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Noninvasive hemoglobin monitoring for maintaining hemoglobin concentration within the target range during major noncardiac surgery: A randomized controlled trial
Park, S. K., Hur, C., Kim, Y. W., Yoo, S., Lim, Y. J., Kim, J. T.
Journal of clinical anesthesia. 2023;93:111326
Abstract
STUDY OBJECTIVE The effect of noninvasive CO-oximetry hemoglobin (SpHb) monitoring on the clinical outcomes of patients undergoing surgery remains unclear. This trial aimed to evaluate whether SpHb monitoring helps maintain hemoglobin levels within a predefined target range during major noncardiac surgeries with a potential risk of intraoperative hemorrhage. DESIGN A single-center, prospective, randomized controlled trial. SETTING University hospital. PATIENTS One hundred and thirty patients undergoing elective noncardiac surgery with a potential risk of hemorrhage. INTERVENTIONS Patients were randomly allocated to undergo either SpHb-guided management (SpHb group) or usual care (control group). MEASUREMENTS The primary outcome was the rate of deviation of the total hemoglobin concentration (determined from laboratory testing) from a pre-specified target range (8-14 g/dL). This was defined as the number of laboratory tests revealing such deviations divided by the total number of laboratory tests performed during the surgery. MAIN RESULTS The primary outcome occurred significantly less frequently in the SpHb group as compared to that in the control group (15/555 [2.7%]) vs. 68/598 [11.4%]; relative risk, 0.24; 95% confidence interval, 0.13-0.41; P < 0.001). Fewer point-of-care blood tests were performed in the SpHb group than in the control group (median [interquartile range], 2 [1-4] vs. 4 [2-5]; P < 0.001). There were no significant intergroup differences in the number of patients who received red blood cell transfusions during surgery (SpHb vs. control, 33.8% vs. 46.2%; P = 0.201). The incidence of unnecessary red blood cell preparation (>2 units) was lower in the SpHb group than in the control group (3.1% vs. 16.9%; P = 0.024). CONCLUSIONS Compared with routine care, SpHb-guided management resulted in significantly lower rates of hemoglobin deviation outside the target range intraoperatively in patients undergoing major noncardiac surgeries with a potential risk of hemorrhage. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (identifier: NCT03816514).
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Optimisation and Effect Analysis of the Blood Collection Method in Pre-Deposit Autotransfusion Patients Undergoing Thoracotomy Surgery
Jia, L., Wang, Y., Zhang, W., Lin, Y., Chen, F., Wan, Y., Fu, X.
Journal of multidisciplinary healthcare. 2023;16:2793-2798
Abstract
BACKGROUND AND PURPOSE To explore the feasibility of the modified blood collection method in pre-deposit autotransfusion in patients undergoing thoracotomy surgery. METHODS This double-blinded randomised controlled trial enrolled 92 patients from the cardiothoracic surgery department from February 2019 to October 2020. RESULTS Compared with the conventional blood collection method, the modified blood collection method avoided blood overflow from the oblique plane of the needle (χ(2) = 61.986, P < 0.01) and reduced the diameter of the bruising area after 24 hours (χ(2) = 24.611, P < 0.01). Furthermore, due to optimising the blood collection method, diastolic blood pressure reduced slightly before and after blood collection (t = 2.036, P < 0.05), and patients in the test group had less pain (based on the numerical rating score) (t = 5.556, P < 0.01). Meanwhile, the time required to collect 400 mL of blood was shortened (t = 17.744, p < 0.01). CONCLUSION An improved blood collection method can enhance the blood donation experience, avoid blood spillage, lessen pain and reduce adverse reactions. This may be of great significance in ensuring blood quality and the safety of subsequent transfusions. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov Identifier: NCT05539846.
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3.
