Intraoperative Blood Management Strategies for Patients Undergoing Noncardiac Surgery: The Ottawa Intraoperative Transfusion Consensus

Efficacy of a problem, intervention, control, and outcomes (PICO)-based perioperative blood management plan developed for patients undergoing long-segment lumbar spine posterior surgery

BACKGROUND

This study aimed to develop and evaluate the effectiveness of a perioperative blood management plan based on the problem, intervention, control, and outcomes (PICO) model for long-segment lumbar spine posterior surgery.

METHODS

In this retrospective study, 51 patients who needed long-segment posterior lumbar spine surgery at the Second Affiliated Hospital of Nantong University Department of Spinal Surgery from July 2020 to June 2022 were included in the control group, while 51 patients who needed long-segment posterior lumbar spine surgery from July 2021 to June 2022 were selected as the observation group. Patients in the control group received conventional blood management, while those in the observation group were additionally administered an evidence-based perioperative blood management plan. We compared the intervention outcomes in both the groups.

RESULTS

Patients in the observation group demonstrated significantly higher postoperative hemoglobin levels and hematocrit at various time points compared to those in the control group (P < 0.05). Intraoperative blood loss, postoperative drainage volume, and average volume of allogeneic blood transfused per recipient, as well as the number and frequency of allogeneic blood transfusions, were significantly lower in the observation group (P < 0.05). The duration of surgical drain placement and postoperative hospital stay were notably shorter in the observation group (P < 0.05). The two groups did not differ significantly in the incidence of postoperative venous thromboembolism (VTE) (P > 0.05).

CONCLUSION

The implementation of a perioperative blood management plan was effective in reducing the total blood loss and transfusion volume in the perioperative period, improving hemoglobin and hematocrit levels, facilitating earlier removal of surgical drains, and accelerating patient discharge.

Effects of oral clonidine on bleeding in pelvic and acetabular fractures surgery: a randomized controlled trial

BACKGROUND

High blood loss results in major complications in pelvic and acetabular surgeries. Decrement of blood loss during and after surgery reduces morbidity and mortality of the patients. Clonidine is an antihypertensive alpha-2 agonist that has been shown to reduce blood loss in different surgeries. This study aims to evaluate the effects of preoperative oral administration of clonidine in patients who underwent surgery for pelvic and acetabulum fractures.

METHODS

A randomized, triple-blinded clinical trial was conducted on 88 patients (79 men and 9 women) scheduled for pelvic or acetabular fracture surgery. Patients were divided into two groups. The intervention group received 200 mcg of oral clonidine 75 to 90 min before anesthesia. Control groups received a placebo with a similar color and shape to clonidine. We compared two groups regarding the blood loss volume, postoperative pain, quality of the surgical visual field, and day one and three postoperative hemoglobin levels.

RESULTS

Postoperation hemoglobin level was significantly dropped in both groups (P < 0.05). Post-surgery, the hemoglobin level difference between the groups increased and became significant by day three (9.8 ± 1.2 Vs. 8.4 ± 1.2, P = 0.02). The number of patients who required postoperative blood transfusion in the intervention group was less than in the control group (3 vs. 10, P = 0.03). Preoperative clonidine significantly reduced postoperation pain and improved the quality of the surgeon's visual field (P < 0.001).

CONCLUSIONS

Preoperative oral clonidine administration reduced blood loss and the number of postoperative transfusion units in pelvic and acetabular fracture surgeries. In addition, it improved the surgeon's visual field quality and reduced postoperative pain.

The Association Between Perioperative Red Blood Cell Transfusions and 1-Year Mortality After Major Cancer Surgery: An International Multicenter Observational Study

BACKGROUND

Packed red blood cell (pRBC) transfusions in patients undergoing surgery for cancer are given to treat anemia or acute hemorrhage. Evidence indicates that pRBC transfusions are associated with poor perioperative and oncological outcomes. The ARCA-1 (Perioperative Care in the Cancer Patient-1) study was designed to test the association between perioperative pRBC transfusions and postoperative morbidity and mortality in patients undergoing cancer surgery. The primary hypothesis of our study was that perioperative pRBC transfusions have a negative impact on postoperative morbidity and 1-year mortality.

METHODS

ARCA-1 was an international multicenter prospective observational cohort study. Participating centers enrolled a minimum of 30 consecutive adult patients with cancer who underwent surgery with curative intent. The primary end point was all-cause mortality 1 year after major cancer surgery. Secondary end points were rates of perioperative blood product use, 1-year cancer-specific mortality, overall survival, and 30-day morbidity and mortality. We performed a propensity score matching analysis to adjust for selection bias. A multivariable logistic regression model was fitted to estimate the effects of significant covariates on 1-year mortality, cancer-related mortality, and overall survival.

RESULTS

A total of 1079 patients were included in the study. The rate of perioperative pRBC transfusions was 21.1%. Preoperative comorbidities, including anemia, American Society of Anesthesiologists (ASA) score of III to IV, a history of coronavirus disease 2019 (COVID-19), myocardial infarction, stroke, need for dialysis, history of blood transfusions, and metastatic disease were statistically significantly more frequent in transfused patients compared to nontransfused patients. The 1-year mortality rate was higher in transfused patients before (19.7% vs 6.5%; P < .0001) and after (17.4% vs 13.2%; P = .29) propensity score matching. 1-year mortality was 1.97 times higher in transfused than in no-transfused patients (odd ratio [OR], 1.97; 95% confidence interval [CI], 1.13-3.41). The odds of 1-year cancer mortality for patients who had perioperative pRBCs was 1.82 times higher (OR, 1.82; 95% CI, 0.97-3.43) compared to those who did not receive perioperative pRBC transfusion. The effect of perioperative pRBC transfusion on overall survival was also significant (hazard ratio [HR], 1.85; 95% CI, 1.15-2.99). Transfused patients also had a higher rate of 30-day postoperative mortality before (3.5% vs 0.7%; P = .0009) and after propensity score matching (4.2% vs 1.8%; P = .34).

