Restrictive Transfusion Practice Research Articles

Data-driven education improves patient blood management: A pilot study

Abstract Introduction: We sought to increase the use of a restrictive transfusion protocol through clinician education and a standard approach to Patient Blood Management (PBM) in our gynecologic oncology service. Optimal PBM requires the consistent application of evidence-based, restrictive transfusion guidelines, however the use of restrictive transfusion is understudied in surgical oncology populations. We hypothesized that provider specific education that includes data derived from their own clinical practice would result in improved compliance current evidence-based transfusion guidelines. Methods: We created an educational activity that described evidence-based restrictive transfusion guidelines followed by data showing providers their own clinical transfusion practice where compliance with restrictive guidelines was poor. After the education, a plan to improve compliance was developed and put into place. Comparison of transfusion practices and complication/morbidity rates before and after the education was performed. Results: During the 18 months post-education the number of RBC units transfused decreased from 316 152, a 57% reduction and monthly transfusion events were reduced by 42% from 12 to 7 per month. The percent of transfusions with a pretransfusion hemoglobin less than 7 g/dL increased from 40% to 56%. The percent of transfusions with a hemoglobin less than 8 g/dL increased to 90%. Finally, the use of single unit transfusions increased from 49 to 85%, a major contributor to the reduction in units transfused. Conclusion: We created a service-specific educational intervention that improved compliance with evidence-based restrictive transfusion practice. This intervention improved provider compliance with lower transfusion thresholds and increased the use of single-unit transfusions.

Proposals for revised International Working Group–European LeukemiaNet criteria for anemia response in myelofibrosis

AbstractWith emerging new drugs in myelofibrosis (MF), a robust and harmonized framework for defining the severity of anemia and response to treatment will enhance clinical investigation and facilitate interstudy comparisons. Accordingly, the lead authors on the 2013 edition of the International Working Group–European LeukemiaNet (IWG-ELN) response criteria in MF were summoned to revise their document with the intent to (1) account for gender-specific differences in determining hemoglobin levels for eligibility criteria; (2) revise the definition of transfusion-dependent anemia (TDA) based on current restrictive transfusion practices; and (3) provide a structurally simple and easy to apply response criteria that are sensitive enough to detect efficacy signals (minor response) and also account for major responses. The initial draft of the 2024 IWG-ELN proposed criteria was subsequently circulated around a wider group of international experts and their feedback incorporated. The proposed articles include new definitions for TDA (≥3 units in the 12 weeks before study enrollment) and hemoglobin thresholds for eligibility criteria (<10 g/dL for women and <11 g/dL for men). The revised document also provides separate (TDA vs non-TDA) and graded (major vs minor response) response criteria while preserving the requirement for a 12-week period of screening and observation on treatment.

Paradigm shift in transfusion practices during early COVID-19 pandemic: A single center retrospective study

BACKGROUND The advent of coronavirus disease 2019 (COVID-19) unveiled the worst national blood crisis that the United States had witnessed in over a decade. With the pandemic influencing the different stages of the acquisition of blood products outside the hospital setting, we aimed to explore the possible barriers contributing to the shortage of blood products within the medical community. AIM To assess the adherence to restrictive blood transfusion practices for patients in the COVID era and pre-COVID era. METHODS We conducted a retrospective cross-sectional study on hospitalized patients distinguishing the pattern of blood transfusion during the COVID and pre-COVID era in a community hospital. Data was tabulated to include the number of red blood cell (RBC) transfusions and if transfusions met restrictive blood transfusion criteria as per institutional guidelines. Chi-square was applied to test the statistical association between qualitative variables. Unpaired t test and Mann Whitney U test were applied respectively to test the mean difference of quantitative variables. RESULTS A total of 208 patients were included in the study, of which 108 were during COVID era and 100 were during pre-COVID era. The leading reason for admission in both the COVID era and pre-COVID era transfused patients was shortness of breath (53.7% and 36% P = 0.001), followed by gastrointestinal bleeding (25.9% and 21% P = 0.001). There was a higher percentage of RBC transfusions in the intensive care unit in the COVID-era group than in the pre-COVID era group (38.9% vs 22%, P = 0.008). The restrictive transfusion criteria were met in 62% vs 79% in the COVID and pre-COVID eras, respectively (P = 0.008). CONCLUSION The COVID-era group received RBC transfusions with less stringent adherence to restrictive blood transfusion practices in comparison to pre-COVID era group.

