Patient Blood Management Interventions Research Articles

Including the patient in patient blood management: Development and assessment of an educational animation tool.

Patient blood management (PBM) programs are effective at reducing transfusion-associated mortality and morbidity; however, patient engagement within the realm of PBM remains relatively unstudied. Our objectives were to develop a novel educational tool utilizing animation to educate preoperative patients about anemia and to evaluate the effectiveness of this intervention. We created a patient-facing animation for preoperative surgical patients. The animation addressed characters' health journeys from diagnosis to treatment, addressing the role of PBM. We utilized the concept of patient activation as a means to empower patients, and developed the animation to be as accessible as possible. Post-viewing, patients provided feedback utilizing an electronic survey. A final version of the animation can be found here: https://vimeo.com/495857315. A total of 51 participants viewed our animation, the majority of whom were planned to undergo joint replacement or cardiac surgery. Almost all (94%, N = 4) agreed that taking an active role in their health was the most important factor in determining their ability to function. The video was felt to be easy to understand (96%, N = 49), and 92% (N = 47) agreed that they had a better understanding of anemia and its treatment. After watching the animation, patients felt more certain that they could follow through with their PBM plan (98%, N = 50). To the best of our knowledge, there are no other PBM-specific patient education animations. Patients enjoyed learning about PBM though animation, and patient education may lead to better uptake of PBM interventions. We hope that other hospitals will be inspired to pursue this approach.

Reporting conflicts of interest in randomised trials of patient blood management interventions in patients requiring major surgery: a systematic review and meta-analysis

ObjectiveThis study aimed to systematically review the effects of declared and undeclared conflicts of interest on randomised controlled trials (RCTs) of patient blood management (PBM) interventions.DesignWe performed a secondary analysis...

Improving Awareness about Patient Blood Management in Portugal: A Call for Action Arising from a Delphi Panel.

Anaemia and iron deficiency are associated with increased mortality and poor surgical outcomes. Consensus in their definitions is expected to optimize their management, which is encompassed by patient blood management, providing patient-centred care while improving patient safety and clinical outcomes. Patient blood management implementation is even more relevant in contingency times and faces barriers due to lack of standardization, among others. The aim is to establish a consensus on these diagnoses and implement patient blood management principles in clinical practice in Portugal. Eight experts in Transfusion Medicine, Haematology, Anaesthesiology, Internal Medicine, and Obstetrics/Gynaecology were assembled; a focus group was conducted, defining 33 statements. A Delphi panel was conducted, with experts from the clinical specialities named above as well as from General Surgery, Urology, and Orthopaedics. The Delphi panel's rounds had 70 (Round 1) and 46 (Round 2) respondents. Specialists were consensual in only two statements, on the existence of a preoperative patient blood management consultation for candidates to elective surgeries in which the use of blood derivatives is anticipated and, on the importance of the correction of postoperative anaemia and iron deficiency. Of the remaining 31 statements, 27 reached high agreement or disagreement by the respondents. Consensus was reached in only two (6%) of the 33 statements. There was a consensual agreement on the relevance of establishing patient blood management as the standard of care and of valuing preoperative and postoperative patient blood management interventions. Nevertheless, our results point to the lack of awareness regarding patient blood management principles - which could result in better postoperative outcomes, shorter hospitalizations, reduced costs and increased availability of beds. Training and literacy initiatives could help further implement patient blood management standards in Portuguese hospitals.

Perioperative Trajectory of Haemoglobin, Predictors of Blood Transfusion and Tailoring Targets for Patient Blood Management Interventions: A Single-centre, Retrospective Study of Non-emergent Cardiac Surgery Patients.

