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The effect of thromboelastogram-guided transfusion on postoperative complications and transfusion requirement in the post-reperfusion period in liver transplantation surgery. JOURNAL OF SURGERY AND MEDICINE 2023. [DOI: 10.28982/josam.7694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Background/Aim: Liver transplantation surgery is one of the most common abdominal surgeries requiring blood transfusion. Coagulation parameters vary during the perioperative period because of the patient profile. Blood transfusion management should be carefully controlled to avoid causing dysfunction in the newly transplanted organ. Various laboratory parameters are used to achieve this. This study aimed to investigate the effect of transfusion managed by conventional coagulation tests or thromboelastogram (TEG) on blood product consumption and postoperative outcomes in the post-reperfusion period.
Methods: The records of 90 recipients who underwent transplantation between January 1, 2012, and November 30, 2022, were retrospectively analyzed. Twenty patients who were administered blood transfusion under TEG guidance in the post-reperfusion period constituted the case group, while 20 patients non-consecutive randomly selected among other patients who were administered blood transfusion with conventional coagulation tests constituted the control group. In conclusion, 40 patients were included in this retrospective case-control study. We retrospectively analyzed demographic data, surgical data, perioperative laboratory parameters, intraoperative total and post-reperfusion blood and blood product transfusions, TEG parameters, and postoperative complications.
Results: No difference was found between the groups regarding demographic data, etiological factors, surgical data, and preoperative laboratory parameters (P>0.05). There was a significant decrease in the amount of fresh frozen plasma (FFP) transfused in the case group compared to the control group in the intraoperative total and post-reperfusion period (P=0.011, P=0.003). There was no difference between the groups regarding other blood product transfusions and postoperative complications (P>0.05). Regarding the effects of intraoperative total and post-reperfusion blood and blood products on ventilator stay, intensive care unit stay, length of stay (LOS), hepatic artery thrombosis, graft rejection, postoperative kidney damage, and first 28-day mortality, only a weak negative correlation was found between intraoperative total and postreperfusion fibrinogen use and LOS (r=-0.325/P=0.041, r=-0.354/P=0.025).
Conclusion: TEG-guided transfusion in the post-reperfusion period reduced total blood product consumption. Besides, the increase in the use of fibrin has led to a decrease in LOS. However, using TEG has no significant effect on postoperative mortality and morbidity. TEG and an objective assessment of patient clinical status may be an ideal guide for transfusion strategy.
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Ulutas E, Tas Tuna A, Aydin A, Hacibekiroglu T. How Did We Organize a Patient Blood Management Outpatient Anemia Unit at Our Hospital? EURASIAN JOURNAL OF FAMILY MEDICINE 2022. [DOI: 10.33880/ejfm.2022110406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Dear Editor,
Preoperative anemia is a common condition among surgical patients. Its prevalence can reach up to 75%, depending on comorbidity, gender, age, and the underlying pathology necessitating surgery (1).
Anemia and transfusion have been associated with increased morbidity and mortality in surgical patients, and the systematic application of a patient blood management (PBM) program in the perioperative period has consistently been found to improve patients’ clinical outcomes following surgery (2,3). PBM is an evidence-based, multimodal, multidisciplinary approach adopted to limit the use of and the need for allogeneic blood transfusions in all at-risk patients, to improve their clinical outcomes (4,5). PBM has three main objectives: improving red cell mass, minimizing blood loss, and optimizing the tolerance of anemia (6).
Anemia management is an important principle of PBM. Therefore, to manage preoperative anemia treatment, we organized a specific outpatient anemia unit.
Within the scope of planning, we sought answers to three questions:
- Which department(s) will manage the anemia outpatient clinic?
- Which department(s) will manage the detection of patients with preoperative anemia and their referrals to the outpatient clinic?
- Which departments will be required to cooperate in the management of patients with anemia?
Patients with anemia who were evaluated preoperatively by the anesthesia and reanimation clinic were referred to the anemia outpatient clinic opened within the family medicine clinic. The first evaluation was conducted in this outpatient clinic. Patients with iron deficiency anemia were treated after evaluation; those who required further examination and treatment were referred to the hematology clinic.
A PBM outpatient anemia unit was established on January 17, 2022, at Sakarya University Training and Research Hospital. This is the first PBM outpatient anemia unit in the world. Patients with iron deficiency who are scheduled for elective surgery are referred to this unit during the preoperative period. After oral or intravenous iron treatment, their hemoglobin levels are optimized, and then their surgeries are performed. In this way, the need for blood transfusions during surgery and transfusion-related complications are reduced. At the same time, this unit plays an active role in patient follow-up during the post-surgical period. PBM is teamwork, and we believe that it would be helpful to collaborate with hematology, family medicine, anesthesiology, and surgery specialists to organize the PBM outpatient unit. It may be beneficial to establish PBM outpatient anemia units so that anemia management can be carried out regularly by a single source in hospitals.
Keywords: anemia, patient care management, blood, preoperative period, iron deficiencies
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Affiliation(s)
- Erdi Ulutas
- Sakarya University Training and Research Hospital
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Clinical, economical and safety impact of ferric carboxymaltose use in Patient Blood Management programme in Portuguese National Health Service hospitals. Sci Rep 2022; 12:19335. [PMID: 36369296 PMCID: PMC9652329 DOI: 10.1038/s41598-022-21929-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/06/2022] [Indexed: 11/13/2022] Open
Abstract
Ferric carboxymaltose (FCM) can be used in Patient Blood Management (PBM) to promote the optimization of preoperative haemoglobin (Hb), which aims to minimise the use of allogeneic blood components and improve clinical outcomes, with better cost-effectiveness. This was an observational study conducted in a retrospective and multicentre cohort with adults from elective orthopaedic, cardiac and colorectal surgeries, treated according to local standards of PBM with allogeneic blood product transfusions (ABTs) on demand and with FCM to correct iron deficiency with or without anaemia. In this work, only the first pillar of the PBM model issue by Directorate-General for Health (DGS) was evaluated, which involves optimising Hb in the preoperative period with iron treatment if it's necessary/indicated. Before the implementation of PBM in Portugal, most patients did not undergo preoperative laboratory evaluation with blood count and iron kinetics. Therefore, the existence of Iron Deficiency Anaemia (IDA) or Iron Deficiency (ID) without anaemia was not early detected, and there was no possibility of treating these patients with iron in order to optimise their Hb and/or iron stores. Those patients ended up being treated with ABTs on demand. A total of 405 patients from seven hospitals were included; 108 (26.7%) underwent FCM preoperatively and 197 (48.6%) were transfused with ABTs on demand. In the FCM preoperative cohort, there was an increase in patients with normal preoperative Hb, from 14.4 to 45.7%, before and after FCM, respectively, a decrease from 31.7 to 9.6% in moderate anaemia and no cases of severe anaemia after FCM administration, while 7.7% of patients were severely anaemic before FCM treatment. There were significant differences (p < 0.001) before and after correction of preoperative anaemia and/or iron deficiency with FCM in Hb, serum ferritin and transferrin saturation rate (TS). In the ABT group, there were significant differences between pre- and postoperative Hb levels (p < 0.001). Hb values tended to decrease, with 44.1% of patients moving from mild anaemia before transfusion to moderate anaemia in the postoperative period. Concerning the length of hospital stay, the group administered with ABTs had a longer hospital stay (p < 0.001). Regarding the clinical outcomes of nosocomial infection and mortality, there was no evidence that the rate of infection or mortality differed in each group (p = 0.075 and p = 0.243, respectively). However, there were fewer nosocomial infections in the FCM group (11.9% versus 21.2%) and mortality was higher in the transfusion group (21.2% versus 4.2%). Economic analysis showed that FCM could reduce allogenic blood products consumption and the associated costs. The economic impact of using FCM was around 19%. The preoperative Hb value improved when FMC was used. Patients who received ABTs appeared to have a longer hospital stay. The FCM group reported fewer infections during hospitalisation. The economic results showed savings of around €1000 for each patient with FCM administration. The use of FCM as part of the PBM program had a positive impact on patients' outcomes and on economic results. However, it will be essential to perform studies with a larger sample to obtain more robust and specific results.