Neonatal Blood Transfusion in Africa; Towards Optimizing Scarce Resource

Neonatal transfusion is a common practice in Africa, where many infants are born with low birth weight and require blood transfusions. The use of paediatric packs for neonatal blood transfusions has been recommended. However, the optimal use of these packs in Africa is not clearly understood by some healthcare practitioners. This review aims to provide insights into the optimal use of paediatric packs in neonatal transfusion in Africa.The World Health Organization (WHO) recommends restrictive transfusion practices for paediatric patients, including neonates, based on expert opinion. Transfusion triggers in neonates are controversial and mainly based on expert clinical opinion, although recent randomized controlled trials of ‘liberal’ versus ‘restrictive’ red cell transfusion policies in very low birth weight preterm babies are starting to influence clinical guidelines. Many neonatal red cell transfusions are given to replace losses from frequent blood sampling. This can be reduced by avoiding non-essential tests, using low-volume sample tubes, validated near patient testing, micro-techniques in the laboratory, and non-invasive monitoring where possible.The use of CMV-seronegative blood products for transfusion in low birth weight neonates is not deemed necessary. The primary rationale is that the risk of transfusion-transmitted infections should be reduced by stringent screening of donors, restrictive transfusion practice and certain interventions like irradiation of blood units before transfusion. A recent international survey of transfusion practices for extremely premature infants showed that factors considered “very important” regarding the need to administer blood transfusions included degree of oxygen requirement and need for respiratory support. Donor exposure can also be reduced by allocating single donor units, split into paedipacks, to babies predicted to need more than one transfusion episode within the expiry date of the donation. Implementing a program to improve compliance with neonatal intensive care unit transfusion guidelines was accompanied by a reduction in transfusion rate. The implementation of guidelines to improve compliance with neonatal intensive care unit transfusion guidelines can also reduce the transfusion rate.

Haemoglobin thresholds for transfusion: how are we doing in the era of Choosing Wisely? A retrospective cohort study.

Clinical practice guidelines and the Choosing Wisely initiative launched in 2012 recommend a haemoglobin (Hb) threshold of 70-80 g/lfor red blood cell (RBC) transfusions in stable hospitalised patients. Data on transfusion practices and their trends in medical inpatients are limited. To address this gap, we investigated transfusion practices and their trends in general internal medicine and other clinics. This retrospective cohort study analysed data from all hospitalisations with RBC transfusions at a Swiss university hospital between 2012 and 2019. We included all first transfusion episodes if pretransfusion Hb was available. The primary endpoint was mean pretransfusion Hb; secondary endpoints included potentially inadequate transfusions (i.e., transfusions at Hb ≥80 g/l) and receipt of a single RBC unit. Trends in mean pretransfusion Hb over time were estimated using generalised estimating equations, and risk factors for potentially inadequate transfusions were identified using multivariable adjusted generalised estimating equations models. Of 14,598 hospitalisations with RBC transfusions, 1980 (13.6%) were discharged from general internal medicine. From 2012 to 2019, mean pretransfusion Hb decreased from 74.0 g/l to 68.8 g/l in general internal medicine (mean annual decrease -0.76 g/l, 95% confidence interval [CI] -0.51 to -1.02) and from 78.2 g/l to 72.7 g/l in other clinics (mean annual decrease -0.69, 95% CI -0.62 to -0.77; p for interaction 0.53). The overall proportion of potentially inadequate transfusions was 17.8% in general internal medicine and 24.1% in other clinics (p <0.001) and decreased over the study period from 26.9% to 5.5% in general internal medicine and from 37.0% to 15.2% in other clinics. In contrast, the proportion of cases receiving a single RBC unit increased (39.5% to 81.4% in general internal medicine, 42.7% to 66.1% in other clinics). Older age (adjusted odds ratio [aOR] 1.45, 95% CI 1.32-1.58 for ≥65 vs <65 years), having surgery (aOR 1.24, 95% CI 1.14-1.36), acute haemorrhage (aOR 1.16, 95% CI 1.02-1.33), chronic heart failure (aOR 1.17, 95% CI 1.04-1.32), ischaemic heart diseases (aOR 1.27, 95% CI 1.15-1.41), chronic pulmonary diseases (aOR 1.24, 95% CI 1.08-1.42), malignancy (aOR 1.11, 95% CI 1.01-1.21), and rheumatic disease (aOR 1.27, 95% CI 1.01-1.59) were risk factors for potentially inadequate transfusions. More restrictive transfusion practices were adopted in general internal medicine and other clinics over time, suggesting that guideline recommendations and the Choosing Wisely initiative may have been increasingly followed. Interventions to reduce potentially inadequate transfusions should target providers who care for older patients and those with surgery or chronic cardiac and pulmonary diseases.

