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Theusinger OM, Schenk P, Dette-Oltmann K, Mariotti S, Baulig W. Treatment of Seizures in Children and Adults in the Emergency Medical System of the City of Zurich, Switzerland - Midazolam vs. Diazepam - A Retrospective Analysis. J Emerg Med 2019; 57:345-353. [PMID: 31296354 DOI: 10.1016/j.jemermed.2019.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Seizures count to critical situations emergency medical systems (EMS) are confronted with. OBJECTIVES Evaluation of a modified treatment algorithm (MTAS-EMS) using diazepam and midazolam due to a supply bottleneck of iv lorazepam in 2012. METHODS Retrospective study where data from patients treated for seizures by the EMS of the city of Zurich were analyzed. Effectiveness of the MTAS-EMS and i.v. diazepam in children and adults was compared with respect of cessation of seizure without recurrence over the period until arrival at the hospital. The chi-square and Fisher's exact test were used to compare categorical data. The Student's t-test and Mann Whitney test were used to compare numerical data. p-values < 0.05 are considered significant. RESULTS Of 584 documented missions, 165 treated patients (126 adults and 39 children) were included. 115 patients (80 adults and 35 children) were treated according the MTAS-EMS. Cessation of seizure was achieved in 85% of the adults and in 97% of the children, if all options of the MTAS-EMS were used. The first dose of nasal midazolam was more successful in children compared to adults (p = 0.012). In adults, the single dose of i.v. diazepam terminated the seizure in 98% (p = 0.001) compared to 57% for the single dose of iv and 64% for nasal midazolam. CONCLUSIONS The treatment success of the MTAS-EMS is high. However, in adults the single dose of i.v. diazepam is as successful as the completely used MTAS-EMS and seems to be superior to the single dose iv and nasal midazolam.
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Affiliation(s)
- Oliver M Theusinger
- Blood Transfusion Service Zürich, SRC, Schlieren, Switzerland; University of Zurich, Zurich, Switzerland
| | - Peter Schenk
- Institute of Anesthesiology, University and University Hospital, Zurich, Switzerland
| | - Katharina Dette-Oltmann
- Alster-Klinik Hamburg, Department of Plastic, Hand and Restorative Surgery, Hamburg, Germany
| | - Sergio Mariotti
- Schutz und Rettung Zurich, Zurich, Switzerland; City Hospital Triemli, Zurich, Switzerland
| | - Werner Baulig
- Department of Anesthesiology and Intensive Care Medicine, Klinik Im Park, Zurich, Switzerland
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Spahn DR, Schoenrath F, Spahn GH, Seifert B, Stein P, Theusinger OM, Kaserer A, Hegemann I, Hofmann A, Maisano F, Falk V. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet 2019; 393:2201-2212. [PMID: 31036337 DOI: 10.1016/s0140-6736(18)32555-8] [Citation(s) in RCA: 207] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/01/2018] [Accepted: 10/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anaemia and iron deficiency are frequent in patients scheduled for cardiac surgery. This study assessed whether immediate preoperative treatment could result in reduced perioperative red blood cell (RBC) transfusions and improved outcome. METHODS In this single-centre, randomised, double-blind, parallel-group controlled study, patients undergoing elective cardiac surgery with anaemia (n=253; haemoglobin concentration (Hb) <120 g/L in women and Hb <130 g/L in men) or isolated iron deficiency (n=252; ferritin <100 mcg/L, no anaemia) were enrolled. Participants were randomly assigned (1:1) with the use of a computer-generated range minimisation (allocation probability 0·8) to receive either placebo or combination treatment consisting of a slow infusion of 20 mg/kg ferric carboxymaltose, 40 000 U subcutaneous erythropoietin alpha, 1 mg subcutaneous vitamin B12, and 5 mg oral folic acid or placebo on the day before surgery. Primary outcome was the number of RBC transfusions during the first 7 days. This trial is registered with ClinicalTrials.gov, number NCT02031289. FINDINGS Between Jan 9, 2014, and July 19, 2017, 1006 patients were enrolled; 505 with anaemia or isolated iron deficiency and 501 in the registry. The combination treatment significantly reduced RBC transfusions from a median of one unit in the placebo group (IQR 0-3) to zero units in the treatment group (0-2, during the first 7 days (odds ratio 0·70 [95% CI 0·50-0·98] for each threshold of number of RBC transfusions, p=0·036) and until postoperative day 90 (p=0·018). Despite fewer RBC units transfused, patients in the treatment group had a higher haemoglobin concentration, higher reticulocyte count, and a higher reticulocyte haemoglobin content during the first 7 days (p≤0·001). Combined allogeneic transfusions were less in the treatment group (0 [IQR 0-2]) versus the placebo group (1 [0-3]) during the first 7 days (p=0·038) and until postoperative day 90 (p=0·019). 73 (30%) serious adverse events were reported in the treatment group group versus 79 (33%) in the placebo group. INTERPRETATION An ultra-short-term combination treatment with intravenous iron, subcutaneous erythropoietin alpha, vitamin B12, and oral folic acid reduced RBC and total allogeneic blood product transfusions in patients with preoperative anaemia or isolated iron deficiency undergoing elective cardiac surgery. FUNDING Vifor Pharma and Swiss Foundation for Anaesthesia Research.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland.
