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Perioperative red blood cell transfusion for patients undergoing elective non-cardiac surgery: an audit at a Chinese tertiary hospital
Transfusion and Apheresis Science 51 (2014) 99–103
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Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Perioperative red blood cell transfusion for patients undergoing elective non-cardiac surgery: an audit at a Chinese tertiary hospital Chiu-Wen Chou 1,*, Rongrong Xu 1, Lu Yang, Wenqi Huang Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
A R T I C L E
I N F O
Article history: Received 2 March 2014 Received in revised form 25 July 2014 Accepted 14 August 2014 Keywords: Transfusion practices RBC transfusion
A B S T R A C T
Perioperative blood transfusion still takes a large proportion in inappropriate blood transfusion. As the data are limited in China, we reported a perioperative red blood cell (RBC) transfusion practices in a tertiary hospital in Guangzhou, China. In 2008–2009, patients who underwent elective surgeries receiving RBC transfusions were recorded and the rate of overtransfusion was analyzed. Overtransfusion was defined as discharge hemoglobin (Hb) exceeding 10g/dL. The median amount of RBC transfused perioperatively was four units in all 2572 patients. The overall rate of overtransfusion was 48.6% and the Department of Neurosurgery had the highest overtransfusion rate. These results are of great use for the future management of blood resource. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Perioperative inappropriate transfusion is still a significant issue in clinical practice. Allogenic blood transfusion has been associated with an increased incidence of different types of complications: infectious complications, immunological reactions, tumor recurrence, and decreased survival [1]. Some studies have suggested an association between perioperative blood transfusion and the prognosis in various types of cancer [2–4]. Multiple studies also demonstrated a negative impact on mortality and morbidity as the number of units of blood transfused per patient increases [5–7]. On the other hand, blood products are scarce and cherish resources resulting in high medical expenditure [8]. Previous researches have demonstrated that there are important levels of transfusions considered to be inappropriate among health care providers all over the world [9]. In China, blood is collected by the local government from volunteer donors.
1The authors contributed equally for this article. * Corresponding author. Tel.: +862087750632 ext. 8273. E-mail address: [email protected] (C.-W. Chou).
http://dx.doi.org/10.1016/j.transci.2014.08.012 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
Less than 9% of the Chinese populations donate blood while the demand is estimated to increase 10% every year. Although there are interventions to reduce inappropriate transfusion with variable effectiveness [10], inappropriate blood transfusion still take 19–75% in perioperative blood transfusion [11–18]. The unnecessary red blood cell (RBC) use is due to inappropriate decision to transfuse and excessive use of RBC. Undoubtedly, there is a need for institutions to review blood usage to ensure the appropriate use of resources, especially in surgery which is a large consumer of blood products. Furthermore, it would be useful to recognize the likelihood of RBC transfusion associated with particular surgical units so that the healthcare providers may be made aware of unnecessary blood transfusion. While such information has been provided in other countries, similar data are not available for the Chinese population yet. Although the accuracy of retrospective transfusion studies has been questioned [19], previous studies showed that the audits of transfusion practice do have a role in identifying and decreasing the rate of inappropriate transfusion [20–22]. Therefore, we conducted a retrospective study to evaluate the perioperative RBC transfusion practices and the extent of overtransfusion in our hospital. There are several
100
C.-W. Chou et al./Transfusion and Apheresis Science 51 (2014) 99–103
different criteria about inappropriate overtransfusion. According to the report from Edwards, it was suggested discharge hemoglobin level could be taken as a surrogate marker for RBC utilization appropriateness. In fact, the last Hb prior to discharge from the hospital is a much better measure for auditing transfusions since it represents the true endpoint of transfusion therapy. Therefore, transfused patients who had discharge hemoglobin levels greater than 10g/dL were classified as overtransfused in the present study [23]. The objectives of this audit are to identify the rates of overtransfusion in adult patients undergoing elective noncardiac surgery, and further to recognize patterns of RBC usage associated with surgery and the likelihood of RBC overtransfusion for different surgical units in our hospital.