Using blood wisely in oncology patients: An institutional experience implementing Choosing Wisely Canada restrictive transfusion practices.

382 Background: Using Blood Wisely is a national Choosing Wisely Canada (CWC) initiative that challenges hospitals to benchmark themselves on evidence-informed restrictive transfusion strategies, with the aim to decrease inappropriate red blood cell (RBC) transfusions in Canada. We previously assessed transfusion practices among oncology patients at BC Cancer Vancouver during a 12-month period. Here we present the results of a second audit, after implementation of quality improvement (QI) interventions. Methods: BC Cancer Vancouver RBC transfusion records were obtained for the periods of October 2019-September 2020 and April 2021-March 2022. The percentage of transfusions that were single-unit or for hemoglobin (Hg) ≤80 g/L were measured to assess adherence to CWC targets of ≥65% and ≥80%, respectively, for these metrics. QI interventions were implemented after the first audit, including staff education (grand rounds presentation, sitewide email bulletin) and direct engagement of ordering physicians by nursing staff. Uni- and multivariate analyses were used to test associations between patient characteristics and transfusion outcomes. Results: Single-unit transfusions increased from 41% in inpatients (49/120) and 12% in outpatients (69/586) in the first audit, to 86% (126/146) in inpatients ( P&lt;0.001) and 34% (170/495) in outpatients ( P&lt;0.001) in the second audit. Transfusions for Hg ≤80 g/L increased from 79% (95/120) in inpatients and 66% (384/586) in outpatients, to 93% (136/146) in inpatients ( P=0.001) and 78% (384/495) in outpatients ( P&lt;0.001). Patient factors associated with restrictive transfusion practices included inpatient status and having a hematological malignancy. Conclusions: In the face of fluctuating RBC shortages, interventions aimed at high-use populations like oncology patients are crucial to reducing transfusion overuse. Through education and prescriber engagement, we successfully reduced the rate of inappropriate RBC transfusions at our institution and achieved the status of a designated Using Blood Wisely Hospital.[Table: see text]

IRON NOF trial: IV iron for anaemic patients with femoral fracture

BackgroundPreoperative anaemia is associated with increased use of blood transfusions, a greater risk of postoperative complications, and patient morbidity. The IRON NOF trial aimed to investigate whether the administration of i.v. iron in anaemic patients during hip fracture surgery reduced the need for blood transfusion and improved patient outcomes. MethodsThis phase III double-blind, randomised, placebo-controlled trial included patients >60 yr old with preoperative anaemia undergoing surgery for femoral neck or subtrochanteric fracture across seven Australian Hospitals. Patients were randomly allocated on a 1:1 basis to receive either i.v. iron carboxymaltose 1000 mg or placebo (saline) at operation. The primary endpoint was blood transfusion use, with secondary endpoints of haemoglobin concentration at 6 weeks, length of hospital stay, rehabilitation duration to discharge, and 6-month mortality. Subgroup analysis compared outcomes in patients <80 yr old and patients >80 yr old. All analyses were performed by intention-to-treat. This trial was terminated early because of jurisdictional changes of more restrictive transfusion practices and changes in consent requirements. ResultsParticipants (n=143) were recruited between February 2013 and May 2017. There was no difference observed in the incidence of blood transfusion between the treatment group (18/70) (26%) compared with the placebo group (27/73) (37%) (odds ratio for transfusion if receiving placebo: 1.70; 95% confidence interval [CI] 0.83–3.47; P=0.15) and there was no overall difference in the median number of blood units transfused between groups (odds ratio 1.52; 95% CI 0.77–3.00; P=0.22). Patients receiving i.v. iron had a higher haemoglobin 6 weeks after intervention compared with the placebo group (Hb 116 g L−1vs 108 g L−1; P=0.01). No difference was observed in length of hospital stay, rehabilitation duration to discharge, or 6-month mortality. However, in younger patients without major bleeding, the use of placebo compared with i.v. iron was associated with an increased number of units of blood transfused (placebo transfusion incidence rate ratio 3.88; 95% CI 1.16–13.0; P=0.03). ConclusionsIn anaemic patients undergoing surgery for hip fracture, i.v. iron did not reduce the overall proportion of patients receiving blood transfusion. The use of i.v. iron may reduce the amount of blood transfused in younger patients. The use of i.v. iron is associated with increased haemoglobin concentrations 6 weeks after the operation. Clinical trial registrationACTRN12612000448842.

Prevalence and determinants of anemia at discharge in pediatric intensive care survivors.

