Gamze KÜÇÜKOSMAN, Alkım Gizem Yılmaz, Hilal AYOĞLU, Bengü Gülhan AYDIN, Hasan Ali AYDIN

Bir Üniversite Hastanesinin Cerrahi Kliniğinde Çalışan Doktorların Hasta Kan Yönetimine Yönelik Tutumları: Ankete Dayalı Bir Çalışma

Amaç: Amacımız, bir üniversite hastanesi cerrahi kliniklerinde çalı- şan doktorların Hasta Kan Yönetimi (HKY) konusundaki tutumlarını değerlendirmektir. Yöntem: Bu kesitsel çalışma, yerel etik kurul izni alındıktan sonra Aralık 2019-Ocak 2020 tarihleri arasında Zonguldak Bülent Ecevit Üniversitesi Tıp Fakültesi’nde yapıldı. Anket verileri, 33 sorudan oluşan anket formlarının hastanemiz cerrahi kliniklerinde çalışan doktorlara elden dağıtılıp doldurulmasıyla elde edildi. Sorular; de- mografik verileri, HKY uygulamaları hakkındaki tutum ve davranış- larını içermektedir. Bulgular: Eksiksiz doldurulan 91 anket değerlendirildi. Katılımcı- ların %81’i araştırma görevlisi ve %30’u anestezistti. Katılımcıların %61,5’i HKY ve %91’i de preoperatif anemi (POA) ile perioperatif morbidite ve mortalite arasındaki ilişki hakkında bilgi sahibiydi. Ka- tılımcıların %54’ünün de POA’yı rutin olarak tedavi ettiği saptandı. Katılımcıların %85’i elektif cerrahi öncesi aneminin tedavi edilmesi gerektiğini ve bu amaçla ameliyattan hemen önce eritrosit süs- pansiyonu (ES) (%67,5) transfüze ettiklerini belirttiler. Hemoglobin (Hb) değeri dışında ES transfüzyonu kararında en sık kullanılan parametre, kanama miktarı >1000 mL (%80) idi. İntraoperatif kan transfüzyonunu azaltmak için en sık yapılan uygulamanın POA’nın teşhisi ve düzeltilmesi (%85) olduğu saptanırken, katılımcıların yalnızca %27,5’inin normoterminin sağlanması ve transfüzyon kararında Hb eşik değeri için restriktif davranılması gerektiğini bil- dirdiler. Katılımcılara kardiyopulmoner hastalığı ve kanaması olma- yan anemik bir hasta olmaları durumunda kendilerine nasıl davra- nılması gerektiği sorulduğunda; %69’unun ‘elektif cerrahi öncesi anemisinin tanınmasını ve tedavi edilmesini istedikleri’ görüldü. Katılımcıların sadece %22’si kurumlarında HKY konusunda yazılı bir protokolün olmadığının farkındaydı. Sonuç: Bulgularımız HKY kılavuzlarının benimsenmesinin teşvik edilmesi, bu programları uygulamak için daha fazla ivme kazandı- rılması gerektiğini ve bu alanda yapılacak başka çalışmalara ihtiyaç olduğunu düşündürmektedir.

The Attitudes of Doctors Working in the Surgical Clinic of a University Hospital for Patient Blood Management: A Survey-Based Study

Objective: Our aim is to evaluate the attitudes of the doctors working in the surgical clinics of a university hospital on Patient Blood Management (PBM). Methods: This cross-sectional study was conducted in Zonguldak Bülent Ecevit University, Faculty of Medicine between December 2019 and January 2020, after obtaining ethical permission. The survey data were obtained by handing out the survey forms which consist of 33 questions to the doctors working in the hospital’s surgical clinics to fill out. The questions include demographic data, and attitudes on PBM. Results: Fully completed 91 surveys were evaluated. Of the par- ticipants, 81% were research assistants and 30% were anesthesi- ologists. The 61.5% of participants had PBM knowledge, 91% of them knew the relationship between preoperative anemia (POA) and preoperative morbidity, and mortality, and 54% were found to treat POA regularly. The 85% of the participants stated that anemia should be treated before elective surgery, and for this purpose, they transfused erythrocyte suspension (RBC) (67.5%) immediately before surgery. Apart from the hemoglobin (Hb) val- ue, the most commonly used parameter in the RBC transfusion decision was the amount of bleeding >1000 mL. While it was found that the most common practice to reduce intra-operative blood transfusion was the diagnosis and correction of POA (85%), only 27.5% of the participants reported that it is necessary to act restrictively to ensure normothermia and for the Hb threshold val- ue in the decision of transfusion. When participants were asked ‘how should they be treated if they are an anemic patient without cardiopulmonary disease and bleeding’, 69% of them said they ‘want their anemia to be recognized and treated before elective surgery'. Only 22% of the participants were aware that there was no written protocol on PBM in their institution. Conclusion: Study findings suggest that the adoption of PBM guidelines should be encouraged, more momentum should be given to implementing these programs, and other studies in this area are needed.

