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News Americas

Blood transfusion is the most common procedure performed in U.S. hospitals. (Photo: maska/Shutterstock)
Jul 27, 2012 | News Americas

Blood transfusion practices vary widely during surgery

by Surgical Tribune

BALTIMORE, Md., USA: Blood transfusion has wide variation in frequency by surgical procedure and physician, as well as wide variation in the hemoglobin trigger used to help decide whether to transfuse, researchers have found. Their study also found that a significant number of transfusion decisions are made without laboratory hemoglobin measurements.

The research adds to the growing clinical evidence that highlights the need for improved blood-management strategies. It also underscores the opportunity for noninvasive and continuous total hemoglobin (SpHb, Masimo) monitoring to facilitate optimal transfusion decision-making to improve patient safety and reduce costs.

In the study, researchers at Johns Hopkins Hospital in Baltimore collected data on 48,086 surgical patients over 18 months and evaluated blood transfusion frequency and hemoglobin triggers by surgical procedure and physician. A total of 2,981 patients (6.2 percent) received an intra-operative red blood cell transfusion, with two-thirds of those patients receiving two or more units. Transfusion rates varied up to threefold between different physicians performing the same procedure. The average transfusion hemoglobin trigger used to determine the need for blood transfusion varied widely among both surgeons and anesthesiologists. The final hemoglobin values after the last recorded transfusion also varied widely among both surgeons and anesthesiologists. A recent laboratory hemoglobin measurement was not available when 31 percent of transfusion decisions were made.

Blood transfusion always carries a risk. In a previous meta-analysis of 45 studies evaluating the risks of blood transfusion, 42 studies showed a significant association with mortality, infection or adult respiratory distress syndrome. Contrary to the historical belief that withholding transfusions harms patients, multiple randomized controlled trials have now proven that restrictive transfusion practice is safe. This has led recent transfusion guidelines to focus transfusion decisions on overall patient condition and to suggest hemoglobin transfusion triggers of 6–7 g/dL for most patients and above 7 g/dL only in select, high-risk patients.

Blood transfusions are one of the largest cost centers in hospitals. While the material cost of blood ranges from $200 to $300 per unit, the additional costs from storage, labor, and waste result in an actual cost per unit of between $522 and $1,183. In addition to the cost of blood itself, each unit of blood transfused increases the cost of care, with even higher costs incurred when patients are transfused at higher hemoglobin levels.

A recent systematic evaluation of 494 studies concluded that 59 percent of transfusions were "inappropriate" based on their impact on patient outcomes. The risks and costs of blood transfusion paired with unnecessary transfusions led the Joint Commission in 2011 to introduce new patient blood management measures that hospitals are being encouraged to adopt as a quality indicator. The new measures include recording the clinical indication for transfusion along with the hemoglobin value of the patient prior to each unit transfused. With the need to stem rising health-care expenditures, the Joint Commission and the American Medical Association have tabled blood transfusion as one of the top procedures to be considered for reduction during the National Summit on Overuse scheduled for September 2012.

There is no doubt that clinicians desire the best care for their patients without unnecessary costs, but they are also limited in their precise ability to determine the need for transfusion with existing tools. Estimates of blood loss in the operating room can be inaccurate. Researchers at Duke University recently reported that estimated surgical blood loss exceeded measured blood loss by more than 40 percent. The likely reason for this discrepancy is the inability to estimate blood loss accurately based on visual inspection of blood and fluid in suction canisters and surgical sponges. While estimating blood loss is challenging and laboratory hemoglobin results are only availably intermittently and are often delayed, transfusion decisions are made in real time. Acknowledging these challenges, the Duke researchers stated: "Use of bedside hemoglobin concentration devices and continuous, noninvasive hemoglobin monitors may improve transfusion decisions."

Masimo's breakthrough SpHb measurement allows clinicians to monitor hemoglobin noninvasively and continuously. Results from an earlier randomized controlled trial conducted by researchers at Massachusetts General Hospital and Harvard Medical School demonstrated that SpHb helped anesthesiologists reduce the frequency of blood transfusion by 87 percent and quantity of blood by 90 percent in 327 patients undergoing orthopedic surgery.

Dr. Aryeh Shander, Executive Medical Director of the Institute for Patient Blood Management and Bloodless Medicine and Surgery, and Chief of Anesthesiology and Critical Care Medicine at Englewood Hospital and Medical Center in New Jersey, stated: "The ability of Masimo's noninvasive hemoglobin technology to continuously monitor hemoglobin during surgeries can offer earlier, real-time information that can result in diagnosis leading to interventions other than transfusion. And fewer unnecessary transfusions can mean improved patient outcomes."

This year Masimo launched the Blood Transfusion Related Cost Reduction program to help hospitals improve patient care and reduce costs. The program guarantees that a hospital's blood transfusion-related cost reductions will be greater than the cost of SpHb monitoring.

The study was published in the July issue of the Anesthesiology journal.

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