Reduction In Allogeneic Blood Transfusions Research Articles

Impact of a Patient Blood Management monitoring and feedback programme on allogeneic blood transfusions and related costs

A Patient Blood Management programme was established at the University Hospital of Zurich, along with a monitoring and feedback programme, at the beginning of 2014 with a first analysis reported in 2015. Our study aimed to investigate the further impact of this Patient Blood Management monitoring and feedback programme on transfusion requirements and related costs. We included adult patients discharged between 2012 and 2017. A total of 213,882 patients underwent analysis: 66,659 patients in the baseline period (2012-2013); 35,309 patients in the year after the introduction of the Patient Blood Management monitoring and feedback programme (2014) and 111,914 patients in the continued sustainability period (2015-2017). The introduction of the Patient Blood Management monitoring and feedback programme reduced allogeneic blood product transfusions by 35%, from 825 units per 1000 hospital discharges in 2012 to 536 units in 2017. The most sustained effect was an approximately 40% reduction in red blood cell transfusions, from 535 per 1000 discharges to 319 units. Fewer patients were transfused in the periods after the introduction of the Patient Blood Management monitoring and feedback programme (6251 (9.4%) vs. 2932 (8.3%) vs. 8196 (7.3%); p<0.001). Compared with 2012, the yearly OR for being exposed to any blood transfusion declined steadily after the introduction of the Patient Blood Management monitoring and feedback programme to 0.64 (95%CI 0.61-0.68; p<0.001) in 2017. For patients requiring extracorporeal membrane oxygenation, transfusion requirements were also sustainably reduced. This reduction in allogeneic blood transfusions led to savings of 12,713,754 Swiss francs (£ 9,497,000 sterling; EUR 11,100,000; US$ 12,440,000) in blood product acquisition costs over 4years. In-hospital mortality was not affected by the programme. The Patient Blood Management monitoring and feedback programme sustainably reduced transfusion requirements and related costs, without affecting in-hospital mortality.

Blood Transfusion Strategies in Elective Vascular Surgery

Autotransfusion techniques used in vascular surgery: intraoperative cell salvage (ICS) and acute normovolemic haemodilution (ANH), are evaluated in this article, especially their effectiveness in the reduction of allogeneic blood transfusions and cost. In comparison with ICS, ANH does not need any special equipment, is more accessible and cheaper, but the other method, ICS, is more adopted by vascular surgeons and anaesthetists. Even if ICS is preferred to ANH, only one study among the randomized studies confirmed the convincing benefit of using the cell salvage technique, and only 2 non-randomized studies had similar results, moreover, meta-analyses of these studies have not resolved the dispute over the efficiency of ICS. Only three meta-analyses assessing ICS in a subpopulation of patients who underwent abdominal aortic aneurysm surgery showed a decrease in the use of allogeneic blood and improvement of clinical outcomes. ANH in vascular surgery was evaluated in 6 randomized studies and 1 retrospective study. There was no study, except one, which would evaluate ANH as the only autotransfusion method in vascular surgery. ANH was assessed in combination with ICS and 3 randomized studies confirmed that this combination could be effective in the achievement of the reduction in exposure to allogeneic blood. Because ANH can have an impact on microcirculatory and macrocirculatory levels, two studies evaluated it from this point of view, but without any significant results. For the future, both ANH and ICS can have a potential to save allogeneic blood and money but positive results depend on blood loss and the type of elective infrarenal aortic surgery. ANH should be evaluated separately and in greater detail. Although the general risks of blood transfusion have been reduced during recent years, the risk of the transmission of infectious diseases, bacterial, fungal as well as viral, transfusion reactions, immunosuppression and postoperative infectious complications still remains. To avoid allogeneic transfusion, autotransfusion techniques are preferred. They include the intraoperative cell salvage technique (ICS), acute normovolemic haemodilution (ANH) and preoperative blood donation. Each of the autotransfusion techniques can be used for vascular surgery but some of them have more often been adopted by vascular surgeons. The most popular technique in vascular surgery seems to be intraoperative cell salvage whereas acute normovolemic haemodilution is not used as frequently. Techniques (ICS, ANH), their advantages and disadvantages as well as their effectiveness in the reduction of cost and allogeneic blood transfusions in elective vascular surgery are evaluated in this article.