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Hofmann A, Shander A, Blumberg N, Hamdorf JM, Isbister JP, Gross I. Patient Blood Management: Improving Outcomes for Millions While Saving Billions. What Is Holding It Up? Anesth Analg 2022; 135:511-523. [PMID: 35977361 DOI: 10.1213/ane.0000000000006138] [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
Patient blood management (PBM) offers significantly improved outcomes for almost all medical and surgical patient populations, pregnant women, and individuals with micronutrient deficiencies, anemia, or bleeding. It holds enormous financial benefits for hospitals and payers, improves performance of health care providers, and supports public authorities to improve population health. Despite this extraordinary combination of benefits, PBM has hardly been noticed in the world of health care. In response, the World Health Organization (WHO) called for its 194 member states, in its recent Policy Brief, to act quickly and decidedly to adopt national PBM policies. To further support the WHO's call to action, this article addresses 3 aspects in more detail. The first is the urgency from a health economic perspective. For many years, growth in health care spending has outpaced overall economic growth, particularly in aging societies. Due to competing economic needs, the continuation of disproportionate growth in health care spending is unsustainable. Therefore, the imperative for health care leaders and policy makers is not only to curb the current spending rate relative to the gross domestic product (GDP) but also to simultaneously improve productivity, quality, safety of patient care, and the health status of populations. Second, while PBM meets these requirements on an exceptional scale, uptake remains slow. Thus, it is vital to identify and understand the impediments to broad implementation. This includes systemic challenges such as the so-called "waste domains" of failure of care delivery caused by malfunctions of health care systems, failure of care coordination, overtreatment, and low-value care. Other impediments more specific to PBM are the misperception of PBM and deeply rooted cultural patterns. Third, understanding how the 3Es-evidence, economics, and ethics-can effectively be used to motivate relevant stakeholders to take on their respective roles and responsibilities and follow the urgent call to implement PBM as a standard of care.
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Affiliation(s)
- Axel Hofmann
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia.,Institute of Anesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Aryeh Shander
- Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Health, Englewood, New Jersey.,College of Medicine, University of Florida, Gainesville, Florida.,School of Medicine at Mount Sinai, New York, New York.,Rutgers University, Newark, New Jersey
| | - Neil Blumberg
- Department of Pathology and Laboratory Medicine, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey M Hamdorf
- From the Faculty of Health and Medical Sciences, Discipline of Surgery, The University of Western Australia, Perth, Western Australia, Australia
| | - James P Isbister
- School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Irwin Gross
- Department of Medicine, Eastern Maine Medical Center, Bangor, Maine
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Perioperative blood transfusions in hip and knee arthroplasty: a retrospective assessment of combined risk factors. Arch Orthop Trauma Surg 2022; 142:1817-1822. [PMID: 33606085 DOI: 10.1007/s00402-021-03763-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/01/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Accurate identification of patients at risk of blood transfusion can reduce complications and improve institutional resource allocation. Probabilistic models are used to detect risk factors and formulate patient blood management strategies. Whether these predictors vary among institutions is unclear. We aimed to identify risk factors among our patients who underwent total hip (THA) or knee (TKA) arthroplasty, and combine these predictors to improve our model. MATERIALS AND METHODS We retrospectively assessed risk factors among 531 adults who underwent elective THA or TKA from January 2016 to November 2018. Using relevant surgical and patient characteristics gathered from electronic medical records, we conducted univariable and multivariable analyses. For our logistic regression model, we measured the impact of independent variables (age, gender, operation type (THA or TKA) and preoperative hemoglobin concentration) on the need for a transfusion. RESULTS Of the 531 patients, 321 had THA (uncemented) and 210 had TKA. For the selected period, our transfusion rate of 8.1% (10.6% THA and 4.3% TKA) was low. Univariable analyses showed that lower BMI (p < 0.001) was associated with receiving a transfusion. Important factors identified through logistic regression analyses were age (estimated effect of an interquartile range increase in age: OR 3.89 [CI 95% 1.96-7.69]), TKA (OR - 0.77 [CI 95% - 1.57-0.02]), and preoperative hemoglobin levels (estimated effect of interquartile range increase in hemoglobin: OR 0.47 [CI 95% 0.31-0.71]). Contrary to findings from previous reports, gender was not associated with transfusion. CONCLUSIONS Previously published predictors such as advanced age, low preoperative hemoglobin, and procedure type (THA) were also identified in our analysis. However, gender was not a predictor, and BMI showed the potential to influence risk. We conclude that, when feasible, the determination of site-specific transfusion rates and combined risk factors can assist practitioners to customize care according to the needs of their patient population. LEVEL OF EVIDENCE Level 3, retrospective cohort study.
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A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients. J Plast Reconstr Aesthet Surg 2021; 75:823-830. [PMID: 34776392 DOI: 10.1016/j.bjps.2021.08.022] [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: 04/30/2020] [Revised: 04/21/2021] [Accepted: 08/26/2021] [Indexed: 11/20/2022]
Abstract
Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.
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Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med 2021; 10:jcm10112454. [PMID: 34205971 PMCID: PMC8198483 DOI: 10.3390/jcm10112454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 11/16/2022] Open
Abstract
About 15 years ago, Patient Blood Management (PBM) emerged as a new paradigm in perioperative medicine and rapidly found support of all major medical societies and government bodies. Blood products are precious, scarce and expensive and their use is frequently associated with adverse short- and long-term outcomes. Recommendations and guidelines on the topic are published in an increasing rate. The concept aims at using an evidence-based approach to rationalize transfusion practices by optimizing the patient's red blood cell mass in the pre-, intra- and postoperative periods. However, elegant as a concept, the implementation of a PBM program on an institutional level or even in a single surgical discipline like cardiac surgery, can be easier said than done. Many barriers, such as dogmatic ideas, logistics and lack of support from the medical and administrative departments need to be overcome and each center must find solutions to their specific problems. In this paper we present a narrative overview of the challenges and updated recommendations for the implementation of a PBM program in cardiac surgery.
