Implementation of a Personalized Blood Management Program in Cardiac Surgery: A Single-Center, Retrospective Before-and-After Study

Implementation of a Personalized Blood Management Program in Cardiac Surgery: A Single-Center, Retrospective Before-and-After Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Implementation of a Personalized Blood Management Program in Cardiac Surgery: A Single-Center, Retrospective Before-and-After Study Constance Bougnoux, Sacha Rozencwajg, Jacques Thes, Sylvain Diop, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7567325/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 7 You are reading this latest preprint version Abstract Background Preoperative anemia and iron deficiency are common in patients undergoing cardiac surgery and are associated with increased transfusion requirements, morbidity, mortality, and healthcare costs. The implementation of Patient Blood Management (PBM) strategies remains challenging in routine clinical practice. Methods We conducted a single-center, retrospective before-and-after study including patients scheduled for elective on-pump cardiac surgery during one year before and one year after PBM implementation. The PBM protocol included preoperative anemia correction, reduction of intraoperative hemodilution, reinforcement of single-unit red blood cell (RBC) transfusion strategies, and postoperative iron supplementation. The primary outcome was the rate of RBC transfusion. Secondary outcomes included postoperative complications and cost analysis. Results A total of 782 patients were included (377 pre-PBM and 411 post-PBM). Baseline characteristics were comparable, except for a lower preoperative hemoglobin level in the pre-PBM group (13.7 ± 1.7 vs. 14.0 ± 1.5 g/dL; p=0.03). RBC transfusion rate decreased significantly (33% vs. 26%, p=0.02), with a higher proportion of single-unit transfusions. The post-PBM group received less intraoperative fluids and maintained higher hemoglobin levels throughout hospitalization. In multivariable analysis, PBM implementation was independently associated with reduced transfusion risk (OR 0.58; 95% CI 0.40–0.86; p<0.01). The estimated annual cost savings were €67,454. There was no significant difference in postoperative complications, including acute kidney injury, stroke, new-onset atrial fibrillation, and hospital length of stay. Conclusions Implementation of a pragmatic PBM program in cardiac surgery reduced RBC transfusions and healthcare costs without increasing postoperative complications. Trial registration : Not applicable. Cardiac Surgical Procedures Iron Deficiency Anemia Patient Blood Management Blood Transfusion Costs and Cost Analysis Figures Figure 1 Background Preoperative anemia and iron deficiency affect approximately 20-30% and 30-80% of patients scheduled for cardiac surgery, respectively [1–3]. Both conditions are associated with higher transfusion rates which are linked to an increase in postoperative morbidity and mortality [2,4–8]. These factors also contribute to higher healthcare costs, primarily driven by prolonged hospital length of stay [9]. In response, the World Health Organization has been promoting the implementation of Patient Blood Management (PBM) protocols since 2010. PBM is a patient-centered multimodal, evidence-based strategy based on three main pillars: perioperative anemia management, minimization of iatrogenic blood loss, and optimization of anemia tolerance aiming to reduce transfusion requirements while improving patient outcomes [10]. Despite strong evidence from prospective randomized controlled trials and endorsement by international guidelines, many cardiac surgery centers fail to integrate PBM into their routine practice, hindered by upfront financial investment, organizational constraints, and resistance to change clinical routines [11–14]. Moreover, the benefit of individual PBM measures remains uncertain. For instance, intravenous iron supplementation alone, without erythropoiesis-stimulating agents or other perioperative interventions did not reduce transfusion exposure [15]. Additionally, fluid management remains a critical yet under-researched component of PBM in cardiac surgery. Factors such as hemodilution during cardiopulmonary bypass (CPB), circuit priming strategies, and perioperative fluid management can significantly impact transfusion requirements. Recent meta-analyses support the use of retrograde autologous priming and restrictive fluid management protocols but their integration into a comprehensive PBM strategy in cardiac surgery warrants further investigation [16,17]. The real-world impact of a structured PBM protocol remains insufficiently evaluated. The aim of this study was to evaluate the impact of a pragmatic, multimodal PBM protocol on transfusion rates, complications and costs in cardiac surgery. Materials and methods Study design and population We conducted a retrospective, single-center, before-and-after observational study involving adult patients undergoing elective on-pump cardiac surgery. The study was conducted between June 2022 and May 2024 in a teaching hospital in Paris area. All adult patients scheduled for elective on-pump cardiac surgery were eligible. Exclusion criteria included urgent surgery, known hypersensitivity or contraindication to iron or erythropoietin, and “uncommon” surgical procedures such as tumor resection, ventricular septal defect closure, pericardiectomy or surgical correction for congenital heart disease. The control cohort comprised patients treated between June 1, 2022, and May 31, 2023, prior to the implementation of the perioperative PBM protocol. The intervention cohort included all consecutive patients treated between June 1, 2023, and May 31, 2024, following full protocol implementation. This study was approved by the institutional ethics committee (IRB 00012157). Patient consent for data collection was obtained beforehand, and an information letter was sent subsequently. No additional examinations were performed as part of this study. PBM-protocol Before implementation of the full PBM protocol, standard perioperative care adhered to the French guidelines [18]. This included systematic discontinuation of preoperative blood thinning therapies (antiplatelets at the exception of acetylsalicylic acid, vitamin K antagonist and direct oral anticoagulants), personalized heparin and protamine dosing (detailed in Additional files: Table S1 ), normothermic cardiopulmonary bypass (CPB), systematic use of intraoperative cell salvage, and administration of tranexamic acid (10 mg/kg bolus followed by continuous infusion at 1mg/kg/hour until surgical closure). Administration of procoagulant agents was protocolized using viscoelastic point-of-care testing with rotational thromboelastometry (ROTEM®; Werfen, Barcelona, Spain), and a restrictive transfusion threshold (hemoglobin 7-8 g/dL) was applied at the discretion of the clinical team based on patient-specific tolerance. The full PBM protocol (details in Additional files: Table S2 ) consisted of the following additional interventions: Systematic correction of preoperative anemia, defined as hemoglobin (Hb) level <13 g/dL, using intravenous ferric carboxymaltose (Ferinject®, Vifor (International) AG, St Gallen, Switzerland) and subcutaneous EPOetin alfa (Binocrit®, Sandoz AG, Bale, Switzerland); Targeted correction of preoperative iron deficiency without anemia (Hb ≥13 g/dL with ferritin <100 µg/L or transferrin saturation <20%) using intravenous ferric carboxymaltose; Promotion of CPB retrograde autologous priming use and of a restrictive fluid management strategy; Systematic correction of postoperative anemia (Hb <12 g/dL) with intravenous ferric carboxymaltose; Implementation of a single-unit RBC transfusion strategy (defined by the number of transfusions that were single unit), whereby one unit was transfused at a time and the need for further transfusion was reassessed. Data collection All data were retrospectively extracted from our institutional electronic health record system by two independent reviewers, in accordance with the General Data Protection Regulation. These data comprised: demographic data (age, sex, body mass index – BMI), main comorbidities and treatments, preoperative laboratory results and echocardiography findings, intraoperative data (surgical type, CPB and aortic cross-clamp time, transfusion and fluid administration), and postoperative outcomes (blood products transfusion, acute kidney injury, stroke), length of stay (LOS) in intensive care unit (ICU) and hospital, and in-hospital mortality. Preoperative hemoglobin was measured during the preoperative anesthesia consultation, which was typically performed between 1 month and 3 days before surgery. With regard to the cardiopulmonary bypass protocol, the proportion of retrograde priming use was not available; therefore, this variable was assessed indirectly based on the total priming volume per patient, which was recorded. Postoperative acute kidney injury was staged according to KDIGO criteria, excluding urine output component which was not available in our database. The complete list of variables was defined a priori based on international definitions and can be found in Additional files: Table S3 . Outcomes The primary outcome was the proportion of patients requiring at least one RBC transfusion between surgery and hospital discharge. Secondary outcomes included: Transfusion rates defined as the proportion of patients who received at least one allogeneic blood product between surgery and hospital discharge, and number of allogenic blood products transfused at predefined time points (intraoperative, and on postoperative days 5 and 7); Hemoglobin levels during hospitalization; ICU and hospital lengths of stay; In-hospital mortality; Incidence of postoperative complications including stroke, new onset atrial fibrillation, acute kidney injury (defined by an increase in serum creatinine of 26 µmol/L or more or by a rise greater than 1.5 times the baseline level), surgical site infection (mediastinitis and superficial wound infection) and myocardial infarction (defined as the need for a stenting of a coronary artery in the postoperative period); 30-day readmission rate; Total cost associated with blood management. Statistical analysis Continuous variables were reported as mean ± standard deviation (SD) or median with interquartile range (IQR) and compared between groups using the Mann-Whitney test or Student’s t -test as appropriate. Normality was assessed using the Shapiro-Wilk test and homogeneity of variance using Levene’s test. Categorical variables were expressed as frequencies (percentages) and compared using the chi-squared test or Fisher’s exact test, as appropriate. A two-sided p-value <0.05 was considered statistically significant. Risk factors for perioperative RBC transfusion were first assessed in univariable logistic regression. All variables with a p-value <0.05 were entered into a multivariable logistic regression model. Missing data were handled using multiple imputation by chained equations (MICE). Twenty imputed datasets were generated with 10 iterations each. The dependent variable (RBC transfusion) was not imputed but was included as a predictor in the imputation models. Each regression model was fitted separately in the 20 imputed datasets, and estimates were then combined using Rubin’s rules. Collinearity was assessed by calculating the Variance Inflation Factor (VIF). No variable exhibited problematic collinearity (all adjusted VIF < 2). As a sensitivity analysis, complete-case models (without imputation) yielded virtually identical results, confirming the robustness of the findings. Results are presented as odds ratios (OR) with 95% confidence intervals (95% CI). A two-sided p-value <0.05 was considered statistically significant. Hemoglobin levels at predefined timepoints (preoperative, postoperative days 0 to 7) were compared using a repeated-measures analysis of variance (ANOVA), with intervention group (pre- vs. post-PBM) as the between-subject factor and timepoints as the within-subject factor. Analyses were performed with R software (version 4.4.3). A large language model (ChatGPT, OpenAI) was used for language polishing only. All scientific content, analyses, and interpretations were performed by the authors. Cost analysis The costs of ferric carboxymaltose and erythropoietin were obtained from the hospital pharmacy. The cost of one RBC unit encompassed both the purchase price – set by the French national regulations at €214.11 per unit – and the administration cost, estimated at €152.43 per unit, based on a 2020 French medico-economic study [19]. The reimbursement for a day-hospital visit for iron and erythropoietin administration was the price invoiced to the patient by the hospital's billing department. A budget-impact analysis was conducted for a hypothetical cohort of 400 on-pump cardiac surgeries per year, reflecting the average annual case-volume performed in our institution. The prevalence of preoperative anemia and iron deficiency without anemia, as well as the number of patients receiving preoperative corrective treatment, was derived from the post-PBM cohort data. Transfusion rates and the average number of RBC units transfused per patient were obtained from both cohorts. Results Population Between June 2022 and May 2024, 996 adult patients underwent on-pump cardiac surgery at our institution. Of these, 209 patients were excluded for the following reasons: urgent surgeries (n=159), uncommon surgical procedures (n=38) and withdrawal of authorization of the use of their personal data for research purposes (n=12). Ultimately, 787 patients were included in the analysis, with 377 in the pre-PBM group and 410 in the post-PBM group ( Figure 1 ). Preoperative and intraoperative characteristics are presented in Table 1 . Patients were predominantly male (75%), with a mean age of 65 ± 11 years. They had similar characteristics except for left ventricular hypertrophy (18% vs. 27%; p<0.01) and preoperative pre-corrective hemoglobin (13.7 ±1.7 g/dL vs. 14 ±1.5 g/dL; p=0.02) in the pre-PBM and post-PBM groups, respectively. PBM protocol PBM actions are presented in Table 2 . 