoglobin based oxygen carriers

Hemoglobin based oxygen carriers (HBOCs) have been developed as alternative oxygen transporting formulations for the acute treatment of anemia and ischemia. Efficacy has been demonstrated in a variety of preclinical models and selected human patients; however, a higher overall incidence of mortality and myocardial infarction in those dosed with HBOCs in later stage clinical trials has prevented widespread regulatory approval. Diagnosis of myocardial infarction is confounded by the fact that HBOCs interfere with troponin assays, as well as other clinical chemistry measurements. Analysis of data pertaining to potential toxicity mechanisms suggests that coronary vasoconstriction is an unlikely contributor, but promotion of intravascular thrombosis may occur by several mechanisms. In addition, fluid and anemia management in patients infused with HBOCs has been suboptimal. Elucidation of potential toxicity mechanisms, refinement of use protocols, and definition of improved patient inclusion/exclusion criteria remain active areas of inquiry in understanding the best manner in which to utilize HBOCs.

Management of the patient presenting with anaemia in the preoperative setting

Preoperative anaemia is common, seen in a third of patients before major surgery. Both preoperative anaemia and blood transfusion are associated with increased patient risk and adverse outcome. Patient Blood Management (PBM) is the multidisciplinary, multimodal approach to optimising the care of patients who may require blood transfusion. Guidelines exist with many recommendations throughout the perioperative pathway. However, the efficacy of individual recommendations as an intervention in terms of clinical outcome can be confusing. In the UK the first national audit of PBM in surgery was carried out in 2015. This reviewed the use and impact of PBM recommendations in hospitals throughout the UK where major surgery was undertaken. The current evidence base for these PBM recommendations was reviewed and the patient outcome in terms of blood transfusion use and length of hospital stay assessed in those where PBM interventions were followed. For the patient who presents with preoperative anaemia, 'quick wins' were identified that reduced blood transfusion use and reduced length of stay in hospital; preoperative discontinuation of anticoagulation or antiplatelet therapy, and intraoperative use of tranexamic acid and cell salvage.

The effect of perioperative blood transfusion on kidney functions in total knee Arthroplasty

Objective:

Various studies have examined the effects of perioperative blood transfusion on kidney functions. In this study, we investigated the effects of blood transfusion on the kidney functions of patients undergoing total knee arthroplasty.

Methods:

: This retrospective study was carried out on 216 patients who had undergone total knee arthroplasty between January 2016 and January 2017. The patients were divided into two groups according to the level of blood transfusion used during surgery. Group-1 comprised 157 patients (72.7%) needing a blood transfusion of less than three units, while the 59 (27.3) patients in Group-2 required three or more than three units.

Results:

No statistical difference was found between the two groups regarding hypertension before surgery, diabetes mellitus, chronic kidney failure, smoking habits or lung disease (p> 0.05). Likewise, there was no significant difference related to pulmonary and other complications or mortality (p> 0.05). When the groups were compared according to their blood parameters, no statistical differences in postoperative renal or other system functions were found (p> 0.05).

Conclusions:

Blood transfusion does not have a negative effect on postoperative blood urea nitrogen (BUN) and creatinine levels, or glomerular filtration rate in total knee arthroplasty.

Survival analysis of intraoperative blood salvage for patients with malignancy disease: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Intraoperative blood salvage as a blood-saving strategy has been widely used in surgery. Considering its theoretic risk of malignant tumor cells being reinfused and the corresponding blood metastases, the safety of intraoperative blood salvage in cancer surgery remains controversial.

METHODS

Following the Preferred Reporting Items for Systemic Review and Meta-Analysis (PRISMA), we searched the Cochrane Library, MEDLINE and EMBASE to November 2017. We included only studies comparing intraoperative blood salvage with allogeneic blood transfusion.

RESULTS

This meta-analysis included 9 studies with 4354 patients with 1346 patients in the intraoperative blood salvage group and 3008 patients in the allogeneic blood transfusion group. There were no significant differences in the 5-year overall survival outcome (odds ratio [OR] 1.12; 95% confidence interval [CI], 0.80-1.58), 5-year disease-free survival outcome (OR 1.08; 95% CI 0.86-1.35), or 5-year recurrence rate (OR 0.86; 95% CI 0.71-1.05) between the 2 study groups. Subgroup analysis also showed no significant differences in the 5-year overall survival outcome (OR 0.97; 95% CI 0.57-1.67) of hepatocellular carcinoma patients in liver transplantation.

CONCLUSIONS

For patients with malignant disease, intraoperative blood salvage did not increase the tumor recurrence rate and had comparable survival outcomes with allogeneic blood transfusion.