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Clevenger B, Richards T. Surgeons' view of the preoperative intravenous iron to treat anaemia before major abdominal surgery trial. Response to Br J Anaesth 2021; 126: e84-6. Br J Anaesth 2021; 126:e203-e204. [PMID: 33771343 DOI: 10.1016/j.bja.2021.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ben Clevenger
- Department of Anaesthesia, Royal National Orthopaedic Hospital, London, UK
| | - Toby Richards
- Division of Surgery, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia.
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Perioperative Management of Elderly patients (PriME): recommendations from an Italian intersociety consensus. Aging Clin Exp Res 2020; 32:1647-1673. [PMID: 32651902 PMCID: PMC7508736 DOI: 10.1007/s40520-020-01624-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Surgical outcomes in geriatric patients may be complicated by factors such as multiple comorbidities, low functional performance, frailty, reduced homeostatic capacity, and cognitive impairment. An integrated multidisciplinary approach to management is, therefore, essential in this population, but at present, the use of such an approach is uncommon. The Perioperative Management of Elderly patients (PriME) project has been established to address this issue. AIMS To develop evidence-based recommendations for the integrated care of geriatric surgical patients. METHODS A 14-member Expert Task Force of surgeons, anesthetists, and geriatricians was established to develop evidence-based recommendations for the pre-, intra-, and postoperative care of hospitalized older patients (≥ 65 years) undergoing elective surgery. A modified Delphi approach was used to achieve consensus, and the strength of recommendations and quality of evidence was rated using the U.S. Preventative Services Task Force criteria. RESULTS A total of 81 recommendations were proposed, covering preoperative evaluation and care (30 items), intraoperative management (19 items), and postoperative care and discharge (32 items). CONCLUSIONS These recommendations should facilitate the multidisciplinary management of older surgical patients, integrating the expertise of the surgeon, the anesthetist, the geriatrician, and other specialists and health care professionals (where available) as needed. These roles may vary according to the phase and setting of care and the patient's conditions.
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Rigal JC, Riche VP, Tching-Sin M, Fronteau C, Huon JF, Cadiet J, Boukhari R, Vourc'h M, Rozec B. Cost of red blood cell transfusion; evaluation in a French academic hospital. Transfus Clin Biol 2020; 27:222-228. [PMID: 32810606 DOI: 10.1016/j.tracli.2020.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The economic impact of Patient blood management (PBM) must be assessed beyond the acquisition cost of blood products alone. The estimate of indirect costs may vary depending on the organization and the elements taken into account. The transposition of data from the literature into a specific local context is therefore delicate. The objective of this work was to evaluate the overall cost of red blood cell concentrate (RBC) transfusion from a French healthcare establishment point of view. METHODS We carried out an activity based costing analysis in our hospital for the year 2018. The steps of the transfusion process and additional costs were detailed and cumulated (resource consumption, labor time, frequency) to populate the ABC model. Several scenarios were developed focusing either on RBC, all blood products or the surgical activity, and a univariate sensitivity analysis was conducted. RESULTS The average total cost of transfusion, including acquisition cost, was 339,64 euros per RBC transfused. The cost of administration was 138.41 euros/RBC. Focusing only on surgical activities increased this cost (152.43 euros) while taking all blood products into account reduced it (92.49 euros). CONCLUSION The difference in our results with the literature confirms the local variability in the cost of transfusion, which may affect the economic impact of PBM. Our study related to the specific context of a single French institution has limitations that a multicenter study would clarify in order to carry out economic modelling of transfusion optimization and alternatives and to guide the choice of PBM strategies at the national level.
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Affiliation(s)
- J-C Rigal
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - V P Riche
- Département recherche clinique partenariat et innovation, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - M Tching-Sin
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - C Fronteau
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - J-F Huon
- Pharmacie centrale, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - J Cadiet
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - R Boukhari
- Unité de sécurité transfusionnelle et d'hémovigilance, centre hospitalier universitaire de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - M Vourc'h
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
| | - B Rozec
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France; CNRS, Inserm, l'institut du thorax, université de Nantes, CHU de Nantes, 5, allée de l'Île Gloriette, 44093 Nantes cedex 1, France.
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Drabinski T, Zacharowski K, Meybohm P, Rüger AM, Ramirez de Arellano A. Estimating the Epidemiological and Economic Impact of Implementing Preoperative Anaemia Measures in the German Healthcare System: The Health Economic Footprint of Patient Blood Management. Adv Ther 2020; 37:3515-3536. [PMID: 32562124 PMCID: PMC7370967 DOI: 10.1007/s12325-020-01372-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Indexed: 01/10/2023]
Abstract
INTRODUCTION This study aimed to quantify the potential epidemiological and health economic benefits of implementing preoperative anaemia measures (PAMs) in clinical practice in the German healthcare system. METHODS An evidence-based health economic model was developed to assess the possible impact of implementing PAMs, the first pillar of patient blood management (PBM), in a German population. The analysis of two risk factors-iron-deficiency anaemia (IDA) and receipt of a red blood cell concentrate (RBC) transfusion during elective surgery-allowed the estimation of relative risks (RRs), average cost per patient, average length of hospital stay, and avoided hospital deaths after the implementation of PAMs. RESULTS A total of 4,591,060 patients who had undergone elective surgery during 2015 were identified, of which 29,170 (0.64%) were diagnosed with preoperative IDA. These patients had an increased RR of receiving a RBC transfusion during surgery (RR 5.031; 95% confidence interval [CI] 4.928, 5.136) and increased mortality risk (RR 3.630; 95% CI 3.401, 3.874) versus patients without IDA. Patients who received a RBC transfusion during surgery had a 24.6-times higher risk of death than those who did not (RR 24.593; 95% CI 24.121, 25.075). Average cost of treatment was €7883 in patients with IDA, €21,744 in patients with IDA and RBC transfusion, and €4560 in patients without risk factors. The model identified 29,714 patients (0.65%) who had received a RBC transfusion and who potentially had IDA but remained undiagnosed before surgery. Hypothetical implementation of PAMs would have resulted in an estimated annual net hospital direct cost saving of €1029 million (1.58%) of total hospital direct costs of the German healthcare system and 3036 hospital deaths (0.07%) avoided. CONCLUSIONS This model estimated the impact of implementing PAMs for patients with IDA undergoing elective surgery. A significant number of deaths, costly treatments, and hospital days could have been avoided by the introduction of PAMs in routine clinical practice in Germany.
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Affiliation(s)
- Thomas Drabinski
- Institut für Mikrodaten-Analyse (IfMDA), Harmsstr. 13, 24114, Kiel, Germany.