Table 1 Demographic characteristics of patients. Sex Male Female Age (in years) Mean (±SD) Weight (in kg) Mean (±SD) ASA status I II III Preoperative Hb level (g/dL) Less than 6 6–9 9–11 More than 11
1292 (50.2%) 1280 (49.8%) 51.1 (±16.2) 57.4 (±9.8) 338 (13.1%) 1187 (46.2%) 670 (26.0%) 48 (1.9%) 437 (17.0%) 456 (17.7%) 1665 (64.7%)
2. Materials and methods A retrospective audit was conducted reviewing RBC use in adult patients who underwent noncardiac elective surgery and received intra- or post-operative (within 72 h) RBC transfusion during the period from January 1, 2008 to December 31, 2009 at The First Affiliated Hospital of Sun Yat-sen University, Guangzhou. The individual patient consent was waived as this study involved only the use of anonymized patient records from the hospital database. The following data were collected: demographic characteristics, surgical unit, diagnosis, surgical procedure, American Society of Anesthesiologists (ASA) status, hemoglobin level before surgery, intraoperative blood loss, amount of perioperative (intraand postoperative) RBC transfusion, hemoglobin level before discharge, and reasons for blood transfusion. An intraoperative RBC transfusion was defined as transfusion occurring after anesthetic induction and before discharge from the post-anesthestic care unit (PACU) while a postoperative RBC transfusion was defined as occurring between discharge from PACU and 72 h thereafter. The hemoglobin (Hb) prior to discharge is relevant when the hospital stay after transfusion is short. Overtransfusion due to excessive RBC use was defined as discharge Hb exceeding 10g/dL in transfused patients. Patients with age less than 18 years were excluded in this study. Patients suffering massive bleeding during the surgery (defined as loss of more than 80% of circulating blood volume) and patients having cardiac surgeries were also excluded from subsequent analysis because estimation of blood loss and its replacement is very likely to be inaccurate. Considering severe systemic disease might interfere with the result, patients with ASA status higher than III were excluded in present study as well. All data manipulation and calculations were performed and carefully documented by epidata 3.02 (EpiData Association, Odense, Denmark) with double check by two different groups of researchers. Statistical analysis was carried out using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Data were expressed as percentage for categorical variables and mean ± standard deviation (SD) or median with interquartile range (IQR) for continuous variables. As distribution of the number of RBC units transfused per person was generally skewed, these data are summarized using a median and interquartile range.
3. Results Over the 2 years, 2723 adult patients underwent elective non-cardiac major surgeries receiving intra- and postoperative blood transfusions were extracted from our hospital database. There were 59 cases involved massive blood loss, 17 cases with missing data and 48 cases with ASA status more than III; therefore, 2572 patients were included in the final analysis. The demographic characteristics of these patients are shown in Table 1. The median of the RBC transfusion amount was four units (IQR: 2; 6). Of these, 2181 patients (91.8% of total) received RBC transfusion intraoperatively while the rest 391 patients received RBC transfusion postoperatively. The number of units of RBC transfused and the overtransfusion rate are shown in Table 2. There were 843 patients (32.8%) were transfused 3U to 4U red blood cells intraoperatively (Table 2). The median of intraoperative blood loss was four units (IQR: 2; 8). The common reasons for transfusion include the blood loss exceeding the maximum allowable blood loss, anticipation of further blood loss, intraoperative Hb less than 7 g/dL, and hemodynamic instability. In this audit, 1250 individuals had discharge Hb more than 10 g/dL and were considered overtransfused, which accounted for 48.6% in total 2572 patients. In these overtransfused patients, 497 of them (39.8%) had discharge Hb greater than 12 g/dL. The rate of overtransfusion
Table 2 Number of units of RBC transfused and overtransfusion rate. Units transfused
1–2 3–4 5–6 7–8 9–10 More than 10 Only transfused postoperatively Total
Total number of transfused patients
No. of overtransfused patients
Overtransfusion rate (%)
628 843 232 185 82 211 391
326 411 113 101 29 106 164
51.9 48.8 48.7 54.6 35.4 50.2 41.9
2572
1250
48.6
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4. Discussion
Table 3 Details of population in different medical units. Medical unit
No. of patients
Age in years
Operation time (min)
Burns Dentistry Gastroenterology Gynecology Hepatobiliary surgery Neurosurgery Obstetrics Orthopedics Otolaryngology Plastics surgery Thoracic surgery Urinary surgery Vascular and thyroid surgery Others Total
30 41 461 281 362 325 17 532 27 22 159 149 134 32 2572
42.2 ± 18.7 46.0 ± 19.5 58.0 ± 14.8 42.0 ± 11.2 52.6 ± 12.3 46.5 ± 14.1 32.0 ± 5.5 52.3 ± 19.1 47.3 ± 19.1 40.7 ± 16.1 54.8 ± 13.0 55.4 ± 14.7 52.3 ± 17.8 56.9 ± 15.5 51.1 ± 16.2
160 ± 70 315 ± 164 265 ± 116 161 ± 106 297 ± 112 475 ± 223 95 ± 77 213 ± 107 287 ± 169 220 ± 138 182 ± 72 217 ± 112 238 ± 149 260 ± 85 265 ± 162
was highest in patients receiving 7U to 8U of RBC and lowest in patients receiving 9U to 10U of RBC transfusion (Table 2). There were 941 patients (36.0% of total) with hemoglobin level less than 11 g/dL after admission defined anemia. The rate of overtransfusion in anemic group was 34.9%, while the rate in non-anemic group reached to 62.4%. There were 14 surgical sub-specialties present in the database of our hospital. The Departments of Orthopedics, Gastroenterological Surgery and Neurosurgery were the top three users of RBC in our hospital (Table 3). The thoracic surgery had the lowest median RBC use per person transfused (two units) while other units had the same median of RBC use per person transfused (four units). The neurosurgery had the highest overtansfusion rate, which even reached 69.5%. Other subspecialties related to high overtansfusion rate include thoracic surgery and hepatobiliar surgery (Table 4).
