BACKGROUND Blood loss in hip and knee arthroplasties may necessitate allogeneic blood transfusions. Different blood-saving measures (BSMs) were introduced to reduce these transfusions. Purpose of... Show moreBACKGROUND Blood loss in hip and knee arthroplasties may necessitate allogeneic blood transfusions. Different blood-saving measures (BSMs) were introduced to reduce these transfusions. Purpose of the present study was to assess the frequency of BSM use, stratified by type and hospital setting of orthopaedic departments in the Netherlands. METHODS An internet-based questionnaire was sent to all heads of orthopaedic departments of Dutch hospitals and private clinics (n = 99). Questions were asked on how often BSMs were used, reported on a 5-point Likert scale (never, almost never, regularly, almost always, always). In addition there were questions about discontinuation of anticoagulants preoperatively, the number of annually performed arthroplasties (size) and hospital setting. RESULTS The survey was completed by 81 (82%) departments. BSMs used frequently (regularly, almost always, always) were erythropoietine (EPO), with 55 (68%) departments being frequent users; acute normovolemic hemodilution, used frequently in 26 (32%) departments; cell saver in 25 (31%) and postoperative drainage and re-infusion in 56 (69%) departments. When compared by size, frequent EPO use was more common in large departments (with 22 (88%) large departments being frequent users versus 13 (63%) small departments and 16 (55%) intermediate departments, p = 0.03). No differences by size or type were observed for other BSMs. CONCLUSIONS Compared with previous survey's there is a tremendous increase in use of BSMs. EPO and autologous blood salvage techniques are the most often used modalities. Costs might be saved if use of non-cost-effective BSMs is stopped. Show less
BACKGROUND: Peri-operative red blood cell transfusions have been associated with post-operative complications in patients undergoing elective orthopaedic hip or knee replacement surgery. MATERIALS... Show moreBACKGROUND: Peri-operative red blood cell transfusions have been associated with post-operative complications in patients undergoing elective orthopaedic hip or knee replacement surgery. MATERIALS AND METHODS: We performed a post-hoc analysis of data extracted from a randomised study on transfusion triggers using pre-storage leucocyte-depleted red blood cells. Patients who were assigned to the most restrictive transfusion policy ("restrictive group") were compared with patients who were assigned to the most liberal policy ("liberal group"). End-points were red blood cell use, hospital stay, haemoglobin levels, post-operative complications and quality of life scores. RESULTS: Of 603 patients, 26.4% patients in the restrictive group and 39.1% in the liberal group were transfused (P =0.001). The rate of post-operative infections was lower, although not statistically significantly so, in the restrictive group than in the liberal group (5.4% vs 10.2%, respectively) as was the rate of respiratory complications (1.7% vs 4.9%, respectively), whereas hospital stay, cardiovascular complications and mortality rate were not different in the two groups. Quality of life scores were not associated with type of transfusion policy, the number of red blood cell transfusions or the transfusion status. DISCUSSION: A restrictive transfusion protocol was not associated with worse outcome and resulted in a lower transfusion rate compared to the liberal policy. Well-being (quality of life) was not associated with transfusion policy or with red blood cell transfusions. Show less
ABSTRACT: BACKGROUND: Total hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery. Different blood-saving measures (BSMs) are used to reduce the often... Show moreABSTRACT: BACKGROUND: Total hip and knee arthroplasties are two of the most commonly performed procedures in orthopedic surgery. Different blood-saving measures (BSMs) are used to reduce the often-needed allogenic blood transfusions in these procedures. A recent large randomized controlled trial showed it is not cost effective to use the BSMs of erythropoietin and perioperative autologous blood salvage in elective primary hip and knee arthroplasties. Despite dissemination of these study results, medical professionals keep using these BSMs. To actually change practice, an implementation strategy is needed that is based on a good understanding of target groups and settings and the psychological constructs that predict behavior of medical professionals. However, detailed insight into these issuses is lacking. Therefore, this study aims to explore which groups of professionals should be targeted at which settings, as well as relevant barriers and facilitators that should be taken into acount in the strategy to implement evidence-based, cost-effective blood transfusion management and to de-implement BSMs. METHODS: The study consists of three phases. First, a questionnaire survey among all Dutch orthopedic hospital departments and independent treatment centers (n = 99) will be conducted to analyze current blood management practice. Second, semistructured interviews will be held among 10 orthopedic surgeons and 10 anesthesiologists to identify barriers and facilitators that are relevant for the uptake of cost-effective blood transfusion management. Interview questions will be based on the Theoretical Domains Interview framework. The interviews will be followed by a questionnaire survey among 800 medical professionals in orthopedics and anesthesiology (400 professionals per discipline) in which the identified barriers and facilitators will be ranked by frequency and importance. Finally, an implementation strategy will be developed based on the results from the previous phases, using principles of intervention mapping and an expert panel. DISCUSSION: The developed strategy for cost-effective blood transfusion management by de-implementing BSMs is likely to reduce costs for elective hip and knee arthroplasties. In addition, this study will lead to generalized knowledge regarding relevant factors for the de-implementation of non-cost-effective interventions and insight in the differences between implementation and de-implementation strategies. Show less
