Perioperative Blood Management Research Articles

Over the Past Decade, Preoperative Anemia Has Become a Greater Predictor of Transfusions after Total Knee Arthroplasty.

With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA. A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization (WHO) definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation. There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The OR (odds ratio) associated with anemia as a predictor of transfusion increased from 3.1 (95% CI [confidence interval]: 2.1 to 4.6) in 2010 to 14.0 (95% CI: 8.9 to 24) in 2021. The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA.

Consensus of the Brazilian association of hematology, hemotherapy and cellular therapy on patient blood management: Antifibrinolytics

The use of strategies to reduce blood loss and transfusions is essential in the treatment of surgical patients, including in complex cardiac surgeries and those that use cardiopulmonary bypass. Antifibrinolytics, such as epsilon-aminocaproic acid (EACA) and tranexamic acid (TXA), are widely used in these procedures, as well as in other types of surgeries. These medicines are included in the World Health Organization (WHO) list of ‘essential medicines’. Scientific evidence demonstrates the effectiveness of EACA in reducing bleeding and the need for transfusions in heart surgery. EACA is highly recommended for use in heart surgery by the American Society of Anesthesiology Task Force on Perioperative Blood Management. Regarding the safety of EACA, there is no robust evidence of any significant thrombotic potential. TXA has also been shown to be effective in reducing the use of blood transfusions in cardiac and non-cardiac surgeries and is considered safer than other antifibrinolytic agents. There is no evidence of any increased risk of thromboembolic events with TXA, but doses greater than 2 g per day have been associated with an increased risk of seizures. It is also important to adjust the dose in patients with renal impairment. In conclusion, antifibrinolytics, such as EACA and TXA, are effective in reducing blood loss and transfusion use in cardiac and non-cardiac surgeries, without causing serious adverse effects.

Does pumping iron bring gains? A review of the role of intravenous iron in perioperative blood management

Does pumping iron bring gains? A review of the role of intravenous iron in perioperative blood management

Impact of intraosseous regional administration of tranexamic acid in total knee arthroplasty on perioperative blood loss: a protocol for a randomised controlled trial

IntroductionTotal knee arthroplasty (TKA) is a common surgical intervention to treat joint diseases. However, TKA is associated with significant blood loss. Tranexamic acid (TXA) has been used to reduce perioperative...

A Perioperative Blood Management Algorithm Aimed at Conservation of Platelets in Clinical Practice: The Role of the Anesthesiologist in Decision-Making.

Platelet dysfunction and thrombocytopenia are associated with postoperative morbidity not only from modifiable preoperative factors but also from a lack of local patient blood management algorithms. In this regard, platelet transfusions have risen after the COVID-19 pandemic. Simultaneously, there has been a shortage of donors. It is logical, therefore, that each hospital should develop a triage tool, posting their algorithm on walls. Anesthesiologists should assist in planning a strategy to minimize blood transfusions while improving tissue oxygenation. A flowchart posted in each operating theatre may be customized per patient and hospital. Clinicians need reminders to draw a prothrombin time, fibrinogen, complete blood count every hour, and the appropriate threshold to transfuse. In summary, anesthesiologists are often unable to have a discussion with a patient until the preoperative day; thus, the onus falls on our surgical colleagues to reduce risk factors for coagulopathy or to delay surgery until after proper consultants have optimized a patient. The most important problems that an individual patient has ideally should be listed in a column where an anesthesiologist can write a timeline of key steps across a row, corresponding to each problem. If a handoff in the middle of the case is required, this handoff tool is superior to simply checking a box on an electronic medical record. In summary, in the operating suite, an anesthesiologist should emphasize the importance of a multidisciplinary approach. Continuing education, regular stakeholder meetings, and posters can assist in reinforcing algorithms in clinical practice.

Survey of the Impact of Decision Support in Preoperative Management of Anemia (i-Anemia): Survey Study.

