Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery

Blood Loss Estimation Using Gauze Visual Analogue

Background

Estimating intraoperative blood loss can be a difficult task, especially when blood is mostly absorbed by gauze. In this study, we have provided an improved method for estimating blood absorbed by gauze.

Objectives

To develop a guide to estimate blood absorbed by surgical gauze.

Materials and Methods

A clinical experiment was conducted using aspirated blood and common surgical gauze to create a realistic amount of absorbed blood in the gauze. Different percentages of staining were photographed to create an analogue for the amount of blood absorbed by the gauze.

Results

A visual analogue scale was created to aid the estimation of blood absorbed by the gauze. The absorptive capacity of different gauze sizes was determined when the gauze was dripping with blood. The amount of reduction in absorption was also determined when the gauze was wetted with normal saline before use.

Conclusions

The use of a visual analogue may increase the accuracy of blood loss estimation and decrease the consequences related to over or underestimation of blood loss.

Large Variation in Blood Transfusion Use After Colorectal Resection: A Call to Action

BACKGROUND

Perioperative blood transfusions are associated with an increased risk of adverse postoperative outcomes through immunomodulatory effects.

OBJECTIVE

The purpose of this study was to identify factors associated with variation in blood transfusion use after elective colorectal resection and associated postoperative infectious complications

DESIGN

This was a retrospective cohort study.

SETTINGS

The study included elective colorectal resections in New York State from 2001 to 2013.

PATIENTS

The study cohort consists of 125,160 colorectal resections. Patients who were admitted nonelectively or who were admitted before the date of surgery were excluded.

MAIN OUTCOME MEASURES

Receipt of a perioperative allogeneic red blood cell transfusion and the secondary end points of postoperative pneumonia, surgical site infection, intra-abdominal abscess, and sepsis were measured.

RESULTS

The overall rate of perioperative blood transfusion for the study cohort was 13.9%. The unadjusted blood transfusion rates ranged from 2.4% to 58.7% for individual surgeons and 2.9% to 32.8% for individual hospitals. After controlling for patient-, surgeon-, and hospital-level factors in a 3-level mixed-effects multivariable model, significant variation was still present across both surgeons (p < 0.0001) and hospitals (p < 0.0001), with a 16.8-fold difference in adjusted blood transfusion rates across surgeons and a 13.2-fold difference in adjusted blood transfusion rates across hospitals. Receipt of a blood transfusion was also independently associated with pneumonia (OR = 3.23 (95% CI, 2.92-3.57)), surgical site infection (OR = 2.27 (95% CI, 2.14-2.40)), intra-abdominal abscess (OR = 2.72 (95% CI, 2.41-3.07)), and sepsis (OR = 4.51 (95% CI, 4.11-4.94)).

LIMITATIONS

Limitations include the retrospective design and the possibility of miscoding within administrative data.

CONCLUSIONS

Large surgeon- and hospital-level variations in perioperative blood transfusion use for patients undergoing colorectal resection are present despite controlling for patient-, surgeon-, and hospital-level factors. In addition, receipt of a blood transfusion was independently associated with an increased risk of postoperative infectious complications. These findings support the creation and implementation of perioperative blood transfusion protocols aimed at limiting unwarranted variation.

Extent of Surgery Does Not Influence 30-Day Mortality in Surgery for Metastatic Bone Disease: An Observational Study of a Historical Cohort

Estimating patient survival has hitherto been the main focus when treating metastatic bone disease (MBD) in the appendicular skeleton. This has been done in an attempt to allocate the patient to a surgical procedure that outlives them. No questions have been addressed as to whether the extent of the surgery and thus the surgical trauma reduces survival in this patient group. We wanted to evaluate if perioperative parameters such as blood loss, extent of bone resection, and duration of surgery were risk factors for 30-day mortality in patients having surgery due to MBD in the appendicular skeleton. We retrospectively identified 270 consecutive patients who underwent joint replacement surgery or intercalary spacing for skeletal metastases in the appendicular skeleton from January 1, 2003 to December 31, 2013. We collected intraoperative (duration of surgery, extent of bone resection, and blood loss), demographic (age, gender, American Society of Anesthesiologist score [ASA score], and Karnofsky score), and disease-specific (primary cancer) variables. An association with 30-day mortality was addressed using univariate and multivariable analyses and calculation of odds ratio (OR). All patients were included in the analysis. ASA score 3 + 4 (OR 4.16 [95% confidence interval, CI, 1.80-10.85], P = 0.002) and Karnofsky performance status below 70 (OR 7.34 [95% CI 3.16-19.20], P < 0.001) were associated with increased 30-day mortality in univariate analysis. This did not change in multivariable analysis. No parameters describing the extent of the surgical trauma were found to be associated with 30-day mortality. The 30-day mortality in patients undergoing surgery for MBD is highly dependent on the general health status of the patients as measured by the ASA score and the Karnofsky performance status. The extent of surgery, measured as duration of surgery, blood loss, and degree of bone resection were not associated with 30-day mortality.

Effects of prehospital hypothermia on transfusion requirements and outcomes: a retrospective observatory trial

OBJECTIVES

Prehospital hypothermia is defined as a core temperature <36.0 °C and has been shown to be an independent risk factor for early death in patients with trauma. In a retrospective study, a possible correlation between the body temperature at the time of admission to the emergency room and subsequent in-hospital transfusion requirements and the in-hospital mortality rate was explored.

SETTING

This is a retrospective single-centre study at a primary care hospital in Germany.

PARTICIPANTS

15,895 patients were included in this study. Patients were classified by admission temperature and transfusion rate. Excluded were ambulant patients and patients with missing data.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome values were length of stay (LOS) in days, in-hospital mortality, the transferred amount of packed red blood cells (PRBCs), and admission to an intensive care unit. Secondary influencing variables were the patient's age and the Glasgow Coma Scale.

RESULTS

In 22.85% of the patients, hypothermia was documented. Hypothermic patients died earlier in the course of their hospital stay than non-hypothermic patients (p<0.001). The administration of 1-3 PRBC increased the LOS significantly (p<0.001) and transfused patients had an increased risk of death (p<0.001). Prehospital hypothermia could be an independent risk factor for mortality (adjusted OR 8.521; p=0.001) and increases the relative risk for transfusion by factor 2.0 (OR 2.007; p=0.002).

CONCLUSIONS

Low body temperature at hospital admission is associated with a higher risk of transfusion and death. Hence, a greater awareness of prehospital temperature management should be established.

Packed red blood cell transfusion after surgery: are we "overtranfusing" our patients?

BACKGROUND

Data on the hemoglobin (Hb) after transfusion, or the "target," which reflects the "dose" of blood given are not well studied. We sought to examine the incidence and causes of "over transfusion" of red blood cells after surgery.

METHODS

Data on blood utilization including Hb triggers and targets were obtained for patients undergoing colorectal, pancreas, or liver surgery between 2010 and 2013.

RESULTS

A total of 2,905 patients were identified, of which 895 (31%) were transfused (median age 64, interquartile range: 53 to 72; 51% men; median American Society of Anesthesiologists class 3, interquartile range: 3-3; 51% pancreatic, 14% hepatobiliary, 21% colorectal, and 14% other). Among these, 512 (57%) were overtransfused (final Hb target after transfusion ≥9.0 g/dL). Among patients who were overtransfused, 171 (33%) were transfused at too high an initial trigger (>8.0 g/dL), whereas 304 (59%) had an appropriate trigger but received ≥2 packed red blood cell (PRBC) units, suggesting an opportunity to have transfused fewer units. There was significant variation in overtransfusion among surgeons (range 0% to 80%, P = .003).

CONCLUSIONS

Excess use of blood transfusion is common and was due to PRBC utilization for too high a transfusion trigger, as well as too many units transfused.

Preoperative Anemia: Evaluation and Treatment

Previously undiagnosed anemia is often identified during routine assessment of surgical patients. Although studies suggest that perioperative anemia is associated with worse outcomes and a strong predictor for postoperative red cell transfusions, anemia is frequently ignored. Preoperative optimization of patients undergoing elective surgical procedures associated with significant blood loss, along with strategies to minimize intraoperative blood loss, shows promise for reducing postoperative transfusions and improving outcomes. In most situations, anemia can be corrected prior to elective surgeries and interventions. Future research should assess the timing and methods of optimization of preoperative anemia in surgery and which patients are best candidates for therapy.

Association Between Anemia, Bleeding, and Transfusion with Long-term Mortality Following Noncardiac Surgery

BACKGROUND

Preoperative anemia is a well-established risk factor for short-term mortality in patients undergoing noncardiac surgery, but appropriate thresholds for transfusion remain uncertain. The objective of this study was to determine long-term outcomes associated with anemia, hemorrhage, and red blood cell transfusion in patients undergoing noncardiac surgery.

METHODS

We performed a long-term follow-up study of consecutive subjects undergoing hip, knee, and spine surgery between November 1, 2008 and December 31, 2009. Clinical data were obtained from administrative and laboratory databases, and retrospective record review. Preoperative anemia was defined as baseline hemoglobin < 13 g/dL for men and < 12 g/dL for women. Hemorrhage was defined by International Classification of Diseases, Ninth Revision coding. Data on long-term survival were collected from the Social Security Death Index database. Logistic regression models were used to identify factors associated with long-term mortality.

