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Houston BL, McIsaac DI, Breau RH, Andrews M, Avramescu S, Bagry H, Balshaw RF, Daya J, Duncan K, Harle C, Jacobsohn E, Kerelska T, McIsaac S, Ramsay T, Saha T, Perelman I, Recio A, Solvason D, Szoke D, Tenenbein M, Fergusson DA, Zarychanski R. Hospital policy of tranexamic acid to reduce transfusion in major non-cardiac surgery (TRACTION): protocol for a phase IV randomised controlled trial. BMJ Open 2024; 14:e084847. [PMID: 38830735 DOI: 10.1136/bmjopen-2024-084847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) is an inexpensive and widely available medication that reduces blood loss and red blood cell (RBC) transfusion in cardiac and orthopaedic surgeries. While the use of TXA in these surgeries is routine, its efficacy and safety in other surgeries, including oncologic surgeries, with comparable rates of transfusion are uncertain. Our primary objective is to evaluate whether a hospital-level policy implementation of routine TXA use in patients undergoing major non-cardiac surgery reduces RBC transfusion without increasing thrombotic risk. METHODS AND ANALYSIS A pragmatic, registry-based, blinded, cluster-crossover randomised controlled trial at 10 Canadian sites, enrolling patients undergoing non-cardiac surgeries at high risk for RBC transfusion. Sites are randomised in 4-week intervals to a hospital policy of intraoperative TXA or matching placebo. TXA is administered as 1 g at skin incision, followed by an additional 1 g prior to skin closure. Coprimary outcomes are (1) effectiveness, evaluated as the proportion of patients transfused RBCs during hospital admission and (2) safety, evaluated as the proportion of patients diagnosed with venous thromboembolism within 90 days. Secondary outcomes include: (1) transfusion: number of RBC units transfused (both at a hospital and patient level); (2) safety: in-hospital diagnoses of myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism; (3) clinical: hospital length of stay, intensive care unit admission, hospital survival, 90-day survival and the number of days alive and out of hospital to day 30; and (4) compliance: the proportion of enrolled patients who receive a minimum of one dose of the study intervention. ETHICS AND DISSEMINATION Institutional research ethics board approval has been obtained at all sites. At the completion of the trial, a plain language summary of the results will be posted on the trial website and distributed in the lay press. Our trial results will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER NCT04803747.
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Affiliation(s)
- Brett L Houston
- Hematology and Medical Oncology, University of Manitoba/CancerCare Manitoba, Winnipeg, Manitoba, Canada
| | - Daniel I McIsaac
- University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Rodney H Breau
- University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | | | | | - Hema Bagry
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Jayesh Daya
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kaitlin Duncan
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | | | | | - Tina Kerelska
- Humber River Regional Hospital, Toronto, Ontario, Canada
| | - Sarah McIsaac
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Tarit Saha
- Queen's University, Kingston, Ontario, Canada
| | - Iris Perelman
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Angela Recio
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | | - Dean A Fergusson
- Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Ryan Zarychanski
- Hematology and Medical Oncology, University of Manitoba/CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty. Arch Orthop Trauma Surg 2023; 143:1643-1650. [PMID: 35195782 DOI: 10.1007/s00402-022-04391-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty. METHODS A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis. RESULTS The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis. CONCLUSION This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning. LEVEL OF EVIDENCE III, case-control retrospective analysis.