84 of 410 (20%) patients in the post-PBM group met the criteria for preoperative anemia correction, and all of them received the appropriate therapy, leading to a median increase in hemoglobin level of 1.15 [0–2] g/dL. The median time interval between preoperative PBM intervention and surgery was 14 [6-22] days. The mean administrated dose was 944 ±313 mg for intravenous ferric carboxymaltose and 856 ±484 UI/kg for erythropoietin. Compared with the pre-PBM group, patients in the post-PBM group received significantly lower total intraoperative fluid administration (55.9 ±19.2 vs. 52.9 ±21.8 mL/kg; p<0.01) and lower cardiopulmonary bypass priming volume (14.7 ±3.4 vs. 13.9 ±4.1 mL/kg; p<0.01), higher cell-salvage volume reinfusion (8.2 ±4.8 vs. 9.4 ±6.6 mL/kg; p<0.01), and higher fluid resuscitation on postoperative day 1 (21.2 ±14.7 vs. 25.1 ±18.5 mL/kg; p<0.01). The use of single-unit RBC transfusion increased significantly in the post-PBM group (37% vs. 55%; p<0.01). 53% of patients with postoperative anemia in the post-PBM group received postoperative intravenous iron supplementation. Table 1: Main characteristics of all patients and comparisons between pre and post-PBM groups Variables Pre-PBM group n=377 Post-PBM group n=410 p-value Men 282 (75) 310 (76) 0.86 Age, year 65 ± 11 64 ± 11 0.27 BMI, kg/m² 27 ± 5 27 ± 5 0.61 Comorbidities LVEF <50% 55 (15) 74 (18) 0.23 Pulmonary hypertension 45 (12) 52 (13) 0.83 Right ventricular dysfunction 12 (3) 7 (2) 0.25 Dilated cardiomyopathy 94 (25) 101 (25) 0.99 Coronary artery disease 233 (62) 268 (65) 0.36 Left Ventricular Hypertrophy 69 (18) 112 (27) <0.01 Atrial fibrillation 53 (14) 54 (13) 0.80 Diabetes 94 (25) 106 (26) 0.89 Stroke 25 (7) 31 (8) 0.71 Chronic kidney disease 73 (19) 65 (16) 0.23 Preoperative blood thinning therapies Dual antiplatelet inhibition 32 (8) 32 (8) 0.83 VKAs or DOACs 62 (16) 84 (20) 0.17 Hematological characteristics Preoperative pre-corrective hemoglobin, g/dL 13.7 ± 1.7 14 ± 1.5 0.02 Ferritin, µg/L 241 [75-309] 231 [86-306] 0.36 Transferrin saturation, % 26 ± 14 26 ± 13 0.67 Intraoperative characteristics Type of surgery 0.12 CABG only 166 (44) 197 (48) Valve only 143 (38) 123 (30) Aortic surgery 50 (13) 68 (17) CAGB + valve 18 (5) 22 (5) Redo-surgery 28 (7) 23 (6) 0.37 CPB duration, min 111 [76-129] 117 [76-144] 0.37 Aortic cross-clamp duration, min 84 [59-101] 89 [62-107] 0.22 Norepinephrine peak, µg/kg/min 0.3 [0.1-0.4] 0.3 [0.1-0.4] 0.30 Dobutamine administration 73 (19) 82 (20) 0.88 ECLS or IABP 8 (2) 9 (2) >0.99 SAPS II at ICU admission 34 ± 11 34 ± 11 0.36 Continuous variables were reported as mean ±SD or median (IQR). Categorical variables were reported as frequencies (percentages). Abbreviations: BMI= Body mass index, CABG= Coronary artery bypass grafting, CPB= Cardiopulmonary bypass, DOAC= Direct oral anticoagulant, ECLS= Extracorporeal life support, IABP= Intra-aortic balloon pump, ICU= Intensive care unit, LVEF= Left ventricular ejection fraction, SAPS= Simplified acute physiology score, VKA= Vitamin K antagonist. Table 2: PBM interventions' characteristics and comparisons between pre and post-PBM groups Variables Pre-PBM group N=377 Post-PBM group N=410 p-value Preoperative EPO administration 1 (0.3) 84 (20) <0.01 Preoperative iron administration 1 (0.3) 106 (26) <0.01 CPB priming volume, mL/kg 14.7 ± 3.4 13.9 ± 4.1 <0.01 Fluid volume during CPB, mL/kg 15.5 ± 12.5 16.3 ± 14 0.39 Total intraoperative fluid volume administered, mL/kg 55.9 ± 19.2 52.9 ± 21.8 <0.01 Cell salvage reinfusion volume, mL/kg 8.2 ± 4.8 9.4 ± 6.6 <0.01 Fluid volume administered during first postoperative day, mL/kg 21.2 ± 14.7 25.1 ± 18.5 <0.01 Postoperative iron administration 42 (13) 53 (15) 0.42 Single-unit transfusion 46 (37) 58 (55) <0.01 Continuous variables were reported as mean ±SD or median [IQR]. Categorical variables were reported as frequencies (percentages). Abbreviations: CPB= Cardiopulmonary bypass, EPO= Erythropoietin, Hb= Hemoglobin level, PBM= Patient blood management. Primary outcome RBC transfusion from surgery to hospital discharge occurred in 126 of 377 patients (33%) in the pre-PBM group and 105 of 410 patients (26%) in the post-PBM group (p=0.02), representing a 21% relative reduction in the risk of transfusion. Thus, a number needed to treat of 15 to prevent one patient from receiving RBC transfusion. The distribution of the number of RBC units transfused until hospital discharge in shown in Additional files: Figure S1 . Secondary outcomes Hemoglobin evolution during hospitalization The ANOVA revealed a significant main effect of group (p<0.01), a significant effect of time (p<0.01), and a significant time × group interaction (p=0.03), indicating that hemoglobin levels varied over time and followed different trajectories between the pre- and post-PBM groups. Preoperative hemoglobin levels were significantly lower in the pre-PBM group, even before the administration of erythropoietin or intravenous ferric carboxymaltose (13.7 ±1.7 vs. 14 ±1.5 g/dL; p=0.02). This difference remained statistically significant throughout the postoperative course: immediately after surgery (11.3 ±1.5 vs. 11.6 ± 1.5 g/dL; p<0.05), on postoperative day 3 (9.6 ±1.4 vs. 9.9 ±1.5 g/dL; p=0.01) and at hospital discharge (10.2 ±1.3 vs. 10 ±1.3 g/dL; p=0.01) as shown in Additional files: Figure S2 . Factors associated with RBC transfusion In univariable analysis ( Table 3 ), female sex, older age, chronic kidney disease, preoperative anemia, the post-PBM group, aortic and combined surgery, redo surgery, longer cardiopulmonary bypass duration, greater intraoperative fluid replacement, higher intraoperative norepinephrine dose, higher SAPS II score, and increased fluid resuscitation on day 1 were all associated with an increased risk of RBC transfusion. In multivariable analysis ( Table 3 ), inclusion in the post-PBM protocol was independently associated with a significantly lower risk of RBC transfusion (OR=0.58; 95% CI: 0.40-0.86; p<0.01). Other independent predictors included female sex (OR=1.99; 95% CI: 1.26-3.14; p<0.01), preoperative anemia (OR=3.79; 95% CI: 2.44-5.86; p<0.01), longer CPB duration (OR=1.02; 95% CI: 1.01-1.03; p=0.01), higher total intraoperative fluid replacement (OR=1.0; 95% CI:1,0-1.0; p<0.01), higher SAPS II score (OR=1.03; 95% CI: 1.01-1.05; p<0.01) and higher fluid resuscitation on the first postoperative day (OR=1.02; 95% CI: 1.01-1.03; p<0.01). Collinearity diagnostics showed no evidence of multicollinearity between predictors (all VIF < 2). Importantly, results were robust in sensitivity analyses restricted to complete cases, with consistent effect estimates and significance levels. Table 3 : Multivariable analysis of variables associated with RBC transfusion Risk factors Univariable analysis Multivariable analysis Odd Ratio p-value Odd Ratio p-value Female sex 2.91 [2.07-4.09] <0.01 1.99 [1.26-3.14] <0.01 Age 1.02 [1.01-1.04] <0.01 1.01 [0.99-1.03] 0.29 VKA or DOAcs 1.05 [0.71-1.55] 0.82 Dual antiplatelets inhibition 1.10 [0.63-1.92] 0.73 Chronic kidney disease 2.23 [1.53-3.26] <0.01 1.33 [0.81-2.19] 0.26 Preoperative anemia 5.20 [3.67-7.36] <0.01 3.79 [2.44-5.86] <0.01 Post-PBM group 0.69 [0.50-0.93] 0.02 0.58 [0.40-0.86] <0.01 Aortic surgery 1.88 [1.20-2.93] <0.01 0.91 [0.46-1.80] 0.79 Valve surgery 1.41 [0.98-2.01] 0.06 Combined surgery 4.42 [2.26-8.68] <0.01 1.53 [0.65-3.60] 0.33 Redo-surgery 4.15 [2.31-7.46] <0.01 1.64 [0.74-3.64] 0.23 CPB duration 1.01 [1.01-1.01] <0.01 1.02 [1.01-1.03] 0.01 Total intraoperative fluid replacement 1.04 [1.03-1.04] <0.01 1.02 [1.01-1.03] <0.01 Intraoperative norepinephrine administered 5.12 [3.04-8.61] <0.01 1.82 [0.96-3.42] 0.07 SAPS II 1.06 [1.05-1.08] <0.01 1.03 [1.01-1.05] <0.01 Fluid resuscitation on day 1 1.05 [1.04-1.06] <0.01 1.03 [1.02-1.05] <0.01 Explanatory variables included those significantly associated with transfusion in univarianle analysis (p<0.05). Results were expressed as odds ratio (OR) with relative 95% confidence intervals (95% CI). Abbreviations: CABG= Coronary artery bypass grafting, CPB= Cardiopulmonary bypass, DOAC= Direct oral anticoagulant, PBM= Patient blood management, SAPS= Simplified acute physiology score, VKA= Vitamin K antagonist. Postoperative complications and length of stay Table 4 summarizes the postoperative outcomes. There was no significant difference between the two groups regarding the use of fresh frozen plasma, platelets concentrate, fibrinogen or prothrombin complex concentrate administration. No significant difference was observed between the pre- and post-PBM groups in terms of ICU length of stay (2 [1-4] vs 2 [1-4] days; p=0.44), hospital length of stay (8 [7-11] vs 8 [7-10] days; p=0.17) or mortality (3% vs. 2%; p=0.53). Other main postoperative outcomes were similar between groups, including postoperative acute kidney injury (12% vs 10%, p=0.27). Notably, the post-PBM group had a lower postoperative high-sensitivity troponin levels compared to the pre-PBM group (2,978 [1,483-8,439] ng/L vs. 4,195 [1,759-10,033]; p=0.01). Table 4: Per and postoperative outcomes and comparison between pre and post-PBM group Variables Pre-PBM group N=377 Post-PBM group N=410 p-value Primary outcome RBC transfusion from surgery to hospital discharge 126 (33) 105 (26) 0.02 Secondary outcomes RBC transfusion Number of RBC ( total ) 481 480 0.19 Number of RBC ( per transfused patient ) 2 [2-4] 2 [2-4] 0.25 Interval from surgery to RBC, day 0 [0-3] 0 [0-3] 0.11 Intraoperative transfusion 70 (19) 45 (11) <0.01 Number of intraoperative RBC 2 [1.3-3] 2 [2-3] 0.19 RBC transfusion before D2 85 (22) 64 (16) 0.02 RBC transfusion before D5 120 (32) 87 (21) <0.01 RBC transfusion before D7 123 (33) 96 (23) <0.01 Other allogenic products FFP transfusion 23 (6) 34 (8) 0.30 Number of FFP transfused 3 [3-5.5] 4 [2-6] 0.86 Interval from surgery to FFP, day 0 [0-0] 0 [0-0] 0.70 Platelet concentrate transfusion 46 (12) 46 (11) 0.75 Number of platelets concentrate 1 [1-1.75] 1 [1-2] 0.26 Interval from surgery to platelets concentrates, day 0 [0-0] 0 [0-0] 0.98 Intraoperative fibrinogen 152 (40) 183 (45) 0.25 Fibrinogen dose, g 3 ± 1.6 3.4 ± 1.8 <0.01 Intraoperative PCC administration 82 (22) 95 (23) 0.72 PCC dose, UI/kg 14 [10-19] 15 [12-21] 0.07 Postoperative laboratory findings Lactate on ICU admission, mmol/L 1.7 [1.3-2.4] 1.7 [1.3-2.4] 0.94 Postoperative troponin peak, µg/L 4,195 [1,759-10,033] 2,978 [1,483-8,439] 0.01 Hemoglobin at hospital discharge 10 ± 1.3 10.2 ± 1.3 0.01 Length of stay ICU length of stay, day 2 [1-4] 2 [1-4] 0.44 Hospital length of stay, day 8 [7-11] 8 [7-10] 0.17 Postoperative mortality Inhospital death 13 (3) 10 (2) 0.53 Postoperative morbidity Hospital readmission within 30 days 26 (7) 35 (9) 0.47 Reoperation for bleeding in first 24h 12 (3) 10 (2) 0.68 Acute kidney injury 47 (12) 40 (10) 0.27 KDIGO I 23 (6) 16 (4) 0.21 KDIGO II 10 (3) 11 (3) >0.99 KDIGO III 20 (5) 14 (3) 0.26 Dialysis 16 (4) 10 (2) 0.22 Stroke 7 (2) 5 (1) 0.57 New onset atrial fibrillation 137 (33) 133 (32) 0.28 Mediastinitis and sternal infection 12 (3) 19 (5) 0.39 Superficial surgical site infection 4 (1) 10 (2) 0.23 Continuous variables were reported as mean ±SD or median [IQR]. Categorical variables were reported as frequencies (percentages). Abbreviations: CPB= Cardiopulmonary bypass, FFP= Fresh frozen plasma, ICU= Intensive care unit, KDIGO= Kidney Disease Improving Global Outcomes, PBM= Patient blood management, PCC= Prothrombin complex concentrate; RBC= Red blood cells. Cost analysis Table 5 summarizes the unitary and total costs for intravenous ferric carboxymaltose and erythropoietin alfa supplementation, RBC transfusion and the reimbursement of one-day hospital visit. The total cost introduced by the post-PBM protocol was €20,370. However, these were offset by the reduction in RBC unit transfused (-68 units) and the reimbursement of one-day hospital visit per patient (n=113). In total, the mean cost per patient decreased from €447.18 in the pre-PBM group to €278.54 in the post-PBM group, resulting in an estimated saving of €67 454.65 for 400 on-pump cardiac surgeries a year. Table 5 : Cost analysis for 400 on-pump cardiac surgeries Unitary cost (€) Number needed annually Estimated costs (€) Pre-PBM Post-PBM Pre-PBM Post-PBM Ferric carboxymaltose 1000 mg 153.88 0 84 0 12,925.92 Epoetin alfa 30 0 84 0 2,520 Ferric carboxymaltose 500 mg 76.94 0 64 0 4,924.16 RBC units 366.54 488 420 178,871.52 153,946.8 Day-hospital visit - 425 0 113 0 - 62,900 Total costs 178,871.52 111,416.99 Total cost per patient 447.18 278.54 Costs are expressed in euros (€). Abbreviations: PBM= Patient blood management, RBC= Red blood cells. Subgroup analysis Additional files: figures S3 and S4 present the results of the predefined subgroup analysis. RBC transfusion was significantly reduced for anemic patients (68% vs. 43%; p<0.01) and patients with iron deficiency associated or not with anemia (51% vs. 27%; p<0.01). However, there was no significant difference for patients with iron deficiency without anemia or according to the type of surgery. Discussion In this single-center, retrospective before-and-after study, involving 787 patients undergoing on-pump cardiac surgery, we found that the implementation of a pragmatic PBM program for elective cardiac surgery was associated with a significant reduction of RBC transfusion rates. This