RESULTS

There were 3050 subjects who underwent orthopedic surgery. Preoperative anemia was present in 17.6% (537) of subjects, hemorrhage occurred in 33 (1%), and 766 (25%) received at least one red blood cell transfusion. Over 9015 patient-years of follow-up, 111 deaths occurred. Anemia (hazard ratio [HR] 3.91; confidence interval [CI], 2.49-6.15) and hemorrhage (HR 5.28; 95% CI, 2.20-12.67) were independently associated with long-term mortality after multivariable adjustment. Red blood cell transfusion during the surgical hospitalization was associated with long-term mortality (HR 3.96; 95% CI, 2.47-6.34), which was attenuated by severity of anemia (no anemia [HR 4.39], mild anemia [HR 2.27], and moderate/severe anemia [HR 0.81]; P for trend .0015).

CONCLUSIONS

Preoperative anemia, perioperative bleeding, and red blood cell transfusion are associated with increased mortality at long-term follow-up after noncardiac surgery. Strategies to minimize anemia and bleeding should be considered for all patients, and restrictive transfusion strategies may be advisable. Further investigation into mechanisms of these adverse events is warranted.

Defining Transfusion Triggers and Utilization of Fresh Frozen Plasma and Platelets Among Patients Undergoing Hepatopancreaticobiliary and Colorectal Surgery

BACKGROUND

We sought to define the overall utilization of fresh frozen plasma (FFP) and platelets and the impact on perioperative outcomes among patients undergoing hepatopancreaticobiliary and colorectal resections, as well as analyze the utility of laboratory triggers in guiding transfusion practice.

METHODS

We identified 3027 patients undergoing pancreatic, hepatic, and colorectal resections between 2010 and 2013 at Johns Hopkins Hospital. Data on international normalized ratio (INR) and platelet counts that triggered the perioperative utilization of these non-RBC (red blood cell) products were obtained and analyzed.

RESULTS

Overall FFP and platelet transfusion rates were 8.9% and 3.8%, respectively. Mean INR and platelet triggers for FFP and platelet transfusions were 1.9 ± 1.3 and 60000 ± 44000, respectively. INR triggers varied depending on resection type, patient race, and comorbidity status (all P <0.05). Nearly one-half of patients (48.0%) received FFP in the postoperative period with an INR trigger less than 1.7. FFP transfusions were independently associated with an increased length of stay [odds ratio (OR) = 3.66], perioperative morbidity (OR = 3.96) and in-hospital mortality (OR = 91.85) (all P < 0.001). Similarly, patients receiving platelets were at increased risk for worse overall perioperative outcomes (all OR >1, P <0.001).

CONCLUSIONS

The utilization and indication of non-RBC components vary significantly across surgical specialties. Nearly one-half of patients transfused with FFP during the postoperative period had an INR of less than 1.7, indicating possible overutilization of these products. Furthermore, the use of FFP and platelets are associated with poorer perioperative outcomes. Further studies are needed to study the impact and management of a more restrictive use of FFP and platelets on surgical patients.

Coagulopathy and transfusion therapy in pediatric liver transplantation

Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.

Risk factors for intraoperative allogeneic blood transfusion during craniotomy for brain tumor removal in children

BACKGROUND

Several clinical and surgical factors can influence the occurrence of allogeneic blood transfusion (ABT) during oncologic neurosurgery.

OBJECTIVES

To identify the potential predictive factors of ABT during craniotomy for the removal of brain tumors in children and the potential impact of intraoperative ABT on early postoperative outcome.

METHODS

A retrospective study was performed in all pediatric patients younger than 18 years who underwent craniotomy for brain tumor removal from December 2009 to December 2012 in our institution. Pre-, intra-, and postoperative data were collected from medical and stored electronic anesthesia records. The predictors of intraoperative ABT were determined using multivariate logistic regression.

RESULTS

A total of 110 patients were included. Twenty-seven patients (25%) received intraoperative ABT with a volume of 16 ± 8 ml·kg(-1) . On multivariate analysis, an age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) were independently associated with the need for intraoperative ABT. We did not show any significant difference concerning postoperative early outcome and length of stay between the transfused and non-transfused patients except for the duration of postoperative mechanical ventilation that was significantly higher in the transfused group (P = 0.04).

CONCLUSION

In children, craniotomy for brain tumor removal is at risk of intraoperative ABT. An age <4 years, a duration of surgery >270 min, and a preoperative hemoglobin <12.2 g·dl(-1) are the main factors associated with intraoperative ABT during this surgery.

Impact of length of red blood cells transfusion on postoperative delirium in elderly patients undergoing hip fracture surgery: A cohort study

PURPOSE

The purpose of the present study was to test whether older red blood cells (RBCs) transfusion results in an increased risk of postoperative delirium (POD) and various in-hospital postoperative complications in elderly patients undergoing hip fracture surgery.

