Evaluation of clinical practice in perioperative patient blood management.

BACKGROUND: Several guidelines have been published to facilitate implementation of patient blood management (PBM). This study was performed to evaluate clinical practices in PBM. METHODS: An online survey based on the guidelines for the management of severe perioperative bleeding from the European Society of Anaesthesiology (ESA) was conducted among ESA members. We assessed characteristic data of participating physicians, preoperative assessment of bleeding risk and anaemia, intraoperative transfusion practices, specific pharmacologic treatment of significant bleeding, and clinical use of PBM algorithms. Data distributions for five European regions and the workplace and experience of physicians were analysed using a χ2 test. RESULTS: We received 706 fully completed surveys from physicians in 57 countries. Most (99%) respondents were anaesthetists or intensive care physicians, and 68% worked at university or university-affiliated hospitals. A standardised bleeding history before surgery is routinely obtained by 48% of physicians. When bleeding history is negative, 55% of physicians routinely order preoperative coagulation testing. Only 24% of physicians timely assess patients at risk of bleeding during surgery for anaemia before elective surgery. When anaemia is diagnosed, 38% of physicians routinely investigate its cause. The rate of routinely performed targeted haemostatic interventions with fibrinogen, vitamin K or prothrombin complex, and tranexamic acid was 60%, 52%, and 54%, respectively. Algorithms to guide PBM are used by 62% of physicians. Results varied between geographic regions. CONCLUSIONS: Major deficits exist in the use of recommended PBM among anaesthetists, indicating an opportunity to improve clinical standards.

Preoperative anaemia is associated with poor clinical outcome in non-cardiac surgery patients.

BACKGROUND: Retrospective studies suggest that preoperative anaemia is associated with poor outcomes after surgery. The objective of this study was to describe mortality rates and patterns of intensive care resource use for patients with anaemia undergoing non-cardiac and non-neurological in-patient surgery. METHODS: We performed a secondary analysis of a large prospective study describing perioperative care and survival in 28 European nations. Patients at least 16 yr old undergoing in-patient surgery during a 7 day period were included in the study. Data were collected for in-hospital mortality, duration of hospital stay, admission to intensive care, and intensive care resource use. Multivariable logistic regression analysis was performed to understand the effects of preoperative haemoglobin (Hb) levels on in-hospital mortality. RESULTS: We included 39 309 patients in the analysis. Preoperative anaemia had a high prevalence in both men and women (31.1% and 26.5%, respectively). Multivariate analysis showed that patients with severe [odds ratio 2.82 (95% confidence interval 2.06-3.85)] or moderate [1.99 (1.67-2.37)] anaemia had higher in-hospital mortality than those with normal preoperative Hb concentrations. Furthermore, hospital length of stay (P<0.001) and postoperative admission to intensive care (P<0.001) were greater in patients with anaemia than in those with normal Hb concentrations. CONCLUSIONS: Anaemia is common among non-cardiac and non-neurological surgical patients, and is associated with poor clinical outcome and increased healthcare resource use. CLINICAL TRIAL REGISTRATION: NCT01203605 (ClinicalTrials.gov).

Epidemiology and outcome following post-surgical admission to critical care.

PURPOSE: To describe the factors related to outcome in patients admitted to the intensive care unit (ICU) after major surgery at a national level (in Austria). METHODS: Analysis of a prospectively collected database of ICU admissions over an 11-year period. Factors associated with mortality and how this changed with time were explored using logistic multilevel modelling. RESULTS: A total of 88,504 surgical patients had a mean ICU length of stay of 6.5 days and total hospital stay of 31.3 days. They had an ICU mortality of 7.6% and a hospital mortality of 11.8%. Factors associated with hospital mortality included age (odds ratio (OR) 1.42 per 10 years of age), urgency of operation (2.02 for emergency when compared to elective), SAPS II score (OR 1.09), reason for admission being a medical cause and the specific nature of the surgery itself: thoracic (OR 1.81), cardiovascular (OR 1.25), trauma (OR 1.22) or gastrointestinal surgery (OR 1.71). In addition patients who had pre-existing chronic renal (OR 1.40), respiratory (OR 1.20) or cardiac failure (OR 1.29), cirrhosis (OR 2.50), alcoholism (OR 1.42), acute kidney injury (OR 1.88) and/or non-metastatic cancer (OR 1.20) were associated with higher hospital mortality than patients without this co-morbidity. There was a reduction in the OR for death over the whole 11-year period. This improved outcome remained valid even after adjusting for the identified risk factors for mortality (OR per year 0.96). CONCLUSIONS: This study has shown the high level of demand for critical care for this patient group and an improving rate of survival.