Implementation of a "Patient Blood Management" program in medium sized hospitals: Results of a survey among German hemotherapists.

Background and aims: Germany uses more blood transfusions than the majority of other countries. The objective of this study was to detect the degree of Patient Blood Management (PBM) implementation within Germany and to identify obstacles to establishing PBM programs. Methods: An electronical questionnaire containing 21 questions and 4 topics was sent in 2018 to the members of the German interdisciplinary hemotherapy (IAKH) society in Germany. The degree of PBM (described as pre-, intra-, postoperative period) was established via questions within the topics "management of preoperative anemia" (PA) (n = 5), "preoperative management and transfusion preparation" (n = 3), PBM organization and structure (n = 5), coagulation management (n = 3), perioperative transfusion performance and habits (n = 3), best practices and problems (n = 2). Results: 533 German hospitals with transfusion activity received the questionnaire with a 32.5% response rate to the survey. A dedicated PBM program had not been established in a quarter of all small and medium sized institutions. Red blood cell transfusion was the only therapeutic option in a third of institutions. Approximately half of the hospitals did not use knowledge of PA rates or transfusion needs of surgical procedures. Institutions failed to implement PBM because of a lack of profit, workload, personnel shortage, and administrative support. Conclusion: PBM was not present in at least a quarter of the hospitals interrogated. Factors for improvement were the relationship between health care disciplines and sectors, economic incentives, inclusion of relevant disciplines, and the structure of the blood industry. To improve BPM implementation, hospitals need support to implement top-down PBM projects.

Safety of Intraoperative Cell Salvage in Cancer Surgery: An Updated Meta-Analysis of the Current Literature.

Background: Allogeneic blood transfusions in oncologic surgery are associated with increased recurrence and mortality. Adverse effects on outcome could be reduced or avoided by using intraoperative autologous blood cell salvage (IOCS). However, there are concerns regarding the safety of the autologous IOCS blood. Previous meta-analyses from 2012 and 2020 did not identify increased risk of cancer recurrence after using autologous IOCS blood. The objective of this review was to reassess a greater number of IOCS-treated patients to present an updated and more robust analysis of the current literature. Methods: This systematic review includes full-text articles listed in PubMed, Cochrane, Cochrane Reviews, and Web of Science. We analyzed publications that discussed cell salvage or autotransfusion combined with the following outcomes: cancer recurrence, mortality, survival, allogeneic transfusion rate and requirements, length of hospital stay (LOS). To rate the strength of evidence, a Grading of Recommendations Assessment, Development and Evaluation (GRADE) of the underlying evidence was applied. Results: In the updated meta-analysis, 7 further observational studies were added to the original 27 observational studies included in the former 2020 analysis. Studies compared either unfiltered (n = 2,311) or filtered (n = 850) IOCS (total n = 3,161) versus non-IOCS use (n = 5,342). Control patients were either treated with autologous predonated blood (n = 484), with allogeneic transfusion (n = 4,113), or did not receive a blood transfusion (n = 745). However, the current literature still contains only observational studies on these topics, and the strength of evidence remains low. The risk of cancer recurrence was reduced in recipients of autologous salvaged blood with or without LDF (odds ratio [OR] 0.76, 95% confidence interval [CI]: 0.64-0.90) compared to nontransfused patients or patients with allogeneic transfusion. There was no difference in mortality (OR 0.95, 95% CI: 0.71-1.27) and LOS (mean difference -0.07 days, 95% CI: -0.63 to 0.48) between patients treated with IOCS blood or those in whom IOCS was not used. Due to high heterogeneity, transfusion rates or volumes could not be analyzed. Conclusion: Randomized controlled trials comparing mortality and cancer recurrence rate of IOCS with or without LDF filtration versus allogeneic blood transfusion were not found. Outcome was similar or better in patients receiving IOCS during cancer surgery compared to patients with allogeneic blood transfusion or nontransfused patients.

Research for transfusion safety- priority of administration safety.

In Trasci recently various articles issued opinions where research for transfusion safety should be heading. A majority of them concentrated of production and standardization of the perfect and safe blood product in the future. However, the way the product is used by clinicians should be supported first to increase administration safety since the risks from inadequate administration exceeds the risk of product associated harm by far. Technical or computerized solutions have been tried in pilots but are far from marketability. Research efforts are needed to secure the clinical path of already very safe blood products.

