Variation of blood transfusion in patients undergoing major noncardiac surgery

Reduction of red blood cell transfusions by implementation of a concise pretransfusion checklist

BACKGROUND

This study assesses the effect of the implementation of a concise pretransfusion checklist as a means for restrictive blood transfusion strategy.

OBJECTIVES

To achieve an optimal use of red blood cells and to prevent overdosing of transfusion by implementation of a decision support algorithm.

METHODS

To ensure adequate use of red blood cells, physicians were obliged to complete the checklist with pretransfusion patient information before transfusion was approved. Laboratory employees checked the information and provided approval or refused to process the request. The red blood cell transfusion events, length of stay and mortality were analysed during a pre- and post-implementation period of 1 year.

RESULTS

Transfusion requests decreased by 17·0%. The proportion of 1-unit and 2-unit transfusions decreased by 5·6% and 29·2%, respectively, corresponding with a total red blood cell units reduction of 22·6% and a yearly direct local cost reduction of 190·000 €. The median length of stay of transfused patients on wards decreased by 1·07 days (P < 0·05). Average pre- and post-transfusion haemoglobin levels before and after implementation of the checklist decreased by 0·32-0·35 g L(-1) (P < 0·05) for one unit red blood cell transfusions and 0·72-0·87 g L(-1) (P < 0·05) for two units of red blood cell transfusions.

CONCLUSION

Decision support for transfusion necessity, in the form of a concise checklist as part of the transfusion request, is an example of a successful restricted blood transfusion strategy. The checklist can be applied in other hospitals as well.

Patient blood management: is it worth to be employed?

PURPOSE OF REVIEW

In recent years, the view changed from 'product orientated' to 'patient orientated' and a new concept, named 'patient blood management' (PBM), was created with the aim to improve patient care and safety. However, changing long lasting work practice is more than challenging but the outcomes of several recently published studies confirm the concept and warrant the effort. This review will exemplify the need of patient centered treatments and highlight recent findings in the field of PBM.

RECENT FINDINGS

Anemia is the biggest predictor for red blood cell transfusion that may by itself be associated with adverse outcome. PBM is a multiprofessional and multidisciplinary composition addressing a patient-centered prevention and treatment of both preoperative and hospital-acquired anemia. Thereby, red blood cell utilization can be reduced and patient perioperative outcome improved.

SUMMARY

During recent years, a tremendous movement has been observed in respect of patient safety and patient blood use. However, the majority of hospitals hazard with the implementation of PBM practice mostly because the awareness about recent findings and current recommendations regarding PBM is lacking.

Preoperative platelet transfusions and perioperative red blood cell requirements in patients with thrombocytopenia undergoing noncardiac surgery

BACKGROUND

Perioperative hemorrhage impacts patient outcomes and health care resource utilization, yet the risks of transfusion therapies are significant. In patients with preoperative thrombocytopenia, the effects of prophylactic preoperative platelet (PLT) transfusion on perioperative bleeding complications remain uncertain.

STUDY DESIGN AND METHODS

This is a retrospective cohort study of noncardiac surgical patients between January 1, 2008, and December 31, 2011. Propensity-adjusted analyses were used to evaluate associations between preoperative thrombocytopenia, preoperative PLT transfusion, and the outcomes of interest, with a primary outcome of perioperative red blood cell (RBC) transfusion.

RESULTS

A total of 13,978 study participants were included; 860 (6.2%) had a PLT count of not more than 100 × 10(9) /L with 71 (8.3%) receiving PLTs preoperatively. Administration of PLTs was associated with higher rates of perioperative RBC transfusion (66.2% vs. 49.1%, p = 0.0065); however, in propensity-adjusted analysis there was no significant difference between groups (odds ratio [OR] [95% confidence interval {95% CI}], 1.68 [0.95-2.99]; p = 0.0764]. Patients receiving PLTs had higher rates of intensive care unit (ICU) admission (OR [95% CI], 1.95 [1.10-3.46]; p = 0.0224) and longer hospital lengths of stay (estimate [95% bootstrap CI], 7.2 [0.8-13.9] days; p = 0.0006) in propensity-adjusted analyses.

CONCLUSION

Preoperative PLT transfusion did not attenuate RBC requirements in patients with thrombocytopenia undergoing noncardiac surgery. Moreover, preoperative PLT transfusion was associated with increased ICU admission rates and hospital duration. These findings suggest that more conservative management of preoperative thrombocytopenia may be warranted.

Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection

PURPOSE

Perioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications.

METHODS

The Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications.

RESULTS

Among 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94).

CONCLUSION

Significant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.

Hospital Blood Transfusion Patterns During Major Noncardiac Surgery and Surgical Mortality

We retrospectively examined intraoperative blood transfusion patterns at US veteran's hospitals through description of national patterns of intraoperative blood transfusion by indication for transfusion in the elderly; assessment of temporal trends in the use of intraoperative blood transfusion; and relationship of institutional use of intraoperative blood transfusion to hospital 30-day risk-adjusted postoperative mortality rates.Limited data exist on the pattern of intraoperative blood transfusion by indication for transfusion at the hospital level, and the relationship between intraoperative transfusion rates and institutional surgical outcomes.Using the Department of Veterans Affairs Surgical Quality Improvement Program database, we assigned 424,015 major noncardiac operations among elderly patients (≥65 years) in 117 veteran's hospitals, from 1997 to 2009, into groups based on indication for intraoperative blood transfusion according to literature and clinical guidelines. We then examined institutional variations and temporal trends in surgical blood use based on these indications, and the relationship between these institutional patterns of transfusion and 30-day postoperative mortality.Intraoperative transfusion occurred in 38,056/424,015 operations (9.0%). Among the 64,390 operations with an indication for transfusion, there was wide variation (median: 49.9%, range: 8.7%-76.2%) in hospital transfusion rates, a yearly decline in transfusion rates (average 1.0%/y), and an inverse relationship between hospital intraoperative transfusion rates and hospital 30-day risk-adjusted mortality (adjusted mortality of 9.8 ± 2.8% vs 8.3 ± 2.1% for lowest and highest tertiles of hospital transfusion rates, respectively, P = 0.02). In contrast, for the 225,782 operations with no indication for transfusion, there was little variation in hospital transfusion rates (median 0.7%, range: 0%-3.4%), no meaningful temporal change in transfusion (average 0.0%/y), and similar risk-adjusted 30-day mortality across all tertiles of hospital transfusion rates.Among patients ≥65 years with an indication for intraoperative transfusion, intraoperative transfusion patterns varied widely across hospitals and declined through the 1997 to 2009 study period. Hospitals with higher transfusion rates in these patients have lower risk-adjusted 30-day postoperative mortality rates.

Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis

BACKGROUND

Preoperative anemia is a common and potentially serious hematological problem in elective surgery and increases the risk for perioperative red blood cell (RBC) transfusion. Transfusion is associated with postoperative morbidity and mortality. Preoperative intravenous (IV) iron therapy has been proposed as an intervention to reduce perioperative transfusion; however, studies are generally small, limited, and inconclusive.

METHODS/DESIGN

We propose performing a systematic review and meta-analysis. We will search MEDLINE, EMBASE, EBM Reviews, Cochrane-controlled trial registry, Scopus, registries of health technology assessment and clinical trials, Web of Science, ProQuest Dissertations and Theses, and conference proceedings in transfusion, hematology, and surgery. We will contact our study drug manufacturer for unpublished trials. Titles and abstracts will be identified and assessed by two reviewers for potential relevance. Eligible studies are: randomized or quasi-randomized clinical trials comparing preoperative administration of IV iron with placebo or standard of care to reduce perioperative blood transfusion in anemic patients undergoing major surgery. Screening, data extraction, and quality appraisal will be conducted independently by two authors. Data will be presented in evidence tables and in meta-analytic forest plots. Primary efficacy outcomes are change in hemoglobin concentration and proportion of patients requiring RBC transfusion. Secondary outcomes include number of units of blood or blood products transfused perioperatively, transfusion-related acute lung injury, neurologic complications, adverse events, postoperative infections, cardiopulmonary complications, intensive care unit (ICU) admission/readmission, length of hospital stay, acute kidney injury, and mortality. Dichotomous outcomes will be reported as pooled relative risks and 95% confidence intervals. Continuous outcomes will be reported using calculated weighted mean differences. Meta-regression will be performed to evaluate the impact of potential confounding variables on study effect estimates.

