Transfusion Risk Score Research Articles

Development and Validation of a Predictive Risk Score for Blood Transfusion in Patients Undergoing Curative-Intent Surgery for Intrahepatic Cholangiocarcinoma.

Among patients undergoing liver resection for intrahepatic cholangiocarcinoma (ICC), perioperative bleeding requiring blood transfusion is a common complication, yet preoperative identification of patients at risk for transfusion remains challenging. The objective of this study was to develop a preoperative risk score for blood transfusion requirement during surgery for ICC. Patients undergoing curative-intent liver surgery for ICC (1990-2020) were identified from a multi-institutional database. A predictive model was developed and validated. An easy-to-use risk calculator was made available online. Among 1420 patients, 300 (21.1%) received an intraoperative transfusion. Independent predictors of transfusion included severe preoperative anemia (OR = 1.65, 95% CI 1.10-2.47), T2 category or higher (OR = 2.00, 95% CI 1.36-3.02), positive lymph nodes (OR = 1.75, 95% CI 1.32-2.32) and major resection (OR = 2.56, 95%CI 1.85-3.58). Receipt of blood transfusion significantly correlated with worse outcomes. The model showed good discriminative ability in both training (AUC = 0.68, 95% CI 0.66-0.72) and bootstrapping validation (C-index = 0.67, 95% CI 0.65-0.70) cohorts. An online risk calculator of blood transfusion requirement was developed (https://catalano-giovanni.shinyapps.io/TransfusionRisk). Intraoperative blood transfusion was significantly associated with poor postoperative outcomes among patients undergoing surgery for ICC. The identification of patients at high risk of transfusion could improve perioperative patient care and blood resources allocation.

Les anémies aiguës et la stratégie transfusionnelle chez les drépanocytaires adultes: Acute anemias transfusion strategy in adult sickle cell patients

Worsening of anemia is very common in sickle cell disease. It is important to investigate specific complications related to sickle cell disease but also other causes of anemia in general. Transfusions or exchange transfusions are major therapeutic options and are frequently used for acute complications of sickle cell disease but also for primary and secondary prevention of some of the chronic complications. The transfusion strategy has been modified since the awareness of post-transfusion hemolysis by taking into account the transfusion risk score. A strong collaboration between the patient's expert center, the Blood center and the patient's hospitalization unit is required to make decisions. © 2023 Société nationale française de médecine interne (SNFMI). Published by Elsevier Masson SAS. All rights reserved.

Towards optimized red blood cells ordering prior to cardiac surgery: a single center retrospective study

Background: Cardiac surgery is associated with a high rate of intraoperative transfusion, requiring pre- ordering or ordering of packed red blood cell (PRBC) before surgery. Our institutional strategy is based on a systematic type and screen (T/S) ordering of 3 PRBCs at the blood bank then stored in a dedicated refrigerator in the operating room for each patient scheduled for cardiac surgery. However, these PRBC units are not always transfused and are therefore at risk of destruction if temperature fluctuations are detected during transport and storage processes. In addition, these orders represent a burden for the blood bank. Therefore, it is relevant to move towards a more tailored PRBC order before cardiac surgery and challenge the systematic ordering protocol. Methods: The Transfusion Understanding Scoring Tool (TRUST) and the Transfusion Risk and Clinical Knowledge (TRACK) Score are designed to stratify blood transfusion needs in cardiac surgery. We retrospectively performed both scores for each patient scheduled for cardiac surgery. Then, we compared their performance to predict PRBC transfusion and determined the optimal threshold to optimize the preoperative PRBC order reflecting the needs of our population managed with our local standards. Results: Receiver operating characteristic (ROC) curves for prediction of PRBC transfusion using the two scores were computed for the whole cohort (n=1249). Both scores performed well (areas under ROC curves: 0.81 and 0.82 (95% CI) using the TRACK Score and the TRUST, respectively). A TRUST < 3 identified a subgroup of patients (53.6%) at low risk of transfusion. The availability of 1 T/S PRBC in the OR would cover the needs of the majority (92.5%) of this group. Conclusions: In our institution, the use of the TRUST preoperatively could offer a more tailored T/S PRBC order for the intraoperative period, especially in the low-risk transfusion group.