Administration Safety of Blood Products - Lessons Learned from a National Registry for Transfusion and Hemotherapy Practice.

BACKGROUND: Compared to blood component safety, the administration of blood may not be as safe as intended. The German Interdisciplinary Task Force for Clinical Hemotherapy (IAKH) specialized registry for administration errors of blood products was chosen for a detailed analysis of reports. METHODS: Voluntarily submitted critical incident reports (n = 138) from 2009 to 2013 were analyzed. RESULTS: Incidents occurred in the operation room (34.1%), in the ICU (25.2%), and in the peripheral ward (18.5%). Procedural steps with errors were administration to the patient (27.2%), indication and blood order (17.1%), patient identification (17.1%), and blood sample withdrawal and tube labeling (18.0%). Bedside testing (BST) of blood groups avoided errors in only 2.6%. Associated factors were routine work conditions (66%), communication error (36%), emergency case (26%), night or weekend team (39%), untrained personnel (19%). Recommendations addressed process and quality (n = 479) as well as structure quality (n = 314). In 189 instances, an IT solution would have helped to avoid the error. CONCLUSIONS: The administration process is prone to errors at the patient assessment for the need to transfuse and the application of blood products to patients. BST is only detecting a minority of handling errors. According to the expert recommendations for practice improvement, the potential to improve transfusion safety by a technical solution is considerable.

[Anaesthesiological management of patients with dementia]. / Der demenzkranke Patient--Was ist beim anästhesiologischen Management zu beachten?

The aging society challenges anaesthesiologists with a growing number of patients with dementia. These and their relatives worry about an aggravation of an already existing dementia or even the postoperative evocation of one. Common volatile anaesthetics and propofol are suspected to increase dementia - associated protein tau and amyloid-betalevels in the brain. Perioperative complications such as cognitive dysfunction and delirium occur more frequently in dementia patients. For anaesthesiologists, it seems prudent toassess the grade of dementia in the elderly to adjust anaesthesia drug doses and monitoring intra- and postoperatively. Pharmacological interactions with antidementic andneuroleptic current medications affectanaesthetic and analgesic effects.In dementia, perioperative malfunction of cognition, memory, attention, information processing, communication and social interaction abilities is of profound influence on the perioperative management.This review mentions actual knowledge about dementia forms and symptoms in brief. Recommendations for the anaesthesia care are given in more detail.

[Rare medical incidents: Actual consensus statement for the removal of neuraxial catheter fragments]. / Nervenschäden bei Regionalanästhesie - Umgang mit in situ verbliebenen wirbelsäulennahen Katheterfragmenten.

The rupture of a catheter near the spine is rare. There are no evidence-based guidelines for diagnosis and therapy. Opinions derived from German anesthesiologists, neurosurgeons, orthopaedics and trauma surgeons are: Infants should have immediate surgery. In an asymptomatic adult, the catheter fragment does not require removal surgery. Antibiotic prophylaxis is not necessary. If symptomatic, the catheter fragment should be localized by a thin slice computed tomography or fluoroscopy. Otherwise surgical exploration is indicated. Direct surgery is recommended for cases with neurological symptoms, infections, loss of spinal fluid, pain and local discomfort. Relative indications for surgery are severe pain, tissue infection and intrathecal localization of the fragment. Surgery should be performed in prone position and under general anesthesia. Starting at the entry wound, the surgical access should be microsurgical and preferably by a neurosurgeon. If the entry is not detectable, a midline incision is suggested.

[Neuromonitoring in anaesthesia]. / Narkosetiefenmessung in der Anästhesie - Neue Möglichkeiten und Ziele der Narkoseüberwachung.

Modern computer-based methods to monitor anesthesia are widespread. They are used in order to avoid awareness, to reduce consumption of anesthetics, to optimize recovery times and to detect prolonged times of deep anesthesia and associated immunsuppression, mortality and morbidity. This review illustrates the evidence with which these goals were achieved until now. Finally, a recommendation for each indication is given. The useage of EEG-monitoring may help to avoid awareness and allows a reduced of consumption of anesthetics. The question if a cumulated time of deep anesthesia is associated with elevated mortality might be of a certain importance in the future.