Restrictive transfusion practices are increasingly being followed in pediatric intensive care units (PICU); consequently, more patients are discharged anemic from PICU. Given the possible impact of anemia on long-term neurodevelopmental outcomes, we aim to describe the epidemiology of anemia at PICU discharge in a mixed (pediatric and cardiac) cohort of PICU survivors and to characterize risk factors for anemia. We performed a retrospective cohort study in the PICU of a multidisciplinary tertiary-care university-affiliated center. All consecutive PICU survivors for whom a hemoglobin level was available at PICU discharge were included. Baseline characteristics and hemoglobin levels were extracted from an electronic medical records database. From January 2013 to January 2018, 4750 patients were admitted to the PICU (97.1% survival); discharge hemoglobin levels were available for 4124 patients. Overall, 50.9% (n= 2100) were anemic at PICU discharge. Anemia at PICU discharge was also common in the cardiac surgery population (53.3%), mainly in acyanotic patients; only 24.6% of cyanotic patients were anemic according to standard definitions of anemia. Cardiac surgery patients were transfused more often and at higher hemoglobin levels than medical and non-cardiac surgery patients. Anemia at admission was the strongest predictor of anemia at discharge (odds ratios (OR): 6.51, 95% confidence interval (CI:5.40;7.85)). Half of PICU survivors are anemic at discharge. Further studies are required to determine the course of anemia after discharge and to ascertain whether anemia is associated with adverse long-term outcomes.

Community-Based Hospitals Benefit From Restrictive Transfusion Practices.

Blood availability was uncertain during the COVID-19 pandemic, yet transfusion remained a common and sometimes necessary procedure. Substantial work on optimizing transfusion practices is centered in tertiary hospitals as high utilizers of blood while the care delivered in smaller community hospitals comprises more than half the nation's transfusions. Improving transfusion practices in community hospitals represents a substantial opportunity to enhance patient safety and the availability of blood resources. Clinical specialists developed a dashboard to retrospectively examine transfusion events including an evidence-based analysis of the patient's clinical situation at the time of transfusion to more accurately identify how appropriately blood was used. The compiled data were discussed and shared with transfusing providers. It was hypothesized that the data provided and communication strategies used would educate providers to current evidence-based practice, leading to more appropriate transfusion with an overall reduction in packed red blood cell utilization. There was an 11% increase in transfusion appropriateness (p = <.001) and a 14% decrease in the units transfused (p = .004). Improvement in transfusion practices demonstrates a significant impact on patient safety and the availability of blood resources. Although absolute opportunity may be less in a community hospital, fewer resources are needed to achieve meaningful change.

Editor's Choice Articles for February.

Editor's Choice Articles for February.

The Impact of Restrictive Transfusion Practices on Hemodynamically Stable Critically Ill Children Without Heart Disease: A Secondary Analysis of the Age of Blood in Children in the PICU Trial.

Guidelines recommend against RBC transfusion in hemodynamically stable (HDS) children without cardiac disease, if hemoglobin is greater than or equal to 7 g/dL. We sought to assess the clinical and economic impact of compliance with RBC transfusion guidelines. A nonprespecified secondary analysis of noncardiac, HDS patients in the randomized trial Age of Blood in Children (NCT01977547) in PICUs. Costs analyzed included ICU stay and physician fees. Stabilized inverse propensity for treatment weighting was used to create a cohort balanced with respect to potential confounding variables. Weighted regression models were fit to evaluate outcomes based on guideline compliance. Fifty international tertiary care centers. Critically ill children 3 days to 16 years old transfused RBCs at less than or equal to 7 days of ICU admission. Six-hundred eighty-seven subjects who met eligibility criteria were included in the analysis. Initial RBC transfusions administered when hemoglobin was less than 7 g/dL were considered "compliant" or "non-compliant" if hemoglobin was greater than or equal to 7 g/dL. Frequency of new or progressive multiple organ system dysfunction (NPMODS), ICU survival, and associated costs. The hypothesis was formulated after data collection but exposure groups were masked until completion of planned analyses. Forty-nine percent of patients (338/687) received a noncompliant initial transfusion. Weighted cohorts were balanced with respect to confounding variables (absolute standardized differences < 0.1). No differences were noted in NPMODS frequency (relative risk, 0.86; 95% CI, 0.61-1.22; p = 0.4). Patients receiving compliant transfusions had more ICU-free days (mean difference, 1.73; 95% CI, 0.57-2.88; p = 0.003). Compliance reduced mean costs in ICU by $38,845 U.S. dollars per patient (95% CI, $65,048-$12,641). Deferring transfusion until hemoglobin is less than 7 g/dL is not associated with increased organ dysfunction in this population but is independently associated with increased likelihood of live ICU discharge and lower ICU costs.