Major surgery on patients with anemia has demonstrated an increased risk of perioperative blood transfusions and postoperative morbidity and mortality. Recent studies have shown that integrating preoperative anemia treatment as a component of perioperative blood management may reduce blood product utilization and improve outcomes in both cardiac and noncardiac surgery. However, outpatient management of anemia falls outside of daily practice for most anesthesiologists and is probably weakly understood. We conducted a simulated case survey with anesthesiologists to accomplish the following aims: (1) evaluate the baseline knowledge of the preoperative optimization of anemia and (2) determine the impact of real-time clinical decision support on anemia management. We sent a digital survey (i-Anemia) to members of the French Society of Anaesthesia and Critical Care. The i-Anemia survey contained 7 simulated case vignettes, each describing a patient's brief clinical history and containing up to 3 multiple-choice questions related to preoperative anemia management (12 questions in total). The cases concerned potential situations of preoperative anemia and were created and validated with a committee of patient blood management experts. Correct answers were determined by the current guidelines or by expert consensus. Eligible participants were randomly assigned to control or decision support groups. In the decision support group, the primary outcome measured was the correct response rate. Overall, 1123 participants were enrolled and randomly divided into control (n=568) and decision support (n=555) groups. Among them, 763 participants fully responded to the survey. We obtained a complete response rate of 65.6% (n=364) in the group receiving cognitive aid and 70.2% (n=399) in the group without assistance. The mean duration of response was 10.2 (SD 6.8) minutes versus 7.8 (SD 5) minutes for the decision support and control groups, respectively (P<.001). The score significantly improved with cognitive aid (mean 10.3 out of 12, SD 2.1) in comparison to standard care (mean 6.2 out of 12, SD 2.1; P<.001). Management strategies to optimize preoperative anemia are not fully known and applied by anesthesiologists in daily practice despite their clinical importance. However, adding a decision support tool can significantly improve patient care by reminding practitioners of current recommendations.

Optimizing Preoperative Iron Deficiency Anemia in Patients Undergoing Cardiac Surgery

Background: Preoperative anemia is common in patients undergoing cardiac surgery, with iron deficiency being the most common cause of anemia in these patients. Patients who are anemic in the preoperative setting have worse perioperative outcomes than patients with normal hemoglobin levels including higher rates of red cell transfusions, acute kidney injury, increased length of stay, and increased mortality. At the University of Virginia (UVA) Medical Center, there was no institutional process in place to identify and treat iron deficiency anemia in patients planned to undergo cardiac surgery. Objective: The UVA Perioperative Blood Management Committee is a newly-formed multidisciplinary group consisting of members from the departments of Hematology, Anesthesiology, Thoracic and Cardiovascular Surgery, Perfusion, and Blood Bank who work together to improve perioperative patient outcomes and blood product utilization. We set out to implement a testing algorithm with the purpose of improving the proportion of anemic patients undergoing cardiac surgery who have iron studies performed in the outpatient setting, thereby improving the percentage of patients receiving intravenous (IV) iron preoperatively. Methods: We adapted two published perioperative treatment algorithms (Lin, Hematology Am Soc Hematol Educ Program 2019; Munting and Klein, Anaesthesia 2019) which recommend iron therapy in patients with hemoglobin &amp;lt; 13 g/dL, ferritin &amp;lt; 100 µg/L, and/or transferrin saturation &amp;lt; 20% for our cardiac surgery preoperative clinic. In November 2022, we implemented a reflex test within Epic electronic medical record that automatically sent ferritin, iron, and transferrin for patients with hemoglobin &amp;lt; 13 g/dL to evaluate for iron deficiency. Patients meeting parameters for iron deficiency (ferritin &amp;lt; 30 ng/mL and/or transferrin saturation &amp;lt; 20%) were then scheduled for iron infusions. We compared the percentage of patients undergoing testing for iron deficiency, as well as the percentage of anemic patients receiving iron infusion preoperatively, to those from a six month period prior to our start date. Results: Between May 31, 2022 and October 31, 2022, 19% of cardiac surgery patients at UVA with hemoglobin values &amp;lt; 13 g/dL had iron studies drawn in the three months prior to surgery. After implementing outpatient reflex iron testing, that number increased to 42% between November 2022 and May 2023 (p &amp;lt; 0.001). In the six months prior to implementation, four iron deficient cardiac surgery patients received preoperative IV iron an average of one day prior to surgery. Between November 1, 2022 and May 29, 2023, fifteen patients received IV iron an average of 5.7 days prior to surgery. The patients who received IV iron had lower rates of blood transfusions than anemic patients who did not receive IV iron (53% vs. 65%) and fewer units of blood transfused per patient who received blood (3.1 vs. 5.7). Conclusions: Results from the first seven months of this project suggest that using a standardized testing methodology in the outpatient setting can increase the uptake of iron testing and thereby treatment of iron deficiency anemia in the preoperative setting. Patients who received IV iron had lower rates of blood transfusions and received fewer units of blood on average than anemic patients who did not receive IV iron. We next plan to implement an iron testing strategy in cardiac surgery inpatients to further improve rates of iron testing and iron infusions in this population. We have created an IRB-approved database to study more patient-centered outcomes such as acute kidney injury, stroke, length of stay, readmissions, and mortality to determine if we can detect a measurable impact from IV iron administration in our patient population.