Chapter 2 describes the results of a RCT on the effect of a restrictive trigger on RBC sparing. In three hospitals, a restrictive transfusion policy was compared with standard care transfusion... Show moreChapter 2 describes the results of a RCT on the effect of a restrictive trigger on RBC sparing. In three hospitals, a restrictive transfusion policy was compared with standard care transfusion policy. A randomised comparison of transfusion triggers in elective orthopaedic surgery using leucocyte-depleted red blood cells was performed. The clinical consequences of this restrictive transfusion policy on post-operative complications and well-being are discussed in Chapter 3. Quality of Life and fatigue scores in relation to postoperative haemoglobin levels were analysed in Chapter 4. In Chapter 5 we investigated the efficacy and feasibility of two types of postoperative drainage and re-infusion systems and compared these to a control group. To evaluate the immuno-modulatory effects of salvaged blood in the post-operative patient, we analysed the effect of autologous salvaged blood re-infusion on the patients__ cytokine gene expression profiles compared to the effect of surgery itself (Chapter 6). Chapter 7 reports the combined strategies of Epo and autologous salvaged blood on RBC use compared to a control group under a restrictive transfusion policy (TOMaat study). In Chapter 8, future trends and ongoing studies are discussed in order to aim for an optimal and Tailor Made Patient Blood Management Program for elective orthopaedic surgery patients. In the final chapter, Chapter 9, an implementation protocol is described to investigate the barriers and facilitators for implementation of the TOMaat study results in daily practice. Show less
Voorn, V.M.A.; So-Osman, C.; Vlieland, T.P.M.V.; Nelissen, R.G.H.H.; Koopman-van Gemert, A.W.; Marang-van de Mheen, P.J.; Bodegom-Vos, L. 2012
BACKGROUND Lower limb joint replacement surgery provides a considerable improvement in quality of life (QoL), but is associated with peroperative blood loss and with anemia in the direct... Show moreBACKGROUND Lower limb joint replacement surgery provides a considerable improvement in quality of life (QoL), but is associated with peroperative blood loss and with anemia in the direct postoperative period. General acceptance of low transfusion thresholds and shorter postoperative hospital stays will result in patients leaving hospital with low hemoglobin (Hb) levels. To evaluate the role of QoL scores as a possible alternative for Hb values to serve as a further indicator for red blood cell transfusion, we performed a secondary analysis of a previously conducted randomized clinical trial to compare QoL and fatigue scores with simultaneously measured pre- and postoperative Hb levels, in total hip and knee arthroplasty patients. STUDY DESIGN AND METHODS QoL measurement was measured preoperatively and twice up to 14 days postoperatively using the Functional Status Index (FSI), the Visual Analogue Score (VAS)-Fatigue score, and the Functional Assessment of Cancer Therapy Anemia (FACT-Anemia) subscale. Pearson correlation coefficients between (change in) FSI, VAS-Fatigue, and FACT-Anemia subscale scores and (change in) Hb levels were calculated. Additionally, partial correlations were calculated and linear regression analysis was performed, correcting for possible confounding variables. RESULTS A total of 603 patients were evaluated. All patients scored worse postoperatively, but none of the scores correlated with Hb values, neither after correcting for confounding factors. Even more, the changes between preoperative and postoperative Hb levels were not correlated with changes in fatigue scores. CONCLUSION In hip and knee prosthesis surgery no correlation existed between postoperative Hb levels or acute postoperative decline in Hb values and QoL scores (FSI, VAS-Fatigue, or FACT-Anemia). Show less
Objective In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. Study Design and Methods A... Show moreObjective In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. Study Design and Methods A randomized, controlled study. A new uniform, restrictive transfusion policy was compared with standard care, which varied among the three participating hospitals. Only prestorage leucocyte-depleted RBC(s) were used. Primary end-point was RBC usage, related to length of hospital stay. Secondary end-points were Hb levels, mobilization delay and postoperative complications. Results Six hundred and three patients were evaluated. Adherence to the protocol was over 95%. Overall mean RBC usage was 0 center dot 78 U/patient in the new policy group and 0 center dot 86 U/patient in the standard care policy group (mean difference 0 center dot 08;95% CI [-0 center dot 3; 0 center dot 2]; P = 0 center dot 53). In two hospitals, the new transfusion policy resulted in a RBC reduction of 30% (0 center dot 58U RBC/patient) (P = 0 center dot 17) and 41% (0 center dot 29 U RBC/patient) (P = 0 center dot 05) respectively. In the third hospital, however, RBC usage increased by 39% (0 center dot 31 U RBC/patient) (P = 0 center dot 02) with the new policy, due to a more restrictive standard care policy in that hospital. Length of hospital stay was not influenced by either policy. Conclusions Implementation of a uniform transfusion protocol for elective lower joint arthroplasty patients is feasible, but does not always lead to a RBC reduction. Length of hospital stay was not affected. Show less
