Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC)

Comparison of minimal invasive extracorporeal circulation versus standard cardiopulmonary bypass systems on coronary artery bypass surgery

Background

In this study, we shared our experience with the minimal invasive extracorporeal circulation system for coronary artery bypass grafting patients.

Methods

A total of 163 patients were included in the retrospective study, with 83 patients (63 males, 20 females; mean age: 61.9±8.9 years; range, 35 to 81 years) undergoing coronary artery bypass grafting with minimal invasive extracorporeal circulation and 80 patients (65 males, 15 females; mean age: 60.5±8.8 years; range, 43 to 82 years) undergoing coronary artery bypass grafting with conventional cardiopulmonary bypass between July 2021 and April 2023. Elective coronary bypass performed by same surgical team were included in the study. Mortality, major adverse cardiac and cerebrovascular event, hospital stays and transfusion requirements were evaluated.

Results

There were no significant differences in sex distribution, age, comorbidities, and blood values between the two groups. Intraoperatively, the minimal invasive extracorporeal circulation group had a slightly higher number of distal anastomoses and comparable times for aortic cross-clamp and cardiopulmonary bypass. Postoperative outcomes such as tamponade, bleeding, atrial fibrillation, left ventricular ejection fraction improvement or reduction, and postoperative drainage were similar between the two groups. However, the minimal invasive extracorporeal circulation group had fewer transfusions of packed red blood cells and fresh frozen plasma and a shorter length of stay in the intensive care unit.

Conclusion

The minimal invasive extracorporeal circulation system effectively preserves blood, works with lower activated clotting time values without additional complications in coronary artery bypass grafting, and could present a better option for patients with anemia or patients with a relatively high risk for high-dose heparinization.

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.

Cost-Effectiveness and Budget Impact of Comprehensive Anemia Management, The First Pillar of Patient Blood Management, on the Turkish Healthcare System

Purpose

Methods

Results

Conclusion

Blood and Blood Product Conservation: Results of Strategies to Improve Clinical Outcomes in Open Heart Surgery Patients at a Tertiary Hospital Are Maintained 4 Years after Initiation

Blood product usage is an important outcome for patients undergoing cardiac surgery. In 2015, our center made a concerted effort with multiple departments to focus on reducing transfusion rates in surgical patients requiring cardiopulmonary bypass (CPB). Specific changes included an upgrade of the oxygenator in mid-2015 and, in early 2016, implementation of a hemostasis management system (HMS) that used heparin dose-response titration assays for heparin and protamine management. A retrospective chart review demonstrated significant decreases in the quarterly average of patients receiving packed red blood cells (PRBCs) from a baseline of 26.7% to 22.7% following the oxygenator upgrade (p = .021) and from 22.7% to 8.8% following implementation of the HMS (p = .0017). Platelet usage decreased from an average of 50.5% during the baseline and oxygenator upgrade periods to 22.2% following implementation of the HMS (p < .0001). Usage of fresh frozen plasma (FFP) decreased from an average of 28.2% of cases during the baseline and oxygenator upgrade periods to 10.4% during 2016, and cryoprecipitate usage decreased from 38.5% to 15.4%. Heparin usage averaged 56,903 units before implementation of the HMS, decreasing to an average of 43,796 units following HMS implementation (p < .0001). During the same time periods, protamine usage averaged 340.3 mg and 183.2 mg, respectively. Because improvements achieved during quality initiatives may revert back to their pre-intervention state once the assessment period is over, we performed a second retrospective analysis to determine whether the improvements achieved were maintained during the 48 months following the initial study. During 2017-2020, quarterly average usage of blood products was as follows: PRBCs, 11.9%; platelets, 14.7%; FFP, 6.2%; and cryoprecipitate, 11.5%. Quarterly, average use of heparin and protamine were 31,556 ± 2,757 units and 189 ± 113 mg, respectively. These findings indicate that the improvements achieved were not limited to the duration of the initial quality initiative.

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.