[The German interdisciplinary taskforce for clinical hemotherapy IAKH and its national critical incident reporting system specifically for blood transfusion]. / Die Interdisziplinäre Arbeitsgemeinschaft für Klinische Hämotherapie - Startschuss für ein deutsches Hämovigilanzsystem.

The German interdisciplinary task force for clinical hemotherapy (IAKH) is an independent association of clinicians. It aims for the improvement of blood transfusion application processes, procedures and safety in the absence of a German hemovigilance system. Whereas the producers of blood products concentrate on product safety, the IAKH focuses on administrative needs such as forms and regulations associated with the administration of blood products. It provides information about coagulation disorders, autologous blood donation and cell saving as well as techniques that reduce the amount of allogeneic transfusion needs. Benefits of a membership in IAKH are electronic and individual recommendations to clinical hemotherapy issues, an exchange forum, as well as low cost participation at conventions and meetings. Just recently, a critical incident reporting system for errors in blood transfusion and hemotherapy was launched (www.iakh.de/ BeinaheFehlerErfassung/). The entries reported are analyzed, feedback and recommendations are given. Everybody in contact with the administration of blood products is asked to report errors and critical incidents.

Routine use of nasogastric tubes does not reduce postoperative nausea and vomiting.

Routine use of a nasogastric (NG) tube has been suggested to prevent postoperative nausea and vomiting (PONV) despite conflicting data. Accordingly, we tested the hypothesis that routine use of a NG tube does not reduce PONV. Our work is based on data from a large trial of 4055 patients initially designed to quantify the effectiveness of combinations of antiemetic treatments for the prevention of PONV. This analysis uses propensity scores for case matching to ensure group comparability on baseline factors. Intraoperative NG tube use patients and perioperative NG tube use patients were respectively matched to nonuse patients on all available potential confounders. Matched-pairs were identified using propensity scores for 1032 patients with or without intraoperative NG tube use and 176 patients with or without perioperative NG tube use. The incidences of PONV in the intraoperative group were 44.4% vs 41.5% (P = 0.35) with and without tube use, respectively, and 27.8% vs 31.3% (P = 0.61) in the perioperative group. Our results provide evidence that routine use of a NG tube does not reduce the incidence of PONV.

Hyperfibrinolysis after major trauma: differential diagnosis of lysis patterns and prognostic value of thrombelastometry.

BACKGROUND: The aim of this study was to diagnose hyperfibrinolysis (HF) and its pattern using thrombelastometry and to correlate the diagnosis with mortality. Furthermore, routine laboratory based and the rotational thrombelastometry analyzer (ROTEM)-derived variables were also correlated with survival. METHODS: Severe trauma patients showing HF in ROTEM were consecutively enrolled in the study. Three different HF patterns were compared: fulminant breakdown within 30 minutes, intermediate HF of 30 to 60 minutes, and late HF after 60 minutes. Injury severity score (ISS), hemodynamics, hemoglobin, hematocrit, platelet count (PC), fibrinogen, and ROTEM variables at admission were analyzed. The observed mortality was compared with the predicted trauma and injury severity score mortality. RESULTS: Thirty-three patients were diagnosed with HF. The mean ISS was 47 +/- 14. Fulminant, intermediate, or late HF (n = 11 each group) resulted in 100%, 91%, or 73% mortality, respectively, with the best prognosis for late HF (p = 0.0031). The actual overall mortality of HF (88%) exceeded the predicted trauma and injury severity score mortality (70%) (p = 0.039). Lower PC (123 +/- 53 vs. 193 +/- 91; p = 0.034), ROTEM prolonged clot formation time [CFT, 359 (140/632) vs. 82 (14/190); p = 0.042], and lower platelet contribution to maximum clot firmness [MCF(EXTEM) - MCF(FIBTEM), 34 (20/40) vs. 46 (40/53); p = 0.026] were associated with increased mortality. CONCLUSION: ROTEM-based diagnosis of HF predicted outcome. Further independent predictors of death were combination of HF with hemorrhagic shock, low PC, and prolonged CFT in ROTEM. ROTEM-based point of care testing in the emergency room is thus able to identify prognostic factors such as prolonged CFT and low platelet contribution to clot firmness (MCF(EX) - MCF(FIB)) earlier than standard laboratory-based monitoring.

