The Impact of Intraoperative Patient Blood Management on Quality Development in Cardiac Surgery

Abstract

Patient blood management (PBM) is increasingly introduced into clinical practice. Minimizing effects on transfusion have been proven, but relevance for clinical outcome has been sparsely examined. In regard to this, the authors analyzed the impact of introducing intraoperative PBM to cardiac surgery. Retrospective case-control study. Single center. A total of 3,170 patients who underwent either coronary artery bypass grafting, isolated aortic valve replacement, or a combined procedure at the authors' institution between January 1, 2007, and December 31, 2015. In 2013, an intraoperative PBM service was established offering therapy recommendations on the basis of real-time laboratory monitoring. Comparisons to conventional coagulation management were adjusted for optimization of general, surgical, and perioperative care standards by interrupted time-series analysis and risk-dependent confounding by propensity- score matching. Primary study endpoints were in-hospital mortality and morbidity. Morbidity was defined as clinically relevant prolongation of hospital stay, which was related to accumulation of postoperative complications. Transfusion requirements, bleeding, and thromboembolic complications were not treated as primary endpoints, but were also explored. The recommendations on the basis of real-time laboratory monitoring were adopted by the operative team in 72% of patients. Intraoperative PBM was associated independently with a reduction of morbidity (8.3% v 6.3%, p = 0.034), whereas in-hospitalmortality (3.0% v 2.6%, p = 0.521) remained unaffected. The need for red blood cell transfusion decreased (71.1% v 65.0%, p < 0.001), as did bleeding complications requiring surgical re-exploration (3.5% v 1.8%, p = 0.004). At the same time, stroke increased by statistical trend (1.0% v 1.9%, p = 0.038; after correction for imbalanced type of surgical procedure p = 0.085). Real-time laboratory recommendations achieved a high acceptance rate early after initiation. Improvement of clinical outcome by intraoperative PBM adds to the optimized surgical care. However, the corridor between hemostatic optimization and thromboembolic risk may be narrow.