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Patrick Meybohm
- Clinic and Polyclinic for Anaesthesiology, Intensive Medicine and Pain Therapy, University Hospital Würzburg, Würzburg, Germany
| | - Alexandra M Rüger
- Vifor Pharma, Baierbrunner Str. 29 (Eingang Baierbrunner Str. 27), 81379, Munich, Germany
- Charité Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Kardiologie Campus Virchow-Klinikum, Berlin, Germany
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12
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Godfrey L. Selling the role of salvage: Cell salvage past and present. J Perioper Pract 2020; 30:336-339. [PMID: 32638658 DOI: 10.1177/1750458920921826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The use of transfused blood, be it from an allogenic (donor) or autologous (same patient) source, is not a new treatment and in fact has been experimented with since the mid 1800s. The role of cell salvage and re-infusion of a patient's own blood, however, has only begun to gain real popularity in the last 20 years, after the undertaking of several large scale meta-analyses which have shown that not only is autologous transfusion no less efficacious when compared to allogenic transfusion, but also potentially safer for a number of reasons. Autologous transfusion is also more cost effective overall and potentially quicker to initiate in an emergency situation. Despite the body of evidence to support the use of salvaged blood for transfusion, hesitation around its use still persists, with staff apprehension around set up of cell salvage equipment and general underestimation of intraoperative blood loss being key factors in its underuse.
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Affiliation(s)
- Lucy Godfrey
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
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Rigal JC. WITHDRAWN: Évaluation du coût de la transfusion de concentrés de globules rouges dans un établissement de soins français. Transfus Clin Biol 2020:S1246-7820(20)30080-X. [PMID: 32593713 DOI: 10.1016/j.tracli.2020.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/14/2020] [Accepted: 06/18/2020] [Indexed: 10/24/2022]
Affiliation(s)
- J-C Rigal
- Service d'anesthésie et de réanimation chirurgicale, hôpital Guillaume-et-René-Laënnec, centre hospitalier universitaire de Nantes, 5, allée de l'Île-Gloriette, 44093 Nantes cedex 1, France
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Lekerika Royo N, Martinez Ruiz A, Arco Vázquez J, Gutierrez Rico RM, Prieto Molano L, Arana Arri E, Valdivieso Lopez A. Transfusional optimization in liver transplant using viscoelastic test guided therapy. ACTA ACUST UNITED AC 2020; 67:292-300. [PMID: 32439229 DOI: 10.1016/j.redar.2020.01.015] [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: 10/24/2019] [Revised: 12/30/2019] [Accepted: 01/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Assess the reduction of packed red blood cells (PRBCs) transfusion in liver transplantation (LT) after the introduction of the thromboelastometry as intraoperative coagulation monitor. METHODS We conducted a retrospective cohort study (n=92), randomized into two groups: groupA (control), in whom transfusion therapy was based on conventional laboratory tests (CLT), and groupB (ROTEM), whose blood transfusion was performed as protocolized algorithms, guided by thromboelastometry (ROTEM). We analyzed packed red blood cells (PRBCs) units, transfused units of fresh frozen plasma (FFP), platelets units, fibrinogen and tranexamic acid. We used the chi square test for the comparison of proportions and Student's t test to compare means when the distribution was normal. Otherwise, Mann-Whitney U test was performed. RESULTS In groupA 84.8% of patients required transfusion of PRBCs, with a median (IQR) of 4 (1.5-6), compared with 67.4% in groupB with a median (IQR) of 2 (0-4) (P<.05). We also found differences in the following variables: FFP transfusion rate was 84.8% with a median (IQR) of 5 (2-12) IU in groupA and 56.5% (median (IQR) of 1 (0-4.5) in B (P<.001) and in the fibrinogen administration, that was 6.5% in groupA and 34.8% in groupB (P<.01). Backward stepwise logistic regression model showed associations between the clamping time, the preoperative hemoglobin, the portal hypertension (PHT) and being or not in the treatment group and the need for perioperative transfusion. We didn't find significant differences in the incidence of complication during the early postoperative period between the two groups. CONCLUSIONS The introduction of thromboelastometry (ROTEM) measurements in hemostatic therapy algorithms reduces the transfusion rate of FFP and PRBCs during liver transplantation. The using of ROTEM derived thresholds leads to detecting higher requirements of fibrinogen compared to conventional laboratory tests.
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Affiliation(s)
- N Lekerika Royo
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España.
| | - A Martinez Ruiz
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - J Arco Vázquez
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - R M Gutierrez Rico
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - L Prieto Molano
- Servicio de Anestesiología y Cuidados Críticos, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - E Arana Arri
- Unidad de Epidemiología Clínica, BioCruces Health Research Institute, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
| | - A Valdivieso Lopez
- Unidad de Cirugía Hepatobiliar y Trasplante Hepático, Hospital Universitario Cruces, Baracaldo, Vizcaya, España
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Thromboelastography Parameters Are Associated with Cirrhosis Severity. Dig Dis Sci 2019; 64:2661-2670. [PMID: 30915655 DOI: 10.1007/s10620-019-05597-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/19/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Coagulopathy in cirrhosis represents complex coagulation derangements, and thromboelastography (TEG) measures these complex derangements. AIM We sought to evaluate associations between TEG parameters and validated measures of cirrhosis severity, which have not been previously investigated. MATERIALS AND METHODS Adults with cirrhosis undergoing liver transplant (LT) were identified. Patients had TEG drawn immediately prior to LT. TEG parameters included reaction time (R), kinetic time (K), alpha angle (α), and maximum amplitude (MA). The validated measures of cirrhosis severity were MELD-Na and clinical stage of cirrhosis (classified using history of varices, variceal bleeding, or ascites). Multivariable linear and logistic regression analyses were conducted to evaluate the associations between TEG and stage of cirrhosis and MELD-Na. RESULTS Among 164 patients with cirrhosis, advancing stage of cirrhosis was associated with more hypocoagulable TEG parameters including longer K-time (p = 0.05) and lower MA (p < 0.001). Similarly, with increasing MELD-Na quartiles, K-time was longer (p < 0.001), and both MA and α-angle decreased (p < 0.001, for both). Variceal bleeding within 6 weeks prior to LT was associated with longer R-times (p = 0.02), longer K-times (p = 0.04), smaller α-angle (p = 0.03), and lower MA (p = 0.01). On multivariable analyses, decreasing MA remained statistically significantly associated with advancing stage of cirrhosis and increasing MELD-Na, after adjusting for multiple covariates including platelet count, (p = 0.02 and p < 0.0001, respectively). CONCLUSIONS Hypocoagulable TEG measurements are associated with advancing stage of cirrhosis and increasing MELD-Na among patients with cirrhosis. These data indicate that TEG, as an informative measure of complex hemostatic function, may be a useful objective marker of liver disease severity in cirrhosis.