[Hemostasis management in multiple trauma patients--value of near-patient diagnostic methods]. / Hämostaseologisches Management beim Polytrauma--Stellenwert der patientennahen diagnostischen Methoden.

Massively transfused multiple trauma patients commonly develop a complex coagulopathy which needs immediate treatment. Near-patient diagnostic methods are available for the management of this coagulopathy and for the guidance of the therapeutic options with blood products and haemostatic drugs: conventional laboratory analysis methods adapted to the point-of-care (POC) situation (blood gas analysis, point of care PT, APTT and platelet count), and the complex whole blood methods used for near-patient coagulation monitoring (thromboelastometry and platelet function analysis). Based on the new Guidelines of the German Medical Association for the use of blood and plasma derivates, interventions with blood products and haemostatic drugs in multiple trauma patients are suggested. The diagnostic value of near-patient methods for coagulation monitoring is discussed.

Increased arterial oxygen content by artificial haemoglobin induces a decrease in regional cerebral blood flow and decreased regional cerebral oxygen delivery.

BACKGROUND AND OBJECTIVE: Under physiological conditions, cerebral oxygen delivery is kept constant by adaptation of the regional cerebral blood flow (CBF) in relation to the oxygen content. So far, decreases of the regional CBF induced by a higher arterial oxygen content have been produced under hyperbaric or hyperviscous conditions. We tested whether local CBF is also reduced by a high haemoglobin (Hb) concentration at a normal haematocrit (Hct). METHODS: Compared with controls (n=8), Hb content was increased to 19 g dl(-1) in conscious rats by isovolaemic replacement of the plasma fraction with an artificially high Hb solution (Hb-based oxygen carriers; HH group, n=8). In another group (n=8), Hct was decreased by isovolaemic exchange with an Hb-based oxygen carrier resulting in a normal Hb content (NH group). Mean and regional CBF was measured by iodo-[(14)C]-antipyrine autoradiography. Oxygen delivery was calculated from arterial oxygen content and CBF. RESULTS: Compared with the controls (Hb 15.3 g dl(-1), Hct 0.44), mean CBF was lower in the HH (Hb 20.3 g dl(-1), Hct 0.44) group by 23% (P < or = 0.05), but remained unchanged in the NH group (Hb 15.0 g dl(-1), Hct 0.29). On a local level, hyperoxygenation reduced CBF in 22 out of 39 brain regions. In the NH group mean CBF was unchanged, whereas local CBF was higher in 10 areas. In both groups, overall cerebral oxygen delivery was unchanged compared with the control group. Locally though, high arterial Hb content decreased oxygen delivery in one-third of the brain structures. CONCLUSION: Whereas the overall cerebral oxygen delivery in the brain is maintained during hyperoxygenation and haemodilution, local oxygen delivery is decreased by high arterial Hb content in some brain regions.

Leukodepletion of autologous whole blood has no impact on perioperative infection rate and length of hospital stay.

BACKGROUND: Several mechanisms have been proposed as possible causes of transfusion-related immunomodulation (TRIM) after allogeneic transfusion. If one of these mechanisms, the release of mediators of immunity and inflammation ("biologic response modifiers"[BRMs]) from disintegrating blood cells during storage of blood products, really causes TRIM, it should in principle also occur after autologous transfusion. As a consequence, prestorage leukoreduction of autologous blood should be able to prevent the clinical consequences of TRIM after autologous transfusion. STUDY DESIGN AND METHODS: This hypothesis was investigated in a multicenter, double-blind, randomized controlled trial. A total of 1089 patients scheduled for total hip arthroplasty and eligible for preoperative autologous blood donation were randomly assigned to receive autologous whole blood (AWB) either unmodified or leukoreduced when transfusion was indicated. RESULTS: Neither the primary study outcome, that is, the overall postoperative infection rate (17.3% vs. 17.6%, p = 0.59), nor several secondary outcomes like median length of hospital stay (14 days vs. 14 days, p = 0.17) were significantly different between groups, whether analyzed according to the intention-to-treat principle or "as treated." CONCLUSION: This trial provides strong evidence, from clinically relevant outcome data, that leukoreduction of AWB does not improve postoperative patient outcome and that the release of BRMs from disintegrating blood cells during storage cannot explain the immunomodulatory effect of blood transfusion.