Pre-operative autologous blood donation versus no blood donation in total knee arthroplasty: a prospective randomised trial

During total knee arthroplasty (TKA) blood loss can be significant and in spite of all techniques for reducing blood loss there is still a significant possibility for blood transfusions. For blood loss management during TKA, pre-operative autologous blood donation (PABD) is still a standard of care. In this prospective randomised study we have evaluated the efficacy of PABD in patients undergoing TKA to answer the question whether there is any need for autologous blood donations during TKA and, if yes, for which group of patients. Patients were randomised to three groups. In group 1 patients did not donate autologous blood, in group 2 patients donated 1 dose 72hours prior to TKA and in group 3 patients donated autologous blood 14days prior to TKA. In all patients haemoglobin, haematocrit, thrombocyte and reticulocyte values, iron concentrations (Fe, unsaturated iron binding capacity, total iron binding capacity), activated partial thromboplastin time, prothrombin time, and intra-operative and post-operative blood loss were measured and compared. With PABD there was no reduction in allogeneic blood transfusions and a large number of taken doses of autologous blood was discarded, which significantly increased the cost of treatment for these patients. For patients undergoing TKA, PABD can provoke iatrogenic anaemia and thereby increase the likelihood of the need for allogeneic blood transfusion. Results of our study showed that PABD in non-anaemic patients is not justified and is not economically feasible.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty

Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions. 176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements. All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005). While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Potential Cost Saving of Epoetin alfa in Elective Hip or Knee Surgery due to Reduction in Blood Transfusions and Their Side Effects: A Discrete-Event Simulation Model

ObjectivesTransfusion of allogeneic blood is still common in orthopedic surgery. This analysis evaluates from the perspective of a German hospital the potential cost savings of Epoetin alfa (EPO) compared to predonated autologous blood transfusions or to a nobloodconservationstrategy (allogeneic blood transfusion strategy)during elective hip and knee replacement surgery.MethodsIndividual patients (N = 50,000) were simulated based on data from controlled trials, the German DRG institute (InEK) and various publications and entered into a stochastic model (Monte-Carlo) of three treatment arms: EPO, preoperative autologous donation and nobloodconservationstrategy. All three strategies lead to a different risk for an allogeneic blood transfusion. The model focused on the costs and events of the three different procedures. The costs were obtained from clinical trial databases, the German DRG system, patient records and medical publications: transfusion (allogeneic red blood cells: €320/unit and autologous red blood cells: €250/unit), pneumonia treatment (€5,000), and length of stay (€300/day). Probabilistic sensitivity analyses were performed to determine which factors had an influence on the model's clinical and cost outcomes.ResultsAt acquisition costs of €200/40,000 IU EPO is cost saving compared to autologous blood donation, and cost-effective compared to a nobloodconservationstrategy. The results were most sensitive to the cost of EPO, blood units and hospital days.ConclusionsEPO might become an attractive blood conservation strategy for anemic patients at reasonable costs due to the reduction in allogeneic blood transfusions, in the modeled incidence of transfusion-associated pneumonia andthe prolongedlength of stay.

Analysis of Autologous Platelet-Rich Plasma During Ascending and Transverse Aortic Arch Surgery

Coagulopathy is a common complication after ascending and transverse arch aortic surgery with profound hypothermic circuit arrest (PHCA). Blood conservation strategies to reduce transfusion have been ongoing and involve multiple treatment modalities in modern cardiac surgery. The purpose of this study is to evaluate the effectiveness of autologous platelet-rich plasma (aPRP) as a blood conservation technique to reduce blood transfusion in ascending and arch aortic surgery. Between 2003 and 2009, we retrospectively reviewed 685 cases of ascending aorta and transverse arch repair using PHCA. A total of 287 patients in which aPRP was used (aPRP group) were compared with 398 patients who did have aPRP (non-aPRP group). Perioperative transfusion requirements and clinical outcomes that included early mortality, postoperative stroke, renal dysfunction, prolonged ventilation, coagulopathy, and length of postoperative intensive care unit stay were analyzed. The data were analyzed by mean and frequency for continuous variables and qualitative variables. To account for potential selection bias, 2 types of propensity analysis were performed. In both unadjusted and adjusted analysis, perioperative transfusions were fewer in the aPRP group compared with the non-aPRP group: (3.9 units fewer packed red blood cells, 4.5 units fewer fresh frozen plasma, 7.9 units fewer platelets, and 6.8 units fewer cryoprecipitate). In all analyses, postoperative morbidity (stroke, duration of mechanical ventilation, and intensive care unit stay) were significantly improved. Hospital mortality rate was not significantly decreased. The utilization of aPRP was associated with a reduction in allogeneic blood transfusions as well as a decrease in early postoperative morbidity during repairs of the ascending and transverse arch aorta using PHCA.

