Therapeutic options to minimize allogeneic blood transfusions and their adverse effects in cardiac surgery: a systematic review

Patient Blood Management Program Implementation: Comprehensive Recommendations and Practical Strategies

INTRODUCTION

Blood transfusion is one of the most common medical practices worldwide. However, current scientific literature has shown that the immunomodulatory effects of blood transfusion are associated with an increased likelihood of infection, prolonged hospitalization, and morbimortality. Also, it means high costs for healthcare systems.

METHODS

In this context, acknowledging that blood transfusions are essentially heterologous cell transplantations, the use of therapeutic options has gained strength and is collectively known as the patient blood management (PBM) program. PBM is an approach based on three main pillars: (1) treating anemias and coagulopathies in an optimized manner, especially in the preoperative period; (2) optimizing perioperative hemostasis and the use of blood recovery systems to avoid the loss of the patient's blood; (3) anemia tolerance, with improved oxygen delivery and reduced oxygen demand, particularly in the postoperative period.

RESULTS

Current scientific evidence supports the effectiveness of PBM by reducing the need for blood transfusions, decreasing associated complications, and promoting more efficient and safer blood management. Thus, PBM not only improves clinical outcomes for patients but also contributes to the economic sustainability of healthcare systems.

CONCLUSION

The aim of this review was to summarize PBM strategies in a comprehensive, evidence-based approach through a systematic and structured model for PBM implementation in tertiary hospitals. The recommendations proposed herein are from researchers and experts of a high-complexity university hospital in the network of the Sistema Único de Saúde, presenting itself as a strategy that can be followed as a guideline for PBM implementation in other settings.

The effectiveness of cell salvage in extracorporeal circulation surgeries in relation to use of health resources after use: A systematic review and meta-analysis

Background

Alternatives to allogeneic blood transfusions are sought for resource management reasons and it is necessary to investigate the efficiency and efficacy on Cell Salvage use. The objective of this study is to analyze the effectiveness of the Cell Salvage system in addressing factors related to healthcare service utilization that may lead to increased healthcare expenditure.

Methods

A systematic review with meta-analysis was conducted through literature search in Medline, CINAHL, Scopus, Web of Science, and Cochrane Library. Inclusion criteria were studies in English/Spanish, without year restriction and Randomized Controlled Trials design, conducted in adults.

Results

Twenty-six studies were included in the systematic review, involving a total of 4781 patients (nexperimental group = 2365; ncontrol group = 2416). Significant differences favored the Cell Salvage system in units of transfused Red Blood Cells, in terms of units (p = 0.04; SMD = -0.42 95 % CI = -0.83 to -0.02) and individuals (p = 0.001; RR = 0.71, 95 % CI = 0.60 to 0.84) transfused. No significant differences were found in ICU (p = 0.93) and hospital stay duration (p = 0.21), number of reoperations (p = 0.68), and number of units and individuals transfused in terms of platelets (p > 0.05).

Conclusions

Cell Salvage use holds high potential for reducing healthcare costs and indirectly contributing to improving blood and blood product reserves within blood banks. Results obtained thus far do not provide definitive evidence regarding the duration of hospital stay, ICU stay, need for reoperation, or the quantity of transfused platelets. Therefore, it is recommended to increase the number of studies to assess the impact on the economic models of the Cell Salvage system.

Extract from the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery - Patient Blood Management

The 2022 Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology are an update on the previous guidelines reported in 2014. The revised guidelines provide standardized perioperative cardiovascular management of surgical patients and emphasis on risk assessment of the patient combined with the inherent risk of the surgical procedure. One of the novelties in these guidelines is the Patient Blood Management programme, which is based on a three pillar concept: preoperative hemoglobin optimization, minimize iatrogenic blood loss and bleeding, and harness tolerance to anemia in an effort to improve patient outcome. In this review, we highlight the three pillars of Patient Blood Management and recommendations made by the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

FORCE Risk Stratification Tool for Pediatric Cardiac Rehabilitation and Fitness Programs