[Neurological diseases in pregnancy: implications for anesthesia care - part 2]. / Die Schwangere mit neurologischen Begleiterkrankungen - Implikationen für das peripartale Anästhesiemanagement - Teil II.

In the parturient as well as in the pregnant patient with neurological disease, surgery is necessary more frequently than in healthy pregnants. Most pregnancies of these patients will result in a slightly increased rate for cesarean section. The focus of anesthesia care is mostly to avoid damage to the fetus, in some pathologies to protect the mother. Pregnancy itself may change the course of pre-existent chronic neurological diseases such as epileptic seizure, multiple sclerosis, or myasthenia gravis. Other diseases will have their onset predominantly in pregnancy such as back pain, nerve compression syndromes, some brain tumors or cerebrovascular events. Subarachnoidal hemorrhage and intracranial bleeding contribute to 65 % of maternal mortality. Finally, pregnancy induced conditions such as eclampsia and HELLP syndrome and its management are reviewed where the concerns for the nervous system have high relevance for anesthesiological management. Anesthesia care for the pregnant and the parturient presenting with a neurological disease requires 1.) expertise with neuroanesthesia and obstetric anesthesia care, 2.) accurate physical examination of the neurological system preoperatively, 3.) safe choice and conductance of the anesthesia technique (mostly regional anesthesia) 4.) avoidance of unfavorable drug effects for the fetus and the nervous system of the mother and 5.) intraoperative neuromonitoring together with the control of the fetal heart rate.

[Neurological diseases in pregnancy: implications for anesthesia care--Part 1]. / Die Schwangere mit neurologischen Begleiterkrankungen - Implikationen für das peripartale Anästhesiemanagement - Teil I.

In the parturient as well as in the pregnant patient with neurological disease, surgery is necessary more frequently than in healthy pregnants. Most pregnancies of these patients will result in a slightly increased rate for cesarean section. The focus of anesthesia care is mostly to avoid damage to the fetus, in some pathologies to protect the mother. Pregnancy itself may change the course of pre-existent chronic neurological diseases such as epileptic seizure, multiple sclerosis, or myasthenia gravis. Other diseases will have their onset predominantly in pregnancy such as back pain, nerve compression syndromes, some brain tumors or cerebrovascular events. Subarachnoidal hemorrhage and intracranial bleeding contribute to 65 % of maternal mortality. Finally, pregnancy induced conditions such as eclampsia and HELLP syndrome and its management are reviewed where the concerns for the nervous system have high relevance for anesthesiological management. Anesthesia care for the pregnant and the parturient presenting with a neurological disease requires 1.) expertise with neuroanesthesia and obstetric anesthesia care, 2.) accurate physical examination of the neurological system preoperatively, 3.) safe choice and conductance of the anesthesia technique (mostly regional anesthesia) 4.) avoidance of unfavorable drug effects for the fetus and the nervous system of the mother and 5.) intraoperative neuromonitoring together with the control of the fetal heart rate.

Excessive erythrocytosis does not elevate capillary oxygen delivery in subcutaneous mouse tissue.

OBJECTIVE: Acclimatization to reduced environmental oxygen includes erythropoietin-regulated increase in erythrocytes enhancing the blood's oxygen content. However, increased hematocrit levels result in elevated blood viscosity that might impair microcirculation and tissue oxygenation. To assess this oxygen supply to the skin, the authors used erythropoietin overexpressing transgenic mice (tg6) that develop excessive erythrocytosis in an oxygen-independent manner. These animals have been previously reported to elevate their blood viscosity 4-fold. METHODS: The partial oxygen pressure (pO2) distribution was evaluated in microvessels as well as in subcutaneous interstitial tissue within a dorsal skinfold chamber of resting conscious mice using automated phosphorescence quenching. RESULTS: Compared to wildtype (wt) animals, transgenic blood viscosity increased 4-fold but microvessel diameter was not altered. Despite sharing similar blood pO2 as the wt siblings, tg6 animals nearly doubled their oxygen content. Moreover, tg6 erythrocytes reduced hemoglobin's oxygen affinity by decreased 2,3-DPG levels and an increased Hill number. Transgenic arterioles and venules showed increased pO2 compared to wt controls whereas capillary and tissue pO2 were not altered. CONCLUSIONS: Excessive erythrocytosis does not elevate capillary oxygen delivery.