PMS16 Potential Cost Saving of Epoetin Alfa Compared to Autologous Blood Donation or to No-Blood-Conservation-Strategy Before Elective Hip or Knee Surgery Due to reduction in Allogeneic Blood Transfusions and Its Side Effects

PMS16 Potential Cost Saving of Epoetin Alfa Compared to Autologous Blood Donation or to No-Blood-Conservation-Strategy Before Elective Hip or Knee Surgery Due to reduction in Allogeneic Blood Transfusions and Its Side Effects

416 Improved surgical outcomes with the universal use of individualized heparin and protamine management system for pediatric cardiac surgery with cardiopulmonary bypass

In a recent clinical trial we established that the use of the Hemostatic Management System (HMS) with a pediatric-specific protocol, for the individualized management of heparin and protamine dosing during cardiac surgeries performed on patients <1 year of age resulted in enhanced anticoagulation and improved surgical outcomes. Based on the results of this study the HMS system was thereafter employed for all cardiac surgeries. We sought to determine whether the universal use of the HMS was associated improved program-wide post-operative outcomes. A total of 622 pediatric cardiac surgeries performed between April 2009 and August 2010 using the HMS were compared to 1,542 surgeries performed between July 2004 and December 2007, using standard weight-based heparin dosing using the activated clotting time for monitoring (HMS was evaluated/deployed between those 2 periods). Outcomes between the 2 periods were compared with adjustments for multiple patients and surgical characteristics in multivariable regression models. Patients and surgical characteristics between the pre-HMS and post-HMS era were similar. The HMS failed to achieve sufficiently high heparin blood concentration after the initial heparin bolus in 52% of cases and required an additional heparin bolus prior to bypass initiation. Most patients (361, 58%) received additional heparin during the surgery, despite normal activated clotting time (>400s). Patients in the post-HMS era required significantly lower amount of allogeneic red blood cell (87ml/kg vs. 118 ml/kg, P < 0.001) and platelets (8ml/kg vs. 14ml/kg, P < 0.001). Use of recombinant factor VIIa in post-operative period was less likely in the post-HMS era (1.1% vs. 3.5%, P = 0.03). Intubation time (9 vs. 27 hours, P < 0.001), intensive care unit stay (2 vs. 3 days, P = 0.009) and hospital stay (6.3 vs. 8.0 days, P = 0.02) were all shorter in the post-HMS period. Failure of the HMS system to achieve sufficient blood heparin concentration after the initial dose shows that further refinements in the pediatric protocol are necessary. Even considering this, the use of the HMS system for all pediatric cardiac surgeries was associated with system-wide improvement in post-surgical outcomes. Although the effect cannot be entirely ascribed to the use of the HMS because of additional concurrent changes in surgical and post-operative protocols, the reduction of allogeneic blood transfusions and bleeding-related complications suggest that the HMS system was a contributor to the improved surgical outcomes observed between the 2 periods.

417 Sudden death risk in patients with tetralogy of Fallot and 22q11.2 deletion syndrome

achieve sufficiently high heparin blood concentration after the initial heparin bolus in 52% of cases and required an additional heparin bolus prior to bypass initiation. Most patients (361, 58%) received additional heparin during the surgery, despite normal activated clotting time ( 400s). Patients in the postHMS era required significantly lower amount of allogeneic red blood cell (87ml/kg vs. 118 ml/kg, P 0.001) and platelets (8ml/kg vs. 14ml/kg, P 0.001). Use of recombinant factor VIIa in post-operative period was less likely in the post-HMS era (1.1% vs. 3.5%, P 0.03). Intubation time (9 vs. 27 hours, P 0.001), intensive care unit stay (2 vs. 3 days, P 0.009) and hospital stay (6.3 vs. 8.0 days, P 0.02) were all shorter in the post-HMS period. CONCLUSION: Failure of the HMS system to achieve sufficient blood heparin concentration after the initial dose shows that further refinements in the pediatric protocol are necessary. Even considering this, the use of the HMS system for all pediatric cardiac surgeries was associated with system-wide improvement in post-surgical outcomes. Although the effect cannot be entirely ascribed to the use of the HMS because of additional concurrent changes in surgical and post-operative protocols, the reduction of allogeneic blood transfusions and bleeding-related complications suggest that the HMS system was a contributor to the improved surgical outcomes observed between the 2 periods.