Evaluation of a novel Cardiac Peri-Operative Transfusion Trigger Scoring system in patients with coronary artery disease
Ma HP, Zhang L, Chen CL, Li J, Ma ZT, Jiang QQ, Liang YY, Li SS, Long F, Zheng H
BMC cardiovascular disorders. 2021;21(1):40
Abstract
BACKGROUND A simple and accurate scoring system to guide perioperative blood transfusion in patients with coronary artery disease (CAD) undergoing cardiac surgery is lacking. The trigger point for blood transfusions for these patients may be different from existing transfusion guidelines. This study aimed to evaluate the safety and efficacy of a new scoring strategy for use in guiding transfusion decisions in patients with CAD. METHODS A multicenter randomized controlled trial was conducted at three third-level grade-A hospitals from January 2015 to May 2018. Data of 254 patients in a Cardiac Peri-Operative Transfusion Trigger Score (cPOTTS) group and 246 patients in a group receiving conventional evaluation of the need for transfusion (conventional group) were analysed. The requirements for transfusion and the per capita consumption of red blood cells (RBCs) were compared between groups. RESULTS Baseline characteristics of the two groups were comparable. Logistic regression analyses revealed no significant differences between the two groups in primary outcomes (1-year mortality and perioperative ischemic cardiac events), secondary outcomes (shock, infections, and renal impairment), ICU admission, and ICU stay duration. However, patients in the cPOTTS group had significantly shorter hospital stays, lower hospital costs, lower utilization rate and lower per capita consumption of transfused RBCs than controls. Stratified analyses revealed no significant differences between groups in associations between baseline characteristics and perioperative ischemic cardiac events, except for hemofiltration or dialysis and NYHA class in I. CONCLUSIONS This novel scoring system offered a practical and straightforward guideline of perioperative blood transfusion in patients with CAD. Trial registration chiCTR1800016561(2017/7/19).
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Thromboelastometry and a hemostasis management system are most beneficial for guiding hemostatic therapy in cardiac surgery patients with a EuroSCORE II of >/=1.83%: a randomized controlled two-step trial
Kodaka M, Ichikawa J, Ando K, Komori M
J Anesth. 2020
Abstract
PURPOSE We evaluated the efficacy of hemostatic therapy based on point-of-care (POC) testing in patients undergoing cardiac surgery. METHODS This was a single-institution, prospective, randomized, double-blinded study. In step 1, 90 patients scheduled for elective cardiac surgery underwent complete blood count and fibrinogen measurements at baseline, after cardiopulmonary bypass (CPB) initiation (CPB start), just after CPB end, and in the intensive care unit (ICU). In step 2, 72 patients scheduled for elective cardiac surgery underwent conventional laboratory coagulation tests (control group) or POC coagulation tests (POC group). Transfusions were prepared using the fibrinogen and platelet values at mainly "CPB start" for the control group, and using the ROTEM values at mainly "CPB end" for the POC group. Consequently, the step 2 patients were divided into high- and low-risk subgroups based on the EuroSCORE II by logistic regression analysis; transfusion data and bleeding volumes were compared between the control and POC groups within the high- and low-risk subgroups. RESULTS In step 1, all blood components were significantly decreased at CPB start compared with baseline, and platelet and fibrinogen levels remained almost constant from CPB start to end. In step 2, the transfusion rates and perioperative bleeding volumes did not significantly differ between the control and POC groups. Subgroup analysis suggested that only the high-risk subgroup significantly differed regarding perioperative red blood cell transfusion and total bleeding volume in the ICU. CONCLUSIONS POC testing is beneficial for cardiac surgery patients with a EuroSCORE II of ≥1.83%.
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A cluster-randomized controlled trial of a blood conservation algorithm in patients undergoing total hip joint arthroplasty
Wong CJ, Vandervoort MK, Vandervoort SL, Donner A, Zou G, MacDonald JK, Freedman J, Karkouti K, MacDonald SJ, Feagan BG
Transfusion. 2007;47((5):):832-41.
Abstract
BACKGROUND The optimum strategy for reducing allogeneic blood transfusion in patients undergoing total hip joint arthroplasty (THJA) is unknown. STUDY DESIGN AND METHODS The effectiveness of a comprehensive blood conservation algorithm (BCA) was evaluated by means of a cluster randomization trial. Thirty hospitals performing primary THJA were randomly assigned to implement the algorithm or to continue with usual care (UC). Subsequently, the institutional rate of allogeneic transfusion was determined for 60 consecutive patients who underwent surgery at each site. The BCA consisted of patient and provider education, hemoglobin-based recommendations for specific blood conservation strategies (recombinant human erythropoietin [rHuEPO] or autologous blood donation [ABD]) and transfusion guidelines. The main outcome measure was the institutional allogeneic transfusion rate. RESULTS One hospital withdrew consent after randomization, resulting in 14 hospitals assigned to BCA and 15 to UC. In the BCA arm, the institutional rates of rHuEPO use and ABD participation were 20. 1 and 27. 1 percent compared to 0. 6 and 25. 8 percent, respectively, in the UC arm. The allogeneic transfusion rate was substantially reduced in hospitals assigned to the BCA group (p = 0. 02; absolute risk reduction, 9. 6% [26. 1% UC vs. 16. 5% BCA]). Multivariate analysis of patient-level data showed that assignment to the UC arm was an independent risk factor for allogeneic transfusion (p = 0. 037; odds ratio, 1. 8; 95% confidence interval, 1. 0-3. 1) when adjusted for other prognostic factors. No differences were observed in the use of autologous blood. CONCLUSION A comprehensive approach to blood conservation was superior to UC for reducing allogeneic transfusion in patients undergoing THJA.