MATERIALS AND METHODS

Patients (≥65 years) who underwent hip fracture surgery were enrolled, 179 patients were divided into two groups according to the storage time of the RBCs. The shorter storage time of RBCs transfusion group comprised patients who received RBCs ≤14 days old and the longer storage time of RBCs transfusion group comprised patients who received RBCs >14 days old. The blood samples were collected before anaesthesia induction, 4 and 24 h after RBCs transfusion for the determination of proinflammatory mediators, malondialdehyde, and superoxide dismutase activity.

RESULTS

There was no difference in the baseline characteristics, the incidence of POD, and the in-hospital postoperative complications between the shorter storage time of RBCs transfusion group and the longer storage time of RBCs transfusion groups (P>0.05). Compared with the shorter storage time of RBCs transfusion group, the longer storage time of RBCs transfusion caused significantly longer duration of POD (P<0.05). There were significantly increased plasma levels of IL-8 and malondialdehyde at 24 h and IL-1β at 4 h after RBCs transfusion in the POD group compared with the non-POD group (P<0.05).

CONCLUSION

Transfusion of the longer storage RBCs is not associated with a higher incidence of POD or in-hospital postoperative complications, but with longer duration of POD in elderly patients undergoing hip fracture surgery.

Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study

BACKGROUND

Patient blood management (PBM) must be promoted in orthopedic surgery and relies on different strategies implemented during the entire perioperative period. Our aim was to assess whether the introduction of a pre-, intra-, and postoperative PBM protocol combining erythropoietin (EPO), ferric carboxymaltose (FCM), and tranexamic acid was effective in reducing perioperative transfusion and postoperative anemia.

STUDY DESIGN AND METHODS

In a two-phase prospective observational study, all patients admitted for total hip or knee arthroplasty were included the day before surgery. In Phase 1, use of EPO, iron, and tranexamic acid was left to the discretion of the anesthesiologists. In Phase 2, a protocol combining these treatments was implemented in the perioperative period. Perioperative hemoglobin levels and transfusion rates were recorded.

RESULTS

A total of 367 patients were included (184 and 183 in Phase 1 and 2, respectively). During Phase 2, implementing a PBM protocol allowed an increase in preoperative EPO prescription in targeted patients (i.e., with Hb < 13 g/dL; 18 [38%] vs. 34 [62%], p = 0.03) and in postoperative use of intravenous iron (12 [6%] vs. 32 [18%], p = 0.001) and tranexamic acid (157 [86%] vs. 171 [94%] patients, p = 0.02). In Phase 2, the number of patients who received transfusions (24 [13%] vs. 5 [3%], p = 0.0003) and of patients with a Hb level of less than 10 g/dL at discharge (46 [25%] vs. 26 [14%], p = 0.01) were reduced.

CONCLUSION

Introduction of a PBM protocol, using EPO, FCM, and tranexamic acid, reduces the number of perioperative transfusions and of patients with a Hb level of less than 10 g/dL at discharge.

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.

[Diagnosis and treatment of iron deficiency, with or without anemia, before and after bariatric surgery]

Bariatric surgery (BS) is an increasingly used therapeutic option for severe obesity which allows patients to achieve sustained weight loss over time and resolution or improvement in most associated pathological conditions. Major mid- and long-term complications of BS include iron deficiency and iron-deficient anemia, which may occur in up to 50% of cases and significantly impair patient quality of life. These changes may be present before surgery. The aim of this review was to prepare schemes for diagnosis and treatment of iron deficiency and iron-deficient anemia before and after bariatric surgery.

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.

Is there a "magic" hemoglobin number? Clinical decision support promoting restrictive blood transfusion practices

Blood transfusion has been identified as one of the most frequently performed therapeutic procedures, with a significant percentage of transfusions identified to be inappropriate. Recent key clinical trials in adults have provided Level 1 evidence to support restrictive red blood cell (RBC) transfusion practices. However, some advocates have attempted to identify a "correct" Hb threshold for RBC transfusion; whereas others assert that management of anemia, including transfusion decisions, must take into account clinical patient variables, rather than simply one diagnostic laboratory test. The heterogeneity of guidelines for blood transfusion by a number of medical societies reflects this controversy. Clinical decision support (CDS) uses a Hb threshold number in a smart Best Practices Alert (BPA) upon physician order, to trigger a concurrent utilization self-review for whether blood transfusion therapy is appropriate. This review summarizes Level 1 evidence in seven key clinical trials in adults that support restrictive transfusion practices, along strategies made possible by CDS that have demonstrated value in improving blood utilization by promoting restrictive transfusion practices.

[Treatment of anemia in Patient Blood Management from an economic perspective]

The liberal use of transfusions is not only a risk for patients but also represents a significant healthcare expenditure. The rational use of allogeneic blood transfusions and the use of transfusion alternatives, such as the optimization of preoperative hemoglobin levels, can offer substantial savings to health departments by reducing the cost of transfusions and the morbidity related to the transfusions.

[Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss]

To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.

