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Overtransfusion


Intraoperative Blood Management

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Overtransfusion


Intraoperative Blood Management

The Overtransfusion Epidemic

Transfusions are the single most commonly billed hospital in-patient procedure. 15 million transfusions are performed annually in the U.S., with a direct cost of $10-$15 billion annually. A recent study by Premier, a healthcare performance improvement alliance of approximately 2,900 U.S. community hospitals and 100,000 alternate sites, looked at 464 member hospitals and concluded that blood utilization represents the eighth highest savings opportunity for hospitals – a savings of $1.06 million per hospital, per year.

Empirical distribution of percentage morbidity with respect to difference between actually transfused and model-estimated numbers of packs of red blood cells (PRBC). Source: Simeone et al. BMC Medical Informatics and Decision Making. 2011, 11:44

Empirical distribution of percentage morbidity with respect to difference between actually transfused and model-estimated numbers of packs of red blood cells (PRBC). Source: Simeone et al. BMC Medical Informatics and Decision Making. 2011, 11:44

Overuse 

Up to 60% of RBC transfusions are inappropriate. [1] A recent study of 48,000 patients at Johns Hopkins reported wide variability in intraoperative blood use among clinicians when using Hb (g/dl) values to trigger transfusions [2]

Risk

Blood transfusion significantly increases patient risk of mortality (88%), infections (69%), and acute respiratory distress syndrome, ARDS (250%) [3] and cancer recurrence (42%) [4]

 

Cost

The direct cost of an RBC unit is estimated to be as high as  $1,183/unit, [5] and the incremental cost of bleeding-related complications and transfusion is reported to be as high as $17,279 per patient. [6]

 

“Blood conservation is one of the few areas in medicine where outcomes can be improved, risk reduced, and costs saved, all at the same time.” 

Steven Frank, MD
Johns Hopkins University


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Hemodilution Effect


Limitation of Hb/Hct Monitoring

Hemodilution Effect


Limitation of Hb/Hct Monitoring

Limitations of Hb/Hct Triggers 

Over-reliance on the Hb/Hct triggers for transfusion decision making has been called into question. Use of Hb/Hct alone may overstate anemia, potentially leading to unnecessary transfusion since the volemic status of the patient is unknown. Specifically, intra-operative Hb/Hct measurements are subject to the following limitations: 

Demonstration of the Hemodilution Effect. Source: Marino PL, Sutin KM. The ICU Book. Lippincott Williams & Wilkins; 2012. 

Demonstration of the Hemodilution Effect. Source: Marino PL, Sutin KM. The ICU Book. Lippincott Williams & Wilkins; 2012. 

 

  • Hb/Hct is confounded by intravascular hemodilution due to crystalloid/colloid infusion, blood transfusion, insensible losses, third spacing, or acute hemorrhage.

  • In the early hours after a bleeding event, the Hb/Hct is only a reflection of the resuscitation effort and not the true reduction in red cells  [7-9]

  • Hb/Hct measurments are often delayed or highly unreliable in the dynamic surgical setting. [10]

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Estimation of Blood Loss


Visual Estimation of Blood Loss is Inaccurate.

Estimation of Blood Loss


Visual Estimation of Blood Loss is Inaccurate.

Clinical need for Accurate Blood Loss Monitoring

Estimation of blood loss (EBL) during surgery has been an enigma for decades, and studies have shown the current practice of “eyeballing” to be wildly inaccurate. This has fueled an epidemic of overtransfusion in surgical patients, with 20-60% of transfusions reported as unnecessary.

Vicki Ting, MD discusses the clinical importance of estimating blood loss accurately.

Visual estimation

Visual estimation is highly inaccurate. Clinicians underestimating at high volumes and overestimating at low volumes, most likely resulting in under- or over-transfusion [11-12]. Didactic training has failed to show long-term retention of estimation skills. [13]

Gravimetric Method

The gravimetric/volumetric estimation of blood loss by weighing soaked sponges and subtracting their known dry weight is laborious and inaccurate to the presence of confounding nonsanguineous fluids (e.g., saline, ascites, amniotic fluid). [14-16]

Lab Photometry

Rinsing and assaying Hb content from blood-absorbing media is used in research studies but is impractical for OR use. [14-16] Hemoglobin values (g/dl) have been shown to be poor predictors of intraoperative blood loss due to the dynamic volemic status of the patient.

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References


Intraoperative Blood Management Literature

References


Intraoperative Blood Management Literature

Clinical Literature

Learn more about Blood Management and the need for accurate intraoperative Hb Loss Monitoring

  1. Shander et. al., TransMed Rev. 2011. 232-246

  2. Frank et. al. Anesthesiology. 2012 Jul;117(1):99-106

  3. Marik et. al., Crit Care Med. 2008. 36(9):2667-74

  4. Nikolsky et. al., JACC: Cardiovascular Interventions. 2009. 624-632 

  5. Shander et al.Transfusion. 2010. 50(4): 753-765

  6. Stokes et. al., BMC Health Services Research. 2011. 11:23

  7. Marino et. al., The ICU Book. Lippincott Williams & Wilkins; 2012 

  8. Van et. al., J Trauma. 2011;70(3):646-51.

  9. S. Naqvi et. al., Transfusion. 2012. 52(Supplement):7A

  10. Gayat et. al., PLoS ONE. 2012;7(1):e30065.

  11. Schorn MN. J Midwifery Womens Health. 2010;55(1):20-7.

  12. Budny, et. al., Burns. 1993 Apr;19(2):134-7.

  13. Toledo et. al., Simul Healthc. 2012 Feb;7(1):18-21

  14. Konig et. al., Anesth Analg. 2014 May 6. [Epub ahead of print]

  15. Holmes et. al., Anesth Analg. 2014 May 6. [Epub ahead of print]

  16. Satish et. al., Obstet Gynecol. 2014 May;123 Suppl 1:170S