Bloodless Care Research Articles

Clinical Outcomes, Blood Utilization, and Ethical Considerations for Pediatric Patients in a Bloodless Medicine and Surgery Program.

Pediatric patients requesting bloodless care represent a challenging clinical situation, as parents cannot legally refuse lifesaving or optimal interventions for their children. Here, we report clinical outcomes for the largest series of pediatric inpatients requesting bloodless care and also discuss the ethical considerations. We performed a single-institution retrospective cohort study assessing 196 pediatric inpatients (<18 years of age) who requested bloodless care between June 2012 and June 2016. Patient characteristics, transfusion rates, and clinical outcomes were compared between pediatric patients receiving bloodless care and those receiving standard care (including transfusions if considered necessary by the clinical team) (n = 37,271). Families were informed that all available measures would be undertaken to avoid blood transfusions, although we were legally obligated to transfuse blood if the child's life was threatened. The primary outcome was composite morbidity or mortality. Secondary outcomes included percentage of patients transfused, individual morbid events, length of stay, total hospital charges, and total costs. Subgroup analyses were performed after stratification into medical and surgical patients. Of the 196 pediatric patients that requested bloodless care, 6.1% (n = 12) received an allogeneic blood component, compared to 9.1% (n = 3392) for standard care patients ( P = .14). The most common indications for transfusion were perioperative bleeding and anemia of prematurity. None of the transfusions were administered under a court order. Overall, pediatric patients receiving bloodless care exhibited lower rates of composite morbidity compared to patients receiving standard care (2.6% vs 6.2%; P = .035). There were no deaths in the bloodless cohort. Individual morbid events, length of stay, and total hospital charges/costs were not significantly different between the 2 groups. After multivariable analysis, bloodless care was not associated with a significant difference in composite morbidity or mortality (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.12-1.11; P = .077). Pediatric patients receiving bloodless care exhibited similar clinical outcomes compared to patients receiving standard care, although larger studies with adequate power are needed to confirm this finding. There were no mortalities among the pediatric bloodless cohort. Although a subset of our pediatric bloodless patients received an allogeneic transfusion, no patients required a court order. When delivered in a collaborative and patient-centered manner, blood transfusions can be safely limited among pediatric patients.

Methods of Bloodless Care, Clinical Outcomes, and Costs for Adult Patients Who Decline Allogeneic Transfusions

(Anesth Analg. 2022;135:576–585) When blood banking and storage began in the 1940s, blood transfusions became common, however, some patients desired a “bloodless” approach to health care without allogeneic transfusions. Over time, many large, randomized trials have shown that a restrictive transfusion strategy is optimal compared with a liberal one. Bloodless care has grown in popularity. This study aimed to report data on a large group of patients receiving bloodless care, health care methods, and outcomes.

Does Bloodless Care Significantly Improve Patient Outcomes?

Does Bloodless Care Significantly Improve Patient Outcomes?

Methods of Bloodless Care, Clinical Outcomes, and Costs for Adult Patients Who Decline Allogeneic Transfusions.

Providing bloodless medical care for patients who wish to avoid allogeneic transfusion can be challenging; however, previous studies have demonstrated favorable outcomes when appropriate methods are used. Here, we report one of the largest series of patients receiving bloodless care, along with the methods used to provide such care, and the resulting outcomes. In a retrospective cohort study, 1111 adult inpatients (age ≥18 years) at a single institution who declined allogeneic transfusion for religious or personal reasons between June 2012 and June 2016 were included, and the patient blood management methods are described. Patient characteristics, laboratory data, and transfusion rates, as well as clinical outcomes (morbidity, mortality, and length of stay) were compared to all other patients in the hospital who received standard care, including transfusions if needed (n = 137,009). Medical and surgical patients were analyzed as subgroups. The primary outcome was composite morbidity (any morbid event: infectious, thrombotic, ischemic, renal, or respiratory). Secondary outcomes included individual morbid events, in-hospital mortality, length of stay, total hospital charges, and costs. The bloodless cohort had more females and a lower case mix index, but more preadmission comorbidities. Mean nadir hemoglobin during hospitalization was lower in the bloodless (9.7 ± 2.6 g/dL) compared to the standard care (10.1 ± 2.4 g/dL) group (P < .0001). Composite morbidity occurred in 14.4% vs 16.0% (P = .16) of the bloodless and standard care patients, respectively. Length of stay and in-hospital mortality were similar between the bloodless and standard care patients. After Bonferroni adjustment for multiple comparisons, hospital-acquired infection occurred less frequently in the bloodless compared to the standard care cohort (4.3% vs 8.3%) (P < .0001) in the medical patient subgroup, but not in the surgical subgroup. After propensity score adjustment in a multivariable model and adjustment for multiple comparisons, bloodless care was associated with less risk of hospital-acquired infection (OR, 0.56; 95% CI, 0.35-0.83; P = .0074) in the medical subgroup, but not in the surgical subgroup. Median total hospital charges (by 8.5%; P = .0017) and costs (by 8.7%; P = .0001) were lower in the bloodless compared to the standard care cohort, when all patients were included. Overall, adult patients receiving bloodless care had similar clinical outcomes compared to patients receiving standard care. Medical (but not surgical) bloodless patients may be at less risk for hospital-acquired infection compared to those receiving standard care. Bloodless care is cost-effective and should be considered as high-value practice.

