Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Nuttall, Gregory A.; Brost, Brian C.; Connis, Richard T.; Gessner, J; Harrison, Christopher; Miller, Ronald D.; Nickinovich, David G.; Nussmeier, Nancy A.; Rosenberg, Andrew D.; Spence, Ríchard K.

doi:10.1097/00000542-200607000-00030

Cited by 789 publications

(125 citation statements)

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“…Over the past decade, a number of medical societies have emphasized the need to reduce unnecessary transfusion by following evidence-based guidelines. 1-4 However, reducing the unnecessary ordering and preparation of blood components remains an area of opportunity to improve care and reduce costs.…”

Section: Introductionmentioning

confidence: 99%

Reducing Unnecessary Preoperative Blood Orders and Costs by Implementing an Updated Institution-specific Maximum Surgical Blood Order Schedule and a Remote Electronic Blood Release System

Frank

Oleyar²,

Ness³

et al. 2014

Anesthesiology

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Background Using blood utilization data acquired from our anesthesia information management system, an updated institution-specific maximum surgical blood order schedule (MSBOS) was introduced. We evaluate whether the MSBOS, along with a remote electronic blood release system (EBRS), reduced unnecessary preoperative blood orders and costs. Methods At a large academic medical center, data for preoperative blood orders were analyzed for 63,916 surgical patients over a 34-month period. The new MSBOS and the EBRS (Hemosafe®, Haemonetics Corp., Braintree, MA) were introduced mid-way through this time period. We assessed whether these interventions led to reductions in unnecessary preoperative orders and associated costs. Results Among patients having surgical procedures deemed not to require a type and screen or crossmatch (n = 33,216), the percentage of procedures with preoperative blood orders decreased by 38% [from 40.4% (7,167 of 17,740 patients) to 25.0% (3,869 of 15,476 patients), P < 0.001]. Among all hospitalized inpatients, the crossmatch-to-transfusion ratio decreased by 27% (from 2.11 to 1.54; P < 0.001) over the same time period. The proportion of patients who required emergency release uncrossmatched blood increased from 2.2 to 3.1 per 1,000 patients (P = 0.03); however, most of these patients were having emergency surgery. Based on the realized reductions in blood orders, annual costs were reduced by $137,223 ($6.08/patient) for surgical patients, and by $298,966 ($6.20/patient) for all hospitalized patients. Conclusions Implementing institution-specific, updated MSBOS-directed preoperative blood ordering guidelines along with an EBRS results in a substantial reduction in unnecessary orders and costs, with a clinically insignificant increase in requirement for emergency release blood transfusions.

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Section: Introductionmentioning

confidence: 99%

Reducing Unnecessary Preoperative Blood Orders and Costs by Implementing an Updated Institution-specific Maximum Surgical Blood Order Schedule and a Remote Electronic Blood Release System

Frank

Oleyar²,

Ness³

et al. 2014

Anesthesiology

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“…In the last years, efforts to optimise the use of blood have been undertaken in several countries, transfusion guidelines for RBC concentrated have been published [7,8,9,10,11,12,13], and a further optimisation is ongoing under the concept of patient blood management [14,15,16,17]. Projects aimed to achieve this goal are time-consuming, and under the current financial and performance pressure it is often difficult to find the resources needed.…”

Section: Discussionmentioning

confidence: 99%

“…Results of clinical trials published in recent years have shown that optimising the use of blood components, particularly red blood cell (RBC) concentrates, not only reduces the costs related to blood transfusion but also may influence positively the outcome of patients, or at least does not worsen it [2,3,4,5,6]. As a consequence, several guidelines for the use of RBCs have been developed by different societies and institutions [7,8,9,10,11,12,13]. Currently, further efforts to optimise patient care and use of blood components are ongoing under the concept of blood patient management [14,15,16,17].…”

Section: Introductionmentioning

confidence: 99%

A Simple Guideline Reduces the Need for Red Blood Cell Transfusions in Swiss Hospitals: A Prospective, Multicentre, Before-and-After Study in Elective Hip and Knee Replacement

