title: A New Intraoperative Protocol for Reducing Perioperative Transfusions in Cardiac Surgery.
abstract: BACKGROUND
  Perioperative anemia and blood product transfusion increases short-term and long-term morbidity and mortality during cardiac surgery. We hypothesized that streamlined cardiopulmonary bypass circuit and rotational thromboelastometry (ROTEM) would reduce blood product usage and improve outcomes.
  
  
  METHODS
  All patients with Society of Thoracic Surgeons risk scores at our institution from January 2013 to June 2015 were included. Individuals were chronologically stratified into 2 groups according to institutional changes to a streamlined bypass circuit and ROTEM-guided transfusion. Blood product transfusion, hematocrit, and observed to expected outcomes (O/E) were compared between the groups.
  
  
  RESULTS
  Patients were defined as either control group (533 patients, 12 months) or intervention group (804 patients, 18 months). The intervention group was further subdivided into streamlined circuit (290 patients, 6 months) and ROTEM (514 patients, 12 months). Use of streamlined bypass circuit correlated with significantly reduced intraoperative transfusion of packed red blood cells (pRBCs) (23.8% versus 17.9%; p = 0.05) and platelets (28.0% versus 19.3; p = 0.01) with improvement in lowest intraoperative hematocrit (26.0 versus 26.9; p = 0.02). ROTEM was associated with a further reduction in intraoperative pRBCs (17.9% versus 11.28%; p = 0.01) and postoperative transfusion pRBCs (38.3% versus 23.5%; p = 0.02). The combination was associated with reduced intraoperative (44.6% versus 34.1; p < 0.001) and postoperative transfusions (45.6% versus 40.1; p < 0.001) in the intervention group, while maintaining a higher hematocrit at discharge (28.1 versus 29.1; p < 0.001). Finally, the intervention was associated with a statistically significant reduction in the O/E for reoperation (p = 0.003).
  
  
  CONCLUSIONS
  Use of streamlined cardiopulmonary bypass circuit and ROTEM may reduce transfusion and reoperation rates and improve perioperative anemia in cardiac surgical patients. This study demonstrates reproducible intraoperative methods for reducing blood product usage and improving outcomes.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: J Hunter
authors.initials: JH
authors.lastname: Mehaffey
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Schubert
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Gelvin
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Charles
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Robert B
authors.initials: RB
authors.lastname: Hawkins
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Lily E
authors.initials: LE
authors.lastname: Johnston
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Gorav
authors.initials: G
authors.lastname: Ailawadi
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
authors.forename: Irving L
authors.initials: IL
authors.lastname: Kron
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia. Electronic address: ljt9r@virginia.edu.
authors.forename: Leora T
authors.initials: LT
authors.lastname: Yarboro
mesh_terms: D000368:Aged; D000740:Anemia / Q000097:blood / Q000150:complications / Q000628:therapy*; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D006348:Cardiac Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006331:Heart Diseases / Q000097:blood / Q000150:complications / Q000601:surgery*; D006400:Hematocrit; D006801:Humans; D015994:Incidence; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D011183:Postoperative Complications / Q000097:blood / Q000453:epidemiology* / Q000517:prevention & control; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013916:Thrombelastography; D014768:Virginia / Q000453:epidemiology