Bloodless Autologous Hematopoeitic Stem Cell Transplant: An Alternative for Jehovah's Witnesses and Others Who Prefer to Go Bloodless

Topic Significance & Study Purpose/Background/Rationale Every year people are diagnosed with Non-Hodgkin's Lymphoma (NHL) and Multiple Myeloma (MM). As an alternative treatment modality, they may seek to have a Hematopoietic Stem Cell Transplant (HSCT), which usually requires blood product transfusions. This poses a challenge when treating Jehovah's Witnesses, who normally refuse whole blood products based on religious beliefs; however, many will accept minor blood fractions and recombinant products, such as erythropoietin and granulocyte colony stimulating factors (G-CSF). Methods, Intervention, & Analysis In this study, five Jehovah's Witnesses were enrolled in the Bloodless Care Program and went through a series of pretransplant testing. Testing included an echocardiogram, electrocardiogram, and stress test to evaluate possible underlying coronary artery disease and cardiac amyloidosis. Once they qualified for a transplant, a conditioning regimen was determined and they were prepared for apheresis. Before apheresis, the patient must have hemoglobin of 11.0 g/dL and platelet count of 100 K/mm3; if not, erythropoietin and intravenous iron were given to achieve that goal. Patients were then prepped with G-CSF and Plerixafor for stem cell collection. The goal for collection was a minimum of 4 million CD34+ cells per kilogram. Post collection, there was a two week window given prior to admission for the bloodless autologous HSCT. The conditioning regimen varied on their diagnosis. For the four MM patients, the regimen was Melphalan 140mg/m2; for the one NHL patient, the regimen was Carmustine, Etoposide, and Cytoxan (BECy). When the platelet count fell below 30 K/mm3 post-transplant, Amicar was administered. Minimal phlebotomy and pediatric tubes were recommended to reduce iatrogenic anemia. Findings & Interpretation The Average length of stay was 16.7 days. After transplant, the median nadir hemoglobin was 9.15 g/dL, while the platelets were 5.5 K/mm3. One patient was readmitted within 30 days after transplant for fever during engraftment. One patient relapsed and received a second bloodless autologous HSCT 9 months later. There were no mortalities. Discussion & Implications Utilizing minor fractions, blood conservation modalities, and appropriate pre-transplant workup, resulted in safely performing bloodless autologous HSCT for Jehovah's Witness; therefore, proving this can be an alternative treatment for those who prefer to go bloodless.

Bloodless medicine: current strategies and emerging treatment paradigms.

Advances in our understanding of the risks associated with allogeneic blood transfusions (ABTs) and the growing number of patients who wish to avoid ABTs have led to the emergence of new treatment paradigms for "bloodless" medicine and surgery. Here, we review prior studies and summarize current strategies for bloodless care used at our institution. We advocate three basic principles: 1) diagnosing and aggressively treating anemia, 2) minimizing blood loss from laboratory testing and invasive procedures, and 3) identifying and managing bleeding diatheses. Anemia is treated with erythropoiesis-stimulating agents as well as iron, folate, and B12 when indicated. Low-volume phlebotomy tubes are used for laboratory testing. Autologous blood salvage is used for childbirth and surgical patients who have the potential for substantial bleeding. Although there have been few retrospective studies and no prospective studies to guide management, prior studies suggest that outcomes for surgical patients managed without ABTs are comparable to those of historic controls. Given the emerging evidence that patients who avoid ABTs do as well if not better than patients who accept ABTs, further efforts are needed to determine whether all patients could benefit from bloodless strategies. Bloodless approaches in selected patients could reduce risks, improve outcomes, and decrease costs for all patients.

Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

Bloodless Cardiac Surgery

Blood transfusions after cardiac surgery are very common, and the rates are highly variable among institutions. Transfusion carries the risk of infectious and noninfectious hazards and is often clinically unnecessary. This article discusses the history of bloodless cardiac surgery, the hazards of transfusion, the benefits of reducing or eliminating transfusion, and strategies to conserve blood. It also provides a list of resources for those who are interested in learning more about bloodless care.