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1. Isbister J. Why should health professionals be concerned about blood management and blood conservation? Updates in Blood Conservation and Transfusion Alternatives 2005;2: 3-7.
2. Roman MA, Abbasciano RG, Pathak S, et al. Patient blood management interventions do not lead to important clinical benefits or cost-effectiveness for major surgery: A network meta-analysis. Br J Anaesth 2021;126(1):149-56.
3. Shander A, Fink A, Javidroozi M, et al. Appropriateness of allogeneic red blood cell transfusion: The international consensus conference on transfusion outcomes. Transfus Med Rev 2011;25(3):232-46.e53.
4. Velati C, Romanò L, Piccinini V, et al. Prevalence, incidence and residual risk of transfusion-transmitted hepatitis C virus and human immunodeficiency virus after the implementation of nucleic acid testing in Italy: A 7-year (2009-2015) survey. Blood Transfus 2018;16(5):422-32.
5. Riva L, Petrini C. Blood safety policy: Should cautionary policies be adopted with caution? Blood Transfus 2018;16(5): 405-7.
6. Muñoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia 2017;72(2):233- 47.
7. Muñoz M, Franchini M, Liumbruno GM. The post-operative management of anaemia: More efforts are needed. Blood Transfus 2018;16(4):324-25.
8. Spahn DR, Theusinger OM, Hofmann A. Patient blood management is a win-win: A wake-up call. Br J Anaesth 2012; 108(6):889-92.
9. Franchini M, Marano G, Mengoli C, et al. Red blood cell transfusion policy: a critical literature review. Blood Transfus 2017;15(4):307-17.
10. Yenicesu İ, Çetin AT, Topçuoğlu P, et al. Türkiye’de Kan Transfüzyon Yönetim Sisteminin Geliştirilmesi İçin Teknik Yardım Projesi, Ulusal hasta kan yönetim stratejisi, Türkiye’de Kan Kullanım Standartları Anketi, 2019. Available from: https://hastakanyonetimi.saglik.gov.tr/dokumanlar/1_2/ Ulusal_Hasta_Kan_Yonetimi_Stratejisi_TR.pdf (Ek 1a). E7. Available date: March/2019
11. Manzini PM, Dall’Omo AM, D’Antico S, et al. Patient blood management knowledge and practice among clinicians from seven European university hospitals: A multicentre survey. Vox Sang 2018;113(1):60-71.
12. Baron DM, Metnitz PGH, Fellinger T, Metnitz B, Rhodes A, Kozek-Langenecker SA. Evaluation of clinical practice in perioperative patient blood management. Br J Anaesth 2016; 117(5):610-6.
13. Fischer DP, Zacharowski KD, Müller MM, et al. Patient blood management strategies and their effect on physician risk perception, clinical knowledge and perioperative practice-the Frankfurt experience. Transfus Med Hemother 2015;42(2):91-7.
14. Abad-Motos A, Ripollés-Melchor J, Jericó C, et al. Patient blood management for primary hip and knee replacement. A survey among POWER.2 study researchers. Rev Esp Anestesiol Reanim (Engl Ed) 2020;67(5):237-44.
15. WHA. 63.12 - Sixty-Third World Health Assembly, Agenda item 11.17, 21 May 2010 -Availability, safety and quality of blood products 2010. Available from: http://apps. who. int/medicinedocs/documents/s19998en/s19998en.pdf [accessed 19.10.19].
16. Shander A, Van Aken H, Colomina MJ, et al. Patient blood management in Europe. Br J Anaesth 2012;109(1):55-68.
17. The United States Department of Health, Human Services (HHS). The 2011 National Blood Collection and Utilization Survey Report. 2011. Available at: http://www.hhs.gov/ash/ bloodsafety/2011-nbcus.pdf. Assessed December 20, 2015.