CONCLUSIONS

This international, multicenter observational study showed that perioperative pRBC transfusion was associated with an increased mortality risk.

Transfusion Thresholds and Risk Factors of Acute Kidney Injury in Gastrointestinal Oncology Surgery: Insights from a Retrospective Study

Objectives: To identify transfusion thresholds and risk factors for acute kidney injury (AKI) in gastrointestinal oncology surgery, enhancing early intervention and improving postoperative outcomes. Methods: From 2018 to 2022, 765 patients with gastric or colorectal cancer who underwent major gastrointestinal surgery were retrospectively enrolled. The primary outcome was AKI development within 7 days postoperatively. Clinicopathological characteristics and short-term outcomes were recorded and compared. Results: Of all enrolled patients, 39 (5.1%) developed AKI. Patients with AKI were predominantly older and had more preoperative comorbidities, lower levels of preoperative hemoglobin and serum albumin, but higher levels of blood urea nitrogen and serum creatinine (SCr). Patients developing AKI experienced higher rates of in-hospital complications (overall: 48.3% vs. 14.2%, p < 0.001), prolonged hospital stays (25.4 ± 22.5 days vs. 12.3 ± 7.9 days, p < 0.001), increased intensive care unit (ICU) admissions (53.8% vs. 22.5%, p < 0.001), and higher rates of 30-day re-admission (13.9% vs. 2.4%, p = 0.003). Significant AKI risk factors included age (per 10 years, OR: 1.567, 95% CI: 1.103-2.423, p = 0.043), preoperative SCr (per 10 μmol/L, OR: 1.173, 95% CI: 1.044-1.319, p = 0.007), intraoperative RBC transfusion (per 1000 mL, OR: 1.992, 95% CI: 1.311-3.027, p = 0.001 with a significant surge in AKI risk at transfusions exceeding 1500 mL), patient-controlled analgesia (protective, OR:0.338, 95% CI: 0.163-0.928, p = 0.033), and diuretic use (OR: 5.495, 95% CI: 1.720-17.557, p = 0.004). Conclusions: Early intervention is essential for patients with preoperative low perfusion or anemia, with particular emphasis on moderating interventions to avoid fluid overload while carefully avoiding nephrotoxic medications, thereby improving postoperative outcomes.

Transfusion-induced HLA sensitization in wait-list patients and kidney transplant recipients

Human leukocyte antigen (HLA) sensitization remains an impediment to successful solid organ transplantation, whether it be chances of receiving a transplant offer or subsequent transplant longevity. Current treatments targeting HLA antibodies lack long-term effectiveness; therefore, preventing HLA sensitization should remain a priority in all potential wait-list candidates and transplant recipients. Recent advances in the management of anemia in patients with chronic kidney disease may reduce the need for red cell transfusions. However, data from several anemia intervention studies of novel therapeutic agents have shown that a need for transfusion will remain. It has also been increasingly recognized that blood transfusions following kidney transplantation, especially in the peri-operative period, are common. Routine data on transfusion incidence, indications, and outcomes are not captured by most kidney and transplant registries across the globe. This restricts the evidence to inform both clinicians and patients on the clinical effects of transfusion, which have been considered both an allogeneic stimulus and to be immunomodulatory.This review aims to provide an update on what is currently known about transfusion-induced HLA sensitization in wait-list candidates and transplant recipients, summarizes where evidence is lacking, and demonstrates the distinct need for patient blood management guidelines in the field of kidney transplantation.

Blood Bonds: Transforming Blood Donation Through Innovation, Inclusion, and Engagement

The journey of receiving blood as a patient with transfusion-dependent beta thalassemia has profoundly shaped my understanding of the life-saving power of blood donation. This personal experience underscores the critical importance of blood donors, not just for individual recipients but for the broader community, enhancing public health, productivity, and well-being. There are several challenges to securing a blood donor pool in current health care climate. Solutions that focus on the engagement of donors, clinicians, and patients are key to improving the donor pool and utilizing the blood supply in a judicious manner.

Perioperative Blood Transfusions and Cancer Progression: A Narrative Review

PURPOSE OF REVIEW

To examine the most recent evidence about known controversies on the effect of perioperative transfusion on cancer progression.

RECENT FINDINGS

Laboratory evidence suggests that transfusion-related immunomodulation can be modified by blood management and storage practices, but it is likely of less intensity than the effect of the surgical stress response. Clinical evidence has questioned the independent effect of blood transfusion on cancer progression for some cancers but supported it for others. Despite major changes in surgery and anesthesia, cancer surgery remains a major player in perioperative blood product utilization. Prospective data is still required to strengthen or refute existing associations. Transfusion-related immunomodulation in cancer surgery is well-documented, but the extent to which it affects cancer progression is unclear. Associations between transfusion and cancer progression are disease-specific. Increasing evidence shows autologous blood transfusion may be safe in cancer surgery.

Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study

STUDY OBJECTIVE

Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality.

DESIGN

Multicenter cohort study.

SETTING

Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark.

PATIENTS

We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery.

INTERVENTIONS

No interventions were carried out.

MEASUREMENTS

Principal values collected included measurements of peripheral perfusion index and hemoglobin values.

METHODS

The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days.

MAIN RESULTS

We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62-5.45]) and 90-day mortality (3.13, [1.45-7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57-162.10]).

CONCLUSION

High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.

Perioperative Transfusion Practices in Adults Having Noncardiac Surgery

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices.