Blood Utilization Research Articles

Blood transfusion related to procedure in adult patients undergoing cardiac surgery

Introduction: Blood transfusions are associated with increased adverse outcomes and healthcare costs. While the aim of transfusion is to improve patient outcomes by enhancing tissue oxygenation, this must be weighed against the risks of transfusion-associated complications. Patient blood management programmes (PBM) have been implemented in many developed countries and have shown decreased blood utilisation and improved outcomes. Cardiac surgery is a significant consumer of blood supplies, despite evidence demonstrating the safety of restrictive transfusion strategies. This study aimed to determine the risk of blood transfusion, according to type of surgical procedure, in cardiac surgical patients in a quaternary level referral hospital in South Africa. Methods: This single centre, prospective observational study conducted over 18 weeks at Inkosi Albert Luthuli Central Hospital investigated the risk of packed red blood cell (PRBC) transfusion from the intraoperative period until discharge in adult patients undergoing elective CABG (n = 30), valve surgery (n = 53) or redo surgery (n = 11) under cardiopulmonary bypass. Poisson regression assessed the effect of type of procedure, age, gender, body mass index, preoperative haemoglobin and EuroSCORE II as risk factors for PRBC transfusion. Results: Ninety-four patients were recruited. There was no statistically significant association between risk of PRBC transfusion in valve surgery (IRR 0.71; 95% CI 0.51–1; p = 0.052) and redo surgery (IRR 0.87; CI 0.49–1.52; p = 0.621) when compared to CABG. Increased risk of PRBC transfusion was associated with female gender (IRR 1.72; 95% CI 1.24–2.41; p = 0.001) and EuroSCORE II (IRR 1.06; 95% CI 1.02–1.1; p = 0.001). Increasing preoperative haemoglobin levels were associated with a lower risk of PRBC transfusion (IRR 0.89; 95% CI 0.82–0.98; p = 0.013). Median number of PRBC units transfused was: 2 units (entire cohort); 3 units (CABG); 2 units (valve surgery); and 3 units (redo surgery). Conclusions: PRBC transfusion occurred in 80% of patients undergoing cardiac surgery, however the risk of blood transfusion was not associated with the type of surgical procedure. Implementation of a PBM protocol may decrease the incidence of preoperative anaemia, which was present in half the study population.

Cost-benefit analysis of tranexamic acid and blood transfusion in elective lumbar spine surgery for degenerative pathologies.

Blood transfusions are given to approximately one-fifth of patients undergoing elective lumbar spine surgery, and previous studies have shown that transfusions are accompanied by increased complications and additional costs. One method for decreasing transfusions is administration of tranexamic acid (TXA). The authors sought to evaluate whether the cost of TXA is offset by the decrease in blood utilization in lumbar spine surgery patients. The authors retrospectively reviewed patients who underwent elective lumbar or thoracolumbar surgery for degenerative conditions at a tertiary care center between 2016 and 2018. Patients who received intraoperative TXA (TXA patients) were matched with patients who did not receive TXA (non-TXA patients) by age, sex, BMI, ASA (American Society of Anesthesiologists) physical status class, and surgical invasiveness score. Primary endpoints were intraoperative blood loss, number of packed red blood cell (PRBC) units transfused, and total hemostasis costs, defined as the sum of TXA costs and blood transfusion costs throughout the hospital stay. A subanalysis was then performed by substratifying both cohorts into short-length (1-4 levels) and long-length (5-8 levels) spinal constructs. Of the 1353 patients who met inclusion criteria, 68 TXA patients were matched to 68 non-TXA patients. Patients in the TXA group had significantly decreased mean intraoperative blood loss (1039 vs 1437 mL, p = 0.01). There were no differences between the patient groups in the total costs of blood transfusion and TXA (p = 0.5). When the 2 patient groups were substratified by length of construct, the long-length construct group showed a significant net cost savings of $328.69 per patient in the TXA group (p = 0.027). This result was attributable to the finding that patients undergoing long-length construct surgeries who were given TXA received a lower amount of PRBC units throughout their hospital stay (2.4 vs 4.0, p = 0.007). TXA use was associated with decreased intraoperative blood loss and significant reductions in total hemostasis costs for patients undergoing surgery on more than 4 levels. Furthermore, the use of TXA in patients who received short constructs led to no additional net costs. With the increasing emphasis put on value-based care interventions, use of TXA may represent one mechanism for decreasing total care costs, particularly in the cases of larger spine constructs.

"Whatever Works": Innovations in the Treatment of Hemophilia in the United States 1783-1950.

Treatment of the bleeding disorder hemophilia in the nineteenth century was empirical, based on clinical experience. Medications, transfusions of human or animal blood, and injections of blood sera were utilized in an attempt to halt life-threatening hemorrhages. After 1900, the application of clinical laboratory science facilitated the utilization of anti-coagulated blood and donor blood compatibility tests for safer emergency transfusions. But repeated transfusions produced blood incompatibility that limited future utilization. Investigation of hormones and snake venom as coagulants appeared hopeful during the 1930s, but plasma globulin research during World War II resulted in the isolation of antihemophilic factors that promptly reduced hemorrhage. Their application to bleeding episodes resulted in a more normal life for hemophiliacs after 1950.

Transfusion-associated adverse events and implementation of blood safety measures - findings from the 2017 National Blood Collection and Utilization Survey.

Serious transfusion-associated adverse events are rare in the United States. To enhance blood safety, various measures have been developed. With use of data from the 2017 National Blood Collection and Utilization Survey (NBCUS), we describe the rate of transfusion-associated adverse events and the implementation of specific blood safety measures. Data from the 2017 NBCUS were used with comparison to already published estimates from 2015. Survey weighting and imputation were used to obtain national estimates of transfusion-associated adverse events, and the number of units treated with pathogen reduction technology (PRT), screened for Babesia, and leukoreduced. The rate of transfusion-associated adverse events requiring any diagnostic or therapeutic interventions was stable (275 reactions per 100,000 transfusions in 2015 and 282 reactions per 100,000 transfusions in 2017). In 2017 among US blood collection centers, 16 of 141 (11.3%) reported screening units for Babesia and 28 of 144 (19.4%) reported PRT implementation; 138 of 2279 (6.1%) hospitals reported transfusing PRT-treated platelets. In 2017, 134 of 2336 (5.7%) hospitals reported performing secondary bacterial testing of platelets (50,922 culture-based and 63,220 rapid immunoassay tests); in 2015, 71 of 1877 (3.8%) hospitals performed secondary testing (87,155 culture-based and 21,779 rapid immunoassay tests). Nearly all whole blood/red blood cell units and platelet units were leukoreduced. Besides leukoreduction, implementation of most blood safety measures reported in this study remains low. Nationally, hospitals might be shifting from culture-based secondary bacterial testing to rapid immunoassays.

Table of Contents

TransfusionVolume 60, Issue S2 p. III-III ISSUE INFORMATIONFree Access Table of Contents First published: 05 March 2020 https://doi.org/10.1111/trf.15724AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume60, IssueS2Special Issue: A Supplement to TRANSFUSION Blood Collection and Transfusion Practices in the United States: Findings from the 2017 National Blood Collection and Utilization SurveyMarch 2020Pages III-III RelatedInformation

Supplemental findings of the 2017 National Blood Collection and Utilization Survey.

This report provides supplemental results from the 2017 National Blood Collection and Utilization Survey on characteristics of the donor population, autologous and directed donations and transfusions, platelets, plasma and granulocyte transfusions, pediatric transfusions, severe donor-related adverse events, cost of blood units, hospitals policies and practices, and inventory, dosing, and supply. Weighting and imputation were used to generate national estimates including number of donors, donations, donor deferrals, autologous and directed donations and transfusions, severe donor-related adverse events, platelet and plasma collections and transfusions, number of cross-match procedures, irradiation and leukoreduction, and pediatric transfusions. Between 2015 and 2017, successful donations decreased slightly by 2.1% with a 10.3% decrease in donations by persons aged 16-18 years and a 14.4% increase in donations by donors aged >65 years. The median price paid for blood components by hospitals decreased from $211 to $207 for leukoreduced red blood cell units, from $523 to $517 for leukoreduced apheresis platelet units, and from $54 to $51 for fresh frozen plasma units. Plasma transfusions decreased 13.6%, but group AB plasma units transfused increased 24.7%. Between 2015 and 2017, blood donations declined slightly because of decreases in donations from younger donors, but the number of donations from older donors increased. The price hospitals pay for blood has continued to decrease. Plasma transfusions have decreased, but the proportion of plasma transfusions involving group AB plasma have increased.

Slowing decline in blood collection and transfusion in the United States - 2017.

The National Blood Collection and Utilization Survey (NBCUS) has demonstrated declines in blood collection and transfusion in the United States since 2008, including declines of 11.6% in red blood cell (RBC) collections and 13.9% in RBC transfusions during 2013-2015. This study described the 2017 NBCUS results. The 2017 NBCUS was distributed to all US blood collection centers, all hospitals performing at least 1000 surgeries annually, and a 40% random sample of hospitals performing 100 to 999 surgeries annually. Weighting and imputation were used to generate national estimates for units of blood and components collected, deferred, distributed, transfused, and outdated. Response rates for the 2017 NBCUS were 88% for blood collection centers and 86% for transfusing hospitals. Compared with 2015, the number of RBC units collected during 2017 (12,211,000; 95% confidence interval [CI], 11,680,000-12,742,000) declined by 3.0%, and transfused RBC units (10,654,000, 95% CI, 10,314,000-10,995,000) declined by 6.1%. Distributed platelet (PLT) units (2,560,000; 95% CI, 2,391,000-2,730,000 units) increased by 5.1%, and transfused PLT units (1,937,000, 95% CI, 1,794,000-2,079,000) declined by 2.3%. Distributed plasma units (3,209,000; 95% CI, 2,879,000-3,539,000) declined by 13.6%, and transfused plasma units (2,374,000; 95% CI, 2,262,000-2,487,000) declined by 12.9%. The 2017 NBCUS suggests a continued but slowing decline in demand for RBCs. The decline in blood collection and use will likely continue. Despite decreasing demand and increasing manufacturing costs of blood products, the US blood industry has met the regular and emergent needs of the country.

Are we underutilizing bone marrow and cord blood? Review of their role and potential in the era of cellular therapies.

Since the first hematopoietic stem cell transplant, over a million transplants have been performed worldwide. In the last decade, the transplant field has witnessed a progressive decline in bone marrow and cord blood utilization and a parallel increase in peripheral blood as a source of stem cells. Herein, we review the use of bone marrow and cord blood in the hematopoietic stem cell transplant setting, and we describe the recent advances made in different medical fields using cells derived from cord blood and bone marrow.

Cerium Oxide Nanoparticles Improve Lifespan of Stored Blood.

Blood is a precious commodity, with storage limited to 42days under refrigeration. Degradative changes in red blood cells (RBCs) begin as early as 11-21days after collection, and compromise their function. Materials that extend the life of RBCs will improve blood utilization in the field, as well as in hospital settings. Cerium oxide nanoparticles (CeONPs) are widely used in the materials industry to counteract oxidative stress and improve oxygen storage. We have previously shown that CeONPs extended the lifespan of cells in culture and counteract oxidative stress in vitro and in vivo. Here, we test the hypothesis that CeONPs extend the lifespan of RBCs in whole stored blood. Rat whole blood was collected with sodium citrate and stored at 4°C. Groups consisted of control (no CeONPs), and 10 and 100nM CeONPs (average particle size 10nm) added. Aliquots of stored blood were removed weekly and analyzed for different blood parameters. Results demonstrate that CeONPs improve storage and functional lifespan of RBCs in stored whole blood. This work suggests that CeONPs may be a promising additive for extending storage and function of blood and blood products.

Hb S/β-Thalassemia in the REDS-III Brazil Sickle Cell Disease Cohort: Clinical, Laboratory and Molecular Characteristics

We described the clinical, laboratory and molecular characteristics of individuals with Hb S (HBB: c.20A>T)/β-thalassemia (Hb S/β-thal) participating in the Recipient Epidemiology and Donor Evaluation Study (REDS-III) Brazil Sickle Cell Disease cohort. HBB gene sequencing was performed to genotype each β-thal mutation. Patients were classified as Hb S/β0-thal, Hb S/β+-thal-severe or Hb S/β+-thal based on prior literature and databases of hemoglobin (Hb) variants. Characteristics of patients with each β-thal mutation were described and the clinical profile of patients grouped into Hb S/β0-thal, Hb S/β+-thal and Hb S/β+-thal-severe were compared. Of the 2793 patients enrolled, 84 (3.0%) had Hb S/β0-thal and 83 (3.0%) had Hb S/β+-thal; 40/83 (48.2%) patients with Hb S/β+-thal had mutations defined as severe. We identified 19 different β-thal mutations, eight Hb S/β0-thal, three Hb S/β+-thal-severe and eight Hb S/β+-thal. The most frequent β0 and β+ mutations were codon 39 (HBB: c.118C>T) and IVS-I-6 (T>C) (HBB: c.92+6T>C), respectively. Individuals with Hb S/β0-thal had a similar clinical and laboratory phenotype when compared to those with Hb S/β+-thal-severe. Individuals with Hb S/β+-thal-severe had significantly lower total Hb and Hb A levels and higher Hb S, white blood cell (WBC) count, platelets and hemolysis markers when compared to those with Hb S/β+-thal. Likewise, individuals with Hb S/β+-thal-severe showed a significantly higher occurrence of hospitalizations, vaso-occlusive events (VOE), acute chest syndrome (ACS), splenic sequestration, blood utilization, and hydroxyurea (HU) therapy.

Prevalence of clinically significant antibodies in patients undergoing elective surgery in a Nigerian teaching hospital: A case for the type and screen method.

Provision of safe and adequate blood is challenging in our environment due to paucity of voluntary donors as well as inappropriate blood ordering and utilization. The type and screen (TS) method (typing of blood group and screening for antibodies) reduces the demand for blood reservation in hospital blood banks. The aim of this study is to determine the safety (detection clinically significant antibodies) and cost effectiveness of the TS method compared to the conventional antiglobulin crossmatch (ACM). This was a cross-sectional prospective study carried out at the University of Port Harcourt Teaching Hospital (UPTH). 124 participants booked for elective surgeries with no history of blood transfusion or pregnancy were investigated. ACM was performed on all participants' serum against 159 donor red cells. TS was also performed blindly on the same participants' sera, antibody screening was done with three-screen-cells using the gel method. An 11-cell panel was used for antibody identification. Blood utilization was calculated using the crossmatch: transfusion ratio (CTR), probability of transfusion (%T) and transfusion index (TI). Out of the 159 units crossmatched for 124 study participants, only 19 were actually transfused (88.1% not utilized). The prevalence of compatible ACM was 100%, however the TS detected one antibody (0.81%) in a male participant identified as anti-M. The overall CTR, %T and TI were 8.4, 15.6% and 0.16 respectively, with N384,750 ($963.1) wastage in terms of cost. The TS method would have saved N266,000{$665.9} (N1900{4.78} per un-transfused patient). There was improper utilization of blood in elective surgeries. The TS method identified an antibody not detected by ACM. This would have saved N266,000 {$665.9}, and reduced the demand for blood reservation in the bank. Although The TS method was found not to be significantly different in outcome compared to the ACM, it was found to be cost effective.

An Evaluation of the Practice for the Requisition of Blood Products and its Utilization in Neurosurgical Patients Undergoing Elective Surgery at a Tertiary Care Hospital.

Background:Neurosurgical procedures are associated with profound blood loss that necessitates need for intraoperative and postoperative blood transfusion. Excessive ordering of blood based on physicians' habitual practice may lead to unintentional misuse of blood bank services. For the optimal use of blood resources, transfusion practices have to be appropriate.Aims:The aim of this study is to study the cross match to transfusion ratio and to review the blood utilization practices (transfusion index and maximal surgical blood order schedule) in elective neurosurgical procedures.Settings and Design:A prospective, observational study comprising 740 patients undergoing elective neurosurgical procedures.Materials and Methods:Blood requisition forms and patient records were analyzed of patients undergoing elective neurosurgical procedures from December 2017 to December 2018. A review and note was made of the patient's age, sex, and diagnosis. The number of units prepared, cross matched, and transfused were noted.Statistical Analysis:Statistical analysis was performed with the IBM SPSS software version 21.0. Blood utilization indices were computed and expressed as percentage.Results:A total of 740 patients underwent elective surgical procedures. Among these, 346 patients were requested to prepare 614 units of blood. Out of these 740 patients, there were 56 patients who were in the pediatric age group. A total of 178 units were transfused in 102 patients. One hundred and forty-two units were transfused in the intraoperative period, whereas as 36 units were transfused in the postoperative period.Conclusion:There is an efficient usage of blood for patients undergoing surgery for meningiomas, posterior fossa tumors, spinal dysraphism, and craniovertrebral junctional anomalies. However, the blood resources were poorly utilized in patients undergoing surgery for subarachnoid hemorrhage and pituitary tumors. A revision of blood transfusion policy within the hospital is needed.

