Variation In Transfusion Practice Research Articles

Nonclinical factors affecting intraoperative red blood cell transfusion: a systematic review.

There is significant variability in intraoperative red blood cell (RBC) transfusion practice. We aimed to use the theoretical domains framework (TDF) to categorize nonclinical and behavioural factors driving intraoperative RBC transfusion practice in a systematic review of the literature. We searched electronic databases from inception until August 2021 to identify studies evaluating nonclinical factors affecting intraoperative RBC transfusion. Using the Mixed Methods Appraisal Tool, we assessed the quality of included studies and identified relevant nonclinical factors, which were coded into TDF domains by two independent reviewers using NVivo (Lumivero, QSR International, Burlington, MA, USA). We identified common themes within domains and sorted domains based on the frequency of reported factors. Our systematic review identified 18 studies: nine retrospective cohort studies, six cross-sectional surveys, and three before-and-after studies. Factors related to the social influences, behavioural regulation, environmental context/resources, and beliefs about consequences domains of the TDF were the most reported factors. Key factors underlying the observed variability in transfusion practice included the social effects of peers, patients, and institutional culture on decision-making (social influences), and characteristics of the practice environment including case volume, geographic location, and case start time (environmental context/resources). Studies reported variable beliefs about the consequences of both intraoperative transfusion and anemia (beliefs about consequences). Provider- and institutional-level audits, educational sessions, and increased communication between surgeons/anesthesiologists were identified as strategies to optimize intraoperative transfusion decision-making (behavioural regulation). Our systematic review has synthesized the literature on nonclinical and behavioural factors impacting intraoperative transfusion decision-making, categorized using the TDF. These findings can inform evidence-based interventions to reduce intraoperative RBC transfusion variability. Open Science Framework ( https://osf.io/pm8zs/?view_only=166299ed28964804b9360c429b1218c1 ; first posted, 3 August 2022).

Racial differences in transfusion practices: Time to address structural racism

See article on page 1519–1526, in this issue

Knowledge, attitudes and practices of resident doctors and interns on safe blood transfusion practices: a survey-based study

IntroductionThe knowledge of clinicians regarding blood transfusion services may impact patient care and transfusion outcome. The wide variation in transfusion practices among clinicians leads to inappropriate blood product usage and jeopardizes patient safety. Hence, this survey study aimed to assess knowledge, attitude and practice among the residents and interns of safe blood transfusion. MethodsThe online survey was based on self-administered questionnaires of three sections: 1. Demography; 2. Knowledge, and; 3. Attitude and Practice. One point was assigned for the correct response of each question in every section. The knowledge score was further categorized into three categories, depending on the points obtained. The participants were also divided into four groups, depending on their experience. The Kruskal-Wallis test was applied to determine the difference of knowledge and practice scores in three designated groups of residents and interns. A p-value of less than 0.05 was considered to be significant. ResultA total of 247 residents and interns participated in this study. Thirteen participants had an incomplete response. Out of 234 participants, Senior Residents (SR), Junior Residents (JR), and interns were 70, 96 and 68 participants, respectively. The knowledge scores of interns were significantly low, as compared to SRs and JRs. Practice scores of interns were also significantly low, compared to the JRs. However, most of the residents and interns (85%) were aware of the pre-transfusion testing. ConclusionTherefore, the mandatory incorporation of the transfusion medicine subject in the undergraduate curriculum can help the young budding doctors to better implement the patient blood management.

Racial differences in red blood cell transfusion in hospitalized patients with anemia.

BackgroundGuidelines recommend transfusion of red blood cells (RBC's) when a hospitalized patient's hemoglobin (Hb) drops below a restrictive transfusion threshold, either at 7 or 8 g. Hospitals have implemented transfusion policies to encourage compliance with guidelines and reduce variation in transfusion practice. However, variation in transfusion practice remains. The purpose of this study was to examine whether there is variation in the receipt of transfusion by patient race.MethodsHospitalized general medicine patients with anemia (Hb < 10 g/dL) were eligible. Chi‐squared tests were used to compare the percent of patients receiving a transfusion by race overall and within strata of their nadir Hb. Linear regression was used to test the association between a patient's race, their nadir Hb, receipt of an RBC transfusion, and the number of units transfused.ResultsFour thousand nine hundred and fifty‐one patients consented, including 1363 (28%) who received a transfusion. 71% of patients were African American, 25% were White, and 4% were Other Race. Overall African Americans were less likely to be transfused compared to Whites (25% vs. 30%, p < .01), and within Hb strata below a Nadir Hb of 9 g/dL (Hb 8.0–8.9 g/dL 1% vs. 7%, p < .01; 7.0–7.9 g/dL 15% vs. 28%, p < .01; <7 g/dL 80% vs. 86%, p < .01). African Americans also received fewer units of RBC's (β = −.17, p < .01) overall and at lower Hb levels (β = .14, p < .01) compared to Whites.DiscussionThe Hb level at which patients are transfused at and the total number of RBC units received during hospitalization differ by patient race.