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, partner site Berlin, Germany
| | - Gabriela H Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Philipp Stein
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Oliver M Theusinger
- Department of Anaesthesiology, University of Zurich and University Hospital Balgrist, Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Inga Hegemann
- Division of Haematology, University of Zurich and Zurich University Hospital, Zurich, Switzerland
| | - Axel Hofmann
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Zurich, Switzerland; School of Surgery, University of Western Australia and School of Public Health Research, Curtin University, Perth, Western Australia, Australia
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre Berlin, Berlin, Germany; German Centre for Cardiovascular Research, Berlin, Germany; Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Stein P, Studt JD, Albrecht R, Müller S, von Ow D, Fischer S, Seifert B, Mariotti S, Spahn DR, Theusinger OM. The Impact of Prehospital Tranexamic Acid on Blood Coagulation in Trauma Patients. Anesth Analg 2018; 126:522-529. [DOI: 10.1213/ane.0000000000002708] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Stein P, Kaserer A, Sprengel K, Wanner GA, Seifert B, Theusinger OM, Spahn DR. Change of transfusion and treatment paradigm in major trauma patients. Anaesthesia 2017; 72:1317-1326. [PMID: 28542848 DOI: 10.1111/anae.13920] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2017] [Indexed: 11/29/2022]
Abstract
Trauma promotes trauma-induced coagulopathy, which requires urgent treatment with fixed-ratio transfusions of red blood cells, fresh frozen plasma and platelet concentrates, or goal-directed administration of coagulation factors based on viscoelastic testing. This retrospective observational study compared two time periods before (2005-2007) and after (2012-2014) the implementation of changes in trauma management protocols which included: use of goal-directed coagulation management; admission of patients to designated trauma centres; whole-body computed tomography scanning on admission; damage control surgery; permissive hypotension; restrictive fluid resuscitation; and administration of tranexamic acid. The incidence of massive transfusion (≥ 10 units of red blood cells from emergency department arrival until intensive care unit admission) was compared with the predicted incidence according to the trauma associated severe haemorrhage score. All adult (≥ 16 years) trauma patients primarily admitted to the University Hospital Zürich with an injury severity score ≥ 16 were included. In 2005-2007, the observed and trauma associated severe haemorrhage score that predicted the incidence of massive transfusion were identical, whereas in 2012-2014 the observed incidence was less than half that predicted (3.7% vs. 7.5%). Compared to 2005-2007, the proportion of patients transfused with red blood cells and fresh frozen plasma was significantly lower in 2012-2014 in both the emergency department (43% vs. 17%; 31% vs. 6%, respectively), and after 24 h (53% vs. 27%; 37% vs. 16%, respectively). The use of tranexamic acid and coagulation factor XIII also increased significantly in the 2012-2014 time period. Implementation of a revised trauma management strategy, which included goal-directed coagulation management, was associated with a reduced incidence of massive transfusion and a reduction in the transfusion of red blood cells and fresh frozen plasma.
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Affiliation(s)
- P Stein
- Institute of Anaesthesiology, University and University Hospital Zürich, Zürich, Switzerland
| | - A Kaserer
- Institute of Anaesthesiology, University and University Hospital Zürich, Zürich, Switzerland
| | - K Sprengel
- Division of Trauma Surgery, University and University Hospital Zürich, Zürich, Switzerland
| | - G A Wanner
- Department of Orthopaedics and Traumatology, Schwarzwald-Baar Hospital, Affiliated Hospital University of Freiburg, Villingen-Schwenningen, Germany
| | - B Seifert
- Department of Biostatistics, University and University Hospital Zürich, Zürich, Switzerland
| | - O M Theusinger
- Institute of Anaesthesiology, University and University Hospital Zürich, Zürich, Switzerland
| | - D R Spahn
- Institute of Anaesthesiology, University and University Hospital Zürich, Zürich, Switzerland
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Frimmel S, Theusinger OM, Kniestedt C. Analysis of Ocular Firework-Related Injuries and Common Eye Traumata: a 5-year Clinical Study. Klin Monbl Augenheilkd 2017; 234:611-616. [PMID: 28282696 DOI: 10.1055/s-0042-123515] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background A comparative study of eye injuries related to fireworks or acts of violence around New Year's Eve and the Swiss National Day on August 1st. The two groups were compared with respect to the overall numbers of eye accidents within the period of review. Patients and Methods Retrospective analysis of emergency consultations at the Department of Ophthalmology, University Hospital Zurich with eye accidents around the Swiss National Day on August 1st and New Year's Eve over the last 5 years. Two subgroups were formed: (1) Firework-related eye traumata, (2) Eye injuries due to acts of violence. The groups were analysed by age, gender, active participant or bystander, eye involved, severity of trauma (from clinical findings), surgical interventions, time of follow-up and visits, visual acuity and outcome. Results The study included 97 patients (100 eyes) with 74 male (76 %) and 23 female (24 %) victims. After filtering out 67 common traumata cases (all unilateral), 17 patients (18 eyes) with firework-related injuries and 13 patients (15 eyes) with damage due to an act of violence remained. Firework injuries accounted for 18 % of cases (65 % men); eye injuries caused by an act of violence accounted for 15 % of cases (92 % men). In the fireworks group, women were significantly older than men (mean age men 32 ± 14 years versus women 38 ± 16 years, p = 0.002). 