Single shot of intravenous iron in cardiac surgery: The ICARUS study

BackgroundIron deficiency (ID), with or without anemia, is commonly observed among patients scheduled for cardiac surgery. We investigated if screening ID in the immediate preoperative period and treating ID patients regardless of anemia could reduce perioperative transfusion requirements. MethodsThis is an observational single-center propensity score-matched study including candidates to elective cardiac surgery prospectively and retrospectively enrolled. Prospectively enrolled patients were screened for ID at hospital admission: if ferritin was ≤100 μg/L or ≤ 300 μg/L with transferrin saturation index ≤20% they received intravenous ferric carboxymaltose, B12-vitamin, and folic acid. A retrospective series of patients not screened for ID and matched for gender, type of surgery, BMI, Goudie transfusion risk score, hemoglobin level, and red blood cell (RBC) indices, served as controls. The primary outcome was the proportion of patients requiring ≤1 packed RBC (pRBC) unit within day 7 or discharge The main secondary outcomes were intraoperative and postoperative pRBC transfusions, duration of hospitalization, and cost-effectiveness of ID screening and treatment. ResultsWe included 479 prospective and 833 retrospective cases: 442 patients screened for ID and 442 matched controls with unknown iron status were analyzed. ID was observed in 196 patients (44.3%) and iron was administered 1 day (IQR 1–2) before surgery. Overall, 76.9% of patients in the prospective group and 69.7% of controls received ≤1 pRBC transfusion (p = 0.014). The risk for multiple transfusions was lower in patients screened for ID (OR 0.689, 95% CI 0.510–0.930). Despite similar Hb levels at day 7, patients in the prospective group received fewer postoperative pRBC transfusions (p < 0.001) and had a shorter hospital length of stay (p < 0.001). Globally, hospitalization costs were lower in patients screened and treated for ID. ConclusionsShort-term pre-operative iron therapy is associated with a reduction in postoperative transfusions in anemic and non-anemic ID cardiac surgery patients and has a favorable impact on hospitalization costs. Clinical trial registrationNCT04744181

Poor utility of current nomograms assessing the risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma and proposal of a new model

BackgroundThe Memorial Sloan Kettering Cancer Center nomogram, the predictive scoring system of Yamamoto et al, and the 3-point transfusion risk score of Lemke et al are models used to determine the probability of receiving intraoperative blood transfusion in patients undergoing liver resection. However, the external validity of these models remains unknown. The objective of this study was to evaluate their predictive performance in an external cohort of patients with hepatocellular carcinoma. We also aimed to identify predictors of blood transfusion and develop a new predictive model for blood transfusion. MethodsPost hoc analysis of our prospective database of 1,081 patients undergoing liver resection for hepatocellular carcinoma from 2001 to 2018. The predictive performance of current prediction models was evaluated using C statistics. Demographic and clinical variables as predictors of blood transfusion were assessed. Using logistic regression, an alternative model was created. ResultsThe Lemke transfusion risk score performed better than the Memorial Sloan Kettering Cancer Center nomogram (0.69, 95% confidence interval 0.66–0.73 vs 0.66, 95% liver resection 0.62–0.69) (P < .001). The model from Yamamoto et al performed comparably with no statistically significant differences found through pairwise comparison. In our alternative model, hemoglobin level, albumin level, liver resection type, and tumor size were independent predictors of blood transfusion. The new HATS model obtained a C statistic of 0.74 (95% confidence interval 0.71–0.78), performing significantly better than the previous 3 models (P ≤ 0.001 for all). ConclusionThe existing Memorial Sloan Kettering Cancer Center, Yamamoto et al, and Lemke et al had nomograms with the suboptimal accuracy of predicting risk of intraoperative blood transfusion in patients undergoing liver resection for hepatocellular carcinoma. The proposed HATS model was more accurate at predicting patients at risk of blood transfusion.

Selective type & screen for elective colectomy based on a transfusion risk score may generate substantial cost savings.