2021 Canadian Surgery Forum: Virtual, online Sept. 21-24, 2021.

# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Blood product utilisation for coronary artery bypass graft surgery at a public and a private hospital in Western Cape Province, South Africa

Numerous studies have documented variation in transfusion practice for coronary artery bypass graft (CABG) surgery, despite the widespread availability of clinical guidelines. Blood management systems seek to streamline utilisation, with key indicators being patient care and outcome as well as reduction of waste and cost.To facilitate this view, this study sought to audit blood product utilisation for CABG surgery at a private and a public sector hospital in Western Cape Province, South Africa.A retrospective audit of 100 consecutive patients undergoing CABG surgery at a private and a public hospital during 2017 was performed. Blood product use was compared between the two hospitals, and the influence of confounding factors such as gender, weight, age, pre- and intraoperative medications, type and complexity of the procedure, and patient comorbidities was analysed.The proportion of patients receiving red cell concentrates (RCCs) at the public hospital was significantly higher than at the private hospital (92% v. 56%; p&lt;0.001), which resulted in significantly higher postoperative haemoglobin concentrations (p&lt;0.001). Although the increased proportion of RCC transfusion observed at the public hospital may have been influenced by decreased body mass (p&lt;0.001), the patient population at the private hospital was older (p&lt;0.05) and had higher rates of ischaemia (p&lt;0.001), increased numbers of grafts (p&lt;0.001) and higher preoperative use of aspirin (p&lt;0.05).This study demonstrated increased use of blood products at the public hospital, despite performing fewer grafts. Although this study had limitations, which included low patient numbers and the inclusion of only two hospitals, we concluded that there is a significant variation in the use of blood products despite the risks associated with blood transfusion. These findings could be used to employ systems that will lead to improved blood usage practices.

Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgery

ObjectiveTo identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery. MethodsObservational cohort study using the Perfusion Measures and Outcomes Registry from 43 adult cardiac surgical programs from July 1, 2011, to July 1, 2017. Iterative multilevel logistic regression models were constructed using patient demographic characteristics, preoperative risk factors, and intraoperative conservation strategies to progressively explain center-level transfusion variation. ResultsOf the 22,272 adult patients undergoing isolated coronary artery bypass surgery using cardiopulmonary bypass, 7241 (32.5%) received at least 1 U allogeneic red blood cells (range, 10.9%-59.9%). When compared with patients who were not transfused, patients who received at least 1 U red blood cells were older (68 vs 64 years; P < .001), were women (41.5% vs 15.9%; P < .001), and had a lower body surface area (1.93 m2 vs 2.07 m2; P < .001), respectively. Among the models explaining center-level transfusion variability, the intraclass correlation coefficients were 0.07 for model 1 (random intercepts), 0.12 for model 2 (patient factors), 0.14 for model 3 (intraoperative factors), and 0.11 for model 4 (combined). The coefficient of variation for center-level transfusion rates were 0.31, 0.29, 0.40, and 0.30 for models 1 through 4, respectively. The majority of center-level variation could not be explained through models containing both patient and intraoperative factors. ConclusionsThe results suggest that variation in center-level red blood cells transfusion cannot be explained by patient and procedural factors alone. Investigating organizational culture and programmatic infrastructure may be necessary to better understand variation in transfusion practices.

