Implementation of a Blood Management Program at a Tertiary Care Hospital

Gani, Faiz; Cerullo, Marcelo; Ejaz, Aslam; Gupta, Pranjal B.; DeMario, Vincent M.; Frank, Steven M.; Pawlik, Timothy M.

doi:10.1097/sla.0000000000002585

Cited by 44 publications

(5 citation statements)

References 46 publications

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“…Twenty cohort studies investigated whether the implementation of a comprehensive PBM program (ie, at least 1 intervention for 2 of the 3 PBM pillars) was effective . The most common interventions of these PBM programs included (restrictive) RBC transfusion strategies (PBM pillar “RBC transfusion” [19 studies]), the use of pharmacologic hemostatic agents (PBM pillar “minimize blood loss” [12 studies]), and/or the use of ESA/iron therapy (PBM pillar “optimize erythropoiesis” [14 studies]).…”

Section: Resultsmentioning

confidence: 99%

Patient Blood Management

Mueller

Remoortel

Meybohm

et al. 2019

JAMA

465

146

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IMPORTANCE Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. OBJECTIVE To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. EVIDENCE REVIEWThe scientific committee developed 17 Population/Intervention/ Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018.FINDINGS From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration <7 g/dL) as well as for patients undergoing cardiac surgery (recommended threshold for RBC transfusion, hemoglobin concentration <7.5 g/dL). For implementation of PBM programs, 2 clinical and 3 research recommendations were developed, including recommendations to implement comprehensive PBM programs and to use electronic decision support systems (both conditional recommendations) to improve appropriate RBC utilization. CONCLUSIONS AND RELEVANCEThe 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

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Section: Resultsmentioning

confidence: 99%

Patient Blood Management

Mueller

Remoortel

Meybohm

et al. 2019

JAMA

465

146

View full text Add to dashboard Cite

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“…But there are several limitations that should be considered when interpreting the results of this study. The outcomes included in the definition of TO were limited to the variables available in the database, thus we did not include some potentially relevant postoperative complications, such as prolonged operative time, intraoperative blood loss, or postoperative transfusions-variables that have been found to be associated with worse outcomes (25). Also, surgeon case volume could not be examined; however, hospital volume may be relevant for complex cancers such as RPS as it acts as surrogate for multidisciplinary care and ability to rescue patients who suffer postoperative complications (26)(27)(28).…”

Section: Discussionmentioning

confidence: 99%

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection

et al. 2020

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Background/Aim: Recently, the concept of textbook outcome (TO) has emerged as a novel effort to develop a benchmark that reflects multiple domains of quality. The aims of the current study were to define TO for retroperitoneal sarcoma (RPS), evaluate the relationship of TO with hospital volume and assess the association of TO with overall survival. Patients and Methods: Patients who underwent resection for RPS diagnosed between 2004 and 2015 were identified in the National Cancer Database. The primary outcome was TO that was defined as: hospital length of stay<75 th percentile, survival>90 days from surgery, no readmission within 30 days and grossly negative margins. Results: Of the 11,032 patients analyzed, 54.0% had a TO. Among patients who had a TO, 57.8% were treated in high-volume hospitals. Undergoing surgery at high-volume centers was associated with a higher probability of a TO (p=0.009). TO were associated with significantly longer overall survival (p<0.001). In a subgroup analysis with grossly negative margins and no 90day mortality, the association of TO with improved survival persisted (p<0.001). Conclusion: The concept of TO is a promising tool for measuring patient-level hospital performance and may be useful for identifying important variations in care for patients with RPS.

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“…Blood management strategies to reduce the use of blood products have been shown to improve outcomes, such as morbidity, mortality, hospital stay, etc., in a variety of clinical settings. 52 53 54 55 56 Data from this meta-analysis suggest that the use of thromboelastography can similarly reduce blood product use and improve outcomes in patients with cirrhosis.…”

Section: Discussionmentioning

confidence: 94%

Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

Hartmann

Dias

Pivalizza

et al. 2022

Semin Thromb Hemost

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Patients with cirrhosis often have abnormal hemostasis, with increased risk of hemorrhage and thrombosis. Thromboelastography provides a rapid assessment of the coagulation status and can guide product transfusions in adult patients with cirrhosis. This study aimed to determine whether the use of thromboelastography in adult patients with cirrhosis decreases blood product use and impacts adverse events or mortality compared with standard practice. A registered (PROSPERO CRD42020192458) systematic review and meta-analysis was conducted for randomized controlled trials (RCTs) comparing thromboelastography-guided hemostatic management versus standard practice (control). Co-primary outcomes were the number of transfused platelet units and fresh frozen plasma (FFP) units. Secondary outcomes were mortality, adverse events, utilization of individual blood products, blood loss or excessive bleeding events, hospital/intensive care unit stay, and liver transplant/intervention outcomes. The search identified 260 articles, with five RCTs included in the meta-analysis. Platelet use was five times lower with thromboelastography versus the control, with a relative risk of 0.17 (95% confidence interval [CI]: [0.03–0.90]; p = 0.04), but FFP use did not differ significantly. Thromboelastography was associated with less blood product (p < 0.001), FFP + platelets (p < 0.001), and cryoprecipitate (p < 0.001) use. No differences were reported in bleeding rates or longer term mortality between groups, with the thromboelastography group having lower mortality at 7 days versus the control (relative risk [95% CI] = 0.52 [0.30–0.91]; p = 0.02). Thromboelastography-guided therapy in patients with cirrhosis enhances patient blood management by reducing use of blood products without increasing complications.

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Implementation of a Blood Management Program at a Tertiary Care Hospital

Cited by 44 publications

References 46 publications

Patient Blood Management

Patient Blood Management

Textbook Outcomes Among Patients Undergoing Retroperitoneal Sarcoma Resection

Thromboelastography-Guided Therapy Enhances Patient Blood Management in Cirrhotic Patients: A Meta-analysis Based on Randomized Controlled Trials

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