Did Physicians Have a Role to Play in National Blood Crisis?

Background: The pandemic of COVID-19 (Coronavirus disease 2019) impacted the practices of blood product procurement and transfusion in multiple ways, including failed blood donation drives, staffing limitations and low donor turnout. On January 1, 2022, the American Red Cross declared the worst national blood crisis in over a decade. The effect was most notable on the community medical centers with limited resources in securing products for blood transfusion. However, evidence is lacking for the usage of blood products in a community teaching hospital during this pandemic. Study Design and Methods: We aimed to contrast the adherence to restrictive transfusion practice in the COVID era with the pre-COVID era irrespective of COVID-19 diagnosis. We performed a retrospective observational study involving packed red blood cell (PRBC) transfusions in patients from June 2020 to August 2020 (COVID era) and September 2019 to November 2019 (pre-COVID era). Patients with hemoglobinopathies were excluded. A detailed chart review to include the number of PRBC transfusions, documented indication for transfusion and it was also determined if transfusions met restrictive blood transfusion criteria (as per guidelines from the Association for the Advancement of Blood & Biotherapies (AABB)) (Table 1). Demographic data included age, gender, history of coronary artery disease (CAD) or prior gastrointestinal bleed, use of antiplatelet and anticoagulation, use of deep vein thrombosis prophylaxis inpatient, and diagnosis on admission. Chi-square was applied to test the statistical association between qualitative variables and Unpaired t-test/Mann Whitney U test was applied to test the mean difference of quantitative. The level of significance was set at 5%. Results: A total of 215 patients were screened and 208 met our inclusion criteria. There were 108 PRBC transfusions in the COVID era group and 100 PRBC transfusions in the pre-COVID era group, with equal distribution in both groups for age, sex, ethnicity and prior gastrointestinal bleed. The leading diagnosis on admission in both COVID era and pre-COVID era groups was acute hypoxia (53.7% and 36% p<0.001), followed by gastrointestinal bleeding. Lower proportion of patients receiving transfusion were on anticoagulant or antiplatelet therapy in COVID era group as compared to pre-COVID era (antiplatelet: 6.2% vs 19%, p<0.001 and anticoagulant: 12.1% vs 27%, p<0.001), though COVID era group had lower fraction of patients receiving pharmacological prophylaxis for deep vein thrombosis (DVT) (13.9% vs 29%, p<0.001). There was a higher percentage of transfusions in critical care units in the COVID era group than pre-COVID era group (38.9% vs 22%, p<0.008). Documented indications for transfusions in both groups were hemoglobin < 7 (47.2% vs 43%), acute coronary syndrome (ACS) or history of CAD (12% vs 11%), active bleed (35.2% vs 35%) and down trending hemoglobin (5.6% vs 11%). Restrictive transfusion criteria were met in only 67% vs 79% in COVID era and pre-COVID era transfusion cases respectively (p=0.008). Subgroup analysis of documented indications for transfusion among both groups is displayed in Graph 1. Conclusions: As evident from our results, the COVID era group despite having comparable, if not fewer risk factors associated with blood loss, received blood transfusion with less stringent adherence to restrictive blood transfusion guidelines. COVID pandemic had a significant impact on the landscape of blood transfusion and our study brought to light the physician's role in more liberal use of blood products. Due to a higher number of critical care admissions and the morbidity/mortality during this pandemic, compel physicians to have a more liberal mindset towards blood transfusions. However, given the acute shortage of blood products it is vital that we adhere to restrictive blood transfusion guidelines. In view of the ongoing National Blood Crisis, please visit RedCrossBlood.org or call 1-800-RED CROSS (1-800-733-2767) to donate blood. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Development of necrotizing enterocolitis after blood transfusion in very premature neonates.

Prior studies report conflicting evidence on the association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC), especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life (DOL) 14 in verypremature neonates. A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14. Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis, discharge, or death. Wilcoxon ranked-sum and Fisher's exact tests, Cox proportional hazards regression, and Kaplan-Meier curves were used to analyze data. Of 549 premature neonates, 186 (34%) received transfusions after DOL 14 and nine (2%) developed NEC (median DOL = 38; interquartile range = 32-46). Of the nine with NEC after DOL 14, all were previously transfused (P < 0.001); therefore, hazard of NEC could not be estimated. Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14, and the hazard of NEC increased by a factor of nearly six after PRBC transfusion (hazard ratio = 5.76, 95% confidence interval = 1.02-32.7; P = 0.048). Transfusions were strongly associated with NEC after DOL 14. Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.