Preoperative type and screen are currently recommended for all patients undergoing colectomy. We aimed to identify risk factors for transfusion and define a low-risk cohort of patients undergoing colectomy in whom type and screen may be safely avoided. We identified all patients undergoing elective colectomy in the National Surgical Quality Improvement Project-Targeted Colectomy files from 2012 to 2016. Patients transfused preoperatively and those undergoing other concurrent major abdominal procedures were excluded. We compared patients who received blood transfusion on the day of surgery to those who did not. Half of the cohort was randomly selected for development of a points-based model predicting blood transfusion on the day of surgery. This model was then validated using the remaining patients. Of 61,964 patients undergoing colectomy, 3128 (5%) patients were transfused with 1290 (2.1%) occurring on the day of surgery. Preoperative anemia was the strongest predictor of blood transfusion on the day of surgery. Among patients with hematocrit > 35%, day of surgery transfusion risk was 0.8%; 99% of patients with hematocrit > 35% had a score 20 or less. Selective type and screen for patients with score ≤ 20 or hematocrit > 35% would avoid type and screen in 91% and 81% of patients, respectively. Transfusion following elective colectomy is rare and can be accurately predicted by preoperative patient characteristics. Selective type and screen based on these parameters have the potential to prevent operative delays and lower cost.

External Validation of the ACTA-PORT Transfusion Risk Score in Older Cardiac Surgery Patients at Risk of Frailty

Accurate preoperative transfusion risk stratification may serve to better manage older patients undergoing cardiac surgery. Therefore, the aim of the present study was to externally validate the existing Association of Cardiothoracic Anesthetists perioperative risk of blood transfusion (ACTA-PORT) score in a population ≥70 years of age scheduled for cardiac surgery. Furthermore, the study authors investigated the additional prognostic value of individual frailty variables to this transfusion risk score. A retrospective analysis. At a tertiary-care hospital. Five hundred seven patients aged ≥70 years undergoing elective cardiac surgery from July 2015 to August 2017. None. The primary outcome was the administration of a perioperative blood transfusion. Frailty domains were assessed in a preanesthesia geriatric assessment, and a priori selection of biomarkers derived from blood was determined. The original ACTA-PORT score resulted in a c-statistic of 0.78 (95% confidence interval 0.74-0.82), with moderate calibration in predicting perioperative allogeneic transfusion in older patients undergoing cardiac surgery. Model updating, using the closed testing procedure, resulted in model revision with a higher discriminatory performance (c-statistic of 0.83, 95% confidence interval 0.79-0.86) and corrected calibration slope. Iron deficiency, impaired nutritional status, and physical impairment were associated with perioperative transfusions. The addition of individual frailty variables to the updated ACTA-PORT model did not result in improved predictive performance. External validation of the original ACTA-PORT score showed good discrimination and moderate calibration in older patients at risk of frailty undergoing cardiac surgery. Updating the original ACTA-PORT improved the predictive performance. Careful evaluation of additional frailty domains did not add prognostic value to the ACTA-PORT score.

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

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

Development and Validation of a Transfusion Risk Score for Patients Receiving Maintenance Hemodialysis.

In patients on dialysis with anemia, avoiding red blood cell transfusions is preferable. We sought to develop and validate a novel transfusion prediction risk score for patients receiving maintenance hemodialysis. This retrospective cohort study used United States Renal Data System data to create a model development cohort (patients who were point prevalent and on hemodialysis on November 1, 2012) and a validation cohort (patients who were point prevalent and on hemodialysis on August 1, 2013). We characterized comorbidity, inflammatory conditions, hospitalizations, anemia and anemia management, iron parameters, intravenous iron use, and vitamin D use during a 6-month baseline period to predict subsequent 3-month transfusion risk. We used logistic least absolute shrinkage and selection operator regression. In an exploratory analysis, model results were used to calculate a score to predict 6- and 12-month hospitalization and mortality. Variables most predictive of transfusion were prior transfusion, hemoglobin, ferritin, and number of hospital days in the baseline period. The resulting c-statistic in the validation cohort was 0.74, indicating relatively good predictive power. The score was associated with a significantly increased risk of subsequent mortality (hazard ratios 1.0, 1.22, 1.26, 1.54, 1.71, grouped from lowest to highest score), but not with hospitalization. We developed a transfusion prediction risk score with good performance characteristics that was associated with mortality. This score could be further developed into a clinically useful application, allowing clinicians to identify patients on hemodialysis most likely to benefit from a timely, proactive anemia treatment approach, with the goal of avoiding red blood cell transfusions and attendant risks of adverse clinical outcomes.