did not significantly affect postoperative complications or hospital length of stay, but it was cost-effective, yielding annual savings of €67,454 for 400 on-pump cardiac surgeries. Our findings are consistent with previous randomized controlled trials and observational studies that demonstrated similar reduction in transfusion rates after implementation of a PBM protocol, with an absolute reduction ranging from 33 to 26% [11,20,21]. However, our study provides new insights by evaluating a real-world PBM strategy based not solely on preoperative erythropoiesis optimization but on a perioperative bundle of care that included restrictive fluid management, retrograde priming, and single-unit transfusion. Indeed, our bundle relies on measures that had been previously studied separately, such as autologous retrograde priming that reported decreased transfusion rates from 25% to 14% and an increase in postoperative hemoglobin levels, in a study by Mekhail et al. [22]. We observed a relative risk reduction of 21% and a number needed to treat of 15, which underscores the clinical relevance of this strategy. Importantly, Multivariable logistic regression confirmed that the PBM protocol was independently associated with lower transfusion rates. Results were consistent after adjustment for all significant risk factors, with no relevant collinearity between predictors and similar findings in complete-case analyses, supporting the reliability of our conclusions. This highlights the strength of the intervention’s effect and suggests that its benefits persist beyond baseline patient characteristics or surgical complexity. This result is reinforced by the subgroup analysis which showed that the PBM protocol was especially efficient in patients with preoperative anemia or iron deficiency – adding physiological strength to the results. This suggests that, despite previous awareness of preoperative optimization challenges, standardization through PBM has improved outcomes in this vulnerable population. Also, hemoglobin trajectories further support the biological plausibility of the intervention as patients in the post-PBM group consistently maintained higher hemoglobin levels throughout hospitalization. The PBM protocol led to a median increase in hemoglobin of 1.15 g/dL. Nevertheless, the interquartile range (0–2 g/dL) indicates substantial variability in treatment response. A proportion of patients showed no measurable hemoglobin gain despite receiving intravenous iron and erythropoietin. Several hypotheses may explain this heterogeneity, including the presence of a functional iron deficiency or chronic inflammation, suboptimal timing relative to surgery, or individual variability in erythropoietic response. This observation underscores the need for early screening, individualized dosing strategies, and potentially longer lead times before surgery to optimize the efficacy of preoperative correction. Our strategy was also found to be safe: the reduction in hemodilution led to a significantly lower total intraoperative volume expansion in the post-PBM group without any increase in peroperative catecholamine requirements, postoperative acute kidney injury or need for dialysis. Interestingly, the PBM protocol was associated with a modest but statistically significant reduction in peak postoperative troponin levels. While this finding is exploratory, it raises the hypothesis that optimized preoperative hemoglobin and fluid strategies might attenuate perioperative myocardial stress. Although multimodal PBM did not significantly affect postoperative complications or hospital length of stay, it was cost-effective, yielding a per-patient cost reduction of €168.64, resulting in annual savings of €67,454 for our institution. This was primarily driven by reduced RBC transfusion and reimbursement of day-hospital admissions. Several studies incorporating broader hospitalization cost analyses also reported overall cost reductions, reinforcing these findings [23,24]. The protocol leveraged existing hospital pathways (i.e., day-hospital visits), generating revenue without additional infrastructure. This real-world analysis may support broader institutional adoption by aligning clinical value with budgetary incentives. This study has several methodological strengths. It included a large, unselected, consecutive cohort of patients undergoing on-pump cardiac surgery over a two-year period, enhancing its external validity. The before-and-after design, while observational, was implemented using strict chronological inclusion and clearly defined, protocolized interventions, minimizing selection and information biases. Data collection was comprehensive, leveraging electronic health records and standardized clinical documentation. We report a full compliance for preoperative anemia correction (100%) when needed. Median time from preoperative PBM intervention to surgery usually ranges between 4 and 6 weeks in recent series [20,21]. It was only 14 days in our cohort, underscoring that a short delay before the surgical procedure should not contraindicate PBM interventions. 15.9% (159/996) of our patients were not considered for PBM because of urgent surgery. We trust this population may also benefit from PBM. In addition, the integration of economic and biologic endpoints alongside clinical outcomes provides a holistic assessment of the PBM protocol’s impact. Beyond its methodological rigor, this study offers several clinical and operational strengths. It evaluates a comprehensive and pragmatic PBM protocol that is both actionable and cost-effective, making it readily transferable to other centers. The intervention was designed with minimal disruption to existing workflows, promoting adherence among multidisciplinary teams. By demonstrating a significant transfusion reduction in a real-world setting without compromising patient safety, the findings contribute strong evidence to support broader implementation of PBM in cardiac surgery centers. Finally, these interventions were safe, with no reported adverse event, consistent with existing literature [25]. This study has several limitations, mostly inherent to its retrospective design. First, although we adjusted for major confounding variables and perioperative protocols remained unchanged, unmeasured confounders cannot be entirely excluded. Second, preoperative hemoglobin levels were statistically lower in the pre-PBM group (13.7 vs. 14.0 g/dL), which could represent a potential confounder, given that low baseline hemoglobin is one of the strongest predictors of RBC transfusion. However, this difference was small and not clinically meaningful, and the multivariable analysis, which adjusted for preoperative anemia and other risk factors, still identified PBM implementation as an independent protective factor against transfusion. This suggests that the observed reduction in transfusion is not solely attributable to differences in baseline hemoglobin levels. Third, only preoperative anemia correction was individualized and standardized in the post-PBM group, whereas other key components, such as restrictive fluid management, CPB techniques and postoperative transfusions indications were not. Nonetheless, our results show that intraoperative hemodilution was reduced, and that single-unit transfusions increased. This seems to have translated into a higher fluid administration on day one in the post-PBM group, suggesting possible early hypovolemia. Further studies are warranted to evaluate the implementation and impact of personalized protocols for intraoperative fluid management and postoperative transfusion triggers. Additionally, there was no transition period between the pre- and post-PBM phases, as the preoperative optimization program was implemented immediately and systematically, reflecting a real-world organizational change. The absence of an implementation gap may have attenuated the impact of intra- and postoperative components of the PBM bundle; the small difference observed in priming volumes suggests that retrograde priming was not systematically performed, postoperative iron supplementation remained limited, and single-unit transfusion practice was not consistently applied. Fourth, this analysis reflects the effect of a multifaceted PBM bundle; therefore, the independent contribution of each component cannot be determined. Fifth, while transfusion rates decreased in both anemic and iron-deficient patients, these was no significant difference between the pre-PBM and post-PBM groups in the subgroup of patients with isolated iron deficiency without anemia. This may be explained by the low transfusion rates and the low preoperative iron supplementation in this population, or the limited statistical power due to the small sample size. However, Friedman et al. demonstrated reduced transfusion rates in non-anemic patients receiving preoperative iron supplementation, but it was not associated with any change in postoperative outcomes in meta-analyses [26,27]. Finally, the monocentric nature of the study may limit external generalizability, especially to institutions with different transfusion practices or reimbursement models, and the economic analysis presented here cannot be directly extrapolated to other institutions or countries with different healthcare systems or cost structures. Conclusion A personalized PBM program in the perioperative setting of elective on-pump cardiac surgery was associated with a significant reduction in the incidence of perioperative red blood cell transfusion and generated substantial cost savings, without compromising patient safety. Declarations Ethics approval and consent to participate: Approved by the Institutional Review Board (IRB 00012157). Written informed consent for data collection was obtained from all patients. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to GDPR restrictions but are available from the corresponding author on reasonable request. Competing interests: The authors declare no conflicts of interest. Funding: No external funding was received for this work; the analysis compared two standard-of-care protocols implemented within the department and required no dedicated study budget or additional resources. Authors’ Contributions: Constance Bougnoux: Data curation, Formal analysis, Visualization, Writing – original draft, Writing – review & editing. Sacha Rozencwajg: Formal analysis, Writing – review & editing. Jacques Thes: Writing – review & editing. Sylvain Diop: Writing – review & editing. Iolanda Ion: Resources. Julien Guihaire: Conceptualization, Supervision, Writing – review & editing. Baptiste Monnier: Conceptualization, Investigation, Methodology, Data curation, Supervision, Writing – review & editing. All authors have read and approved the final manuscript. Acknowledgments: The authors thank the Department of Anesthesiology and Intensive Care and the Department of Cardiac Surgery for institutional support, as well as the perfusionists, operating room nurses, and ICU nurses for their technical assistance with implementation of the perioperative PBM pathway and data capture. We also acknowledge the contributions of the hospital pharmacy and clinical informatics teams for logistical support and electronic health record extraction. References Karkouti K, Wijeysundera DN, Beattie WS, Reducing Bleeding in Cardiac Surgery (RBC) Investigators. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 29 janv 2008;117(4):478‑84. Klein AA, Collier TJ, Brar MS, Evans C, Hallward G, Fletcher SN, et al. The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia. juin 2016;71(6):627‑35. Capdevila X, Lasocki S, Duchalais A, Rigal JC, Mertl P, Ghewy P, et al. Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study. Anesth Analg. 1 août 2023;137(2):322‑31. Goel R, Patel EU, Cushing MM, Frank SM, Ness PM, Takemoto CM, et al. Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry. JAMA Surg. 1 sept 2018;153(9):826‑33. Horvath KA, Acker MA, Chang H, Bagiella E, Smith PK, Iribarne A, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg. juin 2013;95(6):2194‑201. Lee E, Hart D, Ruggiero A, Dowling O, Ausubel G, Preminger J, et al. The Relationship Between Transfusion in Cardiac Surgery Patients and Adverse Outcomes. J Cardiothorac Vasc Anesth. juill 2024;38(7):1492‑8. Paone G, Likosky DS, Brewer R, Theurer PF, Bell GF, Cogan CM, et al. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg. janv 2014;97(1):87‑93; discussion 93-94. Hajjar LA, Vincent JL, Galas FRBG, Nakamura RE, Silva CMP, Santos MH, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 13 oct 2010;304(14):1559‑67. Rössler J, Schoenrath F, Seifert B, Kaserer A, Spahn GH, Falk V, et al. Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study. Br J Anaesth. janv 2020;124(1):25‑34. Shander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, et al. A Global Definition of Patient Blood Management. Anesth Analg. 1 sept 2022;135(3):476‑88. Spahn DR, Schoenrath F, Spahn GH, Seifert B, Stein P, Theusinger OM, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet. 1 juin 2019;393(10187):2201‑12. Casselman FPA, Lance MD, Ahmed A, Ascari A, Blanco-Morillo J, Bolliger D, et al. 2024 EACTS/EACTAIC Guidelines on patient blood management in adult cardiac surgery in collaboration with EBCP. Eur J Cardiothorac Surg. 10 oct 2024;ezae352. M R G, Vlot E, van Dijk T. Quality of registration and adherence to guidelines for blood management in CABG surgeries: a case study. J Cardiothorac Surg. 20 janv 2025;20(1):78. Rancati V, Scala E, Ltaief Z, Gunga MZ, Kirsch M, Rosner L, et al. Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med. 1 juin 2021;10(11):2454. Quarterman C, Shaw M, Hughes S, Wallace V, Agarwal S. Anaemia in cardiac surgery – a retrospective review of a centre’s experience with a pre-operative intravenous iron clinic. Anaesthesia. mai 2021;76(5):629‑38. Gupta S, McEwen C, Basha A, Panchal P, Eqbal A, Wu N, et al. Retrograde autologous priming in cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 1 déc 2021;60(6):1245‑56. Vretzakis G, Kleitsaki A, Stamoulis K, Bareka M, Georgopoulou S, Karanikolas M, et al. Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial. J Cardiothorac Surg. 24 févr 2010;5:7. Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, et al. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med. juin 2022;41(3):101059. Rigal JC, Riche VP, Tching-Sin M, Fronteau C, Huon JF, Cadiet J, et al. Cost of red blood cell transfusion; evaluation in a French academic hospital. Transfus Clin Biol. nov 2020;27(4):222‑8. Charbonneau H, Savy S, Savy N, Pasquié M, Mayeur N, Angles O, et al. Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion. Journal of Clinical Anesthesia. 2024;98:111560. Czarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, et al. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth. janv 2024;38(1):73‑9. Mekhail A, Clayton N, Rhadakrishnan K, Blakey A, Galvin S. Utilizing retrograde autologous priming for blood conservation in cardiac surgery. ANZ J Surg. oct 2023;93(10):2406‑10. Kleinerüschkamp A, Meybohm P, Straub N, Zacharowski K, Choorapoikayil S. A model-based cost-effectiveness analysis of Patient Blood Management. Blood Transfus. janv 2019;17(1):16‑26. Gross I, Seifert B, Hofmann A, Spahn DR. Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion. mai 2015;55(5):1075‑81. Kei T, Mistry N, Curley G, Pavenski K, Shehata N, Tanzini RM, et al. Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis. Can J Anaesth. juin 2019;66(6):716‑31. Friedman T, Dann EJ, Bitton-Worms K, Makhoul M, Glam R, Weis A, et al. Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia. Br J Anaesth. déc 2023;131(6):981‑8. Peri V, Devlin P, Perry L, Richards T, Miles LF. Associations Between Nonanemic Iron Deficiency and Postoperative Outcomes in Cardiac Surgery: A Systematic Review and Meta-Analysis. Anesth Analg. 1 juill 2024;139(1):47‑57. Additional Declarations No competing interests reported. Supplementary Files Additionalfiles.docx Additional file 1: Figure S1. Distribution of the number of red blood cell (RBC) units transfused until hospital discharge. Additional file 2: Figure S2. Hemoglobin trajectories during hospitalization (preoperative, postoperative days 0–7, and at discharge) in the pre- and post-PBM groups. Additional file 3: Table S1. Standard perioperative management protocol before PBM implementation (antithrombotic discontinuation, heparin/protamine dosing, CPB strategy, cell salvage, antifibrinolytics, transfusion thresholds, and coagulation management). Additional file 4: Table S2. Complete description of the multimodal PBM protocol implemented in the intervention group (preoperative anemia correction, iron supplementation, CPB management, postoperative interventions, and transfusion strategies). Additional file 5: Table S3. Complete list of collected variables and their definitions according to international consensus guidelines. Additional file 6: Figure S3. Predefined subgroup analysis of RBC transfusion rates according to anemia and iron status. Additional file 7: Figure S4. Predefined subgroup analysis of RBC transfusion rates according to type of surgery. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 24 Mar, 2026 Reviews received at journal 07 Jan, 2026 Reviewers agreed at journal 02 Jan, 2026 Reviewers invited by journal 29 Dec, 2025 Editor assigned by journal 09 Sep, 2025 Submission checks completed at journal 09 Sep, 2025 First submitted to journal 08 Sep, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7567325","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":566944927,"identity":"2f23ad96-945b-4104-9f76-66437d554391","order_by":0,"name":"Constance 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10:47:08","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151906,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7567325/v1/a01f695dde1d6e534cac355f.html"},{"id":99320698,"identity":"8c8ff258-53e0-4d76-a2a1-e5cf76fa7d19","added_by":"auto","created_at":"2025-12-31 16:38:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119193,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart\u003c/p\u003e\n\u003cp\u003eAbbreviations: PBM= Patient blood management.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7567325/v1/8697cee606fecd77a5b55d3d.png"},{"id":99324288,"identity":"d84b7488-fc12-4906-aa8f-741b7862c73d","added_by":"auto","created_at":"2025-12-31 16:47:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1051862,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7567325/v1/739b4f8e-ce9b-4339-a2eb-7b6be5d09db9.pdf"},{"id":99319882,"identity":"07a27748-7306-4fe1-bf6a-0988fc4f4863","added_by":"auto","created_at":"2025-12-31 16:37:58","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":663667,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAdditional file 1: Figure S1.\u003c/strong\u003e Distribution of the number of red blood cell (RBC) units transfused until hospital discharge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 2: Figure S2.\u003c/strong\u003e Hemoglobin trajectories during hospitalization (preoperative, postoperative days 0–7, and at discharge) in the pre- and post-PBM groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 3: Table S1.\u003c/strong\u003e Standard perioperative management protocol before PBM implementation (antithrombotic discontinuation, heparin/protamine dosing, CPB strategy, cell salvage, antifibrinolytics, transfusion thresholds, and coagulation management).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 4: Table S2.\u003c/strong\u003e Complete description of the multimodal PBM protocol implemented in the intervention group (preoperative anemia correction, iron supplementation, CPB management, postoperative interventions, and transfusion strategies).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 5: Table S3.\u003c/strong\u003e Complete list of collected variables and their definitions according to international consensus guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 6: Figure S3.\u003c/strong\u003e Predefined subgroup analysis of RBC transfusion rates according to anemia and iron status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional file 7: Figure S4.\u003c/strong\u003e Predefined subgroup analysis of RBC transfusion rates according to type of surgery.\u003c/p\u003e","description":"","filename":"Additionalfiles.docx","url":"https://assets-eu.researchsquare.com/files/rs-7567325/v1/59731a0f35d7fac3b197c91b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation of a Personalized Blood Management Program in Cardiac Surgery: A Single-Center, Retrospective Before-and-After Study","fulltext":[{"header":"Background","content":"\u003cp\u003ePreoperative anemia and iron deficiency affect approximately 20-30% and 30-80% of patients scheduled for cardiac surgery, respectively [1–3]. Both conditions are associated with higher transfusion rates which are linked to an increase in postoperative morbidity and mortality [2,4–8]. These factors also contribute to higher healthcare costs, primarily driven by prolonged hospital length of stay [9]. In response, the World Health Organization has been promoting the implementation of Patient Blood Management (PBM) protocols since 2010. PBM is a patient-centered multimodal, evidence-based strategy based on three main pillars: perioperative anemia management, minimization of iatrogenic blood loss, and optimization of anemia tolerance aiming to reduce transfusion requirements while improving patient outcomes [10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite strong evidence from prospective randomized controlled trials and endorsement by international guidelines, many cardiac surgery centers fail to integrate PBM into their routine practice, hindered by upfront financial investment, organizational constraints, and resistance to change clinical routines [11–14]. Moreover, the benefit of individual PBM measures remains uncertain. For instance, intravenous iron supplementation alone, without erythropoiesis-stimulating agents or other perioperative interventions did not reduce transfusion exposure [15]. Additionally, fluid management remains a critical yet under-researched component of PBM in cardiac surgery. Factors such as hemodilution during cardiopulmonary bypass (CPB), circuit priming strategies, and perioperative fluid management can significantly impact transfusion requirements. Recent meta-analyses support the use of retrograde autologous priming \u0026nbsp;and restrictive fluid management protocols but their integration into a comprehensive PBM strategy in cardiac surgery warrants further investigation [16,17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe real-world impact of a structured PBM protocol remains insufficiently evaluated. The aim of this study was to evaluate the impact of a pragmatic, multimodal PBM protocol on transfusion rates, complications and costs in cardiac surgery.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cem\u003eStudy design and population\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective, single-center, before-and-after observational study involving adult patients undergoing elective on-pump cardiac surgery. The study was conducted between June 2022 and May 2024 in a teaching hospital in Paris area.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll adult patients scheduled for elective on-pump cardiac surgery were eligible. Exclusion criteria included urgent surgery, known hypersensitivity or contraindication to iron or erythropoietin, and “uncommon” surgical procedures such as tumor resection, ventricular septal defect closure, pericardiectomy or surgical correction for congenital heart disease. The control cohort comprised patients treated between June 1, 2022, and May 31, 2023, prior to the implementation of the perioperative PBM protocol. The intervention cohort included all consecutive patients treated between June 1, 2023, and May 31, 2024, following full protocol implementation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was approved by the institutional ethics committee (IRB 00012157). Patient consent for data collection was obtained beforehand, and an information letter was sent subsequently. No additional examinations were performed as part of this study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePBM-protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore implementation of the full PBM protocol, standard perioperative care adhered to the French guidelines [18]. This included systematic discontinuation of preoperative blood thinning therapies (antiplatelets at the exception of acetylsalicylic acid, vitamin K antagonist and direct oral anticoagulants), personalized heparin and protamine dosing (detailed in \u003cstrong\u003eAdditional files:\u003c/strong\u003e \u003cstrong\u003eTable S1\u003c/strong\u003e), normothermic cardiopulmonary bypass (CPB), systematic use of intraoperative cell salvage, and administration of tranexamic acid (10 mg/kg bolus followed by continuous infusion at 1mg/kg/hour until surgical closure). Administration of procoagulant agents was protocolized using viscoelastic point-of-care testing with rotational thromboelastometry (ROTEM®; Werfen, Barcelona, Spain), and a restrictive transfusion threshold (hemoglobin 7-8 g/dL) was applied at the discretion of the clinical team based on patient-specific tolerance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe full PBM protocol (details in \u003cstrong\u003eAdditional files: Table S2\u003c/strong\u003e) consisted of the following additional interventions:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSystematic correction of preoperative anemia, defined as hemoglobin (Hb) level \u0026lt;13 g/dL, using intravenous ferric carboxymaltose (Ferinject®, Vifor (International) AG, St Gallen, Switzerland) and subcutaneous EPOetin alfa (Binocrit®, Sandoz AG, Bale, Switzerland);\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTargeted correction of preoperative iron deficiency without anemia (Hb ≥13 g/dL with ferritin \u0026lt;100 µg/L or transferrin saturation \u0026lt;20%) using intravenous ferric carboxymaltose;\u003c/li\u003e\n \u003cli\u003ePromotion of CPB retrograde autologous priming use and of a restrictive fluid management strategy;\u003c/li\u003e\n \u003cli\u003eSystematic correction of postoperative anemia (Hb \u0026lt;12 g/dL) with intravenous ferric carboxymaltose;\u003c/li\u003e\n \u003cli\u003eImplementation of a single-unit RBC transfusion strategy (defined by\u0026nbsp;the number of transfusions that were single unit), whereby one unit was transfused at a time and the need for further transfusion was reassessed. \u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eData collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll data were retrospectively extracted from our institutional electronic health record system by two independent reviewers, in accordance with the General Data Protection Regulation. These data comprised: demographic data (age, sex, body mass index – BMI), main comorbidities and treatments, preoperative laboratory results and echocardiography findings, intraoperative data (surgical type, CPB and aortic cross-clamp time, transfusion and fluid administration), and postoperative outcomes (blood products transfusion, acute kidney injury, stroke), length of stay (LOS) in intensive care unit (ICU) and hospital, and in-hospital mortality. Preoperative hemoglobin was measured during the preoperative anesthesia consultation, which was typically performed between 1 month and 3 days before surgery. With regard to the cardiopulmonary bypass protocol, the proportion of retrograde priming use was not available; therefore, this variable was assessed indirectly based on the total priming volume per patient, which was recorded. Postoperative acute kidney injury was staged according to KDIGO criteria, excluding urine output component which was not available in our database. The complete list of variables was defined a priori based on international definitions and can be found in \u003cstrong\u003eAdditional files: Table S3\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOutcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was the proportion of patients requiring at least one RBC transfusion between surgery and hospital discharge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondary outcomes included:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTransfusion rates defined as the proportion of patients who received at least one allogeneic blood product between surgery and hospital discharge, and number of allogenic blood products transfused at predefined time points (intraoperative, and on postoperative days 5 and 7);\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHemoglobin levels during hospitalization;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eICU and hospital lengths of stay;\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eIn-hospital mortality;\u003c/li\u003e\n \u003cli\u003eIncidence of postoperative complications including stroke, new onset atrial fibrillation, acute kidney injury (defined by an increase in serum creatinine of 26 µmol/L or more or by a rise greater than 1.5 times the baseline level), surgical site infection (mediastinitis and superficial wound infection) and myocardial infarction (defined as the need for a stenting of a coronary artery in the postoperative period);\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e30-day readmission rate;\u003c/li\u003e\n \u003cli\u003eTotal cost associated with blood management.