In this audit, the proportion of patients with discharge hemoglobin greater than 10g/dL was 48.6%, suggesting that nearly half of the patients are overtransfused. Although previous studies stating that the incidence of overtransfusion may vary between 19% and 75% [12–14,16–18], it should be notice that the overtransfusion rate varied from the definition of overtransfusion, research population, methods, and other reasons. Comparing with the report by Edwards, the overtransfusion rate in our hospital (48.6%) was higher than the average of hospitals in the USA (27–47%) [23]. Therefore the reason for this high overtransfusion rate should be investigated. We found the rate of overtransfusion was much higher in non-anemic group than anemic group before surgery (60.2% vs 34.8%). Also, patients with ASA I and ASA II had high overtransfusion rates (53.5% and 57.8%), while ASA III patients had lower overtransfusion rate (39.8%). Maybe anemic patients or patients with ASA III are under more intensive control and consequently the transfusion practice is more adequate. Therefore, RBC transfusion in nonanemic, ASA I and ASA II patients should be more intensive monitored. Blood transfusion is not always needed during the surgery. The common indication of initiating red blood transfusion are the blood loss exceeding the maximum allowable blood loss, anticipation of further blood loss, and Hb<7 g/dL. However, there is no mandatory requirement of recording reasons for every transfusion and no restrict policy to limit the amount of blood transfused in our hospital, especially in the operating room. It has been suggested that documentation of reason for transfusion may decrease the incidence of inappropriate transfusion [17]. In our hospital, the anesthesiologist is able to perform intraoperative Hb testing by blood gas analyzer GEM premier 3000 (Instrumentation Laboratory, Lexington, KY, USA) [24] at any given time during the anesthesia. This device had been validated for all parameters with the accuracy and the reliability
Table 4 Transfusion incidence in the perioperative period for each surgical subspecialty. Surgical unit
Burns Dentistry Gastroenterology Gynaecology Hepatobiliary surgery Neurosurgery Obstetrics Orthopedics Otolaryngology Plastics surgery Thoracic surgery Urinary surgery Vascular and thyroid surgery Others Total
No. of patients transfused with RBC
30 41 461 281 362 325 17 532 27 22 159 149 134 32 2572
No. of perioperative RBC units transfused in each surgical unit
No. of perioperative RBC units per person transfused
Intraoperative
Postoperative (within 72 h)
Total
Median
IQR
124 130 2036 1029 1170 1474 42 1968 138 77 409 669 574 216 10923
22 6 172 75 90 73 24 378 8 14 78 59 73 29 985
146 136 2208 1104 1260 1547 66 2346 146 91 487 728 647 245 10909
4 4 4 4 4 4 4 4 4 4 2 4 4 4 4
2–6 2–4 4–6 2–4 4–8 2–6 2–6 2–4 4–6 2–8 2–4 2–6 3–8 3–7 2–6
No. of patients receiving over transfusion
Rate of overtransfusion (%)
15 17 227 90 197 226 9 223 14 9 98 77 39 7 1250
50.0 41.5 49.2 32.0 54.4 69.5 52.9 41.9 51.9 40.9 61.6 51.7 29.1 35.0 48.6
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of traditional laboratory system, and it may decrease unnecessary transfusion. Because of the easy access of this device, the decision to transfuse RBC to patients was made mainly by anesthesiologists in our hospital; however, the surgeon tends to order more blood because of the anticipation of further blood loss. They are concerned about postoperative blood loss and the following postoperative complications due to hemodynamic instability. Therefore, when the anesthesiologist makes the decision of transfusion, the surgeon tends to increase the transfusion dose, which may contribute to the high rate of overtransfusion. In this audit, a profile of RBC consumers in our hospital was shown and it was found that the rates of overtransfusion in 14 surgical units varied obviously. Among them, the department of neurosurgery has the most patients receiving RBC transfusion and their overtransfusion rates are the highest. As far as we know, most of their patients had intracranial tumors with long surgical time. The duration of neurosurgery in our hospital normally took 7.9 ± 3.7 h, making neurosurgeons more concerned about the invisible blood loss from the wound for such a long surgical time. Besides, some tumors such as meningiomas are highly vascular tumors and the blood loss may be substantial, so many neurosurgeons tend to order more RBC in case of hemodynamic instabilities. This might contribute to this high rate of overtransfusion (69.5%). There is a need for a change in their transfusion practice. The implementation of transfusion guidelines may decrease the overtransfusion rate. Further investigation into the surgical type and the reason for transfusion might be helpful to improve the practice of transfusion. There were some limitations to this study. First, we did not comment on RBC transfusion in terms of circulating patient blood volumes while it might be better reflected by volume transfused as a fraction of circulating blood volume rather than total number of RBC units. Second, this study only examined the use of RBC, fresh frozen plasma and platelet transfusion were not evaluated in this study. The use of these other blood products is also concerned as a serious issue for the clinician and blood banks. Third, we only examined the amount of RBC transfusion but not the appropriateness