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Pavithran P, Rajesh MC, Kaniyil S, Kaniachalil K, Anoop B, Jithin TN. Current transfusion practices of anesthesiologists in a major city in South India. J Anaesthesiol Clin Pharmacol 2019; 35:261-266. [PMID: 31303719 PMCID: PMC6598582 DOI: 10.4103/joacp.joacp_296_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Allogenic blood transfusion is a double edged sword with a delicate balance between benefits and risks. There is heavy use of blood products in the perioperative setting mostly initiated by anesthesiologists. Limited research has been done in evaluating the transfusion practices of anesthesiologists especially in Indian setting. We conducted a survey among the anesthesiologists in our city to assess their blood transfusion practices, to evaluate the level of adherence to principles of Patient Blood Management and to look for innovative strategies to improve the perioperative transfusions. Methods: A validated questionnaire with four sets of questions was distributed among the practitioners in the Indian Society of Anaesthesiologists city branch and the responses were collected and analysed. The first and second parts were structured to assess the current blood transfusion practices. The third part evaluated the keenness of participants in further updating their practices as per the recommended protocols of patient blood management. The last part assessed how the participants would act in a given clinical scenario. Statistical analysis was done using Statistical Package for the Social Sciences version 21. Results are expressed in numbers and percentages. Results: Moderate preoperative anemia was acceptable to majority of the responders. There was a high demand for continuing medical education in transfusion medicine and for formulating Indian guidelines for perioperative transfusion. The clinical scenarios demonstrated the restrictive transfusion strategy of the majority of our anesthesiologists. The lack of institutional protocols and blood transfusion committees was also seen. Conclusion: The restrictive strategy of our practitioners was an encouraging finding. There is lack of uniformity in patient blood management services. Regular educational interventions are needed to update the clinicians. Formulation and implementation of institutional protocols for perioperative blood transfusion is mandatory.
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Affiliation(s)
| | - M C Rajesh
- Department of Anaesthesiology, BMH, Calicut, Kerala, India
| | - Suvarna Kaniyil
- Department of Anaesthesiology, Govt. Medical College, Calicut, Kerala, India
| | | | - Bindiya Anoop
- Department of Anaesthesiology, MEITRA, Calicut, Kerala, India
| | - T N Jithin
- Department of Anaesthesiology, BMH, Calicut, Kerala, India
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Biancofiore G, Blasi A, De Boer MT, Franchini M, Hartmann M, Lisman T, Liumbruno GM, Porte RJ, Saner F, Senzolo M, Werner MJ. Perioperative hemostatic management in the cirrhotic patient: a position paper on behalf of the Liver Intensive Care Group of Europe (LICAGE). Minerva Anestesiol 2019; 85:782-798. [PMID: 30945514 DOI: 10.23736/s0375-9393.19.13468-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recent data demonstrated that amongst patients undergoing elective surgery the prevalence of cirrhosis is 0.8% equating to approximately 25 million cirrhotic patients undergoing surgery each year worldwide. Overall, the presence of cirrhosis is independently associated with 47% increased risk of postoperative complications and over two and a half-increased risk of in-hospital mortality in patients undergoing elective surgery. In particular, perioperative patients with chronic liver disease have long been assumed to have a major bleeding risk on the basis of abnormal results for standard tests of hemostasis. However, recent evidence outlined significant changes to traditional knowledge and beliefs and, nowadays, with more sophisticated laboratory tests, it has been shown that patients with chronic liver disease may be in hemostatic balance as a result of concomitant changes in both pro- and antihemostatic pathways. The aim of this paper endorsed by the Liver Intensive Care Group of Europe was to provide an up-to-date overview of coagulation management in perioperative patients with chronic liver disease focusing on patient blood management, monitoring of hemostasis, and current role of hemostatic agents.
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Affiliation(s)
- Gianni Biancofiore
- Department of Transplant Anesthesia and Critical Care, University School of Medicine, Pisa, Italy -
| | - Annabel Blasi
- Department of Anesthesia, Hospital Clinic, Barcelona, Spain
| | - Marieke T De Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Massimo Franchini
- Department of Hematology and Transfusion Medicine, Hospital of Mantua, Mantua, Italy
| | - Matthias Hartmann
- Department of Anesthesiology and Critical Care, University of Duisburg-Essen, Duisburg, Germany
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Robert J Porte
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Fuat Saner
- Department of General-, Visceral- and Transplant Surgery, University Duisburg-Essen, Duisburg, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Maureen J Werner
- Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Affiliation(s)
- J. Isbister
- Sydney Medical School, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Ceanga AI, Ceanga M, Eveslage M, Herrmann E, Fischer D, Haferkamp A, Wittmann M, Müller S, Van Aken H, Steinbicker AU. Preoperative anemia and extensive transfusion during stay-in-hospital are critical for patient`s mortality: A retrospective multicenter cohort study of oncological patients undergoing radical cystectomy. Transfus Apher Sci 2018; 57:739-745. [PMID: 30301602 DOI: 10.1016/j.transci.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 08/27/2018] [Accepted: 08/31/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Preoperative anemia and allogeneic blood transfusions (ABTs) may affect outcomes in cancer surgery. The prevalence of anemia, the use of ABTs, the risks of transfusions, lengths of stay and mortality of oncological patients undergoing radical cystectomy were investigated in three University Hospitals in Germany. PATIENTS AND METHODS Hospital records of 220 consecutive patients undergoing radical cystectomy from 2010 to 2012 were retrospectively analyzed for independent risk factors of ABT and unfavorable outcomes (readmission, increased length of stay (LOS) or death) using multivariate regression analysis. RESULTS Preoperative anemia was present in 40%. 70% of patients received blood transfusions. Low preoperative and intraoperative nadir hemoglobin levels were associated with receipt of ABT (OR 1.33, P = 0.04 and OR 2.94, P < 0.001 respectively). Transfusion of ten or more red blood cell units (RBCs) during the entire hospital stay was a predictor of an increased LOS (P < 0.001) and death (OR 52, 95%CI [5.9, 461.3], P < 0.001), compared to non-transfused patients. Preoperative ABT and ASA scores were associated with ≥10RBCs. CONCLUSION Anemic patients undergoing radical cystectomy had a high risk to receive ABTs. Preoperative transfusions and transfusion of ≥10RBCs during the entire hospital stay may increase patient`s mortality. Prospective, randomized controlled studies have to follow this study.
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Affiliation(s)
- Andreea-Iuliana Ceanga
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Mihai Ceanga
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| | - Maria Eveslage
- Institute of Biostatistics and Clinical Research, University of Muenster, Muenster, Germany
| | - Edwin Herrmann
- Department of Urology, University Hospital Muenster, Muenster, Germany
| | - Dania Fischer
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Frankfurt, Frankfurt, Germany
| | - Axel Haferkamp
- Department of Urology, University Hospital Mainz, Mainz, Germany
| | - Maria Wittmann
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Müller
- Department of Urology, University Hospital Bonn, Bonn, Germany
| | - Hugo Van Aken
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany
| | - Andrea Ulrike Steinbicker
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Muenster, Muenster, Germany.
