Programmes for the management of preoperative anaemia: audit in ten European hospitals within the PaBloE (Patient Blood Management in Europe) Working Group

BACKGROUND AND OBJECTIVES

Preoperative anaemia is an independent risk factor for a higher morbidity and mortality, a longer hospitalization and increased perioperative transfusion rates. Managing preoperative anaemia is the first of three pillars of Patient Blood Management (PBM), a multidisciplinary concept to improve patient safety. While various studies provide medical information on (successful) anaemia treatment pathways, knowledge of organizational details of diagnosis and management of preoperative anaemia across Europe is scarce.

MATERIALS AND METHODS

To gain information on various aspects of preoperative anaemia management including organization, financing, diagnostics and treatment, we conducted a survey (74 questions) in ten hospitals from seven European nations within the PaBloE (Patient Blood Management in Europe) working group covering the year 2016.

RESULTS

Organization and activity in the field of preoperative anaemia management were heterogeneous in the participating hospitals. Almost all hospitals had pathways for managing preoperative anaemia in place, however, only two nations had national guidelines. In six of the ten participating hospitals, preoperative anaemia management was organized by anaesthetists. Diagnostics and treatment focused on iron deficiency anaemia which, in most hospitals, was corrected with intravenous iron.

CONCLUSION

Implementation and approaches of preoperative anaemia management vary across Europe with a primary focus on treating iron deficiency anaemia. Findings of this survey motivated the hospitals involved to critically evaluate their practice and may also help other hospitals interested in PBM to develop action plans for diagnosis and management of preoperative anaemia.

Health economics of Patient Blood Management: a cost-benefit analysis based on a meta-analysis

BACKGROUND AND OBJECTIVES

Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts designed to improve haemoglobin concentration, optimize haemostasis and minimize blood loss in an effort to improve patient outcomes. The focus of this cost-benefit analysis is to analyse the economic benefit of widespread implementation of a multimodal PBM programme.

MATERIALS AND METHODS

Based on a recent meta-analysis including 17 studies (>235 000 patients) comparing PBM with control care and data from the University Hospital Frankfurt, a cost-benefit analysis was performed. Outcome data were red blood cell (RBC) transfusion rate, number of transfused RBC units, and length of hospital stay (LOS). Costs were considered for the following three PBM interventions as examples: anaemia management including therapy of iron deficiency, use of cell salvage and tranexamic acid. For sensitivity analysis, a Monte Carlo simulation was performed.

RESULTS

Iron supplementation was applied in 3·1%, cell salvage in 65% and tranexamic acid in 89% of the PBM patients. In total, applying these three PBM interventions costs €129·04 per patient. However, PBM was associated with a reduction in transfusion rate, transfused RBC units per patient, and LOS which yielded to mean savings of €150·64 per patient. Thus, the overall benefit of PBM implementation was €21·60 per patient. In the Monte Carlo simulation, the cost savings on the outcome side exceeded the PBM costs in approximately 2/3 of all repetitions and the total benefit was €1 878 000 in 100·000 simulated patients.

CONCLUSION

Resources to implement a multimodal PBM concept optimizing patient care and safety can be cost-effectively.

Preoperative Anaemia in Primary Hip and Knee Arthroplasty

INTRODUCTION

Approximately one in three patients has untreated preoperative anaemia, which in turn is associated with an increased need for transfusion of allogenic red blood cell concentrates (RBC) and complications in the context of a surgical intervention. Here, the prevalence of preoperative and postoperative anaemia as well as their effects on transfusion rate, hospital length of stay and hospital mortality in primary hip and knee arthroplasty has been analysed.

METHODS

From January 2012 to September 2018, 378,069 adult inpatients from 13 German hospitals were analysed on the basis of an anonymized registry. Of these, n = 10,017 patients had a hip and knee joint primary arthroplasty. The primary endpoint was the incidence of preoperative anaemia, which was analysed by the first available preoperative haemoglobin value according to the WHO definition. Secondary endpoints included in-hospital length of stay, number of patients with red blood cell concentrate transfusion, incidence of hospital-acquired anaemia, number of deceased patients, and postoperative complications.

RESULTS

The preoperative anaemia rate was 14.8% for elective knee joint arthroplasty, 22.9% for elective hip joint arthroplasty and 45.0% for duo-prosthesis implantation. Preoperative anaemia led to a significantly higher transfusion rate (knee: 8.3 vs. 1.8%; hip: 34.5 vs. 8.1%; duo-prosthesis: 42.3 vs. 17.4%), an increased red blood cell concentrate consumption (knee: 256 ± 107 vs. 29 ± 5 RBC/1000 patients; hip: 929 ± 60 vs. 190 ± 16 RBC/1000 patients; duo-prosthesis: 1411 ± 98 vs. 453 ± 42 RBC/1000 patients). Pre-operative anaemia was associated with prolonged hospital stay (12.0 [10.0; 17.0] d vs. 11.0 [9.0; 13.0] d; p < 0.001) and increased mortality (5.5% [4.6 - 6.5%] vs. 0.9% [0.7 - 1.2%]; Fisher p < 0.001) compared to non-anaemic patients. In patients aged 80 years and older, the incidence of preoperative anaemia and thus the transfusion rate was almost twice as high as in patients under 80 years of age.

SUMMARY

Preoperative anaemia is common in knee and hip primary arthroplasty and was associated with a relevant increase in red blood cell concentrate consumption. In the context of patient blood management, a relevant potential arises, especially in elective orthopaedic surgery, to better prepare elective patients, to avoid unnecessary transfusions and thus to conserve the valuable resource blood.

[Cell Salvage in Anesthesiology]

Re-infusion of washed autologous blood cell salvage from the operative field and wound drainages is used as part of blood conservation strategy within Patient Blood Management (PBM). Cell salvage is an effective method to reduce allogeneic blood transfusion. A main advantage of cell salvage is the prevention of storage-related damage to the erythrocytes.Cell salvage has wide applications in surgeries with expected blood loss higher than 500 ml like cardiac, vascular, orthopedic surgery, and by the use of blood irradiation also in cancer surgery.

[Patient Blood Management: Preoperative Anemia and Case Reports from the Anemia Walk-In Clinic]

Preoperative anemia is independently associated with increased morbidity and mortality and represents the strongest predictor for transfusion of red blood cells. Iron deficiency anemia is the most frequent form of anemia and could easily be treated by supplementation with iron. Patient Blood Management (PBM) focusses on prevention and management of anemia to optimize the patient and reduce unnecessary allogeneic blood products.

[Point-of-care Coagulation Testing in Neurosurgery]

Disorders of the coagulation system can seriously impact the clinical course and outcome of neurosurgical patients. Due to the anatomical location of the central nervous system within the closed skull, bleeding complications can lead to devastating consequences such as an increase in intracranial pressure or enlargement of intracranial hematoma. Point-of-care (POC) devices for the testing of haemostatic parameters have been implemented in various fields of medicine. Major advantages of these devices are that results are available quickly and that analysis can be performed at the bedside, directly affecting patient management. POC devices allow identification of increased bleeding tendencies and therefore may enable an assessment of hemorrhagic risks in neurosurgical patients. Although data regarding the use of POC testing in neurosurgical patients are limited, they suggest that coagulation testing and hemostatic therapy using POC devices might have beneficial effects in this patient population. This article provides an overview of the application of point-of-care coagulation testing in clinical practice in neurosurgical patients.