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1. Laparoscopic D1+ Lymph Node Dissection for Gastric Cancer in Jehovah’s Witness Patients: A 1:3 Matched Case Control Study...... 1

2. A Multimodal Approach Reduced Allogeneic Blood Transfusions by Over 50% in Pediatric Posterior Spinal Fusion (PSF) Surgeries...... 2

3. A Successful Selective Concurrent Audit of Platelet Utilization in a Large Academic Hospital ��4

4. Total Knee Arthroplasty is Safe in Jehovah’s Witness Patients—A 12-year Perspective...... 6

5. Automated Quantification of Blood Loss Versus Visual Estimation: A Prospective Study of 274 Vaginal Deliveries . . . .7

6. The Little Hospital That Could: Building a Nationally Recognized Patient Blood Management Program ...... 8

7. Sickle Red Blood Cells are More Susceptible to In Vitro Hemolysis when Exposed to Normal Saline versus Plasma-Lyte A...... 10

8. Discharge Hemoglobin <8 g/dL is Associated with Increased 30-day Readmission Rates after CABG...... 11

9. Blood Utilization, Mortality, and Costs for Transfused Victims of Gun Violence...... 12

10. Iron Deficiency in Pregnancy: A Commonly Unrecognized Problem...... 14

11. Program to Reduce Redundant Laboratory Sampling in an Intensive Care Unit Leads to Non-Inferior Patient Care and Outcomes ...... 15

12. The Safety of Restrictive Allogeneic Blood Transfusions Strategy in Patients with Extremity Sarcoma...... 16

13. Impact of Perioperative Allogeneic Blood Transfusion on Prognosis in High-Grade Extremity Sarcoma: A Meta-Analysis ...... 18

14. A Patient Blood Management Program Improves Blood Utilization and Clinical Outcomes in Orthopaedic Surgery . . .20

15. Prevalence of Folate Deficiency Among Preoperative Anemia Clinic Patients: Retrospective Research and Quality Improvement Study ...... 22

16. Nurses Promoting Patient Blood Management Standards ...... 23

17. Utilizing Change Management to Reduce Transfusions in Isolated Coronary Artery Bypass Grafting: Leveraging Business Models for Clinical Improvement...... 24

18. Decreasing Plasma Utilization with Education, Clinical Decision Support, and Guideline Creation...... 26

19. Assessment of Hyperfibrinolysis and Coagulopathy in Gastrointestinal Hemorrhage using Rotational Thromboelastometry...... 28

20. Risk Reduction versus Blood Conservation in the in the Neonatal ICU...... 30

21. Anemia Clinic Treatment and Pre-Operative Management of Cardiovascular Surgery Patients ...... 31

22. Evaluation of the Quantra™ System vs TEG 5000 in Cardiac Surgery: A Community-based Hospital System Experience...... 33

23. The Decision to Transfuse Blood is Not Just a Numbers Game...... 35

24. Thromboelastography for Bleeding Risk Assessment in Invasive Procedures...... 37

25. The Benefits of Establishing a Dynamic Platelet Inventory Management System...... 39

26. Assessment of Intensive Care Unit Nursing Knowledge and Practices Regarding Patient Blood Management...... 40

27. Two Cases of Successful Management of Severe Retroperitoneal Bleeding Through Embolization Without Blood Transfusion...... 41

28. Tissue Molecular Genotyping Improves Patient Blood Management in Syrian Injured Patients Treated in Israel . . . . 42 29. Can Thromboelastography Really Assess Coagulation in Anemic Patients?...... 43

30. Variation on Transfusion Practice in First Elective Coronary Artery Bypass Graft (CABG) Surgery Demonstrated by a Statewide Quality Initiative...... 45

31. Bloodless Revascularization: The Protected PCI Approach at Englewood Hospital...... 46

32. Utilizing Data Combined with Specialty Champions as Drivers for Accelerating and Maximizing Patient Blood Management Initiatives...... 47

33. Comparison of Noninvasive Hemoglobin Analysis to Invasive Hemoglobin Analysis...... 49

34. Standardization Reliable Recognition and Treatment of Pre-Operative Anemia Using Anemia Reflex Testing and Pharmacy Driven Workflows...... 50

35. Desmopressin Reverses Platelet Inhibition in the ADP Pathway in Patients with Blunt Traumatic Brain Injuries. . . . 51

36. Computer Physician Order Entry Decision Support Aids in Reduction of Red Blood Cell Transfusion Dose in Pediatrics...... 52

37. High Autologous Wastage Rate Identifies Opportunities for Improving Patient Blood Management ...... 53

38. Promoting High-Value Practice by Reducing Unnecessary Transfusions ...... 54

39. How Much is Too Much Blood? Association Between Diagnostic Laboratory Testing and Hospital-Acquired Anemia in the Critically Ill...... 56

40. Correlation of Preoperative Anemia to Transfusion Rates in Spine Deformity Surgeries at a Major Academic Medical Center ...... 58

41. Implementing a Patient Blood Management Program in a Complex, Multi-State Hospital System...... 59

42. Time for a Check-Up! Assessment of Our Patient Blood Management Program...... 60

43. Prospective Review of All Blood Component Orders: Evaluating the Economic Impact at an Academic Medical Center...... 61

44. Collaboration in Bloodless Care of Major Obstetric Haemorrhage with Acute Extreme Anaemia...... 62

45. Do Patients with Thalassemia Minor or Trait Benefit from Blood Conservation Methods Preoperatively Before Undergoing High Blood Loss Surgery?...... 63

46. Tranexamic Acid Inhibits Plasminogen in Adolescent Scoliosis Surgery: A New Approach to Defining Efficacy and Antifibriolytic Action...... 64

47. Comparison of the Efficacy and Pharmacokinetics of Two Tranexamic Acid Dosage Regimes for Craniosynostosis Surgery. A multicenter double-blind RCT study...... 66

48. Saving Lives: Applying Patient Blood Management to Patients with High Risk for Postpartum Hemorrhage...... 68

49. Impact of Treatment of Pre-operative Anemia on Patient Perception of Care...... 69

50. Massive Transfusion Support for Gastrointestinal Bleeding: A Single-Center, Intensive Care Unit Assessment...... 71

51. Effects of RBC Usage After Implementation of CPOE-CDS and BPA ...... 72

52. Retrospective Evaluation of the Efficacy and Safety of 4-factor Prothrombin Complex Concentrate Compared to Fresh Frozen Plasma for Warfarin Reversal in Emergent Surgery or Invasive Procedure...... 74

53. Salvage of Life-Threatening Acute Blood Loss Anemia in the Traumatic and Post-Operative Setting: A Case Series of Clinical Experiences with Hemopure (HBOC-201) Blood Substitute...... 75

54. Bloodless Medicine: An Ecuadorian Experience with 73 patients...... 76

55. Extended Reliability and Clinical Utility of a Validated Intraoperative Bleeding Scale (VIBe SCALE)...... 78 1. Laparoscopic D1+ Lymph Node Dissection for Gastric Cancer in Jehovah’s Witness Patients: A 1:3 Matched Case Control Study

Author: Prof. Yong Jin Kim

Author Institution: Soonchunhyang University College of Medicine, Seoul Hospital XXX00CopyrightXXX ©XXX 2017 International Anesthesia Research Society2017

Purpose: Laparoscopic gastrectomy in early gastric cancer patients is accepted as standard, but it is sometimes challenging for patients who refuse blood transfusions such as Jehovah’s Witness (JW) patients, because of the risk of bleeding related to radical lymph node dissection. This study aimed to confirm the adequacy and safety of laparoscopic gastrectomy with D1 + lymphadenectomy in JW patients. Methods: From January 2009 to December 2015, 265 gastric cancer patients underwent laparoscopic gastrectomy in our institute. Among them, there were 25 JW, and they were statistically matched with 75 patients from the control groups depending on age, sex, and body mass index (BMI). In a retrospective review, patient laboratory values and their pathology results were analyzed. Results: There was no significant difference when comparing the clinical characteristics of JW and control groups. There was no statistically significant difference in blood loss or operation time between the two groups. Mean blood loss was 202.4±172.6 mL in the JW group and 179.7±163.8 mL in the control group (p=0.556). The number of retrieved lymph nodes was 27.8±13.9 in the JW group and 29.3±12.1 in the control group (p=0.607). Hemoglobin and hematocrit were measured after surgery and there was no statistically significant difference between the two groups. Conclusion: Laparoscopic D1+ gastrectomy in a JW patient may be performed with an equivalent risk to the control group. Thus, specialized gastric cancer center can do laparoscopic gastrectomy safely in JW patients, even with limited experience of bloodless surgery. ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott Williams & Wilkins

DOI:

1 2. A Multimodal Approach Reduced Allogeneic Blood Transfusions by Over 50% in Pediatric Posterior Spinal Fusion (PSF) Surgeries

Authors: Gee Mei Tan MD1, Thomas Austin MD2, Sumeet Garg MD1, Mindy N. Cohen MD1

Author Institutions: 1Department of Anesthesiology, University of Colorado School of Medicine and Children’s Hospital Colorado; 2Department of Anesthesiology, Emory University School of Medicine.

Summary: We created a perioperative multidisciplinary team to decrease blood loss and blood transfusion in pediatric posterior spinal fusion (PSF) surgeries. Interventions included restricting cases to specialized spine anesthesiologists, using antifibrinolytics, pre-incision intrathecal morphine, intraoperative cell salvage, and reduction of number of spine surgeons. Over a 5-year period, we significantly reduced both the rate of blood transfusion and the volume of blood transfused. Hypothesis: In patients having PSF, multi-disciplinary coordination and adherence to best practice protocols will result in 1) decreased transfusion rates and 2) decreased transfusion volumes. Design: The interventions were applied to all elective PSF surgeries in a consecutive manner over a 5-year period. Introduction: PSF surgery can result in a large amount of blood loss and blood transfusion. Transfusion has been associated with postoperative infection, prolonged hospital stay and delayed wound healing. Research shows that antifibrinolytics and intrathecal morphine decrease blood loss in PSF. Specialized teams, transfusion guidelines and cell salvage have been shown to decrease blood transfusion in PSF surgery. Methods: A multi-disciplinary team collaborated on interventions: 1) recruiting anesthesiologists committed to improving PSF patient care for neuromuscular scoliosis (NMS/High Risk), 2) antifibrinolytics, 3) intrathecal morphine, 4) restricting adolescent idiopathic scoliosis (AIS/ Low Risk) to spine anesthesiologists, 5) cell salvage and reduction of number of spine surgeons from 5 to 2. In a sequential manner, the interventions were applied to all PSF patients. Retrospective data included patient demographics, surgeons, amount of allogeneic blood transfusions, hematocrit levels, and length of hospital stay. Results: 795 patients were included. In AIS/Low Risk patients, packed red blood cell (PRBC) exposure decreased from 63.6% to 3.8% (p <0.001). In NMS/High Risk patients, PRBC exposure decreased from 97.3% to 45.2% (p <0.001). After accounting for patient risk and surgeon, antifibrinolytics (OR 0.44, p = 0.002), dedicated spine anesthesiologists (OR 0.47, p = 0.003), and cell salvage (OR 0.17, p <0.001) were associated with decreased PRBC transfusion. Tranexamic acid use (p = 0.036) and cell salvage use (p = 0.016) were both associated with a decrease in PRBC volume. Conclusion: Standardized multidisciplinary collaboration improved transfusion outcomes. With the cumulative effect of all interventions, overall PRBC transfusion fell to less than 4% in AIS/Low Risk and less than 50% in NMS/High Risk patients.

3 3. A Successful Selective Concurrent Audit of Platelet Utilization in a Large Academic Hospital

Authors: Kellie Simmons-Massey, PhD1, Mr. Ian James, Ms1, Dr. Linda Mamone, MD1, Dr. Shiguang Liu, Md, PhD1, Dr. Xunda Luo, MD, PhD1, Dr. Michelle Grant, MD, PhD1, Mr. Abhiraj Pudhota, Bs2, Ms. Tanjila Afronz, Bs2, Mr. Saumil Shah, Bs2, Mr. Alay Shah, Bs2, Dr. Maureen Miller, MD3, Dr. Ding Wen Wu, MD, PhD3, Dr. Timothy Hilbert, MD, PhD3, Dr. Yanhua Li, MD3

Author Institutions: 1Temple University Hospital; 2Temple University; 3New York University School of Medicine

Purpose: Patient Blood Management(PBM) is an evidence-based, multidisciplinary approach to optimizing the care of patients who may need transfusion. One major aspect of PBM is to decrease inappropriate transfusions. We developed an auditing process to evaluate blood ordering practices and utilization of>1 apheresis unit within 24 hours without pre-transfusion platelet count(PltC). Our aim was to evaluate if concurrent audits with real-time education/ feedback based on current guidelines would improve platelet utilization and clinical practice. Methods: The institution’s platelet transfusion (PltT) indications are: 1. PLT<10,000/ul, patient stable, not bleeding; 2. PLT≤20,000/ul and signs of bleeding; 3. PLT≤50,000/ul and active hemorrhage; 4. PLT≤ 50,000/ul with invasive procedure (recent, in progress or planned); 5. PLT ≤100,000/ul with bleeding/anticipated surgery in closed anatomical space (CNS, eye); 6. PLT dysfunction with active or anticipated hemorrhage/procedures; 7. Others. Based on these criteria, a PltT auditing process was developed which included an audit form with clear instructions. First review was done by laboratory staff: third shift staff reviewed all PltTs within past 24 hours. Trauma and surgical patients were excluded. For patients transfused with>1 apheresis unit of Plt, staff checked for a pre-transfusion PltC. If no pre-transfusion PltC or the PltC was >100K/ul, the case failed first review and was subject to second review by the pathology residents, who then reviewed the patient’s chart and related clinical information. If the resident deemed the transfusion medically inappropriate, the resident discussed the case with the ordering physicians utilizing the current guidelines to drive clinical practice. When alloimmune refractoriness was suspected, further workup was recommended. The medical director answered all questions raised during audit and completed the third/final audit. Results: A total of 96 audit forms (96 cases, 213 units) on file(approximately two-thirds of total audit forms) over thirteen months (September 2015-September 2016) were reviewed. During the first review, 79/96(82.3%) cases failed and warranted a second review. 42/79(53.2%) of second review cases failed to comply with PltT criteria representing 42/96(43%) of all cases. Three cases were sent for alloimmune refractoriness workup, of which two were confirmed as HLA alloimmunization mediated platelet transfusion refractoriness. PltTs in FY2016(1,515 units) decreased by 322 units (17.5%, 322/1,837) from FY2015(1,837 units). During the same time period(FY2016), surgeries (14488) and transplantations (183) increased compared to FY2015(14272 surgeries, 147 transplantations). Conclusion: PltTs markedly decreased after one-year concurrent audit, suggesting that selective concurrent audit with real-time education/feedback is both an effective and feasible strategy/method to decrease inappropriate transfusions, improve patient care, save blood products and reduce costs.

4 5 4. Total Knee Arthroplasty is Safe in Jehovah’s Witness Patients—A 12-year Perspective 5. Automated Quantification of Blood Loss Versus Visual Estimation: A Prospective Study of 274 Vaginal Deliveries Authors: Dr. Theodore Wolfson, Mr. David Novikov, Mr. Kevin Chen, Mr. Kelvin Kim, Dr. Afshin Anoushiravani, Dr. Ajit Deshmukh, Dr. Claudette Lajam; Authors: Dr. Andrew Rubenstein1, Dr. Stacy Zamudio1, Ms. Claudia Douglas1, Ms. Sharon Sledge1, Dr. Robert Thurer2 Author Institutions NYU Langone Health Author Institutions: 1Hackensack Meridian Health; 2Gauss Surgical Introduction: Despite the evolution of blood management protocols, total knee arthroplasty 00 (TKA) is still associated with blood loss, occasionally requiring allogeneic blood transfusion. Introduction: Failure to recognize significant blood loss can lead to delayed diagnosis of obstet- This poses a particular challenge for Jehovah’s Witnesses (JW) who believe that the Bible ric hemorrhage and consequent maternal morbidity and mortality. Accurate quantification of strictly prohibits the use of blood products. The aim of this study was to compare JW and a blood loss is therefore recommended to facilitate rapid recognition and implementation of matched-control cohort of non-JW candidates undergoing TKA to assess the safety using mod- hemorrhage protocols and to improve outcomes. ern blood management protocols. Methods: We quantified blood loss (QBL) using an automated system (Triton L&D™, Gauss Methods: Fifty-five JW patients (64 knees) who underwent TKA at our institution between Surgical, Los Altos, CA) during 274 vaginal deliveries. The results were compared to the obste- 2005 and 2017 were matched to 61 non-JW patients (62 knees). Patient demographics, intra- trician’s visual estimates (EBL). The Triton system batch weighs all blood containing sponges, operative details, and postoperative complications including revisions and reoperations were towels, pads and other supplies and automatically subtracts their dry weights. It also subtracts collected and compared between groups. Additionally, subgroup analysis was performed com- the measured amount of amniotic fluid. Each method was performed independently and clini- paring JW patients who were administered tranexamic acid (TXA) between the two groups. cians were blinded to the device’s results. Results: Baseline demographics did not vary significantly between the study cohorts. The Results: Mean QBL (399.8 ± 277.3 ml) was significantly greater than EBL (304.9 ± 135.2 mean follow-up was 3.1 years in both the JW and non-JW cohorts. Postoperative complications, ml) (P<.0001). Critically, QBL measured blood loss > 500 ml occurred in 73 (26.6%) patients including in-hospital complications (7.8% vs. 4.8%; p=0.49), revision TKA (1.6% vs. 0.98%; compared to 14 (5.1%) patients using visual estimation (P<.0001). QBL of ≥ 1,000 ml was p=0.98), and 90-day readmission (1.6% vs. 0.98%; p=0.98) were not significantly different recorded in 11 patients (4.0%), whereas only one patient had an EBL blood loss ≥ 1,000 ml between the JW and non-JW groups. Three patients (4.8%) in the non-JW arm received blood (P<.0001). transfusion during the perioperative period. Subgroup analysis demonstrated JW patients that received TXA had a significantly lower decline in postoperative Hgb (8.6% vs. 13.8%; p<0.01). In patients with a low visual estimation (≤ 500 ml; n=260, 94.9%), 63 (24.2%) had QBL > 500 ml and 8 (3.1%) had QBL >1,000 ml. In patients with higher QBL (> 500 ml; n=73, 26.6%), Discussion: At a follow-up of up to 12 years, JW patients who underwent TKA have outcomes only 10 (13.7%) had EBL > 500 ml. (Table) equivalent to non-JW patients without the need for transfusion. Moreover, the use of TXA in the JW group resulted in significantly less blood loss and shorter length of stay. These findings Conclusion: QBL facilitated by an automated system recognizes more patients with excessive validate the utility of modern blood management protocols, in particular TXA, to mitigate blood blood loss than visual estimation. The value of QBL as a public health safety initiative requires loss during and after TKA. clinicians to accept the long-known inadequacy of qualitative visual estimation and to implement hemorrhage protocols based on QBL values. Further studies of clinical outcomes related to implementation of QBL are needed.

Quantified Blood Loss (QBL) – Triton Device ≤ 500 ml 501 – 999 ml ≥ 1,000 ml Visually Estimated ≤ 500 ml 197 (71.9%) 55 (20.1%) 8 (2.9%) Blood Loss (EBL) 501 – 999 ml 4 (1.5%) 7 (2.6%) 2 (0.7%) ≥ 1,000 ml 0 0 1 (0.4%)

6 5. Automated Quantification of Blood Loss Versus Visual Estimation: A Prospective Study of 274 Vaginal Deliveries

Authors: Dr. Andrew Rubenstein1, Dr. Stacy Zamudio1, Ms. Claudia Douglas1, Ms. Sharon Sledge1, Dr. Robert Thurer2

Author Institutions: 1Hackensack Meridian Health; 2Gauss Surgical 00 Introduction: Failure to recognize significant blood loss can lead to delayed diagnosis of obstetric hemorrhage and consequent maternal morbidity and mortality. Accurate quantification of blood loss is therefore recommended to facilitate rapid recognition and implementation of hemorrhage protocols and to improve outcomes. Methods: We quantified blood loss (QBL) using an automated system (Triton L&D™, Gauss Surgical, Los Altos, CA) during 274 vaginal deliveries. The results were compared to the obste- trician’s visual estimates (EBL). The Triton system batch weighs all blood containing sponges, towels, pads and other supplies and automatically subtracts their dry weights. It also subtracts the measured amount of amniotic fluid. Each method was performed independently and clinicians were blinded to the device’s results. Results: Mean QBL (399.8 ± 277.3 ml) was significantly greater than EBL (304.9 ± 135.2 ml) (P<.0001). Critically, QBL measured blood loss > 500 ml occurred in 73 (26.6%) patients compared to 14 (5.1%) patients using visual estimation (P<.0001). QBL of ≥ 1,000 ml was recorded in 11 patients (4.0%), whereas only one patient had an EBL blood loss ≥ 1,000 ml (P<.0001). In patients with a low visual estimation (≤ 500 ml; n=260, 94.9%), 63 (24.2%) had QBL > 500 ml and 8 (3.1%) had QBL >1,000 ml. In patients with higher QBL (> 500 ml; n=73, 26.6%), only 10 (13.7%) had EBL > 500 ml. (Table) Conclusion: QBL facilitated by an automated system recognizes more patients with excessive blood loss than visual estimation. The value of QBL as a public health safety initiative requires clinicians to accept the long-known inadequacy of qualitative visual estimation and to implement hemorrhage protocols based on QBL values. Further studies of clinical outcomes related to implementation of QBL are needed.

6. The Little Hospital That Could: Building a Nationally Recognized Patient Blood Management Program

Authors: Robert Raggi, MD, JD; Karen Klein, RN, BSN, CPHQ; John Yamashita, MD; Marci Swearingen, MS, MT(ASCP), SBB, CIS; Mark Domantay, MHA, CPHQ

Authors Institution: Providence Holy Cross Medical Center

Abstract: PHCMC became the third hospital in the country and the first community hospital to achieve TJC/AABB PBM Certification, joining Georgetown and Johns Hopkins University. Their journey began after 9/11 when the hospital liaison from the International Kingdom Hall of the Jehovah’s Witnesses walked into the Anesthesia Chairman’s office in Brooklyn. That community hospital became the largest bloodless medicine program in NYC. The Anesthesia Chairman later joined the team at PHCMC. The journey at PHCMC continued with analyzing the EMR data for every blood transfusion in the Providence System. Identifying the transfusion trigger outliers became the basis for educating all caregivers. The adverse outcomes related to blood transfusions were key education pieces responsible for the culture change. We educated both outlier departments and individual physicians. The Nephrology Department made great strides in blood conservation. The Oncology Department continued to improve and decreased their preemptive treatment of expected anemia secondary to chemo and radiation therapy. A PBM report was added to our Transfusion Committee agenda. Our education on transfusion triggers became a revelation for the 20th century medical graduates. The fact that hemo- globins of 7 or 8 improved patient stroke volumes due to decreased blood viscosity startled providers. Also, the old 10/30 transfusion trigger was not evidence-based but an excellent guesstimate by Dr. Lundy. During the TJC survey, surveyors made an analogy that similar to an AMS program, a PBM program should be embraced by all community hospitals. Utilizing the teachings of SABM and AABB blended well with a culture of improving patient safety in a High Reliability Organization. Education alone changed the culture and increased awareness for all caregivers. We continue to work on improved treatment of IDA, focus on single-unit transfusions and preoperative anemia. Next steps include expanding the program to other blood products such as platelets and plasma. This program was shared with 5 other hospitals in the Providence LA region. After the first year the ROI showed a $700,000 savings and $4.5 million savings for the SoCal region. Quality pays. The journey of “The Little Hospital That Could” competing with university medical centers to provide patient safety in a community setting speaks volumes to all pursuing patient safety.

6. The Little Hospital That Could: Building a Nationally Recognized Patient Blood Management Program

Authors: Robert Raggi, MD, JD; Karen Klein, RN, BSN, CPHQ; John Yamashita, MD; Marci Swearingen, MS, MT(ASCP), SBB, CIS; Mark Domantay, MHA, CPHQ

Authors Institution: Providence Holy Cross Medical Center

9 7. Sickle Red Blood Cells are More Susceptible to In Vitro Hemolysis 8. Discharge Hemoglobin <8 g/dL is Associated with Increased when Exposed to Normal Saline versus Plasma-Lyte A 30-day Readmission Rates after CABG

Authors: Majed A. Refaai, MD1,3; Kelly Henrichs, MT(ASCP)1; Jill Cholette, MD2; Authors: Mereze Visagie, BA1; Vincent M. DeMario, BS1; Brian C. Cho, MD1; Michael C. Grant, Anthony Pietropaoli, MD3; Sherry Spinelli, PhD1; Suzie Noronha, MD4; MD1; Nadia B. Hensley, MD1; Charles H. Brown IV, MD, MHS1; Sachidanand Hebbar, PhD1; Richard Phipps, PhD1,3,5; Christine Cahill, RN1; and Neil Blumberg, MD1 Kaushik Mandal, MBBS, MD, MPH2; Glen J. Whitman, MD2; Steven M. Frank, MD1,3

Authors Institutions: 1Departments of Pathology and Laboratory Medicine (Transfusion Authors Institutions: Departments of 1Anesthesiology/Critical Care Medicine and 2Cardiac Medicine), Pediatrics (Critical Care,2 Cardiology2 and Hematology-Oncology4); 3Medicine; Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3The Armstrong 5Microbiology and Immunology and Environmental Medicine, University of Rochester Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions. Medical Center Background: Restrictive transfusion strategies supported by large randomized trials are result- Background: Normal saline (NS) has been the fluid of choice for resuscitation, rehydration ing in decreased blood utilization in cardiac surgery. What remains to be determined, however, and fluid replacement during therapeutic red blood cell (RBC) exchange for patients with sickle is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed cell anemia. There are increased concerns about NS’s renal toxicity, and data demonstrating patients with higher versus lower Hb levels upon discharge to compare 30-day readmission greater in vitro hemolysis of normal RBC with NS than with buffered solutions such as Plasma- rates after coronary artery bypass grafting (CABG). Lyte A (PL-A). Methods: We retrospectively evaluated 1,552 patients undergoing isolated CABG at our insti- Methods: We investigated the degree of hemolysis of normal RBCs (n=10) and sickle RBCs tution from Jan 2013 to May 2016. We evaluated two Hb cohorts: “High” (above) and “Low” (n=20) after in vitro incubation with either NS or PLA. We also analyzed RBC indices including (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood mean corpuscular volume (MCV) to assess the biophysical effects of short term (24 hours) utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the storage in these solutions. effects of the lowest (< 8 g/dL) discharge Hb levels on 30-day readmission rates. Risk adjustment accounted for age, gender, Charlson comorbidity index, preoperative comorbidities, and Results: Sickle RBC experienced significantly greater hemolysis (p<0.0001) than normal RBC patient blood management program implementation. in both crystalloid solutions (Table). NS caused increased hemolysis compared with PLA for sickle RBC after 24 hours of exposure (p<0.0001) (Table). In patient samples containing Results: Figure 1A is a LOWESS curve showing an increase in 30-day readmission rates when increasing quantities of hemoglobin S red cells, increasing hemoglobin S was associated with discharge Hb levels are < 8 g/dL, and a plateau in the 30-day readmission rate between 8 g/ increasing hemolysis in NS (Spearman’s correlation coefficient = 0.52; p=0.003). A similar dL and 12.5 g/dL. Figure 1B shows an increase in readmissions with discharge Hb < 8 g/dL. but smaller effect was seen for PLA (Spearman’s=0.44; p=0.02). After 24 hours of exposure, On multivariable analysis, the risk-adjusted odds of readmission in the “Low” Hb cohort (OR sickle RBC increased their MCV by 7.3 fl in NS vs. 6.3 fl in PLA (p=0.0078) (n=10). MCV of 1.16; 95% CI 0.84 to 1.61) (P = 0.36) was not significant compared to the “High” Hb cohort. normal RBC increased by 13 fl in NS and 12.4 in PLA (p=0.15) (n=5). However, a Hb < 8 g/dL upon discharge was predictive of increased 30-day readmissions (OR 1.77; 95% CI 1.05 – 2.88) (P = 0.036). Conclusions: This in vitro model demonstrates that short term exposure of sickle RBC to crystalloid leads to greater hemolysis than for normal RBC. This effect is significantly greater with Conclusions: A discharge Hb < 8 g/dL after CABG surgery may increase the risk for 30-day NS than PLA. Whether use of NS causes increased hemolysis in vivo is unknown. Given recent readmission. Although several trials support a restrictive transfusion strategy in cardiac evidence that NS increases renal failure and mortality in critically ill patients, further investiga- surgery, further studies are needed to determine the lower limit for a safe discharge Hb. tions are well justified. Until further studies can be conducted. patients with sickle cell anemia may benefit from rehydration and resuscitation with PLA or similar buffered solutions, given the existing evidence for adverse effects of low level hemolysis. Table: Free Hemoglobin (mg/dL) concentrations after 24 hour in vitro incubation of normal RBC and sickle RBC with normal saline or Plasma-Lyte A. Data are median and interquartile range ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott (IQR). p value by Wilcoxon signed rank test. Williams & Wilkins

10 8. Discharge Hemoglobin <8 g/dL is Associated with Increased 30-day Readmission Rates after CABG

Authors: Mereze Visagie, BA1; Vincent M. DeMario, BS1; Brian C. Cho, MD1; Michael C. Grant, MD1; Nadia B. Hensley, MD1; Charles H. Brown IV, MD, MHS1; Sachidanand Hebbar, PhD1; Kaushik Mandal, MBBS, MD, MPH2; Glen J. Whitman, MD2; Steven M. Frank, MD1,3

Authors Institutions: Departments of 1Anesthesiology/Critical Care Medicine and 2Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 3The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions.