65 % of cases were bystanders. The two subgroups contained 30 patients (33 eyes) with 22 left eyes (67 %, p < 0.001). The anterior segment was most frequently involved (79 %), significantly more often than the posterior part of the eye (p < 0.001). The posterior segment was injured more often in the fireworks group (28 %), than in the violence group (13 %). 87 % of the victims in the group of common traumata were mild trauma, 10 % moderate and 3 % severe. In the fireworks group the distribution was 53 % mild, 12 % moderate and 35 % severe, in the violence group 46 %, 23 % and 31 % respectively. Severe trauma cases occurred significantly more often around the New Year, with 36 % versus August 1st with 18 % (p = 0.0028). They are more often related to firework injuries than caused by violence (40 % versus 33 %). In summary, 7 victims (23 %) needed 8 interventions, with 3 having additional issues with their intraocular pressure. Full final visual acuity was noted in 88 %, which was alike in the two subgroups. On the contrary common traumata happened significantly more often around August 1st (66 %) than New Year (34 %; p < 0.001). Conclusions The number of injured eyes in the two subgroups of fireworks and violence was twice as high around New Year's Eve than around the Swiss National Day. If the two events were combined, eye injuries were caused by an act of violence in 45 % and by fireworks in 55 % of cases. Injuries from fireworks can be decreased by professional fireworks. Both types of accident can be decreased by public awareness.
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Affiliation(s)
- S Frimmel
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland (Chairwoman: Prof. Dr. med. Klara Landau)
| | - O M Theusinger
- Department of Anesthesiology, Balgrist University Hospital Zurich, Switzerland and University of Zurich, Switzerland (Chairman: PD Dr. med. Urs Eichenberger)
| | - C Kniestedt
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland (Chairwoman: Prof. Dr. med. Klara Landau)
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Theusinger OM, Goslings D, Studt JD, Brand-Staufer B, Seifert B, Spahn DR, Frey BM. Quarantine versus pathogen-reduced plasma-coagulation factor content and rotational thromboelastometry coagulation. Transfusion 2016; 57:637-645. [DOI: 10.1111/trf.13935] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/12/2016] [Accepted: 10/12/2016] [Indexed: 01/04/2023]
Affiliation(s)
- Oliver M. Theusinger
- Institute of Anesthesiology, University and University Hospital Zurich; Zurich Switzerland
| | - David Goslings
- Regional Blood Transfusion Service, Zurich Swiss Red Cross; Zurich Switzerland
| | - Jan-Dirk Studt
- Division of Hematology; University and University Hospital Zurich; Zurich Switzerland
| | | | - Burkhardt Seifert
- Department of Biostatistics, Epidemiology; Biostatistics, and Prevention Institute, University of Zurich; Zurich Switzerland
| | - Donat R. Spahn
- Institute of Anesthesiology, University and University Hospital Zurich; Zurich Switzerland
| | - Beat M. Frey
- Regional Blood Transfusion Service, Zurich Swiss Red Cross; Zurich Switzerland
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Baulig W, Seifert B, Spahn DR, Theusinger OM. Accuracy of non-invasive continuous total hemoglobin measurement by Pulse CO-Oximetry in severe traumatized and surgical bleeding patients. J Clin Monit Comput 2015; 31:177-185. [DOI: 10.1007/s10877-015-9816-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 12/14/2015] [Indexed: 11/29/2022]
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Theusinger OM, Spahn DR. Perioperative blood conservation strategies for major spine surgery. Best Pract Res Clin Anaesthesiol 2015; 30:41-52. [PMID: 27036602 DOI: 10.1016/j.bpa.2015.11.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 11/12/2015] [Accepted: 11/20/2015] [Indexed: 01/25/2023]
Abstract
BACKGROUND Orthopedic surgery, especially spine and spinal deformity surgery, may be associated with high perioperative blood loss. In order to reduce the risk of excessive blood loss and unnecessary blood transfusions, strategies such as Patient Blood Management including goal-directed coagulation management have been developed. RECENT FINDINGS Adverse effects of allogeneic blood transfusions have been shown for most surgical fields including orthopedic surgery. Several efforts have been made to increase the preoperative red blood cell (RBC) mass, to reduce the intraoperative blood loss, and to use restrictive transfusion triggers in order to minimize or avoid RBC transfusions. Measures to reduce intraoperative blood loss include new surgical techniques, use of cell salvage where possible, bedside coagulation management with point-of-care devices, substitution of coagulation factors, antifibrinolytic agents, and desmopressin, induced hypotension, and avoidance of hypothermia. SUMMARY Blood conservation in spinal surgery is a multidisciplinary approach and the efficacy of most single measures has been shown. Cost-effectiveness and the benefits of long-term patient outcomes are the subjects of current and future research.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland.
