Anaemia and blood transfusion incorporating patient blood management

Chronic anaemia in the stable patient carries a small risk in non-haemorrhagic surgery. Where bleeding is anticipated, anaemia can be treated medically to avoid transfusion. Both intravenous (IV) iron and erythropoiesis stimulating agents (ESA) are gaining popularity to raise the haemoglobin (Hb) in anaemic patients. Bleeding causes acute anaemia requiring maintenance of blood volume and only transfusion to keep the haematocrit (Hct) >21% and Hb >74 g/L in low-risk patients without coronary artery disease (CAD) and Hct 24–27% or Hb >80 g/L in high-risk patients. Both anaemia and transfusion increase the morbidity and mortality associated with surgery. The most significant impact on adverse outcomes is major bleeding (MB). Medical, surgical and anaesthetic management should focus on correcting anaemia and avoidance of bleeding to prevent adverse outcomes for the patient.     

SinoSCORE对成人心脏手术后院内死亡风险的预测——中国成人心脏外科数据库华西医院数据报告

目的评价中国冠状动脉旁路移植手术风险评估系统(Sino System for Coronary Operative Risk Evalua-tion,SinoSCORE)对华西医院(本中心)成人心脏手术后院内死亡风险的预测价值。方法连续纳入2010年1月至2012年5月进入中国成人心脏外科数据库、本中心2 088例行心脏手术患者的临床资料,比较本中心与中国成人心脏外科数据库中所有患者术前危险因素的差异。计算每例患者的SinoSCORE累计积分,评价SinoSCORE预测本中心患者院内死亡风险的鉴别度和校准度。结果本中心2 088例患者中行冠状动脉旁路移植术(CABG)168例(8.05%),心瓣膜手术1 884例(90.23%),其它手术36例(1.72%)。本中心患者的高脂血症、脑卒中、心血管手术史、肾脏疾病等与中国成人心脏外科数据库中全部患者的差异有统计学意义。本中心患者实际术后院内病死率为2.25%(47/2 088),SinoSCORE预测院内病死率为2.35%(49/2 088)[95%CI(2.18,2.47)]。SinoSCORE预测本中心患者术后院内病死率的校准度(χ2=3.164,P=0.582)和鉴别度[受试者工作特征曲线下面积0.751,95%CI(0.719,0.924)]均较好。结论 SinoSCORE对中国西南地区成人心脏手术后院内死亡风险的预测虽高估风险,但仍适用。     

Complications of blood transfusions

Transfusion in any setting is associated with risk and has the potential to cause major morbidity and even mortality. Surgical patients may have a higher risk of transfusion-associated complications because of the increased likelihood of patients requiring unplanned components in an emergency setting. Risk factors for transfusion may include acute surgical bleeding or longstanding anaemia in elective patients who have pre-existing morbidity. This article outlines potential complications which can be broadly divided into immediate or delayed. Through awareness of transfusion-associated complications there can be prompt recognition and appropriate management. Where possible, prevention of complications is key to improve outcomes in surgical patients who require blood products.     

Strategies to avoid intraoperative blood transfusion

Transfusion of donor blood is sometimes unavoidable during the surgical episode. However, it is associated with adverse outcomes. Interventions that improve preoperative haemoglobin and reduce the need for donor transfusion a have positive impact upon outcome. The principle of reducing the need for transfusion is known as patient blood management (PBM) and incorporates three pillars (anaemia management, limitation of blood loss and use of alternatives to donor blood products, and restrictive transfusion triggers) when used in combination appear the most effective way to limit the impact of surgical blood loss.     

Anaemia and blood transfusion: incorporating patient blood management

Both red blood cell (RBC) transfusion and anaemia or low haematocrit increase morbidity and mortality associated with surgery. Chronic anaemia in the elective patient carries a small risk in non-haemorrhagic surgery. Where bleeding is anticipated anaemia should be treated medically to avoid (RBC) transfusion which will increase the risk to the patient. Major bleeding (MB) has the biggest impact on adverse outcomes. Acute anaemia is caused by surgical bleeding and requires RBC transfusion to keep the haematocrit (Hct) above 21% and haemoglobin (Hb) above 7 g/dl in patients without coronary artery disease (CAD) and between Hct 24–27% or Hb >8 g/dl in patients with CAD. Having a patient blood management programme can mitigate the problem. Medical, surgical and anaesthetic planning are paramount to avoid bleeding and transfusion which together have a significant impact on adverse outcomes for the patient.     

