Optimising bloodless cardiovascular surgery for Jehovah's Witnesses and beyond.

Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.

Intraoperative Autologous Blood Donation Leads to Fewer Transfusions in Cardiac Surgery.

BACKGROUND: Blood conservation with antifibrinolytics, topical hemostatics, and strict transfusion triggers are becoming commonplace in cardiac surgery. The aim of this study was to evaluate the effect of a blood conservation protocol centering on standardized intraoperative autologous blood donation (IAD) use in cardiac surgery. METHODS: We reviewed charts of patients who underwent cardiac surgery at our hospital over an 8-year period to analyze transfusion tendencies before and after a new blood conservation policy was implemented. Propensity score matching was used to account for population differences in preoperative and perioperative covariates. RESULTS: Over an 8-year period (January 2009 to December 2017) 1002 patients were studied. Three hundred fifty-two patients before the new blood conservation policy (group 1) were compared with 650 patients after the change (group 2). Fewer group 2 patients required blood transfusions during their hospital stay (78% vs 61%, P < .001), were transfused fewer units (2.8 vs 1.81 units, P < .001), and experienced a shorter length of stay (8.02 vs 7.28 days, P = .012). Propensity score-matched cohorts revealed reductions in any complication (29.5% vs 18.8%, P = .007), fewer postoperative transfusions (70.1% vs 50.9%, P < .001), and a lower transfusion volume (1.82 vs 1.21 units, P = .002) associated with IAD without any associated change in mortality. CONCLUSIONS: IAD use is associated with reduced transfusions in cardiac surgery and may be considered a complementary aspect of blood conservation. Our experience suggests it may be applied with few limitations. A causal relationship between IAD and outcomes should be established with prospective studies.

Blood utilization in revision versus first-time cardiac surgery: an update in the era of patient blood management.

BACKGROUND: Relative to first-time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era. STUDY DESIGN AND METHODS: Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components. RESULTS: Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two- to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6-10 RBC units) and massive intraoperative transfusion. CONCLUSIONS: In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre-PBM era.

Blood Conservation-A Team Sport.

Cardiac surgery accounts for between 15% and 20% of all blood product utilization in the United States. A body of literature suggests that patients who are exposed to even small quantities of blood have an increased risk of morbidity and mortality, even after adjusting for pre-operative risk. Despite this body of literature supporting a restrictive blood management strategy, wide variability in transfusion rates exist across institutions. Recent blood management guidelines have shed light on a number of potentially promising blood management strategies, including acute normovolemic hemodilution (ANH) and retrograde autologous priming (RAP). We evaluated the literature concerning ANH and RAP, and the use of both techniques among centers participating in the Perfusion Measures and outcomes (PERForm) registry. We leveraged data concerning ANH and RAP among 10,203 patients undergoing isolated coronary artery bypass grafting (CABG) procedures from 2010 to 2014 at 27 medical centers. Meta-analyses have focused on the topic of ANH, with few studies focusing specifically on cardiac surgery. Two meta-analyses have been conducted to date on RAP, with many reporting higher intra-operative hematocrits and reduced transfusions. The rate of red blood cell transfusions in the setting of CABG surgery is 34.2%, although varied across institutions from 16.8% to 57.6%. Overall use of ANH was 11.6%, although the utilization varied from .0% to 75.7% across institutions. RAP use was 71.4%, although varied from .0% to 99.0% across institutions. A number of blood conservation strategies have been proposed, with varying levels of evidence from meta-analyses. This uncertainty has likely contributed to center-level differences in the utilization of these practices as evidenced by our multi-institutional database. Perfusion databases, including the PERForm registry, serve as a vehicle for perfusionist's to track their practice, and contribute to multidisciplinary team efforts aimed at assessing and improving the value of cardiac surgical care.

Trends in red blood cell transfusion and 30-day mortality among hospitalized patients.

BACKGROUND: Blood conservation strategies have been shown to be effective in decreasing red blood cell (RBC) utilization in specific patient groups. However, few data exist describing the extent of RBC transfusion reduction or their impact on transfusion practice and mortality in a diverse inpatient population. STUDY DESIGN AND METHODS: We conducted a retrospective cohort study using comprehensive electronic medical record data from 21 medical facilities in Kaiser Permanente Northern California. We examined unadjusted and risk-adjusted RBC transfusion and 30-day mortality coincident with implementation of RBC conservation strategies. RESULTS: The inpatient study cohort included 391,958 patients who experienced 685,753 hospitalizations. From 2009 to 2013, the incidence of RBC transfusion decreased from 14.0% to 10.8% of hospitalizations; this change coincided with a decline in pretransfusion hemoglobin (Hb) levels from 8.1 to 7.6 g/dL. Decreased RBC utilization affected broad groups of admission diagnoses and was most pronounced in patients with a nadir Hb level between 8 and 9 g/dL (n = 73,057; 50.8% to 19.3%). During the study period, the standard deviation of risk-adjusted RBC transfusion incidence across hospitals decreased by 44% (p < 0.001). Thirty-day mortality did not change significantly with declines in RBC utilization in patient groups previously studied in clinical trials nor in other subgroups. CONCLUSIONS: After the implementation of blood conservation strategies, RBC transfusion incidence and pretransfusion Hb levels decreased broadly across medical and surgical patients. Variation in RBC transfusion incidence across hospitals decreased from 2010 to 2013. Consistent with clinical trial data, more restrictive transfusion practice did not appear to impact 30-day mortality.

