Evaluation of the approaches of the doctors working in the perioperative period in Turkey to patient blood management

Authors

Abstract

AimPatient blood management is a thoroughly researched and inclusive strategy to improve care of patients who may need blood transfusions by utilizing a team-based approach. The World Health Organization (WHO) has been providing support for it since 2010. Patient blood management aims to improve patient safety by reducing mortality and morbidity rates while avoiding unnecessary blood transfusions and related products. Our research is focused on identifying the methods used by medical professionals in patient blood management during the perioperative phase and evaluating their level of understanding of the subject matter.
MethodsBetween July and September 2022, a study was carried out, which consisted of 21 questionnaire questions focused on the method of patient blood management. The survey was electronically sent out to anesthesiologists and doctors of different branches who participate in preoperative preparations across numerous centers in Turkey, utilizing the Google Forms TM application.
ResultsOut of all the participants, 59.8% have undergone training on patient blood management. Among them, 39.6% were aware of the perioperative anemia treatment protocol in their center. In the Anesthesiology group, there was a statistically significant increase in awareness that perioperative anemia can result in higher perioperative morbidity and mortality. Anesthesiologists preferred to delay surgery by starting oral iron replacement 4-8 weeks prior, while the other physicians preferred performing ES transfusion before starting replacement therapy.
ConclusionVarious European countries have adopted Patient Blood Management guidelines, and healthcare professionals have welcomed this approach. A survey conducted in Turkey shows a greater awareness of this practice, particularly in anesthesia.

Keywords

Introduction

Patient Blood Management (PBM) is a well-researched and comprehensive strategy that aims to enhance the treatment of patients who may require blood transfusions, utilizing a team
based approach.^1,2 The concept of PBM in perioperative care was introduced to the literature by James Isbister approximately 17 years ago as a novel approach.^3,4 Since 2010, the World Health Organization (WHO) has provided support for it. The primary objectives of PBM are to enhance patient safety by minimizing mortality and morbidity rates and to avoid unnecessary blood transfusions and blood products.² In regards to PBM, there are three fundamental goals: maintaining an appropriate hemoglobin (Hb) concentration, optimizing hemostasis to prevent excessive bleeding, and reducing blood loss while enhancing the patient’s tolerance to anemia.² The ultimate goal is to enhance patient outcomes by effectively managing anemia and minimizing the risks associated with unnecessary blood and blood products.⁵ The occurrence of perioperative anemia (POA) varies around 33% and is dependent on the surgical procedure (25-40%).^6,7,8 Hospital stays, and complications are more likely to occur when a patient has POA or receives a blood transfusion during the perioperative period. There is a direct correlation between POA and higher perioperative risk.⁸ When PBMs are followed more strictly, the rate of postoperative complications and deaths tends to be lower. However, there are differences in practice due to different health care systems in countries. It is crucial to identify effective methods and strategies that offer practical solutions to achieve successful PBM. The main objective of our study was to identify the approaches employed by healthcare professionals in PBM and to assess their level of expertise on the
matter. Our secondary aim was to analyze the approaches utilized by physicians at PBM clinics to adhere to existing guidelines.

Materials and Methods

The Health Sciences University Ankara City Hospital Clinical Research Ethics Committee 1 approved the study with the reference number E1-22-2521 on June 4th, 2022. We have created a survey that contains a total of 21 questions. Six questions are about personal information, while 11 are centered around preoperative anemia. The remaining four questions are about managing a patient’s blood during surgery. The questionnaire was sent to participants electronically through the Google forms TM application. Participants were given information about the study’s scope and purpose at the beginning of the questionnaire, and their informed consent to participate was obtained as volunteers. All responses were collected electronically. Physicians in the perioperative field in Turkey have been invited to participate in the survey.
Evaluation Of DataThe study involved 634 physicians categorized into two groups: Anesthesiology and Reanimation physicians (AR) with 339 members and other surgical branch physicians (OSB) with 295 members. A comparison was made between the characteristics of physicians in these groups and their respective responses to the survey questions.
Ethical ApprovalEthical approval for this study was obtained from the Clinical Research Ethics Committee of Health Sciences University Ankara City Hospital (Date: June 4, 2022; Decision No: E1-22-2521).
Statistical AnalysisThe IBM SPSS 25.0 program was used for data analysis. The study data was evaluated using various descriptive statistical methods such as frequency, percentage, mean, standard deviation, median, and minmax. To compare qualitative data, the Chi-Square (x2) test was utilized. Multiple comparisons were made using pairwise comparisons and Bonferroni correction. To assess the normal distribution of the data, we utilized both the Kolmogorov-Smirnov and Shapiro-Wilk tests. The comparison of normally distributed quantitative data between groups in the study was conducted using Independent Samples t-test and One-Way ANOVA (one-way analysis of variance). The accepted level of statistical significance was p<0.05. Power analysis was performed with the statistical package program G*Power 3.1.9.7 (Franz Foul, Universitat Kiel, Germany). The question posed in specialization comparisons is whether preoperative anemia increases perioperative morbidity and mortality. The parameters for the study were n1=339, n2=298, P1=0.97, P2=0.90, p<0.05, and a power of 95%.
Reporting GuidelinesThe study was reported in accordance with STROBE guidelines.

