1.
Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference
Mueller MM, Van Remoortel H, Meybohm P, Aranko K, Aubron C, Burger R, Carson JL, Cichutek K, De Buck E, Devine D, et al
Jama. 2019;321(10):983-997
Abstract
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 Review: The 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 17607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23143 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 Relevance: The 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.
2.
The impact of a restrictive transfusion trigger on post-operative complication rate and well-being following elective orthopaedic surgery: a post-hoc analysis of a randomised study
So-Osman C, Nelissen R, Brand R, Faber F, Slaa RT, Stiggelbout A, Brand A
Blood Transfusion. 2013;11((2):):289-95.
Abstract
BACKGROUND Peri-operative red blood cell transfusions have been associated with post-operative complications in patients undergoing elective orthopaedic hip or knee replacement surgery. MATERIALS AND METHODS We performed a post-hoc analysis of data extracted from a randomised study on transfusion triggers using pre-storage leucocyte-depleted red blood cells. Patients who were assigned to the most restrictive transfusion policy (restrictive group) were compared with patients who were assigned to the most liberal policy (liberal group). End-points were red blood cell use, hospital stay, haemoglobin levels, post-operative complications and quality of life scores. RESULTS Of 603 patients, 26.4% patients in the restrictive group and 39.1% in the liberal group were transfused (P =0.001). The rate of post-operative infections was lower, although not statistically significantly so, in the restrictive group than in the liberal group (5.4% vs. 10.2%, respectively) as was the rate of respiratory complications (1.7% vs. 4.9%, respectively), whereas hospital stay, cardiovascular complications and mortality rate were not different in the two groups. Quality of life scores were not associated with type of transfusion policy, the number of red blood cell transfusions or the transfusion status. DISCUSSION A restrictive transfusion protocol was not associated with worse outcome and resulted in a lower transfusion rate compared to the liberal policy. Well-being (quality of life) was not associated with transfusion policy or with red blood cell transfusions.
3.
A randomized comparison of transfusion triggers in elective orthopaedic surgery using leucocyte-depleted red blood cells
So-Osman C, Nelissen R, Te Slaa R, Coene L, Brand R, Brand A
Vox Sanguinis. 2010;98((1):):56-64.
Abstract
OBJECTIVE In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. STUDY DESIGN AND METHODS A randomized, controlled study. A new uniform, restrictive transfusion policy was compared with standard care, which varied among the three participating hospitals. Only prestorage leucocyte-depleted RBC(s) were used. Primary end-point was RBC usage, related to length of hospital stay. Secondary end-points were Hb levels, mobilization delay and postoperative complications. RESULTS Six hundred and three patients were evaluated. Adherence to the protocol was over 95%. Overall mean RBC usage was 0. 78 U/patient in the new policy group and 0. 86 U/patient in the standard care policy group (mean difference 0. 08;95% CI [-0. 3; 0. 2]; P = 0. 53). In two hospitals, the new transfusion policy resulted in a RBC reduction of 30% (0. 58U RBC/patient) (P = 0. 17) and 41% (0. 29 U RBC/patient) (P = 0. 05) respectively. In the third hospital, however, RBC usage increased by 39% (0. 31 U RBC/patient) (P = 0. 02) with the new policy, due to a more restrictive standard care policy in that hospital. Length of hospital stay was not influenced by either policy. CONCLUSIONS Implementation of a uniform transfusion protocol for elective lower joint arthroplasty patients is feasible, but does not always lead to a RBC reduction. Length of hospital stay was not affected.
4.
A randomized comparison of transfusion triggers in elective orthopedic surgery using leukocyte-depleted red blood cells
So-Osman C, Nelissen R, Te Slaa R, Coene L, Brand R, Brand A
Transfusion Alternatives in Transfusion Medicine. 2008;10((Suppl 1):):30. Abstract No. P31.
5.
Pre-operative risk factors for a red blood cell transfusion in elective orthopaedic surgery
So-Osman C, Nelissen RGHH, Brand R, Brand A
Vox Sanguinis. 2007;93((Suppl 1):):267-8.. Abstract No. P-556.