of RBC transfusion. The inappropriateness of transfusion trigger might be another reason for overtransfusion. Last, we categorized our cases by surgical units. It should be noted that each hospital has a different case mix; therefore, it might be more useful if we analyzed our data by surgical procedures. Although the Task Force on Blood Component Therapy published by American Society of Anesthesiologists in 2006 states that hemoglobin levels less than 6g/dL could justify RBC transfusion [25], there are complicated situations that make it hard for anesthesiologists to define the proper transfusion indications. It was shown that enforcement of transfusion guidelines can reduce overall transfusion rates with no adverse outcomes and with sustained effect [17]. Initial audit on transfusion following the implementation of transfusion guidelines was found as having a 43% decrease in transfusions, suggesting that audits on transfusion can help improve transfusion [25]. We believe that with our audit, more accurate information can be provided for planning strategies to minimize the frequency of RBC transfusion
in our hospital. In addition, it is also of value for the blood banks to allocate resource in the face of blood shortages and for the clinician to aware the high incidence of overtransfusion. 5. Conclusions Patients in our hospital were being transfused more out of routine and nearly half of perioperative RBC transfusion resulted in overtransfusion. Therefore, audits on perioperative transfusion are indeed necessary to identify the problem and the further implementation of transfusion guidelines should be carried in the future practice. References [1] Madjdpour C, Heindl V, Spahn DR. Risks, benefits, alternatives and indications of allogenic blood transfusions. Minerva Anestesiol 2006;72:283–98. [2] Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 2006;(1):CD005033. [3] Dionigi G, Boni L, Rovera F, Rausei S, Cuffari S, Cantone G, et al. Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer. World J Gastroenterol 2009;15:3976–83. [4] Shiba H, Ishida Y, Wakiyama S, Iida T, Matsumoto M, Sakamoto T, et al. Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection. J Gastrointest Surg 2009;13:1636–42. [5] Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 2009;208:931–7, 7 e1–2, discussion 8–9. [6] Vochteloo AJ, Borger van der Burg BL, Mertens B, Niggebrugge AH, de Vries MR, Tuinebreijer WE, et al. Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskelet Disord 2011;12:262. [7] Yildirim IO, Salihoglu Z, Bolayirli MI, Colakoglu N, Yuceyar L Prospective evaluation of the factors effective on morbidity and mortality of the patients having liver resection surgeries. Hepatogastroenterology 2012;59:1928–32. [8] Morton J, Anastassopoulos KP, Patel ST, Lerner JH, Ryan KJ, Goss TF, et al. Frequency and outcomes of blood products transfusion across procedures and clinical conditions warranting inpatient care: an analysis of the 2004 healthcare cost and utilization project nationwide inpatient sample database. Am J Med Qual 2010;25:289–96. [9] Hasley PB, Lave JR, Kapoor WN. The necessary and the unnecessary transfusion: a critical review of reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994;34:110–5. [10] Wilson K, MacDougall L, Fergusson D, Graham I, Tinmouth A, Hebert PC. The effectiveness of interventions to reduce physician’s levels of inappropriate transfusion: what can be learned from a systematic review of the literature. Transfusion 2002;42:1224–9. [11] Barr PJ, Donnelly M, Cardwell CR, Parker M, Morris K, Bailie KE The appropriateness of red blood cell use and the extent of overtransfusion: right decision? Right amount? Transfusion 2011;51:1684–94. [12] Choy YC, Lim WL, Ng SH. Audit of perioperative blood transfusion. Med J Malaysia 2007;62:299–302. [13] Grey DE, Finlayson J. Red cell transfusion for iron-deficiency anaemia: a retrospective audit at a tertiary hospital. Vox Sang 2008;94:138–42. [14] Hallissey MT, Crowson MC, Kiff RS, Kingston RD, Fielding JW. Blood transfusion: an overused resource in colorectal cancer surgery. Ann R Coll Surg Engl 1992;74:59–62. [15] Joshi G, McCarroll M, O’Rourke P, Coffey F. Role of quality assessment in improving red blood cell transfusion practice. Ir J Med Sci 1997;166:16–9. [16] Mallett SV, Peachey TD, Sanehi O, Hazlehurst G, Mehta A. Reducing red blood cell transfusion in elective surgical patients: the role of audit and practice guidelines. Anaesthesia 2000;55:1013–9. [17] Spencer J, Thomas SR, Yardy G, Mukundan C, Barrington R. Are we overusing blood transfusing after elective joint replacement? – a
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[18] [19] [20]
[21]
[22]
simple method to reduce the use of a scarce resource. Ann R Coll Surg Engl 2005;87:28–30. Sudhindran S. Perioperative blood transfusion: a plea for guidelines. Ann R Coll Surg Engl 1997;79:299–302. Kanter MH. The transfusion audit as a tool to improve transfusion practice: a critical appraisal. Transfus Sci 1998;19:69–81. McMillan D, Dando H, Potger K, Southwell J, O’Shaunghnessy K. Intra-operative autologous blood management. Transfus Apher Sci 2002;27:73–81. Tinmouth A, Macdougall L, Fergusson D, Amin M, Graham ID, Hebert PC, et al. Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians’ transfusion practices. Arch Intern Med 2005;165:845–52. Toy P. Guiding the decision to transfuse. Arch Pathol Lab Med 1999;123:592–4.
