Patient Blood Management Strategies Research Articles

Impact of ferric carboxymaltose in patient blood management in Portuguese hospitals

Abstract Background The use of transfusions leads to excessive blood consumption, implying risks such as infections and immunological reactions, so it should be used only when strictly necessary. Patient Blood Management (PBM) aims to minimize the use of allogeneic blood and improve clinical outcomes, with better cost-effectiveness, using three essential points: improving hematopoiesis, minimize blood loss in and optimize the hemoglobin reserves of each patient. The aim of this work is to assess the preoperative haemoglobin optimization using ferric carboxymaltose as part of PBM implementation, in elective orthopaedic, cardiac and colorectal surgery in Portuguese hospitals. Methods This is an observational study materialized in a retrospective and multicenter cohort with data collection from medical records. The population and sample will be patients over 18 years from elective orthopaedic, cardiac and colorectal surgeries, treated according with local standards before PBM implementation were assigned to the pre-PBM cohort and patients after PBM implementation with ferric carboxymaltose to preoperative haemoglobin optimization to the PBM cohort. The criteria for selecting hospitals will be the implementation of PBM during the study period. Expected Results Based on a previous review, it is expected that the results of the use of ferric carboxymaltose to correct iron deficiency anaemia for preoperative haemoglobin optimization will contribute positively to reducing the number of transfusions, the length of hospital stays and will have a direct impact on economic results. Conclusions The use of ferric carboxymaltose and other ferric compounds, as part of PBM program, has demonstrated a positive impact on patients' outcomes (morbility and mortality), adverse events and on economic results. This study might show that clinical guidelines and programs like PBM are a major contribution not just for hemovigilance and blood safety but also for patient safety and health quality. Key messages This work is focused on Portuguese hospitals and aims to assess the impact of ferric carboxymaltose and its benefit on PBM strategy. Specially this study intends to conduct the assessment on health outcomes and costs.

Cost of red blood cell transfusion; evaluation in a French academic hospital.

The economic impact of Patient blood management (PBM) must be assessed beyond the acquisition cost of blood products alone. The estimate of indirect costs may vary depending on the organization and the elements taken into account. The transposition of data from the literature into a specific local context is therefore delicate. The objective of this work was to evaluate the overall cost of red blood cell concentrate (RBC) transfusion from a French healthcare establishment point of view. We carried out an activity based costing analysis in our hospital for the year 2018. The steps of the transfusion process and additional costs were detailed and cumulated (resource consumption, labor time, frequency) to populate the ABC model. Several scenarios were developed focusing either on RBC, all blood products or the surgical activity, and a univariate sensitivity analysis was conducted. The average total cost of transfusion, including acquisition cost, was 339,64 euros per RBC transfused. The cost of administration was 138.41 euros/RBC. Focusing only on surgical activities increased this cost (152.43 euros) while taking all blood products into account reduced it (92.49 euros). The difference in our results with the literature confirms the local variability in the cost of transfusion, which may affect the economic impact of PBM. Our study related to the specific context of a single French institution has limitations that a multicenter study would clarify in order to carry out economic modelling of transfusion optimization and alternatives and to guide the choice of PBM strategies at the national level.

Viscoelastic coagulation test for liver transplantation.

Coagulation and transfusion management in patients undergoing liver transplantation is challenging. Proper perioperative monitoring of hemostasis is essential to predict the risk of bleeding during surgery, to detect potential causes of hemorrhage in time, and to guide hemostatic therapy. The value of conventional coagulation test is questionable in the acute perioperative setting due to their long turnaround time and the inability to adequately reflect the complex changes in hemostasis in patients with liver disease. Viscoelastic coagulation tests provide simultaneous measurement of multiple aspects of whole-blood coagulation including plasmatic coagulation and fibrinolytic factors and inhibitors that reflect most aspects of hemostasis. Coagulation initiation, mechanical clot stability, and fibrinolysis can be estimated immediately using point-of-care techniques. Therefore, viscoelastic coagulation tests including ROTEM & TEG would be useful to guide patient blood management strategy during liver transplantation.

Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure.

Introduction: Preoperative anemia in patients undergoing a two-stage septic revision arthroplasty may be a factor of reinfection, even in the presence of aggressive antimicrobial therapy. Patient Blood Management (PBM) in such patients is challenging. We evaluate the impact of anemia existing before re-implantation on a failure rate after two-stage septic total knee arthroplasty (rTKA), and explore feasibility of a PBM strategy implementation in these patients. Materials and methods: A retrospective study of patients from January 2010 to January 2015 in a French regional referral center was performed. Patients undergoing a two-stage rTKA for infection after successful primary TKA were identified and followed up to 31.12.2018. The primary outcome (failure) was defined as surgical site infection after re-implantation requiring new surgery. The secondary outcomes were time to failure, the time between explantation/reimplantation, transfusion rate during the second stage. Preoperative anemia was defined as Hb level < 12 g/L before the re-implantation. Results: 69 patients were identified; 17 (24%) developed reinfection of rTKA in 105 [11.4–156] days. In these patients pre-implantation anemia was more frequent (n = 13(76.5%) in failed vs. n = 21(40%) in non-failed, p = 0.0110). During the explantation stage, there were no significant group differences in age, sex, comorbidity, type of spacer and antimicrobial therapy, iron supplementation, or transfusion rate. The median time between explantation/reimplantation surgery was 51 [43–71.5] days, indifferent between the two groups. Intraoperative transfusion during reimplantation was required in 12 (17%) patients, more frequent in failed patients. None of the patients had contraindications for the PBM strategy except the cell-saver use. Conclusion: In two-stage septic rTKA preoperative anemia was almost two times more frequent and associated with an elevated rate of septic failure. The time-frame between explantation and-re-implantation is sufficient to implement a PBM strategy for all anemic patients. Before-after studies would be of interest to determine the best PBM strategy to prevent anemia-associated septic failure in such a condition.

Impact of Iron Supplementation on Patient Outcomes in Women Undergoing Gynecological Procedures: Systematic Review and Meta-Analysis of Randomized Trials