DISCUSSION

Reducing unnecessary RBC transfusions in perioperative medicine is a clinical priority. This involves the identification of patients at risk of receiving transfusions along with blood conservation strategies. Of potential pharmacological blood conservation strategies, IV iron is a compelling intervention to treat preoperative anemia; however, existing data are uncertain. We propose performing a systematic review and meta-analysis evaluating the efficacy and safety of IV iron administration to anemic patients undergoing major surgery to reduce transfusion and perioperative morbidity and mortality.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015016771.

Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland

BACKGROUND

The aim of this study was to investigate the impact of the introduction of a Patient Blood Management (PBM) programme in elective orthopaedic surgery on immediate pre-operative anaemia, red blood cell (RBC) mass loss, and transfusion.

MATERIALS AND METHODS

Orthopaedic operations (hip, n=3,062; knee, n=2,953; and spine, n=2,856) performed between 2008 and 2011 were analysed. Period 1 (2008), was before the introduction of the PBM programme and period 2 (2009 to 2011) the time after its introduction. Immediate pre-operative anaemia, RBC mass loss, and transfusion rates in the two periods were compared.

RESULTS

In hip surgery, the percentage of patients with immediate pre-operative anaemia decreased from 17.6% to 12.9% (p<0.001) and RBC mass loss was unchanged, being 626±434 vs 635±450 mL (p=0.974). Transfusion rate was significantly reduced from 21.8% to 15.7% (p<0.001). The number of RBC units transfused remained unchanged (p=0.761). In knee surgery the prevalence of immediate pre-operative anaemia decreased from 15.5% to 7.8% (p<0.001) and RBC mass loss reduced from 573±355 to 476±365 mL (p<0.001). The transfusion rate dropped from 19.3% to 4.9% (p<0.001). RBC transfusions decreased from 0.53±1.27 to 0.16±0.90 units (p<0.001). In spine surgery the prevalence of immediate pre-operative anaemia remained unchanged (p=0.113), RBC mass loss dropped from 551±421 to 404±337 mL (p<0.001), the transfusion rate was reduced from 18.6 to 8.6% (p<0.001) and RBC transfusions decreased from 0.66±1.80 to 0.22±0.89 units (p=0.008).

DISCUSSION

Detection and treatment of pre-operative anaemia, meticulous surgical technique, optimal surgical blood-saving techniques, and standardised transfusion triggers in the context of PBM programme resulted in a lower incidence of immediate pre-operative anaemia, reduction in RBC mass loss, and a lower transfusion rate.

What factors contribute to hospital variation in obstetric transfusion rates?

Background and Objectives

To explore variation in red blood cell transfusion rates between hospitals, and the extent to which this can be explained. A secondary objective was to assess whether hospital transfusion rates are associated with maternal morbidity.

Materials and Methods

Linked hospital discharge and birth data were used to identify births (n = 279 145) in hospitals with at least 10 deliveries per annum between 2008 and 2010 in New South Wales, Australia. To investigate transfusion rates, a series of random-effects multilevel logistic regression models were fitted, progressively adjusting for maternal, obstetric and hospital factors. Correlations between hospital transfusion and maternal, neonatal morbidity and readmission rates were assessed.

Results

Overall, the transfusion rate was 1·4% (hospital range 0·6–2·9) across 89 hospitals. Adjusting for maternal casemix reduced the variation between hospitals by 26%. Adjustment for obstetric interventions further reduced variation by 8% and a further 39% after adjustment for hospital type (range 1·1–2·0%). At a hospital level, high transfusion rates were moderately correlated with maternal morbidity (0·59, P = 0·01), but not with low Apgar scores (0·39, P = 0·08), or readmission rates (0·18, P = 0·29).

Conclusion

Both casemix and practice differences contributed to the variation in transfusion rates between hospitals. The relationship between outcomes and transfusion rates was variable; however, low transfusion rates were not associated with worse outcomes.

Preoperative Thrombocytopenia and Postoperative Outcomes after Noncardiac Surgery

Background:

Most studies examining the prognostic value of preoperative coagulation testing are too small to examine the predictive value of routine preoperative coagulation testing in patients having noncardiac surgery.

Methods:

Using data from the American College of Surgeons National Surgical Quality Improvement database, the authors performed a retrospective observational study on 316,644 patients having noncardiac surgery who did not have clinical indications for preoperative coagulation testing. The authors used multivariable logistic regression analysis to explore the association between platelet count abnormalities and red cell transfusion, mortality, and major complications.

