| Section 1.Quality Management of a Comprehensive Blood Conservation Program During Cardiopulmonary BypassBackground Red blood cell transfusion is common and associated with adverse outcomes for cardiac surgery,while present blood conservation guidelines have not been fully implemented until now.Blood transfusion reduction during cardiopulmonary bypass(CPB)may have a positive impact on the prognosis of patients.The CPB department in our hospital has promoted five blood conservation measures to reduce blood use,and has conducted quality management of these measures since January 2018.This study evaluated our comprehensive blood conservation program after quality management and explored its impact on blood transfusion and outcomes in patients undergoing CPB.Methods We retrospectively compared blood transfusions and outcomes of patients from two different periods,before and after initiation of the quality management of the comprehensive blood conservation program.The comprehensive program included strict transfusion indications,conventional ultrafiltration,cell salvage,residual pump blood ultrafiltration,and a modified minimal extracorporeal circulation system.A 1:1 propensity score matching and subgroup analysis were conducted.Results There were 3977 pairs after matching.A significant decrease of red blood cell transfusion was observed before vs after the comprehensive blood conservation program during CPB(28.4%vs 18.6%,P<0.001),in the operation(40.7%vs 34.3%,P<0.001),and after the operation(6.2%vs 4.3%,P<0.001).Also reduced in 30-day mortality and some major complications.Subgroup analysis showed that the comprehensive blood conservation program was more beneficial for patients aged>60 years,male,and with a medium-risk European System for Cardiac Operative Risk Evaluation(EuroSCORE)of score 3 to 5.Conclusions The comprehensive blood conservation program during CPB is effective and safe in adult cardiac operations,reducing blood use,with no adverse outcomes.For patients who are older,male,and have a EuroSCORE of 3 to 5,blood transfusion should be more cautious.Section 2.Application of a Comprehensive Patient Blood Management Program During Cardiopulmonary Bypass in Elderly PatientsBackground Due to the special physiological state of elderly patients,we need to pay more attention to the balance between anemia and blood transfusion,and the appropriate blood transfusion threshold.The research on blood transfusion strategy for elderly patients has not been unified.This study aimed to analyzed the effect of comprehensive patient blood management program applying on elderly patients,in order to explore the association of old age,patient blood management and postoperative outcomes in cardiovascular surgery,as well as whether old age would affect the patient blood management program.Methods This study is a retrospective study,which included elderly patients over 60 years old who received cardiovascular surgery under cardiopulmonary bypass(CPB)in our hospital between 2015 and 2020.The patients were divided into two groups,aged 6074 years,75 years and over.The clinical characteristics,red blood cell(RBC)transfusion and outcomes were compared between two age groups,and two periods(before and after the comprehensive patient blood management).Then compared the clinical outcomes of patient blood management stratified by the two age groups.Baseline was adjusted by propensity score matching method to make it balanced.Then multivariable logistic regression model or multivariable ANOVA were fitted to evaluate the age-by-management interaction.Results A total of 9703 elderly patients were included in the analysis.Compared with patients aged 60-74 years,the patients aged 75 years and over had more comorbidity and higher RBC transfusion rate during CPB.After the application of patient blood management program,the RBC transfusion rate were significantly reduced during CPB,in the operation and after the operation,and the risk of some adverse events was also reduced.There was no interaction between age and patient blood management.Old age does not affect the effect of patient blood management on reducing RBC transfusion rate(e.g.RBC transfusion rate during CPB:aged 60-74 years,OR 0.20,95%CI 0.170.23;aged 75 years and over,OR 0.32,95%CI 0.20-0.49,Pinteraction=0.245),mortality(aged 60-74 years,OR 0.64,95%CI 0.35-1.16;aged 75 years and over,OR 0.33,95%CI 0.07-1.64,Pinteraction=0.829),composite major complication(aged 60-74 years,OR 0.9,95%CI 0.79-1.03;aged 75 years and over,OR 0.91,95%CI 0.57-1.48,Pinteraction=0.68)and other complications.Conclusions Different age stages of elderly patients do not affect the effect of the comprehensive patient blood management program during CPB.The management program is safe and effective in elderly patients undergoing cardiovascular surgery,reducing RBC transfusion with no adverse event.Section 3.A Transfusion Risk Stratification Score to Facilitate Quality Management in Cardiopulmonary BypassBackground Our previous