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[23] Edwards J, Morrison C, Mohiuddin M, Tchatalbachev V, Patel C, Schwickerath VL, et al. Patient blood transfusion management: discharge hemoglobin level as a surrogate marker for red blood cell utilization appropriateness. Transfusion 2012;52:2445–51. [24] Beneteau-Burnat B, Pernet P, Pilon A, Latour D, Goujon S, Feuillu A, et al. Evaluation of the GEM Premier 4000: a compact blood gas CO-Oximeter and electrolyte analyzer for point-of-care and laboratory testing. Clin Chem Lab Med 2008;46:271–9. [25] American Society of Anesthesiologists Task Force on Perioperative Blood T, Adjuvant T. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 2006;105:198–208.
Contents lists available at ScienceDirect
Transfusion and Apheresis Science j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / t r a n s c i
Perioperative red blood cell transfusion for patients undergoing elective non-cardiac surgery: an audit at a Chinese tertiary hospital Chiu-Wen Chou 1,*, Rongrong Xu 1, Lu Yang, Wenqi Huang Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
A R T I C L E
I N F O
Article history: Received 2 March 2014 Received in revised form 25 July 2014 Accepted 14 August 2014 Keywords: Transfusion practices RBC transfusion
A B S T R A C T
Perioperative blood transfusion still takes a large proportion in inappropriate blood transfusion. As the data are limited in China, we reported a perioperative red blood cell (RBC) transfusion practices in a tertiary hospital in Guangzhou, China. In 2008–2009, patients who underwent elective surgeries receiving RBC transfusions were recorded and the rate of overtransfusion was analyzed. Overtransfusion was defined as discharge hemoglobin (Hb) exceeding 10g/dL. The median amount of RBC transfused perioperatively was four units in all 2572 patients. The overall rate of overtransfusion was 48.6% and the Department of Neurosurgery had the highest overtransfusion rate. These results are of great use for the future management of blood resource. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction Perioperative inappropriate transfusion is still a significant issue in clinical practice. Allogenic blood transfusion has been associated with an increased incidence of different types of complications: infectious complications, immunological reactions, tumor recurrence, and decreased survival [1]. Some studies have suggested an association between perioperative blood transfusion and the prognosis in various types of cancer [2–4]. Multiple studies also demonstrated a negative impact on mortality and morbidity as the number of units of blood transfused per patient increases [5–7]. On the other hand, blood products are scarce and cherish resources resulting in high medical expenditure [8]. Previous researches have demonstrated that there are important levels of transfusions considered to be inappropriate among health care providers all over the world [9]. In China, blood is collected by the local government from volunteer donors.
1The authors contributed equally for this article. * Corresponding author. Tel.: +862087750632 ext. 8273. E-mail address: [email protected] (C.-W. Chou).
http://dx.doi.org/10.1016/j.transci.2014.08.012 1473-0502/© 2014 Elsevier Ltd. All rights reserved.
Less than 9% of the Chinese populations donate blood while the demand is estimated to increase 10% every year. Although there are interventions to reduce inappropriate transfusion with variable effectiveness [10], inappropriate blood transfusion still take 19–75% in perioperative blood transfusion [11–18]. The unnecessary red blood cell (RBC) use is due to inappropriate decision to transfuse and excessive use of RBC. Undoubtedly, there is a need for institutions to review blood usage to ensure the appropriate use of resources, especially in surgery which is a large consumer of blood products. Furthermore, it would be useful to recognize the likelihood of RBC transfusion associated with particular surgical units so that the healthcare providers may be made aware of unnecessary blood transfusion. While such information has been provided in other countries, similar data are not available for the Chinese population yet. Although the accuracy of retrospective transfusion studies has been questioned [19], previous studies showed that the audits of transfusion practice do have a role in identifying and decreasing the rate of inappropriate transfusion [20–22]. Therefore, we conducted a retrospective study to evaluate the perioperative RBC transfusion practices and the extent of overtransfusion in our hospital. There are several
100
C.-W. Chou et al./Transfusion and Apheresis Science 51 (2014) 99–103
different criteria about inappropriate overtransfusion. According to the report from Edwards, it was suggested discharge hemoglobin level could be taken as a surrogate marker for RBC utilization appropriateness. In fact, the last Hb prior to discharge from the hospital is a much better measure for auditing transfusions since it represents the true endpoint of transfusion therapy. Therefore, transfused patients who had discharge hemoglobin levels greater than 10g/dL were classified as overtransfused in the present study [23]. The objectives of this audit are to identify the rates of overtransfusion in adult patients undergoing elective noncardiac surgery, and further to recognize patterns of RBC usage associated with surgery and the likelihood of RBC overtransfusion for different surgical units in our hospital.