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Lenet T, Skanes S, Tropiano J, Verret M, McIsaac DI, Tinmouth A, Hallet J, Nicholls SG, Fergusson DA, Martel G. Patient perspectives on intraoperative blood transfusion: A qualitative interview study with perioperative patients. Transfusion 2023; 63:305-314. [PMID: 36625559 DOI: 10.1111/trf.17242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/05/2022] [Accepted: 11/29/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND While red blood cell (RBC) transfusions are frequently administered during surgery, little is known about patient perspectives regarding intraoperative transfusion. The aim of this study was to understand patient perspectives about intraoperative RBC transfusion and explore their willingness to engage in transfusion prevention strategies. STUDY DESIGN AND METHODS This descriptive qualitative study used semi-structured patient interviews before and after surgery. Purposive sampling was used to select adult patients with varying perioperative courses, including having perioperative transfusion or postoperative anemia. Inductive and deductive thematic analyses were conducted to identify themes. RESULTS Twenty patients (nine preoperative and 11 postoperative patients) were interviewed. The following themes were identified: Risk-benefit perception of transfusion, transfusion acceptance, trust, patient involvement in transfusion decisions, acceptance of transfusion prevention interventions, and communication. Patients perceived transfusions as low-risk compared to the surgery itself. Factors influencing transfusion acceptance included trust in the healthcare system and the perception of the treatability of transfusion-related complications. Some patients preferred to defer transfusion decision making to the perioperative team, citing trust in professional judgment and building a positive relationship with their surgeon. Others wished for their preferences to be incorporated into transfusion decisions. Some desired detailed blood consent conversations and most were willing to participate in strategies to reduce intraoperative transfusion. CONCLUSION In our sample, patients consider intraoperative transfusions as low-risk high-reward interventions and trust the healthcare system and perioperative team to guide intraoperative transfusion decision making. However, preoperative transfusion consent discussions were recalled as being superficial and lacking nuance. Targeted strategies are required to improve blood consent discussions to better integrate patient preferences.
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Affiliation(s)
- Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Stephanie Skanes
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joseph Tropiano
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Anesthesia, CHU de Québec - Université Laval, Quebec City, Quebec, Canada
| | - Daniel I McIsaac
- Departments of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Tinmouth
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Julie Hallet
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Surgical Oncology, Odette Cancer Centre - Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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ONTraC: A 20-Year History of a Successfully Coordinated Provincewide Patient Blood Management Program: Lessons Learned and Goals Achieved. Anesth Analg 2022; 135:448-458. [PMID: 35977355 DOI: 10.1213/ane.0000000000006065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Our understanding of the risks associated with perioperative anemia and transfusion, in terms of increased morbidity and mortality, has evolved over the past 2 decades. By contrast, our understanding of the potential mechanisms of injury and optimal treatment strategies remains incomplete. As such, the important role of effective patient blood management (PBM) programs, which address both the effective treatment of anemia and minimizes the need for red blood cell (RBC) transfusion, is of central importance to optimizing patient care and improving patient outcomes. We report on important clinical outcomes of the Ontario Transfusion Coordinator (ONTraC Program), a network of 25 hospital sites, working in coordination over the past 20 years. Transfusion nurse coordinators were assigned to apply multimodal best practice in PBM (including recommended changes in surgical approach; diagnosis, assessment, and treatment of anemia; and adherence to more restrictive RBC transfusion thresholds). Data were collected on various clinical parameters. We further described lessons learned and difficulties encountered in this multisite PBM initiative. A significant reduction in RBC transfusions was observed for numerous indexed surgeries. For example, RBC transfusion rates for knee arthroplasty decreased from 25% in 2002 to 0.4% in 2020. For coronary artery bypass graft (CABG) surgery, transfusion rates decreased from 60% in 2002 to 27% in 2020. We also observed a decrease in RBC units utilized per transfused patient for knee (2.1 ± 0.5 [2002] vs 1.0 ± 0.6 [2020] units per patient) and CABG surgery (3.3 ± 0.6 [2002] vs 2.3 ± 1.9 [2020] units per patient). These reductions were associated with favorable clinical outcomes, including reduced length of hospital stay (P = .00003) and a reduced rate of perioperative infections (P < .001) for nontransfused versus transfused patients. These advances have been achieved with estimated savings in the tens of millions of dollars annually. Our experience and data support the hypothesis that instituting an integrated network of transfusion nurse coordinators can provide an effective provincewide PBM program, reduce RBC transfusions, improve some patient outcomes, and reduce health care costs, as an example of a "win-win-win" medical program.
