Retrospective Analysis of TEG-Directed Transfusion in Isolated CABG: Impact on Blood Product Usage, Cost, and Outcomes
Kevin Fleming, Roberta E Redfern, Gabriel Naimy, John Bazydlo, Michael Kuehne, Nathan Bobulski, Michael Moront
ProMedica Toledo Hospital, Toledo, OH
OBJECTIVES:Cardiac procedures often require blood transfusion due to surgical bleeding or coagulopathy. Thrombelastography (TEG) was introduced in our institution to direct transfusion management in cardiothoracic surgery. The goal of this study was to quantify the effect of TEG on transfusion rates, costs, and surgical bleeding-associated reoperations in complex cases.
METHODS:Patients who underwent CABG before and after implementation of TEG (2008 and 2012, respectively) were retrospectively identified and analyzed. Those cases in which maze procedure, left atrial appendage resection, carotid endarterectomy or additional cardiac procedures were also performed were not included. Cases performed without cardiopulmonary bypass were excluded; only cases performed by the same three surgeons during both time frames were eligible for inclusion. Variables including mean perioperative (<24 hours) and postoperative transfusion rates (25-48 hours and >48 hours), costs, and mean use of blood product by type, were collected and compared by study period. Total patient blood product exposure, exposure by product type, return to the operating room for exploration of bleeding complications, and related transfusions were compared between study periods by t-test and chi square tests.
RESULTS:In total, 651 patients in the pre-TEG period and 466 patients in the post-TEG period were identified. In the perioperative period, use of all blood products was significantly reduced after TEG was implemented including red blood cells (p=0.01), plasma (p<0.0001), and cryoprecipitate (p<0.0001) and platelets (p=0.04). Postoperative blood use was also reduced but did not reach significance. Mean number of units of blood used in the perioperative period (2.8 vs. 1.7) and over the entire stay (3.5 vs. 2.2) were reduced by approximately 40% (p<0.0001). The proportion of patients exposed to transfusion was lower after introduction of TEG (64.8% vs. 55.8%, p=0.0001). Rate of re-operation due to bleeding decreased significantly with TEG guidance (4.8% vs 1.5%, p=0.003). Cost reduction with implementation of TEG was significant with approximately $150,000 in blood product acquisition savings for the cohort.
CONCLUSIONS:TEG-directed management of blood product administration during isolated CABG significantly reduced the units of blood products received; fewer patients were exposed to allogenic blood and re-operation rates were reduced more than half. The use of TEG to guide blood product administration significantly impacted transfusion therapy, costs, and outcomes.
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