Table 1 Demographic characteristics of patients. Sex Male Female Age (in years) Mean (±SD) Weight (in kg) Mean (±SD) ASA status I II III Preoperative Hb level (g/dL) Less than 6 6–9 9–11 More than 11
1292 (50.2%) 1280 (49.8%) 51.1 (±16.2) 57.4 (±9.8) 338 (13.1%) 1187 (46.2%) 670 (26.0%) 48 (1.9%) 437 (17.0%) 456 (17.7%) 1665 (64.7%)
2. Materials and methods A retrospective audit was conducted reviewing RBC use in adult patients who underwent noncardiac elective surgery and received intra- or post-operative (within 72 h) RBC transfusion during the period from January 1, 2008 to December 31, 2009 at The First Affiliated Hospital of Sun Yat-sen University, Guangzhou. The individual patient consent was waived as this study involved only the use of anonymized patient records from the hospital database. The following data were collected: demographic characteristics, surgical unit, diagnosis, surgical procedure, American Society of Anesthesiologists (ASA) status, hemoglobin level before surgery, intraoperative blood loss, amount of perioperative (intraand postoperative) RBC transfusion, hemoglobin level before discharge, and reasons for blood transfusion. An intraoperative RBC transfusion was defined as transfusion occurring after anesthetic induction and before discharge from the post-anesthestic care unit (PACU) while a postoperative RBC transfusion was defined as occurring between discharge from PACU and 72 h thereafter. The hemoglobin (Hb) prior to discharge is relevant when the hospital stay after transfusion is short. Overtransfusion due to excessive RBC use was defined as discharge Hb exceeding 10g/dL in transfused patients. Patients with age less than 18 years were excluded in this study. Patients suffering massive bleeding during the surgery (defined as loss of more than 80% of circulating blood volume) and patients having cardiac surgeries were also excluded from subsequent analysis because estimation of blood loss and its replacement is very likely to be inaccurate. Considering severe systemic disease might interfere with the result, patients with ASA status higher than III were excluded in present study as well. All data manipulation and calculations were performed and carefully documented by epidata 3.02 (EpiData Association, Odense, Denmark) with double check by two different groups of researchers. Statistical analysis was carried out using SPSS 18.0 (SPSS Inc., Chicago, IL, USA). Data were expressed as percentage for categorical variables and mean ± standard deviation (SD) or median with interquartile range (IQR) for continuous variables. As distribution of the number of RBC units transfused per person was generally skewed, these data are summarized using a median and interquartile range.
3. Results Over the 2 years, 2723 adult patients underwent elective non-cardiac major surgeries receiving intra- and postoperative blood transfusions were extracted from our hospital database. There were 59 cases involved massive blood loss, 17 cases with missing data and 48 cases with ASA status more than III; therefore, 2572 patients were included in the final analysis. The demographic characteristics of these patients are shown in Table 1. The median of the RBC transfusion amount was four units (IQR: 2; 6). Of these, 2181 patients (91.8% of total) received RBC transfusion intraoperatively while the rest 391 patients received RBC transfusion postoperatively. The number of units of RBC transfused and the overtransfusion rate are shown in Table 2. There were 843 patients (32.8%) were transfused 3U to 4U red blood cells intraoperatively (Table 2). The median of intraoperative blood loss was four units (IQR: 2; 8). The common reasons for transfusion include the blood loss exceeding the maximum allowable blood loss, anticipation of further blood loss, intraoperative Hb less than 7 g/dL, and hemodynamic instability. In this audit, 1250 individuals had discharge Hb more than 10 g/dL and were considered overtransfused, which accounted for 48.6% in total 2572 patients. In these overtransfused patients, 497 of them (39.8%) had discharge Hb greater than 12 g/dL. The rate of overtransfusion
Table 2 Number of units of RBC transfused and overtransfusion rate. Units transfused
1–2 3–4 5–6 7–8 9–10 More than 10 Only transfused postoperatively Total
Total number of transfused patients
No. of overtransfused patients
Overtransfusion rate (%)
628 843 232 185 82 211 391
326 411 113 101 29 106 164
51.9 48.8 48.7 54.6 35.4 50.2 41.9
2572
1250
48.6
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4. Discussion
Table 3 Details of population in different medical units. Medical unit
No. of patients
Age in years
Operation time (min)
Burns Dentistry Gastroenterology Gynecology Hepatobiliary surgery Neurosurgery Obstetrics Orthopedics Otolaryngology Plastics surgery Thoracic surgery Urinary surgery Vascular and thyroid surgery Others Total
30 41 461 281 362 325 17 532 27 22 159 149 134 32 2572
42.2 ± 18.7 46.0 ± 19.5 58.0 ± 14.8 42.0 ± 11.2 52.6 ± 12.3 46.5 ± 14.1 32.0 ± 5.5 52.3 ± 19.1 47.3 ± 19.1 40.7 ± 16.1 54.8 ± 13.0 55.4 ± 14.7 52.3 ± 17.8 56.9 ± 15.5 51.1 ± 16.2
160 ± 70 315 ± 164 265 ± 116 161 ± 106 297 ± 112 475 ± 223 95 ± 77 213 ± 107 287 ± 169 220 ± 138 182 ± 72 217 ± 112 238 ± 149 260 ± 85 265 ± 162
was highest in patients receiving 7U to 8U of RBC and lowest in patients receiving 9U to 10U of RBC transfusion (Table 2). There were 941 patients (36.0% of total) with hemoglobin level less than 11 g/dL after admission defined anemia. The rate of overtransfusion in anemic group was 34.9%, while the rate in non-anemic group reached to 62.4%. There were 14 surgical sub-specialties present in the database of our hospital. The Departments of Orthopedics, Gastroenterological Surgery and Neurosurgery were the top three users of RBC in our hospital (Table 3). The thoracic surgery had the lowest median RBC use per person transfused (two units) while other units had the same median of RBC use per person transfused (four units). The neurosurgery had the highest overtansfusion rate, which even reached 69.5%. Other subspecialties related to high overtansfusion rate include thoracic surgery and hepatobiliar surgery (Table 4).