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Morgan PN, Coleman PL, Martinez-Garduno CM, Gunaratne AW, McInnes E, Middleton S. Implementation of a patient blood management program in an Australian private hospital orthopedic unit. J Blood Med 2018; 9:83-90. [PMID: 29950914 PMCID: PMC6014436 DOI: 10.2147/jbm.s157571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Preoperative anemia in surgical patients has been linked to increased rates of allogeneic blood transfusion (ABT) and associated adverse patient outcomes such as prolonged ventilation in intensive care, increased length of hospital stay, and infections. We conducted a multifaceted implementation for orthopedic surgeons to improve preoperative patient assessment of anemia and iron deficiency to reduce perioperative blood transfusions. Materials and methods Using a before-and-after study design of independent samples, we recruited a convenience sample of surgeons who performed primary total hip arthroplasty at 1 Australian private hospital. Our implementation intervention consisted of: executive support, interactive education, and peer-to-peer support to encourage adherence to the National Blood Authority’s Patient Blood Management Program (PBMP) guidelines. We also used monthly reminders, e-learning access, and posters. Pre and post medical record audits evaluated preoperative blood tests, preoperative anemia, and number of blood units transfused between day of surgery until discharge. The primary outcome was an increase in the proportion of patients with preoperative blood tests undertaken prior to total hip arthroplasty surgery as recommended by the PBMP guidelines. Results Audits from 239 pre- and 263 postimplementation patients from 3 surgeons were conducted. Our primary outcome showed a significantly increased proportion of patients who had all the required preoperative tests postimplementation (0% to 94.6%; P<0.0001). Administration of ABT significantly decreased (pre: 9.2%, n=22; post: 2.3%, n=6; P=0.001) as well as the standard 2 blood units transfused (pre: 73%, n=16; post: 17%, n=1; P=0.022). The time between preoperative tests and day of surgery increased from 16 to 20 days (P<0.0001), allowing more time for physician’s review of test results. Conclusion Our results demonstrated successful implementation of a targeted PBMP to improve preoperative assessment to diagnose and treat anemia and/or iron deficiency prior to orthopedic surgery. This avoided unnecessary ABT and therefore mitigated potential risk to the patient.
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Affiliation(s)
- Paul N Morgan
- Quality Improvement Unit, The Mater Private Hospital (Sydney), St. Vincent's Health Australia, North Sydney, NSW, Australia
| | | | - Cintia Mayel Martinez-Garduno
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and the Australian Catholic University School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
| | - Anoja W Gunaratne
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and the Australian Catholic University School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and the Australian Catholic University School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
| | - Sandy Middleton
- Nursing Research Institute, St Vincent's Health Australia (Sydney) and the Australian Catholic University School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, NSW, Australia
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21
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Economic Evaluation of Pharmacologic Pre- and Postconditioning With Sevoflurane Compared With Total Intravenous Anesthesia in Liver Surgery: A Cost Analysis. Anesth Analg 2017; 124:925-933. [PMID: 28067701 PMCID: PMC5305288 DOI: 10.1213/ane.0000000000001814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pharmacologic pre- and postconditioning with sevoflurane compared with total IV anesthesia in patients undergoing liver surgery reduced complication rates as shown in 2 recent randomized controlled trials. However, the potential health economic consequences of these different anesthesia regimens have not yet been assessed. METHODS An expostcost analysis of these 2 trials in 129 patients treated between 2006 and 2010 was performed. We analyzed direct medical costs for in-hospital stay and compared pharmacologic pre- and postconditioning with sevoflurane (intervention) with total IV anesthesia (control) from the perspective of a Swiss university hospital. Year 2015 costs, converted to US dollars, were derived from hospital cost accounting data and compared with a multivariable regression analysis adjusting for relevant covariables. Costs with negative prefix indicate savings and costs with positive prefix represent higher spending in our analysis. RESULTS Treatment-related costs per patient showed a nonsignificant change by -12,697 US dollars (95% confidence interval [CI], 10,956 to -36,352; P = .29) with preconditioning and by -6139 US dollars (95% CI, 6723 to -19,000; P = .35) with postconditioning compared with the control group. Results were robust in our sensitivity analysis. For both procedures (control and intervention) together, major complications led to a significant increase in costs by 86,018 US dollars (95% CI, 13,839-158,198; P = .02) per patient compared with patients with no major complications. CONCLUSIONS In this cost analysis, reduced in-hospital costs by pharmacologic conditioning with sevoflurane in patients undergoing liver surgery are suggested. This possible difference in costs compared with total IV anesthesia is the result of reduced complication rates with pharmacologic conditioning, because major complications have significant cost implications.
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Plumb JOM, Taylor MG, Clissold E, Grocott MPW, Gill R. Transfusion in critical care - a UK regional audit of current practice. Anaesthesia 2017; 72:633-640. [PMID: 28213888 DOI: 10.1111/anae.13824] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2017] [Indexed: 01/28/2023]
Abstract
A consistent message within critical care publications has been that a restrictive transfusion strategy is non-inferior, and possibly superior, to a liberal strategy for stable, non-bleeding critically ill patients. Translation into clinical practice has, however, been slow. Here, we describe the degree of adherence to UK best practice guidelines in a regional network of nine intensive care units within Wessex. All transfusions given during a 2-month period were included (n = 444). Those given for active bleeding or within 24 h of major surgery, trauma or gastrointestinal bleeding were excluded (n = 148). The median (IQR [range]) haemoglobin concentration before transfusion was 73 (68-77 [53-106]) g.l-1 , with only 34% of transfusion episodes using a transfusion threshold of < 70 g.l-1 . In a subgroup analysis that did not study patients with a history of cardiac disease (n = 42), haemoglobin concentration before transfusion was 72 (68-77 [50-98]) g.l-1 , with only 36% of transfusion episodes using a threshold of < 70 g.l-1 (see Fig. 3). Most blood transfusions given to critically ill patients who were not bleeding in this audit used a haemoglobin threshold > 70 g.l-1 . The reason why recommendations on transfusion triggers have not translated into clinical practice is unclear. With a clear national drive to decrease usage of blood products and clear evidence that a threshold of 70 g.l-1 is non-inferior, it is surprising that a scarce and potentially dangerous resource is still being overused within critical care. Simple solutions such as electronic patient records that force pause for thought before blood transfusion, or prescriptions that only allow administration of a single unit in non-emergency circumstances may help to reduce the incidence of unnecessary blood transfusions.