So-Osman, C.; Cicilia, J.; Brand, A.; Schipperus, M.; Berning, B.; Scherjon, S. 2010
Background and Objective Despite published guidelines, a proportion of red blood cell (RBC) transfusions seem unnecessary. To evaluate the indications for and the appropriateness of RBC... Show moreBackground and Objective Despite published guidelines, a proportion of red blood cell (RBC) transfusions seem unnecessary. To evaluate the indications for and the appropriateness of RBC transfusions in the postpartum patient, we performed a retrospective audit over a 1-year period in two Dutch hospitals. Study Design and Methods Observational study of transfused obstetric patients, admitted in 2006 to the Departments of Obstetrics of a university and a general hospital, was carried out. Relevant clinical and laboratory data were recorded. The appropriateness of RBC transfusions was assessed using the national and age-based transfusion guidelines for the general population; for the studied group the transfusion threshold haemoglobin (Hb) value was 6 center dot 4 g/dl for non-massive and 8 center dot 1 g/dl for massive blood loss. From these we derived target Hb levels. Results Ninety patients received one or more RBC units within 48 h of delivery. Mean pretransfusion Hb level was 6 center dot 9 [SD 1 center dot 2] g/dl. Median number of transfusions was 2. Mean Hb level at discharge was 9 center dot 7 [SD 1 center dot 1] g/dl. Taking threshold Hb and the derived target Hb level into account, 68% (n = 61) of the patients may have received one or more RBC units inappropriately. Of 311 RBC units transfused, 143 units (46%) were possibly inappropriate, partly due to over-transfusion. Conclusion A significant proportion of postpartum RBC transfusions are possibly inappropriate, partly due to over-transfusion. If current guidelines would be more specific, in particular, with respect to the target Hb levels, the total amount of RBC transfusions may be considerably decreased. Show less
OBJECTIVE: In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. STUDY DESIGN AND METHODS: A... Show moreOBJECTIVE: In elective orthopaedic hip- and knee replacement surgery patients, we studied the effect of implementation of a uniform transfusion policy on RBC usage. STUDY DESIGN AND METHODS: A randomized, controlled study. A new uniform, restrictive transfusion policy was compared with standard care, which varied among the three participating hospitals. Only prestorage leucocyte-depleted RBC(s) were used. Primary end-point was RBC usage, related to length of hospital stay. Secondary end-points were Hb levels, mobilization delay and postoperative complications. RESULTS: Six hundred and three patients were evaluated. Adherence to the protocol was over 95%. Overall mean RBC usage was 0.78 U/patient in the new policy group and 0.86 U/patient in the standard care policy group (mean difference 0.08;95% CI [-0.3; 0.2]; P = 0.53). In two hospitals, the new transfusion policy resulted in a RBC reduction of 30% (0.58U RBC/patient) (P = 0.17) and 41% (0.29 U RBC/patient) (P = 0.05) respectively. In the third hospital, however, RBC usage increased by 39% (0.31 U RBC/patient) (P = 0.02) with the new policy, due to a more restrictive standard care policy in that hospital. Length of hospital stay was not influenced by either policy. CONCLUSIONS: Implementation of a uniform transfusion protocol for elective lower joint arthroplasty patients is feasible, but does not always lead to a RBC reduction. Length of hospital stay was not affected. Show less
So-Osman, C.; Cicilia, J.; Brand, A.; Schipperus, M.; Berning, B.; Scherjon, S. 2010
BACKGROUND AND OBJECTIVE: Despite published guidelines, a proportion of red blood cell (RBC) transfusions seem unnecessary. To evaluate the indications for and the appropriateness of RBC... Show moreBACKGROUND AND OBJECTIVE: Despite published guidelines, a proportion of red blood cell (RBC) transfusions seem unnecessary. To evaluate the indications for and the appropriateness of RBC transfusions in the postpartum patient, we performed a retrospective audit over a 1-year period in two Dutch hospitals. STUDY DESIGN AND METHODS: Observational study of transfused obstetric patients, admitted in 2006 to the Departments of Obstetrics of a university and a general hospital, was carried out. Relevant clinical and laboratory data were recorded. The appropriateness of RBC transfusions was assessed using the national and age-based transfusion guidelines for the general population; for the studied group the transfusion threshold haemoglobin (Hb) value was 6.4 g/dl for non-massive and 8.1 g/dl for massive blood loss. From these we derived target Hb levels. RESULTS: Ninety patients received one or more RBC units within 48 h of delivery. Mean pretransfusion Hb level was 6.9 [SD 1.2] g/dl. Median number of transfusions was 2. Mean Hb level at discharge was 9.7 [SD 1.1] g/dl. Taking threshold Hb and the derived target Hb level into account, 68% (n = 61) of the patients may have received one or more RBC units inappropriately. Of 311 RBC units transfused, 143 units (46%) were possibly inappropriate, partly due to over-transfusion. CONCLUSION: A significant proportion of postpartum RBC transfusions are possibly inappropriate, partly due to over-transfusion. If current guidelines would be more specific, in particular, with respect to the target Hb levels, the total amount of RBC transfusions may be considerably decreased. Show less