Risk-adjusted clinical outcomes in patients enrolled in a bloodless program.

BACKGROUND: Although clinical outcomes have been reported for patients who do not accept allogeneic blood transfusion (ABT), many previous studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery. STUDY DESIGN AND METHODS: We report a risk-adjusted, propensity score-matched, retrospective case-control study of clinical outcomes for inpatients who did not accept ABT (bloodless, n = 294) and those who did accept ABT (control, n = 1157). Multidisciplinary specialized care was rendered to the bloodless patients to conserve blood and optimize clinical outcomes. Differences in hemoglobin (Hb), mortality, five morbid outcomes, and hospital charges and costs were compared. Subgroups of medical and surgical patients were analyzed, and independent predictors of outcome were determined by multivariate analysis. RESULTS: Overall, mortality was lower in the bloodless group (0.7%) than in the control group (2.7%; p = 0.046), primarily attributed to the surgical subgroup. After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome (death or any morbid event; p = 0.91; odds ratio, 1.02; 95% confidence interval, 0.68-1.53). Discharge Hb concentrations were similar in the bloodless (10.8 ± 2.7 g/dL) and control (10.9 ± 2.3 g/dL) groups (p = 0.42). Total and direct hospital costs were 12% (p = 0.02) and 18% (p = 0.02) less, respectively, in the bloodless patients, a difference attributed to the surgical subgroup. CONCLUSIONS: Using appropriate blood conservation measures for patients who do not accept ABT results in similar or better outcomes and is associated with equivalent or lower costs. This specialized care may be beneficial even for those patients who accept ABT.

Jehovah's Witnesses and cardiac surgery: a single institution's experience.

BACKGROUND: Based on biblical doctrines, patients of the Jehovah's Witness faith refuse allogeneic blood transfusion. Cardiac surgery carries a high risk of blood transfusion, but has been performed in Jehovah's Witnesses for many years. The literature contains information on the outcomes of this cohort, but does not detail the perioperative care of these patients. This article describes a single institution's experience in perioperative care of Jehovah's Witnesses undergoing cardiac surgery. STUDY DESIGN AND METHODS: A chart review of adult Jehovah's Witness patients undergoing cardiac surgery at Duke University between January 2005 and June 2012 was completed. Institutional protocols regarding preoperative erythropoietin (EPO) therapy and intraoperative isovolemic hemodilution are detailed. Patient demographics and use of various blood conservation techniques are described. Hemoglobin (Hb) at various points throughout the perioperative management, hospital length of stay, and mortality are reviewed as indicators of outcome. RESULTS: Forty-five Jehovah's Witness patients underwent cardiac surgery at Duke University Medical Center. Preoperative EPO increased the mean Hb by 1.2 g/dL before surgery. Intraoperative normovolemic hemodilution was used in 37 patients with intraoperative mean nadir Hb of 10.3 g/dL. Antifibrinolytics and desmopressin were commonly used as coagulation adjuncts. Mean cardiopulmonary bypass time was 137 minutes, with mean nadir temperature of 30.5°C. The mean length of hospital stay was 6.2 days, with mean intensive care unit stay of 1.7 days. This cohort had zero 90-day mortality in the perioperative period. CONCLUSIONS: This case series demonstrates that bloodless cardiac surgery can be performed in select patients refusing allogeneic blood transfusion.

[Gynaecological surgery of Jehovah´s Witnesses]. / Chirurgická lécba gynekologických onemocnení u Svedkyn Jehovových.

OBJECTIVE: To present experience with surgical treatment of various gynaecological diseases in patients belonging to the Church of Jehova´s Witness. DESIGNE: Retrospective study. SETTING: Department of Obstetrics and Gynaecology, Palacky University Olomouc, Institute of Health Care Studies, Faculty of Humanity Studies, Thomas Bata University, Zlín. METHODS AND RESULTS: The study included 24 patients belonging to the Church of Jehova´s Witness who reject blood tranfusion. The operations in these patients were performed for malignant as well as nonmalignant gynaecological disorders which could not be treated by conservative therapeutic procedures. The operation records were analysed and evaluated according to a set of criteria including the type of surgical procedure, estimated amount of blood loss, postoperative complications and the outcome of surgical treatment. CONCLUSION: Jehovas´s Witnesses represent a risk group of patients considering their refusal of blood transfusion. The indication for the operation and its performing is responsible decision which always inherits a certain degrese of risk. On the other hand, when adhering to the principles of bloodless surgery, the therapeutic results are very good and in the properly indicated cases the scope of risk is acceptable.