Perioperative Blood Management Protocols Improve Outcomes: What Does the Future Hold?

Perioperative Blood Management Protocols Improve Outcomes: What Does the Future Hold?

Blood Management for the Orthopaedic Surgical Patient.

Prevention and management of anemia and blood loss in the orthopaedic patient undergoing surgery is a major concern for healthcare providers and patients. Although transfusion technology can be lifesaving, there are risks to blood products that have led to increased awareness of blood management and development of hospital patient blood management programs. Use of patient blood management can be effective in addressing preoperative anemia, a major modifiable risk factor in patients undergoing surgery. In this informational article, evidence-based practice guidelines for perioperative blood management are addressed. A case scenario is introduced focusing on a patient whose religious preference is Jehovah's Witness having "no blood wishes" undergoing elective orthopaedic surgery. Orthopaedic nurses can facilitate optimal patient blood management through multidisciplinary collaboration.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases.

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves. Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039). Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study

Anemia and transfusion are common in cardiac surgery patients, and are associated with significant morbidity and mortality. Multiple perioperative interventions have been described to reduce blood transfusion, but are rarely combined altogether. The aim of this study was to compare the incidence of red blood cell (RBC) transfusion in adult patients undergoing cardiac surgery before and after the implementation of a perioperative patient blood management (PBM) program. Before-and-after observational study. Single-center French university teaching hospital. Adult patients scheduled for cardiac surgery. Perioperative patient blood management program including pre-, intra-, and postoperative interventions aimed at identifying and correcting anemia, minimizing blood loss during surgery, and optimizing coagulation. Four hundred thirty-four patients were included in the study from January 2021 to July 2022. The incidence of perioperative RBC transfusion (intraoperatively and during the first 2 postoperative days) was significantly reduced from 43% (90/213) in the pre-PBM period to 27% (60/221) in the post-PBM period (p < 0.001). The application of a PBM program was associated with a reduction in perioperative RBC transfusion by multivariate analysis (odds ratio 0.55, 95% CI 0.36-0.85, p=0.007), and was associated with a reduction in the median number of RBC units transfused within transfused patients (p=0.025). These effects persisted at day 30 after surgery (p=0.029). A perioperative PBM program in adult patients undergoing cardiac surgery was associated with a significant reduction in perioperative RBC transfusion, which persisted at day 30.