Patient blood management to reduce surgical risk

BACKGROUND

Preoperative anaemia and perioperative blood transfusion are both identifiable and preventable surgical risks. Patient blood management is a multimodal approach to address this issue. It focuses on three pillars of care: the detection and treatment of preoperative anaemia; the reduction of perioperative blood loss; and harnessing and optimizing the patient-specific physiological reserve of anaemia, including restrictive haemoglobin transfusion triggers. This article reviews why patient blood management is needed and strategies for its incorporation into surgical pathways.

METHODS

Studies investigating the three pillars of patient blood management were identified using PubMed, focusing on recent evidence-based guidance for perioperative management.

RESULTS

Anaemia is common in surgical practice. Both anaemia and blood transfusion are independently associated with adverse outcomes. Functional iron deficiency (iron restriction due to increased levels of hepcidin) is the most common cause of preoperative anaemia, and should be treated with intravenous iron. Intraoperative blood loss can be reduced with antifibrinolytic drugs such as tranexamic acid, and cell salvage should be used. A restrictive transfusion practice should be the standard of care after surgery.

CONCLUSION

The significance of preoperative anaemia appears underappreciated, and its detection should lead to routine investigation and treatment before elective surgery. The risks of unnecessary blood transfusion are increasingly being recognized. Strategic adoption of patient blood management in surgical practice is recommended, and will reduce costs and improve outcomes in surgery.

Variation in Transfusion Practices and the Effect on Outcomes After Noncardiac Surgery

OBJECTIVES

To identify the patient-level effects of blood transfusion on postoperative outcomes and to estimate the effects of different transfusion practices on hospital-level risk-adjusted outcomes.

BACKGROUND

Postoperative transfusion practices and their effects on short-term outcomes in patients undergoing noncardiac surgery are not well understood.

METHODS

Demographic, operative, and outcomes data for 48,720 patients undergoing general or vascular surgery at 52 hospitals between July 2012 and April 2014 were obtained. The main exposure variable was receipt of any blood transfusion within 72 hours after surgery. Thirty-day mortality, any morbidity, infectious complications, and postoperative myocardial infarction were the outcomes of interest. Propensity score matching was used to minimize confounding by indication. Hospitals were categorized as having a restrictive, average, or liberal transfusion practice based on average trigger hemoglobin values.

RESULTS

A total of 2243 (4.6%) patients received a postoperative blood transfusion. After propensity matching, a postoperative transfusion was associated with increased 30-day mortality (3.6% excess absolute risk), any morbidity (4.4% excess absolute risk), and infectious morbidity (1.0% excess absolute risk). However, a transfusion was associated with 3.5% absolute risk reduction in postoperative myocardial infarction. At the hospital level, there was a wide variation in transfusion practices. Hospitals with liberal practices were twice as likely to transfuse patients and had higher risk-adjusted mortality rates than restrictive hospitals (3.1% vs 2.2%; P = 0.002).

CONCLUSIONS AND RELEVANCE

Postoperative transfusions after noncardiac surgery are associated with increased adverse postoperative outcomes, with the exception of postoperative myocardial infarction. Hospitals that are liberal in their transfusion practices have higher 30-day mortality rates, suggesting potential interventions for quality improvement.

Is estimated intra-operative blood loss a reliable predictor of surgical outcomes in laparoscopic colorectal cancer surgery?

BACKGROUND

Studies have shown that laparoscopic surgery for colorectal cancer is often associated with significantly reduced intra-operative blood loss compared to the corresponding open procedures. Increased intra-operative blood loss can be associated with increased risk of post-operative morbidity and mortality. We sought to determine whether estimated intra-operative blood loss was a reliable predictor of post-operative surgical outcomes.

METHOD

Prospective data were collected for patients undergoing elective laparoscopic colorectal cancer resections from July 2011 to November 2013. Weighing swabs and measuring blood volume in suction devices calculated the estimated intra-operative blood loss. The operative outcome data including post-operative 30 day morbidity and mortality, length of hospital stay, re-admission and re-operation within 30 days were collected. The operative blood loss was grouped into Group 1 (less than 50 ml, Group 2 (50-150 ml) and Group 3 (over 150 ml). Patients who underwent open operations and laparoscopic conversions were excluded.

RESULTS

The median age, length of hospital stay, male to female ratio and body mass index were similar in the three groups. There was no 30-day mortality in any of the groups. The number of re-admissions within 30 days was similar in all groups. The re-operation rates within 30 days were higher in Groups 2 and 3 at 11% and 8.6%, respectively. The post-operative complications were 12.5%, 16.7%, and 26% in groups 1, 2 and 3, respectively. There were no anastomotic leaks requiring re-operation noted in Group 3.

DISCUSSION

This study has shown that intra-operative blood loss was not associated with increased median length of stay nor did it increase the 30 day re-admission rate. However, increased intra-operative blood loss was associated with increased incidence of post-operative morbidity and risk of reoperation within 30 days.

