To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2–9.5 vs. 8.2, 7.7–8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.
Hinweise
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Blood transfusions are commonly used in general, cardiac, and orthopedic surgery [1‐3].
On a large scale, approximately 30% of patients undergoing major abdominal surgery require blood transfusion, with those undergoing hepatic and pancreatic resections at higher risk of receiving blood products during hospitalization [2].
Anzeige
Transfusion may prevent severe complications during uncontrolled bleeding and is considered a life-saving treatment; however, it has negative impacts on the post-operative morbidity and long-term outcomes in oncologic surgical patients [4‐7].
By analyzing more than 1200 patients who underwent resection for hepatocellular carcinoma (HCC) or colorectal metastases, we demonstrated that blood transfusion had a negative impact on mortality and that the number of units of packed red cells administered is strongly related to early outcomes; patients receiving two or more units of packed red cells demonstrated a significantly increased risk of post-operative morbidity and mortality [8]. Similarly, Gruttadauria et al. [9], analyzing a cohort of liver resections for colorectal metastases, found that patients who received intraoperative blood transfusions were at higher risk to experience major postoperative complications and, consequently, a longer length of hospital stay.
Patient blood management (PBM) has been introduced in the last decade to reduce the use of blood products and improve tolerance to anemia [10‐14]. Most data regarding the relationship between the implementation of PBM and the reduction in the consumption of blood products come from North America [14‐17].
To evaluate the effect of PBM since its introduction in our Center in 2018, we analyzed the need for transfusion and the post-operative outcomes in the last 4 years in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM.
Anzeige
Patients and methods
Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery at Morgagni-Pierantoni Hospital of Forlì from 2017 to 2020 were included in the analysis.
The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (from January 1, 2017 to April 30, 2018; pre-PBM) versus after the implementation (from May 1, 2018 to December 31, 2020; post-PBM).
For each patient record, sociodemographic characteristics (age and sex) and illness-related variables (American Society of Anesthesiologists (ASA) score, diagnosis of malignancy) were recorded.
Preoperative Hemoglobin (Hb), platelets count, and INR was also recorded. The type of surgery, the approach (open versus minimally invasive) and postoperative complications were also collected.
Length of hospital stay was defined as the interval between the day of surgery and the day of discharge.
The hemoglobin trigger was defined as the value of hemoglobin below which a transfusion was performed.
Blood management protocol
In 2017, a multidisciplinary working group was established to promote the most appropriate transfusion practices in accordance with the PBM approaches. Surgeons, anesthesiologists, and specialists in transfusion medicine were involved in this project. A team coordinator was also identified and formally commissioned by hospital management.
The constructed protocol was based on the three pillars of PBM [10, 18] and the blood component transfusion policy was defined in compliance with the current transfusion guidelines for red blood cells, platelets, and plasma.
Anzeige
As shown in Table 1, the protocol included pre-operative, intra-operative, and post-operative precautions to prepare the patient to the procedure and to prevent and manage potential blood losses.
Table 1
Summary of the main indications included in the protocol
Pre-operative
Intra-operative
Post-operative
Identify patients with anemia (Hb < 12 g/dl in male and < 13 g/dl in female) at least 30 days before surgery and refer them to Transfusion Medicine
Careful hemostasis and meticulous surgery
Stimulate erythropoiesis and avoid anemia caused by deficiencies
Correct iron, folic acid vitamin B12 deficiencies
Assess the most appropriate approach, using minimally invasive surgery whenever possible
Monitor for postoperative bleeding
Assess the indication for erythropoiesis stimulating agents
Review and management of medications affecting the coagulation
Use hemostatic agents
Avoid/treat infections
Formulate patient-specific plans to minimize blood loss including the use of appropriate blood conservation modalities
Optimize oxygenation, ventilation and cardiac output
The restrictive trigger and single-unit blood transfusion practice were part of the protocol to correct peri-operative anemia. Different triggers were modulated and used according to patients’ conditions and comorbidities (Fig. 1). All patients were reassessed before a second unit was requested.