Developing a predictive risk score for perioperative blood transfusion: a retrospective study in patients with oral and oropharyngeal squamous cell carcinoma undergoing free flap reconstruction surgery.

BackgroundA simple and accurate scoring system to predict risk of blood transfusion in patients having surgical tumor resection with immediate free flap reconstruction primary surgery for oral and oropharyngeal squamous cell carcinoma (OOSCC) is lacking. Anticipating the blood transfusion requirements in patients with oral cancer is of great clinical importance. This research aimed to propose a valid model to predict transfusion requirements in patients undergoing surgery with free flap reconstruction for an OOSCC.MethodsThis retrospective study consisted of 385 patients who underwent oncologic surgery with immediate free flap reconstruction for locally advanced OOSCC from 2012 to 2019. The primary outcome measured was the exposure of patients to perioperative allogeneic blood transfusion. Based on a multivariate model of independent risk variables and their odds ratio, a blood transfusion risk score (TRS) was developed to predict the likelihood of the perioperative blood transfusion. The discriminatory accuracy of the model was evaluated using the area under the receiver operating characteristic (ROC) curve, and Youden index was used to identify the optimal cut-point.ResultsLogistic regression analyses identified lymph node status, preoperative hemoglobin (Hb) levels, bone resection, osseous free tissue transfer, and operative duration were identified as independent predictors of blood transfusion. A TRS integrating these variables was separated into three categories. The TRS assessed the transfusion risk with good predictive ability, with an overall area under the ROC curve (AUC) was 0.826. At the optimal cut-point of 5.5, the TRS had a sensitivity of 72.3% and a specificity of 78.2%. The ROC analysis showed that patients with a TRS of 5.5 or more had a greater requirement for perioperative transfusion.ConclusionsThe use of the integer-based TRS allowed the identification of high-risk patients who may require perioperative transfusion undergoing tumor resection surgery for the treatment of OOSCC.

Predictors and Outcomes of Pancreatic Fistula Following Pancreaticoduodenectomy: a Dual Center Experience.

Fistula following leaked pancreatico-enteric anastomosis is a common, potentially lethal complication of pancreaticoduodenectomy (PD). Early assessment and prediction of its occurrence can improve postoperative outcomes. Various perioperative factors were analyzed for its contribution to clinically relevant postoperative pancreatic fistula (crPOPF). Also, the difference in clinical outcomes of patients with and without fistula was studied. Sixty-seven patients undergoing PD for malignancies were analyzed during 3-year period in a dual-institutional study. Various preoperative, intraoperative, and postoperative factors were assessed. The incidence and severity of POPF and its association with the development of other post-PD complications were observed. Patients with and without POPF were divided into groups and compared with univariate and multivariate analyses, to identify significant contributing factors. Clinically relevant POPF was present in 20.9% cases. crPOPF contributed to delayed gastric emptying, albeit insignificant (p = 0.403), but was significantly associated with increased incidence of post-pancreatectomy hemorrhagic (p = 0.005) and infectious complications (p = 0.013). Soft pancreas (p = 0.024), intraoperative blood loss (p = 0.045), blood transfusion (p = 0.024), and fistula risk score (p = 0.001) were significant predictors of crPOPF. First postoperative day (POD1) drain fluid amylase (DFA) values at cut-off of 1336U/L (AUC = 0.871; p < 0.001) significantly predicted crPOPF with good sensitivity and specificity. POD1 DFA was only factor significant on multivariate analysis (p = 0.014). There was no significant difference in overall survival between groups. crPOPF results in significant post-pancreatectomy hemorrhagic and septic complications, along with increased mortality. It can be accurately predicted by several preoperative and intraoperative factors. POD1 DFA can independently predict crPOPF development.