Construction and effect evaluation of prediction model for red blood cell transfusion requirement in cesarean section based on artificial intelligence

ObjectivesThis study intends to build an artificial intelligence model for obstetric cesarean section surgery to evaluate the intraoperative blood transfusion volume before operation, and compare the model prediction results with the actual results to evaluate the accuracy of the artificial intelligence prediction model for intraoperative red blood cell transfusion in obstetrics. The advantages and disadvantages of intraoperative blood demand and identification of high-risk groups for blood transfusion provide data support and improvement suggestions for the realization of accurate blood management of obstetric cesarean section patients during the perioperative period.MethodsUsing a machine learning algorithm, an intraoperative blood transfusion prediction model was trained. The differences between the predicted results and the actual results were compared by means of blood transfusion or not, blood transfusion volume, and blood transfusion volume targeting postoperative hemoglobin (Hb).ResultsArea under curve of the model is 0.89. The accuracy of the model for blood transfusion was 96.85%. The statistical standard for the accuracy of the model blood transfusion volume is the calculation of 1U absolute error, the accuracy rate is 86.56%, and the accuracy rate of the blood transfusion population is 45.00%. In the simulation prediction results, 93.67% of the predicted and actual cases in no blood transfusion surgery; 63.45% of the same predicted blood transfusion in blood transfusion surgery, and only 20.00% of the blood transfusion volume is the same.ConclusionsIn conclusion, this study used machine learning algorithm to process, analyze and predict the results of a large sample of cesarean section clinical data, and found that the important predictors of blood transfusion during cesarean section included preoperative RBC, surgical method, the site of surgery, coagulation-related indicators, and other factors. At the same time, it was found that the overall accuracy of the AI model was higher than actual blood using. Although the prediction of blood transfusion volume was not well matched with the actual blood using, the model provided a perspective of preoperative identification of high blood transfusion risks. The results can provide good auxiliary decision support for preoperative evaluation of obstetric cesarean section, and then promote the realization of accurate perioperative blood management for obstetric cesarean section patients.

Perioperative Blood Management Programme in Jehovah’s Witnesses Undergoing Total Hip Arthroplasty

Total hip arthroplasties aim to improve quality of life and reduce pain in patients suffering from late-stage hip osteoarthritis. On the other hand, it may represent a risky surgical procedure in people who refuse blood products because of religious beliefs, such as Jehovah’s Witnesses (JW). Preoperative optimisation protocols of these patients allow medical professionals to perform arthroplasties in a safer manner, avoiding allogeneic blood transfusion. In our retrospective study, two groups of patients were evaluated. Group 1 included JW patients who underwent a preoperative Hb optimisation program; Group 2 included non-JW patients authorizing transfusion in case of necessity. Differences in Hb levels were as follows: before surgery (JW 14.24 ± 1.10 vs. non-JW 12.48 ± 1.00, p-value ≤ 0.05), and after surgery (day 1 Hb: JW 12.88 ± 0.90 vs. non-JW 10.04 ± 1.30, p-value ≤ 0.05; day 3 Hb: JW 14.65 ± 0.80 vs. non-JW 9.10 ± 0.90 p-value ≤ 0.05). Moreover, cost-effectiveness strategies were evaluated in both groups. Our findings support that patient blood management programs are a safe and good strategy in hip prosthetic surgery, decreasing risks and transfusion overuse.

Risk factors for in-hospital mortality in geriatric patients aged 80 and older with axis fractures: a nationwide, cross-sectional analysis of concomitant injuries, comorbidities, and treatment strategies in 10,077 cases