Blood utilization quality indicators in a tertiary care center in South India

Background: Injudicious over-ordering of blood components not only burdens the physical and human resources but also increases the cost of health care. Moreover, such practices have a greater implication in developing countries like ours where there is a scarcity of voluntary blood donors and insufficient blood supply to cater to increasing demands. Therefore, there is a need for continuous monitoring of the utilization of blood components and to audit the transfusion practices to identify areas of concern for blood usage. Ours is a 1600 bedded super specialty health center with 100% bed occupancy. The objective of the study was to analyze the trend of utilization of blood components and transfusion practices by various medical and surgical specialties by determining the blood utilization quality indicators at our center. Methods: This was a retrospective and cross-sectional study done over a period of 7 months from January 2018 to July 2018. The data for blood utilization quality indicators in the first half can be taken as the representative of the entire year. The data pertaining to the number of requisitions received as well as cross-matches done and issues made were collected from transfusion requisition forms, cross-match, and issue registers and analyzed. The parameters used in the analysis were crossmatch to transfusion ratio (CT ratio), transfusion index (TI), and transfusion probability (%T). Results: During the 7-months study period, a total of 28,317 transfusion requisitions were received and 34,701 blood components were issued. The total cross-matched red blood cell (RBC) units were 10,861 and the total RBC units transfused were 10,066. The overall C/T ratio was found to be 1.57. The transfusion probability (%T) and TI were calculated as 79% and 1.18, respectively, in our study. Conclusion: The CT ratio, transfusion probability, and TI demonstrated that there is an efficient blood utilization at our center. Regular auditing of blood transfusion services should be practiced at every hospital wherein the Maximum Surgical Blood Ordering Schedule can be modified and implemented progressively, following evidence-based blood transfusion guidelines.

A retrospective analysis of blood requisition versus utilization practices at national blood bank, jigme dorji wangchuck national referral hospital, Thimphu, Bhutan

Background and Objectives: Although National Guidelines on Clinical Use of Blood has been developed, it is a common practice to order blood based on the subjective anticipation of blood loss, instead of evidence-based requirement at National Referral Hospital, Thimphu. However, National Blood Bank follows the maximum surgical blood ordering schedule, thereby saving the resources and making blood available for emergency patients. Nonetheless, the need-based assessment is not conducted to determine the efficacy of the practice. This study aimed to assess the effectiveness of the current practice of following the national guidelines on maximum surgical ordering of blood by evaluating the blood requisition versus utilization practice. Materials and Methods: A hospital-based retrospective study was conducted at national blood bank over a 1-year period (January–December 2018). Demographic data, such as age and sex, and clinical wards with maximum transfusion done were recorded. Blood utilization indices were computed for cross-match-to-transfusion ratio (C:T, <2.5), transfusion index (TI, >0.5) and transfusion probability (%T, >30) to indicate significant blood usage. All data were processed and analyzed with software programs Microsoft Excel 2013 and GraphPad Prism (v 7.04). Results: Of 4012 blood units cross-matched, 3205 blood units were transfused to patients (C:T ratio 1). Majority (65.33%) of the patients were females and 34.66% were males. The overall TI was 1.49 and %T was 73.07%, implying significant blood usage. The maximum request for blood was made from gynecological and obstetrics ward, emergency, and daycare blood transfusion unit. Similarly, the patients transfused with the cross-matched units were also found to be highest for these wards. Conclusion: The study demonstrates that the current practice of maximum blood ordering schedule is effective in saving valuable time and resources. However, there is a need to sensitize the requesting physician on rational order for effective management of the blood inventory.

Factors for Blood Transfusions Following Hemi Hip Arthroplasty for Patients With Femoral Neck Fracture.