Variation in red cell transfusion practice in the intensive care unit – An international survey

PurposeUnclear recommendations in transfusion guidelines may possibly lead to inconsistency in treatment of patients admitted to the intensive care unit. This study aimed to uncover variation in red blood cell (RBC) transfusion decisions in the ICU worldwide. MethodsMembers of the European Society of Intensive Care Medicine (ESICM) were requested to complete an online questionnaire which included four different hypothetical clinical scenarios. The scenarios represented patients with acute myocardial infarction (AMI), abdominal sepsis, traumatic brain injury (TBI) and post-surgical complications. Hemoglobin level was 7∙3 g/dL in all scenarios. The questionnaire explored the physicians' transfusion decision in each clinical scenario and identified patient characteristics that were most influential in the transfusion decision. ResultsIn total 211 members participated in the study, of whom 142 (67%) completed the entire survey. Most variation was observed in the clinical scenario of sepsis, in which 49% decided to transfuse and 51% decided not to. In the clinical scenarios of AMI, TBI and post-surgical complications this was respectively; 75/25%, 35/65% and 66/34%. ConclusionsCritical care physicians differed in outcome of RBC transfusion decisions and weighed patient characteristics differently. These findings indicate that variation in transfusion practice amongst critical care physicians exists.

Updates in Red Blood Cell and Platelet Transfusions in Preterm Neonates.

Anemia and thrombocytopenia occur frequently in preterm neonates and the majority of them require at least one blood transfusion during the first few weeks of life. However, there is no international consensus on optimal transfusion management neither for red blood cell nor for platelet transfusions, resulting in large worldwide variations in transfusion practices between neonatal intensive care units. In the past decade, several studies performed in adults, infants as well as neonates showed that restrictive transfusion guidelines are just as safe as liberal guidelines. In fact, some studies even showed that liberal guidelines could be associated with an increased risk of morbidity and mortality, suggesting that too many transfusions may have a deleterious effect. In a recent randomized trial in preterm neonates with thrombocytopenia, the liberal transfusion group (receiving more platelet transfusions) had a significantly higher rate of death or major bleeding than the restrictive group (receiving less transfusions). In preterm neonates with anemia, the available evidence is also limited and controversial. Two large randomized controlled trials (ETTNO and TOP) are currently assessing the safety and effectiveness of liberal versus restrictive red blood cell transfusions. Results of these large two studies, including the long-term neurodevelopment outcome, are eagerly awaited. Until then, reduction of anemia of prematurity by implementation of effective preventive measures, such as delayed cord clamping and minimization of iatrogenic blood loss, remain of paramount importance.

Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study

Introduction: The clinical use of blood with regard to cardiac surgeries should be justifiable as it is associated with significant transfusion requirements, and tends to put a great burden on the blood inventory. Storage of red blood cell (RBC) induces various biochemical, biomechanical, and immunological changes that affect red cell viability, deformability, oxygen-carrying capacity, microcirculatory flow, and hence cause various adverse outcomes related to transfusion. Aim of Study: We made an effort to investigate the patterns of usage of allogenic blood products and the effect of volume and storage age of transfused RBCs with morbidity and mortality after cardiac surgery. Methodology: This was a cross-sectional analytical study conducted from January 2016 to June 2017, including all patients undergoing elective open-heart cardiac surgery at a tertiary care hospital. Records were reviewed for the details of blood components issued such as date of collection, date of transfusion, date of expiry and number of units of blood components transfused, details of the surgery, demographic details, postoperative length of stay (PLOS), and complications. Results: A total of 75 patients were included in this study. The majority of the surgeries (60%) were done for rheumatic heart disease. The difference in the transfusion patterns of various blood products with respect to the types of surgery, age or gender was statistically not significant. There was an association between increased PLOS (considered to be >11 days which is the mean) and mean unit age of the transfused packed RBCs (pRBCs) and the difference was statistically significant using the Chi-square test. Conclusion: There is a wide variation in transfusion practices in patients undergoing cardiac surgery. There is no significant association between the number of pRBCs transfusions and postoperative neurological, pulmonary, and other complications when number of pRBCs units ≤4.

The Effect on Blood Use after Adopting Single-Unit Policy and Restrictive Transfusion Trigger in a Hematology Unit: The Ensure Study