Background. Perioperative red blood cell (RBC) transfusion is associated with poor patient outcomes. RBC transfusion rates have been decreasing across different types of surgeries as a results of implementing Patient Blood Management (PBM) strategies; while RBC transfusion rates in gynecologic surgeries have remained static. Women are at increased risk of anemia, specifically iron deficiency anemia from gynecologic blood loss putting them at increased risk of requiring perioperative RBC transfusion. PBM encourages preoperative iron supplementation to optimize patients' hemoglobin (Hb) levels; however, evidence specific to gynecological procedures is lacking. This systematic review was conducted to address the question: Does the use of iron supplementation during the perioperative period impact patient outcomes in women undergoing gynecological procedures when compared to no treatment, placebo, or standard of care? Methods. MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science were searched up to July 2019. Additional records were identified through searching theses, conference proceedings, trials, and grey literature. All randomized controlled trials (RCTs) comparing an intervention group provided with iron supplementation perioperatively to women undergoing gynecological procedures with a comparator were included. Two authors independently assessed studies for inclusion and risk of bias using the Cochrane Risk of Bias tool, extracted data, and evaluated the certainty of evidence using the GRADE approach. Data were pooled using the random-effects (DerSimonian and Laird) method of meta-analysis. Results. A total of eleven RCTs met inclusion criteria. Two RCTs were then excluded; one RCT compared iron supplementation to no intervention but subset data for gynecology patients was unavailable and the full text of another RCT was unavailable. Seven RCTs (n=447) were amenable to meta-analysis; however iron supplementation was used in both treatment arms: four compared iron with erythropoietin stimulating agents (ESA) to iron alone and three compared iron with gonadotropin-releasing hormone (GnRH) analogue/agonist to iron alone. Six studies were judged to be overall low risk of bias and one to be at high risk of bias. RBC Transfusions: There was a statistically significant reduction in RBC transfusions during the perioperative period when iron was used in combination with a blood optimization compound (BOC) compared to iron alone (RR 0.33; 95%CI 0.16 to 0.70; p=0.003) (Figure 1). Preoperative Hb Level: Women who had taken a BOC plus iron had a median preoperative Hb level of 12.87g/dl [95% CI 11.13, 14.61 g/dl]), which was significantly higher (Δ1.16 g/dl; 95% CI 1.01, 1.31g/dl; p&amp;lt;0.00001) than those who took oral iron supplements alone. Postoperative Hb Level: Among 336 women in six RCTs, women who had taken a BOC in addition to iron had a postoperative Hb of 11.53g/dl (95% CI 6.92 g/dl, 16.14g/dl). This was significantly higher (Δ0.96 g/dl; 95% CI 0.45 g/dl, 1.47 g/dl; p&amp;lt;0.00001) than those who took iron supplements alone. Adverse Events (AEs): Five studies including 289 participants reported the incidence of AEs. The addition of a BOC did not have a statistically significant effect on the occurrence of AEs (RR 0.98; 95%CI 0.83, 1.17; p=0.85). One RCT with available data compared iron supplementation to placebo. Meta-analysis was not possible; however, the study found a significant increase in postoperative Hb and decrease in RBC transfusions in patients receiving iron supplementation compared to placebo. Conclusion. Perioperative use of iron in combination with a BOC in women undergoing gynecological procedures may reduce the need for perioperative RBC transfusions and improve preoperative Hb levels with high certainty of evidence. There was very low certainty of evidence for the impact of iron plus BOC on postoperative Hb levels and the number of AEs. The results of this systematic review suggest that the use of perioperative iron with BOC may improve patient outcomes. Lack of RCTs comparing iron to placebo is a limitation. More studies are needed to address the role of perioperative iron supplementation for gynecological procedures, including evaluating different routes of administration. Analysis of existing observational studies may offer additional data to supplement the results of this meta-analysis. Disclosures Arnold: Rigel: Consultancy, Research Funding; Bristol-Myers Squibb: Research Funding; Novartis: Honoraria, Research Funding; Principia: Consultancy. Zeller:Pfizer: Other: Advisory Board; Canadian Blood Services: Consultancy; Ontario Ministry of Health and Long Term Care: Consultancy.

The Effect of Perioperative Intravenous Iron on Hemoglobin in Surgical Patients: A Meta-Analysis

BackgroundPatient blood management aims to maintain hemoglobin level, minimize blood loss, and avoid unnecessary blood transfusion. Ferric carboxymaltose, an intravenous iron agent, was included as a part of surgical patient blood management strategy. However, it is still controversial that ferric carboxymaltose can reduce transfusion requirements. The purpose of this systematic review and meta-analysis is to evaluate the benefits of perioperative ferric carboxymaltose on the postoperative hematological parameters and transfusion requirements. MethodsRandomized controlled trials evaluating the effects of ferric carboxymaltose were searched through databases: MEDLINE, EMBASE, CENTRAL, CINAHL, Scopus, Web of Science, and KoreaMed. Meta-analysis was performed using random effect models. ResultsA total of 8 studies (n = 471) were included in the final analysis. Postoperative hemoglobin was higher in the ferric carboxymaltose group than in the control group (mean difference [MD], 0.58 g/dL; 95% confidence interval [CI], 0.36 to 0.80; P < 0.00001). Postoperative serum ferritin and transferrin saturation were also higher in the ferric carboxymaltose group (MD, 373.85 μg/L; 95% CI, 298.13 to 449.56; P < 0.00001; MD, 10.35%; 95% CI, 4.59 to 16.10; P < 0.00001, respectively). However, there were no significant differences in the number of transfused patients, length of hospital stay, and adverse events between groups. Subgroup analysis revealed that adverse events were lower in the ferric carboxymaltose group than the oral iron group. ConclusionsThis study supports that ferric carboxymaltose may increase the postoperative hemoglobin level in surgical patients. However, transfusion requirements could not be reduced by ferric carboxymaltose. Optimal dose and time should be further analyzed.