Fontana

Cuadra

Müller³

et al. 2014

Transfus Med Hemother

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Introduction: Optimising the use of blood has become a core task of transfusion medicine. Because no general guidelines are available in Switzerland, we analysed the effects of the introduction of a guideline on red blood cell (RBC) transfusion for elective orthopaedic surgery. Methods: Prospective, multicentre, before-and-after study comparing the use of RBCs in adult elective hip or knee replacement before and after the implementation of a guideline in 10 Swiss hospitals, developed together with all participants. Results: We included 2,134 patients, 1,238 in 7 months before, 896 in 6 months after intervention. 57 (34 or 2.7% before, 23 or 2.6% after) were lost before follow-up visit. The mean number of transfused RBC units decreased from 0.5 to 0.4 per patient (0.1, 95% CI 0.08-0.2; p = 0.014), the proportion of transfused patients from 20.9% to 16.9% (4%, 95% C.I. 0.7-7.4%; p = 0.02), and the pre-transfusion haemoglobin from 82.6 to 78.2 g/l (4.4 g/l, 95% C. I. 2.15-6.62 g/l, p < 0.001). We did not observe any statistically significant changes in in-hospital mortality (0.4% vs. 0%) and morbidity (4.1% vs. 4.0%), median hospital length of stay (9 vs. 9 days), follow-up mortality (0.4% vs. 0.2%) and follow-up morbidity (6.9% vs. 6.0%). Conclusions: The introduction of a simple transfusion guideline reduces and standardises the use of RBCs by decreasing the haemoglobin transfusion trigger, without negative effects on the patient outcome. Local support, training, and monitoring of the effects are requirements for programmes optimising the use of blood.

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“…Die aufgezeigten vielfältigen und oft parallel bestehenden Hauptursachen für intraoperative Gerinnungsstörungen und Blutungen erfordern diagnostische Methoden, die in der Lage sind, diese Beeinträchtigungen zeitnah zu detektieren und zu differenzieren, um rasch eine adäquate Gerinnungstherapie durchführen zu können [27]. …”

Section: Diagnostikunclassified

“…Als weiterer großer Nachteil wird in der klinischen Praxis die zeitliche Verzögerung gesehen, mit der die Ergebnisse zur Verfügung stehen. 30-60 Minuten oder länger sind für eine Therapiesteuerung im OP mit hoher Dynamik unzureichend [27]. Deshalb ist es nicht verwunderlich, dass sich Standardtests zur Prädiktion von Blutungen oder zur Steuerung einer intraoperativen Gerinnungstherapie als weniger geeignet erwiesen haben [8].…”

Section: Diagnostikunclassified

Intraoperatives Gerinnungsmanagement

Johanning¹

2013

Visc Med

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Hintergrund: Intraoperative Gerinnungsstörungen kommen bei großen Operationen häufig vor und können verschiedene, oft parallel auftretende Ursachen haben. Die Blutungsdynamik unter laufender Operation erfordert eine gute interdisziplinäre Zusammenarbeit sowie ein effektives Team- und Kontextmanagement. Geeignete diagnostische Methoden sind für ein rasches und zielgerichtetes Gerinnungsmanagement notwendig. Methode: Die Literatur bis April 2013 wurde selektiv, inklusive der neuen europäischen und deutschen anästhesiologischen Handlungsempfehlungen zum perioperativen Blutungsmanagement, berücksichtigt. Ergebnisse: Dilutionskoagulopathien zählen zu den häufigsten intraoperativen Gerinnungsstörungen, da bei Blutverlust zur Aufrechterhaltung der Makrozirkulation kolloidale oder kristalloide Lösungen infundiert bzw. Erythrozytenkonzentrate zur Oxygenierung transfundiert werden. Hypothermien, Azidosen, Hypocalciämien, Anämien, Hyperfibrinolysen, Medikamenteneinnahmen und Vorerkrankungen können die Koagulopathien verstärken. Fibrinogen ist der erste Faktor, der bei massiven Blutungen kritisch abfällt und substituiert werden muss. Schlussfolgerungen: Patientennahe diagnostische Verfahren eignen sich besonders zur Differenzierung von intraoperativen Gerinnungsstörungen und einer zielgerichteten Therapie. Faktorenkonzentrate stehen schneller als Gefrierplasmen (fresh frozen plasma, FFP) zur Verfügung und bilden häufig die Basis einer zielgerichteten Therapie. FFP enthalten alle Faktoren in einem physiologischen Verhältnis, allerdings unkonzentriert. Zu den Limitationen zählen neben geringerer Wirksamkeit die zeitaufwendige Vorbereitung und die nicht unerheblichen unerwünschten Wirkungen. Die Evidenzlage ist noch nicht ausreichend für eindeutige Empfehlungen.

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Practice Guidelines for Perioperative Blood Transfusion and Adjuvant Therapies

Cited by 789 publications

References 0 publications

Reducing Unnecessary Preoperative Blood Orders and Costs by Implementing an Updated Institution-specific Maximum Surgical Blood Order Schedule and a Remote Electronic Blood Release System

Reducing Unnecessary Preoperative Blood Orders and Costs by Implementing an Updated Institution-specific Maximum Surgical Blood Order Schedule and a Remote Electronic Blood Release System

A Simple Guideline Reduces the Need for Red Blood Cell Transfusions in Swiss Hospitals: A Prospective, Multicentre, Before-and-After Study in Elective Hip and Knee Replacement

Intraoperatives Gerinnungsmanagement

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