Eight-year experience of bloodless surgery at a tertiary care hospital in Korea.

BACKGROUND: The Soonchunhyang University Hospital Bloodless Center was established in 2000, and more than 2000 bloodless surgeries has been performed there since. This study was carried out to analyze the characteristics of patients who underwent bloodless surgery and the influences of postoperative lowest hemoglobin level (H(blow)) along with the lowest postoperative Hb/preoperative Hb ratio (H(blow/pre)) on successful completion of bloodless surgery. STUDY DESIGN AND METHODS: A total of 1407 patients were included. Patients were divided according to H(blow) into not more than 7 and more than 7 g/dL groups and compared regarding use of transfusion alternatives, coexisting risk factors, and mortality rate. They were also grouped as H(blow/pre) of not more than 0.5 or more than 0.5, and mortalities were compared between them. RESULTS: Jehovah's Witnesses comprised 1323 (94.0%) of the total population. The frequency of simultaneous use of erythropoietin and iron was significantly higher in H(blow) of not more than 7 group than in more than 7 g/dL group, as was the use of hemostatics. Among risk factors urging transfusion, the frequencies of cardiovascular disease and cerebrovascular accident were higher in H(blow) of not more than 7 than in the more than 7 g/dL group. Mortality rates in H(blow) of not more than 7 g/dL and H(blow/pre) of not more than 0.5 groups were significantly higher than those in H(blow) of more than 7 g/dL and H(blow/pre) of more than 0.5 groups, respectively. CONCLUSION: We have provided an effective bloodless surgery program for the past 10 years. A prospective multicenter study with other bloodless centers in Korea concerning mortality rates, actual operative blood loss, and postoperative complications in high-risk group of patients would be needed to establish evidence-based guidelines for bloodless surgery.

Outcomes in cardiac surgery in 500 consecutive Jehovah's Witness patients: 21 year experience.

BACKGROUND: Refusal of heterogenic blood products can be for religious reasons as in Jehovah's Witnesses or otherwise or as requested by an increasing number of patients. Furthermore blood reserves are under continuous demand with increasing costs. Therefore, transfusion avoidance strategies are desirable. We describe a historic comparison and current results of blood saving protocols in Jehovah's Witnesses patients. METHODS: Data on 250 Jehovah's Witness patients operated upon between 1991 and 2003 (group A) were reviewed and compared with a second population of 250 patients treated from 2003 to 2012 (group B). RESULTS: In group A, mean age was 51 years of age compared to 68 years in group B. An iterative procedure was performed in 13% of patients in group B. Thirty days mortality was 3% in group A and 1% in group B despite greater operative risk factors, with more redo, and lower ejection fraction in group B. Several factors contributed to the low morbidity-mortality in group B, namely: preoperative erythropoietin to attain a minimal hemoglobin value of 14 g/dl, warm blood cardioplegia, the implementation of the Cornell University protocol and fast track extubation. CONCLUSIONS: Cardiac surgery without transfusion in high-risk patients such as Jehovah Witnesses can be carried out with results equivalent to those of low risk patients. Recent advances in surgical techniques and blood conservation protocols are main contributing factors.

Blood conservation strategies in major orthopaedic surgery: efficacy, safety and European regulations.

Several major orthopaedic surgical procedures may result in significant blood loss and the need for allogeneic blood transfusion (ABT). However, overall concerns about adverse effects of ABT have prompted the review of transfusion practice and the search for transfusion alternatives to decrease or avoid the use of ABT. These strategies include the correction of perioperative anaemia, pharmacological and non-pharmacologic measures to reduce blood loss, preoperative autologous blood donation and perioperative red blood cell salvage. We have reviewed the efficacy and safety of these strategies and where appropriate offer evidence-based recommendations on their use in orthopaedic surgery. We also reviewed the European regulations on ABT alternatives. Pharmacological alternatives need to be used with a total adherence to European regulations in their legal and off-label use. The administration and use of pharmacological agents to stimulate erythropoiesis or reduce blood loss needs to be within the context of attempting to use allogenic blood in a rational manner. As for autologous blood, European Directives cover preoperative autologous blood donation, but not its clinical use, and perioperative red blood cell salvage devices, but not the product yielded by them. Therefore, the development of quality standards and good practice guidelines for perioperative red blood cell salvage, as well as its inclusion in the haemovigilance programme, is urgently needed. Finally, it is noteworthy that some recommendations given for ABT alternatives are not supported by a high level of evidence and that the goal of performing major orthopaedic surgical procedures without the use of ABT may be better accomplished by combining several of these techniques within a defined algorithm.