Massive transfusion in upper gastrointestinal bleeding: a new scoring system

Background: Massive transfusion in patients with upper gastrointestinal bleeding (UGIB) was not investigated. We developed a new scoring system to predict massive transfusion and to enhance care and early resource mobilization.Methods: Massive transfusion was defined as transfusion with ≥10 units of red blood cells within the first 24 h. Data were extracted from a 10-year, six-hospital database. Logistic regression was applied to derive a risk score for massive transfusion using data from 2006 to 2010, in 24,736 patients (developmental cohort). The score was then validated using data from 2011 to 2015 in 27,449 patients (validation cohort). Area under the receiver operating characteristic (AUROC) curve was performed to assess prediction accuracy.Results: Five characteristics were independently associated (p < .001) with massive transfusion: presence of band-form cells among white blood cells (band form >0), international normalized ratio (INR) >1.5, pulse >100 beats per minute or systolic blood pressure <100 mmHg (shock), haemoglobin <8.0 g/dL and endoscopic therapy. The new scoring system successfully discriminated well between UGIB patients requiring massive transfusion and those who did not in both cohorts (AUROC: 0.831, 95%CI: 0.827–0.836; AUROC: 0.822, 95% CI: 0.817–0.826, respectively).Conclusions: The new scoring system predicts massive transfusion requirement in patients with UGIB well.Key messagesMassive transfusion is a life-saving management in massive upper gastrointestinal bleeding. How to identify patients requiring massive transfusion in upper gastrointestinal bleeding is poorly documented.Approximately 3.9% of upper gastrointestinal bleeding patients require massive transfusion.A new scoring system is developed to identify patients requiring massive transfusion with high accuracy.

55 – Selective Type & Screen for Elective Colectomy Based on a Transfusion Risk Score May Generate Substantial Cost Savings

55 – Selective Type & Screen for Elective Colectomy Based on a Transfusion Risk Score May Generate Substantial Cost Savings

Factors affecting blood loss and blood transfusion in patients with proximal humeral fractures

The aim of this study was to determine the amount of blood loss and the rateof blood transfusion in patients receiving surgery for proximal humeral fractures depending on the treatment and fracture classification. Moreover, factors associated with blood loss and blood transfusion were analyzed. The study included 420 patients who had received surgery for proximal humeral fractures. Data from medical records were collected retrospectively. The calculated blood loss and the transfusion rate were analyzed depending on the type of surgery (plate fixation, arthroplasty, and others) or the fracture classification (2-, 3-, and 4-part fractures). The extent of blood loss and the need for transfusion were correlated with potential risk factors. A score to estimate the probability of blood transfusion was developed. Average blood loss was 284 mL, and the transfusion rate was 14.5% for all proximal humeral fractures. Shoulder arthroplasty was associated with higher blood loss (353 mL, P < .01) and a higher blood transfusion rate (27.3%, P < .01) than plate fixation (263 mL and 10.9%, respectively). The fracture classification had no effect on either factor. Significant risk factors for blood loss were male sex, body mass index, surgery time, time until surgery, and vitamin K antagonists. Age, blood loss, American Society of Anesthesiologists score greater than 2, vitamin K antagonists, coronary artery disease (CAD), peripheral artery disease (PAD), and renal disease were associated with a higher transfusion rate. Blood loss could be affected by a shorter surgery time and by choosing an adequate time until surgery. The consideration of risk factors and the use of a transfusion risk score allow more elaborate ordering of cross-matched blood units and can decrease institutional costs.

Impact of intraoperative hypovolemic phlebotomy on blood loss and perioperative transfusion in patients undergoing hepatectomy for cancer