The implementation of patient blood management– A survey of european practice

Introduction Approximately 40% of patients undergoing cardiac surgery will require a blood transfusion. Whilst this may be life-saving, there is also a morbidity and mortality associated with it. In recent years Patient Blood Management (PBM) has evolved to integrate peri-operative haemostasis care in an attempt to drive down transfusion. However, it has evolved in different ways across the different health care systems across Europe (1). This has led to discrepancies between guidelines (2,3) and actual clinical practice across countries. The objective of this study is to understand how PBM strategies differ throughout Europe. Methods A 10-minute long online survey was developed with a group of European anesthesiologists. Between January and July 2019 the survey was disseminated by the National and European scientific societies of Austria, Finland, France, Germany, Ireland, Switzerland, the Netherlands and United Kingdom. Its first seven questions provide epidemiological data about transfusion need and local patient blood management practice depending of guidelines. Following this, we present two clinical cases and ask questions about how these patients would be managed by the respondent. Results Results are expected for Summer 2019. These pictures of the local practices will serve as a basis of discussion for the European working group of experts involved in PBM. Discussion This description and analysis of the differences among countries and against current guidelines will help to improve the existing guidelines for PBM (2,3).

Open Heart Surgery in Jehovah’s Witnesses: A Propensity Score Analysis

Jehovah's Witnesses (JW) refuse allogeneic blood transfusions and therefore pose a unique challenge in case of major surgery. This retrospective study reviewed an experience with JW patients who were undergoing open heart surgery. By using patient blood management strategies, 35 adult JW patients underwent cardiac surgery at Kepler University Hospital in Linz, Austria between 2008 and 2017. Outcomes were compared with patients who accepted blood transfusions (non-JW patients) by using propensity score matching. There were no significant differences in clinical and operative data between the groups. Twelve JW patients (34.3%) were pretreated with erythropoietin and iron, with a preoperative increase in mean hemoglobin of 2.0 g/dL. On admission, hemoglobin was 14.1 ± 1.1 g/dL in JW patients, compared with 13.2 ± 2.0 g/dL in non-JW patients (P= .022). The hematocrit in JW patients was higher throughout the hospital stay, even though 51.4% of non-JW patients received allogeneic red blood cell transfusions. The perioperative red blood cell loss was significantly lower in JW patients than in non-JW patients (619 ± 420 mL vs 929 ± 520 mL; P= .010). Major complication rates were not different between the groups. The hemoglobin at discharge was 11.5 ± 1.5 g/dL in JW patients compared with 10.3 ± 1.3 g/dL in non-JW patients (P < .001). In-hospital mortality was 2.9% in each group, and long-term survival was comparable. By implementing patient blood management, open heart surgery in JW patients can be performed with low morbidity and mortality. Preoperative optimization of hemoglobin and minimization of perioperative blood loss are cornerstones in the prevention of blood loss, anemia, and transfusions.

Valoración del grado de conocimiento de los profesionales sobre el Patient Blood Management en su organización. Modelo y resultados de la encuesta del proyecto MAPBM

