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Almonacid-Cardenas F, Rivas E, Auron M, Hu L, Wang D, Liu L, Tolich D, Mascha EJ, Ruetzler K, Kurz A, Turan A. Association between preoperative anemia optimization and major complications after non-cardiac surgery: a retrospective analysis. Braz J Anesthesiol 2024; 74:744474. [PMID: 38043700 DOI: 10.1016/j.bjane.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients. METHODS In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl-1 in women and 13.0 g.dl-1 in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome. RESULTS Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator. CONCLUSION Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.
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Affiliation(s)
| | - Eva Rivas
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Universidad de Barcelona, Hospital Clinic of Barcelona, IDIBAPS, Department of Anesthesia, Barcelona, Spain
| | - Moises Auron
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Lucille Hu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA
| | - Dong Wang
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Liu Liu
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Deborah Tolich
- Cleveland Clinic, Department of Blood Management, Cleveland, USA
| | - Edward J Mascha
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, USA
| | - Kurt Ruetzler
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Andrea Kurz
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA
| | - Alparslan Turan
- Cleveland Clinic, Anesthesiology Institute, Department of Outcomes Research, Cleveland, USA; Cleveland Clinic, Anesthesiology Institute, Department of General Anesthesia, Cleveland, USA.
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Benson MA, Tolich D, Callum JL, Auron M. Plasma: indications, controversies, and opportunities. Postgrad Med 2024; 136:120-130. [PMID: 38362605 DOI: 10.1080/00325481.2024.2320080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/13/2024] [Indexed: 02/17/2024]
Abstract
Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.
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Affiliation(s)
- Michael A Benson
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Deborah Tolich
- Blood Management, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeannie L Callum
- Department of Laboratory Medicine and Pathobiology, Queens University, Kingston, ON, Canada
| | - Moises Auron
- Department of Hospital Medicine and Department of Pediatric Hospital Medicine, Cleveland Clinic, Outcomes Research Consortium, Cleveland, OH, USA
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Wabeke D, Tolich D. What Are the Barriers and Facilitators for Critical Care Nurse Participation in a Patient Blood Management Program? Dimens Crit Care Nurs 2023; 42:196-201. [PMID: 37219473 DOI: 10.1097/dcc.0000000000000585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Patient blood management (PBM) programs strive to implement best practices, mitigating blood loss through procedures to decrease anemia and the need for transfusion. Critical care nurses may have the greatest impact on blood preservation and anemia prevention for the most critically ill patients. Nurse perceptions of barriers and facilitators in PBM are not fully understood. OBJECTIVES The primary aim was to determine critical care nurses' perceptions of barriers and facilitators to participation in PBM. The secondary aim was to understand ways in which they believe the barriers can be addressed. METHODS A qualitative descriptive method was used following Colaizzi's process. Critical care nurses (n = 110) were recruited from 10 critical care units in 1 quaternary care hospital to participate in focus groups. Data were analyzed using qualitative methodology and NVivo software. Communication interactions were categorized into codes and themes. RESULTS Study findings were gathered under 5 categories: assessing need for blood transfusions, laboratory challenges, availability and appropriateness of supplies, minimizing need for laboratory draws, and communication. Three prominent themes indicated that (a) critical care nurses have a limited awareness of PBM, (b) critical nurses must be empowered to engage in interprofessional collaboration, and (c) addressing barriers is not complex. CONCLUSION The data provide insight into the challenges of critical care nurse participation in PBM, driving next step efforts in building on the institution's strengths and improving engagement. It is imperative that the recommendations derived from critical care nurses' experiences be further developed.