Fig. 1
Blood transfusion management algorithm
×
Educational programs and group discussions with surgeons and anesthesiologists were conducted, as were periodic audits of transfusion practices.
Statistical analysis
Continuous data were shown as median and interquartile range (IQR) and comparisons were performed using the Mann–Whitney U test. Fisher exact test was used to compare categorical variables which were presented as frequencies and percentages. Analyses were performed with statistical software for biomedical research (MedCalc® for Windows®, version 10.2.0.0; MedCalc Software, Ostend, Belgium).
Anzeige
Results
A total of 1302 patients were included in the analysis. In particular, 445 patients were in the pre-PBM group while 857 were in the post-PBM group.
As shown in Table 2, all baseline patients’ characteristics were similar between the groups with the exception of the rate of minimally invasive approaches which was higher in the post-PBM group (140, 31.5% before PBM versus 326, 38% after PBM introduction; p = 0.025).
Table 2
Patients’ characteristics
Total (n = 1302)
Pre-PBM (n = 445)
Post-PBM (n = 857)
p
Age, median (IQR)
68.8 (58.6–77.1)
67.8 (58.4–76.7)
69.3 (58.7–77.7)
0.267
Sex, n (%)
0.906
M
695 (53.4)
239 (53.7)
457 (53.3)
F
607 (56.6)
206 (46.3)
400 (46.7)
ASA score, n (%)
0.248
> 2
833 (64.0)
275 (61.8)
558 (65.1)
< 2
469 (36.0)
170 (38.2)
299 (34.9)
Malignancy, n (%)
0.517
Yes
1102 (84.7)
381 (85.6)
721 (84.1)
No
200 (15.3)
64 (14.4)
136 (15.9)
Minimally invasive surgery, n (%)
0.025
Yes
466 (35.8)
140 (31.5)
326 (38.0)
No
836 (64.2)
305 (78.5)
531 (72.0)
Types of procedure, n (%)
Gastric surgery
204 (15.6)
56 (12.6)
148 (16.7)
0.616
Wedge resection
23 (11.4)
7 (12.5)
16 (10.8)
Subtotal gastrectomy
131 (64.2)
34 (60.7)
97 (65.5)
Total gastrectomy
50 (24.5)
15 (26.8)
35 (23.6)
Colorectal surgery
682 (52.4)
255 (57.3)
427 (49.8)
0.667
Right colectomy/ileocecal resection
285 (41.8)
106 (41.6)
179 (41.9)
Left colectomy/sigmoidectomy
222 (32.5)
89 (34.9)
133 (31.1)
Total colectomy
4 (0.6)
1 (0.4)
3 (0.7)
Anterior rectal resection
171
59 (23.1)
112 (26.2)
Pancreas surgery
153 (11.8)
46 (10.3)
108 (12.6)
0.803
Distal pancreatectomy
43 (28.1)
14 (30.4)
29 (26.8)
Pancreaticoduodenectomy
53 (34.6)
14 (30.4)
39 (36.1)
Total pancreatectomy
57 (37.2)
17 (36.9)
40 (37.0)
Liver surgery
263 (20.2)
83 (18.6)
180 (21.0)
0.343
Lobectomy
22 (8.3)
9 (10.8)
13 (7.2)
Partial hepatectomy
241 (91.6)
74 (89.2)
167 (92.8)
Preoperative hemoglobin (g/dl), median (IQR)
13.4 (12.1–14.4)
13.0 (11.6–14.0)
12.9 (11.5–14.1)
0.881
Preoperative platelets count, median (IQR)
231 (188–278)
221 (182–281)
229 (187–280)
0.301
Preoperative INR, median (IQR)
1.0 (0.0–1.1)
1.0 (0.9–1.1)
1.0 (0.0–1.1)
0.872
The median preoperative Hb was higher in the patients who did not have postoperative transfusions (13.2, 11.9–14.3 versus 10.4, 9.4–11.7; p < 0.0001) and this was seen also within the pre-PBM era (13.2, 12–14.2 versus 10.3, 9.4–11.9; p < 0.0001) and in the post-PBM groups (13.1, 11.9–14.3 versus 10.4, 9.4–11.6; p < 0.001). The rate of transfused patients according to preoperative Hb value (less or more than 13 gr/dl) is reported in Fig. 2
Fig. 2
Rate of transfused patients according to preoperative Hb value (less vs. more than 13 gr/dl)
×
The number of transfused patients per year decreased significantly after the introduction of PBM, as shown in Fig. 3a. The rate of transfusion according to the type of surgery in each group is shown in Fig. 3b. As shown in Fig. 3b and Table 3, a strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery; there was no difference between the two groups of patients requiring colorectal surgery.