Background: Intraoperative blood loss (IOBL) and allogeneic blood transfusion are important determinants of outcome in patients undergoing elective hepatectomy for cancer. We assessed whether intraoperative hypovolemic phlebotomy (HP) used to perform hepatectomy under low central venous pressure (CVP) was associated with lower IOBL and perioperative transfusion rates, and whether these factors were linked to patient oncological outcomes. Methods: Restrospective analysis of a prospectively maintained database of consenting patients who underwent hepatectomy for primary and secondary liver malignancies between 01/2011 and 06/2017 in one academic center. Perioperative blood transfusion was defined as red blood cell unit transfused during hepatectomy until hospital discharge, and data were extracted from the hospital transfusion medicine database. We used the Fisher’s exact test to compare proportions, the Mann-Whitney or the Kruskal-Wallis tests to compare means, the Spearman r test for correlations, and Log Rank test and Cox regression for associations of variables with survival outcomes. Results: Intraoperative HP was used in 520 (76.0%) of the 684 patients included in this study. The median phlebotomy volume was 400 ml (range 50 to 900 ml), and median volume per patient weight was 5.3 ml/kg (range 0.5 to 30.1 ml/kg). Patients with large HP (>5.3 ml/kg) had lower IOBL than those with smaller HP (507 ml vs. 640.2 ml, p = 0.008). HP volume/weight was negatively correlated with IOBL (Spearman r = -0.11, p = 0.019). The perioperative transfusion rate was 14.6% in patients when HP was used, compared to 22.2% (p = 0.022) when HP was not used. The transfusion rate was lower in HP patients compared to non-HP patients even though more major hepatectomies (≥4 segments) (36.0% vs. 27.1%, p = 0.02) and less laparoscopic surgery (4.9% vs. 11.1%) were done in the HP group. Intraoperative HP reduced the perioperative transfusion risk by 8.9% (relative risk 0.91, 95% CI 0.82 to 0.99), and the number needed to treat to avoid one transfusion was 13 patients. The preoperative three-point transfusion risk score (hemoglobin 12.5 g/dl or less, primary liver malignancy, and resection of ≥ 4 liver segments) stratified patients by low vs. high transfusion requirements (13.3% if score 0 or 1 vs. 31% if score 2 or 3, p < 0.0001), irrespective of the use of HP. We did not find a significant association between IOBL or perioperative transfusions and recurrence-free or disease-specific survival. Conclusion: Intraoperative HP in patients undergoing hepatectomy was associated with lower IOBL and a perioperative transfusion rate of 14.6%, which was lower than non-HP patients and the 22% to 32% rate reported in contemporaneous series. Prospective studies with optimized preoperative hemoglobin level, standardized intraoperative hemostatic and fluid management methods, and defined perioperative transfusion criteria are needed to determine whether HP is superior to other anesthesiological techniques of low CVP for reducing IOBL and transfusion requirements.

PLATELET TRANSFUSION PREDICTION IN CARDIAC SURGERY

Impaired platelet function from cardiopulmonary bypass and the use of preoperative anti-platelet agents are important factors in cardiac surgery blood loss. Platelet transfusions are commonly used in the postoperative phase to mitigate bleeding, but subject’s patients to the risk of infection, alloimmunization and lung injury. Guidelines exist for platelet administration; however, there is significant transfusion variability amongst centers. The lack of evidence based criteria for the administration of platelet transfusion in cardiac surgery creates this heterogeneity. In order to enhance our understanding of platelet transfusion, we intended to identify clinical risk factors associated with platelet transfusion and to subsequently develop a platelet transfusion prediction model for cardiac surgical procedures. The Cardiac Surgery Blood Utilization Database (CSBUD) is our hospitals proprietary software used to capture demographic and transfusion specific data for each patient undergoing cardiac surgery. The CSBUD was interrogated (2013-2018) for all consecutive patients (n=2648). The data was randomly divided into a development set (n=1661) and validation set (n=987). Univariable analysis was used to identify covariates for model inclusion (p < 0.25). A multivariable logistic regression model was used to assess treatment effects. A supervised backward stepwise elimination technique (p < 0.10) was employed to identify independent predictors for the final model. The independent predictor coefficients were used to derive a platelet transfusion risk score. The analysis identified preoperative platelet count (OR=0.985, 95%CI: 0.981-0.989, p<0.001), ADP inhibitor (OR=2.507, 95% CI: 1.064-5.904, p=0.036) and GPIIb/IIIa (OR=8.915, 95% CI: 1.061-74.859, p=0.044) use; emergent surgery (OR=1.179, 95% CI: 1.079-2.411, p<0.001), aortic surgery (OR=7.349, 95% CI: 4.017-13.445, p<0.001) and RBC transfusion (OR=15.44, 95% CI: 9.736-24.497, p<0.001) as being independently associated with platelet transfusion. The risk score was divided into low, medium and high categories with a combined (development set and validation set) transfusion rate of 3%, 32% and 86%, respectively (Table 1). No significant differences existed between the development and validation sets. The model demonstrated excellent discrimination (Figure 1). Our analysis identified six independent clinical factors predictive of platelet transfusions. This enabled us to develop a highly discriminative platelet transfusion prediction model, which classifies the probability of a platelet transfusion into low, medium and high-risk categories. To our knowledge this is the first report of such a predictive model and we believe this will help clinicians to tailor their perioperative management accordingly.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A preoperative risk score to predict red blood cell transfusion in patients undergoing hysterectomy for ovarian cancer