Strategies to avoid intraoperative blood transfusion

Anaemia and blood transfusion are risk factors in the perioperative setting. Effective management begins preoperatively and should be individualized. This article addresses the current evidence base for correction of preoperative anaemia, normalization of iatrogenic and pathological coagulopathy, intraoperative strategies for optimal blood product usage and management of postoperative anaemia.     

Anaemia and blood transfusion

Anaemia is a common diagnosis in surgical practice. It may impair oxygen delivery to tissues and cause significant complications. This article discusses definitions, critical levels of anaemia (along with transfusion triggers), an overview of the manufacture provision, and use of various blood products along with novel agents and research areas for the future.     

Anaemia and blood transfusion

Anaemia is a common diagnosis in surgical practice. It may impair oxygen delivery to tissues and cause significant complications. This article discusses definitions, critical levels of anaemia, along with transfusion triggers. An overview of the manufacture provision, and use of various blood products along with novel agents and research areas is also covered.     

Long-term Outcomes Among Noncuratively Treated Men According to Prostate Cancer Risk Category in a Nationwide,Population-based Study

Background

Limited data exist on long-term outcomes among men with prostate cancer (PCa) from population-based cohorts incorporating information on clinical risk category.

Objective

To assess 15-yr mortality for men with PCa treated with noncurative intent according to clinical stage, Gleason score (GS), serum levels of prostate specific antigen (PSA), comorbidity, and age.

Design, setting, and participants

Register-based cohort study of 76 437 cases in the National Prostate Cancer Register (NPCR) of Sweden diagnosed from 1991 through 2009 and treated with noncurative intent. Each case was placed in one of five risk categories: (1) low risk: T1–T2 tumor, PSA level <10 ng/ml, and GS ≤6; (2) intermediate risk: T1–T2 tumor and PSA level 10–<20 ng/ml or GS 7; (3) high risk: T3 tumor or PSA level 20–<50 ng/ml or GS ≥8; (4) regional metastases: N1 or T4 tumor or PSA level 50–100 ng/ml; and (5) distant metastases: M1 tumor or PSA ≥100 ng/ml.

Outcome measurements and statistical analysis

Ten- and 15-yr cumulative risk of death after diagnosis from PCa, cardiovascular disease, and other causes.

Results and limitations

Among men with a Charlson Comorbidity Index (CCI) score of 0, no differences were found in observed versus expected all-cause mortality in the low-risk group. Observed mortality was only slightly greater in the intermediate-risk group, but men with high-risk localized PCa or more advanced disease had substantially higher mortality than expected. CCI was strongly associated with cumulative 10-yr mortality from causes other than PCa, especially for men <65 yr. Limitations include potential misclassification in risk category due to GS assignment.

Conclusions

PCa mortality rates vary 10-fold according to risk category. The risk of death from causes other than PCa is most strongly related to comorbidity status in younger men.     

The Influence of Blood Transfusion on Mortality in Multiply Injured Patients

Abstract Background and Purpose: Severely injured patients often need large amounts of blood transfusion. Besides the life-saving effect, it is known to have negative side effects as well, affecting multiple organ systems. These side effects may add significantly to the already high mortality rate of these patients. This study was undertaken to determine the independent influence of the speed (= relative) as well as the total (= absolute) amount of blood transfusion given to multiply injured patients on mortality. Patients and Methods: All consecutive multiply injured patients with an Injury Severity Score (ISS) 18, based on the Hospital Trauma Index (HTI), treated over a 4-year period in the University Medical Center Utrecht, The Netherlands, were reviewed. Using cross tabulation analysis, the relation between relative and absolute blood transfusion and mortality was described. Potential transfusion-influencing factors were selected on the basis of literature and common knowledge. The independent effect of blood transfusion on mortality was calculated by means of nonparametric tests and binary logistic regression analysis. Results: The mean age of the 668 included patients was 36.8 years (standard deviation [SD] ± 18.5 years) and the median HTI-ISS 30 (range 18–75). 360 patients needed blood transfusion. Their mean relative blood transfusion was 8.5 PRBC_rel (SD ± 11) (and their mean absolute blood transfusion 12.7 PRBC_abs (SD ± 17). The overall mortality was 18.4%. The patients without blood transfusion (n = 308) had a mortality rate of 14%. The mortality rate of the patients with > 30 PRBC_rel relative transfusion (n = 14) was highest with 50%. Both relative as well as absolute transfusion displayed no significant influence on mortality. The HTI-ISS, hemothorax, splenic and hepatic injury, laparotomy, vascular or retroperitoneal injury, and fractures of the pelvis and/or femur were exhibited as having significant influence on blood transfusion. Conclusion: The seemingly significant influence of both relative and absolute blood transfusion on mortality, even in high amounts, disappeared after correction for the significant determinants mentioned above. Blood transfusion itself does not turn the scale in decision-making for treatment of severely injured patients.     