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
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Biro P, Kneschke O, Theusinger OM. Accuracy of calculated volatile agent consumption from fresh gas content. Acta Anaesthesiol Scand 2015; 59:619-24. [PMID: 25882167 DOI: 10.1111/aas.12487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 01/12/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND Case-by-case assessment of volatile anesthetic (VA) consumption is necessary to perform agent sparing dosing measures and for billing purposes. The gold standard technique for this purpose is to measure the weight difference of the vaporizer that occurs during VA delivery. Because suitable equipment is rarely available and weighing the vaporizer is only possible in prospectively planned fashion, a calculation method from recorded fresh gas flow (FGF) and VA courses is a viable alternative. The objective was to evaluate the accuracy of VA calculation from fresh gas composition vs. the gold standard of weighing the vaporizer before and after anesthesia. METHODS In this prospective laboratory investigation, we compared the formula-based calculations of VA consumption to the measured vaporizer weight differences before and after 10 sevoflurane and 10 desflurane anesthesia. We assessed the average difference and spread of values between the calculated and the measured values. RESULTS The calculated sevoflurane consumption overestimated the measured values by 3.0 ± 2.9 ml (6.2%). The calculated desflurane consumption overestimated the measured values by 3.5 ± 6.7 ml (5.0%). All pairs of values from both agents were within ± 1.96 standard deviations. CONCLUSION The calculated VA consumption for sevoflurane and desflurane are sufficiently accurate to estimate the economic impact of VA delivery during inhalational anesthesia. This method enables the assessment of VA consumption both ways: (1) retrospectively from sufficiently detailed and accurate anesthesia recordings, as well as (2) by using this method in a prospective setting.
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Affiliation(s)
- P Biro
- Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland
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Theusinger OM, Baulig W, Seifert B, Müller SM, Mariotti S, Spahn DR. Changes in coagulation in standard laboratory tests and ROTEM in trauma patients between on-scene and arrival in the emergency department. Anesth Analg 2015; 120:627-635. [PMID: 25545751 DOI: 10.1213/ane.0000000000000561] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND When trauma patients arrive in the emergency department (ED), coagulopathy frequently is present. The time course, however, in which this coagulopathy develops is poorly understood. No study has fully evaluated the coagulation status, including thromboelastometry on-scene and at hospital arrival. We hypothesized that measured coagulation variables might change when measured at the scene of injury and upon arrival to the ED. METHODS We performed a prospective, single-center, observational study investigating coagulation status in 50 trauma patients on-scene and at arrival in the ED. Measurements included arterial blood gases, ROTEM®, protein S100, protein C activity, protein S, Quick value, international normalized ratio, activated partial thromboplastin time, D-dimer, coagulation factor V (FV), coagulation factor XIII (FXIII), fibrinogen, hemoglobin, hematocrit, platelets, and volume and blood products being administered during the first 24 hours. RESULTS Significant changes between on-scene and the ED were observed for the following values: partial venous oxygen pressure increased and sodium, glucose, and lactate decreased. For EXTEM, INTEM, and APTEM, clotting time and clot formation time increased significantly, whereas maximal clot firmness and angle α decreased significantly (all P ≤ 0.004). For FIBTEM, clotting time increased significantly and maximal clot firmness decreased significantly. In the laboratory, significant reductions in hemoglobin, hematocrit, platelets, activated partial thromboplastin time, fibrinogen, FV, FXIII, protein C activity, protein S, and protein S100 were observed (all P ≤ 0.001). CONCLUSIONS Although most all laboratory and rotational thromboelastometry coagulation tests worsened over time when measured on-scene and in the ED, monitoring coagulation at the scene of trauma does not provide clinically important information in a majority of trauma patients. One hour after injury, significant activation and consumption of fibrinogen, FV, FXIII, protein C activity, and protein S were observed.