IntroductionThe Maturity Assessment Model in Patient Blood Management project involves the use of a matrix that evaluates the maturity of the centre as regards blood transfusion practice. This tool includes a questionnaire to be completed by physicians to determine their level of knowledge of patient blood management strategies in their centre. Material and methodsForty one hospitals took part in the Maturity Assessment Model in Patient Blood Management project in 2016. The questionnaire included 10 questions, 3 about the centre, specialty, and years of experience, and 7 about patient blood management protocols in the respondent’s centre. The minimum responses required per centre was calculated according to the number of beds. Responses from at least 3 different specialties were required in order to be evaluated. ResultsA total of 1403 questionnaires were completed. The specialty with the highest completion rate was anaesthesiology (40.9%). The distribution as regards professional experience was homogeneous: <10 years, 33.4%, 10-20 years, 33%, and> 20 years 33.6%. Nearly three-quarters (74.2%) knew the patient blood management protocol used in their centre, and 60.7% knew the protocol for the treatment of pre-operative anaemia. Slightly fewer (72%) reported knowing the blood transfusion protocol (transfusion threshold) used in their centre, and 90% considered other factors besides haemoglobin in the decision to transfuse. Only 30.7% of professionals reported receiving periodic information on transfusion practices. ConclusionsThere is a significant lack of knowledge about preoperative anaemia and perioperative transfusion protocols used in the centres polled. Few centres provide their physicians with information on transfusion practices.

Perioperative Anemia and Transfusion in Colorectal Cancer Patients.

Background: Both anemia and blood transfusion are now considered independent risk factors for poor outcome in colorectal cancer patients. Severe anemia can increase tumor aggressiveness and blood transfusion may induce immunosuppression and promote cancer recurrence. Specific Patient Blood Management (PBM) strategies for oncological surgical patients are insufficiently defined and recommended. Primary objectives: Evaluation of the perioperative anemia prevalence and transfusion rate in colorectal cancer patients. Secondary objectives: Sub-group analysis of anemic versus non-anemic patients and colon versus rectal cancer patients. Methods: We retrospectively reviewed records from all consecutive surgical oncological patients admitted between January and June 2017. We selected major lower abdominal surgical patients and then colorectal surgical patients. We evaluated the perioperative hemoglobin values dynamics (preoperative=Hb1, postoperative= Hb2, at discharge= Hb3), anemia prevalence and severity and transfusion rate. Statistical analysis used Student t test, Wilcoxon signed-rank and Chi-square tests from SPSS 17. Results: Of the 1284 patients screened, 546 patients were submitted to major lower abdominal surgery and 260 patients to colorectal cancer surgery. The mean age was 65.6 +- 11.1 years, 57.7% males. The perioperative dynamics of hemoglobin was Hb1/Hb2/Hb3 =12/10.6/10.4 g/dL. Anemia prevalence was 52.3/82.3/82.6% preoperatively/postoperatively/at hospital discharge. Global transfusion rate was 23.8%, with pre/intra/postoperative distribution of 2.3/11.9/10.8%. Anemic patients were older (p=0.005), with a higher transfusion rate (p 0.001) and a longer hospital LOS (p=0.04). Colon cancer patients had lower Hb values (p=0.001) and higher prevalence of preoperative anemia (p=0.001) comparing with rectal cancer patients. Conclusions: The analysis of this cohort of colorectal cancer patients identified an increased prevalence of anemia in all perioperative phases. There is an urgent need of PBM program implementation in this selected group of surgical patients.

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.

PHP159 - PUBLIC HEALTH AND ECONOMIC VALUE OF A NATIONWIDE PATIENT BLOOD MANAGEMENT PROGRAM

Patient Blood Management (PBM) is an evidence-based, multidisciplinary approach aiming to optimize patients’ own blood in order to improve clinical outcomes and healthcare expenditure. This research set out to assess the public health and economic value of a nationwide PBM program in Portugal. A mathematical decision-model was developed to estimate the impact of a nationwide PBM program over a one-year time horizon. Hospital-attended patients from the following therapeutic areas were considered: surgery (orthopaedic/cardiac/urologic), cardiology, oncology, gastrointestinal bleeding, abnormal uterine bleeding, haemodialysis, inflammatory bowel disease and pregnancy. Model inputs, obtained from Portuguese national health databases and literature review, included effectiveness and cost data on PBM strategies, transfusion utilization, hospitalization, mortality, physician visits and drug use. Model structure and inputs were validated by a national expert panel. For an estimated 384,704 patients eligible for PBM strategies, a reduction in the proportion of red blood cell (RBC) transfused patients of 51.2% could be obtained (-17,202 patients), associated with a reduction in the number of transfused RBC units of 57.3% (-65,214 units). Due to an estimated 8.4% and 37.3% decrease in hospital length of stay and readmissions, respectively, 233,141 in-hospital days could be avoided. Furthermore, in-hospital mortality could reduce by 594 cases, resulting in 1,481 life-years gained. Although an increase in drug use and physician visits would lead to an estimated additional €24.1 million in costs, these would be counterbalanced by €91.9 million in savings, mainly due to €70.4 million in hospitalization costs and €17.6 million in RBC transfusions. Net savings of over €67.7 million could be expected, equivalent to a 6.3% reduction in the public expenditure of this population. The implementation of a nationwide PBM program in Portugal could result in a substantial improvement in public health outcomes with high economic value to the national health system.

