Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 Christopher Craver ^1,2 , Kathy W. Belk ¹ , Gerard J. Myers ³

1. Vizient Inc., Health Data Analytics, Irving, TX, USA;
2. University of North Carolina-Charlotte, College of Health and Human Services, Charlotte, NC, USA;
3. Eastern Perfusion International, Dartmouth, Nova Scotia, Canada;

Corresponding author：

Christopher Craver, Email: Christopher.craver@vizientinc.com

Keywords：

Co-oximetry; conductivity; cardiac surgery; cardiopulmonary bypass; hemoglobin; hematocrit; red cell transfusion

DOI：

10.7507/1007-4848.201709052

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Objective Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. Methods A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. Results The study population included 18 169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs. 8.9%, P=0.006 9). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, 95%CI 1.15-1.38,P<0.000 1), longer LOS (IRR=1.08, P<0.000 1) and higher costs (IRR=1.15, P<0.000 1) than tHb-monitored patients. RBC transfusions were a significant driver of LOS (IRR=1.25, P<0.000 1) and cost (IRR=1.22, P<0.000 1). Conclusion tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.

Citation： Christopher Craver, Kathy W. Belk, Gerard J. Myers. Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(9): 742-749. doi: 10.7507/1007-4848.201709052 Copy

1.	Maslow A, Bert A, Singh A, et al. Point-of-care hemoglobin/hematocrit testing: comparison of methodology and technology. J Cardiothorac Vasc Anesth, 2016, 30: 352-362.
2.	Myers G, Browne J. Point of care hematocrit and hemoglobin in cardiac surgery: a review. Perfusion, 2007, 22: 179-183.
3.	Reeves BC, Murphy GJ. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr Opin Cardiol, 2008, 23: 607-612.
4.	Gerber DR. Risks of packed red blood cell transfusion in patients undergoing cardiac surgery. J Crit Care, 2012, 27: 737.e1-9.
5.	Mariscalco G, Biancari F, Juvonen T, et al. Red blood cell transfusion is a determinant of neurological complications after cardiac surgery. Interact Cardiovasc Thorac Surg 2015; 20: 166-171.
6.	Murphy GJ, Reeves BC, Rogers CA, et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation, 2007, 116: 2544-2552.
7.	Yu PJ, Cassiere HA, Dellis SL, et al. Dose-dependent effects of intraoperative low volume red blood cell transfusions on postoperative outcomes in cardiac surgery patients. J Cardiothorac Vasc Anesth, 2014, 28: 1545-1549.
8.	Ang LB, Veloria EN, Evanina EY, et al. Mediastinitis and blood transfusion in cardiac surgery: a systematic review. Heart Lung, 2012, 41: 255-263.
9.	Likosky DS, Paone G, Zhang M, Rogers MA, Harrington SD, Theurer PF, et al. Red blood cell transfusions impact pneumonia rates after coronary artery bypass grafting. Ann Thorac Surg, 2015, 100: 794- 801.
10.	Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. Br J Anaesth, 2012, 109: i29-i38.
11.	Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA, 2010, 304: 1559-1567.
12.	Murphy GJ, Reeves BC, Rogers CA. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. J Vasc Surg, 2008, 47: 894.
13.	Patel NN, Avlonitis VS, Jones HE, et al. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. Lancet Haematol, 2015, 2: e543-e553.
14.	Aronow HD, Peyser PA, Eagle KA, et al. Predictors of length of stay after coronary stenting. Am Heart J, 2001, 142: 799-805.
15.	Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol, 1992, 45: 613-619.
16.	D’Hoore W, Bouckaert A, Tilquin C. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol, 1996, 49: 1429-1433.
17.	Willan AR, Briggs AH, Hoch JS. Regression methods for covariate adjustment and subgroup analysis for non-censored cost-effectiveness data. Health Econ, 2004, 13: 461-475.
18.	Keeling WB, Binongo J, Sarin EL, et al. Predicted risk of mortality, transfusion, and postoperative outcomes in isolated primary valve operations. Ann Thorac Surg, 2016, 101: 620-624.
19.	Sharif H, Ansari HZ, Ashfaq A, et al. Predictive model for blood product use in coronary artery bypass grafting. J Coll Physic Surg-Pakistan, 2016, 26: 731-735.
20.	Christensen MC, Krapf S, Kempel A, et al. Perioperative management: costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg, 2009, 138: 687-693.
21.	LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg, 2013, 145: 796-804.
22.	Ferraris VA, Davenport DL, Saha SP, et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg (Chicago, Ill : 1960), 2012, 147: 49-55.
23.	Mirski MA, Frank SM, Kor DJ, et al. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. Crit Care, 2015, 19: 202.
24.	Enomoto L, Hollenbeak C, Bhayani N, et al. Measuring surgical quality: a national clinical registry versus administrative claims data. J Gastro Surg, 2014, 18: 1416-1422.
25.	Welke KF, Karamlou T, Diggs BS. Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease-a comparison of administrative and clinical data. Cardiol Young, 2008, 18: 137-144.
26.	John T, Rodeman R, Colvin R. Blood conservation in a congenital cardiac surgery program. AORN J, 2008, 87: 1180-1190.
27.	David Mazer C. Review: Blood conservation in cardiac surgery: Guidelines and controversies. Transfus Apher Sci, 2014, 50: 20-25.