Background:Hemi hip arthroplasty is one treatment option for femoral neck fractures; however, there has been limited evidence on factors associated with blood transfusions following hemi hip arthroplasty. Hence, the aim of this study was to identify the predictors of blood transfusion after hemi hip arthroplasty, which could lead to the establishment of proper guidelines for management protocols.Materials and Methods:This study was a retrospective cohort study, conducted in a single center of 323 femoral neck fracture patients having undergone hemi hip arthroplasty. Peri-operative factors and demographic data were extracted from the electronic medical records, from 2007 to 2019. A predictive model was developed by logistic regression (LR), and adjusted by multivariate logistic regression.Result:One hundred and twenty-six (39%) patients received blood transfusions. On multivariate analysis, those of a female gender (odds ratio (OR) 2.00, p = 0.037), having a body mass index lower than 18.5 kg/m2 (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and given general anesthesia (OR 2.07, p = 0.028) were shown to be significantly associated with a higher risk of requiring a blood transfusion.Conclusion:The authors recommend that preparation of blood components coupled with the utilization of blood conserving methods for high risk patients, as studies have stated, in addition to the consideration of spinal anesthesia; if patients have no contraindication, should be implemented.

Rationalizing blood transfusion in elective breast cancer surgery: Analyzing justification and economy.

BACKGROUND:Transfusion of allogeneic blood in breast cancer surgery is variable, and differences of transfusion incidence have been observed in the literature. Most hospital guidelines including ours dictate group and reserve policy of blood before breast surgery. Here, we aimed to audit the blood utilization in patients undergoing elective breast surgery in our hospital and thereby optimize the blood ordering schedule, economic burden, and loss of clinical resources.MATERIALS AND METHODS:The study included 478 breast cancer surgeries over a period of 6 years. Patient and disease details were obtained from patient file and hospital information system. Blood samples sent to blood bank were subjected to compatibility test and reserved. All transfusions were documented, and statistical analysis was done.RESULTS:Of the total 478 patients, most underwent wide local excision of the breast and modified radical mastectomy. A total of 16 patients received 71 units of blood and blood components in all categories of surgeries. Only 103 were younger women (≤40 years), with a mean age of 31 years. Nontransfused patients were significantly more than transfused ones (P < 0.05). Frequency of blood transfusion was more in young patients (4.9%). Seven (22.6%) of the total 31 Stage IV patients received blood transfusions. Frequency of blood transfusion was more in patients undergoing surgery after chemotherapy (8.8%). A significant loss of time and loss of revenue was observed.CONCLUSION:We conclude that routine compatibility test is not justified for all patients undergoing breast surgery. A more targeted approach is needed to reduce blood demand and associated cost to patient and blood transfusion services.

Massive Transfusion Protocol: Role of maximum Surgical Blood Ordering Schedule

Preoperative placement of blood requests frequently overshoots the actual need resulting in unnecessary cross matching, which can be reduced by formulating maximum surgical blood ordering schedule (MSBOS). It is a table of elective surgical procedures, which lists the number of units of blood routinely cross-matched pre-operatively. MSBOS based on the past blood utilization records for different surgeries and keeping patients varia-bles in consideration wherever required would provide an efficient way of blood utilization and appropriate management of blood bank resources. The objective of this review throw eight on is to the blood utilization in various surgeries that can result in unnecessary cross-matching, wastage of blood bank resources, and financial losses to the patients could be reduced. Key words: Blood requests, crossmatch, polytrauma, Blood transfusion

Patient blood management as the standard of care.

Blood transfusion is one of the most common hospital procedures in developed countries. However, inappropriate use of blood transfusion is common, and this is of considerable concern because transfusion is known to be associated with adverse events and is costly. Reductions in blood use have resulted from recent evidence indicating that restrictive use of red blood cell transfusions is associated with similar patient outcomes to liberal strategies and from a focus on patient blood management (PBM), which recognizes the importance of conserving the patient's own blood alongside the judicious use of transfusion. A recent Consensus Conference in Frankfurt developed practice and research recommendations for PBM but also indicated that additional studies are needed to provide better evidence for PBM interventions, including for improved patient outcomes and lower hospital costs as well as for reductions in blood utilization. In the meanwhile, it is of utmost importance to translate PBM guidelines into practical day-to-day recommendations and encourage their use to make PBM "the standard of care."

A Restrictive Hemoglobin Transfusion Threshold of Less Than 7 g/dL Decreases Blood Utilization Without Compromising Outcomes in Patients With Hip Fractures.