Patient blood management: A solution for South Africa

For more than 70 years the default therapy for anaemia and blood loss was mostly transfusion. Accumulating evidence demonstrates a significant dose-dependent relationship between transfusion and adverse outcomes. This and other transfusion-related challenges led the way to a new paradigm. Patient blood management (PBM) is the application of evidence-based practices to optimise patient outcomes by managing and preserving the patient's own blood. 'Real-world' studies have shown that PBM improves patient outcomes and saves money. The prevalence of anaemia in adult South Africans is 31% in females and 17% in males. Improving the management of anaemia will firstly improve public health, secondly relieve the pressure on the blood supply, and thirdly improve the productivity of the nation's workforce. While high-income countries are increasingly implementing PBM, many middle- and low-income countries are still trying to upscale their transfusion services. The implementation of PBM will improve South Africa's health status while saving costs.

Platelet function, but not thrombin generation, is impaired in acute normovolemic hemodilution (ANH) blood

STUDY OBJECTIVE

We investigated the coagulation changes that might occur in acute normovolemic hemodilution (ANH) blood over several hours during cardiac surgery requiring cardiopulmonary bypass.

DESIGN

This study was a prospective observational study.

SETTING

This study took place at a university teaching hospital.

PATIENTS

This study included 26 patients, either ASA 3 or 4 and without known coagulation disorders, undergoing cardiac surgery. Patients were included if the use of cardiopulmonary bypass was expected to reach 2.5 h.

INTERVENTIONS

ANH blood was collected into CPDA-1 collection bags before systemic heparinization. Samples were taken directly from the bags at time of collection and reinfusion to assess changes in platelet and thrombin generation parameters.

MEASUREMENTS

Whole blood from citrated tubes was used immediately for rotational thromboelastometry and platelet aggregometry analyses. Thrombin generation was assessed using calibrated automated thrombography with platelet poor plasma.

MAIN RESULTS

Despite no significant change in platelet count over the ANH storage period, there was significant degradation in platelet function as measured by thrombin receptor activating peptide stimulation on Mulltiplate™ analysis and maximum clot formation on ROTEM™ EXTEM. Notably, there was no change in the ability to generate thrombin.

CONCLUSIONS

Little data exists regarding the quality of coagulation factors in autologous blood. Our study confirms ANH collection results in decreased platelet aggregation with TRAP stimulation; however, this is not appreciated with ADP stimulation. Thrombin generation capacity remains preserved.

When Transfusion Is Not an Option-the Challenges and Rewards

The decision to develop a formal Bloodless Medicine Program to attract and effectively care for patients who decline blood transfusion was made in 1998 by clinical and administrative leaders at our flagship hospital, Allegheny General Hospital, part of the Allegheny Health Network. The Bloodless Medicine Program has more than 20 years of experience in caring for this sometimes challenging patient population and with this experience has provided extensive insight into best practices related to effective, safe, patient blood management. Patient blood management is a patient-centered, evidence-based approach to transfusion that seeks to provide the right care, in the right setting, in the right way, every time. It includes honoring the wishes of patients who decline blood products in their care, that is, "bloodless" medicine. Encouraging patients to participate in their own health care decisions is a vital part of safe, compassionate care. When called upon to provide care to a patient who declines a common therapy such as blood transfusion, clinicians must often develop alternative strategies to achieve the desired results. Their willingness to think creatively and push boundaries has resulted in significant advancement of clinical knowledge and practice related to the use of blood products for all patients. Nurses who advocate for the best care for their patients are a vital component of any successful patient blood management program.

Anemia in hospitalized patients: an overlooked risk in medical care

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.

Patient Blood Management improves outcome in oncologic surgery

Background

Patient Blood Management (PBM) is a systematic quality improving clinical model to reduce anemia and avoid transfusions in all kinds of clinical settings. Here, we investigated the potential of PBM in oncologic surgery and hypothesized that PBM improves 2-year overall survival (OS).

Methods

Retrospective analysis of patients 2 years before and after PBM implementation. The primary endpoint was OS at 2 years after surgery. We identified a sample size of 824 to detect a 10% improvement in survival in the PBM group.

Results

The analysis comprised of 836 patients that underwent oncologic surgery, 389 before and 447 after PBM, was implemented. Patients in the PBM+ presented significantly more frequent with normal hemoglobin values before surgery than PBM− (56.6 vs. 35.7%; p < 0.001). The number of transfusions was significantly reduced from 5.5 ± 11.1 to 3.0 ± 6.9 units/patient (p < 0.001); moreover, the percentage of patients being transfused during the clinic stay was significantly reduced from 62.4 to 40.9% (p < 0.001). Two-year OS was significantly better in the PBM+ and increased from 67.0 to 80.1% (p = 0.001). A normal hemoglobin value (> 12 g/dl in female and > 13 g/dl in male) before surgery (HR 0.43, 95% CI 0.29–0.65, p < 0.001) was the only independent predictive factor positively affecting survival.

Conclusions

PBM is a quality improvement tool that is associated with better mid-term surgical oncologic outcome. The root cause for improvement is the increase of patients entering surgery with normal hemoglobin values.

Electronic supplementary material

The online version of this article (10.1186/s12957-018-1456-9) contains supplementary material, which is available to authorized users.