Impact of Preoperative Anaemia and Blood Transfusion on Postoperative Outcomes in Gynaecological Surgery

OBJECTIVE

To evaluate the effect of preoperative anaemia and blood transfusion on 30-day postoperative morbidity and mortality in patients undergoing gynecological surgery.

STUDY DESIGN

Data were analyzed from 12,836 women undergoing operation in the American College of Surgeons National Surgical Quality Improvement Program. Outcomes measured were; 30-day postoperative mortality, composite and specific morbidities (cardiac, respiratory, central nervous system, renal, wound, sepsis, venous thrombosis, or major bleeding). Multivariate logistic regression models were performed using adjusted odds ratios (ORadj) to assess the independent effects of preoperative anaemia (hematocrit <36.0%) on outcomes, effect estimates were performed before and after adjustment for perioperative transfusion requirement.

RESULTS

The prevalence of preoperative anaemia was 23.9% (95%CI: 23.2-24.7). Adjusted for confounders by multivariate logistic regression; preoperative anaemia was independently and significantly associated with increased odds of 30-day mortality (OR: 2.40, 95%CI: 1.06-5.44) and composite morbidity (OR: 1.80, 95%CI: 1.45-2.24). This was reflected by significantly higher adjusted odds of almost all specific morbidities including; respiratory, central nervous system, renal, wound, sepsis, and venous thrombosis. Blood Transfusion increased the effect of preoperative anaemia on outcomes (61% of the effect on mortality and 16% of the composite morbidity).

CONCLUSIONS

Preoperative anaemia is associated with adverse post-operative outcomes in women undergoing gynecological surgery. This risk associated with preoperative anaemia did not appear to be corrected by use of perioperative transfusion.

Dynamic changes in clot formation determined using thromboelastometry after reinfusion of unwashed anticoagulated cell-salvaged whole blood in total hip arthroplasty

BACKGROUND

Cell salvage is a key part of patient blood management. Different techniques are available for salvaging blood. A new intra-operative autotransfusion filter system became available for reinfusion of unwashed whole blood. Concern exists regarding whether this technique induces coagulation disturbances, offsetting the benefits of the reinfusion of autologous blood. This study was designed to investigate the content of intra-operatively salvaged filtered blood and its impact after reinfusion on clot formation in patients undergoing primary hip arthroplasty.

MATERIALS AND METHODS

Twenty-five patients scheduled for primary total hip arthroplasty were enrolled in the study. Cell salvage was performed using a new intra-operative autotransfusion filter system. Before surgery and within 1 hour of reinfusion of 300 mL or more of salvaged whole blood, blood samples were taken to assess clot formation by thromboelastometry and standard laboratory-based coagulation profiling. Cytokine content of the salvaged blood was assessed by enzyme-linked immunosorbent assays.

RESULTS

Following reinfusion of 460 mL (median) of salvaged blood, thromboelastometry showed normal clot formation and did not indicate a coagulopathy. Clotting time, clot formation time, maximum firmness and maximum lysis all remained within the normal range. Standard laboratory coagulation tests were also normal in all patients before surgery and after reinfusion. Although monocyte chemoattractant protein-1 levels were higher than normal, all other measured cytokines were either undetectable or within the normal range. No adverse events were seen following cell salvage.

DISCUSSION

Reinfusion of unwashed salvaged whole blood did not alter clot formation in our patients. The results add to the knowledge about this approach and contribute to the growing body of evidence regarding the lack of adverse events when reinfusing unwashed shed blood in major orthopaedic procedures.

Tranexamic acid for the reduction of blood loss in total knee arthroplasty

The Journal of Arthroplasty recently published a paper entitled "The Efficacy of Combined Use of Intraarticular and Intravenous Tranexamic Acid on Reducing Blood Loss and Transfusion Rate in Total Knee Arthroplasty". Tranexamic acid (TXA) is an antifibrinolytic drug whose administration during the perioperative period either by intravenous route or topically applied to the surgical field has been shown to reliably reduce blood loss and need for transfusion in patients undergoing total knee arthroplasty (TKA). Although randomized trials and meta-analyses did not show an increase in thromboembolic events, concerns remain about its repeated systemic application. The authors of the study introduced a novel regimen of TXA administration combining a preoperative intravenous bolus followed by local infiltration at the end of surgery with the idea of maximizing drug concentration at the surgical site while minimizing systemic antifibrinolytic effects. The combined dosage regimen appears to be more effective than single dose local application in reducing blood loss and transfusion rate without any complications noted.

Impact of blood transfusions and transfusion practices on long-term outcome following hepatopancreaticobiliary surgery

BACKGROUND

The long-term impact of transfusions with packed red blood cells (PRBC) among patients undergoing hepatopancreaticobiliary (HPB) surgery remains ill-defined. We sought to determine the impact of overall blood utilization, as well as a restrictive transfusion strategy, on long-term outcomes among patients undergoing an HPB resection for a malignancy.

