Respuesta: Transfusión sanguínea, infección nosocomial y trombosis venosa en pacientes de edad avanzada intervenidos de fractura de cadera / Reply: Blood transfusion, nosocomial infection and venous thrombosis in aged patients with surgery of hip fracture

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[Relationship between allogeneic blood transfusion, iron deficiency and nosocomial infection in patients with hip fracture]. / Relación de la transfusión y la ferropenia con la infección nosocomial en pacientes con fractura de cadera.

BACKGROUND AND OBJECTIVE: To know the frequency of nosocomial infection (NI) in surgical hip fracture patients and to analyze the risk factors that favor the NI development, especially its relationship with allogeneic blood transfusion (ABT) and intravenous iron administration. PATIENTS AND METHOD: Unicenter prospective observational study of all hip fracture surgery patients during 8 months. The demographic, clinical and hematimetric differences between the infected and not infected patients were described. A logistic regression analysis was made to know the variables that predicted NI development. RESULTS: 26.1% of all 286 patients studied developed NI, urinary infection being the most frequent. The existence of lower hemoglobin or ferritin levels at admission, as well as increased values in ASA (American Society of Anesthesiologists) scale were associated with a greater risk of NI development. ABT and the number of red blood cell units transfused were also associated with an increase of the NI risk. No relationship between intravenous iron administration and NI was found. CONCLUSIONS: Lower haemoglobin and ferritin levels and ABT are associated with an increasing NI risk in surgical hip fracture patients. Thus, in order to decrease the frequency of NI in surgical patients, the development of blood saving protocols including intravenous iron administration would be recommendable.

Relación de la transfusión y la ferropenia con la infección nosocomial en pacientes con fractura de cadera / Relationship between allogeneic blood transfusion, iron deficiency and nosocomial infection in patients with hip fracture

FUNDAMENTO Y OBJETIVO: El propósito del estudio ha sido conocer la frecuencia de infección nosocomial(IN) en pacientes intervenidos de fractura de cadera y analizar los factores de riesgoque favorecen el desarrollo de esta infección, especialmente el papel de la transfusión de sangrealogénica (TSA) y de la administración de hierro intravenosa.PACIENTES Y MÉTODO: Se trata de un estudio observacional y prospectivo, en el que se ha incluidoa los pacientes intervenidos de fractura de cadera durante 8 meses. Se describieron las diferenciasdemográficas, clínicas y hematimétricas entre los pacientes con IN y los no infectados,y se realizó un análisis de regresión logística para conocer las variables que pudieron influir enel desarrollo de IN.RESULTADOS: Se ha estudiado a 286 pacientes, de los que el 26,1% desarrolló IN, siendo lainfección urinaria la más frecuente. Los valores descendidos de hemoglobina o ferritina al ingresar,así como los valores elevados de riesgo según la escala de la American Society of Anesthesiologists(ASA), se asociaron a un mayor riesgo de desarrollo de IN. El número de concentradosde hematíes transfundidos también se asoció a un aumento del riesgo de infección. Nose encontró relación entre la administración de hierro intravenosa y la IN.CONCLUSIONES: La hemoglobinemia, la ferropenia y la TSA son factores asociados a riesgo de INen pacientes con fracturas de cadera. Con el objeto de reducir la frecuencia de IN en éstos confractura de cadera, podría ser recomendable el desarrollo de protocolos de ahorro de sangreque incluyeran la administración de hierro intravenosa

BACKGROUND AND OBJECTIVE: To know the frequency of nosocomial infection (NI) in surgical hipfracture patients and to analyze the risk factors that favor the NI development, especially its relationshipwith allogeneic blood transfusion (ABT) and intravenous iron administration.Patients and method: Unicenter prospective observational study of all hip fracture surgery patientsduring 8 months. The demographic, clinical and hematimetric differences between theinfected and not infected patients were described. A logistic regression analysis was made toknow the variables that predicted NI development.RESULTS: 26.1% of all 286 patients studied developed NI, urinary infection being the most frequent.The existence of lower hemoglobin or ferritin levels at admission, as well as increasedvalues in ASA (American Society of Anesthesiologists) scale were associated with a greater riskof NI development. ABT and the number of red blood cell units transfused were also associatedwith an increase of the NI risk. No relationship between intravenous iron administration and NIwas found.CONCLUSIONS: Lower haemoglobin and ferritin levels and ABT are associated with an increasingNI risk in surgical hip fracture patients. Thus, in order to decrease the frequency of NI in surgicalpatients, the development of blood saving protocols including intravenous iron administrationwould be recommendable

Coste real de las transfusiones sanguíneas en España. Respuesta de los autores / Cost of blood transfusion in Spain. Authors’ reply

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[Budget impact analysis of a blood saving program for urgent traumatological surgery]. / Análisis del impacto presupuestario de la implantación de medidas de ahorro de sangre en cirugía de urgencia.