Background: Restrictive transfusion strategies supported by large randomized trials are resulting in decreased blood utilization in cardiac surgery. What remains to be determined, however, is the impact of lower discharge hemoglobin (Hb) levels on readmission rates. We assessed patients with higher versus lower Hb levels upon discharge to compare 30-day readmission rates after coronary artery bypass grafting (CABG). Methods: We retrospectively evaluated 1,552 patients undergoing isolated CABG at our institution from Jan 2013 to May 2016. We evaluated two Hb cohorts: “High” (above) and “Low” (below) the mean discharge Hb level of 9.4 g/dL, comparing patient characteristics, blood utilization, and clinical outcomes including 30-day readmission rates. We further evaluated the effects of the lowest (< 8 g/dL) discharge Hb levels on 30-day readmission rates. Risk adjustment accounted for age, gender, Charlson comorbidity index, preoperative comorbidities, and patient blood management program implementation. Results: Figure 1A is a LOWESS curve showing an increase in 30-day readmission rates when discharge Hb levels are < 8 g/dL, and a plateau in the 30-day readmission rate between 8 g/ dL and 12.5 g/dL. Figure 1B shows an increase in readmissions with discharge Hb < 8 g/dL. On multivariable analysis, the risk-adjusted odds of readmission in the “Low” Hb cohort (OR 1.16; 95% CI 0.84 to 1.61) (P = 0.36) was not significant compared to the “High” Hb cohort. However, a Hb < 8 g/dL upon discharge was predictive of increased 30-day readmissions (OR 1.77; 95% CI 1.05 – 2.88) (P = 0.036). Conclusions: A discharge Hb < 8 g/dL after CABG surgery may increase the risk for 30-day readmission. Although several trials support a restrictive transfusion strategy in cardiac surgery, further studies are needed to determine the lower limit for a safe discharge Hb.

11 9. Blood Utilization, Mortality, and Costs for Transfused Victims of Gun Violence

Authors: Vincent M. DeMario, BS1; Mereze Visagie, BA1; Sachidanand Hebbar, PhD1; Val Strockbine, MSN, RN2; Mara A. Serbanescu, MD1; Rica M. Buchanan, MD, MPH1; Eric J. Wang, MD1; Mariuxi C. Manukyan, MD3; David T. Efron, MD3; Kathy Noll, RN3; Paul M. Ness, MD2; Robert A. Sikorski, MD1; Steven M. Frank, MD1,4

Authors Institutions: Departments of 1Anesthesiology/Critical Care Medicine; 2Pathology, and 3Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 4The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions.

Introduction: Massive transfusion protocols are associated with decreased mortality and improved hemostasis in adult trauma patients. Each year, greater than 30,000 deaths and 65,000 injuries are attributed to firearms in the United States. However, the transfusion requirements for this high-risk patient population are not well understood. In this study, blood utilization and mortality differences were assessed between victims of gun violence and victims of non-gun related trauma for patients requiring transfusion at a level-1 urban trauma center. Transfusion costs were also assessed. Methods: The State Trauma Registry was reviewed for all trauma patients who presented to a tertiary care facility from 01/2005 to 06/2017. The main study population was limited to patients who received any blood product during their hospital course. Patients were categorized based on mechanism of injury: 1) gunshot wound (GSW) or 2) all other trauma (non-GSW), and the number and type of all blood products were assessed. The primary outcomes were mortality, blood utilization, and transfusion costs—with costs assessed by two methods: 1) blood acquisition costs, and 2) activity-based costs (total transfusion costs including overhead). A multivariable logistic regression was used to assess risk-adjusted likelihood of mortality in all GSW vs. non-GSW trauma patients (transfused or not). Results: Data are shown in the Figure. Among the 1,336 trauma patients requiring any blood product administration, 538 were victims of gun violence (40.3%). Mortality in the Emergency Department (ED) was ≈6 times higher, and overall mortality was ≈2.5 times higher in the GSW cohort compared to the non-GSW cohort. GSW patients received on average ≈2 times the amount of blood products per patient compared to non-GSW patients (including PRBCs, FFP, platelets, and cryoprecipitate). For the 538 transfused GSW patients, ≈$6 million went to activity-based transfusion costs. The average transfusion cost per patient was ≈2 times higher in GSW victims versus non-GSW trauma patients. GSW victims had a higher risk-adjusted likelihood for ED mortality (OR, 2.36; 95% CI, 1.03 – 6.44; P=0.04), and overall mortality (OR, 3.67; 95% CI, 2.40 – 5.81; P<0.0001), after adjusting for known potential confounding variables. 23,422 trauma patients (transfused or not) were included in the multivariable models. Conclusion: Compared to other traumatic injuries, GSW-related injuries are associated with substantially greater mortality, blood utilization, and costs. After risk-adjustment, GSW injury was a strong independent predictor of mortality.

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12 13 10. Iron Deficiency in Pregnancy: A Commonly Unrecognized Problem 11. Program to Reduce Redundant Laboratory Sampling in an Intensive Care Unit Leads to Non-Inferior Patient Care and Outcomes Authors: Kirsti Ziola, MD1,2; Erwin Karreman, PhD1,2; Christine Lett, MD1,2 Authors: Christine Cahill, MS, BSN, RN1; Neil Blumberg, MD1; Anthony Pietropaoli, MD2; Authors Institutions: 1College of Medicine, University of Saskatchewan; 2Regina Qu’Appelle Michael Maxwell, RN2; Amy Wanck, RN2; Majed A Refaai, MD1 Health Region Authors Institutions: 1Department of Pathology and Laboratory Medicine; 2Department of Objectives: For a community general obstetrics population, the objectives are: 1) To determine the Medicine, Division of Pulmonary & Critical Care Medicine, University of Rochester Medical incidence of iron deficiency and anemia during pregnancy and postpartum; 2) To determine the Center, Rochester, NY, USA. impact of iron supplementation on pre-delivery and postpartum anemia in iron deficient patients. Study methods: A retrospective review of 280 patients between November 2016 and November Background: Studies have shown that laboratory sampling in intensive care units (ICU) accounts for 2017 was performed using an office electronic medical record database. Complete blood an average blood loss of 50–90 mL/day/patient. This significant blood loss exposes these critically count (CBC) and iron studies (iron, %saturation, and ferritin) were performed with second tri- ill patients to higher risk of anemia, a common comorbidity in ICU patients. This may also contribute mester diabetes screening. Anemia was defined as hemoglobin <110g/L and iron deficiency to increased rates of red blood cell (RBC) transfusion, complications, and higher heath care expen- was defined as ferritin < 30 ng/mL and/or %saturation < 15%. Iron deficiency was treated ditures. It has been also reported that up to 42% of laboratory testing in general may be considered with antepartum oral iron supplementation at the discretion of the care provider. Hemoglobin wasteful. In the US redundant testing has been estimated to cost nearly $5 billion/year. values pre-delivery and postpartum were recorded. Methods: As a patient blood management program initiative, a laboratory sample reduction Results: Between the 24th and 28th week of pregnancy, 87% of our sample was iron defi- guideline was developed in March of 2016 for use in the management of critically ill patients. cient. During this time, only 8% was anemic, while this number climbed to 44% postpartum All stakeholders participated in development and approved the protocol for use in the medical (p < .001). A total of 74% (135/182) of iron deficient patients received antepartum oral iron ICU. Interventions to decrease frequency, reduce sample size, and reduce waste are included supplementation. Oral iron supplementation increased pre-delivery hemoglobin by 6.76g/L. as well as education to incorporate iatrogenic anemia focus into the ICU culture. Retrospective The mean pre-delivery hemoglobin levels increased by 2.66 g/L more in iron deficient patients review of two periods before and after the initiation of the guideline was performed. Data collec- who were supplemented compared to those who did not receive a supplement (p = .054). tion consisting of number of laboratory orders, blood sampling, estimated daily blood volumes Antepartum oral iron supplementation did not impact the incidence of postpartum anemia. per patient, usage of point of care testing, average hemoglobin (Hgb) level, and RBC transfusion. ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott Williams & Wilkins Conclusions: Iron deficiency in pregnancy was very common in our cohort and would not have Results: Laboratory data of two eleven-month periods before and after implementation showed sig- been recognized by hemoglobin level measurements only. While anemia is not prevalent during nificant reduction in laboratory ordering (p=0.0153), blood sampling (p=0.0242), and point of care pregnancy, postpartum anemia is common. Finally, oral iron supplementation of iron deficient testing (p=0.0139) (Table). There was no significant difference in average MICU length of stay pre women increased hemoglobin levels prior to delivery but could not prevent a substantial rise and post implementation (6.2 ± 7.7 versus 6.2 ± 7.8, p=0.968). Despite the lower average daily Hgb of postpartum anemia in our cohort. that was observed in our post implementation group, RBC transfusion rate was similar between both groups, which is an indication of staff compliance with our institutional RBC transfusion guidelines. Conclusion: Our pilot program to reduce the risk of iatrogenic anemia in the medical ICU patients showed significant reduction in laboratory tests and blood sampling. Though not directly measured, as a result of reduced sampling we also reduced unnecessary blood loss, improving patient care practice and health care costs. Table: Pre and post program initiation data

Pre Implementation Post Implementation % of Change p Value* N 158 160 - Laboratory Orders 13,455 10,370 -22.9% 0.0153 Number of Blood Specimens 14,786 11,619 -21.4% 0.0242 Number of POCT Specimens 4,568 3,494 -23.5% 0.0139 Patient care days 346.82 344.82 -0.5% 0.892 MICU LOS 6.2 ± 7.7 6.2 ± 7.8 n/a 0.968 Ave daily Hgb (g/dL) 9.7 9.39 -3.1% 0.81 RBC transfusion (Units) 294 293 0 0.909 RBC Units/transfused patient 5.1 4.9 -3.9% 0.984 POCT: Point of Care Test Using Chi-Square; significant p value is <0.05

14 11. Program to Reduce Redundant Laboratory Sampling in an Intensive Care Unit Leads to Non-Inferior Patient Care and Outcomes

Authors: Christine Cahill, MS, BSN, RN1; Neil Blumberg, MD1; Anthony Pietropaoli, MD2; Michael Maxwell, RN2; Amy Wanck, RN2; Majed A Refaai, MD1

Authors Institutions: 1Department of Pathology and Laboratory Medicine; 2Department of Medicine, Division of Pulmonary & Critical Care Medicine, University of Rochester Medical Center, Rochester, NY, USA.

Background: Studies have shown that laboratory sampling in intensive care units (ICU) accounts for an average blood loss of 50–90 mL/day/patient. This significant blood loss exposes these critically ill patients to higher risk of anemia, a common comorbidity in ICU patients. This may also contribute to increased rates of red blood cell (RBC) transfusion, complications, and higher heath care expen- ditures. It has been also reported that up to 42% of laboratory testing in general may be considered wasteful. In the US redundant testing has been estimated to cost nearly $5 billion/year. Methods: As a patient blood management program initiative, a laboratory sample reduction guideline was developed in March of 2016 for use in the management of critically ill patients. All stakeholders participated in development and approved the protocol for use in the medical ICU. Interventions to decrease frequency, reduce sample size, and reduce waste are included as well as education to incorporate iatrogenic anemia focus into the ICU culture. Retrospective review of two periods before and after the initiation of the guideline was performed. Data collection consisting of number of laboratory orders, blood sampling, estimated daily blood volumes per patient, usage of point of care testing, average hemoglobin (Hgb) level, and RBC transfusion. Results: Laboratory data of two eleven-month periods before and after implementation showed significant reduction in laboratory ordering (p=0.0153), blood sampling (p=0.0242), and point of care testing (p=0.0139) (Table). There was no significant difference in average MICU length of stay pre and post implementation (6.2 ± 7.7 versus 6.2 ± 7.8, p=0.968). Despite the lower average daily Hgb that was observed in our post implementation group, RBC transfusion rate was similar between both groups, which is an indication of staff compliance with our institutional RBC transfusion guidelines. Conclusion: Our pilot program to reduce the risk of iatrogenic anemia in the medical ICU patients showed significant reduction in laboratory tests and blood sampling. Though not directly measured, as a result of reduced sampling we also reduced unnecessary blood loss, improving patient care practice and health care costs. Table: Pre and post program initiation data

15 12. The Safety of Restrictive Allogeneic Blood Transfusions Strategy Table 1. Baseline Characteristics of the Patients. in Patients with Extremity Sarcoma Variable Group 1 (N=20) Group 2 (N=17) p-value Age-yr 33.2 ± 21.0 43.1 ± 22.5 0.180 Male sex 11 (55.0%) 8 (47.1%) 0.879 Authors: Woo Young Jang, MD; Seok Ha Hong, MD; Jong Hoon Park, MD Hypertension 2 (10.0%) 3 (17.6%) 0.845 Diabetes mellitus 2 (10.0%) 2 (11.8%) 1.000 Authors Institutions: Korea University Anam Hospital, Seoul, Republic of Korea Absence of renal disease 20 (100.0%) 17 (100.0%) 0.440 Site 0.440 - arm 2 (10.0%) 1 (5.9%) Copyright © 2017 International Anesthesia Research Introduction: Allogeneic blood transfusions (ABT) are common in patient with cancer. The aim - buttock 0 (0.0%) 2 (11.8%) Society2017 was to investigate the safety of restrictive ABT strategy in patients with extremity sarcoma. - leg 10 (50.0%) 7 (41.2%) - thigh 8 (40.0%) 7 (41.2%) Method: We retrospectively reviewed patients who underwent operation for extremity bone or soft tis- Diagnosis -Chondrosarcoma 2 5 sue sarcoma between May 2008 and November 2017. To investigate surgical outcome of restrictive -Osteosarcoma 15 9 ABT strategy, clinical outcome based on variation in hemoglobin (Hb) concentration, postoperative -Fibrosarcoma 1 0 -Angiosarcoma 1 0 surgical site infection, and hospital stay days were compared between 20 patients who underwent -Adamantinoma 1 0 liberal ABT as control (group 1) and 19 patients who underwent restrictive ABT strategy (group 2). -Ewing sarcoma 0 1 -Histiocytic sarcoma 0 1 Rate of distant metastasis and death after operation were also compared between the groups. -Squamous cell carcinoma 0 1 Neoadjuvant Chemotherapy 10 (50.0%) 8 (55.5%) 0.638 Result: There was no significant difference in sex, age, tumor grade and tumor size between Preoperative hemoglobin (g/dL) 11.1 ± 2.8 11.5 ± 2.3 0.708 the groups (p=0.89, p=0.57, p=0.39, p=0.46 respectively). The mean of ABT was 3.6 ± 3.8 Preoperative platelet (x103 µL) 253.7 ± 89.2 213.1 ± 49.0 0.091 unit in group 1 and 0.23± 0.66 unit in group 2. Only 2 of 17 patients received transfusions and Surgery - Wide excision 5 5 2 packs were administered. The Hb had a tendency to fall during the three first days after sur- - Limb salvage operation 11 12 gery and seemed to be stabilized on day 5 in both group. Postoperative surgical site infection - Amputation 4 0 only occurred in 4 patients who underwent ABT. Length of stay was longer in group 1 (40.7 ± 20.9 days) than group 2 (30.9 ± 19.8 days), but there was no significant difference (p= 0.16). Table 2. Postoperative Clinical Outcomes The rate of distant metastasis and death were higher in group 1 than group 2 (18.2 % vs. 6.7%, Variables Group 1 (N=20) Group 2 (N=17) p-value 9.1% vs. 0 % respectively), but no significant difference (p=0.60, 0.64 respectively). Hospital stay (days). 38.2 ± 19.6 43.0 ± 40.5 0.663 Pneumonia 1 (5.0%) 0 (0.0%) 1.000 Conclusion: This study demonstrated that restrictive ABT strategy can be safely performed for Unrinary tract infection 3 (15.0%) 1 (5.9%) 0.720 wide excision or limb salvage operation in patients with extremity sarcoma. Surgical site infection 4 (20.0%) 3 (17.6%) 1.000 Storke 0 (0.0%) 1 (5.9%) 0.934 Recurrence 3 (15.0%) 3 (17.6%) 1.000 Metastasis 6 (30.0%) 2 (11.8%) 0.346 Death 2 (10.0%) 0 (0.0%) 0.541

16 Table 1. Baseline Characteristics of the Patients. Variable Group 1 (N=20) Group 2 (N=17) p-value Age-yr 33.2 ± 21.0 43.1 ± 22.5 0.180 Male sex 11 (55.0%) 8 (47.1%) 0.879 Hypertension 2 (10.0%) 3 (17.6%) 0.845 Diabetes mellitus 2 (10.0%) 2 (11.8%) 1.000 Absence of renal disease 20 (100.0%) 17 (100.0%) 0.440 Site 0.440 - arm 2 (10.0%) 1 (5.9%) - buttock 0 (0.0%) 2 (11.8%) - leg 10 (50.0%) 7 (41.2%) - thigh 8 (40.0%) 7 (41.2%) Diagnosis -Chondrosarcoma 2 5 -Osteosarcoma 15 9 -Fibrosarcoma 1 0 -Angiosarcoma 1 0 -Adamantinoma 1 0 -Ewing sarcoma 0 1 -Histiocytic sarcoma 0 1 -Squamous cell carcinoma 0 1 Neoadjuvant Chemotherapy 10 (50.0%) 8 (55.5%) 0.638 Preoperative hemoglobin (g/dL) 11.1 ± 2.8 11.5 ± 2.3 0.708 Preoperative platelet (x103 µL) 253.7 ± 89.2 213.1 ± 49.0 0.091 Surgery - Wide excision 5 5 - Limb salvage operation 11 12 - Amputation 4 0

Table 2. Postoperative Clinical Outcomes Variables Group 1 (N=20) Group 2 (N=17) p-value Hospital stay (days). 38.2 ± 19.6 43.0 ± 40.5 0.663 Pneumonia 1 (5.0%) 0 (0.0%) 1.000 Unrinary tract infection 3 (15.0%) 1 (5.9%) 0.720 Surgical site infection 4 (20.0%) 3 (17.6%) 1.000 Storke 0 (0.0%) 1 (5.9%) 0.934 Recurrence 3 (15.0%) 3 (17.6%) 1.000 Metastasis 6 (30.0%) 2 (11.8%) 0.346 Death 2 (10.0%) 0 (0.0%) 0.541

17 13. Impact of Perioperative Allogeneic Blood Transfusion on Prognosis in High-Grade Extremity Sarcoma: A Meta-Analysis

Authors: Woo Young Jang, MD; Jong Hoon Park, MD

Authors Institutions: Korea University Anam Hospital, Seoul, Republic of Korea

Background: An accurate understanding of the prognostic effect of allogenic blood transfusion (ABT) is essential in patients with high-grade extremity sarcoma (HGES) who are likely to require perioperative ABT owing to preoperative chemotherapy and blood loss caused by extensive resection. We investigated the impact of ABT on distant metastasis and survival in patients with HGES by a meta-analysis. Study Design and Methods: MEDLINE and EMBASE electronic databases and the reference lists of studies were searched. The following text words and/or medical subject heading (MeSH) terms were used: “tumor” OR “bone” OR “neoplasm” OR “sarcoma” OR “connective tissue” AND “extremity” AND “blood transfusion”. A pooled hazard ratio (HR) was analyzed using an inverse variance weighting method, and the fixed effect model was selected according to heterogeneity. Results: We included 4 high-quality studies conducted at a single institution in the meta- analysis. ABT was found to predict a poor prognosis factor for distant metastasis (HR= 1.91, 95% CI 1.18–3.09) and survival (HR = 2.42, 95% CI 1.29–4.52) compared to no ABT in a fixed effect model with low heterogeneity among studies (I2 = 2%, I2 = 0%, respectively). Funnel plots revealed apparent symmetry among the included studies in terms of distant metastasis and survival. Conclusion: Perioperative ABT can be considered a prognostic factor for increased rates of distant metastasis and decreased survival in patients with HGES. Patient blood management may significantly impact survival after the surgical treatment of HGES. Key Words: allogenic blood transfusion; extremity sarcoma; distant metastasis; survival

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18 13. Impact of Perioperative Allogeneic Blood Transfusion on Prognosis in High-Grade Extremity Sarcoma: A Meta-Analysis

Authors: Woo Young Jang, MD; Jong Hoon Park, MD

Authors Institutions: Korea University Anam Hospital, Seoul, Republic of Korea

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19 14. A Patient Blood Management Program Improves Blood Utilization and Clinical Outcomes in Orthopaedic Surgery

Authors: Pranjal B. Gupta, BE1; Vincent M. DeMario, BS1; Mereze Visagie, BA1; Raj Amin, MD2; Harpal S. Khanuja, MD2; Robert Sterling, MD2; Paul M. Ness, MD3; Steven M. Frank, MD1,4

Authors Institutions: Departments of 1Anesthesiology/Critical Care Medicine; 2Orthopaedic Surgery, and 3Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; 4The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medical Institutions, Baltimore, MD, USA

Background: Although randomized trials show that patients do well when given less blood, there remains a persistent impression that orthopaedic surgery patients require a higher hemoglobin (Hb) transfusion threshold than other patient populations (8 vs. 7 g/dL). We tested the hypothesis in orthopaedic patients that implementation of a patient blood management (PBM) program encouraging a Hb threshold < 7 g/dL results in decreased blood utilization with no change in clinical outcomes. Methods: We launched a multifaceted PBM program, including but not limited to implementing transfusion guidelines, clinical decision support with best practice advisory alerts, data acquisition and analytics, creating blood utilization electronic dashboards with provider transfusion guideline compliance audit reports and specific methods to decrease blood utilization, including a “Why Give 2 When 1 Will Do?” Choosing Wisely campaign and use of intraoperative antifibrinolytics (primarily tranexamic acid). We retrospectively evaluated all adult orthopaedic patients at our primary orthopaedic site comparing transfusion practices and clinical outcomes in the pre- and post-PBM cohorts. For analytical purposes, PBM was considered to be initiated in January 2015, when the majority of the phased-in PBM efforts were implemented, and when the mean hemoglobin trigger point at which transfusion was initiated fell from above 7 g/dL to below 7 g/dL. Risk adjustment accounted for age, gender, surgical procedure, and casemix index. Results: After PBM implementation, the mean Hb trigger threshold level decreased from 7.8 ± 1.0 to 6.8 ± 1.0 g/dL and the mean Hb target discharge level decreased from 9.0 ± 1.1 to 8.3 ± 1.0 g/dL, (both P< 0.0001). Erythrocyte utilization decreased by 32.5% (from 338 to 228 mean erythrocyte units per 1,000 patients; P=0.0007). Figure 1 shows clinical outcomes improved with decreased hospital-acquired morbidity (including infection, thrombosis, kidney injury, respiratory or ischemic events (from 1.3% to 0.54%; P=0.01), composite morbidity or mortality (from 1.5% to 0.75%; P=0.035), and 30-day readmissions (from 9.0% to 5.8%; P=0.0002). Length of stay was decreased by 1 day and mortality was unchanged. After risk adjustment and propensity score sensitivity analysis, PBM was independently associated with decreased composite morbidity or mortality (OR 0.44; 95% CI 0.22 to 0.86; P=0.016). Conclusions: In a retrospective study, PBM resulted in reduced blood utilization with similar or improved clinical outcomes in orthopaedic surgery. A Hb threshold of 7 g/dL appears to be safe for many orthopaedic patients.