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Affiliation(s)
- J O M Plumb
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M G Taylor
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - E Clissold
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - M P W Grocott
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - R Gill
- Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Froessler B, Palm P, Weber I, Hodyl NA, Singh R, Murphy EM. The Important Role for Intravenous Iron in Perioperative Patient Blood Management in Major Abdominal Surgery: A Randomized Controlled Trial. Ann Surg 2016; 264:41-6. [PMID: 26817624 PMCID: PMC4902320 DOI: 10.1097/sla.0000000000001646] [Citation(s) in RCA: 204] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To determine if preoperative intravenous (IV) iron improves outcomes in abdominal surgery patients. SUMMARY BACKGROUND DATA Preoperative iron deficiency anemia (IDA) occurs frequently; however if left untreated, increases the risk of blood transfusion allogeneic blood transfusion (ABT). Limited evidence supports IDA treatment with preoperative IV iron. This randomized controlled trial aimed to determine whether perioperative IV iron reduced the need for ABT. METHODS Between August 2011 and November 2014, 72 patients with IDA were assigned to receive either IV iron or usual care. The primary endpoint was incidence of ABT. Secondary endpoints were various hemoglobin (Hb) levels, change in Hb between time points, length of stay, iron status, morbidity, mortality, and quality of life 4 weeks postsurgery. RESULTS A 60% reduction in ABT was observed in the IV iron group compared with the usual care group (31.25% vs 12.5%). Hb values, although similar at randomization, improved by 0.8 g/dL with IV iron compared with 0.1 g/dL with usual care (P = 0.01) by the day of admission. The IV iron group had higher Hb 4 weeks after discharge compared with the usual care group (1.9 vs 0.9 g/dL, P = 0.01), and a shorter length of stay (7.0 vs 9.7 d, P = 0.026). There was no difference in discharge Hb levels, morbidity, mortality, or quality of life. CONCLUSIONS Administration of perioperative IV iron reduces the need for blood transfusion, and is associated with a shorter hospital stay, enhanced restoration of iron stores, and a higher mean Hb concentration 4 weeks after surgery.
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Affiliation(s)
- Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, South Australia, Australia
| | - Peter Palm
- Department of Anaesthesia, Lyell McEwin Hospital, South Australia, Australia
| | - Ingo Weber
- Department of Anaesthesia, Lyell McEwin Hospital, South Australia, Australia
| | - Nicolette A. Hodyl
- The Robinson Research Institute, School of Medicine, University of Adelaide, South Australia, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, South Australia, Australia
- Discipline of Medicine, University of Adelaide, South Australia, Australia
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Kasivisvanathan R, Ramesh V, Rao Baikady R, Nadaraja S. Preoperative anaemia is associated with increased allogeneic pack red cell transfusion in revision hip and knee joint arthroplasty: a retrospective analysis of 5387 patients over a 10-year period at a single high volume centre. Transfus Med 2016; 26:271-7. [DOI: 10.1111/tme.12322] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 05/01/2016] [Accepted: 05/03/2016] [Indexed: 11/30/2022]
Affiliation(s)
- R. Kasivisvanathan
- The Royal Marsden NHS Foundation Trust; London UK
- The Royal National Orthopaedic Hospital; Stanmore Middlesex UK
| | - V. Ramesh
- The Royal National Orthopaedic Hospital; Stanmore Middlesex UK
| | | | - S. Nadaraja
- The Royal National Orthopaedic Hospital; Stanmore Middlesex UK
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Pre-operative predictors of red blood cell transfusion in liver transplantation. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 15:53-56. [PMID: 27136440 DOI: 10.2450/2016.0203-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 10/28/2015] [Indexed: 12/27/2022]
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Mafirakureva N, Nyoni H, Nkomo SZ, Jacob JS, Chikwereti R, Musekiwa Z, Khoza S, Mvere DA, Emmanuel JC, Postma MJ, van Hulst M. The costs of producing a unit of blood in Zimbabwe. Transfusion 2015; 56:628-36. [DOI: 10.1111/trf.13405] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Nyashadzaishe Mafirakureva
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- National Blood Service Zimbabwe
| | | | | | | | | | | | - Star Khoza
- Department of Clinical Pharmacology; University of Zimbabwe; Harare Zimbabwe
| | | | | | - Maarten J. Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- Institute of Science in Healthy Aging & healthCare (SHARE)
- Department of Epidemiology; University Medical Center Groningen (UMCG)
| | - Marinus van Hulst
- Unit of PharmacoEpidemiology & PharmacoEconomics (PE2), Department of Pharmacy; University of Groningen; Groningen the Netherlands
- Department of Clinical Pharmacy and Toxicology; Martini Hospital; Groningen the Netherlands
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Kotzé A, Harris A, Baker C, Iqbal T, Lavies N, Richards T, Ryan K, Taylor C, Thomas D. British Committee for Standards in Haematology Guidelines on the Identification and Management of Pre-Operative Anaemia. Br J Haematol 2015; 171:322-31. [PMID: 26343392 DOI: 10.1111/bjh.13623] [Citation(s) in RCA: 95] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/22/2015] [Accepted: 06/24/2015] [Indexed: 01/28/2023]
Affiliation(s)
- Alwyn Kotzé
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Charles Baker
- University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Tariq Iqbal
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Nick Lavies
- Western Sussex Hospitals NHS Trust, Pre-Operative Association Representative, Sussex, UK
| | - Toby Richards
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kate Ryan
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Craig Taylor
- Dudley Group of Hospitals NHS Foundation Trust, Dudley, UK
| | - Dafydd Thomas
- Abertawe Bro Morgannwg University Health Board, Swansea, UK
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Clevenger B, Mallett SV, Klein AA, Richards T. Patient blood management to reduce surgical risk. Br J Surg 2015; 102:1325-37; discussion 1324. [PMID: 26313653 DOI: 10.1002/bjs.9898] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 06/08/2015] [Accepted: 06/11/2015] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- B Clevenger
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - S V Mallett
- Division of Surgery and Interventional Science, University College London, London, UK.,Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, London, UK
| | - A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College London, London, UK
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Richards T, Musallam KM, Nassif J, Ghazeeri G, Seoud M, Gurusamy KS, Jamali FR. Impact of Preoperative Anaemia and Blood Transfusion on Postoperative Outcomes in Gynaecological Surgery. PLoS One 2015; 10:e0130861. [PMID: 26147954 PMCID: PMC4492675 DOI: 10.1371/journal.pone.0130861] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 05/26/2015] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Toby Richards
- Division of Surgery and Interventional Science, University College London Hospital, London, United Kingdom
| | - Khaled M. Musallam
- Department of Internal Medicine, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Joseph Nassif
- Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Ghina Ghazeeri
- Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Muhieddine Seoud
- Department of Obstetrics and Gynaecology, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Kurinchi S. Gurusamy
- Division of Surgery and Interventional Science, University College London Hospital, London, United Kingdom
| | - Faek R. Jamali
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
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Shah A, Stanworth SJ, McKechnie S. Evidence and triggers for the transfusion of blood and blood products. Anaesthesia 2014; 70 Suppl 1:10-9, e3-5. [DOI: 10.1111/anae.12893] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 01/28/2023]
Affiliation(s)
- A. Shah
- Adult Intensive Care Unit; John Radcliffe Hospital; Oxford UK
| | - S. J. Stanworth
- Department of Haematology; John Radcliffe Hospital; Oxford UK
| | - S. McKechnie
- Department of Anaesthesia and Intensive Care; John Radcliffe Hospital; Oxford UK
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Clevenger B, Mallett SV. Transfusion and coagulation management in liver transplantation. World J Gastroenterol 2014; 20:6146-6158. [PMID: 24876736 PMCID: PMC4033453 DOI: 10.3748/wjg.v20.i20.6146] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 02/10/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
There is wide variation in the management of coagulation and blood transfusion practice in liver transplantation. The use of blood products intraoperatively is declining and transfusion free transplantations take place ever more frequently. Allogenic blood products have been shown to increase morbidity and mortality. Primary haemostasis, coagulation and fibrinolysis are altered by liver disease. This, combined with intraoperative disturbances of coagulation, increases the risk of bleeding. Meanwhile, the rebalancing of coagulation homeostasis can put patients at risk of hypercoagulability and thrombosis. The application of the principles of patient blood management to transplantation can reduce the risk of transfusion. This includes: preoperative recognition and treatment of anaemia, reduction of perioperative blood loss and the use of restrictive haemoglobin based transfusion triggers. The use of point of care coagulation monitoring using whole blood viscoelastic testing provides a picture of the complete coagulation process by which to guide and direct coagulation management. Pharmacological methods to reduce blood loss include the use of anti-fibrinolytic drugs to reduce fibrinolysis, and rarely, the use of recombinant factor VIIa. Factor concentrates are increasingly used; fibrinogen concentrates to improve clot strength and stability, and prothrombin complex concentrates to improve thrombin generation. Non-pharmacological methods to reduce blood loss include surgical utilisation of the piggyback technique and maintenance of a low central venous pressure. The use of intraoperative cell salvage and normovolaemic haemodilution reduces allogenic blood transfusion. Further research into methods of decreasing blood loss and alternatives to blood transfusion remains necessary to continue to improve outcomes after transplantation.