Mathematical analysis of hemoglobin target in univentricular parallel circulation

ObjectiveThe hemoglobin threshold for a decision to transfuse red blood cells in univentricular patients with parallel circulation is unclear. A pediatric expertise initiative put forth a “weak recommendation” for avoiding reflexive transfusion beyond a hemoglobin of 9 g/dL. We have created a mathematical model to assess the impact of hemoglobin thresholds in patients with parallel circulation. MethodsA univentricular circulation was mathematically modeled. We examined the impact on oxygen extraction ratios and systemic and venous oxygen saturations by varying hemoglobin levels, pulmonary to systemic blood flow ratios, and total cardiac output. ResultsApplying a total cardiac index of 6 L/m2/min, oxygen consumption of 150 mL/min/m2, and a Qp/Qs ∼ 1, we found a hemoglobin level of 9 g/dL would lead to severe arterial (arterial oxygen saturation <70%) and venous (systemic venous oxygen saturation <40%) hypoxemia. To operate above the critical oxygen economy boundary (systemic venous oxygen saturation ∼40%) and maintain arterial oxygen saturation >70% would require either increasing the cardiac index to ∼ 9 L/m2/min or increasing the hemoglobin to greater than 13 g/dL. Further, we found a greater improvement in arterial and venous saturation arises when hemoglobin is augmented from levels below 12 g/dL. ConclusionsBased on our model, a hemoglobin level of 9 g/dL would require a constricted set of features to sustain arterial saturations >70% and systemic venous saturations >40% and would risk unfavorable oxygen economy with elevations in oxygen consumption. Further prospective clinical studies are needed to delineate the impact of restrictive transfusion practices in univentricular circulation.

Perioperative blood transfusion in major abdominal cancer surgery: a multi-centre service evaluation and national survey.

Anaemia is associated with complications and death after surgery. Perioperative red-cell transfusion triggers are not well defined in patients having oncological surgery, or with cardiovascular disease. We carried out a prospective multicentre cohort study and a clinician survey of UK transfusion practice in adult patients undergoing surgery for abdominal malignancy. The primary outcome was red cell transfusion. Secondary outcomes were transfusion trigger haemoglobin, incidence of complications, length of hospital stay, and acute hospital mortality. In this prospective cohort study, data were collected on 412 patients undergoing surgery for intrabdominal malignancy in 14 NHS hospitals. Twenty-two (5.2%) patients received preoperative, 42 (10.2%) intraoperative, and 52 (12.2%) postoperative red blood cell transfusion. The mean postoperative transfusion trigger was 75.3 g L-1, and the mean number of units of red blood cells transfused was 1.5 (standard deviation, 1.1). Seventeen (4.0%) patients had a documented postoperative troponin elevation. Five (1.2%) patients died within 30 days of surgery. In the survey, 117 clinicians submitted complete responses, of whom 62 (53%) indicated that a transfusion threshold of 70 g L-1 was appropriate: however, this decreased to six (5.1%) if there was evidence of recent cardiac ischaemia. There were 100 (86%) respondents who indicated equipoise for a trial of restrictive vs liberal transfusion, decreasing to 56% if there was coexisting cardiovascular disease. Many patients having oncological surgery receive red cell transfusion, the majority being given postoperatively. Restrictive transfusion practice is generally followed; however, variability exists especially in cardiovascular disease. Equipoise exists for a study of transfusion thresholds in this group.

Changing red blood cell transfusion practice in obstetrics and gynaecology: A before and after study of hospital-wide education.

To assess transfusion practices at a Canadian tertiary care center before and after a hospital-wide blood management educational campaign based on the Choosing Wisely toolkit. Red blood cell (RBC) transfusions are an essential intervention in obstetrics and gynaec ology (O&G). However, with limited guidelines outlining the appropriate use of RBC transfusions, clinicians routinely transfuse based on haemoglobin values and habits. We conducted a retrospective chart review of all patients who received a RBC transfusion while admitted under an O&G provider in two 12-month periods-before and after the intervention. The campaign consisted of Grand Rounds, formal and informal teaching, and posters placed within the hospital. We judged appropriateness from a set of criteria guided by the status of ongoing bleeding, pre-transfusion haemoglobin, and the number of units ordered simultaneously. Transfusion appropriateness was poor in pre- and post-intervention periods (46% vs. 51%, p=0.59). The overall rate of RBC transfusion was reduced from 1.8% to 1.2% (83/4610 vs. 55/4618, p=0.02) after the intervention. There was a 52% reduction in the total number of RBC units of transfused (229 vs. 111, p < 0.001), a 33% reduction in the number of patients transfused (83 vs. 55, p=0.016), and fewer multiple-unit transfusions without reassessment (39 vs. 13, p=0.005). RBC transfusion appropriateness remained low after a hospital-wide educational campaign. However, there was a marked decrease in overall transfusion use, reflecting the adoption of more restrictive transfusion practices. The low rate of transfusion appropriateness represents an opportunity for further improvement.