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20 14. A Patient Blood Management Program Improves Blood Utilization and Clinical Outcomes in Orthopaedic Surgery

Authors: Pranjal B. Gupta, BE1; Vincent M. DeMario, BS1; Mereze Visagie, BA1; Raj Amin, MD2; Harpal S. Khanuja, MD2; Robert Sterling, MD2; Paul M. Ness, MD3; Steven M. Frank, MD1,4

ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott Williams & Wilkins

21 15. Prevalence of Folate Deficiency Among Preoperative Anemia Clinic Patients: 16. Nurses Promoting Patient Blood Management Standards Retrospective Research and Quality Improvement Study Author: Hind Jaber-Daou, MSN, MHA, MT 00 Authors: Shirisha Pasula, MD; Peter Tran, MD; Neha Gandhi, MD; Jennifer Steinbrunner, BS, CCRP; Thomas Coyle, MD Author Institution: Virginia Commonwealth University Health System

Authors Institutions: Good Samaritan Hospital, Department of Internal Medicine, Internal Background: Implementing a Patient Blood Management (PBM) program requires a multidisci- Medicine Residency Program, Cincinnati, Ohio; Trihealth Anemia Clinic, Trihealth Cancer plinary approach coordinated and supported by all healthcare providers. Nurses’ knowledge about Institute, Cincinnati, Ohio PBM is empirical as they play a major role in administering blood products. Knowledgeable nurses exhibit confidence for a questioning conduct, contribute to the decision-making process, and participate in knowledge transfer actions. Enhancing nurses’ knowledge about PBM is disseminated Introduction: Anemia is common in patients undergoing elective surgery and is associated in scheduled meetings and educational sessions. The purpose is for nurses to embed in their with increased perioperative morbidity and mortality, increased length of hospital stay and an practice what they learned about PBM, influence other providers’ practices, and educate patients. increased rate of blood transfusions. Correction of anemia by preoperative anemia clinics is Study Design: The study adopted a qualitative research approach and employed the direct a standard procedure to decrease transfusion rates and improve outcomes. Nutritional defi- application of knowledge to change the understanding and influence the thinking and behavior ciency accounts for approximately one-third of preoperative anemia. Folate deficiency is the of nurses toward transfusions. Purposeful sampling of 10 nurses selected based on the inclu- least common of the nutritional deficiency anemias, due to fortification of foods with folate sion criteria that nurses have no previous knowledge about PBM and be working in a clinical since 1998. To assess the effectiveness of routine screening for folic acid deficiency in pre- area where blood products are administered. Data were collected via face-to-face interviews operative anemia clinic patients, this study aimed to assess the prevalence of folic acid defi- with follow-up questions via email, if needed. ciency in this population. Finding: Themes generated from data analysis revealed an increase in knowledge (10/10) related Methods: 930 anemic patients scheduled to undergo elective surgery were referred to the to associated risk factors and adverse reactions of blood transfusions; competence (8/10) con- TriHealth anemia clinic between July 2013 and November 2016. Men with hemoglobin less veyed in performing expertly and acting independently; confidence (7/10) voiced in becoming than 13 g/dl, women less than 12 g/dl who were scheduled for surgery were included in the inquisitive, making decisions, and educating colleagues; and motivation (4/10) to spreading study. The majority were scheduled for joint replacement surgery. A CBC, serum iron, TIBC, knowledge and educating other nurses and providers. All participants initiated action plans to ferritin, vitamin B12 and Folic acid levels were obtained automatically on each patient prior to share their knowledge, spread awareness, and provide support to their clinical units through their being seen at the anemia clinic. Patients who were referred but not seen at the clinic, non exploiting presentations, learning modules, in-services, and creating reference pages for PBM. -preoperative, pregnant patients, and patients with incomplete data were excluded. A total of Feeling empowerment was mutual among 8 participants who were enthusiastic to inform others 512 patients were included in the study. Per TriHealth laboratory values, 90% reference range about risks associated with transfusions, ensure safe and appropriate use of blood products, and of folate level is 5.9 to >24.8 ng/ml. Folate deficiency was defined as a level less than 4 ng/ml encourage patients to make educated decisions on transfusions. Only 2 participants reported consistent with the WHO definition. Descriptive analysis was conducted using SPSS software. empowered, but not to the extent of challenging the inappropriate ordering of blood products. Results: 3(0.58%) patients were found to be folate deficient out of 512 patients. In the folate Conclusion: Educating nurses on PBM standards was constructive and vesting. Nurses empow- deficient population, 33% were male, 67% were female, and all were under the age of 65. The ered by information about PBM, awareness of adverse risks of transfusions, and evidence MCV in these three patients ranged between 78–95 fL. and there were no other signs of mega- of improved outcomes participate in personal knowledge transfer actions that benefit other loblastosis. No patient was treated with folate supplementation. nurses, providers, and patients. Conclusion: Folate deficiency is rare in outpatients referred to a preoperative anemia clinic. Our results suggest that routine serum folate testing may be omitted in this setting unless there are clinical risk factors for folic acid deficiency or signs of megaloblastosis.

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22 16. Nurses Promoting Patient Blood Management Standards

Author: Hind Jaber-Daou, MSN, MHA, MT 00

Author Institution: Virginia Commonwealth University Health System

Background: Implementing a Patient Blood Management (PBM) program requires a multidisciplinary approach coordinated and supported by all healthcare providers. Nurses’ knowledge about PBM is empirical as they play a major role in administering blood products. Knowledgeable nurses exhibit confidence for a questioning conduct, contribute to the decision-making process, and participate in knowledge transfer actions. Enhancing nurses’ knowledge about PBM is disseminated in scheduled meetings and educational sessions. The purpose is for nurses to embed in their practice what they learned about PBM, influence other providers’ practices, and educate patients. Study Design: The study adopted a qualitative research approach and employed the direct application of knowledge to change the understanding and influence the thinking and behavior of nurses toward transfusions. Purposeful sampling of 10 nurses selected based on the inclusion criteria that nurses have no previous knowledge about PBM and be working in a clinical area where blood products are administered. Data were collected via face-to-face interviews with follow-up questions via email, if needed. Finding: Themes generated from data analysis revealed an increase in knowledge (10/10) related to associated risk factors and adverse reactions of blood transfusions; competence (8/10) conveyed in performing expertly and acting independently; confidence (7/10) voiced in becoming inquisitive, making decisions, and educating colleagues; and motivation (4/10) to spreading knowledge and educating other nurses and providers. All participants initiated action plans to share their knowledge, spread awareness, and provide support to their clinical units through exploiting presentations, learning modules, in-services, and creating reference pages for PBM. Feeling empowerment was mutual among 8 participants who were enthusiastic to inform others about risks associated with transfusions, ensure safe and appropriate use of blood products, and encourage patients to make educated decisions on transfusions. Only 2 participants reported empowered, but not to the extent of challenging the inappropriate ordering of blood products. Conclusion: Educating nurses on PBM standards was constructive and vesting. Nurses empowered by information about PBM, awareness of adverse risks of transfusions, and evidence of improved outcomes participate in personal knowledge transfer actions that benefit other nurses, providers, and patients.

23 17. Utilizing Change Management to Reduce Transfusions in Isolated Coronary Artery Bypass Grafting: Leveraging Business Models for Clinical Improvement

Authors: Shanna TenClay, MD1,2,3; Nicholas C. Watson, MD1,2,3; Zachary Kramer2; Christopher J. Michaud, PharmD, BCCCP, BCPS4; Stephane Leung Wai Sang, MD2,5

Authors Institutions: 1Anesthesia Practice Consultants, PC. Grand Rapids, MI; 2Michigan State University College of Human Medicine. Grand Rapids, MI; 3Spectrum Health Affiliate. Grand Rapids, MI; 4Spectrum Health Department of Pharmacy. Grand Rapids, MI; 5Spectrum Health Medical Group.

Introduction: Perioperative packed red blood cell (PRBC) transfusion is associated with increased morbidity and mortality after isolated coronary artery bypass grafting (iCABG). In 2016 our institution performed 598 iCABGs, with 40% of patients receiving one or more PRBC units. The national average was 36.1%. We sought to reduce utilization to 35.5%. To achieve this target, we adopted principles from the discipline of change management. Change management borrows from fields such as social psychology, behavioral science, and information technology. It is most commonly used to structure organizational change in the business world and carries theoretical benefits for quality improvement processes in medicine. Methods: We created a customized change management strategy for blood conservation in iCABGs by employing elements from various change management models. Our focus was on the process of change rather than an event that forced change upon health care workers. We aligned key stakeholders by identifying the shared need to improve transfusion practice and solicited ideas for excellence. We then enlisted a core Change Team comprised of multidisciplinary champions for change. Ideas for excellence, data from a deep dive into our current practices, and multiple societal guidelines were blended to inform the development of our plan. We concentrated on making change easy by aligning the people, equipment, and information technology involved in bedside care. Next, a transitional state established the following: standardized and algorithmic perioperative workflow, routine meetings of stakeholders, seeking and processing feedback, expert consultation, changes to equipment, and changes to the order entry system. Emotional engagement of individual stakeholders was maintained by sharing patient stories and by public reporting of individual provider performance. Finally, in the consolidation phase we asked which interventions were working well and which were not. Answers to this question and the subsequent interventions are an ongoing process in our change management. Results: In the 14-month period following initiation of our change management strategy, PRBC use in iCABG dropped from 40% to 31.2%. Following the 6-month transitional state of our change management, the PRBC use in iCABG was 29.5% for the next 8 months. Discussion: We integrated elements of change management with common quality improvement strategies to design a successful approach to blood conservation in iCABGs. Future work should focus on: (1) refining clinical change management strategies by identifying the factors ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott with the highest impact and the lowest cost and (2) spreading clinical change management Williams & Wilkins into other areas of medicine.

24 17. Utilizing Change Management to Reduce Transfusions in Isolated Coronary Artery Bypass Grafting: Leveraging Business Models for Clinical Improvement

Authors: Shanna TenClay, MD1,2,3; Nicholas C. Watson, MD1,2,3; Zachary Kramer2; Christopher J. Michaud, PharmD, BCCCP, BCPS4; Stephane Leung Wai Sang, MD2,5

25 18. Decreasing Plasma Utilization with Education, Clinical Decision Support, and Guideline Creation

Authors: Benjamin A Hohmuth, MD, MPH1; Mary Ann O’Brien, RN, MSN, CCRN, CNE1; Andrea Berger, MAS2; Amanda Haynes, DO3

Authors Institutions: 1Department of Patient Blood Management, Geisinger, Danville, PA; 2Department of Biostatistics, Geisinger; 3Department of Pathology, Geisinger;

Background: Plasma is frequently used in patients with an elevated international normalized ratio (INR) who are either actively bleeding or are anticipating an invasive procedure. The ratio- nal for use is that the abnormal INR reflects a modifiable risk factor for bleeding that can be modified by replacing clotting factors with plasma infusions. Several systematic review articles have concluded that available evidence does not support current practices regarding therapeutic or prophylactic plasma transfusion. Most plasma is given for modest elevations in INR that may not predict bleeding and are unlikely to be impacted by plasma transfusion. At Geisinger we implemented a multifaced sustained approach to decrease inappropriate use of plasma starting in the fall of 2013. Methods: We identified 3 high priority targets for practice change: the early and appropriate use of vitamin k to reverse warfarin; tolerance of mild elevations in INR (<2) prior to most invasive procedures; and use of thromboelastography (TEG) rather than INR to assess bleeding risk in patients with advanced liver disease. We used a balanced approach of clinician engagement, education, and ‘hard wiring’ practices via guidelines and computerized order entry to drive behavior change. Meetings with procedural based departments including surgery, interventional radiology, and gastroenterology resulted in buy in to our goals as well as mutually agreed REFERENCES: upon guidelines for plasma use. Modifications to the electronic health record (EHR) included Goel R, et al. Trends in red blood cell, plasma, and platelet transfusions in the United States, development of an anticoagulation reversal order set, creation of specific plasma transfusion 1993–2015. JAMA. 2018;319(8):825–827. indications in computerized order entry, and links to our new guidelines within consult orders Seheult JN, et al. Changes in plasma unit distributions to hospitals over a 10 year period. for interventional radiology and gastroenterology. Transfusion. 2018; 58:1012–1020. Green L et al. British Society of Haematology guidelines on the spectrum of fresh frozen The primary outcome we evaluated was the total number of plasma transfusions relative to plasma and cryoprecipitate products: their handling and use in various patient groups in discharges at each of our 3 largest campuses. the absence of major bleeding. British Journal of Haematology. 2018(181):54–67. Yang L, et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of Results: Between October 2013 and March 2018 plasma transfusions per discharge declined randomized controlled trials. Transfusion. 2012;52:1673–1686 64% at Geisinger Medical Center (0.266 to 0.097, p<0.0001) and 76% at Geisinger Wyoming Triulzi D, et al. A multicenter study of plasma use in the United States. Transfusion. Valley (0.207 to 0.050, p<0.0001). At Geisinger Community Medical Center we had a 20% 2015;55:1313–1319. reduction which did not reach statistical significance (0.069 to 0.055, p 0.15). Conclusion: A sustained program involving education, updated guidelines, and modifications to our EHR promoting tolerance of modest elevations in pre-procedure INRs, appropriate use of vitamin k for warfarin reversal, and TEG for assessment of bleeding risk in patients with advanced liver disease was associated with a marked reduction in plasma use.

26 REFERENCES: Goel R, et al. Trends in red blood cell, plasma, and platelet transfusions in the United States, 1993–2015. JAMA. 2018;319(8):825–827. Seheult JN, et al. Changes in plasma unit distributions to hospitals over a 10 year period. Transfusion. 2018; 58:1012–1020. Green L et al. British Society of Haematology guidelines on the spectrum of fresh frozen plasma and cryoprecipitate products: their handling and use in various patient groups in the absence of major bleeding. British Journal of Haematology. 2018(181):54–67. Yang L, et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion. 2012;52:1673–1686 Triulzi D, et al. A multicenter study of plasma use in the United States. Transfusion. 2015;55:1313–1319.

27 19. Assessment of Hyperfibrinolysis and Coagulopathy in Gastrointestinal Hemorrhage using Rotational Thromboelastometry

Authors: Wei, Peng-Peng, MD ; Haas, Thorsten, MD ; Makhani, Sarah, BS ; Jones, Daniel, MD ; Fernandez, Jose, MD ; Crawford, Carl, MD ; Sharma, Rahul, MD ; Goel, Ruchika, MD, MPH ; Cushing,* Melissa, M., MD† * * * * * Authors Institutions: *Departments of Pathology,* Pulmonary Critical Care, Emergency Medicine, Gastroenterology, New York Presbyterian Hospital-Weill Cornell Medical Center; Department of Anesthesiology,* University Children’s Hospital Zurich

Background:† A Rotational Thromboelastometry (ROTEM)-guided transfusion algorithm was implemented for bleeding patients outside the operating room at our institution in 2017. We assessed patients who had significant gastrointestinal (GI) bleeding (transfusion of ≥2 Units RBC 24 hours before/after ROTEM) to characterize ROTEM profiles, evidence of hyperfibrinolysis, and transfusion practices, and compare results of ROTEM and plasmatic coagulation testing. Methods: Bleeding patients’ data were collected from the ROTEM database and medical record and compared using Fisher’s Exact test, Mann-Whitney U test, and Spearman correlation. Results: ROTEM testing was performed for 87 bleeding patients, of which 22(25.3%) had significant GI bleeding (median 1 ROTEM/patient; range 1–3). The median hemoglobin prior to ROTEM was 8.2 g/dL, interquartile range (IQR) (6.7–8.9). Signs of hyperfibrinolysis (i.e. maximum lysis in EXTEM [ML], >15%) were detected in 2 patients (ML, 20 and 100%); median (IQR) ML was 3(1–7)%. An antifibrinolytic was given prior to ROTEM in only one patient who did not exhibit hyperfibrinolysis. Median (IQR) ROTEM parameters were as follows: EXTEM CT 65(56–77) seconds, EXTEM MCF 57(49–65) mm, INTEM CT 165(142–223) seconds, and FIBTEM MCF 17(8–28) mm. In 46.7% of ROTEMs performed, all values were within the reference range. There was a good correlation between platelet count and EXTEM MCF (r=0.73; p<0.001), as well as aPTT and INTEM CT (r=0.82; p<0.001), while the correlation for fibrinogen and FIBTEM MCF (r=0.49; p=0.13), and INR and EXTEM CT, were weak (r=0.51; p=0.02). Overall, 6/22 patients (27.3%) received plasma, 6 (27.3%) cryoprecipitate, 7(31.8%) platelets, and 16(72.7%) RBCs after ROTEM was performed. Patients with an abnormal ROTEM as compared to a normal ROTEM were more likely to receive cryoprecipitate (47 vs 7%;p=0.035) or plasma (60 vs 0%;p=0.001). However, there was no difference in platelet and RBC transfusions for patients with abnormal vs normal ROTEM results. An anatomic cause of bleeding was identified in 14(63.6%) patients vs 8(36.4%) who were coagulopathic based on pre-ROTEM plasmatic coagulation laboratory results. The total number of products transfused post-ROTEM were not different between patients with coagulopathy versus anatomic bleeding. Conclusion: ROTEM detected hyperfibrinolysis in 9.1% of all patients with significant GI bleed- ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott ing, but antifibrinolytics were not used for treatment. Patients with abnormal ROTEM results Williams & Wilkins were more likely to receive cryoprecipitate or plasma than patients with normal ROTEM, while there was no difference for RBC or platelet transfusions. ROTEM algorithms may improve patient blood management practice in patients with GI bleeding.

28 19. Assessment of Hyperfibrinolysis and Coagulopathy in Gastrointestinal Hemorrhage using Rotational Thromboelastometry

29 20. Risk Reduction versus Blood Conservation in the in the Neonatal ICU 21. Anemia Clinic Treatment and Pre-Operative Management of Cardiovascular Surgery Patients Authors: Jerry E. Squires, M.D., Ph.D.; Heather D. Toeppner, MSN, RN Authors: Barlow C.M.1; Upchurch C.A.2; Kober E.3; Mitchell M.D.4; Ford P.A.5; Furukawa, S.6 Authors Institution: Medical University of South Carolina Authors Institutions: 1Department of Medicine; 2The Center for Transfusion-Free Medicine; Background: For a variety of clinical indications, patients in neonatal intensive care units 3Abramson Cancer Center at Pennsylvania Hospital; 4UPHS Center for Evidence-based (NICU) often require multiple, small volume transfusions during their hospital stay. To accom- Practice; 5Division of Hematology and Oncology, Pennsylvania Hospital, University of modate the transfusion needs of these patients, many hospitals dedicate single or partial red Pennsylvania Health System; 6Department of Cardiovascular Surgery, Pennsylvania Hospital, blood cell units to individual neonates. Multiple transfusions from single donor units can then Philadelphia be given during the neonate’s hospitalization thereby reducing donor exposure for the patient. A collateral benefit is that each RBC unit can be more completely used reducing wastage. We Introduction: The efficacy of an Anemia Clinic in medically optimizing cardiovascular surgery report the results of a quality improvement audit to assess our neonatal transfusion program. (CVS) patients preoperatively has not yet been examined. A retrospective chart review was performed to explore whether such an intervention might minimize resource utilization, improve Methods: Our neonatal transfusion protocol is designed to reduce multiple donor exposures outcomes and decrease health system cost. for each neonate. Inpatient transfusions were reviewed for all RBC units assigned for the NICU. The following information was collected: the number of transfusion events and the total volume Methods: Twenty-five patients with a history of anemia (defined as hemoglobin ≤ 13.5 in men transfused for each neonate; the volume of each unit discarded and the number of separate and 12.0 in women) undergoing cardiac surgeries – inclusive of Coronary Artery Bypass Graft units to which each patient was exposed. (CABG), valvular (mitral or aortic) surgery, or a combination of the two – were referred to the Department of Hematology’s Anemia Clinic at Pennsylvania Hospital by cardiovascular sur- Results: In this four month review of NICU blood usage, 31 separate patients were transfused geons throughout the University of Pennsylvania Health System between January 01, 2016 with RBCs involving 116 separate transfusion events. Twenty-three of these patients (72%) and June 01, 2017. Three patients had comorbidities that precluded surgery and one with were exposed to only one unit of RBCs, but 15 received only 1 transfusion. The remaining 8 normal hemoglobin was referred for further optimization. Twenty-one anemic CVS patients met patients received multiple transfusions from the single unit assigned (range 2–6 transfusions). criteria for evaluation and nineteen were treated in the preoperative setting, receiving erythro- Nine patients received RBC transfusions from 2–5 separate units, largely due to patient length poietic-stimulating agents (ESA) and/or IV iron. Eleven of nineteen received both ESA and IV ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott of stay in the NICU or special therapies. In reviewing the aggregate amount of blood transfused iron, while eight received only the latter. Three of the patients in the treatment cohort preemp- Williams & Wilkins from the 66 RBC units used, it was found that 47% of the blood in these units were discarded, tively refused blood products at time of presentation on account of religious convictions. usually due to outdating. Results: Special attention was paid to patients’ hemoglobin at initial encounter, final hemo- Conclusions: It is widely accepted that the use of single RBC units to support the multiple globin prior to surgery, post-operative hemoglobin, doses of ESA and/or IV iron, number of small-volume transfusion needs of NICU patients reduces donor exposure and potentially subsequent transfusions, and 30-day hospital readmissions with comparison to the standard results in the overall use of fewer RBC units. Our data supports this observation in that 116 of care. Four of the sixteen patients (25%) managed pre-operatively with ESA and/or IV iron separate transfusions were completed using only 66 RBC units. An important additional obser- who were willing to accept blood products following CVS ultimately required transfusion, as vation was that 47% of the blood volume assigned for use in the NICU was discarded. We compared to transfusion rates that typically near 50% for patients undergoing cardiac surgery believe that one of the reasons for this is the difficulty in prospectively determining the transfu- (Mehta et al., 2009; Murphy et al., 2015). Two of these four had received both ESA and paren- sion needs of each patient. For example, nearly half of total patients transfused received only teral iron, while two had received iron alone. Zero of the nineteen patients treated pre-opera- one small-volume transfusion in the NICU suggesting that additional patients could have been tively in the Anemia Clinic were readmitted within 30 days of their discharge from the hospital, assigned to that unit further reducing the overall need for RBC units. as compared to a state-specific 30-day readmission rate of 11.7% for patients undergoing CVS between 01/2014 and 03/2016 (Martin, 2017). Conclusion: The medical optimization of cardiovascular surgery patients pre-operatively via an Anemic Clinic platform decreases post-operative transfusions and may play a prominent role in preventing 30-day hospital readmissions. A potential improvement in patient outcomes at decreased cost to the health system advocates strongly for further cost-benefit analysis as well as examination of this model’s validity in larger data sets and across other healthcare specialties.

30 21. Anemia Clinic Treatment and Pre-Operative Management of Cardiovascular Surgery Patients

Authors: Barlow C.M.1; Upchurch C.A.2; Kober E.3; Mitchell M.D.4; Ford P.A.5; Furukawa, S.6

Authors Institutions: 1Department of Medicine; 2The Center for Transfusion-Free Medicine; 3Abramson Cancer Center at Pennsylvania Hospital; 4UPHS Center for Evidence-based Practice; 5Division of Hematology and Oncology, Pennsylvania Hospital, University of Pennsylvania Health System; 6Department of Cardiovascular Surgery, Pennsylvania Hospital, Philadelphia

Introduction: The efficacy of an Anemia Clinic in medically optimizing cardiovascular surgery (CVS) patients preoperatively has not yet been examined. A retrospective chart review was performed to explore whether such an intervention might minimize resource utilization, improve outcomes and decrease health system cost. Methods: Twenty-five patients with a history of anemia (defined as hemoglobin≤ 13.5 in men and 12.0 in women) undergoing cardiac surgeries – inclusive of Coronary Artery Bypass Graft (CABG), valvular (mitral or aortic) surgery, or a combination of the two – were referred to the Department of Hematology’s Anemia Clinic at Pennsylvania Hospital by cardiovascular surgeons throughout the University of Pennsylvania Health System between January 01, 2016 and June 01, 2017. Three patients had comorbidities that precluded surgery and one with normal hemoglobin was referred for further optimization. Twenty-one anemic CVS patients met criteria for evaluation and nineteen were treated in the preoperative setting, receiving erythro- poietic-stimulating agents (ESA) and/or IV iron. Eleven of nineteen received both ESA and IV iron, while eight received only the latter. Three of the patients in the treatment cohort preemp- tively refused blood products at time of presentation on account of religious convictions. Results: Special attention was paid to patients’ hemoglobin at initial encounter, final hemoglobin prior to surgery, post-operative hemoglobin, doses of ESA and/or IV iron, number of subsequent transfusions, and 30-day hospital readmissions with comparison to the standard of care. Four of the sixteen patients (25%) managed pre-operatively with ESA and/or IV iron who were willing to accept blood products following CVS ultimately required transfusion, as compared to transfusion rates that typically near 50% for patients undergoing cardiac surgery (Mehta et al., 2009; Murphy et al., 2015). Two of these four had received both ESA and paren- teral iron, while two had received iron alone. Zero of the nineteen patients treated pre-operatively in the Anemia Clinic were readmitted within 30 days of their discharge from the hospital, as compared to a state-specific 30-day readmission rate of 11.7% for patients undergoing CVS between 01/2014 and 03/2016 (Martin, 2017). Conclusion: The medical optimization of cardiovascular surgery patients pre-operatively via an Anemic Clinic platform decreases post-operative transfusions and may play a prominent role in preventing 30-day hospital readmissions. A potential improvement in patient outcomes at decreased cost to the health system advocates strongly for further cost-benefit analysis as well as examination of this model’s validity in larger data sets and across other healthcare specialties.

31 Works Cited: 22. Evaluation of the Quantra™ System vs TEG 5000 in Cardiac Surgery: A Community- based Hospital System Experience 1. Mehta RH, Sheng S, O’Brien SM, et al. Reoperation for bleeding in patients undergoing coronary artery bypass surgery: incidence, risk factors, time trends, and outcomes. Circ Authors: Deborah A Winegar, PhD1; Francesco Viola, PhD1; Thomas B Washburn, Jr, MD2 Cardiovasc Qual Outcomes. 2009;2:583–90. 2. Murphy, Gavin J., Katie Pike, Chris A. Rogers, Sarah Wordsworth, Elizabeth A. Stokes, Authors Institutions: 1HemoSonics LLC, Charlottesville, VA; 2Huntsville Hospital System, Gianni D. Angelini, and Barnaby C. Reeves. “Liberal or Restrictive Transfusion after Huntsville, AL Cardiac Surgery.” New England Journal of Medicine 372.11 (2015): 997–1008. Web. 31 July 2017. Introduction: Whole blood viscoelastic testing is recommended in cardiac surgery patients to 3. Martin, Joe. Cardiac Surgery Report. Rep. Pennsylvania Health Care Cost Containment monitor coagulation status and guide transfusion of blood products. The Quantra™ Hemostasis Council (PHC4), Jan. 2017. Web. 28 July 2017. Analyzer (HemoSonics, LLC) is a novel, fully automated diagnostic device that uses ultrasound to measure changes in clot stiffness within a consumable cartridge, providing a rapid and comprehensive assessment of coagulation at the point of care. In this study, we aimed to compare coagulation parameters determined using the Quantra System with the QPlus™ cartridge to corresponding parameters obtained with the TEG®5000 (Haemonetics Corp). Methods: Adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were enrolled in this prospective observational study. From each patient, replicate whole blood samples were collected at 2 time points: (1) preoperatively and (2) postoperatively, 1–2 hours after arrival in the ICU. Testing was performed on an Investigational Use Only version of the Quantra System, the TEG 5000, and with conventional laboratory tests. The Quantra System was placed near patient, outside of the operating suites whereas TEG was operated from the local laboratory. The QPlus parameter Clot Time (CT) was compared to TEG R (with kaolin) and aPTT; Clot Stiffness (CS) to TEG MA (with kaolin); Fibrinogen Contribution (FCS) to fibrinogen level (Clauss method); and Platelet Contribution (PCS) to platelet count. Results: Twenty-nine patients completed the study (59% male, mean age 69 years). Analysis of data from both time points combined (n=57–58 samples) showed a very strong correlation of CS with MA (r=0.90), and of FCS with fibrinogen level (r=0.82) (Figures 1 and 2). In addition, PCS exhibited a strong correlation with platelet count (r=0.78) (Figure 3), as did CT with F3 TEG R-K (r=0.76) (Figure 4) and aPTT (r=0.73). Overall, the QPlus parameters demonstrated a higher clinical agreement with conventional laboratory tests than did the TEG parameters (Table 1). Conclusions: In this small study of cardiac surgery patients treated at a community-based hospital system, the Quantra System exhibited very good correlation with the TEG and conventional laboratory assays. In addition, complete Quantra System results were available on average 20 to 50 minutes faster than corresponding TEG results.