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were reported as mean ± standard deviation (SD) or median with interquartile range (IQR) and compared between groups using the Mann-Whitney test or Student’s \u003cem\u003et\u003c/em\u003e-test as appropriate. Normality was assessed using the Shapiro-Wilk test and homogeneity of variance using Levene’s test. Categorical variables were expressed as frequencies (percentages) and compared using the chi-squared test or Fisher’s exact test, as appropriate. A two-sided p-value \u0026lt;0.05 was considered statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRisk factors for perioperative RBC transfusion were first assessed in univariable logistic regression. All variables with a p-value \u0026lt;0.05 were entered into a multivariable logistic regression model. Missing data were handled using multiple imputation by chained equations (MICE). Twenty imputed datasets were generated with 10 iterations each. The dependent variable (RBC transfusion) was not imputed but was included as a predictor in the imputation models. Each regression model was fitted separately in the 20 imputed datasets, and estimates were then combined using Rubin’s rules.\u003c/p\u003e\n\u003cp\u003eCollinearity was assessed by calculating the Variance Inflation Factor (VIF). No variable exhibited problematic collinearity (all adjusted VIF \u0026lt; 2). As a sensitivity analysis, complete-case models (without imputation) yielded virtually identical results, confirming the robustness of the findings. Results are presented as odds ratios (OR) with 95% confidence intervals (95% CI). A two-sided p-value \u0026lt;0.05 was considered statistically significant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHemoglobin levels at predefined timepoints (preoperative, postoperative days 0 to 7) were compared using a repeated-measures analysis of variance (ANOVA), with intervention group (pre- vs. post-PBM) as the between-subject factor and timepoints as the within-subject factor. Analyses were performed with R software (version 4.4.3).\u003c/p\u003e\n\u003cp\u003eA large language model (ChatGPT, OpenAI) was used for language polishing only. All scientific content, analyses, and interpretations were performed by the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCost analysis\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe costs of ferric carboxymaltose and erythropoietin were obtained from the hospital pharmacy. The cost of one RBC unit encompassed both the purchase price – set by the French national regulations at €214.11 per unit – and the administration cost, estimated at €152.43 per unit, based on a 2020 French medico-economic study [19]. The reimbursement for a day-hospital visit for iron and erythropoietin administration was the price invoiced to the patient by the hospital's billing department. A budget-impact analysis was conducted for a hypothetical cohort of 400 on-pump cardiac surgeries per year, reflecting the average annual case-volume performed in our institution. The prevalence of preoperative anemia and iron deficiency without anemia, as well as the number of patients receiving preoperative corrective treatment, was derived from the post-PBM cohort data. Transfusion rates and the average number of RBC units transfused per patient were obtained from both cohorts.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003ePopulation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBetween June 2022 and May 2024, 996 adult patients underwent on-pump cardiac surgery at our institution. Of these, 209 patients were excluded for the following reasons: urgent surgeries (n=159), uncommon surgical procedures (n=38) and withdrawal of authorization of the use of their personal data for research purposes (n=12). Ultimately, 787 patients were included in the analysis, with 377 in the pre-PBM group and 410 in the post-PBM group (\u003cstrong\u003eFigure 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003ePreoperative and intraoperative characteristics are presented in \u003cstrong\u003eTable 1\u003c/strong\u003e. Patients were predominantly male (75%), with a mean age of 65 \u0026plusmn; 11 years. They had similar characteristics except for left ventricular hypertrophy (18% vs. 27%; p\u0026lt;0.01) and preoperative pre-corrective hemoglobin (13.7 \u0026plusmn;1.7 g/dL vs. 14 \u0026plusmn;1.5 g/dL; p=0.02) in the pre-PBM and post-PBM groups, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePBM protocol\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePBM actions are presented in \u003cstrong\u003eTable 2\u003c/strong\u003e. 84 of 410 (20%) patients in the post-PBM group met the criteria for preoperative anemia correction, and all of them received the appropriate therapy, leading to a median increase in hemoglobin level of 1.15 [0\u0026ndash;2] g/dL. The median time interval between preoperative PBM intervention and surgery was 14 [6-22] days. The mean administrated dose was 944 \u0026plusmn;313 mg for intravenous ferric carboxymaltose and 856 \u0026plusmn;484 UI/kg for erythropoietin. Compared with the pre-PBM group, patients in the post-PBM group received significantly lower total intraoperative fluid administration (55.9 \u0026plusmn;19.2 vs. 52.9 \u0026plusmn;21.8 mL/kg; p\u0026lt;0.01) and lower cardiopulmonary bypass priming volume (14.7 \u0026plusmn;3.4 vs. 13.9 \u0026plusmn;4.1 mL/kg; p\u0026lt;0.01), higher cell-salvage volume reinfusion (8.2 \u0026plusmn;4.8 vs. 9.4 \u0026plusmn;6.6 mL/kg; p\u0026lt;0.01), and higher fluid resuscitation on postoperative day 1 (21.2 \u0026plusmn;14.7 vs. 25.1 \u0026plusmn;18.5 mL/kg; p\u0026lt;0.01). \u0026nbsp;The use of single-unit RBC transfusion increased significantly in the post-PBM group (37% vs. 55%; p\u0026lt;0.01). 53% of patients with postoperative anemia in the post-PBM group received postoperative intravenous iron supplementation.\u003c/p\u003e\u003cp\u003eTable 1: Main characteristics of all patients and comparisons between pre and post-PBM groups\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cem\u003eVariables\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003ePre-PBM group\u003c/p\u003e\n \u003cp\u003en=377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003ePost-PBM group\u003c/p\u003e\n \u003cp\u003en=410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eMen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e282 (75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e310 (76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eAge, year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e65 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e64 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003eBMI, kg/m\u0026sup2;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e27 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e27 \u0026plusmn; 5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003eComorbidities\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;LVEF \u0026lt;50%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e55 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e74 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Pulmonary hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e45 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e52 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Right ventricular dysfunction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Dilated cardiomyopathy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e94 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e101 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Coronary artery disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e233 (62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e268 (65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left Ventricular Hypertrophy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e69 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e112 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Atrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53 (14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e54 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Diabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e94 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e106 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e25 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e31 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Chronic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e73 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e65 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003ePreoperative blood thinning therapies\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Dual antiplatelet inhibition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e32 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;VKAs or DOACs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e62 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e84 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003eHematological characteristics\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Preoperative pre-corrective hemoglobin, g/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13.7 \u0026plusmn; 1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e14 \u0026plusmn; 1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Ferritin, \u0026micro;g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e241 [75-309]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e231 [86-306]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Transferrin saturation, %\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e26 \u0026plusmn; 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e26 \u0026plusmn; 13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003eIntraoperative characteristics\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Type of surgery\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CABG only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e166 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e197 (48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Valve only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e143 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e123 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Aortic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e50 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e68 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; CAGB + valve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Redo-surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e23 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;CPB duration, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e111 [76-129]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e117 [76-144]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Aortic cross-clamp duration, min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e84 [59-101]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e89 [62-107]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Norepinephrine peak, \u0026micro;g/kg/min\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.3 [0.1-0.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.3 [0.1-0.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Dobutamine administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e73 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e82 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;ECLS or IABP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u0026gt;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 340px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;SAPS II at ICU admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e34 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e34 \u0026plusmn; 11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 70px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables were reported as mean \u0026plusmn;SD or median (IQR). Categorical variables were reported as frequencies (percentages). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: BMI= Body mass index, CABG= Coronary artery bypass grafting, CPB= Cardiopulmonary bypass, DOAC= Direct oral anticoagulant, ECLS= Extracorporeal life support, IABP= Intra-aortic balloon pump, ICU= Intensive care unit, LVEF= Left ventricular ejection fraction, SAPS= Simplified acute physiology score, VKA= Vitamin K antagonist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e PBM interventions\u0026apos; characteristics and comparisons between pre and post-PBM groups\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 284px;\"\u003e\n \u003cp\u003e\u003cem\u003eVariables\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003ePre-PBM group\u003c/p\u003e\n \u003cp\u003eN=377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003ePost-PBM group\u003c/p\u003e\n \u003cp\u003eN=410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003ePreoperative EPO administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e84 (20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003ePreoperative iron administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (0.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e106 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eCPB priming volume, mL/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e14.7 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e13.9 \u0026plusmn; 4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFluid volume during CPB, mL/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15.5 \u0026plusmn; 12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e16.3 \u0026plusmn; 14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eTotal intraoperative fluid volume administered, mL/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e55.9 \u0026plusmn; 19.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e52.9 \u0026plusmn; 21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eCell salvage reinfusion volume, mL/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8.2 \u0026plusmn; 4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e9.4 \u0026plusmn; 6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eFluid volume administered during first postoperative day, mL/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21.2 \u0026plusmn; 14.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e25.1 \u0026plusmn; 18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003ePostoperative iron administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e42 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e53 (15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 284px;\"\u003e\n \u003cp\u003eSingle-unit transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e46 (37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e58 (55)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 65px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables were reported as mean \u0026plusmn;SD or median [IQR]. Categorical variables were reported as frequencies (percentages). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: CPB= Cardiopulmonary bypass, EPO= Erythropoietin, Hb= Hemoglobin level, PBM= Patient blood management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePrimary outcome\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRBC transfusion from surgery to hospital discharge occurred in 126 of 377 patients (33%) in the pre-PBM group and 105 of 410 patients (26%) in the post-PBM group (p=0.02), representing a 21% relative reduction in the risk of transfusion. Thus, a number needed to treat of 15 to prevent one patient from receiving RBC transfusion. The distribution of the number of RBC units transfused until hospital discharge in shown in \u003cstrong\u003eAdditional files: Figure S1\u003c/strong\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSecondary outcomes\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHemoglobin evolution during hospitalization\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe ANOVA revealed a significant main effect of group (p\u0026lt;0.01), a significant effect of time (p\u0026lt;0.01), and a significant time \u0026times; group interaction (p=0.03), indicating that hemoglobin levels varied over time and followed different trajectories between the pre- and post-PBM groups. Preoperative hemoglobin levels were significantly lower in the pre-PBM group, even before the administration of erythropoietin or intravenous ferric carboxymaltose (13.7 \u0026plusmn;1.7 vs. 14 \u0026plusmn;1.5 g/dL; p=0.02). This difference remained statistically significant throughout the postoperative course: immediately after surgery (11.3 \u0026plusmn;1.5 vs. 11.6 \u0026plusmn; 1.5 g/dL; p\u0026lt;0.05), on postoperative day 3 (9.6 \u0026plusmn;1.4 vs. 9.9 \u0026plusmn;1.5 g/dL; p=0.01) and at hospital discharge (10.2 \u0026plusmn;1.3 vs. 10 \u0026plusmn;1.3 g/dL; p=0.01) as shown in \u003cstrong\u003eAdditional files: Figure S2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFactors associated with RBC transfusion\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eIn univariable analysis (\u003cstrong\u003eTable 3\u003c/strong\u003e), female sex, older age, chronic kidney disease, preoperative anemia, the post-PBM group, aortic and combined surgery, redo surgery, longer cardiopulmonary bypass duration, greater intraoperative fluid replacement, higher intraoperative norepinephrine dose, higher SAPS II score, and increased fluid resuscitation on day 1 were all associated with an increased risk of RBC transfusion.\u003c/p\u003e\n\u003cp\u003eIn multivariable analysis (\u003cstrong\u003eTable 3\u003c/strong\u003e), inclusion in the post-PBM protocol was independently associated with a significantly lower risk of RBC transfusion (OR=0.58; 95% CI: 0.40-0.86; p\u0026lt;0.01). Other independent predictors included female sex (OR=1.99; 95% CI: 1.26-3.14; p\u0026lt;0.01), preoperative anemia (OR=3.79; 95% CI: 2.44-5.86; p\u0026lt;0.01), longer CPB duration (OR=1.02; 95% CI: 1.01-1.03; p=0.01), higher total intraoperative fluid replacement (OR=1.0; 95% CI:1,0-1.0; p\u0026lt;0.01), higher SAPS II score (OR=1.03; 95% CI: 1.01-1.05; p\u0026lt;0.01) and higher fluid resuscitation on the first postoperative day (OR=1.02; 95% CI: 1.01-1.03; p\u0026lt;0.01). Collinearity diagnostics showed no evidence of multicollinearity between predictors (all VIF \u0026lt; 2). Importantly, results were robust in sensitivity analyses restricted to complete cases, with consistent effect estimates and significance levels.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 3\u003c/strong\u003e: Multivariable analysis of variables associated with RBC transfusion\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cem\u003eRisk factors\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003eUnivariable analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 195px;\"\u003e\n \u003cp\u003eMultivariable analysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003eOdd Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003eOdd Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eFemale sex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.91 [2.07-4.09]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.99 [1.26-3.14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.02 [1.01-1.04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.01 [0.99-1.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eVKA or DOAcs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.05 [0.71-1.55]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eDual antiplatelets inhibition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.10 [0.63-1.92]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eChronic kidney disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e2.23 [1.53-3.26]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.33 [0.81-2.19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003ePreoperative anemia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5.20 [3.67-7.36]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e3.79 [2.44-5.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003ePost-PBM group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0.69 [0.50-0.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.58 [0.40-0.86]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eAortic surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.88 [1.20-2.93]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e0.91 [0.46-1.80]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eValve surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.41 [0.98-2.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eCombined surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4.42 [2.26-8.68]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.53 [0.65-3.60]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eRedo-surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e4.15 [2.31-7.46]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.64 [0.74-3.64]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eCPB duration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.01 [1.01-1.01]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.02 [1.01-1.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eTotal intraoperative fluid replacement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.04 [1.03-1.04]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.02 [1.01-1.03]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eIntraoperative norepinephrine administered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e5.12 [3.04-8.61]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.82 [0.96-3.42]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eSAPS II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.06 [1.05-1.08]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.03 [1.01-1.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003eFluid resuscitation on day 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e1.05 [1.04-1.06]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 123px;\"\u003e\n \u003cp\u003e1.03 [1.02-1.05]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 73px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eExplanatory variables included those significantly associated with transfusion in univarianle analysis (p\u0026lt;0.05). Results were expressed as odds ratio (OR) with relative 95% confidence intervals (95% CI).\u003c/p\u003e\n\u003cp\u003eAbbreviations: CABG= Coronary artery bypass grafting, CPB= Cardiopulmonary bypass, DOAC= Direct oral anticoagulant, PBM= Patient blood management, SAPS= Simplified acute physiology score, VKA= Vitamin K antagonist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePostoperative complications and length of stay\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e summarizes the postoperative outcomes. There was no significant difference between the two groups regarding the use of fresh frozen plasma, platelets concentrate, fibrinogen or prothrombin complex concentrate administration. No significant difference was observed between the pre- and post-PBM groups in terms of ICU length of stay (2 [1-4] vs 2 [1-4] days; p=0.44), hospital length of stay (8 [7-11] vs 8 [7-10] days; p=0.17) or mortality (3% vs. 2%; p=0.53). Other main postoperative outcomes were similar between groups, including postoperative acute kidney injury (12% vs 10%, p=0.27). Notably, the post-PBM group had a lower postoperative high-sensitivity troponin levels compared to the pre-PBM group (2,978 [1,483-8,439] ng/L vs. 4,195 [1,759-10,033]; p=0.01).