Anaemia and blood transfusion are two independent contributing factors to perioperative morbidity in cardiac surgery. While preoperative treatment of anaemia has been shown to improve outcomes, in real life, logistical difficulties remain substantial, even in high-income countries. The adequate trigger for transfusion in this population remains controversial, and there is a wide variability in transfusion rates among centres. To assess the impact of preoperative anaemia on perioperative transfusion in elective cardiac surgery,todescribe the perioperative trajectory of haemoglobin (Hb), to stratify outcomes based on preoperative presence of anaemia and to identify predictors of perioperative blood transfusion. and Methods: We included a retrospective cohort of consecutive patients who underwent cardiac surgery with cardiopulmonary bypass in a tertiary centre of cardiovascular surgery. Recorded outcomes included hospital and intensive care unit (ICU) length of stay (LOS), surgical re-exploration due to bleeding, packed red blood cell (PRBC) transfusion pre-, intra- and postoperatively. Other record perioperative variables were preoperative chronic kidney disease, duration of surgery, use of rotation thromboelastometry (ROTEM) and cell saver, and fresh frozen plasma (FFP) and platelet (PLT) transfusion. Hb values were recorded at four distinct time points: Hb1 - at hospital admission, Hb2 - last Hb recorded preoperatively, Hb3 - first Hb recorded postoperatively and Hb4 - at hospital discharge. We compared the outcomes between anaemic and non-anaemic patients. Transfusion was decided by the attending physician on a case-by-case basis. Results: Of the 856 patients operated during the selected period, 716 underwent non-emergent surgery and 710 were included in the analysis. Also, 40.5% (n = 288) of patients were anaemic preoperatively (Hb <13 g/dl); 369 patients (52%) were transfused PRBCs, with differences found between anaemic and non-anaemic patients regarding the percentage of transfused patients perioperatively (71.5% vs 38.6%, p < 0.001) and in the total median number of units transfused (2 [IQR 0-2] vs 0 [IQR 0-1], p <0.001). We built a multivariate model, and logistic regression analysis showed that preoperative Hb <13 g/dl (odds ratio [OR] 3.462 [95% CI 1.766-6.787]), female sex (OR 3.224 [95% CI 1.648-6.306]), age (1.024 per year [95% CI 1.0008-1.049]), hospital LOS (OR 1.093 per day of hospitalisation [95% CI 1.037-1.151]) and FFP transfusion (OR 5.110 [95% CI 1.997-13.071]) are associated with PRBC transfusion. Untreated preoperative anaemia leads to more transfusion in elective cardiac surgery patients, both as a ratio of transfused patients and as the number of units of PRBCs per patient, and this is associated with an increased use in FFP.

Development of a preoperative risk score predicting allogeneic red blood cell transfusion in children undergoing spinal fusion.

Children undergoing spinal fusion often receive blood products. The goal of this study was to develop a preoperative score to help physicians identify those who are at risk of allogeneic red blood cell (RBC) transfusion. This retrospective study of children undergoing spinal fusion in the ACS-NSQIP Pediatric database (2016-2019) aimed at identifying risk factors associated with allogeneic RBC transfusion. Univariable logistic regression and multivariable logistic regression were performed using preoperative patient characteristics and aided in the creation of a simplified scoring system. Out of 13,929 total patients, 2990 (21.5%) were transfused. We created a risk score based on 10 independent predictors of transfusion: age, sex, race, weight < 3rd percentile, American Society of Anesthesiologists physical status classification, cardiac risk factors, hematologic disease, preoperative anemia, deformity type, and number of spinal levels to be fused. Patients in both the training and testing cohorts were assigned a score ranging from 0 (lowest risk) to 21 (highest risk). The developed transfusion risk score showed 77% accuracy in distinguishing patients who did not receive a transfusion during or soon after surgery (AUROC 0.7736 [95% CI, 0.7619-0.7852]) in the training cohort and 77% accuracy (AUROC 0.7732 [95% CI, 0.7554-0.7910]) in the testing cohort. Our score, based on routinely available preoperative data, accurately estimates the risk of allogeneic RBC transfusion in pediatric patients undergoing spinal fusion. Future studies will inform whether patient blood management interventions targeted to high-risk patients can help reduce the need for transfusion and improve outcomes.