IntroductionRed blood cell (RBC) transfusion is a frequently performed medical procedure. But it is not without risk. Evidence suggests that restrictive transfusion is safe and effectively lessens the demand for blood components. Nevertheless, there exist considerable variations in transfusion practice among different centers. The hematology unit of Princess Margaret Hospital, a secondary referral center providing inpatient services for patients with various haematological malignancies and autologous stem cell transplantation, adopted a two-phase patient blood management program to reduce the demand for blood transfusions. Firstly, single-unit policy was implemented in Feb 2015 to replace the original protocol of transfusing two units of RBC in every transfusion episode. Secondly, the hemoglobin (Hb) trigger for transfusion decreased from 8g/dL to 7g/dL in asymptomatic and hemodynamically stable patients without cardiovascular disease in Aug 2016. The impact of these strategies to blood use and patient outcomes is evaluated in the present study.MethodThe study periods included 01/01/2014 - 12/31/2014 (Period A), 04/01/2015 - 03/31/2016 (Period B) and 10/01/2016 - 09/30/2017 (Period C). All patients admitted to the center during the study periods were recruited. Demographic data, RBC consumption, length of hospital stay and all-cause inpatient mortality were retrieved from the electronic medical record system. The proportions of single-unit transfusion and the mean Hb level transfusion triggers in different periods were compared with analysis of variance for continuous variables and logistic regressions for categorical variables respectively. Blood use in different periods was expressed in terms of RBC unit transfused per patient-day of hospitalization, and compared by age and sex adjusted incidence rate ratios (IRRs) obtained from zero-inflation negative binomial regression. To study the length of stay, negative binomial regression was performed to determine the age and sex adjusted IRRs for days of hospitalization in different periods. Clustering of data was further adjusted by applying robust standard errors. Generalized estimating equation for logistic regression, controlling for age, sex, days of hospitalization and number of previous admissions, was applied to compare the inpatient mortality in different periods.ResultsA total of 815 patients were recruited in the study, and the total number of admissions was 1,836. The number of patients in Period A was 232 (median age: 61 [IQR 49-71] years, male 54.7%) with 580 admissions, in Period B was 258 (median age: 63 [IQR 49-71] years, male 53.1%) with 566 admissions, and in Period C was 325 (median age: 62 [IQR 52-70] years, male 57.8%) with 690 admissions. The number of transfusion episodes in Periods A to C was 721, 923 and 803 respectively. The proportion of single-unit transfusion increased from 21.8% in Period A to 81.8% in Periods B (p<0.001) and 79.8% in Period C (p<0.001) respectively. The mean transfusion trigger Hb levels were 7.2±1.1 g/dL and 7.2±0.9 g/dL in Periods A and B respectively, and decreased to 6.6±0.9 in Period C (p<0.001 and <0.001). The proportion of transfusions with trigger Hb level >7g/dL decreased from 64.8% and 67.1% in Periods A and B to 17.7% in Period C (p<0.001 and <0.001) (TABLE 1).The total number of RBC transfused in the center was 1,317 units, 1,116 units and 990 units in Periods A to C respectively. RBC transfusion rate per patient-day of hospitalization reduced by 23% in Period B (p<0.001) and by 37% in Period C (p<0.001) respectively. The median length of hospital stay [IQR] was 7 [5-14], 6 [4-16] and 6 [4-13] days in Periods A to C. The in-patient mortality rates were 7.1%, 7.9% and 8.7% in Periods A to C. There was no statistically significant difference in the length of stay and in-patient mortality between different periods (TABLE 2).ConclusionsOur patient blood management program shows that both single-unit policy and lower Hb transfusion trigger are effective measures to reduce RBC use in hematology patients, without compromising the length of stay and inpatient mortality. Subgroup analysis could determine if restrictive transfusion strategies are applicable to all patients. Prospective studies including the occurrence of transfusion incidents and cost-effectiveness as outcome variables are useful to confirm our findings and substantiate the practicability of patient blood management. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Health Related Quality of Life and Fatigue in Patients with Pyruvate Kinase Deficiency