Bacteriological Evaluation of the Cardiac Surgery Environment Accompanying Hospital Relocation

Purpose Airborne bacteria in the environment are thought to be a cause of postoperative infection. With the relocation of our hospital, the operating room we had used for 35 years was replaced, changing the surgical environment for cardiac operation completely. We conducted this study to evaluate the bacteriological change in the surgical environment between the new and old operating rooms. Methods Airborne contaminants in the operating rooms were collected on blood agar plates, and samples of intraoperative salvaged blood from cardiac surgery were drawn from salvaged bags produced by Cell Saver 5 (Haemonetics, Braintree, MA, USA) in both the old (group O) and the new operating rooms (group N). These samples were cultured and evaluated bacteriologically. Results We collected nine samples of airborne contaminants from both group O and group N. The mean number of isolated bacteria colonies was 5.0 ± 1.2 in group O, and 2.0 ± 0.94 in group N (P < 0.001). Bacterial growth was detected in 85% of the salvaged blood samples from group O (n = 20) versus 60% from group N (n = 15) (P = 0.09). The mean bacteria count was 1.9 ± 2.7 colony-forming units (cfu)/ml in group O versus 0.4 ± 0.5 cfu/ml in group N (P = 0.032). Conclusion Hospital relocation resulted in an improved operating room environment with less bacterial contamination of intraoperative salvaged blood.     

肝移植术患者术中大量输血的危险因素分析

目的 通过对肝移植受体大样本资料的回顾分析,寻找与围术期大量输血有关的危险因素,建立适合国内患者的风险模型.方法 回顾性分析北京大学人民医院2004年7月至2009年2月的263例肝移植受体的临床资料.以术中红细胞输入量是否≥12 U将患者分为两组,比较两组患者术前变量的差异,并对其与术中大量输血之间的关系进行Logistic回归分析.结果 既往上腹部手术史、大量腹水、血清总胆红素、血小板计数(Plt)和红细胞压积(Hct)与术中大量输血存在相关性(P<0.10).成人终末期肝病(ELSD)肝移植术中大量输血发生的预测模型(PSMT)为y=2.591+1.484×上腹部手术史+0.457×大量腹水+0.002×血清总胆红素值-0.004×Plt-0.058×Hct.结论 既往有上腹部手术史、腹水≥20 ml/kg、血清总胆红素升高、Pit和Hct降低是引起术中大量输血的危险因素.     

心脏手术后谵妄的危险因素分析及预测模型构建

目的 探讨心脏手术患者术后谵妄(POD)的危险因素,根据危险因素构建预测模型并评估其预测效能。
方法 本研究为回顾性病例-对照研究。收集2016年5月至2019年5月行心脏手术治疗的患者3 397例临床资料,提取性别、年龄、吸烟史、饮酒史、高血压病史、糖尿病史、高脂血症病史、脑血管疾病史、手术时间、心肺转流（CPB）时间、主动脉阻断时间、术中连续有创动脉血压值、术中出血量、术中麻醉药物使用情况、入ICU时Hb、白细胞计数、氧合指数（PaO2/FiO2）、血乳酸值、呼吸机使用时间、血管活性药物使用情况、术后左心室射血指数（LVEF）等临床指标,采用单因素分析评估上述指标与POD的相关性。采用逐步Logistic回归进行临床指标筛选并构建预测模型,绘制模型列线图,计算预测模型的受试者工作特征（ROC）曲线下面积（AUC）以及最佳阈值下的敏感性和特异性。
结果 有186例（5.48%）患者术后出现谵妄。与非谵妄患者比较,谵妄患者年龄、脑血管疾病和高血压病史比例、术中低血压比例、术中血压变异率、术中丙泊酚用量、术中出血量、术后乳酸值、术后白细胞显著增高的比例、术后左心室收缩功能不全（LVEF<50%）的比例以及术后应用肾上腺素和去甲肾上腺素比例明显增加（P<0.05）,手术时间和CPB时间、术中低血压时间以及术后机械通气时间明显延长（P<0.05）,术后氧合指数和Hb明显降低（P<0.05）。逐步Logistic回归分析显示,老年、脑血管疾病史、手术时间长、术中血压变异率大、术后Hb<100 g/L、机械通气时间延长以及左心室收缩功能不全、应用去甲肾上腺素是心脏手术后谵妄的独立危险因素。应用这些危险因素构建预测模型,AUC为0.932（95%CI 0.897～0.967）,敏感性78.2%,特异性93.5%。
结论 老年、脑血管疾病史、手术时间、术中血压变异率、术后Hb<100 g/L、机械通气时间延长以及左心室收缩功能不全、应用去甲肾上腺素是心脏手术后谵妄的独立危险因素,基于这些危险因素构建的模型可较好地预测心脏手术后谵妄的发生,为早期干预治疗提供参考。     