Results:

Thrombocytopenia or thrombocytosis occurred in 1 in 14 patients without clinical indications for preoperative platelet testing. Patients with mild thrombocytopenia (101,000–150,000 µl−1), moderate-to-severe thrombocytopenia (&lt;100,000 µl−1), and thrombocytosis (≥450,000 µl−1) were significantly more likely to be transfused (7.3%, 11.8%, 8.9%, 3.1%) and had significantly higher 30-day mortality rates (1.5%, 2.6%, 0.9%, 0.5%) compared with patients with a normal platelet count. In the multivariable analyses, mild thrombocytopenia (adjusted odds ratio [AOR], 1.28; 95% CI, 1.18–1.39) and moderate-to-severe thrombocytopenia (AOR, 1.76; 95% CI, 1.49–2.08), and thrombocytosis (AOR, 1.44; 95% CI, 1.30–1.60) were associated with increased risk of blood transfusion. Mild thrombocytopenia (AOR, 1.31; 95% CI, 1.11–1.56) and moderate-to-severe thrombocytopenia (AOR, 1.93; 95% CI, 1.43–2.61) were also associated with increased risk of 30-day mortality, whereas thrombocytosis was not (AOR, 0.94; 95% CI, 0.72–1.22).

Conclusion:

Platelet count abnormalities found in the course of routine preoperative screening are associated with a higher risk of blood transfusion and death.

Patient-centered blood management

BACKGROUND

Transfusions are common in hospitalized patients but carry significant risk, with associated morbidity and mortality that increases with each unit of blood received. Clinical trials consistently support a conservative over a liberal approach to transfusion. Yet there remains wide variation in practice, and more than half of red cell transfusions may be inappropriate. Adopting a more comprehensive approach to the bleeding, coagulopathic, or anemic patient has the potential to improve patient care.

METHODS

We present a patient-centered blood management (PBM) paradigm. The 4 guiding principles of effective PBM that we present include anemia management, coagulation optimization, blood conservation, and patient-centered decision making.

RESULTS

PBM has the potential to decrease transfusion rates, decrease practice variation, and improve patient outcomes.

CONCLUSION

PBM's value proposition is highly aligned with that of hospital medicine. Hospitalists' dual role as front-line care providers and quality improvement leaders make them the ideal candidates to develop, implement, and practice PBM.

Utilization management in the blood transfusion service

The scope of activity of the Blood Transfusion Service (BTS) makes it unique among the clinical laboratories. The combination of therapeutic and diagnostic roles necessitates a multi-faceted approach to utilization management in the BTS. We present our experience in utilization management in large academic medical center.

Association between surgical resident involvement and blood use in noncardiac surgery

BACKGROUND

Although there is significant variability in the rate of blood transfusion in surgical patients, the role of surgical skill as a determinant of blood use is unknown.

STUDY DESIGN AND METHODS

We examined the association between surgery resident participation and intraoperative blood transfusion, and 30-day mortality and complications, among 381,036 patients undergoing noncardiac surgery, adjusting for patient factors and procedure complexity.

RESULTS

Compared to attending surgeons working without a resident, cases in which the attendings worked with either Postgraduate Year (PGY) 3 to 4 resident or a PGY5 to 8 resident had a 56% (adjusted odds ratio [AOR], 1.56; 95% confidence interval [CI, 1.48-1.64) or a 78% (AOR, 1.78; 95% CI, 1.70-1.87) higher odds of receiving a blood transfusion, respectively. Involvement of surgical interns or junior residents (PGY1-2), whose role in the operative procedure is assumed to be limited, was associated with a 27% higher odds of receiving a blood transfusion (AOR, 1.27; 95% CI, 1.18-1.37). Overall, resident involvement was not associated with increased risk of 30-day mortality (AOR, 0.97; 95% CI, 0.91-1.04), but was associated with a slightly increased risk of complications (AOR, 1.13; 95% CI, 1.10-1.16).

CONCLUSION

Senior surgery resident participation in noncardiac surgery is associated with between a 56% to 78% higher risk of receiving a blood transfusion intraoperatively compared to attending surgeons working without a resident. Assuming that senior surgical trainees are performing critical parts of the operative procedure and are less skilled than attending surgeons, the findings from this exploratory study suggest that intraoperative blood transfusion may serve as an indirect measure of surgical technical quality.