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Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol 2014; 27:59-68. [PMID: 23590916 DOI: 10.1016/j.bpa.2013.02.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 02/06/2013] [Indexed: 01/23/2023]
Abstract
In times of escalating health-care cost, it is of great importance to carefully assess the cost-effectiveness and appropriateness of the most resource-consuming health interventions. A long-standing and common clinical practice that has been underestimated in cost and overestimated in effectiveness is the transfusion of allogeneic blood products. Studies show that this intervention comes with largely underestimated service cost and unacceptably high utilisation variability for matched patients, thus adding billions of unnecessary dollars to the health-care expenditure each year. Moreover, a large and increasing body of literature points to a dose-dependent increase of morbidity and mortality and adverse long-term outcomes associated with transfusion whereas published evidence for benefit is extremely limited. This means that transfusion may be a generator for increased hospital stay and possible re-admissions, resulting in additional billions in unnecessary expenditure for the health system. In contrast to this, there are evidence-based and cost-effective treatment options available to pre-empt and reduce allogeneic transfusions. The patient-specific rather than a product-centred application of these multiple modalities is termed patient blood management (PBM). From a health-economic perspective, the expeditious implementation of PBM programmes is clearly indicated. Both patients and payers could benefit from this concept that has recently been endorsed through the World Health Assembly resolution WHA63.12.
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Blut und Blutprodukte. REPETITORIUM INTENSIVMEDIZIN 2014. [PMCID: PMC7123366 DOI: 10.1007/978-3-642-44933-8_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Tighten Your Belts! Reduce Your Transfusion Costs with Preoperative Management of Anemic Patients. Anesth Analg 2013. [DOI: 10.1213/ane.0b013e3182973498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Partridge J, Harari D, Gossage J, Dhesi J. Anaemia in the older surgical patient: a review of prevalence, causes, implications and management. J R Soc Med 2013; 106:269-77. [PMID: 23759887 DOI: 10.1177/0141076813479580] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.
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The chiasm: Transfusion practice versus patient blood management. Best Pract Res Clin Anaesthesiol 2013; 27:37-42. [DOI: 10.1016/j.bpa.2013.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 02/06/2013] [Indexed: 11/18/2022]
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Gross I, Shander A, Sweeney J. Patient blood management and outcome, too early or not? Best Pract Res Clin Anaesthesiol 2013; 27:161-72. [DOI: 10.1016/j.bpa.2012.12.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/17/2012] [Indexed: 01/01/2023]
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Is best transfusion practice alone best clinical practice? BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2013; 11:172-4. [PMID: 23399353 DOI: 10.2450/2012.0283-12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kotzé A, Murphy M. Anaemia management in hospital patients: A UK perspective. Br J Hosp Med (Lond) 2012; 73:544-5. [DOI: 10.12968/hmed.2012.73.10.544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alwyn Kotzé
- Leeds Teaching Hospitals, Leeds General Infirmary, Leeds LS1 3EX
| | - Mike Murphy
- University of Oxford, Consultant Haematologist, NHS Blood & Transplant and Departmentof Haematology, Oxford University Hospitals, Oxford
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Parker S, Mahawar K, Balupuri S, Boyle M, Small P. Routine group and save unnecessary for gastric band surgery: a retrospective case review audit of 1018 bariatric patients. Clin Obes 2012; 2:73-7. [PMID: 25586159 DOI: 10.1111/j.1758-8111.2012.00043.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED What is already known about this subject • The demand for bariatric surgery is increasing. • NHS Trusts are expected to instigate cost-efficiency measures. • Previous articles have discussed the need for routine preoperative cross-match. What this study adds • No gastric band patient suffered a significant drop in haemoglobin or needed a blood transfusion. • Group and save samples could be safely stored in the laboratory and only sent for analysis if clinically indicated. • Even greater cost savings could be achieved if prudent use of perioperative blood testing and blood transfusion was implemented. SUMMARY Current guidance at our Trust is that all bariatric surgical patients should have preoperative group and save (G&S) and full blood count (FBC) tests, as well as a FBC check 1 d post-operatively. Our aim was to investigate blood transfusion requirements of these patients and whether we could reduce the number of investigations requested. 1018 consecutive elective laparoscopic gastric band and laparoscopic Roux-en-Y gastric bypass patients who were operated on in our bariatric unit from March 2000 until January 2011 were identified. Patients' haemoglobin levels, G&S status and blood transfusion requirements were analyzed using our online pathology system. 607 patients had a laparoscopic gastric band, with 411 undergoing a laparoscopic Roux-en-Y gastric bypass. None of our gastric band patients required a transfusion; however, nine patients (2.2%) undergoing a gastric bypass needed a transfusion. Two patients required transfusion within 24 h of surgery while six of the remaining seven patients received blood 3-4 d post-operatively. Costs incurred on FBC and G&S tests during this time were estimated to exceed £15 700. G&S and post-operative FBC tests could be abandoned for laparoscopic gastric band patients with significant financial and person-time savings. However, given that 2.2% of laparoscopic Roux-en-Y gastric bypass patients needed a blood transfusion, we believe that post-operative FBC tests are still warranted in this patient group, with a G&S sample stored in pathology. Much greater financial savings could be achieved if prudent use of preoperative investigations, including storing G&S samples in the laboratory, was adopted for all elective operations.
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Affiliation(s)
- S Parker
- Northern Deanery, Newcastle-Upon-Tyne, UKGeneral Surgery, Sunderland Royal Hospital, Sunderland, UKDietetics, Sunderland Royal Hospital, Sunderland, UK
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