Patient blood management in oncology in the Russian Federation: resolution to improve oncology care.

The huge global burden of oncological diseases is growing and measures to counter this complex challenge are high on national health agendas. The Russian National Long-Term Oncology Strategy 2030 defines priorities, goals and directions in the fight against cancer. Italso contains action plans for more effective prevention, earlier and more specific diagnosis and more effective treatment options. Against this backdrop, experts now suggest to complement standard oncology treatment strategies by adding Patient Blood Management (PBM). For many clinical disciplines where a low blood count and considerable blood loss are commonly encountered, this bundle of care is the new standard. Based on clinical and scientific evidence, it aims to optimise medical and surgical patient outcomes by clinically managing and preserving a patients blood. The principles of this comprehensive concept can and must be transferred to oncology, thus offering value in improving cancer care and the efficacy of medical institutions. Accumulating evidence demonstrates that anaemia and iron deficiency, but also thrombocytopenia, blood loss and coagulopathy are independent risk factors for adverse patient outcomes including morbidity, mortality, reduced quality of life and prolonged average length of hospital stay in both surgical and medical patients. For the timely and effective detection and correction of these risk factors, an international network of multi-disciplinary clinicians and researchers has developed PBM. The rapidly growing body of evidence for PBM not only shows improved patient outcomes, but also reduced resource utilisation including the use of allogeneic blood components. The reduction of allogeneic blood transfusion further improves patient safety and outcomes, since transfusion is another independent risk factor for adverse outcomes. Supported by WHO endorsements and following the recommendations of an increasing number of state or national health authorities, PBM is about to become a new standard of care. However, even though the aforementioned risk factors are highly prevalent in oncology settings due to chemo-/radiotherapy and the pathology of the disease, the integration of PBM in standard oncology treatment pathways is lagging behind. Thus, and in support of the Russian National Long-Term Oncology Strategy 2030 to improve quality of oncological care, with the support of the National Association of Specialists in PBM (NASPBM), the PBM Oncology Working Group of the Russian Federation was created, consisting of national and international experts in oncology and PBM. On July 9, 2020, the Working Group met to discuss the rationale for PBM in oncology and to assess the need to implement PBM in Russian oncology care. As a result, the Group recommended to include PBM as an integral part of standard oncology treatment pathways, delineated the action required from facilitating stakeholders in the Russian Federation, determined a roadmap for implementation and developed a national resolution as a call to action on the matter. Presented herein, this resolution acknowledges the global and local impetus to reduce cancer mortality, and the rationale for PBM interventions to improve patient outcomes and alleviate the social and economic burden of cancer on the healthcare system.

Peri-operative administration of tranexamic acid in lower limb arthroplasty: a multicentre, prospective cohort study.

In the UK, tranexamic acid is recommended for all surgical procedures where expected blood loss exceeds 500ml. However, the optimal dose, route and timing of administration are not known. This study aimed to evaluate current practice of peri-operative tranexamic acid administration. Patients undergoing primary total hip arthroplasty, total knee arthroplasty or unicompartmental knee arthroplasty during a 2-week period were eligible for inclusion in this prospective study. The primary outcome was the proportion of patients receiving tranexamic acid in the peri-operative period. Secondary outcomes included: dose, route and timing of tranexamic acid administration; prevalence of pre- and postoperative anaemia; estimated blood loss; and red blood cell transfusion rates. In total, we recruited 1701 patients from 56 NHS hospitals. Out of these, 1523 (89.5%) patients received tranexamic acid and of those, 1052 (69.1%) received a single dose of 1000mg intravenously either pre- or intra-operatively. Out of the 1701 patients, 571 (33.6%) and 1386 (81.5%) patients were anaemic (haemoglobin <130g.l-1 ) in the pre- and postoperative period, respectively. Mean (SD) estimated blood loss for all included patients was 792 (453) ml and 54 patients (3.1%) received a red blood cell transfusion postoperatively. The transfusion rate for patients with pre-operative anaemia was 6.5%, compared with 1.5% in patients without anaemia. Current standard of care in the UK is to administer 1000mg of tranexamic intravenously either pre- or intra-operatively. Approximately one-third of patients present for surgery with anaemia, although the overall red blood cell transfusion rate is low. These data provide useful comparators when assessing the efficacy of tranexamic acid and other patient blood management interventions in future studies.