32 22. Evaluation of the Quantra™ System vs TEG 5000 in Cardiac Surgery: A Community- based Hospital System Experience

Authors: Deborah A Winegar, PhD1; Francesco Viola, PhD1; Thomas B Washburn, Jr, MD2

Authors Institutions: 1HemoSonics LLC, Charlottesville, VA; 2Huntsville Hospital System, Huntsville, AL

Introduction: Whole blood viscoelastic testing is recommended in cardiac surgery patients to monitor coagulation status and guide transfusion of blood products. The Quantra™ Hemostasis Analyzer (HemoSonics, LLC) is a novel, fully automated diagnostic device that uses ultrasound to measure changes in clot stiffness within a consumable cartridge, providing a rapid and comprehensive assessment of coagulation at the point of care. In this study, we aimed to compare coagulation parameters determined using the Quantra System with the QPlus™ cartridge to corresponding parameters obtained with the TEG®5000 (Haemonetics Corp). Methods: Adult patients undergoing elective cardiac surgery with cardiopulmonary bypass were enrolled in this prospective observational study. From each patient, replicate whole blood samples were collected at 2 time points: (1) preoperatively and (2) postoperatively, 1–2 hours after arrival in the ICU. Testing was performed on an Investigational Use Only version of the Quantra System, the TEG 5000, and with conventional laboratory tests. The Quantra System was placed near patient, outside of the operating suites whereas TEG was operated from the local laboratory. The QPlus parameter Clot Time (CT) was compared to TEG R (with kaolin) and aPTT; Clot Stiffness (CS) to TEG MA (with kaolin); Fibrinogen Contribution (FCS) to fibrinogen level (Clauss method); and Platelet Contribution (PCS) to platelet count. Results: Twenty-nine patients completed the study (59% male, mean age 69 years). Analysis of data from both time points combined (n=57–58 samples) showed a very strong correlation of CS with MA (r=0.90), and of FCS with fibrinogen level (r=0.82) (Figures 1 and 2). In addition, PCS exhibited a strong correlation with platelet count (r=0.78) (Figure 3), as did CT with F3 TEG R-K (r=0.76) (Figure 4) and aPTT (r=0.73). Overall, the QPlus parameters demonstrated a higher clinical agreement with conventional laboratory tests than did the TEG parameters (Table 1). Conclusions: In this small study of cardiac surgery patients treated at a community-based hospital system, the Quantra System exhibited very good correlation with the TEG and conventional laboratory assays. In addition, complete Quantra System results were available on average 20 to 50 minutes faster than corresponding TEG results.

33 34 23. The Decision to Transfuse Blood is Not Just a Numbers Game

Authors: Robert D. Karpinos, MDa; Rene A. Bouquet, DNPa; Valdet Cobaj, BB(ASCP)b; Joel Sender, MDc; Gerard A. Baltazar, DOd; Ding Wen Wu, MD, PhDb

Authors Institutions: aDepartment of Anesthesiology; bBlood Bank; cDepartment of Medicine and dDepartment of Surgery, SBH Health System, Bronx, NY, USA

Introduction: A Patient Blood Management (PBM) program was initiated in 2013 and fully- implemented in 2014 at our inner-city 350-bed community hospital. The program was evidence-based and multidisciplinary in an effort to change and align the perceptions and practices of routine transfusion through training and education. The PBM program included teaching sessions for prescribing medical professionals, laboratory conversion to low-volume samples, adjustments to critical (“panic”) hemoglobin (Hgb) levels which effectively decreased the transfusion trigger to Hgb 6g/dL for general patients and 7 g/dL for patients with known or symptomatic cardiac disease, alignment of transfusion protocols and guidelines across multiple divisions, and modification of the goals of initial packed red blood cell (PRBC) transfusion to provide one instead of two units as was the prior custom. The goal of this study is to review outcome data and examine the value and efficacy of the PBM program at our hospital. Methods: We retrospectively reviewed prospectively-accrued Blood Bank transfusion data from January 1, 2012 through December 31, 2016, including Hgb on transfusion orders, number of PRBC units transfused per event and PRBC wastage. A potential cost-savings analysis was performed to further qualify differences in resource utilization. Student’s t-test was used for year-over-year comparisons. Results: Significant improvement in PRBC transfusion practices and usage occurred after implementation of the PBM program. Median Hgb for PRBC transfusion orders decreased progressively after PBM program implementation from 7.3g/dL in 2012 to 6.7g/dL in 2016 (p<0.0001). Also, the absolute number and percentage of PRBC units administered to patients transfused with a Hgb trigger ≥ 8g/dL significantly decreased progressively each year from 462 units (24.7% of transfused PRBCs) to 194 units (12.8% of transfused PRBCs) (p<0.001). During the same period, yearly wastage of PRBC profoundly decreased (28 units to 7 units). We estimated potential cost-savings at $180,850 for calendar year 2016 with a total potential cost-savings of $557,568 for the full duration of PBM program implementation. Our PBM program was implemented through existing interdepartmental cooperation and teaching methods and received no specific budgetary support. (Table 1). Discussion: An organized, evidence-based multidisciplinary PBM program can modify the practices and customs of transfusing PRBC in an inner-city community hospital, resulting in improvements in patient care and resource utilization and substantial cost-savings. Broader implementation of a PBM program may have additional benefits, if the training and educational efforts are maintained and expanded to include other Blood Bank products including platelet and factor therapy.

35 TABLE 1. Improvement in PRBC unit transfusion data after implementation of Patient Blood Management pro- 24. Thromboelastography for Bleeding Risk Assessment in Invasive Procedures gram in 2014. PRBC Unit Transfusion 2012 2013 2014 2015 2016 Authors: Christine Cahill, BSN, MS, RN1; Ashwani Sharma, MD2; Neil Blumberg, MD1; Units Transfused 1872 2061 1762 1462 1515 1 1 Median Hgb per Transfusion Order (g/dL) 7.3 7.2 6.9* 6.8* 6.7* Amy E. Schmidt, MD, PhD ; Majed A. Refaai, MD Units Transfused for Hgb Trigger ≥ 8g/dL 462 381 286† 222† 194† ‡ † † † Percent Transfused for Hgb Trigger ≥ 8g/dL 24.7 18.5 16.2 15.2 12.8 1 2 Unit Wastage 28 11 11 12 7 Authors Institutions: Department of Pathology and Laboratory Medicine; Department of Potential Savings of Units 0 89 150 139 180 Imaging Science, University of Rochester Medical Center, Rochester Potential Cost-savings (USD) 0 88,623 149,770 138,890 180,285 *p <0.0001, †p <0.001, ‡p =0.002 when compared to 2012 Background: Thromboelastography (TEG) is a point-of-care, whole blood, viscoelastic coagulation assay, which provides information regarding the function of the patient’s coagulation fac- ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott tors, ﬁbrinogen, and platelets in clot formation and breakdown. The international normalized Williams & Wilkins ratio (INR), which was developed to monitor warfarin therapy, is commonly used as a bleeding risk assessment prior to invasive procedures. This practice may be sub optimal since INR is XXXXXXXXX primarily affected by factor VII activity. Several society guidelines recommend correcting INR to ≤1.5 prior to procedures to mitigate bleeding risks. Plasma transfusion or prothrombin complex concentrates (PCC) with and without vitamin K administration are usually used for this purpose. TEG may be a superior tool for risk assessment in these cases. Methods: In addition to the traditional baseline laboratory screening assays, TEG was performed on 14 patients undergoing interventional radiology procedures. Patient characteristics, medical conditions, laboratory results, and adverse events were collected and analyzed. Results: The age range of these patients was 52–87 years. The interventional radiology procedures performed were biopsies (5/14), central line and catheter placement (5/14), thora- centesis (3/14) and drain placement (1/14). The most common diagnosis was pulmonary disorders (n=7, 50%), coronary artery disease (n=5, 36%), and/or renal failure (n=5, 36%). Pre-procedure renal and liver chemistry profiles showed mild to moderate liver abnormalities in 4 (29%) patients and renal failure in 3 (21%). Nine patients (64%) were on warfarin, one patient was on a direct oral anticoagulant (apixiban), and two patients were on aspirin. Although the pre procedure INR’s were >1.5 in 13 patients (93%) with an average of 2.3±0.9, TEG results were largely normal suggesting a low risk of bleeding (Table). No bleeding complications, blood product transfusions, or vitamin K administration were given. Conclusions: In this pilot study TEG appears to be a superior assay to assess bleeding risks in patients undergoing invasive interventional radiology procedures, particularly for patients receiving oral anti-coagulation. Although the INRs were higher than suggested guidelines, no patients had significant bleeding or complications. Thus, utilization of INR in these cases is questionable as well as correction indications. Further studies using a larger cohort are warranted to evaluate for consistent trends. Table: Laboratory results performed prior to the interventional radiology procedure. Data are shown in mean ± standard deviation, median and (range).

36 24. Thromboelastography for Bleeding Risk Assessment in Invasive Procedures

Authors: Christine Cahill, BSN, MS, RN1; Ashwani Sharma, MD2; Neil Blumberg, MD1; Amy E. Schmidt, MD, PhD1; Majed A. Refaai, MD1

Authors Institutions: 1Department of Pathology and Laboratory Medicine; 2Department of Imaging Science, University of Rochester Medical Center, Rochester

Background: Thromboelastography (TEG) is a point-of-care, whole blood, viscoelastic coagulation assay, which provides information regarding the function of the patient’s coagulation factors, ﬁbrinogen, and platelets in clot formation and breakdown. The international normalized ratio (INR), which was developed to monitor warfarin therapy, is commonly used as a bleeding risk assessment prior to invasive procedures. This practice may be sub optimal since INR is XXXXXXXXX primarily affected by factor VII activity. Several society guidelines recommend correcting INR to ≤1.5 prior to procedures to mitigate bleeding risks. Plasma transfusion or prothrombin complex concentrates (PCC) with and without vitamin K administration are usually used for this purpose. TEG may be a superior tool for risk assessment in these cases. Methods: In addition to the traditional baseline laboratory screening assays, TEG was performed on 14 patients undergoing interventional radiology procedures. Patient characteristics, medical conditions, laboratory results, and adverse events were collected and analyzed. Results: The age range of these patients was 52–87 years. The interventional radiology procedures performed were biopsies (5/14), central line and catheter placement (5/14), thora- centesis (3/14) and drain placement (1/14). The most common diagnosis was pulmonary disorders (n=7, 50%), coronary artery disease (n=5, 36%), and/or renal failure (n=5, 36%). Pre-procedure renal and liver chemistry profiles showed mild to moderate liver abnormalities in 4 (29%) patients and renal failure in 3 (21%). Nine patients (64%) were on warfarin, one patient was on a direct oral anticoagulant (apixiban), and two patients were on aspirin. Although the pre procedure INR’s were >1.5 in 13 patients (93%) with an average of 2.3±0.9, TEG results were largely normal suggesting a low risk of bleeding (Table). No bleeding complications, blood product transfusions, or vitamin K administration were given. Conclusions: In this pilot study TEG appears to be a superior assay to assess bleeding risks in patients undergoing invasive interventional radiology procedures, particularly for patients receiving oral anti-coagulation. Although the INRs were higher than suggested guidelines, no patients had significant bleeding or complications. Thus, utilization of INR in these cases is questionable as well as correction indications. Further studies using a larger cohort are warranted to evaluate for consistent trends. Table: Laboratory results performed prior to the interventional radiology procedure. Data are shown in mean ± standard deviation, median and (range).

37 Thromboelastography (TEG) 25. The Benefits of Establishing a Dynamic Platelet Inventory Management System N=14 Reference Range Value R Time (min) 4.0–10.0 6.9±2.6 2 6.9 (3.4–10.6) Authors: Patricia Bochey1, Alex Carterson, MD, PhD K Time (min) 1.0–3.0 1.5±0.6 1.5 (0.8–2.7) Authors Institutions:1Northwestern Memorial Hospital, Laboratory Quality and Compliance, □ angle (degree) 53.0–73.0 69±6.8 2 69 (56–79) Chicago, Illinois, United States; Heartland Blood Centers, Aurora, Illinois, United States MA (mm) 50.0–72.0 69±9 69 (54–79) Introduction: Implementing strategies to optimize platelet inventory in the hospital transfu- LY 30 (%) 0–7.5 1.3±1.3 sion service has a reach outside the walls of the department. Responsible inventory manage- 1 (0–3.9) CI -3.0-3.0 0.8±2.7 ment begins at the hospital but requires collaboration with the blood supplier partner to align 1.2 (-4.9-4.6) goals. The desired outcomes are resource conservation and wastage reduction by leveraging Coagulation Tests opportunities to manage stock levels more efficiently. The function of this strategic partnership INR 0.9–1.1 2.3±0.9 provides an avenue for better communication and advocacy for continuous improvement. 2.2 (1.2–4.9) PT (sec) 10.0–12.9 27.4±10.3 25.4 (16.6–57.7) Results: Inventory platelet wastage was reviewed and stock inventory levels were reassessed. Hemoglobin (mg/dL) 11–14 8.8±1.8 Tracking data for platelet wastage during the development of the system model monitored 8.5 (6.4–13.1) progress and allowed understanding of each initiative’s effectiveness and limitations. Platelet (x109/L) 150–330 205±98 177 (59–380) Discussion: At an institutional level, new staff and changes in supervisory team negatively Hepatic and Renal Function Tests impacted utilization as seen by spikes during FY 2017. Daily documentation was initiated for BUN (mg/dL) 6–20 35.2±35.1 25 (10–132) tracking wastage on shift reports to provide immediate awareness for staff and management. Creatinine (mg/dL) 0.5–1.0 3.1±3.6 The standing order was then reassessed and adjusted to match current utilization. There needed 1.2 (0.4–10.9) to be a comfort level with the established inventory levels and a positive rapport with the blood ALT (U/L) 0–35 F 24.9±18.8 supplier regarding turnaround times and expectations to facilitate a change in practice. Newly 0–50 M 19.5 (10–66) implemented online ordering software from the blood supplier allowed an electronic record for AST(U/L) 0–35 F 34.6±19 0–50 M 28.5 (20–72) blood product delivery and was a valuable asset for the process. The criteria for adjusting the ALK Phosphate (U/L) 35–105 170±142 standing order was cumbersome, so a straightforward guideline was adopted for calculating 130 (89–515) inventory. The maximum designated stock at the beginning of first shift was 30 platelets. More Total Bilirubin (mg/dL) 0.0–1.2 1.3±0.9 1.4 (0.3–2.9) importantly, there could not be more than 20 day-5 platelets on any weekday. This inventory number was further adjusted to <10 day-5 products on weekend days without routine surgeries. Weekly scheduled conference calls with blood supplier provided a smooth transition for changes and review of details. These phone calls also offered quick resolutions for issues such as shifts in blood type proportions for stock shipments and enabled problems to be addressed promptly. Conclusion: Inventory control requires an ongoing cycle of review and evaluation. This partnership enabled the hospital to reduce utilization and product costs and the supplier to increase product availability for its network hospitals. Implementation was successful at this specific institution, but further evaluation is needed to draw broader conclusions.

38 25. The Benefits of Establishing a Dynamic Platelet Inventory Management System

Authors: Patricia Bochey1, Alex Carterson, MD, PhD2

Authors Institutions:1Northwestern Memorial Hospital, Laboratory Quality and Compliance, Chicago, Illinois, United States; 2Heartland Blood Centers, Aurora, Illinois, United States

Introduction: Implementing strategies to optimize platelet inventory in the hospital transfusion service has a reach outside the walls of the department. Responsible inventory management begins at the hospital but requires collaboration with the blood supplier partner to align goals. The desired outcomes are resource conservation and wastage reduction by leveraging opportunities to manage stock levels more efficiently. The function of this strategic partnership provides an avenue for better communication and advocacy for continuous improvement. Results: Inventory platelet wastage was reviewed and stock inventory levels were reassessed. Tracking data for platelet wastage during the development of the system model monitored progress and allowed understanding of each initiative’s effectiveness and limitations. Discussion: At an institutional level, new staff and changes in supervisory team negatively impacted utilization as seen by spikes during FY 2017. Daily documentation was initiated for tracking wastage on shift reports to provide immediate awareness for staff and management. The standing order was then reassessed and adjusted to match current utilization. There needed to be a comfort level with the established inventory levels and a positive rapport with the blood supplier regarding turnaround times and expectations to facilitate a change in practice. Newly implemented online ordering software from the blood supplier allowed an electronic record for blood product delivery and was a valuable asset for the process. The criteria for adjusting the standing order was cumbersome, so a straightforward guideline was adopted for calculating inventory. The maximum designated stock at the beginning of first shift was 30 platelets. More importantly, there could not be more than 20 day-5 platelets on any weekday. This inventory number was further adjusted to <10 day-5 products on weekend days without routine surgeries. Weekly scheduled conference calls with blood supplier provided a smooth transition for changes and review of details. These phone calls also offered quick resolutions for issues such as shifts in blood type proportions for stock shipments and enabled problems to be addressed promptly. Conclusion: Inventory control requires an ongoing cycle of review and evaluation. This partnership enabled the hospital to reduce utilization and product costs and the supplier to increase product availability for its network hospitals. Implementation was successful at this specific institution, but further evaluation is needed to draw broader conclusions.

39 26. Assessment of Intensive Care Unit Nursing Knowledge and Practices Regarding 27. Two Cases of Successful Management of Severe Retroperitoneal Bleeding Through Patient Blood Management Embolization Without Blood Transfusion

Authors: Ashley Hill, MD; Frances Hite Philp, MS; Rita Schwab, CPMSM; Authors: Prof. Yong Jin Kim, Prof. Min Chang Kang, Ms. Haran Jung Molly Kosoglow, RN, BSN, MBA; Erin Suydam, MD Authors Institution: Soonchunhyang University College of Medicine, Seoul Hospital Authors Institution: Allegheny General Hospital, Pittsburgh, PA Case 1: 58-year old women came to emergency room complaining acute abdominal pain and Background: At our Integrated Health Network (IHN), a Patient Blood Management (PBM) leg swelling for one day. She is taking aspirin for two years. There was no history of trauma. Her Program was initiated in 2016, first focusing on establishing evidence-based strategies to guide vital sign showed slight low blood pressure and mild tachycardia (purse rate:114/min). Initial transfusion practices of physicians/physician extenders. We appreciate that nurses have a key hemoglobin was 6.9 gm/dL and CT showed huge pelvic hematoma with iliac vein thrombosis. role in blood transfusions as they receive early notification of critical labs, physically administer Angiogram showed negative, but we tried prophylactic embolization on both iliac artery. And we transfusions, monitor for adverse effects and document in the electronic health record (EHR). also inserted IVC filter simultaneously. She managed with high dose IV iron, antithrombin III, We designed a nursing survey to assess progress of PBM initiatives and guide future efforts. and so on. Eventually, her hemoglobin was increased to 8.2 gm/dL within 3 weeks. Our overall aim is to enhance collaboration with nursing staff to improve outcomes, reduce risks and most effectively care for patients. Case 2: 44-year old man visited ER due to chest and frank pain after fall down injury. He showed alert mental state and stable vital sign. CT showed left kidney injury with active bleed- Methods: Our pilot study population included nursing staff in the trauma intensive care unit. ing and spleen laceration. Angiogram also showed active bleeding in left kidney, so we tried A 15-question survey was created utilizing an electronic, commercially available tool with mul- partial embolization on left renal artery and splenic artery. However, hemoglobin dropped to tiple choice and free text questions to assess familiarity with blood transfusion and identify 5.0 gm/dL after 3-day conservative management. We did angiogram again and total emboliza- areas for improvement. Knowledge based questions were included regarding transfusion trig- tion. He stayed in ICU and general ward for 35 days. His hemoglobin was back to 12.8 gm/dL gers, blood handling guidelines and EHR documentation. with high dose IV iron, EPO, Vitamin K. Results: Eighteen responses were collected, approximately 38% of those surveyed. Nearly 60% reported having more than five years of nursing experience; none reported one year or less. The majority (89%) reported being familiar with transfusion guidelines and most (78%) felt confident with proper transfusion technique/documenting the transfusion in the EHR. Despite the self-reported familiarity, 83% answered more than 20% of the knowledge questions incorrectly (average score 59% for all respondents). Most commonly the risks of blood transfusion were incorrectly identified. Results indicated a lack of awareness regarding iatrogenic blood loss and acute management of anemia. Many of the respondents conveyed interest in learning more about anemia, transfusion risks, and how to correctly document transfusions in the EHR. Nurses expressed a preference for email and lecture-based means of education. Conclusion: This survey highlights an opportunity for improvement in PBM education for nursing staff, as our results illustrate interest in, and need for, focused instruction. Further efforts will specifically reinforce evidence-based guidelines regarding restrictive transfusion practices, benefits of treating anemia and improving transfusion documentation in the EHR. We also anticipate development of multi-modal educational platforms for nurses throughout our IHN, to include faculty teaching sessions, PBM pocket cards and peer reinforcement. Using this approach, we will empower our nurses to engage in PBM and we expect to improve patient safety as well as team-based delivery of quality care.

40 27. Two Cases of Successful Management of Severe Retroperitoneal Bleeding Through Embolization Without Blood Transfusion

Authors: Prof. Yong Jin Kim, Prof. Min Chang Kang, Ms. Haran Jung

Authors Institution: Soonchunhyang University College of Medicine, Seoul Hospital

Case 1: 58-year old women came to emergency room complaining acute abdominal pain and leg swelling for one day. She is taking aspirin for two years. There was no history of trauma. Her vital sign showed slight low blood pressure and mild tachycardia (purse rate:114/min). Initial hemoglobin was 6.9 gm/dL and CT showed huge pelvic hematoma with iliac vein thrombosis. Angiogram showed negative, but we tried prophylactic embolization on both iliac artery. And we also inserted IVC filter simultaneously. She managed with high dose IV iron, antithrombin III, and so on. Eventually, her hemoglobin was increased to 8.2 gm/dL within 3 weeks. Case 2: 44-year old man visited ER due to chest and frank pain after fall down injury. He showed alert mental state and stable vital sign. CT showed left kidney injury with active bleeding and spleen laceration. Angiogram also showed active bleeding in left kidney, so we tried partial embolization on left renal artery and splenic artery. However, hemoglobin dropped to 5.0 gm/dL after 3-day conservative management. We did angiogram again and total embolization. He stayed in ICU and general ward for 35 days. His hemoglobin was back to 12.8 gm/dL with high dose IV iron, EPO, Vitamin K.

41 28. Tissue Molecular Genotyping Improves Patient Blood Management in Syrian Injured 29. Can Thromboelastography Really Assess Coagulation in Anemic Patients? Patients Treated in Israel Authors: Dr. Amir A Kuperman1,2, Dr. Ety Shaoul, B.Sc.2 Rufina Polack2, Authors: Dr. Luiza Akria1,2, Dr. Andrei Braester1,2, Dr. Massad Barhoum2, Dr. Andrei Braester1,2 Dr. Simona Zisman-Rozen1, Dr. Celia Suriu1,2, Dr. Ety Shaoul1 Authors Institutions: “Azriely”* Faculty of Medicine, University Bar Ilan1 and Galilee Medical Authors Institutions: 1 Blood Bank and Molecular Hematology Laboratory, Galilee Medical Center2, Israel Center, Nahariya; 2 “Azrieli” Faculty of Medicine, Bar Ilan University, Safed, Israel Background: Thromboelastography (TEG) is a method performed on whole blood, examining During the last two decades the importance of molecular biology in transfusion medicine has the physical properties of blood clots (figure 1). Two published studies [1,2] investigating the been growing. Reference centers for immunohematology commonly use molecular methods to effect of ex-vivo hemodilution on TEG parameters, revealed conflicting results. Another study clarify problems, discrepancies or unusual results in patient serology. [3] examining the effect of high Hct (hematocrit) in cyanotic congenital heart disease revealed a lower ROTEM MCF, indicating “hypocoagulability”. TEG is often performed in bleeding patients Nowadays there are immunohematology reference laboratories that recommend using molecular so it is essentially important to examine its significance when hematocrit (Hct) decreases. genotyping for patient blood management. Our blood bank laboratory is not a reference center, Copyright © 2017 International Anesthesia Research Society2017 but we routinely use molecular genotyping to solve serologic problems. Due to the proximity to Aim: Assessing the effect of ex-vivo Hct reduction (by erythrocyte removal) on TEG parameters the Syrian border, since the beginning of the Syrian civil war, our medical center has received in healthy volunteers. hundreds of injured patients, some of them with unique features concerning the blood type testing. From our previous experience of such a case in Dec 2015, we realized that due to extreme Methods: Fifty one healthy volunteers aged 18–50 years, were studied. Blood drawn into EDTA war conditions and lack of medical amenities, severely injured patients are likely to receive tube served as a baseline measure. Four citrate tubes were used for measuring TEG, PT, PTT unmatched blood transfusions in Syria, sometimes ABO-incompatible blood transfusions. and derived fibrinogen. Two of the citrate tubes retained Hct of 35–55%, and served as reference. The other tubes were used to produce a variable Hct around 20–25% by removal of red The patients arriving to our medical center are usually in critical condition and without medical blood cells pellet. Two methods of TEG were used: citrate kaolin TEG on all 51 blood samples, records. Serologic tests show double population (DP) blood type. Molecular genotype of blood and FFR (functional fibrinogen reagent) TEG (figure 2) used to determine the functional fibrino- samples is not helpful, because it can detect the blood type of the unmatched/incompatible gen contribution on the TEG MA (maximal amplitude) of 38 blood samples. donor. Results: Using the citrate kaolin TEG, there was a significant elevation of MA correlated with In these cases, we use molecular genotyping from a tissue specimen, usually skin. Until we Hct reduction (Pearson correlation, R = -0.551, p< 0.001, n=51), which may imply a pattern of receive the results, which take about 5 hours in our molecular lab, we give only type O blood hypercoagulation. Using the FFR TEG there was a statistically significant correlation between and AB plasma. Since Dec 2015, 11 injured patients with DP on serologic typing were admit- Hct reduction and elevation of functional fibrinogen levels (Spearman correlation, R = -0.390, ted to our medical center. Tissue genotyping was performed on 8 of these. We determined that p=0.016, n=38), indicating its contribution to the MA changes. Fibrinogen levels measured seven of the eleven patients previously received ABO-incompatible blood in Syria. With one in all tubes were not significantly changed by Hct reduction. The changes in platelet numbers exception, all patients were transfused in Israel (detailed data not shown), three with incom- were in all cases in normal range, and no statistical correlation was found between platelets patible blood upon admission, based on initial serotype (patients 1,3,4 in the table). Tissue number changes and the Hct changes (Spearman correlation, R = 0.027, p=0.850, n=51). genotyping allowed us to transfuse compatible ABO-matched blood components afterward. All patients survived and were released in good condition. Discussion: Rheological studies imply that low Hct contributes to bleeding tendency, wheres low Hct will result in more bleeding. The current study is first to explore why TEG MA unex- Tissue molecular genotyping helps improve patient blood management in the population of pectedly implies hypercoagulation. We chose to perform ex-vivo erythrocyte reduction since injured causalities from Syria. it reflects the pathophysiology of blood loss better then hemodilution with normal saline. We were able to demonstrate, via the TEG FFR test, that the high MA is caused by elevation of func-

Serological blood type at arrival Final tional fibrinogen. The explanation we suggest is that since TEG is performed on whole blood, Incompatible PRBC Blood type by tissue Patient no serological Blood type transfusions in Israel genotype in “anemic blood” which contains higher proportion of plasma (and thus functional fibrinogen); Forward Reverse blood type clot strength may falsely increase ex-vivo. 1 A DP Anti B A 5PRBC type A O1O1 O 2 B DP Anti A B - not done O Conclusions: 1. Ex-vivo reduction of Hct is strongly associated with MA elevation. 2. The high 3 A DP B DP None AB 4PRBC type B A1A1 A MA is explained by elevation of functional fibrinogen levels. 3. It is not clear whether these 4 A B DP None AB 1PRBC type AB A2O1 A 5 A DP Anti B A - O1O1 O findings reflect physiology or an artifact of the method and further in-vivo studies are needed. 6 B DP Anti A B - O1O1 O 7 A DP B DP None AB - O1O1 O

42 29. Can Thromboelastography Really Assess Coagulation in Anemic Patients?