Bombay phenotype (Oh) and high‐titer anti‐H in pregnancy: two case reports and a review of the literature

Antenatal cases of Bombay-phenotype (Oh ) individuals and hemolytic disease of the fetus and newborn (HDFN) are not well described in the literature. We present two case reports of high-titer anti-H in pregnant Oh individuals and their serologic investigation, clinical management, and subsequent outcomes. We describe current published cases detailing pregnancy in Oh individuals, to add to the evidence base for clinical decision making and management of pregnancy. We describe two case reports of high-titer anti-H in pregnancy in Oh individuals. We summarize published cases to date, to inform clinical decision making and antenatal management in individuals with the Bombay phenotype. Of the case reports described, neither were affected by HDFN due to anti-H. Antibody titers were high in both cases (immunoglobulin G titer scores, 512 and 4000, respectively) and would be expected to cause some degree of HDFN, a surprising finding. Regular mean cerebral artery Doppler ultrasound was normal. Patient blood management (PBM) techniques ensured that the patient's hemoglobin (Hb) levels were monitored and maintained. Transfusion intervention was not required, with minimal blood loss recorded at birth in both cases. High-titer anti-H in Oh pregnancies may, in rare cases, cause HDFN, but evidence suggests that this may not be the case in all pregnancies. We recommend a multidisciplinary approach, with prompt referral to a fetomaternal medicine unit, combined with PBM strategies, and a planned delivery with the provision of rare-phenotype units (if available and if indicated) on standby.

Patient blood management in colorectal cancer patients: a survey among Dutch gastroenterologists, surgeons, and anesthesiologists.

There is an increasing awareness to integrate patient blood management (PBM) within routine surgical care. Limited information about the implementation of PBM in colorectal cancer surgery is available. This is curious, as preoperative anemia, associated with increased morbidity, is highly prevalent in colorectal cancer patients. Present study aimed to assess the current PBM strategies in the Netherlands. An online electronic survey was developed and sent to surgeons of the Dutch Taskforce Coloproctology (177 in total). In addition, for each hospital in which surgery for colorectal cancer surgery is performed (75 in total), the survey was sent to one gastroenterologist and one anesthesiologist. Analyses were performed using descriptive statistics. A total of 192 physicians responded to the survey (response rate 58.7%). In 73 hospitals (97.3%) the survey was conducted by at least one physician. Regarding the management of a mild-moderate preoperative anemia, no clear policy was reported in half of the hospitals (49.3%). In 38.7% of the hospitals, iron status was indicated to be measured during screening for colorectal cancer. In addition, in only 13.3% of the hospitals, iron status was measured by the anesthesiologist during preoperative assessment. The Present study shows a distinct variability in PBM practices in colorectal cancer care. Strikingly, this variability was not only seen between, but also within Dutch hospitals, demonstrated by often variable responses from physicians from the same institution. As a result, the present study clearly demonstrates the lack of consensus on PBM, resulting in a suboptimal preoperative blood management strategy.

A data-driven patient blood management strategy in liver transplantation.