1. Maslow A, Bert A, Singh A, et al. Point-of-care hemoglobin/hematocrit testing: comparison of methodology and technology. J Cardiothorac Vasc Anesth, 2016, 30: 352-362.
2. Myers G, Browne J. Point of care hematocrit and hemoglobin in cardiac surgery: a review. Perfusion, 2007, 22: 179-183.
3. Reeves BC, Murphy GJ. Increased mortality, morbidity, and cost associated with red blood cell transfusion after cardiac surgery. Curr Opin Cardiol, 2008, 23: 607-612.
4. Gerber DR. Risks of packed red blood cell transfusion in patients undergoing cardiac surgery. J Crit Care, 2012, 27: 737.e1-9.
5. Mariscalco G, Biancari F, Juvonen T, et al. Red blood cell transfusion is a determinant of neurological complications after cardiac surgery. Interact Cardiovasc Thorac Surg 2015; 20: 166-171.
6. Murphy GJ, Reeves BC, Rogers CA, et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation, 2007, 116: 2544-2552.
7. Yu PJ, Cassiere HA, Dellis SL, et al. Dose-dependent effects of intraoperative low volume red blood cell transfusions on postoperative outcomes in cardiac surgery patients. J Cardiothorac Vasc Anesth, 2014, 28: 1545-1549.
8. Ang LB, Veloria EN, Evanina EY, et al. Mediastinitis and blood transfusion in cardiac surgery: a systematic review. Heart Lung, 2012, 41: 255-263.
9. Likosky DS, Paone G, Zhang M, Rogers MA, Harrington SD, Theurer PF, et al. Red blood cell transfusions impact pneumonia rates after coronary artery bypass grafting. Ann Thorac Surg, 2015, 100: 794- 801.
10. Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. Br J Anaesth, 2012, 109: i29-i38.
11. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA, 2010, 304: 1559-1567.
12. Murphy GJ, Reeves BC, Rogers CA. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. J Vasc Surg, 2008, 47: 894.
13. Patel NN, Avlonitis VS, Jones HE, et al. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. Lancet Haematol, 2015, 2: e543-e553.
14. Aronow HD, Peyser PA, Eagle KA, et al. Predictors of length of stay after coronary stenting. Am Heart J, 2001, 142: 799-805.
15. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol, 1992, 45: 613-619.
16. D’Hoore W, Bouckaert A, Tilquin C. Practical considerations on the use of the Charlson comorbidity index with administrative data bases. J Clin Epidemiol, 1996, 49: 1429-1433.
17. Willan AR, Briggs AH, Hoch JS. Regression methods for covariate adjustment and subgroup analysis for non-censored cost-effectiveness data. Health Econ, 2004, 13: 461-475.
18. Keeling WB, Binongo J, Sarin EL, et al. Predicted risk of mortality, transfusion, and postoperative outcomes in isolated primary valve operations. Ann Thorac Surg, 2016, 101: 620-624.
19. Sharif H, Ansari HZ, Ashfaq A, et al. Predictive model for blood product use in coronary artery bypass grafting. J Coll Physic Surg-Pakistan, 2016, 26: 731-735.
20. Christensen MC, Krapf S, Kempel A, et al. Perioperative management: costs of excessive postoperative hemorrhage in cardiac surgery. J Thorac Cardiovasc Surg, 2009, 138: 687-693.
21. LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg, 2013, 145: 796-804.
22. Ferraris VA, Davenport DL, Saha SP, et al. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg (Chicago, Ill : 1960), 2012, 147: 49-55.
23. Mirski MA, Frank SM, Kor DJ, et al. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. Crit Care, 2015, 19: 202.
24. Enomoto L, Hollenbeak C, Bhayani N, et al. Measuring surgical quality: a national clinical registry versus administrative claims data. J Gastro Surg, 2014, 18: 1416-1422.
25. Welke KF, Karamlou T, Diggs BS. Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease-a comparison of administrative and clinical data. Cardiol Young, 2008, 18: 137-144.
26. John T, Rodeman R, Colvin R. Blood conservation in a congenital cardiac surgery program. AORN J, 2008, 87: 1180-1190.
27. David Mazer C. Review: Blood conservation in cardiac surgery: Guidelines and controversies. Transfus Apher Sci, 2014, 50: 20-25.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Measurement of total hemoglobin reduces red cell transfusion in hospitalized patients undergoing cardiac surgery: a retrospective database analysis

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