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 4:\u003c/strong\u003e Per and postoperative outcomes and comparison between pre and post-PBM group\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cem\u003eVariables\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 121px;\"\u003e\n \u003cp\u003ePre-PBM group\u003c/p\u003e\n \u003cp\u003eN=377\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 128px;\"\u003e\n \u003cp\u003ePost-PBM group\u003c/p\u003e\n \u003cp\u003eN=410\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003ePrimary outcome\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003eRBC transfusion from surgery to hospital discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e126 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e105 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u003cu\u003eSecondary outcomes\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cem\u003eRBC transfusion\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Number of RBC (\u003cem\u003etotal\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e481\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e480\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Number of RBC\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;(\u003cem\u003eper transfused patient\u003c/em\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e2 [2-4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2 [2-4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Interval from surgery to RBC, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0 [0-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0 [0-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intraoperative transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e70 (19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e45 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Number of intraoperative RBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e2 [1.3-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2 [2-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;RBC transfusion before D2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e85 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e64 (16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;RBC transfusion before D5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e120 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e87 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;RBC transfusion before D7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e123 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e96 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u003cem\u003eOther allogenic products\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;FFP transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e23 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e34 (8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Number of FFP transfused\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3 [3-5.5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e4 [2-6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Interval from surgery to FFP, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0 [0-0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0 [0-0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Platelet concentrate transfusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e46 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e46 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Number of platelets concentrate\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1 [1-1.75]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1 [1-2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Interval from surgery to platelets \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;concentrates, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e0 [0-0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e0 [0-0]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intraoperative fibrinogen\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e152 (40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e183 (45)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Fibrinogen dose, g\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e3 \u0026plusmn; 1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e3.4 \u0026plusmn; 1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intraoperative PCC administration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e82 (22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e95 (23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;PCC dose, UI/kg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e14 [10-19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e15 [12-21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Postoperative laboratory findings\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Lactate on ICU admission, mmol/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e1.7 [1.3-2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e1.7 [1.3-2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Postoperative troponin peak, \u0026micro;g/L\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4,195 [1,759-10,033]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2,978 [1,483-8,439]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hemoglobin at hospital discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e10 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e10.2 \u0026plusmn; 1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cem\u003eLength of stay\u003c/em\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; ICU length of stay, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e2 [1-4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e2 [1-4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital length of stay, day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e8 [7-11]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e8 [7-10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cem\u003ePostoperative mortality\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Inhospital death\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e13 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e10 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cem\u003ePostoperative morbidity\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Hospital readmission within 30 days\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e26 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e35 (9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Reoperation for bleeding in first 24h\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e12 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e10 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Acute kidney injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e47 (12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e40 (10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; KDIGO I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e23 (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e16 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; KDIGO II\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e10 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e11 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026gt;0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; KDIGO III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e20 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e14 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Dialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e16 (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e10 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Stroke\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e7 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e5 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; New onset atrial fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e137 (33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e133 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Mediastinitis and sternal infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e12 (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e19 (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 290px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Superficial surgical site infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 121px;\"\u003e\n \u003cp\u003e4 (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 128px;\"\u003e\n \u003cp\u003e10 (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eContinuous variables were reported as mean \u0026plusmn;SD or median [IQR]. Categorical variables were reported as frequencies (percentages).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: CPB= Cardiopulmonary bypass, FFP= Fresh frozen plasma, ICU= Intensive care unit, KDIGO= Kidney Disease Improving Global Outcomes, PBM= Patient blood management, PCC= Prothrombin complex concentrate; RBC= Red blood cells.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCost analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e summarizes the unitary and total costs for intravenous ferric carboxymaltose and erythropoietin alfa supplementation, RBC transfusion and the reimbursement of one-day hospital visit. The total cost introduced by the post-PBM protocol was \u0026euro;20,370. However, these were offset by the reduction in RBC unit transfused (-68 units) and the reimbursement of one-day hospital visit per patient (n=113). In total, the mean cost per patient decreased from \u0026euro;447.18 in the pre-PBM group to \u0026euro;278.54 in the post-PBM group, resulting in an estimated saving of \u0026euro;67 454.65 for 400 on-pump cardiac surgeries a year.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 5\u003c/strong\u003e: Cost analysis for 400 on-pump cardiac surgeries\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003eUnitary cost (\u0026euro;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 158px;\"\u003e\n \u003cp\u003eNumber needed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;annually\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 201px;\"\u003e\n \u003cp\u003eEstimated costs (\u0026euro;)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003ePre-PBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003ePost-PBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003ePre-PBM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003ePost-PBM\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eFerric carboxymaltose 1000 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e153.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e12,925.92\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eEpoetin alfa\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e2,520\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eFerric carboxymaltose\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e500 mg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e76.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e4,924.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eRBC units\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e366.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e488\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e420\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e178,871.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e153,946.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003eDay-hospital visit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e- 425\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e113\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e- 62,900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal costs\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e178,871.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e111,416.99\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cem\u003eTotal cost per patient\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 83px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 88px;\"\u003e\n \u003cp\u003e447.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e278.54\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCosts are expressed in euros (\u0026euro;).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: PBM= Patient blood management, RBC= Red blood cells.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSubgroup analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional files: figures S3\u003c/strong\u003e and \u003cstrong\u003eS4\u003c/strong\u003e present the results of the predefined subgroup analysis. RBC transfusion was significantly reduced for anemic patients (68% vs. 43%; p\u0026lt;0.01) and patients with iron deficiency associated or not with anemia (51% vs. 27%; p\u0026lt;0.01). However, there was no significant difference for patients with iron deficiency without anemia or according to the type of surgery.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this single-center, retrospective before-and-after study, involving 787 patients undergoing on-pump cardiac surgery, we found that the implementation of a pragmatic PBM program for elective cardiac surgery was associated with a significant reduction of RBC transfusion rates. This did not significantly affect postoperative complications or hospital length of stay, but it was cost-effective, yielding annual savings of €67,454 for 400 on-pump cardiac surgeries.\u003c/p\u003e\n\u003cp\u003eOur findings are consistent with previous randomized controlled trials and observational studies that demonstrated similar reduction in transfusion rates after implementation of a PBM protocol, with an absolute reduction ranging from 33 to 26% [11,20,21]. However, our study provides new insights by evaluating a real-world PBM strategy based not solely on preoperative erythropoiesis optimization but on a perioperative bundle of care that included restrictive fluid management, retrograde priming, and single-unit transfusion. Indeed, our bundle relies on measures that had been previously studied separately, such as autologous retrograde priming that reported decreased transfusion rates from 25% to 14% and an increase in postoperative hemoglobin levels, in a study by Mekhail et al. [22]. We observed a relative risk reduction of 21% and a number needed to treat of 15, which underscores the clinical relevance of this strategy. Importantly, Multivariable logistic regression confirmed that the PBM protocol was independently associated with lower transfusion rates. Results were consistent after adjustment for all significant risk factors, with no relevant collinearity between predictors and similar findings in complete-case analyses, supporting the reliability of our conclusions. This highlights the strength of the intervention’s effect and suggests that its benefits persist beyond baseline patient characteristics or surgical complexity. This result is reinforced by the subgroup analysis which showed that the PBM protocol was especially efficient in patients with preoperative anemia or iron deficiency – adding physiological strength to the results. This suggests that, despite previous awareness of preoperative optimization challenges, standardization through PBM has improved outcomes in this vulnerable population. Also, hemoglobin trajectories further support the biological plausibility of the intervention as patients in the post-PBM group consistently maintained higher hemoglobin levels throughout hospitalization.