Predictors and Outcomes of Postoperative Hemoglobin of

Restrictive transfusion practices have decreased transfusions in total joint arthroplasty (TJA). A hemoglobin threshold of <8 g/dL is commonly used. Predictors of this degree of postoperative anemia in TJA and its association with postoperative outcomes, independent of transfusions, remain unclear. We identified predictors of postoperative hemoglobin of <8 g/dL and outcomes with and without transfusion in TJA. Primary elective TJA cases performed with a multimodal blood management protocol from 2017 to 2018 were reviewed, identifying 1,583 cases. Preoperative and postoperative variables were compared between patients with postoperative hemoglobin of <8 and ≥8 g/dL. Logistic regression and receiver operating characteristic curves were used to assess predictors of postoperative hemoglobin of <8 g/dL. Positive predictors of postoperative hemoglobin of <8 g/dL were preoperative hemoglobin level (odds ratio [OR] per 1.0-g/dL decrease, 3.0 [95% confidence interval (CI), 2.4 to 3.7]), total hip arthroplasty (OR compared with total knee arthroplasty, 2.1 [95% CI, 1.3 to 3.4]), and operative time (OR per 30-minute increase, 2.0 [95% CI, 1.6 to 2.6]). Negative predictors of postoperative hemoglobin of <8 g/dL were tranexamic acid use (OR, 0.42 [95% CI, 0.20 to 0.85]) and body mass index (OR per 1 kg/m2 above normal, 0.90 [95% CI, 0.86 to 0.94]). Preoperative hemoglobin levels of <12.4 g/dL in women and <13.4 g/dL in men best predicted postoperative hemoglobin of <8 g/dL. Overall, 5.2% of patients with postoperative hemoglobin of 7 to 8 g/dL and 95% of patients with postoperative hemoglobin of <7 g/dL received transfusions. Patients with postoperative hemoglobin of <8 g/dL had longer hospital stays (p < 0.001) and greater rates of emergency department visits or readmissions (p = 0.001) and acute kidney injury (p < 0.001). Among patients with postoperative hemoglobin of <8 g/dL, patients who received transfusions had a lower postoperative hemoglobin nadir (p < 0.001) and a longer hospital stay (p = 0.035) than patients who did not receive transfusions. Postoperative hemoglobin of <8 g/dL after TJA was associated with worse outcomes, even for patients who do not receive transfusions. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Discharging Patients with Low Hemoglobin Levels on Hospital Readmission and Quality of Life after Adult Spinal Deformity Surgery

Study DesignRetrospective cohort.PurposeThis study aims to evaluate the impact of anemia on functional outcomes, health-related quality of life (HRQoL), and early hospital readmission (EHR) rates after adult spinal deformity (ASD) surgery at the time of discharge from the hospital.Overview of LiteratureConcerns with risks of transfusion, insufficient evidence for its benefits, and the possibility of associated adverse outcomes have led to restrictive transfusion practices. Therefore, patients are discharged according to patient blood management programs that are implemented in hospitals nationwide to reduce unnecessary blood transfusions. However, not many comprehensive kinds of studies exist on the effect of postoperative anemia on functional life and complications.MethodsAnemia severity was defined following the 2011 World Health Organization guidelines. All patients had HRQoL tests as well as complete blood counts pre- and postoperatively. EHR is the admission within 30 days of discharge and was used as the dependent parameter.ResultsThis study comprised 225 surgically treated ASD patients with a median age of 62.0 years, predominantly women (80%). Of the 225 patients, 82, 137, and six had mild, moderate, and severe anemia at the time of discharge, respectively. Seventeen of the patients (mild [11, 64.7%]; moderate [5, 29.4%]; severe [1, 5.9%]) were readmitted within 30 days. The mean hemoglobin values were higher in readmitted patients (p=0.071). Infection was the leading cause of readmission (n=12), but a low hemoglobin level was not observed in any of these patients at the time of discharge. Except for Scoliosis Research Society-22 questionnaire, HRQoL improvements did not reach statistical significance in early readmitted patients in the first year after surgery.ConclusionsThe results of this study demonstrated that the occurrence and the severity of postoperative anemia are not associated with EHR in surgically treated patients with ASD. The findings of the current research suggested that clinical awareness of the parameters other than postoperative anemia may be crucial. Thus, improvements in HRQoL scores were poor in early readmitted patients 1 year after surgery.