Fig. 3
A Number of transfused patients per year. B Rates of transfusion according to the type of surgery
Table 3
Outcomes
Total
Pre-PBM
Post-PBM
p
Gastric Surgery
204
56
148
Patients transfused
33 (16.2)
13 (23.2)
20 (13.5)
0.138
Hb trigger
8.2 (7.6–8.8)
8.2 (7.6–8.6)
8.3 (7.7–9.1)
0.507
Postoperative complications
54 (26.4)
16 (28.6)
38 (25.7)
0.859
Single unit transfusion scheme
0.049
Yes
9 (4.4)
1 (7.7)
9 (45)
No
24 (11.8)
12 (92.3)
11 (55)
Length of hospital stay
10 (8–13)
10 (8–13)
9 (7–14)
0.934
Colorectal Surgery
682
255
427
Patients transfused
62 (9.1)
23 (9.0)
39 (9.1)
1.000
Hb trigger
8.1 (7.6–9.6)
8.3 (7.6–8.6)
8.2 (7.6–8.7)
0.713
Postoperative complications
61 (8.9)
28 (11.0)
33 (7.2)
0.166
Single unit transfusion scheme
1.000
Yes
10 (1.5)
4 (17.4)
6 (15.4)
No
52 (7.6)
19 (82.6)
33 (84.6)
Length of hospital stay
7 (6–8)
7 (5–8)
6 (5–8)
0.058
Pancreas Surgery
153
45
108
Patients transfused
32 (20.9)
11 (24.4)
21 (19.4)
0.517
Hb trigger
8.5 (7.8–9.1)
8.6 (7.8–9.1)
8.5 (8.1–8.5)
0.952
Postoperative complications
50 (32.7)
12 (26.7)
38 (35.2)
0.348
Single unit transfusion scheme
0.681
Yes
8 (5.2)
2 (18.2)
6 (28.6)
No
24 (15.7)
9 (81.8)
15 (71.4)
Length of hospital stay
11 (9–13)
10 (8–13)
13 (10–14)
< 0.001
Liver Surgery
263
83
180
Patients transfused
29 (11.0)
17 (20.5)
12 (6.7)
0.002
Hb trigger
8.3 (8.1–8.9)
8.5 (8.2–9.5)
8.1 (7.7–8.4)
0.039
Postoperative complications
32 (12.2)
13 (15.7)
19 (10.5)
0.219
Single unit transfusion scheme
0.046
Yes
12 (4.6)
3 (17.6)
7 (58.3)
No
17 (6.4)
14 (82.3)
5 (41.7)
Length of hospital stay
8 (6–12)
8 (7–12)
7 (6–11)
0.023
×
Anzeige
The post-operative outcomes are shown in Table 3. The post-operative complications according to surgery type were similar between the groups.
With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (1, 7.7% vs. 9, 55% after PBM; p = 0.049); this was similar in liver surgery (3, 17.6% vs. 7, 58.3% after PBM; p = 0.04). A tendency was observed even for pancreatic surgery, although it did not reach statistical significance. The trend in the rate of adoption of the single-transfusion scheme is shown in Fig. 4.