In this audit, the proportion of patients with discharge hemoglobin greater than 10g/dL was 48.6%, suggesting that nearly half of the patients are overtransfused. Although previous studies stating that the incidence of overtransfusion may vary between 19% and 75% [12–14,16–18], it should be notice that the overtransfusion rate varied from the definition of overtransfusion, research population, methods, and other reasons. Comparing with the report by Edwards, the overtransfusion rate in our hospital (48.6%) was higher than the average of hospitals in the USA (27–47%) [23]. Therefore the reason for this high overtransfusion rate should be investigated. We found the rate of overtransfusion was much higher in non-anemic group than anemic group before surgery (60.2% vs 34.8%). Also, patients with ASA I and ASA II had high overtransfusion rates (53.5% and 57.8%), while ASA III patients had lower overtransfusion rate (39.8%). Maybe anemic patients or patients with ASA III are under more intensive control and consequently the transfusion practice is more adequate. Therefore, RBC transfusion in nonanemic, ASA I and ASA II patients should be more intensive monitored. Blood transfusion is not always needed during the surgery. The common indication of initiating red blood transfusion are the blood loss exceeding the maximum allowable blood loss, anticipation of further blood loss, and Hb<7 g/dL. However, there is no mandatory requirement of recording reasons for every transfusion and no restrict policy to limit the amount of blood transfused in our hospital, especially in the operating room. It has been suggested that documentation of reason for transfusion may decrease the incidence of inappropriate transfusion [17]. In our hospital, the anesthesiologist is able to perform intraoperative Hb testing by blood gas analyzer GEM premier 3000 (Instrumentation Laboratory, Lexington, KY, USA) [24] at any given time during the anesthesia. This device had been validated for all parameters with the accuracy and the reliability
Table 4 Transfusion incidence in the perioperative period for each surgical subspecialty. Surgical unit
Burns Dentistry Gastroenterology Gynaecology Hepatobiliary surgery Neurosurgery Obstetrics Orthopedics Otolaryngology Plastics surgery Thoracic surgery Urinary surgery Vascular and thyroid surgery Others Total
No. of patients transfused with RBC
30 41 461 281 362 325 17 532 27 22 159 149 134 32 2572
No. of perioperative RBC units transfused in each surgical unit
No. of perioperative RBC units per person transfused
Intraoperative
Postoperative (within 72 h)
Total
Median
IQR
124 130 2036 1029 1170 1474 42 1968 138 77 409 669 574 216 10923
22 6 172 75 90 73 24 378 8 14 78 59 73 29 985
146 136 2208 1104 1260 1547 66 2346 146 91 487 728 647 245 10909
4 4 4 4 4 4 4 4 4 4 2 4 4 4 4
2–6 2–4 4–6 2–4 4–8 2–6 2–6 2–4 4–6 2–8 2–4 2–6 3–8 3–7 2–6
No. of patients receiving over transfusion
Rate of overtransfusion (%)
15 17 227 90 197 226 9 223 14 9 98 77 39 7 1250
50.0 41.5 49.2 32.0 54.4 69.5 52.9 41.9 51.9 40.9 61.6 51.7 29.1 35.0 48.6
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of traditional laboratory system, and it may decrease unnecessary transfusion. Because of the easy access of this device, the decision to transfuse RBC to patients was made mainly by anesthesiologists in our hospital; however, the surgeon tends to order more blood because of the anticipation of further blood loss. They are concerned about postoperative blood loss and the following postoperative complications due to hemodynamic instability. Therefore, when the anesthesiologist makes the decision of transfusion, the surgeon tends to increase the transfusion dose, which may contribute to the high rate of overtransfusion. In this audit, a profile of RBC consumers in our hospital was shown and it was found that the rates of overtransfusion in 14 surgical units varied obviously. Among them, the department of neurosurgery has the most patients receiving RBC transfusion and their overtransfusion rates are the highest. As far as we know, most of their patients had intracranial tumors with long surgical time. The duration of neurosurgery in our hospital normally took 7.9 ± 3.7 h, making neurosurgeons more concerned about the invisible blood loss from the wound for such a long surgical time. Besides, some tumors such as meningiomas are highly vascular tumors and the blood loss may be substantial, so many neurosurgeons tend to order more RBC in case of hemodynamic instabilities. This might contribute to this high rate of overtransfusion (69.5%). There is a need for a change in their transfusion practice. The implementation of transfusion guidelines may decrease the overtransfusion rate. Further investigation into the surgical type and the reason for transfusion might be helpful to improve the practice of transfusion. There were some limitations to this study. First, we did not comment on RBC transfusion in terms of circulating patient blood volumes while it might be better reflected by volume transfused as a fraction of circulating blood volume rather than total number