Risk stratification is required to set an exercise prescription for cardiac rehabilitation, but an optimal scheme for congenital heart disease (CHD) is unknown. We piloted a system based on hemodynamic rather than anatomic factors: function, oxygen level, rhythm, complex/coronary anatomy, and elevated load (FORCE). Feasibility, efficacy, and safety of the FORCE tool were evaluated. Patients < 22 years old participating in the Cardiac Fitness Program at Boston Children's Hospital between 02/2017 and 12/2021 were retrospectively analyzed. Assigned FORCE levels, anatomy, adverse events, fitness and exercise test data were collected. Of 63 attempts at FORCE classification, 62 (98%) were successfully classified while one with restrictive cardiomyopathy was not. Thirty-nine (62%) were FORCE 1, 16 (25%) were FORCE 2, and seven (11%) were FORCE 3. Almost half of FORCE 1 patients had simple or complex CHD and the majority of FORCE 2 patients had single ventricle CHD. FORCE 3 patients were more likely to have serious arrhythmias or cardiomyopathy than those in FORCE 1 or 2 (p < 0.001). Postural orthostatic tachycardia syndrome patients appeared in FORCE 1 only. No adverse events occurred over 958 total sessions. The total number of fitness sessions/participant was similar across FORCE levels. It was feasible to risk stratify patients with CHD using a clinical FORCE tool. The tool was effective in categorizing patients and simple to use. No adverse events occurred with fitness training over nearly 1000 exercise training sessions. Adding diastolic dysfunction to the original model may add utility.

Blood components use at two private hospitals in Belo Horizonte, Minas Gerais between July 2017 and June 2019

INTRODUCTION

A retrospective ecological longitudinal study was carried out with data on blood components use from two private hospital units that belong to the same organization located in Belo Horizonte between July 2017 and June 2019.

OBJECTIVES

To describe the monthly series of red blood cells, platelets and plasma use and the rate of blood components use for general hospitalizations in the health network, from the perspective of time series.

METHODS

A total of 15 time series were created with monthly data related to the use of blood components. The stationarity of the series was verified by the unit root test, the trend, by the Cox-Stuart test and seasonality, by the Fisher test (significance levels of 10% for the first test and 5% for the last two).

RESULTS

All series tested positive for the trend component and showed an increasing trend for the use of blood components. Ten series showed statistically significant seasonality and eight series were identified as non-stationary. The percentage of transfusions of blood components due to hospitalization at hospitals 1 and 2 was 29% (22% at hospital 1 and 38.9% at hospital 2).

CONCLUSION

This study was able to describe the components of blood components use dynamics, from the perspective of time series at hospitals. Due to the growing trend in demand for blood components and their high cost, we propose the reduction of blood components use and the expanded use of alternative blood transfusion strategies.

Association of Primary Hemodilution and Retrograde Autologous Priming with Transfusion in Cardiac Surgery: Analysis of the Perfusion Case Database of the Japanese Society of Extra-Corporeal Technology in Medicine

It is important to avoid unnecessary blood cell transfusion. However, the associations of hemodilution and retrograde autologous priming with red blood cell transfusion during and after cardiopulmonary bypass (CPB) in cardiac surgery in Japan are currently unclear. We analyzed these associations using data for 3,090 adults from the Perfusion Case Database of the Japanese Society of Extra-Corporeal Technology in Medicine. Percent hemodilution was calculated by total priming volume and weight. Logistic regression models were used to adjust for covariates including type of surgery, gender, age, hemoglobin concentration before CPB, CPB time, urine volume during CPB, and institution. The percentages of red blood cell transfusions during CPB for patients with <15, 15 to <20, 20 to <25, 25 to <30, and ≥30% hemodilution were 43.0, 51.5, 68.9, 77.3, and 87.7%, respectively. This increase in line with increasing dilution was significant after adjusting for covariates. The percentage of red blood cell transfusion after CPB also increased slightly between 39.0 and 49.4% with percent hemodilution, but the trend after adjusting for covariates was not significant. Use of retrograde autologous priming was significantly associated with blood cell transfusion during CPB after adjusting for covariates, but was not significantly related to blood cell transfusion after CPB. These results suggest that optimizing the percent hemodilution and use of retrograde autologous priming might reduce the use of red blood cell transfusion during CPB in clinical practice in Japan.

Clinical and Surgical Strategies for Avoiding or Reducing Allogeneic Blood Transfusions

Blood transfusions have still been used as a standard therapy to treat severe anemia. Current evidences point to both excessive allogeneic blood consumption and decreased donations, which result in reduced stocks in blood banks. Several studies have increasingly suggested a more restrictive transfusion practice for blood products. Currently, a number of autologous blood conservation protocols in surgeries have been noted. We report a case of severe anemia with 2.9 g/dL hemoglobin, which was successfully handled without using the standard therapy to treat anemia with hemotransfusions. Such a case of severe anemia condition resulted after the patient was submitted to ascending aortic aneurism repair, valvar aortic replacement, reimplantation of right coronary ostium, followed by a coronary artery bypass grafting and several postoperative complications. The main clinical and surgical strategies used in this case to avoid blood transfusions were acute normovolemic hemodilution, intraoperative blood cell salvage, and meticulous hemostasis, beyond epsilon-aminocaproic acid, desmopressin, prothrombin complex concentrate, human fibrinogen concentrate, factor VIIa recombinant, erythropoietin and hyperoxic ventilation.