Authors: Dr. Amir A Kuperman1,2, Dr. Ety Shaoul, B.Sc.2 Rufina Polack2, Dr. Andrei Braester1,2

Authors Institutions: “Azriely”* Faculty of Medicine, University Bar Ilan1 and Galilee Medical Center2, Israel

Background: Thromboelastography (TEG) is a method performed on whole blood, examining the physical properties of blood clots (figure 1). Two published studies [1,2] investigating the effect of ex-vivo hemodilution on TEG parameters, revealed conflicting results. Another study [3] examining the effect of high Hct (hematocrit) in cyanotic congenital heart disease revealed a lower ROTEM MCF, indicating “hypocoagulability”. TEG is often performed in bleeding patients so it is essentially important to examine its significance when hematocrit (Hct) decreases. Aim: Assessing the effect of ex-vivo Hct reduction (by erythrocyte removal) on TEG parameters in healthy volunteers. Methods: Fifty one healthy volunteers aged 18–50 years, were studied. Blood drawn into EDTA tube served as a baseline measure. Four citrate tubes were used for measuring TEG, PT, PTT and derived fibrinogen. Two of the citrate tubes retained Hct of 35–55%, and served as reference. The other tubes were used to produce a variable Hct around 20–25% by removal of red blood cells pellet. Two methods of TEG were used: citrate kaolin TEG on all 51 blood samples, and FFR (functional fibrinogen reagent) TEG (figure 2) used to determine the functional fibrinogen contribution on the TEG MA (maximal amplitude) of 38 blood samples. Results: Using the citrate kaolin TEG, there was a significant elevation of MA correlated with Hct reduction (Pearson correlation, R = -0.551, p< 0.001, n=51), which may imply a pattern of hypercoagulation. Using the FFR TEG there was a statistically significant correlation between Hct reduction and elevation of functional fibrinogen levels (Spearman correlation, R = -0.390, p=0.016, n=38), indicating its contribution to the MA changes. Fibrinogen levels measured in all tubes were not significantly changed by Hct reduction. The changes in platelet numbers were in all cases in normal range, and no statistical correlation was found between platelets number changes and the Hct changes (Spearman correlation, R = 0.027, p=0.850, n=51). Discussion: Rheological studies imply that low Hct contributes to bleeding tendency, wheres low Hct will result in more bleeding. The current study is first to explore why TEG MA unex- pectedly implies hypercoagulation. We chose to perform ex-vivo erythrocyte reduction since it reflects the pathophysiology of blood loss better then hemodilution with normal saline. We were able to demonstrate, via the TEG FFR test, that the high MA is caused by elevation of functional fibrinogen. The explanation we suggest is that since TEG is performed on whole blood, in “anemic blood” which contains higher proportion of plasma (and thus functional fibrinogen); clot strength may falsely increase ex-vivo. Conclusions: 1. Ex-vivo reduction of Hct is strongly associated with MA elevation. 2. The high MA is explained by elevation of functional fibrinogen levels. 3. It is not clear whether these findings reflect physiology or an artifact of the method and further in-vivo studies are needed.

43 REFERENCES: 30. Variation on Transfusion Practice in First Elective Coronary Artery Bypass Graft 1. Nagler M, Kathriner S, Bachmann LM, Wuillemin WA. Impact of changes in haematocrit (CABG) Surgery Demonstrated by a Statewide Quality Initiative. level and platelet count on thromboelastometry parameters. Thromb Res 2013;131(3):249–53. 2. Li L, Yang J, Sun Y, et al. Correction of blood coagulation dysfunction and anemia by sup- Authors: Yanyun Wu, MD, PhD1,3; Jeannie Collins-Brandon1; Tamara Glover, MSc2; plementation of red blood cell suspension, fresh frozen plasma, and apheresis platelet: Trudi Gallagher, RN2; Ravi S. Hira, MD1,4 results of in vitro hemodilution experiments. J Crit Care 2015;30(1):220. e1-12. 3. Westbury SK, Lee K, Reilly-Stitt C, Tulloh R, Mumford AD. High haematocrit in cyanotic Authors Institutions: 1Foundation for Health Care Quality, Seattle, WA; 2Washington State congenital heart disease affects how fibrinogen activity is determined by rotational throm- Hospital Association, Seattle, WA; 3Bloodworks NW, Seattle, WA; 4University of Washington, boelastometry. Thromb Res 2013;132(2):e145-51. Seattle ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott Williams & Wilkins Background/Case Studies: Many factors can result in variation in transfusion practice. As part of a quality program, we evaluated the degree of transfusion practice variation for adult first elective coronary artery bypass graft (CABG) surgery in Washington State. Methods: All hospitals in Washington State that provide adult cardiac surgery are invited to participate in this quality initiative. In order to evaluate variation in blood use we identified a cohort of patients undergoing their first elective CABG surgery. This cohort of patients has been validated in other data sets to evaluate variation in transfusion patterns as they can be optimized prior to surgery and are at lower risk for bleeding compared to other cardiac surgical procedures. Data from cases reported in 2017 was used for this analysis. The data are abstracted from the medical record at each participating hospital following adult cardiac surgery. We used de-identified data for analysis. Results/Finding: We have observed significant unadjusted practice variation both at the hospital and at the provider level. Conclusion: There is wide variation in transfusion practice for patients undergoing first elective CABG in Washington State.

Hospital Level (N=15) Min Max Average Median 25th Percentile 75th Percentile Case Volume 13 146 78 82 45 104 RBC Transfusion Frequency 5.6% 53.8% 17.3% 14.4% 9.3% 20.9% Platelet Transfusion Frequency 0.0% 30.8% 9.9% 7.0% 4.5% 11.9% Plasma Transfusion Frequency 0.0% 38.5% 7.6% 3.4% 1.9% 9.4% Cryo Transfusion Frequency 0.0% 14.3% 4.0% 1.7% 0.5% 7.7% Provider Level (N=50) Min Max Average Median 25th Percentile 75th Percentile Case Volume 1 56 22 18 6 37 RBC Transfusion Frequency 0.0% 100.0% 21.5% 14.3% 6.2% 26.7% Platelet Transfusion Frequency 0.0% 100.0% 14.6% 7.0% 0.0% 20.0% Plasma Transfusion Frequency 0.0% 100.0% 13.2% 3.3% 0.0% 10.9% Cryo Transfusion Frequency 0.0% 100.0% 7.5% 0.0% 0.0% 6.5%

44 30. Variation on Transfusion Practice in First Elective Coronary Artery Bypass Graft (CABG) Surgery Demonstrated by a Statewide Quality Initiative.

Authors: Yanyun Wu, MD, PhD1,3; Jeannie Collins-Brandon1; Tamara Glover, MSc2; Trudi Gallagher, RN2; Ravi S. Hira, MD1,4

Authors Institutions: 1Foundation for Health Care Quality, Seattle, WA; 2Washington State Hospital Association, Seattle, WA; 3Bloodworks NW, Seattle, WA; 4University of Washington, Seattle

Background/Case Studies: Many factors can result in variation in transfusion practice. As part of a quality program, we evaluated the degree of transfusion practice variation for adult first elective coronary artery bypass graft (CABG) surgery in Washington State. Methods: All hospitals in Washington State that provide adult cardiac surgery are invited to participate in this quality initiative. In order to evaluate variation in blood use we identified a cohort of patients undergoing their first elective CABG surgery. This cohort of patients has been validated in other data sets to evaluate variation in transfusion patterns as they can be optimized prior to surgery and are at lower risk for bleeding compared to other cardiac surgical procedures. Data from cases reported in 2017 was used for this analysis. The data are abstracted from the medical record at each participating hospital following adult cardiac surgery. We used de-identified data for analysis. Results/Finding: We have observed significant unadjusted practice variation both at the hospital and at the provider level. Conclusion: There is wide variation in transfusion practice for patients undergoing first elective CABG in Washington State.

45 31. Bloodless Revascularization: The Protected PCI Approach at Englewood Hospital 32. Utilizing Data Combined with Specialty Champions as Drivers for Accelerating and Maximizing Patient Blood Management Initiatives Authors: Dr. Mustapha Serhan1, Dr. Tania Al Shamy1, Dr. Hishan Hakeem1, Dr. Aron Schwarcz2 Authors: Julia Crosby, MT(ASCP) BB1; Megan Gibas, BS, CPHQ2; Sampath Ethiraj, MD, MBA1; Authors Institutions: 1Englewood Hospital and Medical Center; 2Cardiovascular Associates Gail Heflin, BSN, RN3; Carolyn Clancy, MSN, CNS, APRN2 of North Jersey, Englewood, NJ Authors Institutions: 1Parkview Heath, & 2Parkview Regional Medical Center, & 3Accumen Background: Certain patients do not accept blood products in their medical care. We sought to describe the use of Impella® heart pump (ABIOMED, Danvers) as a prophylactic support in Background: Comprehensive patient blood management (PBM) programs, strategically imple- non-emergent procedure in these patients. mented, aid healthcare organizations in reducing unnecessary transfusions, risks, and cost, while improving patient outcomes. The multifaceted demands for improving healthcare with XXX Methods: We reviewed the charts of all bloodless medicine patients who underwent prophylac- reduced resources prove to be a challenge for organizations wanting to incorporate quality tic support with Impella for a non-emergent procedure and all non-shock patients who under- improvement programs such as PBM. Organizations need efficient PBM programs focused on went a Protected PCI with Impella at our institution between Jun 2012 and Dec 2016. We rapid implementation with sustainable outcomes. A midwestern healthcare system partnered compared baseline characteristics and in-hospital outcomes; including in-hospital mortality, with a team of PBM experts to restructure their current PBM program by utilizing data and vascular complications, Impella access site bleeding, requiring surgery or transfusion, and specialty champions as drivers for accelerating and maximizing changes in clinical practice. need for transfusion in general. Methods: Executives within an 8-hospital healthcare system partnered with external PBM Results: A total of 34 patients were included in this analysis; 72.8±13.1 years old and 70.6% experts to restructure their PBM program. A multidisciplinary PBM infrastructure was estab- were male. At baseline 45.5% had diabetes, 24.1% peripheral vascular disease, 21% chronic lished at the system and site levels. The committees placed strategic emphasis on key areas kidney disease, 75.8% coronary artery disease and 73.5% congestive heart failure. Prior to of a standard PBM program plan: early acquisition of system and unblinded provider level ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott Impella initiation the average left ventricular ejection fraction was 30.6%±13.5%, serum cre- data combined with consistent tactical dissemination of data by specialty physician and PBM Williams & Wilkins atinine was 1.5±1.5mg/dL and the hemoglobin was 12.4±2.1 g/dL. Of the 34 patients, 8 expert champions. PBM expert and Physician champion teams were identified utilizing Kotter’s bloodless medicine patients underwent prophylactic Impella for a non-emergent procedure 8 Step Model for Leading Change. A previously validated PBM data ingestion method was (7 Protected PCI, 1 electrophysiology procedure for ventricular tachycardia ablation) and 26 utilized to obtain and analyze baseline organization and physician level performance. Reports underwent prophylactic Impella for a Protected PCI. The two groups were well matched in terms were generated within two months of partnership. Baseline and goal metrics were established of baseline and procedural characteristics. There were no significant differences between the (see below). Transfusion guidelines and computerized transfusion order entry programs were bloodless medicine group and the rest of the patients with regard to in-hospital mortality reviewed and updated. Quarterly education and reports were shared with each PBM commit- (0.0% vs. 3.9%, p=1.00), need for transfusion (0.0% vs. 7.7%%, p=1.00); Impella access site tee and specialty group. Specialties with greatest opportunity received education and reports bleeding (0.0% vs. 3.9%, p=1.00), or days of hospital stay (7.3±5.6 vs. 8.7±7.9, p=0.60). No first. Providers were counseled with individual data specific to their practice; unblinded and in patient had vascular complication requiring surgery or transfusion. comparison with that of their specialty colleagues. Conclusions: Our results suggest that in patients requesting bloodless medicine, prophylactic Results: The Figure shows improvement in physician practice over the 26-month period post Impella support in this patient population in whom avoiding emergent need for surgery and implementation of the strategic plan. Quarterly system reports show red blood cell (RBC) repeat revascularization outweighs the potential related hazard of vascular complications and transfusions at a pre-transfusion Hgb < 7g/dl, Hgb >8 g/dl and % single unit transfusions were bleeding is feasible, especially when meticulous attention to access and closure is used. improved from baseline, 47%, 15%, & 49% respectively, to 66%, 7%, and 84%. Additionally, the system reduced red blood cell utilization by 20% despite an increase in patient volume, resulting in a 16% reduction in blood acquisition costs. Conclusion: System and unblinded provider level data combined with expert PBM and physician champions, who partner to present the data, proves an effective catalyst for changing clinical practice in a PBM program.

46 32. Utilizing Data Combined with Specialty Champions as Drivers for Accelerating and Maximizing Patient Blood Management Initiatives

Authors: Julia Crosby, MT(ASCP) BB1; Megan Gibas, BS, CPHQ2; Sampath Ethiraj, MD, MBA1; Gail Heflin, BSN, RN3; Carolyn Clancy, MSN, CNS, APRN2

Authors Institutions: 1Parkview Heath, & 2Parkview Regional Medical Center, & 3Accumen

Background: Comprehensive patient blood management (PBM) programs, strategically implemented, aid healthcare organizations in reducing unnecessary transfusions, risks, and cost, while improving patient outcomes. The multifaceted demands for improving healthcare with XXX reduced resources prove to be a challenge for organizations wanting to incorporate quality improvement programs such as PBM. Organizations need efficient PBM programs focused on rapid implementation with sustainable outcomes. A midwestern healthcare system partnered with a team of PBM experts to restructure their current PBM program by utilizing data and specialty champions as drivers for accelerating and maximizing changes in clinical practice. Methods: Executives within an 8-hospital healthcare system partnered with external PBM experts to restructure their PBM program. A multidisciplinary PBM infrastructure was established at the system and site levels. The committees placed strategic emphasis on key areas of a standard PBM program plan: early acquisition of system and unblinded provider level data combined with consistent tactical dissemination of data by specialty physician and PBM expert champions. PBM expert and Physician champion teams were identified utilizing Kotter’s 8 Step Model for Leading Change. A previously validated PBM data ingestion method was utilized to obtain and analyze baseline organization and physician level performance. Reports were generated within two months of partnership. Baseline and goal metrics were established (see below). Transfusion guidelines and computerized transfusion order entry programs were reviewed and updated. Quarterly education and reports were shared with each PBM committee and specialty group. Specialties with greatest opportunity received education and reports first. Providers were counseled with individual data specific to their practice; unblinded and in comparison with that of their specialty colleagues. Results: The Figure shows improvement in physician practice over the 26-month period post implementation of the strategic plan. Quarterly system reports show red blood cell (RBC) transfusions at a pre-transfusion Hgb < 7g/dl, Hgb >8 g/dl and % single unit transfusions were improved from baseline, 47%, 15%, & 49% respectively, to 66%, 7%, and 84%. Additionally, the system reduced red blood cell utilization by 20% despite an increase in patient volume, resulting in a 16% reduction in blood acquisition costs. Conclusion: System and unblinded provider level data combined with expert PBM and physician champions, who partner to present the data, proves an effective catalyst for changing clinical practice in a PBM program.

47 33. Comparison of Noninvasive Hemoglobin Analysis to Invasive Hemoglobin Analysis

Authors: Dr. Christian Mabry, Dr. Jeanna Blitz, Dr. Graham Hadley

Authors Institution: New York University Langone Health

Preoperative anemia is the strongest predictor of intra- and postoperative transfusion. Detection of anemia at the earliest possible time during a patient’s preoperative course can maximize the time frame for proper management of this diagnosis. As part of our institution’s implementation of a comprehensive Patient Blood Management (PBM) program, our Pre-Anesthesia Testing (PAT) clinic compared the hemoglobin level (g/dL) using a noninvasive hemoglobin detector versus the traditional laboratory methods (complete blood count). Use of a noninvasive hemoglobin detector during the initial surgical clinic visit quickly screens for undiagnosed anemia. With this information, preoperative lab work then includes an anemia panel to diagnose the etiology of this anemia. For those patients with iron deficiency anemia, the surgeon, anesthesiologist, and primary care physician collaborate on an anemia management plan. This workflow only improves patient safety if the noninvasive hemoglobin analysis is accurate. Our research found that noninvasive hemoglobin detectors report falsely low hemoglobin levels when compared to invasive hemoglobin lab work. We determined that the degree of false reporting was outside the range acceptable for use in our clinic. The noninvasive machine reported, on average, a 2.5 g/dL decrease in hemoglobin from the complete blood count. This correlated to an 18% decrease. A streamlined anemia workflow for surgical patients can potentially diagnose and treat anemia and reduce the risk of allogenic blood product exposure. This improves the value of healthcare by increasing quality and decreasing cost. We discovered a unique patient safety issue because an attempt was made to decrease the cost of an anemia workup by analyzing hemoglobin by noninvasive techniques. With the decrease in cost, however, a decrease in quality was found which neutralized any potential increase in value. Because of this, the traditional use of invasive lab work in the preoperative setting continues to be used at our institution.

48 33. Comparison of Noninvasive Hemoglobin Analysis to Invasive Hemoglobin Analysis

Authors: Dr. Christian Mabry, Dr. Jeanna Blitz, Dr. Graham Hadley

Authors Institution: New York University Langone Health

49 34. Standardization Reliable Recognition and Treatment of Pre-Operative Anemia Using 35. Desmopressin Reverses Platelet Inhibition in the ADP Pathway in Patients with Blunt Anemia Reflex Testing and Pharmacy Driven Workflows Traumatic Brain Injuries

Authors: Joan O’Connell RN, BSN, CCRN; Mary Ann O’Brien RN, MSN, CCRN, CNE; Authors: Benjamin N Cragun, MD; Matthew R Noorbakhsh, MD; Frances Hite Philp, MS; Benjamin Hohmuth MD; Amanda Haynes DO Erin R Suydam, MD; Rita Schwab, CPMSM; Allan S Philp, MD; Alan D Murdock, MD

Affiliations: Geisinger, Danville, PA Authors Institution: Allegheny General Hospital

Background: Geisinger’s patient blood management (PBM) department sees all anemic Introduction: Patients admitted with traumatic brain injury (TBI) with platelet dysfunction are patients who are anticipating major joint arthroplasty to facilitate both diagnosis and treatment thought to have worse outcomes than those without platelet dysfunction. Traditional quantita- of anemia prior to surgery. \Our original workflow relied upon our PBM nurses making recom- tive measures of coagulopathy such as prothrombin time, partial thromboplastin time, or plate- mendations for further diagnostic testing for those patients who were found to be anemic on let count fail to adequately measure platelet function in vivo. Qualitative testing methods, such pre-operative screening. For the subset of these patients found to be iron deficient our PBM as thromboelastography with platelet mapping (TEG-PM), assess platelet function by isolating nurses made further recommendations regarding appropriate treatment. This workflow relied platelet aggregation in the arachidonic acid (AA, or aspirin-mediated) and adenosine diphos- upon surgical teams to enter the recommended orders which compromised reliability of the phate (ADP, or clopidogrel-mediated) pathways. Platelet transfusion and desmopressin are con- process. In addition, bringing back those patients found to be anemic back for an additional troversial treatments for platelet dysfunction in the setting of TBI. Desmopressin increases diagnostic phlebotomy was inconvenient for patients and decreased the time to treat prior to platelet function by releasing endogenous factor VIII and Von Willebrand factor, while platelet surgery. transfusion increases the quantity of available platelets for clot formation. The clinical efficacy of these treatments remains debated, and the effect on TEG-PM is not known. We hypothesize Methods: We developed an anemia reflex test to facilitate anemia diagnosis as well as a that desmopressin reverses platelet dysfunction without the need for platelet transfusion. pharmacy driven protocol to facilitate treatment of iron deficiency. The anemia reflex draws an additional tube of blood with the preoperative screening CBC. If the patient is not anemic the Methods: We retrospectively identified adult patients admitted with isolated blunt TBI between tube is discarded. If the patient is anemic, the MCV determines which additional studies will February 2016 and March 2018 at a single level 1 trauma center. We included any patient who be performed from the additional tube. The pharmacy protocol enables a standardized action underwent TEG-PM testing on admission and a repeat TEG-PM within 24 hours, some of whom to be carried out without relying on the surgical service. Our pharmacists enter orders directly were not on antiplatelet medications. We excluded patients with thrombocytopenia and those as dictated by our anemia management algorithms as well as follow up hemoglobin testing to on anticoagulant medications. We recorded any treatments for platelet inhibition and reviewed assess response to treatment. We piloted this approach at two of our largest campuses for the TEG-PM before and after treatment. hip and knee arthroplasty. Results: We identified 93 patients meeting inclusion criteria during our study period, of whom Results: We have successfully implemented our anemia reflex testing and have treated a total 62% (n=57) were on antiplatelet medications. Patients treated with desmopressin showed ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott of 54 patients using pharmacy driven protocols for iron deficiency. improvement in the ADP pathway (58.2% to 43.8%, p=0.003). Patients treated with desmo- Williams & Wilkins pressin and platelets did not show significantly greater improvement in platelet function in the Conclusion: Anemia reflex testing and pharmacy driven workflow are a viable option for iden- ADP pathway (p=0.7) as compared to desmopressin alone. tifying and treating preoperative anemia. We have hired a full-time pharmacist to focus on expanding this protocol to other preoperative patient populations and are investigating a simi- Conclusions: Desmopressin significantly decreases the degree of platelet inhibition in the ADP lar approach for our ambulatory systolic heart failure patients. pathway on TEG-PM in patients admitted with blunt TBI in patients on antiplatelet medications and those with coagulopathy of trauma. The addition of platelet transfusion does not reverse platelet dysfunction better than desmopressin alone. This suggests that platelet transfusion may be an unnecessary risk in many patients with traumatic brain injury.

50 35. Desmopressin Reverses Platelet Inhibition in the ADP Pathway in Patients with Blunt Traumatic Brain Injuries

Authors: Benjamin N Cragun, MD; Matthew R Noorbakhsh, MD; Frances Hite Philp, MS; Erin R Suydam, MD; Rita Schwab, CPMSM; Allan S Philp, MD; Alan D Murdock, MD

Authors Institution: Allegheny General Hospital

Introduction: Patients admitted with traumatic brain injury (TBI) with platelet dysfunction are thought to have worse outcomes than those without platelet dysfunction. Traditional quantita- tive measures of coagulopathy such as prothrombin time, partial thromboplastin time, or platelet count fail to adequately measure platelet function in vivo. Qualitative testing methods, such as thromboelastography with platelet mapping (TEG-PM), assess platelet function by isolating platelet aggregation in the arachidonic acid (AA, or aspirin-mediated) and adenosine diphos- phate (ADP, or clopidogrel-mediated) pathways. Platelet transfusion and desmopressin are con- troversial treatments for platelet dysfunction in the setting of TBI. Desmopressin increases platelet function by releasing endogenous factor VIII and Von Willebrand factor, while platelet transfusion increases the quantity of available platelets for clot formation. The clinical efficacy of these treatments remains debated, and the effect on TEG-PM is not known. We hypothesize that desmopressin reverses platelet dysfunction without the need for platelet transfusion. Methods: We retrospectively identified adult patients admitted with isolated blunt TBI between February 2016 and March 2018 at a single level 1 trauma center. We included any patient who underwent TEG-PM testing on admission and a repeat TEG-PM within 24 hours, some of whom were not on antiplatelet medications. We excluded patients with thrombocytopenia and those on anticoagulant medications. We recorded any treatments for platelet inhibition and reviewed the TEG-PM before and after treatment. Results: We identified 93 patients meeting inclusion criteria during our study period, of whom 62% (n=57) were on antiplatelet medications. Patients treated with desmopressin showed improvement in the ADP pathway (58.2% to 43.8%, p=0.003). Patients treated with desmopressin and platelets did not show significantly greater improvement in platelet function in the ADP pathway (p=0.7) as compared to desmopressin alone. Conclusions: Desmopressin significantly decreases the degree of platelet inhibition in the ADP pathway on TEG-PM in patients admitted with blunt TBI in patients on antiplatelet medications and those with coagulopathy of trauma. The addition of platelet transfusion does not reverse platelet dysfunction better than desmopressin alone. This suggests that platelet transfusion may be an unnecessary risk in many patients with traumatic brain injury.