Background: Pyruvate Kinase (PK) deficiency is the most common enzyme defect of the glycolytic pathway causing hereditary non-spherocytic hemolytic anemia. Patients have a broad phenotypic spectrum, ranging from mild anemia to transfusion dependence, and there is wide variation in transfusion practices and decisions about splenectomy. No prior studies have reported on the use of validated health related quality of life (HRQoL) measures in this population.Aim: To describe patient reported outcomes including general HRQoL and fatigue in adults with PK deficiency and the correlation with clinical and laboratory features.Methods: Patients were enrolled on the PK Deficiency Natural History Study, a prospective 30 site international study. All patients had molecularly confirmed PK deficiency. Adults (n=132), ages ≥18 years, completed the EuroQol-5D (high index equivalent to better QoL), PROMIS Fatigue Short Form 7a (high scores equivalent to higher fatigue), and the Functional Assessment of Cancer Therapy-Anemia (FACT-An, high scores equivalent to less fatigue) surveys at enrollment and annually. Timing of administration was convenience based. Survey data were analyzed according to proprietary scoring guidelines. Tests of association were performed using Fisher's exact test (categorical) and Wilcoxon rank sum test (continuous). Regular transfusions were defined as ≥6 transfusions in 12 months. Genotypes were grouped as two missense mutations (M/M), one missense/one non-missense (M/NM), or two non-missense mutations (NM/NM)); non-missense included deletions or other drastic variants. The minimal important difference (MID) for the FACT-An has been reported as 7 points (Cella et al, J Pain Symptom Manage 2002). P-values <0.05 were considered statistically significant.Results: At enrollment, 128 adults completed the FACT-An with a median total score of 156 (IQR 122-190). Patients receiving regular transfusions reported significantly lower FACT-An scores than those who were not regularly transfused (median 129 vs 156, p=0.004) with significantly lower scores for physical, emotional, and functional well-being and anemia sub-scores (Table). This difference also surpassed the MID. However, non- regularly transfused patients with hemoglobin (Hb) <8 g/dl did not report significantly different scores than those with Hb≥ 8 g/dl (p=0.75). There were also no significant differences in FACT-An scores by splenectomy status or age. The FACT-An score differences were greater than the MID for patients with iron overload (ferritin >1000 ng/dL or chelation), higher number of lifetime transfusions, and two missense mutations. Females reported significantly lower scores than males (median 143 vs. 160, p=0.006) with significantly lower anemia sub-scores (p=0.0009). FACT-An surveys completed at the one year follow-up time point validated these findings.EuroQol-5D scores (n=124) at enrollment were similar to the healthy population (median PK deficiency index score 0.88; healthy population index mean 0.88, Shaw et al, Medical Care 2005). No significant differences were found by Hb level, splenectomy status, transfusion status, or genotype group. The median PROMIS fatigue T score (n=66) was 52.1 (IQR 40.5-63.7). Similar to the FACT-An survey data, PROMIS fatigue scores were significantly worse in patients who were regularly transfused (67.0 vs 52.4, p=0.02). PROMIS fatigue scores were also significantly worse in patients ≥40 years old (p=0.05) and females (p=0.01).Conclusions: Using the FACT-An and PROMIS Fatigue measures, patients with PK deficiency who are regularly transfused report significantly more fatigue and worse HRQoL compared with those who are not transfused. Important differences were also seen by iron status and mutation group using the FACT-An. Patients report similar fatigue levels regardless of Hb level, which suggests that symptoms, rather than Hb value alone, should be factored into clinical decision making. In contrast to anemia related HRQoL scores, overall HRQoL scores using validated generic measures in patients with PK deficiency show no differences compared with the healthy population, suggesting that disease-specific measures may better detect the effects of PK deficiency on HRQoL. DisclosuresVan Beers:Agios Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Glader:Agios Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Chonat:Agios Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees. Despotovic:AmGen: Research Funding; Novartis: Research Funding; Sanofi: Consultancy. Kwiatkowski:bluebird bio: Consultancy, Honoraria, Research Funding; Agios Pharmaceuticals: Consultancy, Research Funding; Novartis: Research Funding; Apopharma: Research Funding; Terumo: Research Funding. Thompson:La Jolla Pharmaceutical: Research Funding; Baxalta/Shire: Research Funding; Novartis: Research Funding; Celgene: Research Funding; bluebird bio: Consultancy, Research Funding; Biomarin: Research Funding; Amgen: Research Funding. Newburger:TransCytos LLC: Consultancy; Janssen Research & Development, LLC: Consultancy, Honoraria; X4 Pharmaceutics: Consultancy, Honoraria. Ravindranath:AGIOS: Other: Site Investigator for Pyruvate Kinase Deficiency. Sheth:Terumo Corporation: Research Funding; Novartis: Research Funding; La Jolla Pharmaceutical Company: Research Funding; Celgene Corporation: Consultancy, Research Funding; Bluebird Bio: Consultancy. Grace:Agios Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees; Agios Pharmaceuticals: Research Funding; Agios Pharmaceuticals: Consultancy.

