blood product usage pre- and post-implementation of ......patients to compare the differences in...

Metro North Hospital and Health Service

Blood Product Usage Pre- and Post-Implementation of ROTEM® Thromboelastometry

Dr Julie Lee, Dr Shaiyla Sivakumar and Dr Michelle Roets Department of Anaesthesia and Perioperative Services,

Royal Brisbane and Women’s Hospital

Rotational thromboelastometry (ROTEM®) is a point-of-care coagulation test recently implemented at the Royal Brisbane and Women’s Hospital (RBWH) in August 2014 as part of the blood management program incorporating massive transfusion protocol (MTP), intraoperative cell salvage (ICS) and ROTEM®.

MethodsRaw blood product usage data was obtained from the Blood Bank and coded into Diagnostic Related Groups (DRGs). This data was cross-correlated with Auslab data on blood products issued and ROTEM® tests, cell salvage records, Operating Room Management Information System (ORMIS) records and the Automated Anaesthesia Record Keeping (AARK) database.

Intraoperative blood product usage (packed red blood cells, pooled platelets, cryoprecipitate, fresh frozen plasma/extended life plasma (FFP/ELP)) was evaluated for a defined six-month period prior to the implementation of ROTEM® from August 2013 to January 2014 (2013/2014), and this was compared to the post-ROTEM® implementation period from August 2014 to January 2015 (2014/2015).

Results

DiscussionAlthough the uptake of this new test has been gradual, a change in practice in blood transfusion management is reflected particularly by the increase in cryoprecipitate use and the decrease in platelet administration. The increase in cryoprecipitate cost was related to both an increase in individual product cost and an increase in usage during the ROTEM® implementation period. This data is comparable to trends seen at other tertiary hospitals. This change in cryoprecipitate usage may provide an indication for the introduction of fibrinogen concentrate which would reduce blood bank labour costs, pathogen transmission, risk of transfusion related acute lung injury (TRALI) due to the lack of major antibodies, and also improve the availability of fibrinogen replacement therapy due to shorter preparation time and longer shelf-life.

A limitation of this analysis is the absence of parameters to measure a change in patient outcomes as a result of this new utility in blood management. The ICU length of stay (LOS) was 9.9 days for the trauma group of patients in 2014/2015, which had decreased from 12.6 days for 2013/2014. However, there are multiple confounding factors that determine a patient’s LOS in ICU.

Overall, this data shows the potential increased utility of ROTEM® in ICS, MTP and certain additional surgical specialties including colorectal surgery.

Acknowledgements: Natasha Kearey, Transfusion CNC and Clinical Multimedia, Royal Brisbane and Women’s Hospital CMM_150442_Lee_P2_ss

455 of the 14852 patients who presented for surgery (emergency and elective) during the two six-month periods required the transfusion of 2143 units of blood products. Emergency surgery was the predominant area for blood product use accounting for approximately 65% of intraoperative transfusions in both financial years.

While the number of patients requiring a transfusion remained very similar (222 in 2013/14 vs. 233 in 2014/15), the distribution of blood product use has changed. In the six-month period following the implementation of ROTEM®, red blood cell transfusion increased by 19.2%, fresh frozen plasma by 17.5%, cryoprecipitate by 124.7% and platelet transfusion was reduced by 29%. The number of units of cryoprecipitate increased from 150 to 337 (124.7%) and the number of patients transfused with cryoprecipitate increased from 15 to 28 (86.7%).

From 1st August 2014 until 31st January 2015, a total of 161 ROTEM® tests were processed for 107 patients, of which 42 were performed intra-operatively for 33 individual patients. During this period, 113 patients had intraoperative cell salvage (ICS) set up, of which 67 of these patients received cell salvage transfusions and only seven of these patients had a ROTEM® test processed, of which six had cell salvage blood transfused.

Of these seven patients, four were for elective open abdominal aortic aneurysms (AAA), one for an emergency open AAA, one for a Whipple’s procedure and one for an open hepatectomy. During the post-ROTEM® period, 43 massive transfusion protocols (MTP) were triggered hospital-wide with 35 ROTEM® tests being performed on 16 of these patients. Fourteen of these MTPs were triggered intraoperatively, of which five patients had ROTEM® tests performed intraoperatively.

Sub-analyses were performed on various surgical categories where ROTEM® had been used on at least three patients to compare the differences in blood product usage pre- and post- ROTEM®. Usage was compared in major vascular procedures, caesarean sections, rectal resections and multi-trauma patients requiring neurosurgery. Although there were slight variations between the number of patients requiring transfusions in each group (11 +/- 4), the results do show a significant increase in the use of cryoprecipitate post-ROTEM®. Plasma and platelet use appear to be similar, whilst red blood cell use was variable pre- and post-ROTEM®.

Introduction

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Red Blood Cells Platelets Cryoprecipitate Plasma

Blood Product Use in Neurosurgical Procedures for Multiple Trauma

Pre-Rotem 2013/14 (n=7) Rotem 2014/15 (n=11)

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Blood Product Use in Caesarean Sections with Severe Bleeding


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Blood Product Use in Colorectal Resections


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Blood Product Use in Major Reconstructive Vascular Procedures


PRBCs 62%

FFP/ELP 13%

Cryo 17%

Platelets 8%

Emergency Surgery 2013/2014

PRBCs

FFP/ELP

Cryo

Platelets

PRBCs 55% FFP/ELP

17%

Cryo 25%

Platelets 3%

Elective Surgery 2014/2015

PRBCs

FFP/ELP

Cryo

PlateletsPRBCs 80%

FFP/ELP 8%

Cryo 6%

Platelets 6%

Elective Surgery 2013/2014

PRBCs

FFP/ELP

Cryo

PlateletsPRBCs 62%

FFP/ELP 10%

Cryo 24%

Platelets 4%

Emergency Surgery 2014/2015

PRBCs

FFP/ELP

Cryo

Platelets

45

7

42

67

14

0

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20

30

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80

ROTEM Intraoperative CellSalvage - transfused

MTP

Utilisation of ROTEM®, Intraoperative Cell Salvage and Massive Transfusion Protocol in the Operating Theatre

2013/2014

2014/2015

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2013/2014 2014/2015 2013/2014 2014/2015 2013/2014 2014/2015 2013/2014 2014/2015

PRBCs FFP/ELP Cryoprecipitate Platelets

Units of Blood Products Used As Per Type of Surgery

Elective Surgery Emergency Surgery Unclassified Surgery

0 20 40 60 80 100 120

Surgery for Multi-Trauma Patients

Caesarean Delivery

Severe Full Thickness Burns

Major Reconstructive Vascular…

Ectopic Pregnancy

Spinal Fusion

Hip or Knee Replacement

Neurosurgery for Multi-Trauma

Upper Gastrointestinal Procedure

Rectal Resection

Top 10 Procedures for Cryoprecipitate Use

2014/15

2013/14

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2013/2014 2014/2015 2013/2014 2014/2015 2013/2014 2014/2015 2013/2014 2014/2015

PRBCs FFP/ELP Cryoprecipitate Platelets

Number of Patients Transfused As Per Surgery

Elective Surgery Emergency Surgery Unclassified Surgery

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