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Affiliation(s)
- Oliver M Theusinger
- From the Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland; Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Zurich, Switzerland; and Schutz und Rettung Stadt Zürich, Zurich, Switzerland
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Theusinger OM, Stein P, Levy JH. Point of care and factor concentrate-based coagulation algorithms. Transfus Med Hemother 2015; 42:115-21. [PMID: 26019707 DOI: 10.1159/000381320] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 03/03/2015] [Indexed: 11/19/2022] Open
Abstract
In the last years it has become evident that the use of blood products should be reduced whenever possible. There is increasing evidence regarding serious adverse events, including higher mortality and morbidity, related to transfusions. The use of point of care (POC) devices integrated in algorithms is one of the important mechanisms to limit blood product exposure. Any type of algorithm, especially the POC-based ones, allows goal-directed transfusions of blood products and even better targeted factor concentrate substitutions. Different types of algorithms in different surgical settings (cardiac surgery, trauma, liver surgery etc.) have been established with growing interest in their use as they offer objective therapy for management and reduction of blood product use. The use of POC devices with evidence-based algorithms is important in the bleeding patient independent of its origin (traumatic vs. surgical). The use of factor concentrates compared to the classical blood products can be cost-saving, beneficial for the patient, and in agreement with the WHO-requested standard of care. The empiric and uncontrolled use of blood products such as fresh frozen plasma, red blood cells, and platelets without POC monitoring should no longer be followed with regard to actual evidence in literature. Furthermore, the use of factor concentrates may provide better outcomes and potential for cost saving.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital of Zurich, Zurich, Switzerland
| | - Jerrold H Levy
- Cardiothoracic ICU, Duke University School of Medicine, Durham, NC, USA
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Theusinger OM. [A WHO concept- patient blood management]. Praxis (Bern 1994) 2014; 103:1257-1262. [PMID: 25305117 DOI: 10.1024/1661-8157/a001801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Blood transfusions are in general considered as lifesaving. Current data and evidence show, that blood transfusions are associated with increased morbidity and mortality, and this apparently dose-dependent. Basic research and results from randomized controlled trials show a causal relationship between blood transfusion and adverse outcome. Based on the current state of knowledge it has to be questioned that blood transfusions are "life-saving" as patients are exposed to an increased risk of disease or death. Furthermore, blood transfusions are more costly than previously assumed. For these reasons novel approaches in the treatment of anemia and bleeding are needed. Patient Blood Management (PBM) allows reduction of transfusion rates by correcting anemia by stimulating erythropoiesis, minimizing perioperative blood loss and optimizing the physiological tolerance of anemia. In 2010 the World Health Organization has claimed PBM to be considered as golden standard. PBM reduces morbidity and mortality by lowering the excessive use of blood transfusions. This concept has partially and successfully been implemented in the University Hospital Balgrist in Zurich.
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Affiliation(s)
- Oliver M Theusinger
- Institut für Anästhesiologie, Universitätsspital Zürich und Universität Zürich
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Caliskan E, Güsewell S, Seifert B, Theusinger OM, Starck CT, Pavicevic J, Reser D, Holubec T, Plass A, Falk V, Emmert MY. Does body mass index impact the early outcome of surgical revascularization? A comparison between off-pump and on-pump coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2014; 19:749-55. [DOI: 10.1093/icvts/ivu246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Bircher L, Theusinger OM, Locher S, Eugster P, Roth-Z'graggen B, Schumacher CM, Studt JD, Stark WJ, Beck-Schimmer B, Herrmann IK. Characterization of carbon-coated magnetic nanoparticles using clinical blood coagulation assays: effect of PEG-functionalization and comparison to silica nanoparticles. J Mater Chem B 2014; 2:3753-3758. [PMID: 32261721 DOI: 10.1039/c4tb00208c] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Intravascular application of magnetic nanocarriers is a critical step in the development of new therapeutic strategies, including magnetic drug targeting or hyperthermia. However, injection of particulate matter bears the intrinsic risk of contact activation of the blood coagulation cascade. In this work, we use point-of-care assays to study coagulation dynamics and clotting parameters in blood samples exposed to relevant concentrations of surface-functionalized carbon-coated iron carbide nanomagnets using unmodified nanomagnets and poly(ethylene)glycol-functionalized nanomagnets with different end-groups, including -OCH3, -NH2, -COOH, -IgG, and -ProteinA-protected-IgG (-IgG-ProtA). Silica nanoparticles with a comparable surface area are used as a reference material. For magnetic nanoparticles, we observe a decrease in clotting time by 25% compared to native blood at concentrations of 1 mg mL-1, independent of the surface functionalization, and only minor differences in receptor expression on platelets (GP-IIb-IIIa, CD62, and CD63) relative to control samples were observed. Interestingly, the inter-subject variance of the clotting time is similar to the nanoparticle-induced effect in a single subject with average clotting time. Whilst the present study is based on in vitro assays and a small group of healthy blood donors, the comparison to broadly used silica nanoparticles, and the fact that experimental intergroup variability is comparable to the observed effects from the carbon-coated nanomagnets suggests continuing investigations on their potential clinical use.