Fig. 4
Trend in the rate of adoption of the single-transfusion scheme
×
Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%) and a decrease in the Hb trigger for transfusion (8.5, 8.2–9.5 vs. 8.2, 7.7–8.4 g/dl; p = 0.039) was reported after the implementation of the PBM protocol; similarly, a significant decrease in post-operative stay was reported.
Discussion
Blood transfusion is commonly used as a life-saving treatment in surgical patients, although several negative effects on the early and long-term outcomes have been demonstrated [6, 8, 19].
In the last 10 years, several guidelines and recommendations have been reported to improve the pre-, intra-, and post-operative management of patients with the aim of reducing the use of blood products [12, 14, 20].
In 2015 the Italian Ministry of Health published a recommendation to apply the PBM protocol in all Italian hospitals [21].
In our City Hospital, which recently became an HPB hub [22] for the region, a PBM program was introduced in 2018. We have demonstrated a progressive and significant reduction in blood transfusion since the implementation of this protocol, including a more restrictive use of peri-operative transfusion and the use of single units of packed red cells. In particular, we reported a relevant reduction in the use of packed red cells in gastric, pancreatic, and liver surgery. In contrast, we did not identify any difference in transfused patients treated for colorectal tumors between the two periods. However, the incidence of transfused patients after colorectal surgery was low, even in the first period (only 9%); therefore, demonstration of a possible impact of the new policy was difficult. In colorectal surgery, only 10–15% of patients required blood products [23, 24]; however, in a large series such as in our experience, PBM appeared not to reduce this percentage significantly.
In a large series from the national database, 30% of patients requiring hepatic and pancreatic surgery were transfused [1, 2]. However, in North America, several multicenter studies have demonstrated the possibility of reducing the use of blood products after different types of surgery, even in hepatobiliary and pancreatic surgery [15, 20, 25, 26]. We have demonstrated that in both gastric and liver surgery, only 13.5% and 6.7% of patients, respectively, required intra- or post-operative blood transfusion with the precise application of PBM. Even in pancreatic surgery, after PBM implementation, only 19% of resected patients required transfusion. Similar results have been reported in a recent large study using the US nationwide database; even after liver resection, 30% of patients received blood transfusion in the most recent period [17].
We noted a significant increase in post-operative complications in patients receiving two or more transfusions compared to those requiring only one packed red cell unit [8]. Other authors have reported similar data [19]. Thus, in the last 5 years, a strong recommendation to restrict the use of transfusion has been reported. The strategy of transfusing only one unit of packed red cells increased in all types of surgery without any adverse effects on the post-operative outcomes; this tendency reached a significant difference, particularly in patients requiring gastric and liver surgery.
Recently, a tendency to restrict the use of blood transfusion with a trigger point of hemoglobin of only 7 g/dl has been reported [12, 15]. However, concerns exist that an overly restrictive transfusion strategy may impact post-operative outcomes and increase cardiac complications [27, 28]. Thus, one of the most recent recommendations is to use 8 g/dl as a trigger cut-off for blood transfusion [29]; this has also been included in our protocol in common clinical conditions (e.g., coronary artery disease…) since 2018. In this series, we have reported a median trigger point for blood transfusion of approximately 8.5 g/dl; however, we demonstrated a significant reduction in the trigger point for transfusion after PBM implementation in patients requiring liver surgery (from 8.5 to 8.1 g/dl from the first to the second period).
In the last 20 years, minimally invasive surgery has increasingly been used. Both laparoscopic and robotic surgery have demonstrated several advantages over “open” surgery; among these, the reduction of the intraoperative blood loss appears consistent [30‐34]. In the present series, a significant increase in the use of the minimally invasive approach was evident, from 31 to 38% in the first and second periods, respectively. This strategy, which is also recommended in the PBM protocol, may be useful in reducing the use of transfusions.
This study has a few limitations mainly linked to its retrospective design. As such, few variables about specific comorbidities and detailed postoperative complications which could have potentially helped in analyzing the influence of the PBM protocol could not be retrieved. In addition, the number of patients who were transfused per procedure type was relatively low and this might have affected the statistical analysis in the attempt to highlight the impact of the use of the PBM protocol. To overcome these limitations, we believe a multicenter prospective trial may be helpful in confirming the utility of the PBM protocol in limiting the use of red blood cells in patients undergoing HPB and gastrointestinal surgery.