Outcomes of Acute Gastrointestinal Bleeding Without Blood Transfusion: A Specialized Unit Experience

Outcomes of Acute Gastrointestinal Bleeding Without Blood Transfusion: A Specialized Unit Experience Irfan Nawaz, Rabi Kundu, Amit Thaker, George Ahtaridis Purpose: Blood transfusion is a standard practice in the management of acute gastrointestinal bleeding (GIB). Our hospital is a specialized unit to manage patients refusing blood transfusions due to religious or personal reasons. There is no published outcome data regarding the management of acute GIB without blood transfusion. The aim of this study was to evaluate the outcomes of this patient population. Methods: Retrospective case control study designed for acute GIB patients treated in our tertiary center. Study period was January 2002 to October 2005. Bloodless care patients (case) were compared with standard care patients (control) that required blood transfusion. Inclusion criteria were; Hemoglobin drop 2 gm/dl and/or signs of hypovolemia. Patient demographics, presenting complaints, risk factors, time to endoscopy, duration of ICU and hospital stay were evaluated. Dose of erythropoietin,rebleeding rates and mortalities were also reviewed. Results: 39 patients satisfied the inclusion criteria in study group and 115 patients in the control group. There was no significant difference in patient demographics, presentation and risk factors. (Table 1) Mean time to endoscopy in study group was 24.24 hours compared to control 44.12 hours. Mean ICU stay was 2 days in study group and 1.48 days in control (p Z 0.02).There was no significant difference in duration of hospitalization (p Z 0.33) and rebleebing rates (p Z 0.88) between two groups. There was 1 death in bloodless care group and 3 in standard care group (p Z 0.57) (Table 2). All patients in study group received iron, while 70% (27/39) received erythropoietin (mean dose 470 U/kg) Conclusion: In our study,the outcomes of acute GI bleeding in bloodless care group were comparable to standard care group with early endoscopy, closer ICU monitoring and support with IV iron and high dose erythropoietin.

Risk of Anemia and Transfusion Triggers: Implications for Bloodless Care

Risk of Anemia and Transfusion Triggers: Implications for Bloodless Care

Risk of Anemia and Transfusion Triggers: Implications for Bloodless Care

Blood transfusion is a widely used treatment that is expensive and carries a small degree of risk. The level of anemia that patients tolerate and the indications for blood transfusion are controversial. Review of pertinent English language literature. The risk of blood transfusion from viral transmission is very low. The risk of anemia increases as hemoglobin concentration decreases. The risk is very high when the hemoglobin concentration is below 6 g/dL. The risk of death or serious morbidity increases more rapidly in patients with cardiovascular disease than patients without cardiovascular disease. There is only one adequately powered clinical trial that demonstrates that a 7 g/dL transfusion threshold is as safe, and in some subgroups, safer than a 10 g/dL threshold. A restrictive transfusion threshold (7 g/dL) is recommended in most patients. In patients with cardiovascular disease, a 9-10 g/dL may be advisable, but definitive guidelines await further clinical trials. However, as with all such treatments, the decision to transfuse should be based on individual assessment of patients' signs, symptoms, and co-morbidity.

OUTCOMES OF ACUTE GASTROINTESTINAL HEMORRHAGE IN BLOODLESS CARE POPULATION-A SINGLE CENTER EXPERIENCE

Purpose: Acute Gastrointestinal Hemorrhage in bloodless care is a challenge to manage. Our hospital is an established center to manage patients who refuse blood transfusion for religious or other beliefs. No published outcomes data of acute gastrointestinal hemorrhage in this population is available. Methods: Retrospective chart review of acute gastrointestinal hemorrhage from Jan2002 and Dec2003. Study population was defined as admissions with acute GI hemorrhage in bloodless care patients who were compared with controls who received standard care. Inclusion criteria were: hemoglobin drop more than 2gms or hypovolemic shock. Parameters reviewed include demographics, use of antiplatelet agents, NSAIDS, admission diagnoses and hemodynamic parameters at presentation, time to endoscopy and surgery, duration of ICU and hospital stay, iron and erythropoietin use. Rebleeding rate and mortality rate were also reviewed.Table 1: ResultsResults: 26 patients in the study group and 49 control patients satisfied inclusion criteria. There was no significant difference in patient demographics, initial presentation(hematemesis, melena, hematochezia), hematocrit, use of NSAIDS and antiplatelet agents. The mean time to endoscopy in the study group was 21 hours(1–72) as compared to controls 49hours(7–144)(p <0.01). The mean ICU stay for the study group was 2.4 days as compared to controls 1.2 days(p <0.05). There was no significant difference in the duration of hospital stay between the two groups. Mean 7.6 days(1–22) in the study group vs7.0 days(1–19) days in controls. 19%(5/26) had surgery in the study group as compared to 6%(3/49) in controls. 11%(3/26) rebled in the study group as compared to 10%(5/49) in controls. There was no significant difference in mortality. All patients in the study group were treated with Iron and 73%(19/26) received erythropoietin (mean dose 472U/kg). Conclusions: The outcomes of bloodless care patients were comparable to standard care group with early endoscopy, close monitoring in ICU and support with iron and high dose of erythropoietin.

Bloodless care of severely anemic patients with gastrointestinal bleeding: feasibility in a community hospital setting

Bloodless care of severely anemic patients with gastrointestinal bleeding: feasibility in a community hospital setting