METHODS

Data on overall blood utilization and hemoglobin (Hb) levels that triggered a transfusion were obtained for patients with cancer undergoing pancreas or liver surgery between 2009 and 2013. Risk-adjusted recurrence-free (RFS) and overall survival (OS) were assessed based on receipt of PRBC and whether the patient received a transfusion using a restrictive transfusion strategy (intraoperative: Hb <10 g/dL; postoperative: Hb <8 g/dL).

RESULTS

Four hundred forty-two patients underwent either a pancreas (58.1 %) or liver (41.9 %) resection. Most tumors were pancreatic in origin (41.8 %), while a subset were primary (23.1 %) or secondary (18.8 %) liver tumors. One hundred seventy-five (39.6 %) patients received ≥1 PRBC transfusion either intraoperatively (16.7 %), postoperatively (12.7 %), or both (10.2 %). There was a higher incidence of PRBC transfusion among patients undergoing a pancreas resection, those with higher comorbidities, and those with lower preoperative Hb levels. Perioperative morbidity was higher among patients receiving either 1-2 units (OR 3.14) or 3 or more units of PRBC (OR 8.54). Median OS was 31.9 months. Receipt of a blood transfusion was associated with a worse OS (1-2 units: HR 1.76; 3+units: HR 2.50; both P<0.05), and RFS (3+units: HR 2.91; P=0.02). Utilization of a restrictive transfusion strategy did not impact perioperative morbidity or long-term RFS or OS.

CONCLUSIONS

Adoption of a more restrictive transfusion strategy in patients undergoing resection for cancer may preserve a limited resource, reduce costs, as well as avoid exposing oncology patients to the unnecessary risks associated with a transfusion.

An analysis of adult patient risk factors and complications within 30 days after arthroscopic shoulder surgery

PURPOSE

To identify risk factors of adult patients predisposing them to the most common complications that occur within 30 days after arthroscopic shoulder surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for arthroscopic shoulder procedures. Complications and their frequency were calculated. Multivariate analysis was used to identify risk factors of adult patients predisposing them to complications. Risk factors for reoperation and characteristics of patients undergoing repair procedures were also analyzed.

RESULTS

Among 10,255 cases of shoulder arthroscopy, 119 complications were reported in 103 cases within 30 days of surgery. The rates of any, major, and minor complications were 1%, 0.57%, and 0.53%, respectively. Return to the operating room (29% of all complications) was the most frequent complication. With risk adjustment, the odds of complications developing were higher for patients older than 60 years (adjusted odds ratio [AOR], 3.47; P = .03), patients with a surgical time greater than 1.5 hours (AOR, 1.93; P = .01), patients with chronic obstructive pulmonary disease (COPD; AOR, 2.76; P = .03), patients with an inpatient status (AOR, 2.72; P < .01), patients with disseminated cancer (AOR, 21.9; P < .01), and current smokers (AOR, 1.94; P = .01). The presence of COPD (AOR, 4.67; P = .04) was a significant predictor for reoperation within 30 days. Repair procedures did not increase the risk of complications compared with non-repair. Male patients, patients aged younger than 30 years, nondiabetic patients, and nonsmokers were more likely to undergo repair procedures (P < .05 for all).

CONCLUSIONS

Shoulder arthroscopy has a 1.0% thirty-day complication rate, with the most common complication being return to the operating room (29% of all complications). Age older than 60 years, surgical time greater than 90 minutes, COPD, inpatient status, disseminated cancer, and current smoking all increased a patient's risk of complications. Patients undergoing repair procedures were not at increased risk. Pulmonary comorbidity increases the risk of reoperation within 30 days. Patients undergoing repair procedures tend to be younger and carry fewer risk factors for complications.

LEVEL OF EVIDENCE

Level IV, prognostic case series.

Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms

OBJECT

Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms.

METHODS

The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hours postoperatively. The authors separately compared surgical outcome between patients with (n = 198) versus without (n = 470) anemia, and those who underwent (n = 78) versus those who did not receive (n = 521) a transfusion, using a 1:1 match on propensity score.

RESULTS

In the matched cohorts, all observed covariates were comparable between anemic (n = 147) versus nonanemic (n = 147) and between transfused (n = 67) versus nontransfused patients (n = 67). Anemia was independently associated with prolonged hospital length of stay (LOS; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.5), perioperative complications (OR 1.9, 95% CI 1.1-3.1), and return to the operating room (OR 2.1, 95% CI 1.1-4.5). Transfusion was also independently associated with perioperative complications (OR 2.4, 95% CI 1.1-5.3).

CONCLUSIONS

Preoperative anemia and transfusion are each independent risk factors for perioperative complications in patients undergoing surgery for cerebral aneurysms. Perioperative anemia is also associated with prolonged hospital LOS and 30-day return to the operating room.