18. Van der Linden P, Hardy JF. Implementation of patient blood management remains extremely variable in Europe and Canada: The NATA benchmark project. An observational study. Eur J Anaesthesiol 2016;33(12):913-21.
19. European Medicines Agency’s Committee for Medicinal Prod- ucts for Human Use. New recommendations to manage risk of allergic reactions with intravenous iron-containing medi- cines. 2013. Available at: http://www.ema.europa. eu/ema/ index.jsp?curl=pages/news_and_events/news/2013/06/ news_detail_001833.jsp&mid=WC0b01ac058004d5c1. As- sessed May 01, 2014.
20. Hofmann A, Ozawa S, Farrugia A, Farmer SL, Shander A. Economic considerations on transfusion medicine and patient blood management. Best Pract Res Clin Anaesthesiol 2013;27(1):59-68.
21. Unal D, Senaylı Y, Polat R, et al. Peri-operative blood transfusion in elective major surgery: Incidence, indications and outcome-an observational multicentre study. Blood Transfus 2020;18(4):261-79.
22. Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preoperative anemia in noncardiac surgery: A single-center cohort study. Anesthesiology 2009;110 (3):574-81.
23. Jans Ø, Jørgensen C, Kehlet H, Johansson PI; Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group. Role of preoperative anemia for risk of transfusion and postoperative morbidity in fast-track hip and knee arthroplasty. Transfusion 2014;54(3):717-26.
24. Musallam KM, Tamim HM, Richards T, et al. Preoperative anaemia and postoperative outcomes in noncardiac surgery: A retrospective cohort study. Lancet 2011;378(9800):1396- 407.
25. Choorapoikayil S, Zacharowski K, Meybohm P. Patient blood management: Is it worth tobe employed? Curr Opin Anaesthesiol 2016;29(2):186-91.
26. Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: Guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol 2017;34(6):332-95.
27. American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: An updated report by the American Society of Anesthesiologists task force on perioperative blood management. Anaesthesiology 2015; 122(2):241-75.
28. National Blood Authority (NBA). Patient Blood Management Guidelines: Module 2, Perioperative. 2012. Available from: https://www.blood. gov.au/system/files/documents/pbm- module-2.pdf. Accessed on 28/08/2019.
29. Mosieri C, Chandler D, Reed DS, et al. Managing preoperative anemia: Evolving concepts and strategies for improving patient outcomes. Best Pract Res Clin Anaesthesiol 2020; 34(2):183-97.
30. Kansagra AJ, Stefan MS. Preoperative anemia: Evaluation and treatment. Anesthesiol Clin 2016;34(1):127-41.
31. Bisbe E, Basora M, Colomina MJ. Spanish best practice in peri-operative anaemia optimisation panel peri- operative treatmentof anaemia in major orthopaedic surgery: A practical approach from Spain. Blood Transfus 2017;15(4):296-306.
32. Espinosa A, Arsenovic M, Hervig T, et al. Implementing a patient blood management program in Norway: Where to start? Transfus Apher Sci 2016;54(3):422-7.
33. Lasocki S, Krauspe R, von Heymann C, Mezzacasa A, Chainey S, Spahn DR. PREPARE: The prevalence of perioperative anaemia and need for patient blood management in elective orthopaedic surgery: A multicentre, observational study. Eur J Anaesthesiol 2015;32(3):160-7.
34. Kostakis ID, Alexandrou A, Armeni E, et al. Comparison between minimally invasive and open gastrectomy for gastric cancer in Europe: A systematic review and meta-analysis. Scand J Surg 2017;106(1):3-20.
35. Ker K, Beecer D, Roberts I. Topical application of tranexamic acid for the reduction of bleeding. Cochrane Database Syst Rev 2013;7:CD010562.