Blood utilization during liver transplant has decreased, but remains highly variable due to many complex surgical and physiologic factors. Previous models attempted to predict utilization using preoperative variables to stratify cases into two usage groups, usually using entire blood units for measurement. We sought to develop a practical predictive model using specific transfusion volumes (in ml) to develop a data-driven patient blood management strategy. This is a retrospective evaluation of primary liver transplants at a single institution from 2013 to 2015. Multivariable analysis of preoperative recipient and donor factors was used to develop a model predictive of intraoperative red-blood-cell (pRBC) use. Of 256 adult liver transplants, 207 patients had complete transfusion volume data for analysis. The median intraoperative allogeneic pRBC transfusion volume was 1250ml, and the average was 1563±1543ml. Preoperative haemoglobin, spontaneous bacterial peritonitis, preoperative haemodialysis and preoperative international normalized ratio together yielded the strongest model predicting pRBC usage. When it predicted <1250ml of pRBCs, all cases with 0ml transfused were captured and only 8·6% of the time >1250ml were used. This prediction had a sensitivity of 0·91 and a specificity of 0·89. If predicted usage was >2000ml, 75% of the time blood loss exceeded 2000ml. Patients likely to require low or high pRBC transfusion volumes were identified with excellent accuracy using this predictive model at our institution. This model may help predict bleeding risk for each patient and facilitate optimized blood ordering.

Towards a systematic approach for (de)implementation of patient blood management strategies.

Despite the increasing availability of evidence in transfusion medicine literature, this evidence does not automatically find its way into practice. This is also applicable to patient blood management (PBM). It may concern the lack of implementation of effective new techniques or treatments, or it may apply to the (over)use of techniques and treatments (e.g. inappropriate transfusions) that have proven to be of limited benefit for patients (low-value care) and could be abandoned (de-implementation). In PBM literature, the implementation of restrictive transfusion thresholds and the de-implementation of inappropriate transfusions are described. However, most implementation strategies were not preceded by the identification of relevant barriers, and the used strategies were not often supported by literature on behavioural changes. In this article, we describe implementation vs de-implementation, highlight the current situation of (de)implementation in PBM and describe a systematic approach for (de)implementation illustrated by an example of a PBM de-implementation study regarding '(cost-) effective patient blood management in total hip and knee arthroplasty'. The systematic approach used for (de)implementation is based on the implementation model of Grol, which consists of the following five steps: the detection of improvement goals, a problem analysis, the selection of (de)implementation strategies, the execution of the (de)implementation strategy and an evaluation. Based on the description of the current situation and the experiences in our de-implementation study, we can conclude that de-implementation may be more difficult than expected as other factors may play a role in effective de-implementation compared to implementation.

Patient blood management strategies in total hip and knee arthroplasty

Background: Patient blood management in total hip and knee arthroplasty involves a three-pillar approach of optimizing red blood cell mass, minimizing blood loss, and managing anemia. We describe the effect of implementation of various strategies over a 7-year period. Methods: We prospectively collected blood transfusion data over a yearly quarter in the years of 2009, 2012, 2014, and 2015 with patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA), primary and revision procedures. Evidence-based patient blood management strategies were introduced, including a tranexamic acid (TXA) protocol. The data were retrospectively analyzed, with observations of rates and appropriateness of blood transfusions in the context of changes in Australian National Blood Authority guidelines. Results: There was a significant reduction in transfusion rates from 2009 to 2015 in both THA (38.5%, 24.4%, 8.5%, and 12.5% for 2009, 2012, 2014, and 2015, χ2=17.9, P&lt;0.05), and TKA (12.4%, 6.1%, 7.8%, and 2.1% for 2009, 2012, 2014, and 2015, χ2=4.2, P&lt;0.05). This coincided with an increased adherence to national blood management guidelines in both THA and TKA (χ2=7.19, P=0.027). Conclusions: Patient blood management is multifaceted, and significant reductions in transfusion can be achieved in adherence to perioperative patient blood management guidelines. Tranexamic acid also is an important contributor in the improvement of transfusion rates in THA and TKA.

