Heart & Vascular Institute Physician eNewsletter - Fall 2013
A recent study published in The Lancet found that a restrictive approach to blood transfusion has emerged nationally as a best practice, supported by clinical guidelines and evidence-based research. However, researchers identified a high degree of variability from institution to institution for certain procedures such as cardiothoracic surgery.
Cleveland Clinic’s Department of Thoracic and Cardiovascular Surgery strongly advocates blood conservation practices wherever possible, says Colleen Koch, MD, MS, MBA, Vice Chair for Research and Education in Cardiothoracic Anesthesiology at Cleveland Clinic.
Cleveland Clinic’s perioperative management strategies include:
- Discontinuing preoperative medications that may contribute to bleeding
- Identifying and treating anemia preoperatively
- Use of minimally invasive approaches to surgery when possible
- Intraoperative use of antifibrinolytic medications to decrease bleeding
- Use of red blood cell (RBC) salvage devices to re-infuse the patient’s own blood
- Meticulous surgical technique to prevent bleeding due to surgical causes
In addition, the Heart & Vascular Institute's Cardiovascular Intensive Care Units recently transitioned all intensive care units to smaller-volume blood test tubes for routine laboratory testing to further conserve the patients’ own blood and decrease the prevalence of hospital-acquired anemia, Dr. Koch says.
“While we do not definitively know ‘how low one can go’ with anemia, recent research has shown that some cardiac surgery patients can tolerate lower levels of hemoglobin than what was previously believed to be safe,” Dr. Koch says. “Conventional wisdom sometimes leads patients to believe that they will fare better if they get a transfusion, but we now know based on the evidence that patients who don’t receive transfusions often have better outcomes than those who do.”
Tackling hospital-acquired anemia
Cleveland Clinic is currently critically evaluating processes-of-care that contribute to patients developing anemia during their course of hospitalization for both surgical and medical patient populations, Dr. Koch says. Hospital-acquired anemia is defined as patients who are admitted to the hospital with a normal hemoglobin level and who subsequently develop anemia due to a number of factors, such as: frequent phlebotomy, procedural blood loss, patients with unrecognized iron deficiency, and dilution of the patient’s blood volume from intravenous fluids.
If a patient develops hospital-acquired anemia, their LOS is longer, mortality is higher, and they are more likely to be readmitted to the hospital within 30 days of discharge.
“Our strategy has been to more closely investigate modifiable risk factors for both anemia and transfusion during the course of patient care that lend themselves to process improvement and ultimately better patient outcomes,” Dr. Koch says.
Lower risk, greater rewards
In addition to the fact that RBCs are in short supply, the benefits of a successful blood conservation program are clear, Dr. Koch says. For example, a study published recently in Annals of Thoracic Surgery found that patients who received RBC transfusions were more likely than those who did not to develop a major infection. In addition, research done at Cleveland Clinic’s Heart & Vascular Institute found fewer blood transfusions after cardiac surgery translated to lower morbidity rates, increased short- and long-term survival, a lower risk of developing atrial fibrillation after surgery, less time on the ventilator, and shorter average lengths of stay (LOS).
Dr. Koch has observed the variability in institutional transfusion practices that was highlighted in The Lancet paper. For example, routine transfusion practices for patients undergoing coronary artery bypass graft (CABG) can vary widely from center to center — from no transfusion to two units of blood, even for patients with similar clinical profiles.
“Some might suggest that the variability could mean that some centers are overusing blood,” she says.