Patients with ovarian cancer experience a high rate of anemia throughout their treatment course, with rates that range from 19-95%. Blood transfusions offer symptom relief but may be costly, are limited in supply, and have been associated with worse 30-day surgical morbidity and mortality rates. The purpose of this study was to identify risk factors for blood transfusion with packed red blood cell and to develop a transfusion risk score to identify patients who undergo surgery for ovarian cancer and who are at lowest risk for a blood transfusion. Our aim was to help clinicians identify those patients who may not require a crossmatch to encourage resource use and cost-savings. This is a retrospective database cohort study of 3470 patients who underwent hysterectomy for ovarian cancer with the use the National Surgical Quality Improvement Program database from 2014-2016. The association between risk factors with respect to 30-day postoperative blood transfusion was modeled with the use of logistic regression. A risk score to predict blood transfusion was created. Eight hundred ninety-one (25.7%) patients received a blood transfusion. In multivariate analysis, blood transfusion was associated independently with age (odds ratio, 1.90, P<.01), African American race (odds ratio, 2.30; P<.01), ascites (odds ratio, 1.89; P=.02), preoperative hematocrit level <30% (odds ratio, 10.70; P<.01), preoperative platelet count >400×109/L (odds ratio, 1.75; P<.01), occurrence of disseminated cancer (odds ratio, 1.71; P<.01), open surgical approach (odds ratio, 7.88; P<.01), operative time >3 hours (odds ratio, 2.19; P<.01), and additional surgical procedures that included large bowel resection (odds ratio, 4.23; P<.01), bladder/ureter resection (odds ratio, 1.69; P=.02), and pelvic exenteration (P=.02). A preoperative risk score that used age, race, ascites, preoperative hematocrit level, platelets, presence of disseminated cancer, planned hysterectomy approach, and procedures accurately predicted blood transfusion with good discriminatory ability (C-statistic=0.80 [P<.001]; C-statistic=0.69 [P<.001] for derivation and validation datasets, respectively) and calibration (Hosmer-Lemeshow goodness-of-fit, P=.081; P=.56 for derivation and validation datasets, respectively). Patients who undergo hysterectomy for ovarian cancer experience a high incidence of blood transfusions in the perioperative period. Preoperative risk factors and planned surgical procedures can be used in our transfusion risk score to help predict anticipated blood requirements.

Three point transfusion risk score in hepatectomy: an external validation using the American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP)

BackgroundRisk of red blood cell transfusion (RBCT) in partial hepatectomy is 17–27%; strategies to reduce transfusions can be targeted in patients at increased risk. A Three Point Transfusion Risk Score (TRS) was previously developed to predict patients' risk of transfusion during and following hepatectomy. Here, it was subject to external validation using the ACS-NSQIP database. MethodsTRIPOD guidelines were followed. A validation cohort was created with the ACS-NSQIP dataset. Risk groups for RBCT were created using the TRS: anemia (hematocrit ≤36%), major liver resection (≥4 segments) and primary liver malignancy. Concordance index was used to assess the discrimination. The Hosmer–Lemeshow test for goodness of fit and calibration curves were used to assess calibration. ResultsOf 2854 hepatectomies, 18.9% received RBCT. The TRS stratified patients from low (8.5% risk of RBCT) to very high risk (40.6%) of RBCT. The concordance was 0.68 (95% CI 0.66–0.70). Hosmer–Lemeshow test and calibration curves supported good predictive performance of the model. ConclusionThe TRS adequately discriminated risk of RBCT in an external sample of patients undergoing hepatectomy. It provides a simple method to identify patients at high transfusion risk. It can be used to tailor patient blood management initiatives and reduce the use of RBCT.

