How well does your massive transfusion protocol perform? A scoping review of quality indicators
Sanderson B, Coiera E, Asrianti L, Field J, Estcourt LJ, Wood EM
Blood transfusion = Trasfusione del sangue. 2020
BACKGROUND Management of patients with major haemorrhage often requires urgent administration of multiple blood products, commonly termed a massive transfusion (MT). Clinical practice in these scenarios is supported in part by evidence-based MT guidelines, which typically recommend use of an MT protocol (MTP). MTPs aim to provide practical and specific interpretation of MT guidelines for local institutional use, outlining tasks and pre-configuration of blood product packs to be transfused to provide efficient and evidence-based transfusion management. Institutions can support this aim by the measurement of MTP performance and patient outcomes through collection of quality indicators (QI). Many international guidelines now recommend the routine collection of a range of QIs relating to MT/MTP; however, there is significant variation in procedures and no benchmarks or minimal evidence to guide practice. MATERIALS AND METHODS We conducted a scoping review to document and evaluate reported QIs for MTP. We conducted a search of CENTRAL, MEDLINE and EMBASE for published studies from inception until May 14, 2020, that reported at least one MTP QI and use of an MTP or equivalent protocol. Included studies were evaluated using a QI classification system based on current MT QI guidelines and the Donabedian QI framework. RESULTS We identified 107 eligible studies. Trauma patients were the most commonly evaluated group, and total blood products transfused and in-hospital mortality were the most commonly reported QIs. Reflecting the lack of international consensus and benchmarks, we found significant variability in the reporting of QIs, which often did not reflect guideline recommendations. DISCUSSION Our review highlights the importance of establishing international consensus on prioritised QIs with quantifiable targets that are important to the process of MT.
A randomized trial of the safety and benefit of transfusion vs. standard care in the prevention of sickle cell-related complications in adults: a preliminary report from the phase II NHLBI Comprehensive Sickle Cell Centers (CSCC) study of neuropsychological dysfunction and neuroimaging abnormalities in neurologically intact adult patients with sickle cell disease
Vichinsky E, Neumayr L, Gold JI, Weiner MW, Kasten J, Truran D, Snyder C, Kesler K, Hussein AM, Harrington TJ, et al
Blood. 2010;116((21):): Abstract No. 3221.
Bone bleeding during total hip arthroplasty after administration of tranexamic acid
Garneti N, Field J
The Journal of Arthroplasty. 2004;19((4):):488-92.
Numerous methods of controlling bleeding during total hip arthroplasty have been used. Thromboplastic agents have been used with some success, but the resultant fibrin layer interposed between the bone and cement weakens the interface. Topical freezing saline and hypotensive anesthesia have proved to be the most effective to date. The goal of this randomized, double blind, controlled study is to determine the effect of a single bolus dose of tranexamic acid, administered at the time of anesthesia, on bleeding during primary total hip arthroplasty. Fifty patients were randomized to receive either 10 mg/kg of tranexamic acid or a similar volume of normal saline as a preoperative bolus. Patients were not given pharmacologic thrombotic prophylaxis until 48 hours after surgery. The goal was to measure blood loss from the femoral canal at the time of surgery. An estimate of the internal and external blood loss during and after surgery was performed, and the transfusion requirement was recorded. No significant difference was found between the groups in terms of blood loss from the femoral canal, the perioperative bleeding, and postoperative hemoglobin. In the group that received tranexamic acid, a greater number of patients required transfusion than in the placebo group. The results of this study do not support the routine use of tranexamic acid in primary total hip arthroplasty.
Aprotinin (Trasylol) does not reduce bleeding in primary total hip arthroplasty
Langdown AJ, Field J, Grote J, Himayat H
Journal of Arthroplasty. 2000;15((8):):1009-12.
This is a randomized, double-blind, controlled study of the effects of aprotinin (Trasylol) during primary total hip arthroplasty. Sixty patients were randomized to receive either 1.5 x 10(6) KIU of aprotinin or a similar volume of normal saline as a bolus preoperatively. Blood loss was measured from the femoral canal at the time of surgery. An estimate of the total blood loss during the operation was made, and the transfusion requirement was recorded. There was no significant difference between the groups in terms of total blood loss, postoperative hemoglobin, or transfusion requirement. In the group that received aprotinin, there was a trend toward reduced blood loss from the femoral canal, but this was not statistically significant. The results of this study do not support the routine use of aprotinin in primary total hip arthroplasty.