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A prospective randomized trial of the surgical blood order equation for ordering red cells for total hip arthroplasty patients
Nuttall GA, Santrach PJ, Oliver WC Jr, Ereth MH, Horlocker TT, Cabanela ME, Trousdale RT, Bryant S, Currie TW
Transfusion. 1998;38((9):):828-33.
Abstract
BACKGROUND The majority of crossmatched blood is for surgical patients, and most of it is never transfused. An alternative system for ordering red cell (RBC) units, called the surgical blood order equation (SBOE), which incorporates specific patient variables for surgical patients, has been developed. STUDY DESIGN AND METHODS A prospective double-blind randomized trial compared the SBOE with the maximal surgical blood order schedule (MSBOS) system for ordering allogeneic RBC units in 60 patients undergoing total hip arthroplasty. Autologous RBCs were available for none of the patients. RESULTS There were no differences in patient demographic, surgical, or laboratory variables at any time. The median number (range) of allogeneic RBC units ordered was 2 (2-3) for the MSBOS and 0 (0-3) for the SBOE (p<0.0001). The SBOE ordered the correct number of RBC units for 58 percent of patients, while the MSBOS did so for 7 percent (p<0.0001). The SBOE had a lower crossmatch-to-transfusion ratio than the MSBOS (0.83 vs. 4.12). Costs were also lower with the SBOE. CONCLUSION Incorporation of patient factors in the use of the SBOE system resulted in increased efficiency of blood-ordering practices for total hip arthroplasty.
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Prospective evaluation and clinical utility of on-site monitoring of coagulation in patients undergoing cardiac operation
Despotis GJ, Santoro SA, Spitznagel E, Kater KM, Cox JL, Barnes P, Lappas DG
Journal of Thoracic & Cardiovascular Surgery. 1994;107((1):):271-9.
Abstract
Although laboratory coagulation tests permit a rational approach to both diagnosis and management of coagulation disorders after cardiopulmonary bypass, their clinical utility is limited by delays in obtaining results. This study was designed to evaluate prospectively the impact of on-site coagulation testing on blood product use, operative time, and intraoperative management of microvascular bleeding. Patients who underwent cardiac procedures involving cardiopulmonary bypass and subsequently developed microvascular bleeding were randomly assigned to receive either standard therapy (n = 36) or therapy defined by a treatment algorithm based on results from an on-site coagulation monitoring laboratory (n = 30). No differences were found between treatment groups in hematologic assay data, operative procedures, or duration of cardiopulmonary bypass. Patients treated in accordance with on-site laboratory results (algorithm therapy) received significantly less intraoperative fresh frozen plasma (0.4 +/- 1.1 U versus 2.4 +/- 2.8 U; p = 0.0006) during the treatment interval, had shorter operative times, and had less mediastinal chest tube drainage during the initial perioperative interval (158 +/- 169 ml versus 326 +/- 258 ml; p = 0.003) than did patients in the standard therapy group. Patients who underwent algorithm therapy also received fewer platelet (1.6 +/- 5.9 versus 6.4 +/- 8.2 U; p = 0.02) and red blood cell (1.9 +/- 1.7 U versus 4.1 +/- 4.1 U; p = 0.01) transfusions after the operation. Nine of 36 (25%) standard group patients received initial therapy which differed from that which would have been guided by the on-site algorithm protocol. Our findings indicate that rapid and accurate coagulation test results can guide specific therapy and optimize treatment of microvascular bleeding in patients who undergo cardiac operations.
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The effect of an intraoperative treatment algorithm on physicians' transfusion practice in cardiac surgery
Despotis GJ, Grishaber JE, Goodnough LT
Transfusion. 1994;34((4):):290-296.
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9.
Effects of computer-controlled transfusion on recovery from cardiac surgery
Morgan A, Anderson W, Bevilacqua R, Cohn L, Moore FD, Collins JJ Jr
Annals of Surgery. 1973;178((4):):391-8.