Results

The general characteristics of the physicians participating in the study are shown in Table 1.
The comparison of the participants’ training on perioperative BPM and their approaches to anemia in the preoperative period are shown in Table 2. Out of all participants, 59.8% have undergone training on PBM. Among them, 39.6% were aware of the POA treatment protocol in their center. However, 41.5% stated that their center does not have such a protocol. 18.9% of the participants had no knowledge of such a protocol. The AR group showed a statistically significant increase in awareness that POA could result in higher perioperative morbidity and mortality. The AR group delayed surgery by starting oral iron replacement 4-8 weeks prior, while the OSB group preferred performing ES transfusion before starting replacement therapy. A statistically significant difference was observed between the groups in terms of iron deficiency treatment in the preoperative period. However, it was observed that the OSB group also preferred iron replacement therapy more than ES transfusion (46.8% and 20%, respectively).
The transfusion choices made by participants during the intraoperative period are influenced by various factors, as shown in Table 3. There is a significant difference between the groups in terms of preferred strategies to reduce the need for blood transfusion during surgery. Observations from the AR group revealed significantly higher usage of acute normovolemic hemodilution, restricted blood volume and regulation of blood samples for diagnostic purposes, Tranexamic acid (TXA) , and Cell saver.

Discussion

According to our survey results, the participants highlighted the significance of preoperative anemia. Upon analyzing the responses tothe inquiry on the differential diagnosis of preoperative anemia, it was observed that the serum ferritin factor was most commonly taken into account. It was noted that there were a high number of referrals to a hematology physician for differential diagnosis without requesting an examination, while the planning of anemia treatment according to guidelines was low. Approximately 54.1% of physicians working in the perioperative period either use these techniques or believe that they should be used and follow the guidelines accordingly. According to the data, TXA was used in 51.7% of cases as an alternative method to minimize bleeding during surgery, with the AR group more consistent with the guidelines recommended in this area.^9,10,11,12
According to a survey conducted by Bennett et al. on perioperative BPM applications during liver resection operations by surgeons and anesthesiologists, it was found that antifibrinolytics were the most frequently used technique for blood conservation during surgery. Anesthesiologists placed greater importance on hemoglobin levels when deciding on intraoperative transfusion, while surgeons prioritized the patient’s hemodynamics.¹³ In our research, we have found that the utilization of TXA to minimize blood loss during surgical procedures is substantial, as evidenced by our parallel study. In contrast to our research findings, it was observed that the AR group had a preference for a greater rate of hemodynamic change in transfusion decision
making compared to the OSB group.
In a study conducted by Manzini et al. across multiple centers, physicians were queried about PBM and their responses were assessed.¹ A recent study found that 24% of the participants were not aware of the correlation between POA and complications during and after surgery, and more than 50% of clinicians did not consistently treat POA. According to the study, 38% of POA patients preferred ES transfusion as their treatment method. According to our research, it was discovered that 93.8% of the participants were knowledgeable about the correlation between POA and perioperative mortality and morbidity. Additionally, it was observed that this awareness was more prevalent in the AR group compared to the other group. Based on our findings, it was discovered that the percentage of untreated POA was 13.7%. Furthermore, it was observed that the AR group had a higher percentage of untreated POA compared to the OSB group. It is possible that the increased level of education and awareness regarding PBM management among our participants could account for the disparity in findings between the two studies.
In 2015, Sherliker et al. conducted a study on the impact of PBM training practices in the UK on the attitudes of participants. After regulations were implemented and education levels improved, the efficiency of PBM practices saw a significant uptick according to the study’s findings.¹⁴ Our research revealed that the participants were knowledgeable about patient blood management and inclined to follow the guidelines. We believe that education and the development of protocols, in line with the guidelines set by each institution, can be an effective approach.

Limitations

A limitation of our study is that we had to prioritize certain stages of the PBM when structuring our questions. We were unable to thoroughly question every stage of the PBM due to its extensive scope and application. In future studies, the practical use of PBM can be assessed from various perspectives by examining different stages. Another limitation is that there are inconsistencies in numerous studies within the latest literature on iron usage. We have only selected the PBM guideline implemented in Turkey as an illustration.[15]

Conclusion

According to the literature, it has been demonstrated that the regulations pertaining to PBM are implemented in clinical practices and can be utilized effectively. Many European countries have implemented the PBM guidelines, which have also been adopted by numerous healthcare professionals. Through the survey we conducted in Turkey, based on the responses of the participants, we found that the level of awareness regarding PBM was notably higher across all branches, with a particular emphasis on the anesthesia field. We noticed that they were unsure about diagnosing anemia across all branches, including anesthesia. They required hematology consultation to arrive at a decision. With the help of clear instructions and training, we hope that the PBM protocols will be used in all hospitals and departments very soon. This will help all healthcare workers to be more aware of important procedures.

Declarations

Abbreviations

AR: Anesthesiology and Reanimation
ES: Erythrocyte Suspension
Hb: Hemoglobin
OSB: Other Surgical Branches
PBM: Patient Blood Management
POA: Perioperative Anemia
TXA: Tranexamic Acid

References

1. PubMed Google Scholar

About This Article

Received:

July 19, 2023

Accepted:

August 21, 2023

Published Online:

August 25, 2023

Printed:

September 1, 2023