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Affiliation(s)
- Lukas Bircher
- Institute of Anesthesiology, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
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Biro P, Grande B, Kind SL, Spahn DR, Theusinger OM. Concluding results from the first phase of the Zurich Unexpected Difficult Airway course based on exercise of technical skills. Anaesthesia 2014; 69:452-7. [PMID: 24738802 DOI: 10.1111/anae.12606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2014] [Indexed: 11/30/2022]
Abstract
We analysed the results of the first phase of the Zurich Unexpected Difficult Airway course. Two hundred and twenty-eight staff members performed a total of 2712 standardised airway rescue procedures with four airway devices: SensaScope™, LMA Fastrach™, Laryngeal Tube and needle cricothyrodotomy. Four consecutive attempts were performed using each device. We analysed the success rate and the time needed for successful completion for each attempt and device. The success rates and mean (SD) completion times for all participants were 96.2% and 30.2 (15.3) s for the SensaScope, 88.1% and 40.4 (17.2) s for the LMA Fastrach, 99.0% and 12.1 (10.6) s for the Laryngeal Tube and 99.0% and 12.3 (6.1) s for needle cricothyroidotomy. The learning curves resulting from the four consecutive attempts with each device showed a clear pattern of improvement. This institutional airway training course represents a promising method to improve the capability of practitioners to cope with unexpected difficult airway situations.
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Affiliation(s)
- P Biro
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
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Kind SL, Spahn-Nett GH, Emmert MY, Eismon J, Seifert B, Spahn DR, Theusinger OM. Is Dilutional Coagulopathy Induced by Different Colloids Reversible by Replacement of Fibrinogen and Factor XIII Concentrates? Anesth Analg 2013; 117:1063-71. [DOI: 10.1213/ane.0b013e3182a52876] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Faraoni D, Savan V, Levy JH, Theusinger OM. Goal-directed coagulation management in the perioperative period of cardiac surgery. J Cardiothorac Vasc Anesth 2013; 27:1347-54. [PMID: 24103717 DOI: 10.1053/j.jvca.2013.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2013] [Indexed: 01/15/2023]
Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Queen Fabiola Children's University Hospital (QFCUH), Free University of Brussels, Brussels, Belgium.
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Theusinger OM, Schröder CM, Eismon J, Emmert MY, Seifert B, Spahn DR, Baulig W. The Influence of Laboratory Coagulation Tests and Clotting Factor Levels on Rotation Thromboelastometry (ROTEM®) During Major Surgery with Hemorrhage. Anesth Analg 2013; 117:314-21. [DOI: 10.1213/ane.0b013e31829569ac] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Severe trauma is associated with bleeding, coagulopathy, and transfusion of blood and blood products, all contributing to higher rates of morbidity and mortality. The aim of this review is to focus on point-of-care devices to monitor coagulation in trauma. Close monitoring of bleeding and coagulation as well as platelet function in trauma patients allows goal-directed transfusion and an optimization of the patient's coagulation, reduces the exposure to blood products, reduces costs, and probably improves clinical outcome. Noninvasive hemoglobin measurements are not to be used in trauma patients due to a lack in specificity and sensitivity.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, University Zurich, University Hospital Zurich, Zurich, Switzerland.
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Steurer MP, Steurer MA, Baulig W, Piegeler T, Schläpfer M, Spahn DR, Falk V, Dreessen P, Theusinger OM, Schmid ER, Schwartz D, Neff TA, Beck-Schimmer B. Late pharmacologic conditioning with volatile anesthetics after cardiac surgery. Crit Care 2012; 16:R191. [PMID: 23062276 PMCID: PMC3682293 DOI: 10.1186/cc11676] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 10/14/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The aim of this randomized controlled trial was to investigate whether volatile anesthetics used for postoperative sedation have any beneficial effects on myocardial injury in cardiac surgery patients after on-pump valve replacement. METHODS Anesthesia was performed with propofol. After arrival in the intensive care unit (ICU), 117 patients were randomized to be sedated for at least 4 hours with either propofol or sevoflurane. Sevoflurane was administered by using the anesthetic-conserving device. Troponin T, creatine kinase, creatine kinase from heart muscle tissue, myoglobin, and oxygenation index were determined on arrival at the ICU, 4 hours after sedation, and in the morning of the first postoperative day (POD1). Primary end points were cardiac injury markers on POD1. As secondary end points oxygenation, postoperative pulmonary complications, and ICU and hospital stay were documented. RESULTS Fifty-six patients were analyzed in the propofol arm, and 46 patients in the sevoflurane arm. Treatment groups were comparable with regard to patient demographics and intraoperative characteristics. Concentration of troponin T as the most sensitive marker for myocardial injury at POD1 was significantly lower in the sevoflurane group compared with the propofol group (unadjusted difference, -0.4; 95% CI, -0.7 to -0.1; P < 0.01; adjusted difference, -0.2; 95% CI, -0.4 to -0.02; P = 0.03, respectively). CONCLUSIONS The data presented in this investigation indicate that late postconditioning with the volatile anesthetic sevoflurane might mediate cardiac protection, even with a late, brief, and low-dose application. TRIAL REGISTRATION ClinicalTrials.gov: NCT00924222.