of RBC units. Second, this study only examined the use of RBC, fresh frozen plasma and platelet transfusion were not evaluated in this study. The use of these other blood products is also concerned as a serious issue for the clinician and blood banks. Third, we only examined the amount of RBC transfusion but not the appropriateness of RBC transfusion. The inappropriateness of transfusion trigger might be another reason for overtransfusion. Last, we categorized our cases by surgical units. It should be noted that each hospital has a different case mix; therefore, it might be more useful if we analyzed our data by surgical procedures. Although the Task Force on Blood Component Therapy published by American Society of Anesthesiologists in 2006 states that hemoglobin levels less than 6g/dL could justify RBC transfusion [25], there are complicated situations that make it hard for anesthesiologists to define the proper transfusion indications. It was shown that enforcement of transfusion guidelines can reduce overall transfusion rates with no adverse outcomes and with sustained effect [17]. Initial audit on transfusion following the implementation of transfusion guidelines was found as having a 43% decrease in transfusions, suggesting that audits on transfusion can help improve transfusion [25]. We believe that with our audit, more accurate information can be provided for planning strategies to minimize the frequency of RBC transfusion
in our hospital. In addition, it is also of value for the blood banks to allocate resource in the face of blood shortages and for the clinician to aware the high incidence of overtransfusion. 5. Conclusions Patients in our hospital were being transfused more out of routine and nearly half of perioperative RBC transfusion resulted in overtransfusion. Therefore, audits on perioperative transfusion are indeed necessary to identify the problem and the further implementation of transfusion guidelines should be carried in the future practice. References [1] Madjdpour C, Heindl V, Spahn DR. Risks, benefits, alternatives and indications of allogenic blood transfusions. Minerva Anestesiol 2006;72:283–98. [2] Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev 2006;(1):CD005033. [3] Dionigi G, Boni L, Rovera F, Rausei S, Cuffari S, Cantone G, et al. Effect of perioperative blood transfusion on clinical outcomes in hepatic surgery for cancer. World J Gastroenterol 2009;15:3976–83. [4] Shiba H, Ishida Y, Wakiyama S, Iida T, Matsumoto M, Sakamoto T, et al. Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection. J Gastrointest Surg 2009;13:1636–42. [5] Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg 2009;208:931–7, 7 e1–2, discussion 8–9. [6] Vochteloo AJ, Borger van der Burg BL, Mertens B, Niggebrugge AH, de Vries MR, Tuinebreijer WE, et al. Outcome in hip fracture patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskelet Disord 2011;12:262. [7] Yildirim IO, Salihoglu Z, Bolayirli MI, Colakoglu N, Yuceyar L Prospective evaluation of the factors effective on morbidity and mortality of the patients having liver resection surgeries. Hepatogastroenterology 2012;59:1928–32. [8] Morton J, Anastassopoulos KP, Patel ST, Lerner JH, Ryan KJ, Goss TF, et al. Frequency and outcomes of blood products transfusion across procedures and clinical conditions warranting inpatient care: an analysis of the 2004 healthcare cost and utilization project nationwide inpatient sample database. Am J Med Qual 2010;25:289–96. [9] Hasley PB, Lave JR, Kapoor WN. The necessary and the unnecessary transfusion: a critical review of reported appropriateness rates and criteria for red cell transfusions. Transfusion 1994;34:110–5. [10] Wilson K, MacDougall L, Fergusson D, Graham I, Tinmouth A, Hebert PC. The effectiveness of interventions to reduce physician’s levels of inappropriate transfusion: what can be learned from a systematic review of the literature. Transfusion 2002;42:1224–9. [11] Barr PJ, Donnelly M, Cardwell CR, Parker M, Morris K, Bailie KE The appropriateness of red blood cell use and the extent of overtransfusion: right decision? Right amount? Transfusion 2011;51:1684–94. [12] Choy YC, Lim WL, Ng SH. Audit of perioperative blood transfusion. Med J Malaysia 2007;62:299–302. [13] Grey DE, Finlayson J. Red cell transfusion for iron-deficiency anaemia: a retrospective audit at a tertiary hospital. Vox Sang 2008;94:138–42. [14] Hallissey MT, Crowson MC, Kiff RS, Kingston RD, Fielding JW. Blood transfusion: an overused resource in colorectal cancer surgery. Ann R Coll Surg Engl 1992;74:59–62. [15] Joshi G, McCarroll M, O’Rourke P, Coffey F. Role of quality assessment in improving red blood cell transfusion practice. Ir J Med Sci 1997;166:16–9. [16] Mallett SV, Peachey TD, Sanehi O, Hazlehurst G, Mehta A. Reducing red blood cell transfusion in elective surgical patients: the role of audit and practice guidelines. Anaesthesia 2000;55:1013–9. [17] Spencer J, Thomas SR, Yardy G, Mukundan C, Barrington R. Are we overusing blood transfusing after elective joint replacement? – a
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