BACKGROUND AND OBJECTIVE: To assess the cost-effectiveness and the budget impact of a Blood Saving Program (BSP) in patients older than 65 undergoing perthrocanteric hip fracture surgery. PATIENTS AND METHOD: Two groups of patients with perthrocanteric fracture were included. Group 1: patients not receiving treatment for perisurgical anaemia or treated with oral iron; Group 2: patients included in a BSP (treatment with endovenous iron sucrose and alfa epoetin, plus restrictive transfusional criteria). Effectiveness issues were: transfusion rate and number of red blood cell units transfused, length of postoperative stay and infection rate. Treatment cost was calculated using drug and transfused red blood cell unit prizes in 2003. We calculated potential patient population according to 2003 data. RESULTS: 144 patients were included, 43 of which were in the BSP. Both groups were comparable in gender, age, preoperative length of stay, ASA and haemoglobin level at admission. Patients included in the BSP were less transfused and had less infections but postoperative stay was similar in both groups. The budget impact was 239,148 euros 95% [confidence interval (CI) 202,312-311,980] at group 1 and 311,980 euros [95% CI 275,288-348,672] at the BSP group. Including the whole potential population in the BSP (during one year 400 patients) would mean a cost increase of 72,832 euros, avoiding transfusion in 92 patients, infection in 70 patients, and saving 328 red blood cell units. CONCLUSIONS: The cost increase due to endovenous iron sucrose and alfa-epoetin can be considered affordable for the hospital budget. BSP provides lower transfusion and infection rates and saves red blood cell units, compared to the standard procedure. Differences in postoperative stay should be analyzed in further larger and prospective studies including more patients.

Análisis del impacto presupuestario de la implantación de medidas de ahorro de sangre en cirugía de urgencia / Budget impact analysis of a blood saving program for urgent traumatological surgery

Fundamento y objetivo: El objetivo de este trabajo es estudiar la relación coste-efectividad y el impacto presupuestario que supone para un hospital el establecimiento de un programa de ahorro de sangre alogénica en pacientes ancianos intervenidos quirúrgicamente de fractura de cadera pertrocantérea. Pacientes y método: Se incluyó 2 grupos de pacientes. Grupo 1: pacientes sin tratamiento farmacológico de la anemia perioperatoria o que recibieron hierro oral; y Grupo 2: pacientes incluidos en un programa de ahorro de sangre con criterios transfusionales restrictivos y tratamiento con hierro sacarato intravenoso y epoetina alfa. Se definieron como parámetros de efectividad el porcentaje de transfusiones y el número de concentrados de hematíes transfundidos, la duración de la estancia postoperatoria y el porcentaje de infección hospitalaria. Los costes de tratamiento se calcularon usando el precio de venta a farmacia (PVF) de los fármacos y los costes de unidades de sangre transfundidas y cruzadas en el año 2003 según tarifas oficiales. Se utilizó el año 2003 para establecer la población prevalente. Resultados: Se incluyó a 144 pacientes estudiados de marzo a septiembre de 2003 (101 en el grupo 1 y 43 en el grupo 2). Ambos grupos fueron comparables en sexo, edad, tiempo prequirúrgico, riesgo quirúrgico (ASA) y valores de hemoglobina al ingreso. Los pacientes incluidos en el programa de ahorro de sangre recibieron menos transfusiones y presentaron menos infecciones, aunque la estancia posquirúrgica fue similar en ambos grupos. El impacto presupuestario fue 239.148 euros (intervalo de confianza [IC] del 95%, 202.312-311.980 euros) en el grupo 1 y 311.980 euros (IC del 95%, 275.288-348.672 euros) en el programa de ahorro de sangre. La generalización del ahorro de sangre a toda la población prevalente en 2003 (400 pacientes) supondría un aumento medio de costes para el hospital de 72.832 euros, se evitaría transfusiones a 92 pacientes y se ahorraría 328 concentrados de hematíes y 70 infecciones hospitalarias. Conclusiones: El aumento en el gasto que implica la generalización del uso del hierro sacarato intravenoso y la epoetina alfa no se considera especialmente gravoso para el presupuesto del hospital. Este incremento en el coste evita transfusiones sanguíneas, bolsas de sangre e infecciones hospitalarias, pero no queda del todo claro en qué supuestos disminuye la estancia media, punto que se debería analizar con estudios prospectivos o de mayor tamaño muestral

Background and objetive: To assess the cost-effectiveness and the budget impact of a Blood Saving Program (BSP) in patients older than 65 undergoing perthrocanteric hip fracture surgery. Patients and method: Two groups of patients with perthrocanteric fracture were included. Group 1: patients not receiving treatment for perisurgical anaemia or treated with oral iron; Group 2: patients included in a BSP (treatment with endovenous iron sucrose and alfa epoetin, plus restrictive transfusional criteria). Effectiveness issues were: transfusion rate and number of red blood cell units transfused, length of postoperative stay and infection rate. Treatment cost was calculated using drug and transfused red blood cell unit prizes in 2003. We calculated potential patient population according to 2003 data. Results: 144 patients were included, 43 of which were in the BSP. Both groups were comparable in gender, age, preoperative length of stay, ASA and haemoglobin level at admission. Patients included in the BSP were less transfused and had less infections but postoperative stay was similar in both groups. The budget impact was 239,148 euros 95% [confidence interval (CI) 202,312-311,980] at group 1 and 311,980 euros [95% CI 275,288-348,672] at the BSP group. Including the whole potential population in the BSP (during one year 400 patients) would mean a cost increase of 72,832 euros, avoiding transfusion in 92 patients, infection in 70 patients, and saving 328 red blood cell units. Conclusions: The cost increase due to endovenous iron sucrose and alfa-epoetin can be considered affordable for the hospital budget. BSP provides lower transfusion and infection rates and saves red blood cell units, compared to the standard procedure. Differences in postoperative stay should be analyzed in further larger and prospective studies including more patients