Dr. Fiona Ralley
The Perioperative Patient Blood Management (PPBM) program continues to expand its services to any surgical specialty where a surgical procedure has an anticipated chance of a patient receiving a blood transfusion of great than 10%. Classifcally it has directed the majority of its efforts to orthopedic, cardiac and vascular patients. However this year gynecological, colo-rectal and hepatobilary surgery has been encouraged to consult the program when indicated.
Total perioperative patient care continues to focus mainly on the ONTraC targeted surgical procedures (orthopedic, cardiac, and gynecological), as well as patients refusing blood transfusion. With preoperative hemoglobin optimization continuing to be the core of the nurses' work for any patient referred to the program. Thurs, the PPBM program continues to see from 200-250 patients a month, with approximately 2-3% receiving either intravenous iron and or erythropoietin.
The number of orthopedic patients seen in the pre-admission clinic (PAC) with clinical anemia (i.e. Hb<130g/L) has been greatly reduced since the introduction of reporting of outpatient clinic hemoglobin and ferritin testing via the hospital S-drive, which enables identifying iron deficient and anemic patients as early as possible in the preoperative time period (up to three months prior to surgery). This allows for the use of oral iron supplementation as the primary treatment modality for the anemia.
Implementation of this early screening program resulted in a decreased number of orthopedic patients with hemoglobin lower than 130g/L at the time of their PAC assessment compared to a control group prior to implementation. There was also a significant decrease in the use of erythropoietin and/or IV iron pre-operatively in the patients in the early screening program. Initially started in the orthopedic outpatinet clinic in late 2012, this service has now been offered to other specialties including cardiac, gynecological and general surgery. It is hoped that after a recent presentation to the perioperative committee of LHSC describing the excellent results seen in the orthopedic patients, that this will be adopted by these services.
One vs. two unit red blood cell (RBC) transfusion rates continues to be monitored by the program as part of a LHSC Medical Advisory Committee Quality Indicator. This is in preparation for the possible introduction of mandatory reporting of these numbers in the future as requested by the Ontario Transfusion Quality Improvement Plan for 1 unit RBC transfusion being developmed by Ontario Regional Blood Coordinating Network. There has been some significant improvement in this area over the past year so that the numbers at LHSC are approaching those recommended by the national Advisory Committee for Blood Products. Education is being continued to maintain these numbers.
During the past year three major studies have been completed including a multidisciplinary study on the use of a point-of-care algorithm in guiding transfusion decisions in cardiac surgical patients, a study on the comparison of intra-articular tranexamic acid vs. intravenous tranexamic acid in patients undergoing total hip joint replacement, as part of a Master of Surgery thesis, and a review of the impact of early patient screening in orthopedic patients on the incidence of preoperative anemia. All the studies have manuscripts in progress.
In collaboration with Orthopedic Surgery Resident Dr. S. Neely, research project "Is there a role for pre-operative iron supplementation in patients preparing for a total knee or total hip arthroplasty?" patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 represented the control group (hemoglobin optimization strategies implemented at PAC). The treatment group, patients seen in PAC between October 1, 2012 and December 31, 2013 received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L. Implementation of this early screening program using oral iron supplementation resulted in a decrease.
As always the PPBM extends an invitation to anyone who wishes to inquire about any of our many patient blood management strategies to contact any member of the program. In addition, information can be obtained from our hospital website at: www.lhsc.on.ca/bloodmanagement in the number of patients with hemoglobin lower than 130g/L at the time of PAC assessment. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program.
One verses two unit red blood cell (RBC) transfusion reported to MAC as a quality indicator; as of January 1, 2015 data percentage parameters for red, yellow and green designations were revised to less than 50, 50 to 64, and 65 or greater respectively. The revision is in keeping with the Ontario Transfusion Quality Improvement Plan for 1 unit RBC transfusion being developed by Ontario Regional Blood Coordinating Network.