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Sadana D, Kummangal B, Moghekar A, Banerjee K, Kaur S, Balasubramanian S, Tolich D, Han X, Wang X, Hanane T, Mireles-Cabodevila E, Quraishy N, Duggal A, Krishnan S. Adherence to blood product transfusion guidelines-An observational study of the current transfusion practice in a medical intensive care unit. Transfus Med 2021; 31:227-235. [PMID: 33749043 DOI: 10.1111/tme.12771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/17/2021] [Accepted: 03/05/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Blood transfusions though life-saving are not entirely benign. They are the most overused procedure in the hospital and have been under scrutiny by the 'Choosing Wisely campaign'. The strict adoption of restrictive transfusion guidelines could improve patient outcomes while reducing cost. OBJECTIVES In this study, we evaluate adherence to restrictive transfusion guidelines, along with hospital mortality and length of stay (LOS) in transfusion events with a pre-transfusion haemoglobin (Hb) ≥7 g/dl. Additionally, we evaluated associated costs accrued due to unnecessary transfusions. METHODS We conducted a retrospective observational study in a 64-bed medical intensive care unit (MICU) of an academic medical centre involving all adult patients (N = 957) requiring packed red blood cell transfusion between January 2015 and December 2015. RESULTS In total, 3140 units were transfused with a mean pre-transfusion Hb of 6.75 ± 0.86 g/dl. Nine hundred forty-four (30%) transfusion events occurred with a pre-transfusion Hb ≥7 g/dl, and 385 (12.3%) of these occurred in patients without hypotension, tachycardia, use of vasopressors, or coronary artery disease. Forgoing them could have led to a savings of approximately 0.3 million dollars. Transfusion events with pre-transfusion Hb ≥7 g/dl were associated with an increased mortality in patients with acute blood loss (odds ratio [OR] 2.08, 95% confidence interval [CI] 1.11-3.88; p = 0.02) and LOS in patients with chronic blood loss (β1 .8.26, 95% CI 4.09-12.43; p < 0.01). CONCLUSION A subset of anaemic patients in the MICU still receive red blood cell transfusions against restrictive guidelines offering hospitals the potential for effective intervention that has both economic and clinical implications.
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Affiliation(s)
- Divyajot Sadana
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Basheer Kummangal
- Department of Hospital Medicine, Detroit Receiving Hospital, Detroit, Michigan, USA
| | - Ajit Moghekar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kinjal Banerjee
- Department of Internal Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
| | - Simrat Kaur
- Department of Internal Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shailesh Balasubramanian
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah Tolich
- Department of Surgical Operations, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaozhen Han
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Xiaofeng Wang
- Department of Quantitative Health Sciences, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tarik Hanane
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - NurJehan Quraishy
- Department of Clinical Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
The worldwide COVID-19 pandemic has required healthcare systems to implement strategies for effective healthcare delivery while managing blood supply chain disruptions and shortages created by infection-limiting practices that have reduced blood donations. At Cleveland Clinic, we have made multiple synchronous efforts: a call for increased blood collection, alignment of efforts among transfusion medicine departments (blood banks), enhanced monitoring and triage of blood product use, and increased education on patient blood management practices regarding blood utilization and anemia management. In addition, we created an algorithm to assess anemia risks in patients whose elective surgery was cancelled to optimize preoperative hemoglobin levels.
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Affiliation(s)
- Deborah Tolich
- Director, Blood Management, Surgical Operations, Cleveland Clinic
| | - Moises Auron
- Medical Director, Blood Management, Surgical Operations; Department of Hospital Medicine, Cleveland Clinic Community Care; Department of Pediatric Hospital Medicine, Pediatrics Institute, Cleveland Clinic
| | - Kelly McCoy
- Coordinator, Blood Management, Surgical Operations, Cleveland Clinic
| | - Marni Dargis
- Blood Utilization Coordinator, Cleveland Clinic Martin Health, Stuart, Florida
| | - NurJehan Quraishy
- Section Head, Transfusion Medicine, Robert J. Tomsich Pathology & Laboratory Medicine Institute, Cleveland Clinic
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Styron JF, Klika AK, Szubski CR, Tolich D, Barsoum WK, Higuera CA. Relative efficacy of tranexamic acid and preoperative anemia treatment for reducing transfusions in total joint arthroplasty. Transfusion 2016; 57:622-629. [DOI: 10.1111/trf.13955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 11/05/2016] [Accepted: 11/06/2016] [Indexed: 12/13/2022]
Affiliation(s)
- Joseph F. Styron
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Alison K. Klika
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Caleb R. Szubski
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Deborah Tolich
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
| | - Wael K. Barsoum
- Department of Orthopaedic Surgery; Cleveland Clinic; Cleveland Ohio
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