Prospective randomized controlled trial of acute normovolaemic haemodilution in major gastrointestinal surgery

Background. The efficacy of acute normovolaemic haemodilution(ANH) remains uncertain because of a lack of well-designed prospectiverandomized controlled trials. The aim of this study was to assessthe effects of ANH on allogeneic transfusion, postoperativecomplications, and duration of stay. Methods. Consecutive patients undergoing major gastrointestinalsurgery were randomized to a planned 3-unit ANH, or no ANH.Both groups underwent identical management including adherenceto a transfusion protocol after surgery. Outcome measures includedthe number of patients receiving allogeneic blood, complications,and duration of stay. Results. 380 patients were screened of which 160 were includedin the study, median age was 62 yr (range 23–90), ‘ANH’n=78, ‘no ANH’ n=82. There was no significant differencebetween groups in the number of patients receiving allogeneicblood 22/78 (28%) vs 25/82 (30%), the total number of allogeneicunits transfused (90 vs 93), complication rate, or durationof stay. Haemodilution significantly increased anaesthetic time,median 55 (range 15–90) vs 40 min (range 17–80)(P<0.001). Significantly fewer patients in the ANH groupexperienced oliguria in the immediate postoperative period 37/78(47%) vs 55/82 (67%) (P=0.012). The most significant factorsaffecting transfusion were blood loss, starting haemoglobin,and age. When compared with ASA-matched historical controls,the introduction of a transfusion protocol reduced the transfusionrate in colorectal patients from 136/333 (41%) to 37/138 (27%),P=0.004. Conclusions. In this large pragmatic study, ANH did not affectallogeneic transfusion rate in major gastrointestinal surgery.Preoperative haemoglobin, blood loss, and transfusion protocolare the key factors influencing allogeneic transfusion.     

自体输血技术在脊柱外科手术中的应用

目的：探讨自体输血技术在脊柱外科手术中的作用及优点。方法：对213名进行脊柱手术的患者作了比较，患者分为对照组（103例）和实验组（110例）。实验组采用术前预存血和术中自体血回收技术输入自体血，对照组全部使用异体输血。结果：对照组患者平均输入异体血890ml，实验组患者平均输入异体血120ml。结论：在脊柱外科手术中，行内固定和椎间融合等中、大型手术的出血量较多，采用术前预存自体血及术中引流血回输技术可以大大减少异体输血量以及由此带来的各种异体输血后并发症的发生。     

Contemporary outcomes of open thoracic aortic surgery in a veteran population: do risk models exaggerate mortality?

Background

We evaluated contemporary outcomes of open thoracic aortic surgery at a Veterans Affairs (VA) medical center affiliated with a major academic aortic program and examined the predictive value of 2 established cardiac risk models.

Methods

We retrospectively reviewed all open thoracic aortic operations performed between April 1998 and April 2008 (n = 100). Both the EuroSCORE and the VA Continuous Improvement in Cardiac Surgery Program (CICSP) scores were evaluated.

Results

Procedures included ascending aortic repair (n = 74, 15 with arch repair), descending thoracic repair (n = 11, 1 with arch repair), and thoracoabdominal aortic repair (n = 15). Emergency surgery was necessary in 15 cases, and 19 procedures were reoperations. The patients' logistic EuroSCORE and the CICSP scores were similar (18.7% and 18.2%, respectively), but both scores significantly exceeded the observed operative mortality rate (8.0%, P = .008).

Conclusions

Good outcomes can be achieved when thoracic aortic surgery is performed at an experienced VA center. The cardiac risk models we examined overpredicted operative mortality.