Blood transfusion in the surgical treatment of adolescent idiopathic scoliosis-a single-center experience of patient blood management in 210 cases.

The surgical treatment of adolescent idiopathic scoliosis can be associated with substantial blood loss, requiring allogeneic red blood cell (RBC) transfusion. This study describes the use of RBC and the effect of a standardized perioperative patient blood management program. Patients treated with posterior instrumented fusion were consecutively enrolled over a 6-year period. Patient blood management strategies were implemented in 2011, including prophylactic tranexamic acid, intraoperative permissive hypotension, restrictive fluid therapy (including avoidance of synthetic colloids), restrictive RBC trigger according to institutional standardized protocol, the use of cell savage, and goal-directed therapy according to thrombelastography. In total, 210 patients were included. 64 patients (31%) received RBC transfusions. A decline in the intraoperative rate of RBC transfusion was observed, from 77% in 2011 to 13% in 2016 (p < 0.001). Patients in the transfusion group had a significantly larger major curve, lower preoperative hemoglobin, higher estimated blood loss, and an increased use of crystalloid volume resuscitation. Multiple logistic regression showed that significant predictors for RBC transfusion were preoperative hemoglobin level (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.27-0.57), estimated blood loss (OR, 1.26; 95% CI, 1.15-1.42), and year of surgery (indicating the effect of patient blood management) (OR per year, 0.76; 95% CI, 0.58-0.99). A perioperative patient blood management program substantially reduced the need for RBC transfusion. A preoperative evaluation of anemia is essential to further minimize transfusion rates.

Patient blood management: an update of current guidance in clinical practice.

Patient blood management is a global, evidence-based, multidisciplinary initiative to reduce unnecessary blood transfusion while optimizing other available techniques. This article summarizes current patient blood management strategies and highlights future developments in UK practice.

Zika Virus and Patient Blood Management.

Sporadic Zika virus infections had only occurred in Africa and Asia until an outbreak in Micronesia (Oceania) in 2007. In 2013 to 2014, several outer Pacific Islands reported local outbreaks. Soon thereafter, the virus was likely introduced in Brazil from competing athletes from French Polynesia and other countries that participated in a competition there. Transmission is thought to have occurred through mosquito bites and spread to the immunologically naive population. Being also a flavivirus, the Zika virus is transmitted by the Aedes mosquito that is endemic in South and Central America that is also the vector of West Nile virus, dengue, and chikungunya. In less than a year, physicians in Brazil reported a many-fold increase in the number of babies born with microcephaly. Despite initial skepticism regarding the causal association of the Zika virus epidemic and birth defects, extensive basic and clinical research evidence has now confirmed this relationship. In the United States, more than 4000 travel-associated infections have been reported by the middle of 2016 to the Centers for Disease Control and Prevention. Furthermore, many local mosquito-borne infections have occurred in Puerto Rico and Florida. Considering that the virus causes a viremia in which 80% of infected individuals have no symptoms, the potential for transfusion transmission from an asymptomatic blood donor is high if utilizing donor screening alone without testing. Platelet units have been shown to infect 2 patients via transfusion in Brazil. Although there was an investigational nucleic acid test available for testing donors, not all blood centers were initially required to participate. Subsequently, the US Food and Drug Administration issued a guidance in August 2016 that recommended universal nucleic acid testing for the Zika virus on blood donors.In this report, we review the potentially devastating effects of Zika virus infection during pregnancy and its implication in cases of Guillain-Barre syndrome in adults. Furthermore, we urge hospital-based clinicians and transfusion medicine specialists to implement perisurgical patient blood management strategies to avoid blood component transfusions with their potential risks of emerging pathogens, illustrated here by the Zika virus. Ultimately, this current global threat, as described by the World Health Organization, will inevitably be followed by future outbreaks of other bloodborne pathogens; the principles and practices of perioperative patient blood management will reduce the risks from not only known, but also unknown risks of blood transfusion for our patients.