Blood transfusion for anaemia of prematurity: Current practice in Australia and New Zealand

To characterise the current transfusion practice among clinicians in Australasian neonatal units and factors that influence their decision-making. Members of the Australia and New Zealand Neonatal Network (ANZNN) and practitioners at their local institutions were invited to participate in a 15-question web-based survey between 1 June and 31 July 2016. The survey was designed to assess (i) haemoglobin-based transfusion thresholds; (ii) presence of local guidelines; (iii) preference for a restrictive or liberal transfusion policy; (iv) perceived benefits and risks of transfusion; and (v) use of clinical adjuncts to assist decision-making. Overall, 130 participants responded to at least one question. Haemoglobin transfusion thresholds for anaemia of prematurity (AOP) varied significantly from <60 to <120 g/L. Of 103 participants, 36 (35%) reported that they do not have access to local transfusion guidelines. The majority utilise multiple clinical and haematological parameters to guide their decision-making, and approximately half (45/84, 54%) believe that tissue hypoxia detected by near-infrared spectroscopy (NIRS) may better inform transfusion thresholds. Of 102 participants, 51 (50%) support a restrictive rather than liberal transfusion policy. The most commonly reported perceived risks of transfusion for AOP were suppression of endogenous erythropoiesis and increased rates of necrotising enterocolitis. There is a significant variation in transfusion practice in Australasian neonatal units. Quality and safety initiatives may assist with improved consistency of transfusion practice across the ANZNN. However, further research is required to better define optimal transfusion thresholds, quantify potential risks of transfusion and determine clinical utility of newer adjuncts such as NIRS.

Restrictive Transfusion Practices After Esophagectomy Are Associated With Improved Outcome: A Review of the Society of Thoracic Surgeons General Thoracic Database.

Blood transfusion has been associated with poor outcomes in many disciplines, yet transfusion practices and related outcomes in esophagectomy are unknown. We analyzed the Society of Thoracic Surgeons General Thoracic Database to determine patient factors associated with transfusion after esophagectomy, risk-adjusted variation in transfusion practice among institutions, and the association of transfusion practice with mortality. We performed a retrospective review of patients undergoing esophagectomy for cancer from October 2008 to December 31, 2014. Patient comorbidities and procedure variables were used to construct a risk model for transfusion. Using this model, each institution was assigned an observed to expected (O:E) transfusion rate. We examined institutional factors associated with variation in O:E transfusion rate. Finally, O:E transfusion rate was compared to risk-adjusted mortality to determine if there was an association of transfusion practice and survival. Seven thousand one hundred thirty-seven patients underwent esophagectomy at 182 institutions during the study period. The median unadjusted transfusion rate was 23.1%. The risk model for transfusion demonstrated patients who received transfusions were more likely to be older, female, and have low preoperative hemoglobin and other comorbidities, such as CAD, COPD, and low creatinine clearance. Patients who received a minimally invasive procedure were less likely to have received a transfusion.After adjusting for the characteristics above, 13 centers (7.1%) were classified as having lower than average O:E transfusion rate and 16 centers (8.7%) were classified as higher than average O:E transfusion rate.Institutions with lower than expected transfusion rates also had lower risk-adjusted perioperative mortality than institutions with higher than expected transfusion rates (median [IQR] = 0.90 [0.77-0.94] vs. 0.99 [0.94-1.06], P = 0.028). Age, female sex, CAD, COPD, renal insufficiency, and open technique are associated with transfusion after esophagectomy, while tumor stage and preoperative chemoradiation are not. There is wide variation in transfusion practice. Centers with lower than expected transfusion rate also had lower than expected perioperative mortality. At an institutional level, lower transfusion rates are associated with improved outcomes.