274 Healthcare resource utilization associated with a risk-based thromboprophylaxis protocol in obstetric patients

Venous thromboembolism (VTE) is a preventable cause of maternal morbidity and death. Guidelines advise a risk-based approach to mechanical and pharmacologic VTE prophylaxis (ppx) in obstetric patients, yet routine use of prophylactic, heparin-based anticoagulation is largely unstudied in this population. Our institution adopted a risk-based protocol for heparin-based VTE ppx in obstetric patients in 2016 (Table 1); we evaluated the impact of this protocol on healthcare resource utilization. Retrospective cohort study of all deliveries at a single tertiary-care center from 2013-2018. Deliveries were categorized as pre- (2013-2015; no standardized heparin ppx) and post-protocol (2016-2018; Table 1). Patients receiving anticoagulation for active VTE or high VTE risk were excluded. Healthcare resource utilization outcomes included anticoagulation use, blood transfusion, readmissions, maternity triage visits, imaging tests, and hematologic laboratory studies performed (Table 2). Pre- and post-protocol outcomes were compared with student’s t-, χ2, and Fisher’s exact tests; adjusted odds ratios (95%CI) were calculated with the pre-protocol cohort as reference. Of 24,229 total deliveries, 11,799 (49%) were pre-, and 12,430 (51%) post-protocol. There was a 15-fold increase in anticoagulation use after protocol adoption (15.6% vs 1.2%, p<0.001). This was associated with significantly more red blood cell transfusions (3.8% vs 2.9%, p<0.001) despite more restrictive transfusion practices. Except for an increase in postpartum platelet studies related to institutional platelet monitoring in heparinized women (18.6% vs 15.4%, p<0.001), no significant changes were seen in utilization of any other resources (Table 2). A risk-based protocol for heparin-based ppx is associated with more anticoagulation administration, platelet studies, and blood transfusions. Further studies are needed to evaluate resource allocation versus safety and efficacy of routine risk-based obstetric VTE ppx.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

59 Safety and efficacy of a risk-based obstetric heparin-based thromboprophylaxis regimen

Contemporary guidelines recommend a risk-based approach to obstetric venous thromboembolism (VTE) prophylaxis (ppx), yet routine use of heparin-based ppx in obstetric patients is understudied. We examined the efficacy and safety of a risk-based protocol for heparin-based VTE ppx in obstetric patients. Retrospective cohort study of all deliveries at a single center from 2013-2018. Deliveries were categorized as pre- (2013-2015; no standard ppx) and post-protocol (2016-2018; risk-based protocol with heparin-based ppx). Patients anticoagulated for active VTE or high VTE risk were excluded. The primary efficacy outcome was diagnosis of any postpartum VTE; the primary safety outcome was any wound hematoma (other outcomes in Table 2). Outcomes were compared between pre- and post-protocol groups; adjusted odds ratios (95% CIs) were calculated using the pre-protocol group as reference. Numbers needed to treat (NNT) and harm (NNH) were assessed for VTE and wound hematoma, respectively. Of 24,229 total deliveries, 11,799 (49%) were pre-, and 12,430 (51%) were post-protocol. Baseline characteristics are presented in Table 1. Despite 15-times more anticoagulation use post-protocol (Table 2), there was no significant difference in VTE rate (0.1% vs 0.1%, NNT 61,713). Post-protocol, risk of wound hematomas (particularly superficial hematomas) significantly increased 2-fold (aOR 2.3 [1.5-3.6], NNH 333), as did unplanned procedures and blood transfusions despite more restrictive institutional transfusion practices post-protocol (Table 2). Interaction tests indicated no differences by mode of delivery (cesarean vs. vaginal) for VTE (p=0.24) or hematoma (p=0.31). Adoption of a risk-based anticoagulation protocol for obstetric VTE ppx was associated with increased wound hematomas, unplanned procedures, and blood transfusions without decreased VTEs. Given that, for every 60,000 obstetric patients under this protocol needed to prevent 1 VTE, there were an associated 180 wound hematomas, routine risk-based anticoagulation for VTE ppx in obstetric patients should be strongly reconsidered.View Large Image Figure ViewerDownload Hi-res image Download (PPT)