51 36. Computer Physician Order Entry Decision Support Aids in Reduction of Red Blood Cell 37. High Autologous Wastage Rate Identifies Opportunities for Improving Transfusion Dose in Pediatrics Patient Blood Management

Authors: Christine Cahill, BSN, MS, RN1; Jill M. Cholette, MD2; Clinton Morrison, MD3; Authors: Sara Bakhtary, MD; Elena Nedelcu, MD; Alejandro R Perez, BS; Julie Michels, RN4; Sri Harshit Nuvvula1, Majed A. Refaai, MD1 Solmaz P Manuel, MD

Authors Institutions: 1Department of Pathology and Laboratory Medicine, Transfusion Authors Institution: University of California, San Francisco Medicine Unit; 2Department of Pediatrics; 3Department of Pediatric Surgery,4 Department of Nursing, University of Rochester Medical Center Introduction: Despite the very few indications and declining use of preoperative autologous blood donation (PABD), a subset of patients scheduled for elective surgery continue to choose Background: Red blood cell (RBC) transfusions improve anemia though some studies have shown this option. Our study aimed to better understand this practice at our institution by classifying that donor blood is less effective in enhancing oxygen delivery. There is mounting evidence that the patient subset who participated in PABD. RBC transfusion may contribute to adverse outcomes such as infection, lung injury, and immu- nomodulary responses. Neonates and children frequently receive large volumes of blood compo- Methods: A retrospective review was conducted at a multicenter academic institution on the nents in relation to small body mass and significant increase in hemoglobin (Hb) levels in this PABD program. Autologous units received in the transfusion service over a two-year period patient population may contribute to thrombotic complications. Retrospective review of our insti- (1/1/2016 to 12/31/2017) were reviewed and the following data were collected from the tutional pediatric (<30kg) transfusion records and laboratory data revealed administration of high patient medical records: demographics, surgical service and surgery type, estimated blood RBC doses (>15 mL/kg), which would be equivalent to 3–4 units in an adult sized patient. Our loss (EBL), hemoglobin values, and transfusion of any blood products. Statistical analyses main objective was to standardize a 10mL/kg dose in order to minimize extreme increases in Hb. were performed using STATA 15.1 (StataCorp LP Texas, USA). Methods: In an effort to improve compliance with RBC transfusion dosing of pediatric patients, Results: 118 patients underwent PABD and donated 141 autologous red blood cell (RBC) a decision support process built into the electronic order set was designed that encouraged units. 83% donated one unit, and the rest donated 2–5 units. Surgery was canceled or post- use of a lower transfusion dose (10 versus 15 mL/kg). Retrospective chart review of 100 poned for 9%. A total of 95 units were wasted (67%) and 46 (33%) were transfused. The four consecutive pediatric patients before and after the initiation of the new dosing guidelines was most common clinical services using a PABD program were liver transplant (45%), gynecology performed. Acute trauma and actively bleeding patients were excluded. Data collection con- (13%), orthopedic surgery (10%), and urology (9%). The wastage rates for each of the above sisting of patient characteristics, RBC utilization and weight-based dose, and Hb results were services were 59%, 89%, 86%, and 100%, respectively. Of the 141 units, 90 (64%) were col- collected and analyzed. lected for surgeries performed by four surgeons. The most common surgeries performed were hepatic lobectomy for live donor liver transplant (47%), abdominal or laparoscopic myomec- Results: Each cohort displayed similar characteristics of age and weight (Table). The baseline tomy or laparoscopic hysterectomy for fibroids (8%), total hip/knee replacement/revision (8%), Hb in the study cohort (n=48) versus the historical (control) cohort (n=49) were significantly and partial nephrectomy or radical prostatectomy (8%). (p=0.03) lower. Changes in Hb levels following RBC transfusion of the study cohort were lower (24%) versus the control cohort (39%, p<0.0001), indicating compliance with our new transfu- For all surgeries, autologous transfusion was predicted by low pre-donation (p=0.004) and sion dose guidelines. The median dose of RBC transfusion observed in the study cohort was pre-surgery (p=0.011) hemoglobin values. Patients who received autologous transfusion had 10 mL/kg versus 15 mL/kg in the control cohort. mean hemoglobin of 13.3 g/dL (± 1.4) prior to autologous donation and 12.1 g/dL (± 1.2) pre- surgery, whereas patients who were not transfused had mean hemoglobin 14.4 g/dL (± 1.5) Conclusion: A simple change in the RBC transfusion ordering process can yield significant prior to donation and 12.9 g/dL (± 1.5) pre-surgery. Only 29% patients who were transfused changes in post transfusion Hb. Computer physician order entry has been shown to improve had an EBL of 500 mL or greater (range 500–1800). compliance with transfusion guidelines. Further education and reinforcement by the support of the pediatric service champions is needed to maintain appropriate dosing of RBC transfusion. Conclusion: PABD is still utilized for elective surgeries by clinical services and is associated Additional analysis of outcomes will follow to determine benefits of this approach. with high wastage rates without justification for the increased cost. Patients with lower baseline and pre-surgery hemoglobin values were more likely to receive autologous transfusion, but Table: Result of control and study cohorts before and after transfusion guidelines implementation 71% of transfused patients had EBL of less than 500 mL. Education of patients and clinical Control Cohort 1/16-12/16 (N=49) Study Cohort 11/17-1/18 (N=48) services may decrease blood wastage and assist with formulation of guidelines for cost-effec- Mean ± SD Median (Range) Mean ± SD Median (Range) P value Age (months) 4.3 ± 6 1.1 (0.1–25) 6.7 ± 6.4 4.7 (0.3–37) 0.07 tive blood management. Wt. (kg) 5.2 ± 2.8 4.0 (2.5–17.2) 6.2 ± 2.1 6.1 (2.8–12) 0.07 Pre-transfusion Hb (g/dL) 9.6 ± 2.6 10.5 (4.2–14) 8.6 ± 1.2 8.6 (6.3–12.8) 0.03 Post-transfusion Hb (g/dL) 13.3 ± 3 13.4 (6.1–21) 10.7 ± 1.5 10.6 (8.4–17.2) <0.0001 Change in Hb 4.1 ± 2.7 4 (0.4–18) 2.3 ±1.3 2.1 (0.2–5.7) <0.0001 Dose (mL/kg) 13.4 ± 3.1 15 (5–20) 11.5 ± 2.8 10 (5–16) 0.002

52 37. High Autologous Wastage Rate Identifies Opportunities for Improving Patient Blood Management

Authors: Sara Bakhtary, MD; Elena Nedelcu, MD; Alejandro R Perez, BS; Solmaz P Manuel, MD

Authors Institution: University of California, San Francisco

Introduction: Despite the very few indications and declining use of preoperative autologous blood donation (PABD), a subset of patients scheduled for elective surgery continue to choose this option. Our study aimed to better understand this practice at our institution by classifying the patient subset who participated in PABD. Methods: A retrospective review was conducted at a multicenter academic institution on the PABD program. Autologous units received in the transfusion service over a two-year period (1/1/2016 to 12/31/2017) were reviewed and the following data were collected from the patient medical records: demographics, surgical service and surgery type, estimated blood loss (EBL), hemoglobin values, and transfusion of any blood products. Statistical analyses were performed using STATA 15.1 (StataCorp LP Texas, USA). Results: 118 patients underwent PABD and donated 141 autologous red blood cell (RBC) units. 83% donated one unit, and the rest donated 2–5 units. Surgery was canceled or post- poned for 9%. A total of 95 units were wasted (67%) and 46 (33%) were transfused. The four most common clinical services using a PABD program were liver transplant (45%), gynecology (13%), orthopedic surgery (10%), and urology (9%). The wastage rates for each of the above services were 59%, 89%, 86%, and 100%, respectively. Of the 141 units, 90 (64%) were collected for surgeries performed by four surgeons. The most common surgeries performed were hepatic lobectomy for live donor liver transplant (47%), abdominal or laparoscopic myomec- tomy or laparoscopic hysterectomy for fibroids (8%), total hip/knee replacement/revision (8%), and partial nephrectomy or radical prostatectomy (8%). For all surgeries, autologous transfusion was predicted by low pre-donation (p=0.004) and pre-surgery (p=0.011) hemoglobin values. Patients who received autologous transfusion had mean hemoglobin of 13.3 g/dL (± 1.4) prior to autologous donation and 12.1 g/dL (± 1.2) pre- surgery, whereas patients who were not transfused had mean hemoglobin 14.4 g/dL (± 1.5) prior to donation and 12.9 g/dL (± 1.5) pre-surgery. Only 29% patients who were transfused had an EBL of 500 mL or greater (range 500–1800). Conclusion: PABD is still utilized for elective surgeries by clinical services and is associated with high wastage rates without justification for the increased cost. Patients with lower baseline and pre-surgery hemoglobin values were more likely to receive autologous transfusion, but 71% of transfused patients had EBL of less than 500 mL. Education of patients and clinical services may decrease blood wastage and assist with formulation of guidelines for cost-effective blood management.

53 38. Promoting High-Value Practice by Reducing Unnecessary Transfusions

Authors: Marwa Moussa, MD; Jorge Mercado, MD; Erwin Wang, MD; Charles Okamura, MD; Frank Volpicelli, MD

Authors Institution: NYU Langone Health

Introduction: Liberal Blood Transfusion Strategies add no clinical benefit and potentially can result in harm. Historically, two unit liberal transfusions were common practice at our hospital without specific transfusion goals. However, this practice was not supported by any evidence in the medical literature. Guidelines published by the American Society of Hematology recommend not to transfuse more than the minimum number of red cell units necessary to relieve symptoms of anemia or return a patient to a safe hemoglobin level (7 to 8 g/dL in non-cardiac patients). Our main goal was to promote proper utilization of blood products reflective of evidence-based medicine and high value care for our patients. Interventions: Initially, we updated our hospital policy for blood transfusion with evidence-based best practices. With the implementation of a new electronic medical record, we were able to utilize existing best practice alerts and clinical decision support tools to increase awareness in multi-disciplinary approved institutional clinical practice guidelines. We reviewed the data and identified high volume department utilizers, which were Orthopedic Surgery, General Surgery, Critical Care, and General Internal Medicine. Service chiefs for each section were engaged and agreed to participate in the initiative. Blood transfusion utilization was monitored before our intervention and in the years that followed. Results: Through our intervention, we have observed an overall decrease in blood transfusions and an increase in the proportion of patients for whom blood transfusions were clinically indicated. There was also a steady decline in the percentage of non-standard orders of Packed Red Blood Cells. Conclusion: An educational initiative supported by clinical decision support and best practice alerts can reduce inappropriate utilization of blood product.

REFERENCES: Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B; Clinical Transfusion Medicine Committee of the AABB. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med. 2012 Jul 3; 157(1):49–58. Hébert, P. C., Wells, G., Blajchman, M. A., Marshall, J., Martin, C., Pagliarello, G., et al. (1999). A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. New England Journal of Medicine, 340(6), 409–417. http://doi.org/10.1056/ NEJM199902113400601 MD, J. L. C., PhD, M. M. B., MD, J. D. A., MD, B. C., PhD, S. F. K., MD, D. J. T., et al. (2013). Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. American Heart Journal, 165(6), 964–971.e1. http://doi.org/10.1016/j. ahj.2013.03.001

54 55 39. How Much is Too Much Blood? Association Between Diagnostic Laboratory Testing and Hospital-Acquired Anemia in the Critically Ill

Authors: Judy A Trieu, MD, MPH1; Hemalkumar Mehta, PhD2; Anthony Okorodudu, PhD, MBA3; Abe DeAnda, MD2; Sean G. Yates, MD3

Authors Institutions: 1University of Texas Medical Branch, Department of Internal Medicine; 2University of Texas Medical Branch, Department of Surgery; 3University of Texas Medical Branch, Department of Pathology, Galveston

Introduction: Diagnostic laboratory testing (DLT) has been shown to contribute to the development of anemia in patients with prolonged hospitalizations. The presence of anemia in critically ill patients has been associated with adverse patient outcomes and represents a significant cost to the healthcare system. Our study aimed to evaluate current clinical practices within the Surgical Intensive Care Unit (SICU) at our institution to identify if and to what extent DLT-associated anemia exists. Methods: To evaluate the daily DLT-related blood loss, laboratory testing data was retrospectively collected for all patients admitted to the SICU from January 1, 2017-December 31, 2017. The following information was recorded: number of daily DLT collections, specific laboratory test ordered, type of blood collection tube, and average blood volume of each blood collection tube. Hemoglobin trends and blood transfusion for each hospitalization were documented. Descriptive statistics were used to characterize continuous and categorical variables. Regression analysis was performed to evaluate for predictors of hemoglobin decline and red blood cell transfusions. Results: A total of 291 patients (60.4% male, average age 62.1 years) had 299 hospitalizations during the study period. Patient demographics and study outcomes are summarized in Table 1. The average length of stay (LOS) was 15.8 days. Daily blood loss from DLT was 22.0 mL. An average of 7.4 mL of blood was discarded following collection of laboratory test from central access sites. The presence of central access was predictive of an increase in daily DLT-associated blood loss (37.4 mL vs. 11.4 mL for non-central access). Additionally, for every 100 mL of blood drawn for DLT, a corresponding decline in hemoglobin of 1.1 g/dL was observed along with a 1.4-day increase in LOS. Furthermore, the volume of DLT-associated blood loss was predictive of receiving a blood transfusion, independent of a surgical procedure or Charlson Comorbidity Index. Of the cohort of 122 non-anemic patients on admission, 113 (93%) were anemic at discharge with a mean hemoglobin decline of 6.2 g/dL. Conclusion: Taken together, the findings of our study suggest that the volume of DLT-associated blood loss contributes to the incidence and severity of anemia and leads to an increased frequency of blood transfusions. The findings of our investigation complement those demonstrated in previous studies. Efforts should be made to reduce unnecessary DLT and associated adverse events to improve quality of care.

56 39. How Much is Too Much Blood? Association Between Diagnostic Laboratory Testing and Hospital-Acquired Anemia in the Critically Ill

Authors: Judy A Trieu, MD, MPH1; Hemalkumar Mehta, PhD2; Anthony Okorodudu, PhD, MBA3; Abe DeAnda, MD2; Sean G. Yates, MD3

57 40. Correlation of Preoperative Anemia to Transfusion Rates in Spine Deformity Surgeries 41. Implementing a Patient Blood Management Program in a Complex, at a Major Academic Medical Center Multi-State Hospital System

Authors: Dr. Christian Mabry, Dr. Jeanna Blitz Authors: Sunny Bhatia MD, MMM1; Kavitha Reddy Bhatia MD, MMM1; Paryus Patel MD1; Rafael Millare MBA, CLS1; Irwin Gross MD2; Marguerite Johnson MBA, RN2; Lisa Kelly BS, Authors Institution: New York University Langone Health RN2; Carolyn Clancy MSN, RN2

It is well known that preoperative anemia is strongly correlated to intra- and postoperative Authors Institutions: 1Prime Healthcare, Ontario, CA, United States; 2Accumen, San Diego, red blood cell transfusion. We undertook a retrospective systemic review of our spine defor- CA, United States mity surgeries over a 3-month period to assess this correlation at our institution. The adult spine deformity team provided us with the medical record numbers of 24 patients during this Background/Case Studies: Despite acknowledged benefits of Patient Blood Management timeframe. The majority of our spine deformity surgeries include scoliosis repair and multilevel (PBM), implementing effective programs remains challenging especially for multi-hospital thoracic laminectomies. healthcare systems serving multiple states. A large healthcare system with 43 acute care hospitals in 14 states, on a total of 12 electronic medical record platforms, with an initial system- The idea for this review developed because our institution is implementing an anesthesia- wide blood acquisition expenditure blood spend of $18M annually, formed an interdisciplinary directed Preoperative Anemia Clinic. Because of this, knowledge of this correlation was essen- partnership to expedite a comprehensive PBM program in less than a year. tial to hypothesize the benefit our patients would receive from such a clinic. Study Design/Methods: An implementation plan was developed to include first year program Our Preoperative Anemia Clinic will be directed by a team of anesthesiologists; one of which goals: establishing a PBM infrastructure, developing state of the science transfusion guide- serves as the Medical Director of Presurgical Testing. These anesthesiologists will oversee lines and order sets, disseminating education, and providing system and provider level data. an anemia clinic that includes cooperation from various sections of our medical center. These The team developed a prioritization matrix formula consisting of hospital size, data availability, sections include, but are not limited to, anesthesiology, orthopedic spine surgery, neurosur- and transfusion volumes to guide efficient workflow. Strong emphasis was placed on each gery, internal medicine, hematology, oncology, gastroenterology, presurgical testing, strategic phase to maximize behavioral modification effects. A system level PBM Steering Committee planning, our infusion center, surgical coordinators and licensed independent practitioners, formed individual PBM task forces throughout 25 hospitals to carry out the strategic plan. All blood bank and laboratory, the medical center’s laboratory courier service, information technol- 43 hospitals designed and implemented guidelines and CPOE blood order sets. The commit- ogy, and business administration. tee launched an awareness campaign across all hospitals and delivered CME /CE educational programs at the largest hospitals. Transfusion data reports were developed for the hospitals The goal of such a clinic is to screen for and diagnose presurgical patients for iron deficiency utilizing one of the system’s largest information technology platforms (n=12 sites). Key perfor- anemia, appropriately refer those patients who are newly diagnosed, treat those who need iron mance indicators (see below) form the basis for evaluating the program. repletion, and ultimately increase blood volume to decrease transfusion in the perioperative period. Results/Findings: Over a 7-month period, through process-driven and aggressive oversight, RBC utilization declined ~13% for the system overall, despite a 3% patient volume increase. Our analysis found that preoperative anemia correlated with an 89% chance for needing a peri- There was an ~16% decrease in transfusion volume at the 12 sites for which data reports operative transfusion. The same surgical population from the same surgeons had only a 20% were implemented. Overall, RBC transfusions at hemoglobin (Hgb) > 8g/dL declined 5%, RBC chance of needing a perioperative transfusion if preoperative anemia was not present. Thus, transfusion at Hgb <7g/dL increased by 7% and single unit orders increased 12% during the preoperative anemia increases the chance for an allogenic blood transfusion by nearly 450%. first 6 months. The healthcare organization’s blood acquisition costs declined $2.3million; $$/ average patient day fell to $8.48 during 2017 vs. $$9.81 in baseline year 2016 (14.3%). Conclusion: Creating a comprehensive PBM program in an expansive healthcare structure requires innovative strategies to successfully scale key programmatic components. Direct and regular access to key decision makers along with streamlined decision-making processes, provider education, CPOE, and data and analytics were key drivers for success. Findings show a significant reduction in red blood cell utilization is possible across a large system over a one- year time frame. Disclosure of Commercial Conflict of Interest: Authors have no conflicts to disclose.

58 41. Implementing a Patient Blood Management Program in a Complex, Multi-State Hospital System

Authors: Sunny Bhatia MD, MMM1; Kavitha Reddy Bhatia MD, MMM1; Paryus Patel MD1; Rafael Millare MBA, CLS1; Irwin Gross MD2; Marguerite Johnson MBA, RN2; Lisa Kelly BS, RN2; Carolyn Clancy MSN, RN2

Authors Institutions: 1Prime Healthcare, Ontario, CA, United States; 2Accumen, San Diego, CA, United States

Background/Case Studies: Despite acknowledged benefits of Patient Blood Management (PBM), implementing effective programs remains challenging especially for multi-hospital healthcare systems serving multiple states. A large healthcare system with 43 acute care hospitals in 14 states, on a total of 12 electronic medical record platforms, with an initial system- wide blood acquisition expenditure blood spend of $18M annually, formed an interdisciplinary partnership to expedite a comprehensive PBM program in less than a year. Study Design/Methods: An implementation plan was developed to include first year program goals: establishing a PBM infrastructure, developing state of the science transfusion guidelines and order sets, disseminating education, and providing system and provider level data. The team developed a prioritization matrix formula consisting of hospital size, data availability, and transfusion volumes to guide efficient workflow. Strong emphasis was placed on each phase to maximize behavioral modification effects. A system level PBM Steering Committee formed individual PBM task forces throughout 25 hospitals to carry out the strategic plan. All 43 hospitals designed and implemented guidelines and CPOE blood order sets. The committee launched an awareness campaign across all hospitals and delivered CME /CE educational programs at the largest hospitals. Transfusion data reports were developed for the hospitals utilizing one of the system’s largest information technology platforms (n=12 sites). Key performance indicators (see below) form the basis for evaluating the program. Results/Findings: Over a 7-month period, through process-driven and aggressive oversight, RBC utilization declined ~13% for the system overall, despite a 3% patient volume increase. There was an ~16% decrease in transfusion volume at the 12 sites for which data reports were implemented. Overall, RBC transfusions at hemoglobin (Hgb) > 8g/dL declined 5%, RBC transfusion at Hgb <7g/dL increased by 7% and single unit orders increased 12% during the first 6 months. The healthcare organization’s blood acquisition costs declined $2.3million; $$/ average patient day fell to $8.48 during 2017 vs. $$9.81 in baseline year 2016 (14.3%). Conclusion: Creating a comprehensive PBM program in an expansive healthcare structure requires innovative strategies to successfully scale key programmatic components. Direct and regular access to key decision makers along with streamlined decision-making processes, provider education, CPOE, and data and analytics were key drivers for success. Findings show a significant reduction in red blood cell utilization is possible across a large system over a one- year time frame. Disclosure of Commercial Conflict of Interest: Authors have no conflicts to disclose.

59 42. Time for a Check-Up! Assessment of Our Patient Blood Management Program 43. Prospective Review of All Blood Component Orders: Evaluating the Economic Impact at an Academic Medical Center Authors: Ashley Hill, MD; Frances Hite Philp, MS; Rita Schwab, CPMSM; Molly Kosoglow, RN, BSN, MBA; Erin Suydam, MD Authors: Hila Shaim, MD1; Judy A Trieu, MD2; Karen Bingham, BS1; Barbara J. Bryant, MD1; Sean G. Yates, MD1 Authors Institution: Allegheny General Hospital, Pittsburgh, PA Authors Institutions: 1University of Texas Medical Branch, Department of Pathology; Background: A Patient Blood Management Program (PBM) was initiated at our institution in 2University of Texas Medical Branch, Department of Internal Medicine, Galveston 2016. Initial efforts focused on evidence-based strategies to guide transfusion. This program has provided many opportunities for educational outreach to our providers. To assess our Introduction: Evidence demonstrates that a substantial proportion of transfused blood compo- progress and guide future goals, a follow up survey was conducted for comparison to our 2016 nents confer little to no benefit to patients. Moreover, inappropriate ordering practices are often PBM implementation survey. costly and associated with adverse patient outcomes. Evidence-based, institution-approved transfusion guidelines have been implemented at our institution to facilitate appropriate trans- Methods: A 14-question survey was created utilizing an electronic, commercially available fusion practices. This study evaluated the frequency of inappropriate order requests as defined tool with multiple choice and free text questions to assess knowledge regarding transfusion by our institutional guidelines, and the economic impact associated with prospective review of triggers, risks, and anemia management. Respondents were asked for details regarding their blood component orders. transfusion practices and suggestions for program improvement. Our population consisted of attending, resident and fellow physicians, and physician extenders, encompassing all providers Methods: Evidence-based, institution-approved transfusion guidelines were used to prospec- responsible for ordering blood products. tively review all blood product orders. Product orders not complying with guidelines prompted review by a transfusion medicine physician. After evaluating the clinical indications and con- Results: We report our analysis of 195 completed surveys. Responses were compared to our sultation with the ordering provider, products were either approved, modified, or canceled. baseline dataset of 236 surveys collected at the initiation of our PBM program. Respondents Ordering data were retrospectively collected for red blood cell (RBC), plasma, platelet, and identified their role in the hospital; the majority were attending (36%) or resident (29%) physi- cryoprecipitate orders from September 1, 2017 to April 30, 2018. Acquisition cost savings cians. Institutional transfusion guidelines were familiar to an additional 17% of respondents for RBCs and plasma not meeting guidelines was calculated using mean per-unit component (77% vs 60%) with the launching of the PBM program. A self-reported decrease in transfu- costs reported by the 2013 AABB Blood Survey. Indirect and direct cost savings for RBCs and sions given outside of guidelines was reported with 11% of responders stating they transfuse plasma were estimated using values reported by previous studies utilizing an activity-based outside of guidelines less than 75% of the time, down from 20%. Trainee physicians both per- costing model. ceived themselves to be more compliant and proved superior knowledge of transfusion guidelines. Multiple respondents indicated a challenge in complying with guidelines when attending Results: During the eight-month study period, 1,844 of 10,810 (17%) blood products failed physician instructions conflicted. Although providers indicated frequent treatment of anemia, to meet our institutional guidelines and were prospectively reviewed. The frequency of blood responses showed incomplete awareness of anemia therapy and prevention. Interestingly, component orders not meeting guidelines included: 16% RBC units, 23% platelet doses, 15% non-compliance with transfusion guidelines was specifically identified in the Hematology/ plasma units, and 32% cryoprecipitate doses. Of the reviewed products, 688 (37%) were not Oncology population and cancer recurrence was under-recognized as a transfusion complica- clinically indicated and cancelled. This consisted of 414 (60%) RBC units, 151 (22%) plasma tion. Respondents overestimated blood product waste in our system, however demonstrated units, 82 (12%) platelet doses, and 41 (6%) cryoprecipitate doses, corresponding with a total poor understanding of proper product handling to avoid waste. Finally, a wide range of educa- direct cost savings of $154,452.69; annualized this equates to a cost savings of $231,678.04. tional modalities were proposed. The estimated activity-based cost savings range from $289,950 to $434,938.47 for all inap- Conclusion: A need exists for attending physician education to encourage leadership in fol- propriate RBCs (per-unit costs of 3.2 to 4.8 times the acquisition costs) and $80,293.79 for lowing evidence-based guidelines, thus effecting change in practice. Additionally, opportunity plasma orders (per-unit costs 9.8 times the acquisition costs) over the study period. In total, exists to prevent and treat anemia, as well as to optimize handling of products to reduce this translates to an estimated annual cost savings ranging from $555,364 to $772,849. waste. There is a focused need for education in Oncology regarding poorer oncologic outcomes in transfused patients. Our providers communicated a preference for simple, accessible, evi- Conclusion: Our findings suggest that prospective review of all blood components can promote dence-based educational materials. This survey has provided us with valuable information to the evidence-based use of healthcare resources, reduce inappropriate ordering practices, and tailor our PBM approach to achieve success within our System. confer significant cost-savings to an academic medical center.

60 43. Prospective Review of All Blood Component Orders: Evaluating the Economic Impact at an Academic Medical Center

Authors: Hila Shaim, MD1; Judy A Trieu, MD2; Karen Bingham, BS1; Barbara J. Bryant, MD1; Sean G. Yates, MD1

Authors Institutions: 1University of Texas Medical Branch, Department of Pathology; 2University of Texas Medical Branch, Department of Internal Medicine, Galveston

Introduction: Evidence demonstrates that a substantial proportion of transfused blood components confer little to no benefit to patients. Moreover, inappropriate ordering practices are often costly and associated with adverse patient outcomes. Evidence-based, institution-approved transfusion guidelines have been implemented at our institution to facilitate appropriate transfusion practices. This study evaluated the frequency of inappropriate order requests as defined by our institutional guidelines, and the economic impact associated with prospective review of blood component orders. Methods: Evidence-based, institution-approved transfusion guidelines were used to prospectively review all blood product orders. Product orders not complying with guidelines prompted review by a transfusion medicine physician. After evaluating the clinical indications and consultation with the ordering provider, products were either approved, modified, or canceled. Ordering data were retrospectively collected for red blood cell (RBC), plasma, platelet, and cryoprecipitate orders from September 1, 2017 to April 30, 2018. Acquisition cost savings for RBCs and plasma not meeting guidelines was calculated using mean per-unit component costs reported by the 2013 AABB Blood Survey. Indirect and direct cost savings for RBCs and plasma were estimated using values reported by previous studies utilizing an activity-based costing model. Results: During the eight-month study period, 1,844 of 10,810 (17%) blood products failed to meet our institutional guidelines and were prospectively reviewed. The frequency of blood component orders not meeting guidelines included: 16% RBC units, 23% platelet doses, 15% plasma units, and 32% cryoprecipitate doses. Of the reviewed products, 688 (37%) were not clinically indicated and cancelled. This consisted of 414 (60%) RBC units, 151 (22%) plasma units, 82 (12%) platelet doses, and 41 (6%) cryoprecipitate doses, corresponding with a total direct cost savings of $154,452.69; annualized this equates to a cost savings of $231,678.04. The estimated activity-based cost savings range from $289,950 to $434,938.47 for all inappropriate RBCs (per-unit costs of 3.2 to 4.8 times the acquisition costs) and $80,293.79 for plasma orders (per-unit costs 9.8 times the acquisition costs) over the study period. In total, this translates to an estimated annual cost savings ranging from $555,364 to $772,849. Conclusion: Our findings suggest that prospective review of all blood components can promote the evidence-based use of healthcare resources, reduce inappropriate ordering practices, and confer significant cost-savings to an academic medical center.

61 44. Collaboration in Bloodless Care of Major Obstetric Haemorrhage 45. Do Patients with Thalassemia Minor or Trait Benefit from Blood Conservation Methods with Acute Extreme Anaemia Preoperatively Before Undergoing High Blood Loss Surgery?