Worldwide audit of blood transfusion practice in critically ill patients

BackgroundThe aim was to describe transfusion practice in critically ill patients at an international level and evaluate the effects of red blood cell (RBC) transfusion on outcomes in these patients.MethodsThis was a pre-planned sub-study of the Intensive Care Over Nations audit, which involved 730 ICUs in 84 countries and included all adult patients admitted between 8 May and 18 May 2012, except admissions for routine postoperative surveillance.ResultsICU and hospital outcomes were recorded. Among the 10,069 patients included in the audit, data related to transfusion had been completed for 9553 (mean age 60 ± 18 years, 60% male); 2511 (26.3%) of these had received a transfusion, with considerable variation among geographic regions. The mean lowest hemoglobin on the day of transfusion was 8.3 ± 1.7 g/dL, but varied from 7.8 ± 1.4 g/dL in the Middle East to 8.9 ± 1.9 g/dL in Eastern Europe. Hospital mortality rates were higher in transfused than in non-transfused patients (30.0% vs. 19.6%, p < 0.001) and increased with increasing numbers of transfused units. In an extended Cox proportional hazard analysis, the relative risk of in-hospital death was slightly lower after transfusion in the whole cohort (hazard ratio 0.98, confidence interval 0.96–1.00, p = 0.048). There was a stepwise decrease in the hazard ratio for mortality after transfusion with increasing admission severity scores.ConclusionsMore than one fourth of critically ill patients are transfused during their ICU stay, with considerable variations in transfusion practice among geographic regions. After adjustment for confounders, RBC transfusions were associated with a slightly lower relative risk of in-hospital death, especially in the most severely ill patients, highlighting the importance of taking the severity of illness into account when making transfusion decisions.

Variation in Transfusion Practices and the Association With Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative

Variation in Transfusion Practices and the Association With Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative

Late-Breaking Science Abstracts From the American Heart Association's Scientific Sessions 2017 and Late-Breaking Abstracts in Resuscitation Science From the Resuscitation Science Symposium 2017.

### CABG and EP Peri-procedural Dilemmas #### 21574 #### TRiCS III - An International Multicenter Randomized Trial of Transfusion Requirements in Cardiac Surgery C. David Mazer1, Richard P Whitlock2, Dean A Fergusson3, Kevin E Thorpe4, Nadine Shehata5, TRICS III Investigators, Perioperative Anesthesia Clinical Trials Network; 1Anesthesia, St Michaels Hosp, Univ of Toronto, Toronto, Canada, 2Div of Cardiac Surgery and Dept of of Clinical Epidemiology and Biostatistics, Population Health Rsch Institute, McMaster Univ, Hamilton, Canada, 3Depts of Medicine, Surgery, & the Sch of Epidemiology, Public Health and Preventive Medicine, Ottawa Hosp Rsch Institute, Univ of Ottawa, Ottawa, Canada, 4Biostatistics, Applied Health Rsch Cntr and Dalla Lana Sch of Public Health, St. Michael’s Hosp, Univ of Toronto, Toronto, Canada, 5Depts of Medicine, Institute of Health Policy Management and Evaluation, Mount Sinai Hosp, Univ of Toronto, Toronto, Canada. Introduction: There is a critical need to determine the appropriate threshold for red cell transfusion in patients undergoing cardiac surgery since perioperative anemia and allogeneic red blood cell transfusions are both independent predictors of morbidity and mortality. In addition, there is considerable inter-physician and inter-hospital variability in transfusion practice. While restrictive transfusion strategies have been shown to reduce transfusion, their clinical effectiveness and safety in cardiac surgery are not known. Methods: TRICS III is a multicenter randomized controlled trial to evaluate the non-inferiority of a restrictive transfusion strategy compared to a liberal transfusion strategy in cardiac surgery patients with a preoperative European System for Cardiac Operative Risk Evaluation (additive EuroSCORE I) of ≥6 (NCT02042898). Patients were randomized to a “restrictive” strategy (transfusion if hemoglobin <7.5 g/dL intraoperatively and postoperatively) or a “liberal” strategy (transfusion if hemoglobin <9.5 g/dL in the operating room or ICU, and <8.5 g/dL on the ward). The primary outcome is a composite of in hospital death, myocardial infarction, stroke or new renal failure requiring dialysis. Secondary outcomes include duration …

Variation in Transfusion Practices and the Association with Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative

Blood transfusions are associated with adverse events. We examined perioperative transfusion practices and associated complications following open vascular procedures nationwide in the Vascular Quality Initiative (VQI). Adults undergoing open abdominal aortic aneurysm repair (OAR) and lower extremity arterial bypass (Bypass) within VQI (2003-2016) were identified. All emergent cases, patients with preoperative hemoglobin <7g/dL, preoperative hospitalization >1day, or a return to operating room during the index hospitalization were excluded. Units of red blood cells transfused were the primary outcome. Secondary outcomes were postoperative myocardial infarction (MI) and death. Patient, center, and procedural factors were evaluated. Multivariable mixed effects negative binomial regression and multivariable logistic regression were performed. We identified 24,131 procedures (OAR 3885, 16.1%; Bypass 20,246, 83.9%) among 22,532 patients (10.1% had >1 procedure). Overall, 37.5% of OAR and 19.5% of Bypass were transfused. Transfusion rates varied across estimated blood loss quartiles and across various preoperative hemoglobin levels. The overall rate of postoperative MI and death was 4.0% and 1.8% for OAR, and 2.2% and 0.7% for Bypass, respectively. In univariate and multivariable analysis, transfusions were associated with an increased risk of postoperative MI and death. A mixed effects negative binomial model demonstrated variation in transfusions across centers (P<0.001). Female gender and preoperative anemia were significantly associated with transfusions. Blood transfusions are variable across centers in VQI. Transfusions are associated with a higher postoperative MI and death after OAR and Bypass. Efforts to reduce transfusion may focus on center variability, gender, and preoperative anemia.

