From the Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Health System Blood Management Program, The Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
Departments of Anesthesiology/Critical Care Medicine.
Anesth Analg. 2022 Sep 1;135(3):576-585. doi: 10.1213/ANE.0000000000006114. Epub 2022 Aug 17.
Providing bloodless medical care for patients who wish to avoid allogeneic transfusion can be challenging; however, previous studies have demonstrated favorable outcomes when appropriate methods are used. Here, we report one of the largest series of patients receiving bloodless care, along with the methods used to provide such care, and the resulting outcomes.
In a retrospective cohort study, 1111 adult inpatients (age ≥18 years) at a single institution who declined allogeneic transfusion for religious or personal reasons between June 2012 and June 2016 were included, and the patient blood management methods are described. Patient characteristics, laboratory data, and transfusion rates, as well as clinical outcomes (morbidity, mortality, and length of stay) were compared to all other patients in the hospital who received standard care, including transfusions if needed (n = 137,009). Medical and surgical patients were analyzed as subgroups. The primary outcome was composite morbidity (any morbid event: infectious, thrombotic, ischemic, renal, or respiratory). Secondary outcomes included individual morbid events, in-hospital mortality, length of stay, total hospital charges, and costs.
The bloodless cohort had more females and a lower case mix index, but more preadmission comorbidities. Mean nadir hemoglobin during hospitalization was lower in the bloodless (9.7 ± 2.6 g/dL) compared to the standard care (10.1 ± 2.4 g/dL) group (P < .0001). Composite morbidity occurred in 14.4% vs 16.0% (P = .16) of the bloodless and standard care patients, respectively. Length of stay and in-hospital mortality were similar between the bloodless and standard care patients. After Bonferroni adjustment for multiple comparisons, hospital-acquired infection occurred less frequently in the bloodless compared to the standard care cohort (4.3% vs 8.3%) (P < .0001) in the medical patient subgroup, but not in the surgical subgroup. After propensity score adjustment in a multivariable model and adjustment for multiple comparisons, bloodless care was associated with less risk of hospital-acquired infection (OR, 0.56; 95% CI, 0.35-0.83; P = .0074) in the medical subgroup, but not in the surgical subgroup. Median total hospital charges (by 8.5%; P = .0017) and costs (by 8.7%; P = .0001) were lower in the bloodless compared to the standard care cohort, when all patients were included.
Overall, adult patients receiving bloodless care had similar clinical outcomes compared to patients receiving standard care. Medical (but not surgical) bloodless patients may be at less risk for hospital-acquired infection compared to those receiving standard care. Bloodless care is cost-effective and should be considered as high-value practice.
为避免异体输血的患者提供无血医疗护理可能具有挑战性；然而，以前的研究表明，使用适当的方法可以取得良好的结果。在这里，我们报告了最大的一系列接受无血护理的患者之一，以及提供此类护理的方法以及由此产生的结果。
在一项回顾性队列研究中，纳入了 2012 年 6 月至 2016 年 6 月期间在一家机构中因宗教或个人原因拒绝异体输血的 1111 名成年住院患者（年龄≥18 岁），并描述了患者血液管理方法。比较患者特征、实验室数据和输血率以及临床结局（发病率、死亡率和住院时间）与接受标准护理（包括需要时输血的患者，n=137009）的医院中所有其他患者。分析了内科和外科患者作为亚组。主要结局是复合发病率（任何发病事件：感染、血栓形成、缺血、肾或呼吸）。次要结局包括单个发病事件、院内死亡率、住院时间、总住院费用和成本。
无血组的女性更多，病例组合指数较低，但入院前合并症更多。与标准护理组（10.1±2.4 g/dL）相比，无血组住院期间的平均血红蛋白最低值较低（9.7±2.6 g/dL）（P<0.0001）。无血组和标准护理组的复合发病率分别为 14.4%和 16.0%（P=0.16）。无血组和标准护理组的住院时间和院内死亡率相似。在进行多次比较的 Bonferroni 调整后，无血组比标准护理组的医院获得性感染发生率较低（4.3%比 8.3%）（P<0.0001），但在外科亚组中则不然。在多变量模型中进行倾向评分调整和多次比较调整后，无血护理与内科亚组的医院获得性感染风险降低相关（OR，0.56；95%CI，0.35-0.83；P=0.0074），但在外科亚组中则不然。当包括所有患者时，与标准护理组相比，无血组的总住院费用（降低 8.5%；P=0.0017）和成本（降低 8.7%；P=0.0001）中位数较低。
总体而言，接受无血护理的成年患者与接受标准护理的患者相比，临床结局相似。与接受标准护理的患者相比，内科（但不是外科）无血患者可能发生医院获得性感染的风险较低。无血护理具有成本效益，应被视为高价值的实践。