Authors: Nathaniel Usoro, MBBCh, FWACS, FICS; Joseph Enabulele, MBBS; Author Names: Jadunandan, Saudia., RN, Med; Iacovelli, Mark., MN, RN; Lin, Yulia., MD Chinedu Okonkwo, MBBS, PGDM, DA, FMCA; Kenneth Inaku, MBBCh, FMCPath; Marcus Inyama, MBBCh, FMCPath; Cajethan Emechebe, MBBS, FWACS; Etetim Asuquo, Authors Institution: Sunnybrook Health Sciences Centre MBBS, FRCOG, FWACS, FMCOG, FICS, MNIM Thalassemias are inherited blood disorders in which the body makes an abnormal form of Authors Institution: University of Calabar Teaching Hospital, Calabar, Nigeria hemoglobin. This disorder can be challenging in preoperative patient blood management when patients present with chronic anemia. Anemic patients are known to be at increased risk of Introduction: Acute extreme anaemia poses a serious challenge in surgery due to issues of transfusion with increased perioperative morbidity, mortality and hospital length of stay. The haemodynamic instability complicated by tissue hypoxia and possibility of coagulopathy. This purpose of this analysis was to analyze the effectiveness of preoperative erythropoietin in this case report of bloodless surgery in major obstetric haemorrhage with acute extreme anaemia patient population. illustrates how collaboration in bloodless care can be life-saving and more scientific than allogeneic blood transfusion. Methods: A single institution retrospective analysis of patients referred to the Blood Conservation Clinic from January 2009 to March 2018. Inclusion criteria included: preoperative Case report: A 32-year old female Jehovah’s Witness with twin pregnancy had miscarriage at assessment for an elective procedure; recent CBC showing anemia; evidence of thalassemia 23 weeks gestation with massive obstetric haemorrhage. All attempts to control the haem- minor or trait (by hemoglobin electrophoresis, Hb H inclusion bodies, or a documented medical orrhage conservatively failed. Patient had emergency hysterectomy. Preop haemoglobin was history of thalassemia minor or trait); treatment with subcutaneous erythropoietin; and a post- 3.3g/dl, and immediate post-op haemoglobin was 1.8g/dl, but fell to 1.3g/dl on 1st day treatment CBC. Erythropoietin was either given alone or in conjunction with intravenous iron postop. Patient woke up from surgery, and remained on oxygen therapy in ICU, but conscious- (iron sucrose) if iron deficiency was present. In most cases, erythropoietin was administered ness deteriorated subsequently to GCS 6/15 on 1st day post op. Chemical pathologist invited at a dose of 40,000 units weekly targeting a hemoglobin of 12–13 g/dL preoperatively. assayed blood & urine osmolality and electrolytes and diagnosed fluid overload and severe acidosis, which were successfully managed with intravenous mannitol and sodium bicarbon- Results: 45 patients met the inclusion criteria: 37 women and 8 men with a median age of ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott ate. Haematologist invited placed patient on intravenous iron and subcutaneous erythropoi- 66 years (IQR 61–76). The majority (68.9%) were preoperative for orthopedic surgery followed Williams & Wilkins etin. Microbiologist was invited due to postop pyrexia, and patient was placed on antimalarial by cardiac (17.8%) and other surgeries (13.3%) including gynecology and general surgery. The medication. Patient regained consciousness fully by 5th day post op and was moved from ICU median pre-treatment hemoglobin was 10.6 g/dL (IQR 97–112). Patients received an average to the ward on 8th day post op with Hb of 3.5g/dl. She was discharged on 18th day post op of 2.6 doses each with a mean hemoglobin increase of 0.98 g/dL. Treatment was commenced with Hb 6.9g/dl in good condition. Last visit was at 4 months post op, Hb was 12.5g/dl, and a median of 18 days (IQR 14–22) prior to the post-treatment measurement and improved patient was in excellent condition. hemoglobin by at least 10 g/L in 22 patients (48.9%). Seven patients (15.6%) had no change or a decrease following treatment. The median increase in hemoglobin with 1, 2, 3 and 4 Conclusion: Tolerance of anaemia without blood transfusion is one of the pillars of patient doses was 0.6 g/dL (IQR 0.4–0.9), 0.55 g/dL (0.18–1.13), 1.0 g/dL (0.4–1.65) and 2.25 g/ blood management adopted by the World Health Assembly in 2010. Blood transfusion in the dL (1.63–2.58) respectively. index case could have resulted in mortality from circulatory overload, acidosis, hypoxia, hypo- calcemia, coagulopathy, or immunomodulation. Acute extreme anaemia can be successfully Limitations: Beta and alpha thalassemia trait were not differentiated for those who had a managed in bloodless surgery through appropriate collaboration and prompt intervention in documented evidence of thalassemia; therefore the effects of treatment on each type of thal- respect of haemodynamic and metabolic complications. assemia could not be measured. Discussion: With close to half of patients experiencing at least a 1.0 g/dL hemoglobin increase, there can be benefit to treating thalassemia minor or trait patients with erythropoietin preoperatively. Multiple doses may be required to achieve this effect; therefore treatment should start early in the preoperative phase. This analysis is preliminary and warrants further study to determine the effectiveness of erythropoietin with these patients.

62 45. Do Patients with Thalassemia Minor or Trait Benefit from Blood Conservation Methods Preoperatively Before Undergoing High Blood Loss Surgery?

Author Names: Jadunandan, Saudia., RN, Med; Iacovelli, Mark., MN, RN; Lin, Yulia., MD

Authors Institution: Sunnybrook Health Sciences Centre

Thalassemias are inherited blood disorders in which the body makes an abnormal form of hemoglobin. This disorder can be challenging in preoperative patient blood management when patients present with chronic anemia. Anemic patients are known to be at increased risk of transfusion with increased perioperative morbidity, mortality and hospital length of stay. The purpose of this analysis was to analyze the effectiveness of preoperative erythropoietin in this patient population. Methods: A single institution retrospective analysis of patients referred to the Blood Conservation Clinic from January 2009 to March 2018. Inclusion criteria included: preoperative assessment for an elective procedure; recent CBC showing anemia; evidence of thalassemia minor or trait (by hemoglobin electrophoresis, Hb H inclusion bodies, or a documented medical history of thalassemia minor or trait); treatment with subcutaneous erythropoietin; and a post- treatment CBC. Erythropoietin was either given alone or in conjunction with intravenous iron (iron sucrose) if iron deficiency was present. In most cases, erythropoietin was administered at a dose of 40,000 units weekly targeting a hemoglobin of 12–13 g/dL preoperatively. Results: 45 patients met the inclusion criteria: 37 women and 8 men with a median age of 66 years (IQR 61–76). The majority (68.9%) were preoperative for orthopedic surgery followed by cardiac (17.8%) and other surgeries (13.3%) including gynecology and general surgery. The median pre-treatment hemoglobin was 10.6 g/dL (IQR 97–112). Patients received an average of 2.6 doses each with a mean hemoglobin increase of 0.98 g/dL. Treatment was commenced a median of 18 days (IQR 14–22) prior to the post-treatment measurement and improved hemoglobin by at least 10 g/L in 22 patients (48.9%). Seven patients (15.6%) had no change or a decrease following treatment. The median increase in hemoglobin with 1, 2, 3 and 4 doses was 0.6 g/dL (IQR 0.4–0.9), 0.55 g/dL (0.18–1.13), 1.0 g/dL (0.4–1.65) and 2.25 g/ dL (1.63–2.58) respectively. Limitations: Beta and alpha thalassemia trait were not differentiated for those who had a documented evidence of thalassemia; therefore the effects of treatment on each type of thalassemia could not be measured. Discussion: With close to half of patients experiencing at least a 1.0 g/dL hemoglobin increase, there can be benefit to treating thalassemia minor or trait patients with erythropoietin preoperatively. Multiple doses may be required to achieve this effect; therefore treatment should start early in the preoperative phase. This analysis is preliminary and warrants further study to determine the effectiveness of erythropoietin with these patients.

63 46. Tranexamic Acid Inhibits Plasminogen in Adolescent Scoliosis Surgery: A New Approach to Defining Efficacy and Antifibriolytic Action

Author: Dr. Susan Goobie

Author Institution: Boston Childrens’ Hospital, Harvard Medical School

Introduction: Tranexamic acid (TXA), a potent antifibrinolytic, is a competitive inhibitor of plasminogen and the conversion of plasminogen to plasmin. This randomized trial previously reported that (TXA) decreases blood loss in Adolescent Idiopathic Scoliosis Surgery (AIS) by 27% compared to placebo (primary aim)1. Evidence of this biological mechanism of action has not been reported in-vivo. Therefore secondary aim; to define efficacy of TXA in a direct manner using markers of fibrinolysis, is reported here. We define the efficacy of TXA in a direct manner by obtaining these markers of fibrinolysis (as bleeding and blood loss are difficult to measure accurately and are an indirect measure of efficacy; plasminogen, plasmin-antiplasmin complex (PAPC), plasminogen activator inhibitor (PAI-1), tissue plasminogen activator(tPA) and alpha2- antiplasmin (alpha2 AP). Methods: This IRB approved prospective double-blind placebo controlled randomized trial of TXA (50 mg/kg loading dose and 10 mg/kg/h infusion) in 68 successive (of the 119 patients enrolled) AIS patients (clincaltrials.gov NCT01813058). Plasma was analyzed for plasminogen (using sandwich ELISA) and other predetermined presumed markers of fibrinolysis preoperatively and postoperatively. Results: Demographics and variables did not differ in TXA cohort (n=34) compared to placebo controls (n=34). There was no difference in laboratory values between groups (PT, PTT, INR, Fibrinogen). A difference in the change in plasminogen levels is reported where TXA shows a reduction and placebo an increase (p < 0.001), Table. No other group differences were observed, except an increase in the change in mean PAPC with TXA compared to placebo (p = 0.03). Conclusion: The biological mechanism of TXA is to inhibit plasminogen and to inhibit the conversion of plasminogen to plasmin (competitive inhibitor) at therapeutic levels. We report in AIS that plasminogen levels in the TXA group decreased over time while in the placebo group plasminogen increased over time indicating inhibition of the fibrinolytic cascade by tranexamic acid during scoliosis surgery. This is the first report of the in-vivo biological mechanism of action of TXA; a competitive inhibitor of plasminogen. Plasminogen may be used as a biological marker of the antifibrinolytic effects of TXA in future investigations. Reference: Tranexamic Acid is Efficacious at Decreasing the Rate of Blood Loss in Adolescent Scoliosis Surgery: A Randomized Placebo Controlled Trial. JBJS. In print. *This work was supported by a Research grant from the Scoliosis Research Society and was awarded the 2017 HIBBS Clinical Research award.

64 46. Tranexamic Acid Inhibits Plasminogen in Adolescent Scoliosis Surgery: A New Approach to Defining Efficacy and Antifibriolytic Action

Author: Dr. Susan Goobie

Author Institution: Boston Childrens’ Hospital, Harvard Medical School

65 47. Comparison of the Efficacy and Pharmacokinetics of Two Tranexamic Acid Dosage Comparison of Dosage Schemes Regimes for Craniosynostosis Surgery. A multicenter double-blind RCT study. P Low Dosage Scheme (n=34) High Dosage Scheme (n=32) Value Age (months) 8.5 (5–16) 8 (4–13.5) 0.442 1 1 2 3 Authors: Dr. Susan Goobie , Mr. Steven Staffa , Dr. John Meara , Dr. Mark Proctor , Weight (kg) 8.3 (7.1–10.6) 8.5 (6.5–9.7) 0.496 Dr. Nicola Disma4/5 Gender 0.843 Male 21 (62%) 19 (59%) Institutions: 1Department of Anesthesia. Boston Children’s Hospital; 2Department of Plastic Female 13 (38%) 13 (41%) Surgery, Boston Children’s Hospital; 3Department of Neurosurgery, Boston Children’s ASA physical status 0.892 Hospital; 4Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy; 5Department of I 13 (38%) 11 (34%) II 15 (44%) 16 (50%) Anesthesia, Great Ormond Street Hospital, London, UK III 6 (18%) 5 (16%) Presence of craniosynostosis syndrome 7 (21%) 7 (22%) 0.898 Introduction: Tranexamic acid (TXA) in a dose of 50 mg/kg loading dose followed by 5 mg/ Duration of surgery (min) 144 (108–190) 170 (125–199) 0.253 kg/h infusion significantly reduced blood loss in pediatric open craniosynostosis surgery as Preoperative hematocrit (%) 35.8 ± 3.7 34.9 ± 2.1 0.239 well as the overall exposure of children to donor PRBC, compared with placebo1. TXA plasma Preoperative hemoglobin (%) 12.1 ± 1.2 14.3 ± 14.2 0.368 concentrations with this high dosing regimen were shown to exceed the accepted therapeu- Preoperative platelets (103 cells/µl) 382 ± 149.3 375.2 ± 99.4 0.833 tic level by over 10 fold. From pharmacokinetic modeling, we predict that reducing the load- Calculated blood loss (ml/kg) 32.1 (26.8–48.1) 32.4 (22.1–42.9) 0.538 ing dose to 10 mg/kg is adequate to maintain plasma concentrations above the presumed 24 hour blood loss in drain (ml/kg) 17.4 (12.9–20) 14.3 (8.7–19.7) 0.423 accepted therapeutic level of 20 mcg/mL2. This may be safer in terms of side effect profile. PRBC transfused (ml/kg) 19.6 (14.8–26.8) 22.5 (17.7–29.5) 0.154 The hypothesis of this study is to validate our TXA pharmacokinetic model and determine if the Total blood products transfused (ml/kg) 19.7 (16.1–26.9) 22.5 (17.7–30.6) 0.202 Length of stay (days) lower dosage scheme is as effective as the higher dosage scheme in decreasing blood loss ICU 1.9 (0.9–3.1) 1.4 (1–4.8) 0.928 and transfusion requirements in pediatric craniosynostosis surgery. In hospital 8 (4–13) 10 (5–15) 0.205 Total crystalloid (ml/kg) 41.2 (28.5–49.5) 42.7 (31.7–52.8) 0.254 Methods: With IRB (BCH IRB-P00008434) and Ethic (2013-001056-35) approval, we planned Total 5% albumin (ml/kg) 11.7 (9.1–19.7) 15.4 (10–27.6) 0.148 a multicenter, prospective, double-blind equivalence randomized controlled trial to compare Use of cryoprecipitate 1 (3%) 2 (6%) 0.608 high TXA dose (50mg/kg/15min and 5 mg/kg/h) vs a low TXA dose (10 mg/kg/15min and 5 Cryoprecipitate (ml/kg) 0.09 ± 0.56 0.64 ± 3.1 0.319 mg/kg/h) regime. Standardized anesthetic, fluid, blood and blood product management proto- Use of FFP 2 (6%) 1 (3%) 0.591 cols were followed. TXA analysis was performed using liquid chromatography with mass spec- FFP (ml/kg) 0.70 ± 2.9 0.87 ± 4.91 0.859 trometry detection (LC/MS) and utilizing 4 different non-linear sampling schemes randomly Use of platelets 0 (0%) 0 (0%) - assigned. The two participating hospitals were: Boston Children’s Hospital, Boston USA, and The Low Dosage Scheme consists of 10 mg/kg loading dose and 5 mg/kg/h. The High Dosage Scheme consists of 50 mg/kg and 5 mg/kg/h. Values are mean ± standard deviation or median (interquartile range) for continuous variables and frequency (%) for continuous variables. Istituto Gaslini, Genoa, Italy. ClinicalTrials.gov identifier: NCT02188576. Continuous variables were compared between the groups using Student’s t-test or the nonparametric Mann-Whitney U test depending on skewness as appropriate. Categorical variables were compared using the Chi-square test or Fisher’s exact test. Results: 68 children, 3 months to 2 years scheduled for open craniosynostosis surgery were ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott included. Demographics were comparable between groups (Table). There was no significant dif- Williams & Wilkins ference in blood loss (32.1 vs 32.4 mL/kg) or blood product transfusion (PRBC 19.6 vs 22.5 mL/kg) between the high and low dose groups respectively. TXA plasma levels at steady state averaged 50 mcg/mL in the high dose group vs 25 mcg/mL the low dose group; both above the presumed therapeutic threshold. Blood loss and blood product transfusion were also less than our previous study by two fold1. No adverse events such as seizures or thromboembolic events were observed in either group. Conclusions: A low dose regimen of TXA is as effective in reducing blood loss and transfusion requirements in pediatric craniosynostosis reconstruction surgery.

REFERENCES: 1. Anesth 2011; 114:862–71. 2. Clin Pharmacokinet 2013; 52:267–276.

66 47. Comparison of the Efficacy and Pharmacokinetics of Two Tranexamic Acid Dosage Comparison of Dosage Schemes Regimes for Craniosynostosis Surgery. A multicenter double-blind RCT study. P Low Dosage Scheme (n=34) High Dosage Scheme (n=32) Value Age (months) 8.5 (5–16) 8 (4–13.5) 0.442 1 1 2 3 Authors: Dr. Susan Goobie , Mr. Steven Staffa , Dr. John Meara , Dr. Mark Proctor , Weight (kg) 8.3 (7.1–10.6) 8.5 (6.5–9.7) 0.496 Dr. Nicola Disma4/5 Gender 0.843 Male 21 (62%) 19 (59%) Institutions: 1Department of Anesthesia. Boston Children’s Hospital; 2Department of Plastic Female 13 (38%) 13 (41%) Surgery, Boston Children’s Hospital; 3Department of Neurosurgery, Boston Children’s ASA physical status 0.892 Hospital; 4Department of Anesthesia, Istituto Giannina Gaslini, Genoa, Italy; 5Department of I 13 (38%) 11 (34%) II 15 (44%) 16 (50%) Anesthesia, Great Ormond Street Hospital, London, UK III 6 (18%) 5 (16%) Presence of craniosynostosis syndrome 7 (21%) 7 (22%) 0.898 Introduction: Tranexamic acid (TXA) in a dose of 50 mg/kg loading dose followed by 5 mg/ Duration of surgery (min) 144 (108–190) 170 (125–199) 0.253 kg/h infusion significantly reduced blood loss in pediatric open craniosynostosis surgery as Preoperative hematocrit (%) 35.8 ± 3.7 34.9 ± 2.1 0.239 well as the overall exposure of children to donor PRBC, compared with placebo1. TXA plasma Preoperative hemoglobin (%) 12.1 ± 1.2 14.3 ± 14.2 0.368 concentrations with this high dosing regimen were shown to exceed the accepted therapeu- Preoperative platelets (103 cells/µl) 382 ± 149.3 375.2 ± 99.4 0.833 tic level by over 10 fold. From pharmacokinetic modeling, we predict that reducing the load- Calculated blood loss (ml/kg) 32.1 (26.8–48.1) 32.4 (22.1–42.9) 0.538 ing dose to 10 mg/kg is adequate to maintain plasma concentrations above the presumed 24 hour blood loss in drain (ml/kg) 17.4 (12.9–20) 14.3 (8.7–19.7) 0.423 accepted therapeutic level of 20 mcg/mL2. This may be safer in terms of side effect profile. PRBC transfused (ml/kg) 19.6 (14.8–26.8) 22.5 (17.7–29.5) 0.154 The hypothesis of this study is to validate our TXA pharmacokinetic model and determine if the Total blood products transfused (ml/kg) 19.7 (16.1–26.9) 22.5 (17.7–30.6) 0.202 Length of stay (days) lower dosage scheme is as effective as the higher dosage scheme in decreasing blood loss ICU 1.9 (0.9–3.1) 1.4 (1–4.8) 0.928 and transfusion requirements in pediatric craniosynostosis surgery. In hospital 8 (4–13) 10 (5–15) 0.205 Total crystalloid (ml/kg) 41.2 (28.5–49.5) 42.7 (31.7–52.8) 0.254 Methods: With IRB (BCH IRB-P00008434) and Ethic (2013-001056-35) approval, we planned Total 5% albumin (ml/kg) 11.7 (9.1–19.7) 15.4 (10–27.6) 0.148 a multicenter, prospective, double-blind equivalence randomized controlled trial to compare Use of cryoprecipitate 1 (3%) 2 (6%) 0.608 high TXA dose (50mg/kg/15min and 5 mg/kg/h) vs a low TXA dose (10 mg/kg/15min and 5 Cryoprecipitate (ml/kg) 0.09 ± 0.56 0.64 ± 3.1 0.319 mg/kg/h) regime. Standardized anesthetic, fluid, blood and blood product management proto- Use of FFP 2 (6%) 1 (3%) 0.591 cols were followed. TXA analysis was performed using liquid chromatography with mass spec- FFP (ml/kg) 0.70 ± 2.9 0.87 ± 4.91 0.859 trometry detection (LC/MS) and utilizing 4 different non-linear sampling schemes randomly Use of platelets 0 (0%) 0 (0%) - assigned. The two participating hospitals were: Boston Children’s Hospital, Boston USA, and The Low Dosage Scheme consists of 10 mg/kg loading dose and 5 mg/kg/h. The High Dosage Scheme consists of 50 mg/kg and 5 mg/kg/h. Values are mean ± standard deviation or median (interquartile range) for continuous variables and frequency (%) for continuous variables. Istituto Gaslini, Genoa, Italy. ClinicalTrials.gov identifier: NCT02188576. Continuous variables were compared between the groups using Student’s t-test or the nonparametric Mann-Whitney U test depending on skewness as appropriate. Categorical variables were compared using the Chi-square test or Fisher’s exact test. Results: 68 children, 3 months to 2 years scheduled for open craniosynostosis surgery were ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott included. Demographics were comparable between groups (Table). There was no significant dif- Williams & Wilkins ference in blood loss (32.1 vs 32.4 mL/kg) or blood product transfusion (PRBC 19.6 vs 22.5 mL/kg) between the high and low dose groups respectively. TXA plasma levels at steady state averaged 50 mcg/mL in the high dose group vs 25 mcg/mL the low dose group; both above the presumed therapeutic threshold. Blood loss and blood product transfusion were also less than our previous study by two fold1. No adverse events such as seizures or thromboembolic events were observed in either group. Conclusions: A low dose regimen of TXA is as effective in reducing blood loss and transfusion requirements in pediatric craniosynostosis reconstruction surgery.

REFERENCES: 1. Anesth 2011; 114:862–71. 2. Clin Pharmacokinet 2013; 52:267–276.

67 48. Saving Lives: Applying Patient Blood Management to Patients with High Risk for 49. Impact of Treatment of Pre-operative Anemia on Patient Perception of Care Postpartum Hemorrhage Authors: Sherri Ozawa, RNa; Tiina O’Connella Authors: Dr. Ileana Lopez-Plaza, Ms. Patricia Klassa, Ms. Roberta Mooney, Ms. Amanda Poxon Authors Institution: aDepartment of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, 350 Engle Street, Englewood, NJ Authors Institution: Henry Ford West Bloomfield Hospital Objectives: This project will use a survey tool to determine patients’ understanding and per- Background: Although the incidence of obstetrical hemorrhage is on the rise nationally, scientific ception of pre-operative anemia detection and management and its impact on their overall evidence shows that the majority of maternal deaths associated with postpartum hemorrhage patient experience. (PPH) are preventable. In 2010, after a maternal death due to PPH, our institution developed a collaborative team approach to treat obstetrical hemorrhage including the development/utiliza- Background: Algorithms for the detection and management of pre-surgical anemia in patients’ tion of a massive transfusion protocol. Our initiatives also lead to more proactive interventions undergoing elective or semi-elective surgery have been published and include recommended including identifying patients at high risk for bleeding prenatally (i.e. placental implantation screening for hemoglobin levels, with subsequent iron studies at least three to four weeks problems) and offering balloon occlusion and embolization by Interventional Radiology during before surgery. (Goodnough, 2011) The prevalence of preoperative anemia in patients under- birth. Other proactive measures included completing a risk assessment for obstetrical hemor- going joint arthroplasty has been reported as 26% and ranges from 22% - 30% (Karkouti, rhage upon admission to LDRP, liberal use of uterotonics, use of uterine tamponade balloon 2008). However, often practitioners are concerned that pre-operative management will nega- or B-Lynch procedure if needed and use of cell salvage technology. After implementation, we tively affect patients’ perception of care and, will be viewed as an inconvenience or that could discovered fewer blood products were necessary to rescue patients and morbidity/mortality potentially cause delays in scheduling surgery. related to obstetrical hemorrhage decreased overall. The purpose of this study is to determine the impact of the detection and management of pre- Study design: Obstetric hemorrhage care protocol: The protocol is applied to all patients birth- operative anemia on patients’ perception of care and overall experience. Patient experience ing at this community hospital at the time of presentation to the hospital for delivery or if bleed- and perception of the quality of care is becoming an increasingly important driver in clinical ing is observed during the intrapartum or postpartum period. Data acquisition and analysis: settings. Survey tools, such as ones used by the Centers for Medicare and Medicaid Services, Beginning with the implementation of the electronic medical record (EMR), the medical records help to determine patients’ overall perception of quality, outcome and experience. The survey of patients were reviewed for: maternal age, gravida/para status, gestational age, bleeding risk tool in this study is comprised of fourteen questions which evaluate patients’ understand- ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott category assigned at time of delivery, delivery type (vaginal versus Cesarean section), medica- ing of their condition and their perception of the impact that treatment has on their overall Williams & Wilkins tions utilized, procedural intervention and transfusions. Analysis was conducted comparing the experience. first 6 months of data, beginning with the start of EMR (November 2014) to April 2016 and Setting of the Research: The survey will be implemented at a not-for-profit community/aca- expressed in percentage of deliveries. demic medical center that is licensed for a 351 bed count (EHMC). Results: A total of 1930 women were delivered in this program during the study period since Study Design implementation of the massive transfusion protocol, EMR and the proactive approach in the identification of obstetrical patients with bleeding risks. The attached table shows the results a) Recruitment Methods: Lists provided by the hospital’s outpatient infusion center of patients as described under study design. who underwent elective partial/total hip or knee arthroplasty and underwent pre-operative anemia management were collected. Conclusion: By applying a patient blood management concept, the risks associated with obstet- b) Inclusion Criteria: Patients must be over the age of 18; must be able to understand English, rical bleeding were reduced including the need for blood transfusions, admissions to ICU for and have medical decision-making capacity. patients with PPH with 100% successful maternal/infant outcomes. c) Number of Subjects: Approximately 20 patients from Englewood Hospital and Medical Center were enrolled. d) Study Timelines: The duration of the study was 2 months e) Procedures: Patients meeting inclusion criteria received a phone survey from a member of the Patient Blood Management (PBM) Program Staff Conclusion: Patients’ perception of their preoperative clinical care is enhanced by anemia detection and management. They do not perceive it as a negative impact on their overall experience.

