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The effect of an intraoperative treatment algorithm on physicians' transfusion practice in cardiac surgery
G J Despotis1, J E Grishaber, L T Goodnough
1Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri.
Insights
A transfusion algorithm using real-time coagulation data significantly reduced blood component use in cardiac surgery patients. This approach improved transfusion practices and reduced donor exposures, demonstrating its effectiveness as a physician education tool.
Area of Science:
- Cardiovascular Surgery
- Transfusion Medicine
- Coagulation Monitoring
Background:
- Inappropriate blood transfusions in cardiac surgery often stem from empiric practices lacking timely laboratory data.
- Evaluating a transfusion decision algorithm based on intraoperative coagulation monitoring is crucial for improving transfusion practices.
Purpose of the Study:
- To assess the impact of a transfusion decision algorithm utilizing intraoperative coagulation monitoring on physician transfusion practices and patient outcomes.
- To determine if real-time data can mitigate empiric transfusion therapy in cardiac surgery.
Main Methods:
- A randomized, controlled trial involving cardiac surgical patients with microvascular bleeding.
- Patients were assigned to either an algorithm-guided therapy group (A) using rapid on-site coagulation data or a standard therapy group (S) with physician discretion.
- Group A received plasma and platelet therapy based on data available within 4 minutes.
Main Results:
- Group A patients received significantly fewer hemostatic blood component units and had fewer total donor exposures compared to Group S.
- Transfusion algorithm use altered physician transfusion practices, independent of surgical blood loss.
- Statistical analysis accounted for gender as a covariate due to baseline differences between groups.
Conclusions:
- Transfusion decision algorithms incorporating on-site coagulation data effectively alter physician transfusion practices.
- Algorithm-guided therapy serves as an effective physician education intervention to optimize blood component use in cardiac surgery.
Background:
Inappropriate transfusion in cardiac surgery may, in part, be due to empiric transfusion therapy instituted in the absence of timely laboratory data. Therefore, the effect of a transfusion decision algorithm based on intraoperative coagulation monitoring of physicians' transfusion practice and the transfusion outcome was evaluated.
Study Design And Methods:
In a randomized, controlled trial, cardiac surgical patients determined to have microvascular bleeding at the cessation of cardiopulmonary bypass were assigned to algorithm (A) or standard (S) therapy. Group A was treated with plasma and platelet therapy according to a transfusion algorithm based on on-site coagulation data available within 4 minutes. For Group S, the use of laboratory-based data and the decision to transfuse blood components were at physician discretion.
Results:
Sixty-six patients were entered into the study (Group A, n = 30; Group S, n = 36). Other than the fact that there were significantly more female patients in Group S than in Group A, no differences between cohorts in regard to perioperative risk factors for blood transfusion needs were identified. Therefore, gender was factored in as a covariate in the statistical analysis. Group A patients received fewer hemostatic blood component units (p = 0.008) and had fewer total donor exposures (p = 0.007) during the entire hospitalization period. Linear regression analysis of the differences in slopes in Groups A and S for the relationships between the red cell volume lost and the red cell volume transfused (p < 0.03), non-red cell units transfused (p < 0.0001), and total number of blood components transfused (p < 0.0001) demonstrated that physicians' transfusion practice was significantly altered by the use of a transfusion algorithm with on-site coagulation data, independent of surgical blood losses.
Conclusion:
The use of algorithms by transfusion decision makers can serve as an effective physician education intervention.