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Levi M, Fries D, Gombotz H, van der Linden P, Nascimento B, Callum JL, Bélisle S, Rizoli S, Hardy JF, Johansson PI, Samama CM, Grottke O, Rossaint R, Henny CP, Goslings JC, Theusinger OM, Spahn DR, Ganter MT, Hess JR, Dutton RP, Scalea TM, Levy JH, Spinella PC, Panzer S, Reesink HW. Prevention and treatment of coagulopathy in patients receiving massive transfusions. Vox Sang 2011; 101:154-74. [PMID: 21749403 DOI: 10.1111/j.1423-0410.2011.01472.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- M Levi
- Academic Medical Center, Department of Internal Medicine Amsterdam, the Netherlands.
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Emmert MY, Salzberg SP, Seifert B, Schurr UP, Theusinger OM, Hoerstrup SP, Reuthebuch O, Genoni M. Off-pump surgery is not a contraindication for patients with a severely decreased ejection fraction. Heart Surg Forum 2011; 14:E302-6. [PMID: 21997652 DOI: 10.1532/hsf98.20111027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A severely impaired left ventricular ejection fraction (EF) (30%) increases the risk of surgical myocardial revascularization. We evaluated the safety and feasibility of off-pump coronary artery bypass (OPCAB) surgery in patients with a severely decreased EF. METHODS We compared 79 patients with an EF ≤30% (group A) with 863 patients with an EF >30% (group B) who underwent myocardial revascularization between 2003 and 2008. The relationship between EF and outcome after OPCAB was assessed by univariate and logistic regression analyses. A composite end point was constructed from 30-day mortality, renal failure, length of stay in the intensive care unit (ICU) >2 days, neurologic complications, and use of an intra-aortic balloon pump (IABP). Additionally, the completeness of revascularization was assessed. RESULTS The mortality rates for groups A and B were comparable (1.3% and 2.0%, respectively; P = .55), and the 2 groups did not differ with regard to serious postoperative complications, such as stroke (2.5% versus 1.4% for groups A and B, respectively; P = .42), peripheral neurologic complications (2.5% versus 0.7%, P = .14), renal failure (0% versus 1.1%, P = 1.00), use of an IABP (1.3% versus 0.8%, P = .50), ICU length of stay >2 days (17.7% versus 19.6%, P = .77). Similarly, groups A and B did not differ with regard to ventilation time (11.2 ± 12.7 hours versus 12.4 ± 15.5 hours, P = .82), indicating similar postoperative courses for the 2 groups of patients. In contrast, the composite end point occurred significantly more frequently in group A (43.0% versus 29.7%, P = .02), a result driven by the increased rate of rethoracotomy for bleeding in that group (11.4% versus 2.9%, P = .001). The 2 groups were similar with respect to the total number of grafts used per patient (3.82 ± 0.89 versus 3.63 ± 1.01, P = .10) and the completeness of revascularization (94% versus 93%, P = .49). CONCLUSION A standardized OPCAB approach is safe for patients with a severely decreased EF, and its use does not come at the cost of less complete revascularization.
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Theusinger OM, Wanner GA, Emmert MY, Billeter A, Eismon J, Seifert B, Simmen HP, Spahn DR, Baulig W. Hyperfibrinolysis diagnosed by rotational thromboelastometry (ROTEM) is associated with higher mortality in patients with severe trauma. Anesth Analg 2011; 113:1003-12. [PMID: 21918164 DOI: 10.1213/ane.0b013e31822e183f] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND We investigated whether hyperfibrinolysis and its severity was associated with outcome of traumatized and nontraumatized patients. METHODS From April 2008 to April 2010, all emergency patients with hyperfibrinolysis were enrolled in this study. Hyperfibrinolysis patients were divided into traumatized (trauma hyperfibrinolysis group) and nontraumatized (nontrauma hyperfibrinolysis group). The trauma hyperfibrinolysis group was matched with 24 polytrauma patients without hyperfibrinolysis (matched trauma group). Data from rotational thromboelastometry measurements, blood gas analysis (metabolic state), laboratory analysis, injury severity score, and 30-day mortality were collected. RESULTS Thirty-five patients with hyperfibrinolysis were identified (13 traumatized, 22 nontraumatized). Overall mortality for hyperfibrinolysis was 54%. Mortality in the trauma hyperfibrinolysis group (77%±12%) was significantly higher than in the nontrauma hyperfibrinolysis group (41%±10%; P=0.001, 95% CI 5%-67%) and the matched trauma group (33%±10%; P=0.009, 95% CI 13%-74%). Hyperfibrinolysis is significantly (P=0.017) associated with mortality in trauma patients. In the blood gas analysis representing the metabolic state, only pH (P=0.02) and potassium (P=0.01) were significantly lower in the trauma hyperfibrinolysis group compared to the nontrauma hyperfibrinolysis group. CONCLUSIONS Mortality from hyperfibrinolysis is significantly higher in trauma compared with nontrauma patients, and hyperfibrinolysis is an independent factor predicting mortality in trauma patients. Rotational thromboelastometry provides real-time recognition of hyperfibrinolysis allowing early treatment.