68 49. Impact of Treatment of Pre-operative Anemia on Patient Perception of Care

Authors: Sherri Ozawa, RNa; Tiina O’Connella

Authors Institution: aDepartment of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, 350 Engle Street, Englewood, NJ

Objectives: This project will use a survey tool to determine patients’ understanding and perception of pre-operative anemia detection and management and its impact on their overall patient experience. Background: Algorithms for the detection and management of pre-surgical anemia in patients’ undergoing elective or semi-elective surgery have been published and include recommended screening for hemoglobin levels, with subsequent iron studies at least three to four weeks before surgery. (Goodnough, 2011) The prevalence of preoperative anemia in patients undergoing joint arthroplasty has been reported as 26% and ranges from 22% - 30% (Karkouti, 2008). However, often practitioners are concerned that pre-operative management will negatively affect patients’ perception of care and, will be viewed as an inconvenience or that could potentially cause delays in scheduling surgery. The purpose of this study is to determine the impact of the detection and management of preoperative anemia on patients’ perception of care and overall experience. Patient experience and perception of the quality of care is becoming an increasingly important driver in clinical settings. Survey tools, such as ones used by the Centers for Medicare and Medicaid Services, help to determine patients’ overall perception of quality, outcome and experience. The survey tool in this study is comprised of fourteen questions which evaluate patients’ understanding of their condition and their perception of the impact that treatment has on their overall experience. Setting of the Research: The survey will be implemented at a not-for-profit community/academic medical center that is licensed for a 351 bed count (EHMC). Study Design a) Recruitment Methods: Lists provided by the hospital’s outpatient infusion center of patients who underwent elective partial/total hip or knee arthroplasty and underwent pre-operative anemia management were collected. b) Inclusion Criteria: Patients must be over the age of 18; must be able to understand English, and have medical decision-making capacity. c) Number of Subjects: Approximately 20 patients from Englewood Hospital and Medical Center were enrolled. d) Study Timelines: The duration of the study was 2 months e) Procedures: Patients meeting inclusion criteria received a phone survey from a member of the Patient Blood Management (PBM) Program Staff Conclusion: Patients’ perception of their preoperative clinical care is enhanced by anemia detection and management. They do not perceive it as a negative impact on their overall experience.

69 REFERENCES 50. Massive Transfusion Support for Gastrointestinal Bleeding: A Single-Center, E. Saleh, D.B.L. McClelland, A. Hay, D. Semple, T.S. Walsh. (2007). Prevalence of anaemia Intensive Care Unit Assessment. before major joint arthroplasty and the potential impact of preoperative investigation and correction on perioperative blood transfusions. BJA: British Journal of Anaesthesia. Volume Authors: Victor Vakayil, MBBS, MS1,2; Susan Barnett, MLS2; Kayla Hansen, MLS2; 99, Issue 6, Pages 801–808. https://doi.org/10.1093/ bja/aem299 Snider Desir, Ph.D.1; Julie Welbig, MLS4; Nicole Zantek, MD, Ph.D.5; James Harmon MD, Ph.D1 K. Karkouti, D. Wijeysundera and W. Beattie for the Reducing Bleeding in Cardiac Surgery (RBC) Investigators. (2008) Risk Associated With Preoperative Anemia in Cardiac Surgery. Authors Institutions: 1University of Minnesota, Department of Surgery; 2University of Circulation. 117:478–484. https:// doi.org/10.1161/CIRCULATIONAHA.107.718353 Minnesota, School of Public Health; 3Fairview Health Services, Minnesota; 4University of Peters F, Ellerman I, Steinbicker AU. (2018). Intravenous Iron for Treatment of Anemia in Minnesota, Department of Laboratory Medicine and Pathology the 3 Perisurgical Phases: A Review and Analysis of the Current Literature. Anesthesia & Analgesia.126 (4):1268–1282.DOI: 10.1213/ANE.0000000000002591 Background: Blood transfusion (BT) support required for patients with gastrointestinal (GI) L.T. Goodnough, A. Maniatis, P. Earnshaw, G. Benoni, E. Bisbe, D.A. Fergussion, H. Gombotz, bleeding is currently under review. These patients appear to be a unique subset of all patients O. Habler, T.G. Monk, Y. Ozier, R. Slappendel, M. Szpalski.(2011).Detection, evaluation, and requiring Massive Transfusion Protocol (MTP) activation. management of preoperative anaemia in the elective orthopedic surgical patient: NATA guidelines. BJA: British Journal of Anaesthesia, Volume 106.Issue 1.Pages 13–22.https://doi. Methods: We performed a two year, single-center, retrospective analysis of all non-trauma org/10.1093/bja/aeq361 activations of the MTP in our Intensive Care Unit (ICU). We compared the blood utilization for M. Hung, M. Besser, L.D. Sharples, S.K. Nair, A.A. Klein. (2011). The prevalence and associa- patients with GI bleeding to those who had other non-trauma sources of massive hemorrhage. tion with transfusion, intensive care unit stay and mortality of pre-operative anaemia in a We evaluated the demographics, ICU parameters, laboratory values, BT activity and 30-day cohort of cardiac surgery patients. Anaesthesia. Volume 66, Issue 9, Pages 812–818.https:// patient outcomes in both cohorts. doi.org/10.1111/j.1365-2044.2011.06819.x Results: A total of 72 MTP activations were evaluated in 2013 and 2015; 33.3% (N= 24) were for patients with GI bleeding. Patients with GI bleeds had an average age of 56.0 ± 14.5 years. 33% (N = 8) were female with a median duration of 184 minutes of activation. The 30-day mortality for patients with GI bleed was 41.7% (N= 10), 60-day mortality was 50% (N= 12). The lowest hemoglobin for patients with GI bleeding was 6.4 ±1.9 g/dL. Patients with GI bleed received a median of 8 (IQR 5, 16) units of red blood cells, 8.5 (IQR 3.3, 15.8) units of plasma, 3 (IQR 1, 7.5) units of apheresis platelets. These averages were compared to patients with non-GI bleeding in our ICU (Table 1). Conclusion: Patients with massive GI bleeding have been proven to benefit from conservative transfusion practices. The threshold for transfusion was significantly lower for patients with GI bleeding compared to those with non-GI bleeding. The number of blood components transfused, 30 and 60-day mortality were not statistically different between both groups. We continue to be interested in blood conservation strategies using thromboelastography based guidelines and the implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta protocol (REBOA) for patients with massive GI bleeding. Table 1. Variable Non-GI Bleeding GI Bleeding P- Value Age (years) 51.8 ± 18.4 56.0 ± 14.4 0.330 BMI (kg/m2) 28.1 ± 7.2 29.9 ± 8.1 0.327 Lowest Hemoglobin (gm/dl) 8.1 ± 2.4 6.4 ± 1.9 0.002 Packed Red Blood Cells (units) 8 (4.2, 11.7) 8 (5, 16) 0.293 Plasma (units) 5 (2, 9.7) 8.5 (3.2, 15.7) 0.121 Apheresis Platelets (units) 2.5 (1, 6) 3 (1, 7.5) 0.376 60-Day Mortality 62.5% (N=30) 50% (N=12) 0.504

70 50. Massive Transfusion Support for Gastrointestinal Bleeding: A Single-Center, Intensive Care Unit Assessment.

Authors: Victor Vakayil, MBBS, MS1,2; Susan Barnett, MLS2; Kayla Hansen, MLS2; Snider Desir, Ph.D.1; Julie Welbig, MLS4; Nicole Zantek, MD, Ph.D.5; James Harmon MD, Ph.D1

Authors Institutions: 1University of Minnesota, Department of Surgery; 2University of Minnesota, School of Public Health; 3Fairview Health Services, Minnesota; 4University of Minnesota, Department of Laboratory Medicine and Pathology

Background: Blood transfusion (BT) support required for patients with gastrointestinal (GI) bleeding is currently under review. These patients appear to be a unique subset of all patients requiring Massive Transfusion Protocol (MTP) activation. Methods: We performed a two year, single-center, retrospective analysis of all non-trauma activations of the MTP in our Intensive Care Unit (ICU). We compared the blood utilization for patients with GI bleeding to those who had other non-trauma sources of massive hemorrhage. We evaluated the demographics, ICU parameters, laboratory values, BT activity and 30-day patient outcomes in both cohorts. Results: A total of 72 MTP activations were evaluated in 2013 and 2015; 33.3% (N= 24) were for patients with GI bleeding. Patients with GI bleeds had an average age of 56.0 ± 14.5 years. 33% (N = 8) were female with a median duration of 184 minutes of activation. The 30-day mortality for patients with GI bleed was 41.7% (N= 10), 60-day mortality was 50% (N= 12). The lowest hemoglobin for patients with GI bleeding was 6.4 ±1.9 g/dL. Patients with GI bleed received a median of 8 (IQR 5, 16) units of red blood cells, 8.5 (IQR 3.3, 15.8) units of plasma, 3 (IQR 1, 7.5) units of apheresis platelets. These averages were compared to patients with non-GI bleeding in our ICU (Table 1). Conclusion: Patients with massive GI bleeding have been proven to benefit from conservative transfusion practices. The threshold for transfusion was significantly lower for patients with GI bleeding compared to those with non-GI bleeding. The number of blood components transfused, 30 and 60-day mortality were not statistically different between both groups. We continue to be interested in blood conservation strategies using thromboelastography based guidelines and the implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta protocol (REBOA) for patients with massive GI bleeding. Table 1. Variable Non-GI Bleeding GI Bleeding P- Value Age (years) 51.8 ± 18.4 56.0 ± 14.4 0.330 BMI (kg/m2) 28.1 ± 7.2 29.9 ± 8.1 0.327 Lowest Hemoglobin (gm/dl) 8.1 ± 2.4 6.4 ± 1.9 0.002 Packed Red Blood Cells (units) 8 (4.2, 11.7) 8 (5, 16) 0.293 Plasma (units) 5 (2, 9.7) 8.5 (3.2, 15.7) 0.121 Apheresis Platelets (units) 2.5 (1, 6) 3 (1, 7.5) 0.376 60-Day Mortality 62.5% (N=30) 50% (N=12) 0.504

71 51. Effects of RBC Usage After Implementation of CPOE-CDS and BPA Figures

Authors: Ann Marie Gordon, PA-C, MLS (ASCP); Nancy Dean, RN (BSN); Clarie Wang; Brandon Crook; Sarah Khorsand, MD; Ravi Sarode, MD

Authors Institutions: Department of Pathology, Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas

Introduction: Computerized physician order entry (CPOE) - clinical decision support (CDS), and best practice advisories (BPAs) can significantly reduce blood utilization. At UT Southwestern, in Dallas, Texas, we implemented CPOE-CDS and BPAs for hospital use and noticed a significant impact on hospital-wide blood utilization without the implementation of an additional con- tinuation in educational practices. This shows that enacting this single component of Patient Blood Management practices can make noticeable differences in physician’s practices. Methods: BPAs were implemented for blood orders placed with a preceding hemoglobin of 7.0 – 8.0 g/dL on all patients with an inclusive diagnosis. This would alert the ordering provider to a message suggesting that transfusing at this time is outside of guidelines. Active URLs to literature were also provided supporting this evidence. Other modifications included removing blood orders from preference lists and excluding the frequency of products ordered. Both of these modifications limited multiple red blood cell (RBC) unit orders. Results: The positive effects of our CPOE changes were visualized hospital-wide. Figure 1 and Figure 2 shows two versus one packed-RBC unit orders hospital-wide before and after CPOE- CDS/BPA additions. The mean of two unit blood orders decreased from an average of 41.9 units to 25.9 units, and the mean of one unit blood orders increased from an average of 52.3 units to 68.4 units. Lastly, Figure 3 and Figure 4 shows an initial trending reduction in the number of packed-RBC units transfused per 1000 patient days and percent of patients transfused after implementing improvements with CPOE. Discussion: Determining the impact of CPOE and education, solely or in conjunction, has been a major focus in previous literature. However, at UT Southwestern, we have discovered that CPOE/BPA is a form of education that has proven to show significant impact on blood utilization, and this impact translates into changes in behaviors and blood practices on a level demonstrable in the reduction of blood usage.

72 Figures

73 52. Retrospective Evaluation of the Efficacy and Safety of 4-factor Prothrombin Complex 53. Salvage of Life-Threatening Acute Blood Loss Anemia in the Traumatic and Post-Operative Concentrate Compared to Fresh Frozen Plasma for Warfarin Reversal in Emergent Surgery Setting: A Case Series of Clinical Experiences with Hemopure (HBOC-201) Blood Substitute or Invasive Procedure Authors: Hahn Soe-Lin, MD, MS1; Mauricio Lynn, MD1 Authors: Dr. Hannah Mazur, Dr. Sarah Young, Dr. Molly McGraw Authors Institution: 1Jackson Memorial Hospital, University of Miami Miller School of Medicine Authors Institution: Allegheny General Hospital Hemoglobin based oxygen carriers (HBOC) have been broadly studied as alternative oxygen car- 00 Purpose: 4-factor prothrombin complex concentrate (4F-PCC) is approved for use in the United rying blood substitutes for the past three decades. More recently third generation HBOCs such States for urgent vitamin K antagonist (VKA) reversal for emergent surgery or invasive pro- as Hemopure (HBOC-201) have been used in Phase III clinical trials in elective orthopedic, non- cedure. The only available VKA in the United States is warfarin. Published literature includes cardiac elective, post cardiopulmonary bypass, and aortic aneurysm reconstruction surgery. The selected surgical and invasive procedures. There is a lack of efficacy and safety evidence following case series reports our single institutional experience with 7 critically ill patients enrolled comparing 4F-PCC to fresh frozen plasma (FFP) in a wide variety of surgical settings. This study in HBOC-201 therapy. All patients were Jehovah’s Witnesses who had symptomatic anemia with was completed at a level 1shock-trauma, comprehensive stroke center to evaluate efficacy and evidence of end organ ischemia and/or a cutoff Hgb of less than 5. Patients received full pro- safety of current prescribing practices of 4F-PCC and FFP for reversal of warfarin for emergent tocolized hematopoietic support including high dose iron and Procrit therapy. HBOC-201 transfu- surgery or invasive procedure. sion was used as a bridge for maintaining oxygen carrying capacity until surgical hemostasis was obtained and the patient’s intrinsic hematopoiesis replenished their native red blood cell volume. Methods: Medical records of patients presenting to Allegheny General Hospital who received Patients received between 3 and 7 total units of HBOC-201. Our seven patients had a median age 4F-PCC or FFP between January 1, 2016 and March 31, 2018 were reviewed for inclusion. of 73 and a variety of complex surgical problems including cardiac tamponade with arrest follow- Patients who did not undergo an emergent surgery or invasive procedure, were not on war- ing a coronary artery dissection during a percutaneous catheter revascularization with coronary farin, or were reversed for heart transplant were excluded. The primary outcome evaluated artery stent placement, decompensated cirrhosis following a laparoscopic cholecystectomy with efficacy of reversal between treatment groups, assessed by comparing quantity of blood prod- hematogeneous ascites, oropharyngeal bleeding in the setting of a prior maxillofacial squamous ucts required during the procedure. Procedural bleed risk was compared between groups. cell carcinoma resection with sinus involvement, a bleeding root-of-mesentery spindle cell tumor in Secondary outcomes included additional efficacy endpoints as well as safety and adherence the setting of Acute Lymphocytic Leukemia, post-operative massive hematuria following a prostatic to institutional 4F-PCC policy. Safety endpoints compared thromboembolic events and major enucleation, and 2 patients with traumatic falls with complex long-bone femur fractures requiring and minor bleeding. urgent operative fixation. Of the seven patients enrolled with life threatening anemia, four survived to Results: 79 patients were included for analysis (4F-PCC n=28; FFP n=51). Comparing blood discharge. Complications included hypertension, methemoglobinemia, troponemia, and one stroke products utilized in all patients, 4F-PCC used a median of 0mL [IQR:0-500mL] versus 0mL [IQR: with improving residual deficit. No fatal cardiac events were reported. One patient died of decom- ANEAAAnesthesia & AnalgesiaAnesth Analg0003-2999Lippincott pensated cirrhosis while two died from multisystem organ failure as a sequelae of their original Williams & Wilkins 0-0mL] for the FFP group (p=0.15). However, the majority of patients, 18 (64.3%) in the 4F-PCC and 40 (78.7%) in the FFP group, did not require additional products during the procedure hemorrhagic shock. No patients died as a direct result of complications of HBOC administration. (p=0.17). Following administration of reversal agent, an INR ≤ 1.5 was achieved in 19(67.9%) Enthusiasm for broader use in the critically ill trauma and emergency general surgery population of the 4F-PCC compared to only 23 (45.1%) in the FFP group (p=0.05). Thromboembolic events have been tempered by early concerns of increased morbidity and mortality. The following data using within seven days were seen in 2 (7.1%) 4F-PCC patients versus no FFP patients (p=0.05). a third generation HBOC provides evidence that HBOC-201 can be used in the acute traumatic and Non-adherence to institutional 4F-PCC policy occurred in 13 (46.6%) of patients. emergency surgery setting as a salvage strategy for tissue oxygenation in the face of life threatening acute blood loss anemia in those patients for whom allogeneic blood transfusion is not an option. Conclusion: Reversal with 4F-PCC did not utilize additional quantities of blood products, even when undergoing higher bleed risk procedures. 4F-PCC can be used to reverse for high bleed risk procedures, minimizing FFP use prior to procedure. Thromboembolic events occurred in 7.1% of patients in the 4F-PCC group, consistent with current literature, demonstrating risks associated with its use.

74 53. Salvage of Life-Threatening Acute Blood Loss Anemia in the Traumatic and Post-Operative Setting: A Case Series of Clinical Experiences with Hemopure (HBOC-201) Blood Substitute

Authors: Hahn Soe-Lin, MD, MS1; Mauricio Lynn, MD1

Authors Institution: 1Jackson Memorial Hospital, University of Miami Miller School of Medicine

Hemoglobin based oxygen carriers (HBOC) have been broadly studied as alternative oxygen car- 00 rying blood substitutes for the past three decades. More recently third generation HBOCs such as Hemopure (HBOC-201) have been used in Phase III clinical trials in elective orthopedic, non- cardiac elective, post cardiopulmonary bypass, and aortic aneurysm reconstruction surgery. The following case series reports our single institutional experience with 7 critically ill patients enrolled in HBOC-201 therapy. All patients were Jehovah’s Witnesses who had symptomatic anemia with evidence of end organ ischemia and/or a cutoff Hgb of less than 5. Patients received full pro- tocolized hematopoietic support including high dose iron and Procrit therapy. HBOC-201 transfusion was used as a bridge for maintaining oxygen carrying capacity until surgical hemostasis was obtained and the patient’s intrinsic hematopoiesis replenished their native red blood cell volume. Patients received between 3 and 7 total units of HBOC-201. Our seven patients had a median age of 73 and a variety of complex surgical problems including cardiac tamponade with arrest following a coronary artery dissection during a percutaneous catheter revascularization with coronary artery stent placement, decompensated cirrhosis following a laparoscopic cholecystectomy with hematogeneous ascites, oropharyngeal bleeding in the setting of a prior maxillofacial squamous cell carcinoma resection with sinus involvement, a bleeding root-of-mesentery spindle cell tumor in the setting of Acute Lymphocytic Leukemia, post-operative massive hematuria following a prostatic enucleation, and 2 patients with traumatic falls with complex long-bone femur fractures requiring urgent operative fixation. Of the seven patients enrolled with life threatening anemia, four survived to discharge. Complications included hypertension, methemoglobinemia, troponemia, and one stroke with improving residual deficit. No fatal cardiac events were reported. One patient died of decompensated cirrhosis while two died from multisystem organ failure as a sequelae of their original hemorrhagic shock. No patients died as a direct result of complications of HBOC administration. Enthusiasm for broader use in the critically ill trauma and emergency general surgery population have been tempered by early concerns of increased morbidity and mortality. The following data using a third generation HBOC provides evidence that HBOC-201 can be used in the acute traumatic and emergency surgery setting as a salvage strategy for tissue oxygenation in the face of life threatening acute blood loss anemia in those patients for whom allogeneic blood transfusion is not an option.

75 54. Bloodless Medicine: An Ecuadorian Experience with 73 patients

Authors: Evelyn Frías-Toral, MD, MRes; Guido Panchana Eguez MD; Mario Leone Pignataro MD; Cesar Chong Loor MD; Jorge Armijos Vélez MD; Olivia de La Torre Terranova MD; Julio Plaza Rubio MD; Alberto Sánchez Hilbron MD; Carlos García Cruz MD; Katty Posligua León MD; Luis Espin Custodio MD; Juan Tanca Campozano MD

Authors Institution: Sociedad de Lucha Contra el Cáncer (SOLCA) – Guayaquil – Ecuador

Introduction: Risks associated with allogenic blood transfusions (ABTs) are widely known and the growing number of patients who don’t accept ABTs have contributed to new treatment para- digms for bloodless medicine and surgery. So it is important to have alternative therapeutic strategies to the use of ABTs that are effective and practical to apply. The aim of this report is to describe the strategies applied to the patients from this report. Methods: This a retrospective study that provides a summary of strategies for bloodless care used in a private practice with patients who did not accept ABTs under any circumstance, between 2011 and 2017. The therapeutic strategy was based mainly in an early diagnose and aggressive treatment of the anemia and any type of active bleeding. Erythropoiesis-stimulating agents were used as well as iron, folate according to the patient needs. Embolization and normovolemic hemodilution were done in specific cases when the perioperative bleeding was expected to be more than 1000 ml. All the surgical patients received tranexamic acid (10mg/ kg/day) and with them were used other topical hemostatics. Results: A total of 73 patients were considered for this report. The mean age of the patients was 45 years and 38.3% were male. 69.8% of the pathologies treated were cancer and 68.5% were non-surgical patients, from this group 62% received chemotherapy. All the patients increased their hemoglobin levels. The mean initial hemoglobin levels were of 8.9 g/dL (1.8 - 13.7), 3.84 g/dL was the mean value of increased hemoglobin with an improvement that reached up to 12.6 g/dL (9.3 - 15.2). Ferric carboxymaltose was infused intravenously between 300 - 3000 mg per global treatment, the Erythropoietin was applied subcutaneously from 5,000 - 140,000 units per global treatment, folate (10 ucg) was used per day. Additionally, megadoses of Vitamin C were used with a mean of 24 grams per patient per treatment scheme. The expected hemoglobin levels were reached in an average of 25 days. Discussion: These results show that it is essential to initiate an early, preventive and coordinated treatment with a multidisciplinary team of professionals committed to provide the best alternatives to ABTs when these are the only options accepted by a specific group of anemic patients. The patients had a good response to the medicines and dosages received and no side effects were reported. Also we can see that these strategies are effective and feasible to apply.

76 Min Max Mean Age F (n: 45) 3 94 48.5 Age M (n: 28) 1 77 39 Type of Diseases Oncological Hb levels (n: 51) Cervical Cancer 8 12.6 5 Colon Cancer 8.9 13.6 7 Esophageal Cancer 6.9 14 1 Gastric Cancer 7.3 15.2 5 Breast Cancer 5.1 13.4 6 Oropharyngeal Cancer 9 14 3 Prostate Cancer 8.4 13 1 Rectal Cancer 7.2 13.2 3 Vulvar Cancer 7.2 12.4 1 Hematological Cancer 1.8 13.9 7 CNS Cancer 9.3 15 7 Melanoma 10.2 14 1 PNET 10 13 1 Seminoma 9.1 11.4 1 Bone Cancer 3.9 13.1 2 Non Oncological Hb levels (n: 22) Acute Anemia 9.6 13.6 4 Chronic Anemia 5 14.2 10 Esophageal Varices 8 13 1 Myomas 10 13.5 2 Chronic Kidney Failure 9.9 15 1 Osteomas 11.4 13.4 1 Pelvic Tumor 5.6 13 2 Ancylostomiasis 8.4 11.2 1 Type of Treatment Surgical 3.8 15.2 23 Non surgical 1.8 14.2 50 Bloodless Treatment Hemoconcentration 1.8 15 8.4 Iron IV 300 3000 1860 EPO SC 5000 140000 42397 Normovolemic Hemodilution 10.2 15 12.6 Blood Units extracted 1–2 Embolization 1 Hb baseline 1.8 13.7 8.9 Hb trans 4.7 15 11.1 Hb final 9.3 15.2 12.6 Length of Treatment (days) 9 45 25

77 55. Extended Reliability and Clinical Utility of a Validated Intraoperative Bleeding Scale (VIBe SCALE)

Authors: Drew S. Jones, MD, MPH, MBA;1 Qing Li, MD, PhD;1 Kevin M. Lewis, DVM;1 Donald Cheatem, MD, PhD;1 Aryeh Shander, MD, FCCM, FCCP, FASA2,3,4

Authors Institutions: 1Baxter Healthcare Corporation, Deerfield, IL, USA; 2Department of Anesthesiology, Critical Care and Hyperbaric Medicine, TeamHealth Research Institute, Englewood Hospital and Medical Center,; 3Clinical Professor of Anesthesiology, Medicine and Surgery, Icahn School of Medicine at Mount Sinai, Rutgers New Jersey Medical School; 4Institute for Bloodless Medicine and Patient Blood Management, Englewood Hospital & Medical Center, Englewood

Background: Patient blood management recommendations identify periodic, intraoperative communication between surgeons and anesthesiologists as an effective measure to proac- tively manage and effectively treat blood loss. To date such assessments are subjective estimates. A Validated Intraoperative Bleeding Scale (VIBe SCALE) has been developed for use in clinical studies to objectively assess bleeding severity (Table 1). Understanding how the VIBe SCALE is designed and applied, it may have broader applicability in surgical practice. We describe new data and analyses of this scale and explore the clinical utility of the scale for the anesthesia and operating room teams. Methods: The validation of the scale was conducted by having 102 surgeons across 11 specialties use the scale to grade bleeding in 15 videos via an online tool. Construct validation was evaluated according to United States Food and Drug Administration (FDA) criteria: ability to detect change, response range, clarity, relevance, usability, and reliability (repeatability and reproducibility). In addition, reliability over an extended test-retest period was conducted by having 30 surgeons across 5 surgical specialties use the scale to grade bleeding in 10 videos via the same online tool. Results: Participants could detect change in bleeding severity and gave appropriate responses across the full response range. Clarity, relevance and usability were confirmed, with ≥80% of participants agreeing, the scale used objective and non-overlapping terms; all participants confirmed the scale was very or mostly self-explanatory; and 99% of participants considered the scale clinically relevant for evaluating hemostasis. Repeatability and reproducibility of all participants were excellent with Kendall’s W values of 0.977 and 0.906, respectively. Over an average extended test-retest period of 370 days repeatability was excellent, with a Kendall’s W value of 0.934. Reproducibility was appreciable at both the test and retest, with Kendall’s W values of 0.884 and 0.876, respectively. Conclusion: The VIBe SCALE fulfills the FDA criteria for development of a clinician-reported scale and has demonstrated reliability over an extended test-retest period, indicating high clinical utility for the patient care team. The scale allows the surgeon to identify bleeding requiring treatment and clearly communicate the level of blood loss to the anesthesia team consistent with recommendations for patient blood management. The anesthesia team can then proac- tively take appropriate measures to prevent the foreseeable consequences of blood loss.

78 Table 1: Validated Intraoperative Bleeding Scale (VIBe SCALE). (Table reproduced with per- mission from Lewis KM, Li Q, Jones DS, et al. Development and validation of an intraoperative bleeding severity scale for use in clinical studies of hemostatic agents. Surgery. 2017;161(3):771–781. Full article available from http://www.sciencedirect.com/science/ article/pii/S0039606016306055)

Visually Estimated Qualitative Rate of Blood Grade Visual Presentation Anatomic Appearance Description Loss (mL/min) 0 No bleeding No bleeding No bleeding ≤1.0 1 Ooze or intermittent flow Capillary-like bleeding Mild >1.0–5.0 2 Continuous flow Venule and arteriolar-like bleeding Moderate >5.0–10.0 3 Controllable spurting and/or Noncentral venous- and arterial-like bleeding Severe >10.0–50.0 overwhelming flow 4 Unidentified or inaccessible spurting Central arterial- or venous-like bleeding Life threatening >50.0 or gush * Systemic resuscitation is required (e.g., volume expanders, vasopressors, blood products, etc.).