PurposeTo investigate the association between treatment, comorbidities, concomitant injuries, and procedures with in-hospital mortality in patients aged 80 years or older with axis fractures.MethodsData were extracted from the German InEK (Institut für das Entgeltsystem im Krankenhaus) GmbH database (2019–2021) for patients aged 80 years or older with axis fractures and the in-hospital mortality rate was calculated. Differences in comorbidities and concomitant diseases and injuries were analyzed using the Chi-square test. In surgically treated patients, odds ratios (OR) with 95% confidence intervals (95% CI) were used to analyze potential risk factors for in-hospital mortality.ResultsAmong 10,077 patients, the in-hospital mortality rate was 8.4%, with no significant difference between surgically (9.4%) and non-surgically treated patients (7.9%; p = 0.103). The most common comorbidities were essential hypertension (67.3%), atrial fibrillation (28.2%), and chronic kidney disease (23.3%), while the most common concomitant injuries were head and face wounds (25.9%), concussions (12.8%), and atlas fractures (11.6%). In surgically treated patients, spinal cord injury (OR = 4.62, 95% CI: 2.23–9.58), acute renal failure (OR = 3.20, 95% CI: 2.26–4.53), and acute bleeding anemia (OR = 2.06, 95% CI: 1.64–2.59) were associated with increased in-hospital mortality (all p < 0.01). Screw-rod-system fixation of one segment (OR = 0.74, 95% CI: 0.56–0.97) and intraoperative navigation (OR = 0.45, 95% CI: 0.16–0.71) were identified as potential protective factors (both p < 0.05).ConclusionComprehensive geriatric assessment and optimization of comorbidities during treatment are crucial. The indication for surgical treatment must be carefully individualized. Future studies should focus on the choice of surgical technique, perioperative blood management, and intraoperative navigation as potential protective factors.

Perioperative blood management programme in Jehovah’s witnesses undergoing total knee arthroplasty: clinical results and cost-benefit analysis

Introduction Total knee arthroplasties have the purpose to improve quality of life from joint-related pain. On the other hand, it may represent a risky surgical procedure in people who refuse blood products due to their religious beliefs, such as Jehovah’s Witnesses (JW). Preoperative optimization protocols of these patients allow performing arthroplasties in a safer manner avoiding allogeneic blood transfusion. Methods In our retrospective study, 2 groups of patients were evaluated. Group 1, included JW patients who underwent a preoperative Hb optimisation programme; group 2 included non-JW patients authorizing transfusion in case of necessity. Results Differences in Hb levels were: before surgery (JW 13,63±1,26 vs. non-JW 12,83±1,21, p-value=0,22), after surgery (day 1 Hb: JW 12,26±1,47 vs. non-JW 10,88±1,87, p-value=0,1; day 3 Hb: JW 10±2,97 vs. non-JW 9,23±1,07 p-value=0,64). In the JW group the mean Hb concentration decreased from 13,63±1,26 g/dL preoperatively to 12,26±1,47 g/dL (day 1) while in non-JW group fell from 12,83± g/dL to 10,88± g/dL. There was no statistically-difference between the 2 groups. Moreover, cost-effectiveness strategies were evaluated in both groups. Conclusion Our findings support that PBM programs represent a safe and good strategy in knee prosthetic surgery, decreasing costs, risks and transfusion overuse.

Predisposing factors for allogeneic blood transfusion in patients with rheumatoid arthritis undergoing primary unilateral total knee arthroplasty.

To determine the incidence and identify the predisposing factors for allogeneic blood transfusion (ABT) in patients with rheumatoid arthritis (RA) undergoing primary unilateral total knee arthroplasty (TKA). A total of 702 patients with RA who underwent primary unilateral TKA between 2003 and 2022 at a single center, were retrospectively enrolled. Patients were stratified into the ABT and non-ABT groups. Data on patient demographics, laboratory parameters, and disease- and surgery-related parameters were collected from chart reviews and compared between the ABT and non-ABT groups. Multivariate logistic regression analysis was conducted to identify the possible factors associated with postoperative ABT. A total of 173 (24.6%) patients underwent ABT after surgery. Significant risk factors for ABT included the degree of flexion contracture [odds ratio (OR) = 1.018, P = 0.005] and thickness of insertion (OR = 1.170, P = 0.014). Conversely, body mass index (OR = 0.937, P = 0.018), preoperative hemoglobin level (OR = 0.973, P < 0.001), and intraoperative use of tranexamic acid (TXA) (OR = 0.119, P < 0.001) were associated with a lower risk of ABT in TKA. We identified the significant risk and protective factors for ABT during TKA in patients with RA. This information could be helpful in optimizing perioperative blood management strategies during these surgeries.

Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: a retrospective study

BackgroundTotal hip arthroplasty (THA) is an excellent treatment for the end-stage hip disease, and perioperative blood management strategies have been effectively applied to this procedure. However, many patients still experience anemia after the operation, which is usually overlooked by orthopedic surgeons due to the hidden blood loss (HBL) in the perioperative period. Therefore, the objective of this study was to evaluate HBL in patients undergoing primary THA using the posterior approach and to explore its influencing factors.MethodsA retrospective analysis of 707 patients who underwent primary THA through the posterior approach was conducted in our hospital from January 2020 to January 2022. By applying Gross’s and Nadler’s formula, the HBL was calculated. Six quantitative variables (age, body mass index, surgical duration, albumin loss, preoperative hemoglobin, and hemoglobin loss) as well as four qualitative variables (gender, American Society of Anesthesiologists class, major preoperative diagnosis, and hypertension) of patients were analyzed using multivariate linear regression.ResultsThe HBL was recorded at 700.39 ± 368.59 mL. As a result of multivariate linear regression analysis, it was determined that body mass index, surgical duration, and hemoglobin loss were all significant risk factors for HBL, whereas preoperative hemoglobin was considered a protective factor. It has been demonstrated that HBL is not significantly correlated with age, albumin loss, gender, ASA class, or major preoperative diagnosis, but it also did not differ from HBL by hypertension.ConclusionsHidden blood Loss (HBL) in patients after primary total hip arthroplasty (THA) using the posterior approach is large and significant. When optimizing the perioperative management of THA, orthopedic surgeons should keep in mind HBL and its influencing factors, especially for patients with high body mass indexes, long surgical durations, and low preoperative hemoglobin levels.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (ChiCTR2100053888) in 02/12/2021, http://www.chictr.org.cn.

Error traps in Pediatric Patient Blood Management in the Perioperative Period.

Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.

Cardiac Surgery in Jehovah's Witnesses: 329 Consecutive Cases

This study aimed to describe the outcome of Jehovah's Witnesses (JWs) undergoing cardiac surgery at the authors' center. A single-center retrospective cohort study. At a cardiovascular center with a tertiary intensive care unit (ICU) and specific experience with cardiac surgery in JWs. The institutional protocol describing all perioperative care in JWs has been applied for 21 years. All JWs undergoing cardiac surgery in the Amphia Hospital from January 1, 2001 to January 31, 2022. None. The study cohort comprised 329 JWs undergoing cardiac surgery. Twenty-three patients (6.8%) were treated preoperatively for anemia. The mean European System for Cardiac Operative Risk Evaluation score was 5.1 (range 0-18). Coronary artery bypass grafting (53.2%) was performed most frequently, followed by aortic valve replacement (13.4%). Mean preoperative hemoglobin levels were 14.5 g/dL (range 9.8-18.5 g/dL), dropping to 11.6 g/dL (range 6.6-15.6 g/dL) at hospital discharge. Mean blood loss was 439 ± 349 mL in the first 12 hours postsurgery. Maximum mean postoperative troponin levels were 431 ± 424 ng/L. Resternotomy and postoperative myocardial infarction occurred in 3.6% and 4.2% of patients, respectively. On average, patients had an ICU stay of 1.4 ± 1.8 days and a hospital stay of 6.8 ± 4.2 days. Hospital mortality was 0.6% and was related to cardiac failure. This study demonstrated that cardiac surgery in JWs is safe when adhering to a strict perioperative patient blood management protocol.

Con: Artificial Intelligence–Derived Algorithms to Guide Perioperative Blood Management Decision Making

Artificial intelligence has the potential to improve the care that is given to patients; however, the predictive models created are only as good as the base data used in their design. Perioperative blood management presents a complex clinical conundrum in which significant variability and the unstructured nature of the required data make it difficult to develop precise prediction models. There is a potential need for training clinicians to ensure they can interrogate the system and override when errors occur. Current systems created to predict perioperative blood transfusion are not generalizable across clinical settings, and there is a considerable cost implication required to research and develop artificial intelligence systems that would disadvantage resource-poor health systems. In addition, a lack of strong regulation currently means it is difficult to prevent bias.