Joshi Ravi V, Wilkey Andrew L, Blackwell James-Michael, Kwak Jenny, Raphael Jacob, Shore-Lesserson Linda, Greilich Philip E
From the Department of Anesthesiology and Pain Management, University of Texas (UT) Southwestern Medical Center, Dallas, Texas.
Department of Anesthesiology, Minneapolis, University of Minnesota, Minneapolis, Minnesota.
Anesth Analg. 2021 Jul 1;133(1):104-114. doi: 10.1213/ANE.0000000000005553.
Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap.
Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018.
Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria.
The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.
血液保护和止血是减少可避免的输血及其相关发病率和死亡率的重要组成部分。尽管已经发布了心脏手术的血液保护指南，但有证据表明实践模式仍存在持续的差异。心血管麻醉医师协会（SCA）的成员开展了一项调查，以审核对现有指南的遵循情况，并利用结果来缩小证据与实践之间的差距。
SCA及其持续实践改进（CPI）-血液保护工作组的成员制定了一项包含48个条目的心脏手术血液保护与止血（BCHCS）调查。问卷包括麻醉质量研究所（AQI）综合指标AQI49的各个组成部分。该调查在2017年秋季至2018年初期间通过研究电子数据采集（REDCap）联盟以电子邮件的方式分发给了整个SCA会员。
在3152名SCA成员中，有536人回复了调查问卷，回复率为17%。大多数回复者在学术机构工作。体外循环后输血触发的血红蛋白（Hgb）中位数为7.0至8.0 g/dL。AQI49有4个组成部分，由于一个特定组成部分：使用补充了床旁（POC）检测的输血算法，对所有这些组成部分的综合遵循率较低。对AQI49的其他3个组成部分有良好的遵循情况：使用抗纤溶药物、尽量减少血液稀释以及使用红细胞回收。总体而言，拥有多学科患者血液管理（PBM）团队的实践在满足所有4项AQI49标准方面最为成功。
该调查表明几种最佳实践得到了广泛采用，包括对较低血红蛋白输血触发值的耐受、使用抗纤溶药物、尽量减少血液稀释以及使用红细胞回收。该调查还证实，术前贫血管理以及使用补充了POC止血检测的输血算法方面仍存在差距。连续使用该调查可用于识别实施障碍并审核本文所述干预措施的有效性。该工具还可有助于协调地方、区域和国家层面的努力，并成为心脏手术中PBM实施策略的重要组成部分。