Increased mortality in adult patients with trauma transfused with blood components compared with whole blood

Hemorrhage is a preventable cause of death among patients with trauma, and management often includes transfusion, either whole blood or a combination of blood components (packed red blood cells, platelets, fresh frozen plasma). We used the 2009 National Trauma Data Bank data set to evaluate the relationship between transfusion type and mortality in adult patients with major trauma (n = 1745). Logistic regression analysis identified 3 independent predictors of mortality: Injury Severity Score, emergency medical system transfer time, and type of blood transfusion, whole blood or components. Transfusion of whole blood was associated with reduced mortality; thus, it may provide superior survival outcomes in this population.

Efficacy of education followed by computerized provider order entry with clinician decision support to reduce red blood cell utilization

BACKGROUND

Two necessary components of a patient blood management program are education regarding evidence-based transfusion guidelines and computerized provider order entry (CPOE) with clinician decision support (CDS). This study examines changes in red blood cell (RBC) utilization associated with each of these two interventions.

STUDY DESIGN AND METHODS

We reviewed 5 years of blood utilization data (2009-2013) for 70,118 surgical patients from 10 different specialty services at a tertiary care academic medical center. Three distinct periods were compared: 1) before blood management, 2) education alone, and 3) education plus CPOE. Changes in RBC unit utilization were assessed over the three periods stratified by surgical service. Cost savings were estimated based on RBC acquisition costs.

RESULTS

For all surgical services combined, RBC utilization decreased by 16.4% with education alone (p = 0.001) and then changed very little (2.5% increase) after subsequent addition of CPOE (p = 0.64). When we compared the period of education plus CPOE to the pre-blood management period, the overall decrease was 14.3% (p = 0.008; 2102 fewer RBC units/year, or a cost avoidance of $462,440/year). Services with the highest massive transfusion rates (≥10 RBC units) exhibited the least reduction in RBC utilization.

CONCLUSIONS

Adding CPOE with CDS after a successful education effort to promote evidence-based transfusion practice did not further reduce RBC utilization. These findings suggest that education is an important and effective component of a patient blood management program and that CPOE algorithms may serve to maintain compliance with evidence-based transfusion guidelines.

A comparison of the effects of epidural analgesia versus traditional pain management on outcomes after gastric cancer resection: a population-based study

BACKGROUND AND OBJECTIVES

Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not.

METHODS

We used the linked federal Surveillance, Epidemiology, and End Results Program/Medicare database to identify patients aged 66 years or older with nonmetastatic gastric carcinoma diagnosed 1996 to 2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by Current Procedural Terminology codes. Treated recurrence was defined as chemotherapy greater than or equal to 16 months and/or radiation greater than or equal to 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression model.

RESULTS

We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% nonepidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio, 1.40; 95% confidence interval [CI], 0.96-2.05). Median survival did not differ: 28.1 months (95% CI, 24.8-32.3) in the epidural versus 27.4 months (95% CI, 24.8-30.0) in the nonepidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted hazard ratio, 0.93; 95% CI, 0.84-1.03).

CONCLUSIONS

There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts

BACKGROUND

Best practice alerts (BPAs) provide clinical decision support (CDS) at the point of care to reduce unnecessary blood product transfusions, yet substantial transfusions continue outside of recommended guidelines.

OBJECTIVE

To understand why providers order blood transfusions outside of recommended guidelines despite interruptive alerts.

DESIGN

Retrospective review.

SETTING

Tertiary care hospital.

PARTICIPANTS

Inpatient healthcare providers.

INTERVENTION

Provider-BPA interaction data were collected from January 2011 to August 2012 from the hospital electronic medical record.

MEASUREMENTS

Provider (free-text) responses to blood transfusion BPA prompts were independently reviewed and categorized by 2 licensed physicians, with agreement assessed by χ(2) analysis and kappa scoring.

RESULTS

Rationale for overriding blood transfusion BPAs was highly diverse, acute bleeding being the most common (>34%), followed by protocolized behaviors on specialty services (up to 26%), to "symptomatic" anemia (11%-12%). Many providers transfused in anticipation of surgical or procedural intervention (10%-15%) or imminent hospital discharge (2%-5%). Resident physicians represented the majority (55%) of providers interacting with BPAs.

CONCLUSION

Providers interacting with BPAs (primarily residents and midlevel providers) often do not have the negotiating power to change ordering behavior. Protocolized behaviors, unlikely to be influenced by BPAs, are among the most commonly cited reasons for transfusing outside of guidelines. Symptomatic anemia is a common, albeit subjective, indication cited for blood transfusion. With a wide swath of individually uncommon rationales for transfusion behavior, secondary use of electronic medical record databases and integrated CDS tools are important to efficiently analyze common practice behaviors.