Health economics of Patient Blood Management: a cost-benefit analysis based on a meta-analysis.

Patient Blood Management (PBM) is the timely application of evidence-based medical and surgical concepts designed to improve haemoglobin concentration, optimize haemostasis and minimize blood loss in an effort to improve patient outcomes. The focus of this cost-benefit analysis is to analyse the economic benefit of widespread implementation of a multimodal PBM programme. Based on a recent meta-analysis including 17 studies (>235000 patients) comparing PBM with control care and data from the University Hospital Frankfurt, a cost-benefit analysis was performed. Outcome data were red blood cell (RBC) transfusion rate, number of transfused RBC units, and length of hospital stay (LOS). Costs were considered for the following three PBM interventions as examples: anaemia management including therapy of iron deficiency, use of cell salvage and tranexamic acid. For sensitivity analysis, a Monte Carlo simulation was performed. Iron supplementation was applied in 3·1%, cell salvage in 65% and tranexamic acid in 89% of the PBM patients. In total, applying these three PBM interventions costs €129·04 per patient. However, PBM was associated with a reduction in transfusion rate, transfused RBC units per patient, and LOS which yielded to mean savings of €150·64 per patient. Thus, the overall benefit of PBM implementation was €21·60 per patient. In the Monte Carlo simulation, the cost savings on the outcome side exceeded the PBM costs in approximately 2/3 of all repetitions and the total benefit was €1878000 in 100·000 simulated patients. Resources to implement a multimodal PBM concept optimizing patient care and safety can be cost-effectively.

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."

First trimester ferritin screening for pre-delivery anaemia as a patient blood management strategy

ObjectivesTo determine the optimum approach and timing to screen for iron deficiency in pregnancy. BackgroundThere is a lack of consensus on identifying and treating iron deficiency during pregnancy. Patient blood management programs may be refined by evaluating outcomes. MethodsRetrospective data collection on women delivering prior to and following implementation of patient blood management interventions. Ferritin, transferrin saturation and haemoglobin levels were evaluated in first and second trimesters as predictors of pre-delivery anaemia. The optimum time to screen was determined. Comparison with results following a quality improvement intervention was undertaken. A separate retrospective study was performed to validate the predictive value of ferritin using data extracted from the laboratory information system. ResultsFerritin and transferrin saturation in first trimester detected women who subsequently had anaemia pre-delivery, with ferritin being most discriminatory. Both were superior to haemoglobin concentration. Iron studies in second trimester did not predict pre-delivery anaemia and haemoglobin remained poorly discriminatory. Iron studies lost predictive value when a systematic program ensured treatment of iron depletion during pregnancy. The ability of ferritin to predict pre-delivery anaemia in the first, but not the second, trimester was confirmed on the validation cohort. ConclusionFirst trimester serum ferritin may identify candidates for iron therapy during pregnancy. This strategy may be preferable to haemoglobin screening alone or universal replacement in centres at low risk of anaemia.

[Two-year experience with cell salvage in total hip arthroplasty].

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients. We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study. In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system. Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Two-year experience with cell salvage in total hip arthroplasty

Background and objectiveThe aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients. MethodsWe reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study. ResultsIn the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) −4.257 (95% CI −0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001–0.004) were independent risk factors for the usage of cell salvage system. ConclusionCell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Anemia and Patient Blood Management in Hip and Knee Surgery

A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.