Optimizing Coagulation and Reduce Bleeding
- Preoperative evaluation of coagulation abnormalities.
- Minimally invasive surgical techniques.
- Use surgical techniques to minimize bleeding including use of electrocoagulation, bipolar, and argon beam.
- Blood loss minimization techniques; for example, use of vasoconstrictors, topical coagulation agents and tourniquets.
- Maintain normothermia
- Consider controlled hypotension.
- Consider acute normovolemic hemodilution.
- Use blood salvage technologies.
- Basic conditions for hemostasis, reversal of anticoagulants, point-of-care diagnostics in coagulopathic patients, optimized coagulation management with the use of clotting factor concentrates, and the use of antifibrinolytic agents or desmopressin are further important considerations.
- In cardiac surgery, a wide spectrum of blood sparing techniques have been described, e.g. minimized extracorporeal circuits, retrograde autologous priming, modified ultrafiltration, blood cardioplegia, and meticulous hemostasis in saphenous vein graft removal.
Hemorrhage Identification and Control
- Identify patients at risk for development of hemorrhage (OB)
- A massive hemorrhage protocol should be available.
- Where indicated, massive hemorrhage protocols should be extended by specific algorithms for different subgroups of high-risk patients, e.g. postpartum and trauma.
Technology Plan
Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with a particular capability. As other options may exist, please send information on any additional technologies, along with appropriate evidence, to info@patientsafetymovement.org. - Implement electronic health record (EHR) fields requiring documentation of clinical indication for transfusion and hemoglobin value prior to each RBC unit.21 (Decision support iForms)
- Implement noninvasive and continuous hemoglobin monitoring17,18 (SpHb® adhesive sensors connected to rainbow SET monitors with SpHb, or a multi-parameter patient monitor with SpHb, including but not limited to the Dräger® M540/Infinity Acute Care System, Welch Allyn® CVSM, Fukuda Denshi® 8500, Saadat® Aria and Alborz monitors, GE®, Philips®, and more).
- Implement cell recovery technology in the operating room (such as Cobe®, Haemonetics®, or other equivalent devices).
- Implement point of care coagulation testing (such as iStat®, TEG®, and ROTEM®).
- Implement smaller blood test tube volumes
- Reduce priming volume of extracorporeal circuits
- Implement closed blood sampling systems for arterial and central venous lines.
- Implement an IT structure for benchmarking.
Metrics
Topic
Anemia and Transfusion Management
Rate of transfusion, adverse events (AE) and/or mortality for untreated and treated preoperative anemia per 1000 patients undergoing elective surgery.
Outcome Measure Formula
Option 1:
Numerator: Number of adverse events for patients with untreated and treated preoperative anemia.
Denominator: Total number of anemic patients undergoing elective surgery.
*Rate is typically displayed as percentage: Adverse Events/Elective Anemic Surgery Patients
Option 2:
Numerator: Number of adverse events for patients with untreated and treated preoperative anemia.