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Houston BL, Fergusson DA, Falk J, Krupka E, Perelman I, Breau RH, McIsaac DI, Rimmer E, Houston DS, Garland A, Ariano RE, Tinmouth A, Balshaw R, Turgeon AF, Jacobsohn E, Zarychanski R. Prophylactic tranexamic acid use in non-cardiac surgeries at high risk for transfusion. Transfus Med 2021; 31:236-242. [PMID: 33938051 DOI: 10.1111/tme.12780] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/29/2021] [Accepted: 04/18/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Tranexamic acid (TXA) reduces transfusion in a wide range of surgical populations, although its real-world use in non-cardiac surgeries has not been well described. The objective of this study was to describe prophylactic TXA use in non-cardiac surgeries at high risk for transfusion. METHODS This is a retrospective cohort study of all adult patients undergoing major non-cardiac surgery at ≥5% risk of perioperative transfusion at five Canadian hospitals between January 2014 and December 2016. Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database were linked to transfusion and laboratory databases. TXA use was ascertained electronically from The Ottawa Hospital Data Warehouse and via manual chart review for Winnipeg hospitals. For each surgery, we evaluated the percentage of patients who received TXA as well as the specifics of TXA dosing and administration. RESULTS TXA use was evaluable in 14 300 patients. Overall, 17% of surgeries received TXA, ranging from 0% to 68% among individual surgeries. TXA use was more common in orthopaedic (n = 2043/4942; 41%) and spine surgeries (n = 239/1322; 18%) compared to other surgical domains (n = 109/8036; 1%). TXA was commonly administered as a bolus (n = 2097/2391; 88%). The median TXA dose was 1000 mg (IQR 1000-1000 mg). CONCLUSION TXA is predominantly used in orthopaedic and spine surgeries, with little uptake in other non-cardiac surgeries at high risk for red blood cell transfusion. Further studies are needed to evaluate the effectiveness and safety of TXA and to understand the barriers to TXA administration in a broad range of non-cardiac surgeries.
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Affiliation(s)
- Brett L Houston
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Jamie Falk
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Emily Krupka
- Faculty of Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iris Perelman
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada.,Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Emily Rimmer
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Donald S Houston
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Allan Garland
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert E Ariano
- College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alan Tinmouth
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), Ottawa, Ontario, Canada
| | - Robert Balshaw
- George & Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada.,Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Faculty of Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Québec, Canada.,CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Eric Jacobsohn
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada.,Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.,Research Institute in Oncology and Hematology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
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Variation in prophylactic tranexamic acid administration among anesthesiologists and surgeons in orthopedic surgery: a retrospective cohort study. Can J Anaesth 2021; 68:962-971. [PMID: 33594597 DOI: 10.1007/s12630-021-01939-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022] Open
Abstract
PURPOSE Tranexamic acid (TXA) reduces red blood cell transfusion in various orthopedic surgeries, yet the degree of practice variation in its use among anesthesiologists and surgeons has not been described. To target future knowledge transfer and implementation strategies, and to better understand determinants of variability in prophylactic TXA use, our primary objective was to evaluate the influence of surgical team members on the variability of prophylactic TXA administration. METHODS This was a retrospective cohort study of all adult patients undergoing primary total hip arthroplasty (THA), hip fracture surgery, and spine fusion ± vertebrectomy at two Canadian hospitals between January 2014 and December 2016. We used Canadian Classification of Health Interventions procedure codes within the Discharge Abstract Database which we linked to the Ottawa Data Warehouse. We described the percentage of patients that received TXA by individual surgery, the specifics of TXA dosing, and estimated the effect of anesthesiologists and surgeons on prophylactic TXA using multivariable mixed-effects logistic regression analyses. RESULTS In the 3,900 patients studied, TXA was most commonly used in primary THA (85%; n = 1,344/1,582), with lower use in hip fracture (23%; n = 342/1,506) and spine fusion surgery (23%; n = 186/812). The median [interquartile range] total TXA dose was 1,000 [1,000-1,000] mg, given as a bolus in 92% of cases. Anesthesiologists and surgeons added significant variability to the odds of receiving TXA in hip fracture surgery and spine fusion, but not primary THA. Most of the variability in TXA use was attributed to patient and other factors. CONCLUSION We confirmed the routine use of TXA in primary THA, while observing lower utilization with more variability in hip fracture and spine fusion surgery. Further study is warranted to understand variations in use and the barriers to TXA implementation in a broader population of orthopedic surgical patients at high risk for transfusion.
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