article has demonstrated the remarkable results of quality management work for a comprehensive blood conservation program in the department of cardiopulmonary bypass(CPB).But it is inadequate to evaluate the transfusion performance of each perfusionist merely based on their transfusion rates due to patients’different conditions.This study aimed to design a risk stratification score to predict perioperative red blood cell(RBC)transfusion for on-pump cardiac surgery,helping blood conservation measures for patients with different risks,so as to make our quality management work more scientific and comprehensive.Methods This was a retrospective study involving 42435 adult patients who underwent cardiovascular surgery with CPB from January 2012 to December 2018.All patients were divided into a 70%training set and 30%test set,used for model construction and verification respectively.Risk factors with P<0.1 in univariable analysis were screened and simplified for multivariable logistic regression.The variables with P<0.05 in the multivariable analysis constituted the final prediction model.The score of each predictive variable was calculated based on the regression coefficient,and the total RBC transfusion risk score of each patient was the sum of all variable scores.We then grouped the score into three categories according to the predicted RBC transfusion risk:low-risk,medium-risk and high-risk.The area under the receiver operating characteristic curve(AUC)was used to evaluate the discrimination performance,and the Hosmer-lemeshow goodness of fit test and calibration curve were used for its calibration performance test.Results 29704 patients were included in the training set and 12731 patients in the test set.Transfusions occurred in 22.3%(6630)of patients.The final model included 8 predictors:age,sex,anemia,NYHA cardiac function classification,body surface area,previous cardiac surgery,emergency surgery and surgery type.The AUC for the model was 0.77(95%CI,0.76 to 0.77)and 0.77(95%CI,0.76 to 0.78)in the training and test set,respectively.The calibration curves showed a good fit.The total score is 0-36.The higher the score,the higher the risk of RBC transfusion.The risk score was finally grouped into three categories:low-risk(score of 0-13 points),medium-risk(14-19 points)and high-risk(more than 19 points).Conclusion We developed and validated an effective risk stratification score with 8 variables to predict perioperative RBC transfusion for on-pump cardiac surgery,and the patients were grouped into low-risk,medium-risk and high-risk of RBC transfusion.It provides perfusionists guide for decision-making of blood conservation measures and evaluating the quality management work more scientific and more comprehensive.Section 4.Dose-Dependent Influence of Red Blood Cell Transfusion Volume on Adverse Outcomes in Cardiac SurgeryBackground It has been proved the association of red blood cell(RBC)transfusion and clinical outcomes.However,there are few studies on the association of RBC volume and outcomes.The purpose of this study was to evaluate the relationship between intraoperative incremental RBC volume and postoperative adverse outcomes for onpump cardiovascular surgery.Methods This was a retrospective observational analysis.Adult patients who underwent onpump cardiovascular surgery from January 1,2017 to December 31,2018 were included.The patients were grouped into four groups according to their intraoperative RBC transfusion volume:0U,1-2U,3-4U and 5-6U.The clinical characteristics of the four groups were compared.Then,we analyzed the relationship between RBC volume and postoperative adverse outcomes through multivariable logistic regression.Results A total of 12143 patients were analyzed,of which 3353(27.6%)were transfused with 1-6U RBC in the operation.The incidence of death,overall morbidity,acute kidney injury and prolonged mechanical ventilation were increased stepwise along with incremental RBC volume.After adjusting for possible confounders by multivariable regression model,patients transfused with 1-2U were associated with a 1.42-fold risk of death(99%CI,1.21-2.34,P=0.01)compared with patients without RBC,patients with 3-4U were associated with a 1.57-fold risk(99%CI,1.32-2.80,P=0.005)and patients with 5-6U had a 2.26-fold risk of death(99%CI,1.65-3.88,P<0.001).Similarly,the incidence of overall morbidity,acute kidney injury and prolonged mechanical ventilation increased several fold odds as the RBC numbers increased.Conclusion The incremental intraoperative RBC volume was significantly correlated with increased incidence of adverse outcomes such as death,overall morbidity,acute kidney injury and prolonged mechanical ventilation for patients underwent on-pump cardiovascular surgery.There was a significant dose-dependent influence of RBC volume on outcomes.Patient blood management practice should aim to reduce not only transfusion rate but also the volume of blood use. |
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