In patients with hip fracture, a transfusion threshold of hemoglobin (Hb) <8 g/dL is associated with similar or better outcomes than more liberal thresholds. Whether a more restrictive threshold of <7 g/dL Hb produces equivalent outcomes in such patients is unknown. The aim of the study was to examine whether a restrictive threshold of <7 g/dL Hb is safe in this population. In January 2015, a blood management program was implemented that uses a restrictive transfusion threshold of <7 g/dL Hb in hemodynamically stable patients and <8 g/dL in patients with symptomatic anemia or a history of coronary artery disease. We identified 498 patients treated for hip fractures from January 2013 through May 2017. We compared perioperative outcomes of 207 patients treated before with those of 291 patients treated after restrictive threshold implementation. After restrictive threshold implementation, the proportion of patients receiving packed red blood cell (PRBC) transfusions decreased from 51% to 33% (P < 0.001); the mean number of PRBC units transfused per patient decreased by 40% (from 1.1 to 0.7; P < 0.001); inpatient cardiac morbidity decreased from 22.2% to 12.4% (P = 0.004); 30-day readmissions decreased from 14% to 8.6% (P = 0.04); and length of stay was unchanged (P = 0.06). Compared with the prerestrictive threshold cohort, the postrestrictive threshold group had lower odds of transfusion (odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.29 to 0.62); transfusion of >1 unit of PRBCs (OR = 0.34; 95% CI, 0.22 to 0.52); and inpatient cardiac morbidity (OR = 0.45; 95% CI, 0.27 to 0.75). No significant differences were observed in inpatient morbidity, mortality, 30-day readmission, or 90-day survival. A restrictive threshold of <7 g/dL Hb in hemodynamically stable patients with hip fractures is associated with noninferior perioperative outcomes and less blood utilization compared with a threshold of <8 g/dL. Level III, retrospective cohort study.

Improving blood product utilization at an ambulatory surgery center: a retrospective cohort study on 50 patients with lumbar disc replacement

BackgroundThere is minimal literature discussing anterior lumbar spine surgery in ambulatory surgery centers (ASCs). The main concern with the anterior approach to the lumbar spine is the potential for injury to great vessels. In our facility, there are two units of crossmatched blood available in addition to cell saver during the procedure. We retrospectively looked at 50 cases of lumbar total disc arthroplasty (TDA) in our ASC to determine utilization of blood products.MethodsMedical records of 50 consecutive patients who underwent a lumbar TDA at a single ASC were reviewed. Surgeries completed at the ASC were all transferred from the post anesthesia care unit to an attached convalescence care center which allows up to 3 days of observation. Patients who had either a 1 or 2 level lumbar TDA were included in the study. Data consisting of demographics, American Society of Anesthesiologist Physical Status Classification System, length of stay, estimated blood loss, cell saver volume, transfusion, perioperative and postoperative complications were recorded. Preoperative, perioperative and postoperative medical records were reviewed.ResultsMedical records of 50 consecutive patients were reviewed. The mean age was 40.86 ± 9.45. Of these, 48 (96%) had a 1-level lumbar TDA, 1(2%) had a 2-level lumbar TDA, 1 (2%) had a lumbar TDA at L4/5 and an anterior lumbar interbody fusion at L5/S1. There were no mortalities; no patient had recorded perioperative complications. No patients received allogeneic blood transfusion, 4 (8%) were re-transfused with cell saver (2 receiving approximately 400 ml and 2 receiving approximately 200 ml of re-transfused blood). All 50 (100%) were discharged home in stable condition. We had 30-day follow-up data on 35 of 50 patients. Of the 35 patients reviewed, three (8.5%) of the patients were readmitted to the hospital. One additional patient was seen in the emergency department and discharged home after negative testing. No patient was readmitted for post-operative anemia.ConclusionThe routine use of both cell saver and crossmatched blood in the operating suite for lumbar TDA may be an over-utilization of healthcare resources. In our review of 50 patients, we had no need for transfusion of allogeneic packed red blood cells (PRBCs) and only four of the 50 patients had enough blood output for re-transfusion from the cell saver. This opens the conversation for alternatives to crossmatched PRBCs being held in the operating room. Such alternatives may be the use of cell salvage, only type O blood in a cooler for each patient or keeping type O blood on constant hold in ASCs.