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Affiliation(s)
- Oliver M Theusinger
- Institute of Anesthesiology, Clinic of Cardiac and Vascular Surgery, University Hospital Zurich, and Institute of Sockal and Preventive Medicine, University of Zurich, CH-8091 Zurich, Switzerland.
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Emmert MY, Weber B, Theusinger OM, Hoerstrup SP, Falk V, Grünenfelder J, Plass A. Delayed two-step free wall rupture of the right and left ventricular wall after myocardial infarction. Thorac Cardiovasc Surg 2011; 59:248-50. [PMID: 21455883 DOI: 10.1055/s-0030-1250503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We present a 68-year-old female who suffered extensive complications after severe myocardial infarction (MI) in the circumflex (CX) territory. At 24 hours after the initial event, the patient presented with a covered right ventricular free wall rupture (FWR) which was followed by a rupture of the left posterior wall ten days later. We report here on a rare case of delayed two-step biventricular FWR after severe MI in the CX territory.
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Affiliation(s)
- M Y Emmert
- Clinic for Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland.
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Roediger R, Beck-Schimmer B, Theusinger OM, Rusch D, Seifert B, Spahn DR, Schmid ER, Baulig W. The Revised Digital Transcutaneous PCO2/SpO2 Ear Sensor Is a Reliable Noninvasive Monitoring Tool in Patients After Cardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:243-9. [DOI: 10.1053/j.jvca.2010.06.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Indexed: 11/11/2022]
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Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2009; 50:753-65. [PMID: 20003061 DOI: 10.1111/j.1537-2995.2009.02518.x] [Citation(s) in RCA: 528] [Impact Index Per Article: 35.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Blood utilization has long been suspected to consume more health care resources than previously reported. Incomplete accounting for blood costs has the potential to misdirect programmatic decision making by health care systems. Determining the cost of supplying patients with blood transfusions requires an in-depth examination of the complex array of activities surrounding the decision to transfuse. STUDY DESIGN AND METHODS To accurately determine the cost of blood in a surgical population from a health system perspective, an activity-based costing (ABC) model was constructed. Tasks and resource consumption (materials, labor, third-party services, capital) related to blood administration were identified prospectively at two US and two European hospitals. Process frequency (i.e., usage) data were captured retrospectively from each hospital and used to populate the ABC model. RESULTS All major process steps, staff, and consumables to provide red blood cell (RBC) transfusions to surgical patients, including usage frequencies, and direct and indirect overhead costs contributed to per-RBC-unit costs between $522 and $1183 (mean, $761 +/- $294). These exceed previously reported estimates and were 3.2- to 4.8-fold higher than blood product acquisition costs. Annual expenditures on blood and transfusion-related activities, limited to surgical patients, ranged from $1.62 to $6.03 million per hospital and were largely related to the transfusion rate. CONCLUSION Applicable to various hospital practices, the ABC model confirms that blood costs have been underestimated and that they are geographically variable and identifies opportunities for cost containment. Studies to determine whether more stringent control of blood utilization improves health care utilization and quality, and further reduces costs, are warranted.
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Affiliation(s)
- Aryeh Shander
- The Institute for Patient Blood Management and Bloodless Medicine at Englewood Hospital and Medical Center, Englewood, New Jersey, USA.
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Abstract
Understanding the costs associated with blood products requires sophisticated knowledge about transfusion medicine and is attracting the attention of clinical and administrative healthcare sectors worldwide. To improve outcomes, blood usage must be optimized and expenditures controlled so that resources may be channeled toward other diagnostic, therapeutic, and technological initiatives. Estimating blood costs, however, is a complex undertaking, surpassing simple supply versus demand economics. Shrinking donor availability and application of a precautionary principle to minimize transfusion risks are factors that continue to drive the cost of blood products upward. Recognizing that historical accounting attempts to determine blood costs have varied in scope, perspective, and methodology, new approaches have been initiated to identify all potential cost elements related to blood and blood product administration. Activities are also under way to tie these elements together in a comprehensive and practical model that will be applicable to all single-donor blood products without regard to practice type (e.g., academic, private, multi- or single-center clinic). These initiatives, their rationale, importance, and future directions are described.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care, New Jersey Institute for the Advancement of Bloodless Medicine and Surgery Englewood Hospital and Medical Center, 350 Engle Street, Englewood, NJ 07631, USA.
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