In conclusion, after the implementation of a PBM protocol in a City Hospital, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery. Additionally, a tendency to reduce the trigger cut-off for transfusion and to increase the frequency of use of only one packed red cell unit was reported.
Declarations
Conflict of interest
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Ethical approval
All procedures performed in the study were in accordance with ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
The need for an informed consent was waived by the local Institutional Review Board.
Consent for publication
All authors give their consent for publication.
Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Mit der Zeitschrift Die Chirurgie erhalten Sie zusätzlich Online-Zugriff auf weitere 43 chirurgische Fachzeitschriften, CME-Fortbildungen, Webinare, Vorbereitungskursen zur Facharztprüfung und die digitale Enzyklopädie e.Medpedia.
Bis 30. April 2024 bestellen und im ersten Jahr nur 199 € zahlen!
Die Therapie von Echinokokkosen sollte immer in spezialisierten Zentren erfolgen. Eine symptomlose Echinokokkose kann – egal ob von Hunde- oder Fuchsbandwurm ausgelöst – konservativ erfolgen. Wenn eine Op. nötig ist, kann es sinnvoll sein, vorher Zysten zu leeren und zu desinfizieren.
Der OP in der Zukunft wird mit weniger Personal auskommen – nicht, weil die Technik das medizinische Fachpersonal verdrängt, sondern weil der Personalmangel es nötig macht.
Seit November 2023 gibt es evidenzbasierte Empfehlungen zum perioperativen Management bei gastrointestinalen Tumoren (POMGAT) auf S3-Niveau. Vieles wird schon entsprechend der Empfehlungen durchgeführt. Wo es im Alltag noch hapert, zeigt eine Umfrage in einem Klinikverbund.
Auch wenn sich Krankenhäuser nachhaltig und grün geben – sie tragen aktuell erheblich zu den CO2-Emissionen bei und produzieren jede Menge Müll. Ein Pilotprojekt aus Bonn zeigt, dass viele Op.-Abfälle wiederverwertet werden können.
Update Chirurgie
Bestellen Sie unseren Fach-Newsletterund bleiben Sie gut informiert.
Das Karpaltunnelsyndrom ist die häufigste Kompressionsneuropathie peripherer Nerven. Obwohl die Anamnese mit dem nächtlichen Einschlafen der Hand (Brachialgia parästhetica nocturna) sehr typisch ist, ist eine klinisch-neurologische Untersuchung und Elektroneurografie in manchen Fällen auch eine Neurosonografie erforderlich. Im Anfangsstadium sind konservative Maßnahmen (Handgelenksschiene, Ergotherapie) empfehlenswert. Bei nicht Ansprechen der konservativen Therapie oder Auftreten von neurologischen Ausfällen ist eine Dekompression des N. medianus am Karpaltunnel indiziert.
Das Webinar beschäftigt sich mit Fragen und Antworten zu Diagnostik und Klassifikation sowie Möglichkeiten des Ausschlusses von Zusatzverletzungen. Die Referenten erläutern, welche Frakturen konservativ behandelt werden können und wie. Das Webinar beantwortet die Frage nach aktuellen operativen Therapiekonzepten: Welcher Zugang, welches Osteosynthesematerial? Auf was muss bei der Nachbehandlung der distalen Radiusfraktur geachtet werden?
Inhalte des Webinars zur S1-Leitlinie „Empfehlungen zur Therapie der akuten Appendizitis bei Erwachsenen“ sind die Darstellung des Projektes und des Erstellungswegs zur S1-Leitlinie, die Erläuterung der klinischen Relevanz der Klassifikation EAES 2015, die wissenschaftliche Begründung der wichtigsten Empfehlungen und die Darstellung stadiengerechter Therapieoptionen.