A preoperative risk score for transfusion in infrarenal endovascular aneurysm repair to avoid type and cross

ObjectivePreoperative type and cross are often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. MethodsWe queried the targeted vascular module of the National Surgical Quality Improvement Program (NSQIP) for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients transfused within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a model derivation cohort and one third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. ResultsBetween 2011 and 2015, there were 4875 patients who underwent elective infrarenal EVAR, only 221 (4.5%) of whom received a transfusion within 24 hours of surgery. The frequency of transfusion during the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4 [95% confidence interval, 2.1-5.4]; P < .001), aortic diameter (per centimeter increase: OR, 1.2 [1.03-1.4]; P = .02), preoperative dependent functional status (OR, 2.5 [1.1-5.5]; P = .03), and chronic obstructive pulmonary disease (OR, 1.7 [1.04-2.9]; P = .04). A risk prediction model based on these criteria produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and cross in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36%, only 6 (0.1%) had a risk score of >3. ConclusionsPerioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score or simply a hematocrit of <36%. Application of this risk score would avoid unnecessary type and cross in the majority of patients, leading to significant savings in both time and cost.

IP027. A Preoperative Risk Score for Transfusion in Infrarenal Endovascular Aneurysm Repair to Avoid Type and Cross

Preoperative type and crossmatch is often routinely ordered before elective endovascular aneurysm repair (EVAR), but the cost of this practice is high, and transfusion is rare. We therefore aimed to stratify patients by their risk of transfusion to identify a cohort in whom a type and screen would be sufficient. We queried the targeted vascular module of the National Surgical Quality Improvement Program database for all elective EVARs from 2011 to 2015. We included only infrarenal aneurysms and excluded ruptured aneurysms and patients who received a transfusion within 72 hours preoperatively. Two-thirds of the cases were randomly assigned to a prediction cohort and one-third to a validation cohort. We created and subsequently validated a risk model for transfusion within the first 24 hours of surgery (including intraoperatively), using logistic regression. Between 2011 and 2015, 4875 patients underwent elective infrarenal EVAR, of which only 221 (4.5%) received a transfusion within 24 hours of surgery. The frequency of transfusion over the study period declined monotonously from 6.5% in 2011 to 3.2% in 2015. The factors independently associated with transfusion were preoperative hematocrit <36% (odds ratio [OR], 3.4; 95% confidence interval [CI], 2.1-5.4; P < .001), aortic diameter (per cm increase: OR, 1.2; 95% CI, 1.03-1.4; P = .02), preoperative dependent functional status (OR, 2.5; 95% CI, 1.1-5.5; P = .03), and chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.04-2.9; P = .04). A risk-prediction model based on these criteria (Table) produced a C statistic of 0.69 in the prediction cohort and 0.76 in the validation cohort and a Hosmer-Lemeshow goodness of fit of 0.62 and 0.14, respectively. A score of <3 of 9, corresponding to a <5% probability of transfusion, would avoid preoperative type and crossmatch in 86% of patients. Of the 4203 patients (86%) with a hematocrit >36, only six (0.1%) had a risk score >3. Perioperative transfusion for EVAR is becoming increasingly uncommon and is predicted well by a transfusion risk score, or simply a hematocrit of <36. Application of this risk score would avoid unnecessary type and crossmatch in the majority of patients, leading to significant savings in both time and cost.TablePreoperative risk scoreCriteriaPointsTotal pointsRisk of transfusion (%)Cumulative frequency (%)Hematocrit01.9741.54 <30513.0278.91 30-36324.6286.15 ≥36036.9991.02410.4596.12Diameter515.3497.99 >5.51621.9699.36 ≤5.50730.4099.75840.4199.88COPD951.29100 Yes1 No0Dependent functional status Yes2 No0COPD, Chronic obstructive pulmonary disease. Open table in a new tab