Spanish consensus statement on alternatives to allogeneic transfusions: the ‘Seville document’

SUMMARYThe Consensus Document on Alternatives to Allogeneic Blood Transfusion (AABT) has been drawn up by a panel of experts from five scientific societies. The Spanish societies of anesthesiology (SEDAR), critical care medicine and coronary units (SEMICYUC), hematology and hemotherapy (AEHH), blood transfusion (SETS), and thrombosis and hemostasis (SETH) have sponsored and participated in this consensus document. Alternatives to blood transfusion have been divided into pharmacological and nonpharmacological, with four modules and 12 topics. The main objective variable was the reduction of allogeneic blood transfusions and/or the number of transfused patients. The extent to which this objective was achieved by each AABT was evaluated using the Delphi methodology, which classifies the grades of recommendation from ‘A’ (supported by controlled studies) to ‘E’ (noncontrolled studies and expert opinion). The experts concluded that most of the indications for AABT only attained middle or low grades of recommendation, ‘C’, ‘D’ or ‘E’, thus indicating the need for further controlled studies.

Blood Transfusions and Postoperative Recovery in Orthopedic Surgery. The European Eprex Surgery Trial

SUMMARYThis trial compared the effect of preoperative administration of epoetin alfa (EPO) and best standard of care (BSC) on transfusion rate and its impact on postoperative recovery in a daily life setting. Hemoglobin (Hb) concentrations, transfusions, time to ambulation, hospitalization time, infections, and safety parameters were evaluated in orthopedic surgery patients with preoperative Hb values 10–13 g/dL from study entry until 4–6 weeks after surgery (on‐treatment: 460 patients EPO, 235 BSC). Mean Hb values (not different at baseline) were higher in the EPO group than in the BSC group (p &lt; 0.05) from the day of surgery until the end of the observation period. Transfusion rate was 12% in the EPO group vs. 46% in the BSC group (p &lt; 0.05). No significant relation was detected between treatment and postoperative recovery (hospitalization time, time to ambulation, infection rate), probably due to the small number of transfused patients in the EPO group. Hospitalization time and time to ambulation were, however, longer in transfused than in nontransfused patients (p &lt; 0.05). Postoperative infections occurred in 12.9% and 8.9% of transfused and nontransfused patients, respectively (NS). Side effects in both groups were comparable. We conclude that epoetin alfa significantly increases Hb in the perioperative period in mildly to moderately anemic patients, with a significant reduction of allogeneic blood transfusions. Patients exposed to allogeneic blood transfusion require a longer hospitalization. The number of transfusions in this study was too limited to confirm former observations on reduction of postoperative infections.

Reduction of Allogeneic Blood Transfusions After Open Heart Operations by Lowering Cardiopulmonary Bypass Prime Volume

Background. Despite recent advances in blood conservation techniques, up to 30% to 80% of patients undergoing open heart operations require allogeneic blood transfusions. A prospective, randomized study was performed to test the effect of lowering cardiopulmonary bypass prime volume (as an additional component of an integrated blood conservation strategy) on clinical outcome and allogeneic blood transfusion.Methods. One hundred fourteen patients undergoing open heart operations were randomized to either full prime (FP) volume (1,400 mL of Plasmalyte solution) or reduced prime (RP) volume (600 to 800 mL). The reduction of prime volume was achieved by slowly draining the cardiopulmonary bypass circuit into a cell-saving device before the initiation of bypass. Firm transfusion thresholds were observed.Results. There were no significant differences between the groups with respect to baseline characteristics, body surface area, type and urgency of the procedures, perfusion technique, and hematologic profile. Mortality (FP, 1.7%; RP, 0%; p ≈ 1.0) and overall morbidity (FP, 28.1%; RP, 22.8%; p = 0.53) were similar. However, transfusion requirements were significantly lower in the RP group: total donor exposure, 3.8 ± 10.1 versus 1.0 ± 2.4 units (p = 0.044); percentage of patients transfused, 54% (n = 31) versus 35% (n = 20) (p = 0.036). Twenty-four–hour chest tube drainage was similar: 455 ± 223 mL for FP versus 472 ± 173 mL for RP (p = 0.66). The lowest hematocrit on bypass was significantly higher in the RP group: 29.3% ± 4% versus 26.3% ± 5.3% (p = 0.009).Conclusions. Lowering cardiopulmonary bypass prime volume resulted in a significant decrease in allogeneic blood product use. Because postoperative 24-hour chest tube drainage was similar in both groups, and hematocrit during bypass was higher in the RP group, the reduction in allogeneic blood transfusions appears to be related to a decrease in prime-induced hemodilution. This technique is effective, simple, and safe. It therefore should be strongly considered for patients undergoing operations using normothermic or near-normothermic cardiopulmonary bypass who are at high risk for allogeneic blood transfusion.