Newly Published
Perioperative Medicine  |   August 2018
Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery
Author Notes
  • From the Department of Anesthesiology/Critical Care Medicine (V.M.D., S.M.F.), Department of Orthopaedic Surgery (R.M.A., H.S.K., R.S.S.), Department of Pathology (Transfusion Medicine; E.A.G., R.G., P.M.N.), The Johns Hopkins School of Medicine (P.B.G.), Baltimore, Maryland; Simmons Cancer Institute at Southern Illinois University, Springfield, Illinois (R.G.); Armstrong Institute for Patient Safety and Quality (K.H.K.L., S.M.F.), The Johns Hopkins Health System Blood Management Program (S.M.F.), The Johns Hopkins Medical Institutions, Baltimore, Maryland; and Hofstra University School of Medicine, Hempstead, New York (W.W.Y.).
  • Submitted for publication September 25, 2017. Accepted for publication June 20, 2018.
    Submitted for publication September 25, 2017. Accepted for publication June 20, 2018.×
  • Acknowledgments: The authors would like to acknowledge both financial and project management support from The Johns Hopkins Health System Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland.
    Acknowledgments: The authors would like to acknowledge both financial and project management support from The Johns Hopkins Health System Armstrong Institute for Patient Safety and Quality, Baltimore, Maryland.×
  • Research Support: Support for this study was provided solely from institutional and/or departmental sources.
    Research Support: Support for this study was provided solely from institutional and/or departmental sources.×
  • Competing Interests: Dr. Frank has been on advisory boards for Haemonetics (Braintree, Massachusetts) and Medtronic (Minneapolis, Minnesota). The other authors declare no competing interests.
    Competing Interests: Dr. Frank has been on advisory boards for Haemonetics (Braintree, Massachusetts) and Medtronic (Minneapolis, Minnesota). The other authors declare no competing interests.×
  • Correspondence: Address correspondence to Dr. Frank: The Johns Hopkins Hospital, Department of Anesthesiology, Sheik Zayed Tower 6208, 1800 Orleans St., Baltimore, Maryland 21287. sfrank3@jhmi.edu. Information on purchasing reprints may be found at www.anesthesiology.org or on the masthead page at the beginning of this issue. Anesthesiology’s articles are made freely accessible to all readers, for personal use only, 6 months from the cover date of the issue.
Article Information
Perioperative Medicine / Quality Improvement
Perioperative Medicine   |   August 2018
Patient Blood Management Program Improves Blood Use and Clinical Outcomes in Orthopedic Surgery
Anesthesiology Newly Published on August 20, 2018. doi:10.1097/ALN.0000000000002397
Anesthesiology Newly Published on August 20, 2018. doi:10.1097/ALN.0000000000002397
Abstract

What We Already Know about This Topic:

  • A transfusion threshold of 8 g/dl of hemoglobin is considered safe for asymptomatic orthopedic surgery patients, but lower thresholds have not been tested

What This Article Tells Us That Is New:

  • A blood management program using a hemoglobin transfusion threshold of 7 g/dl in asymptomatic orthopedic patients reduces blood use by 32.5% and results in similar or improved clinical outcomes

  • Improved outcomes occurred primarily in patients 65 yr of age and older

Background: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopedic surgery patients require a higher hemoglobin transfusion threshold than other patient populations (8 g/dl vs. 7 g/dl). The authors tested the hypothesis in orthopedic patients that implementation of a patient blood management program encouraging a hemoglobin threshold less than 7 g/dl results in decreased blood use with no change in clinical outcomes.

Methods: After launching a multifaceted patient blood management program, the authors retrospectively evaluated all adult orthopedic patients, comparing transfusion practices and clinical outcomes in the pre- and post-blood management cohorts. Risk adjustment accounted for age, sex, surgical procedure, and case mix index.

Results: After patient blood management implementation, the mean hemoglobin threshold decreased from 7.8 ± 1.0 g/dl to 6.8 ± 1.0 g/dl (P < 0.0001). Erythrocyte use decreased by 32.5% (from 338 to 228 erythrocyte units per 1,000 patients; P = 0.0007). Clinical outcomes improved, with decreased morbidity (from 1.3% to 0.54%; P = 0.01), composite morbidity or mortality (from 1.5% to 0.75%; P = 0.035), and 30-day readmissions (from 9.0% to 5.8%; P = 0.0002). Improved outcomes were primarily recognized in patients 65 yr of age and older. After risk adjustment, patient blood management was independently associated with decreased composite morbidity or mortality (odds ratio, 0.44; 95% CI, 0.22 to 0.86; P = 0.016).

Conclusions: In a retrospective study, patient blood management was associated with reduced blood use with similar or improved clinical outcomes in orthopedic surgery. A hemoglobin threshold of 7 g/dl appears to be safe for many orthopedic patients.