Variation in Transfusion Practices and Their Associations with Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative (VQI)

Blood transfusions are associated with adverse events. We examined perioperative transfusion practices and associated complications following open vascular procedures nationwide in the Vascular Quality Initiative (VQI).

Abstract P34: Variation in Transfusion Practice and Associated Postoperative Complications in Abdominally-Based Autologous Breast Reconstruction Surgery

PURPOSE: Blood transfusion is the most frequently performed procedure in US hospitals. Despite its life-saving potential when clinically indicated, evidence shows that transfusion in some cases does not provide a significant clinical benefit to patients and thus does not justify its associated costs and risks. Increasing emphasis has been placed on reducing these potentially unnecessary transfusions, demonstrated by recently published guidelines from the American Association of Blood Banks (AABB) recommending restrictive hemoglobin thresholds for transfusion (≤7 g/dL). In plastic and reconstructive surgery, free flap procedures are associated with high utilization of blood transfusion, reported in the literature to be as high as 42%. The high volume of flap-based breast reconstructions makes this procedure an ideal target for quality improvement interventions related to blood transfusion practices. In this study, we assessed variation in transfusion practice and its associated clinical outcomes in a large cohort of breast reconstruction patients to identify potential targets for quality improvement. METHODS: After obtaining IRB approval, we extracted perioperative blood utilization data and hemoglobin transfusion triggers from two prospectively-collected anesthesia and blood management databases (Metavision and IMPACT Online) for all patients who underwent abdominally-based autologous breast reconstruction at the Johns Hopkins Hospital between 2009 and 2015. We defined hemoglobin transfusion triggers as the lowest measured hemoglobin level preceding a blood transfusion. We used ANOVA, Chi-squared, and linear regression to examine patient-level and surgeon-level variation in the use of overall blood transfusions, potentially unnecessary blood transfusions, and hemoglobin transfusion triggers. RESULTS: Of 653 patients, 65 (10%) received perioperative blood transfusions. Risk factors for increased blood utilization were higher ASA class (OR: 2.4; p=0.015) and younger age (OR: 1.2 for every 5-year decrease in age; p=0.008), with a trend for the presence of rheumatic comorbidities (OR: 3.7; p=0.098). Use of perioperative blood transfusions varied by surgeon (range: 5% to 24%; p=0.001), suggesting the presence of variation in transfusion practices. Mean hemoglobin trigger was 6.6 g/dL (±0.83 g/dL; range 3.4–8.2 g/dL). Hemoglobin triggers varied by surgeon (range: 6 g/dL to 7.5 g/dL; p<0.001) and patient age (p=0.031), with a trend for Charlson comorbidity index (p=0.093). Of the 65 patients that received blood transfusions, 16 patients (25%) had potentially unnecessary transfusions (hemoglobin triggers ≥7g/dL). Potentially unnecessary utilization of blood transfusion did not vary by surgeon (range: 1% to 4%; p=0.142), but was higher in TRAM flap reconstructions (OR: 9; p=0.001) and showed a trend for higher ASA class (OR: 3; p=0.076). Patients who received blood transfusions experienced worse clinical outcomes in terms of postoperative infections (p=0.006), Clostridium difficile infection (p=0.003), sepsis (p<0.001), and 30-day readmission (p<0.001). CONCLUSION: Use of perioperative blood transfusion varied among surgeons. However, there was no evidence for surgeon-level variation in potentially unnecessary perioperative transfusion. Transfusions were significantly associated with higher risk of perioperative infections and postoperative readmissions. These findings emphasize the importance of standardizing transfusion practices with the goal of minimizing unnecessary transfusions and their potential negative consequences.