\u003c/p\u003e\n\u003cp\u003eThe PBM protocol led to a median increase in hemoglobin of 1.15 g/dL. Nevertheless, the interquartile range (0–2 g/dL) indicates substantial variability in treatment response. A proportion of patients showed no measurable hemoglobin gain despite receiving intravenous iron and erythropoietin. Several hypotheses may explain this heterogeneity, including the presence of a functional iron deficiency or chronic inflammation, suboptimal timing relative to surgery, or individual variability in erythropoietic response. This observation underscores the need for early screening, individualized dosing strategies, and potentially longer lead times before surgery to optimize the efficacy of preoperative correction.\u003c/p\u003e\n\u003cp\u003eOur strategy was also found to be safe: the reduction in hemodilution led to a significantly lower total intraoperative volume expansion in the post-PBM group without any increase in peroperative catecholamine requirements, postoperative acute kidney injury or need for dialysis. Interestingly, the PBM protocol was associated with a modest but statistically significant reduction in peak postoperative troponin levels. While this finding is exploratory, it raises the hypothesis that optimized preoperative hemoglobin and fluid strategies might attenuate perioperative myocardial stress.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough multimodal PBM did not significantly affect postoperative complications or hospital length of stay, it was cost-effective, yielding a per-patient cost reduction of €168.64, resulting in annual savings of €67,454 for our institution. This was primarily driven by reduced RBC transfusion and reimbursement of day-hospital admissions. Several studies incorporating broader hospitalization cost analyses also reported overall cost reductions, reinforcing these findings [23,24]. The protocol leveraged existing hospital pathways (i.e., day-hospital visits), generating revenue without additional infrastructure. This real-world analysis may support broader institutional adoption by aligning clinical value with budgetary incentives.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several methodological strengths. It included a large, unselected, consecutive cohort of patients undergoing on-pump cardiac surgery over a two-year period, enhancing its external validity. The before-and-after design, while observational, was implemented using strict chronological inclusion and clearly defined, protocolized interventions, minimizing selection and information biases. Data collection was comprehensive, leveraging electronic health records and standardized clinical documentation. We report a full compliance for preoperative anemia correction (100%) when needed. Median time from preoperative PBM intervention to surgery usually ranges between 4 and 6 weeks in recent series [20,21]. It was only 14 days in our cohort, underscoring that a short delay before the surgical procedure should not contraindicate PBM interventions. 15.9% (159/996) of our patients were not considered for PBM because of urgent surgery. We trust this population may also benefit from PBM. In addition, the integration of economic and biologic endpoints alongside clinical outcomes provides a holistic assessment of the PBM protocol’s impact. Beyond its methodological rigor, this study offers several clinical and operational strengths. It evaluates a comprehensive and pragmatic PBM protocol that is both actionable and cost-effective, making it readily transferable to other centers. The intervention was designed with minimal disruption to existing workflows, promoting adherence among multidisciplinary teams. By demonstrating a significant transfusion reduction in a real-world setting without compromising patient safety, the findings contribute strong evidence to support broader implementation of PBM in cardiac surgery centers. Finally, these interventions were safe, with no reported adverse event, consistent with existing literature [25].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several limitations, mostly inherent to its retrospective design. First, although we adjusted for major confounding variables and perioperative protocols remained unchanged, unmeasured confounders cannot be entirely excluded. Second, preoperative hemoglobin levels were statistically lower in the pre-PBM group (13.7 vs. 14.0 g/dL), which could represent a potential confounder, given that low baseline hemoglobin is one of the strongest predictors of RBC transfusion. However, this difference was small and not clinically meaningful, and the multivariable analysis, which adjusted for preoperative anemia and other risk factors, still identified PBM implementation as an independent protective factor against transfusion. This suggests that the observed reduction in transfusion is not solely attributable to differences in baseline hemoglobin levels. Third, only preoperative anemia correction was individualized and standardized in the post-PBM group, whereas other key components, such as restrictive fluid management, CPB techniques and postoperative transfusions indications were not. Nonetheless, our results show that intraoperative hemodilution was reduced, and that single-unit transfusions increased. This seems to have translated into a higher fluid administration on day one in the post-PBM group, suggesting possible early hypovolemia. Further studies are warranted to evaluate the implementation and impact of personalized protocols for intraoperative fluid management and postoperative transfusion triggers. Additionally, there was no transition period between the pre- and post-PBM phases, as the preoperative optimization program was implemented immediately and systematically, reflecting a real-world organizational change. The absence of an implementation gap may have attenuated the impact of intra- and postoperative components of the PBM bundle; the small difference observed in priming volumes suggests that retrograde priming was not systematically performed, postoperative iron supplementation remained limited, and single-unit transfusion practice was not consistently applied. Fourth, this analysis reflects the effect of a multifaceted PBM bundle; therefore, the independent contribution of each component cannot be determined. Fifth, while transfusion rates decreased in both anemic and iron-deficient patients, these was no significant difference between the pre-PBM and post-PBM groups in the subgroup of patients with isolated iron deficiency without anemia. This may be explained by the low transfusion rates and the low preoperative iron supplementation in this population, or the limited statistical power due to the small sample size. However, Friedman et al. demonstrated reduced transfusion rates in non-anemic patients receiving preoperative iron supplementation, but it was not associated with any change in postoperative outcomes in meta-analyses \u0026nbsp;[26,27]. Finally, the monocentric nature of the study may limit external generalizability, especially to institutions with different transfusion practices or reimbursement models, and the economic analysis presented here cannot be directly extrapolated to other institutions or countries with different healthcare systems or cost structures.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA personalized PBM program in the perioperative setting of elective on-pump cardiac surgery was associated with a significant reduction in the incidence of perioperative red blood cell transfusion and generated substantial cost savings, without compromising patient safety.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by the Institutional Review Board (IRB 00012157). Written informed consent for data collection was obtained from all patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available due to GDPR restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this work; the analysis compared two standard-of-care protocols implemented within the department and required no dedicated study budget or additional resources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConstance Bougnoux: Data curation, Formal analysis, Visualization, Writing – original draft, Writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Sacha Rozencwajg: Formal analysis, Writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Jacques Thes: Writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Sylvain Diop: Writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Iolanda Ion: Resources.\u003cbr\u003e\u0026nbsp;Julien Guihaire: Conceptualization, Supervision, Writing – review \u0026amp; editing.\u003cbr\u003e\u0026nbsp;Baptiste Monnier: Conceptualization, Investigation, Methodology, Data curation, Supervision, Writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the Department of Anesthesiology and Intensive Care and the Department of Cardiac Surgery for institutional support, as well as the perfusionists, operating room nurses, and ICU nurses for their technical assistance with implementation of the perioperative PBM pathway and data capture. We also acknowledge the contributions of the hospital pharmacy and clinical informatics teams for logistical support and electronic health record extraction.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKarkouti K, Wijeysundera DN, Beattie WS, Reducing Bleeding in Cardiac Surgery (RBC) Investigators. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study. Circulation. 29 janv 2008;117(4):478‑84. \u003c/li\u003e\n\u003cli\u003eKlein AA, Collier TJ, Brar MS, Evans C, Hallward G, Fletcher SN, et al. The incidence and importance of anaemia in patients undergoing cardiac surgery in the UK - the first Association of Cardiothoracic Anaesthetists national audit. Anaesthesia. juin 2016;71(6):627‑35. \u003c/li\u003e\n\u003cli\u003eCapdevila X, Lasocki S, Duchalais A, Rigal JC, Mertl P, Ghewy P, et al. Perioperative Iron Deficiency in Patients Scheduled for Major Elective Surgeries: A French Prospective Multicenter Cross-Sectional Study. Anesth Analg. 1 ao\u0026ucirc;t 2023;137(2):322‑31. \u003c/li\u003e\n\u003cli\u003eGoel R, Patel EU, Cushing MM, Frank SM, Ness PM, Takemoto CM, et al. Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry. JAMA Surg. 1 sept 2018;153(9):826‑33. \u003c/li\u003e\n\u003cli\u003eHorvath KA, Acker MA, Chang H, Bagiella E, Smith PK, Iribarne A, et al. Blood transfusion and infection after cardiac surgery. Ann Thorac Surg. juin 2013;95(6):2194‑201. \u003c/li\u003e\n\u003cli\u003eLee E, Hart D, Ruggiero A, Dowling O, Ausubel G, Preminger J, et al. The Relationship Between Transfusion in Cardiac Surgery Patients and Adverse Outcomes. J Cardiothorac Vasc Anesth. juill 2024;38(7):1492‑8. \u003c/li\u003e\n\u003cli\u003ePaone G, Likosky DS, Brewer R, Theurer PF, Bell GF, Cogan CM, et al. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann Thorac Surg. janv 2014;97(1):87‑93; discussion 93-94. \u003c/li\u003e\n\u003cli\u003eHajjar LA, Vincent JL, Galas FRBG, Nakamura RE, Silva CMP, Santos MH, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 13 oct 2010;304(14):1559‑67. \u003c/li\u003e\n\u003cli\u003eR\u0026ouml;ssler J, Schoenrath F, Seifert B, Kaserer A, Spahn GH, Falk V, et al. Iron deficiency is associated with higher mortality in patients undergoing cardiac surgery: a prospective study. Br J Anaesth. janv 2020;124(1):25‑34. \u003c/li\u003e\n\u003cli\u003eShander A, Hardy JF, Ozawa S, Farmer SL, Hofmann A, Frank SM, et al. A Global Definition of Patient Blood Management. Anesth Analg. 1 sept 2022;135(3):476‑88. \u003c/li\u003e\n\u003cli\u003eSpahn DR, Schoenrath F, Spahn GH, Seifert B, Stein P, Theusinger OM, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet. 1 juin 2019;393(10187):2201‑12. \u003c/li\u003e\n\u003cli\u003eCasselman FPA, Lance MD, Ahmed A, Ascari A, Blanco-Morillo J, Bolliger D, et al. 2024 EACTS/EACTAIC Guidelines on patient blood management in adult cardiac surgery in collaboration with EBCP. Eur J Cardiothorac Surg. 10 oct 2024;ezae352. \u003c/li\u003e\n\u003cli\u003eM R G, Vlot E, van Dijk T. Quality of registration and adherence to guidelines for blood management in CABG surgeries: a case study. J Cardiothorac Surg. 20 janv 2025;20(1):78. \u003c/li\u003e\n\u003cli\u003eRancati V, Scala E, Ltaief Z, Gunga MZ, Kirsch M, Rosner L, et al. Challenges in Patient Blood Management for Cardiac Surgery: A Narrative Review. J Clin Med. 1 juin 2021;10(11):2454. \u003c/li\u003e\n\u003cli\u003eQuarterman C, Shaw M, Hughes S, Wallace V, Agarwal S. Anaemia in cardiac surgery \u0026ndash; a retrospective review of a centre\u0026rsquo;s experience with a pre-operative intravenous iron clinic. Anaesthesia. mai 2021;76(5):629‑38. \u003c/li\u003e\n\u003cli\u003eGupta S, McEwen C, Basha A, Panchal P, Eqbal A, Wu N, et al. Retrograde autologous priming in cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 1 d\u0026eacute;c 2021;60(6):1245‑56. \u003c/li\u003e\n\u003cli\u003eVretzakis G, Kleitsaki A, Stamoulis K, Bareka M, Georgopoulou S, Karanikolas M, et al. Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial. J Cardiothorac Surg. 24 f\u0026eacute;vr 2010;5:7. \u003c/li\u003e\n\u003cli\u003eMertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, et al. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med. juin 2022;41(3):101059. \u003c/li\u003e\n\u003cli\u003eRigal JC, Riche VP, Tching-Sin M, Fronteau C, Huon JF, Cadiet J, et al. Cost of red blood cell transfusion; evaluation in a French academic hospital. Transfus Clin Biol. nov 2020;27(4):222‑8. \u003c/li\u003e\n\u003cli\u003eCharbonneau H, Savy S, Savy N, Pasqui\u0026eacute; M, Mayeur N, Angles O, et al. Comprehensive perioperative blood management in patients undergoing elective bypass cardiac surgery: Benefit effect of health care education and systematic correction of iron deficiency and anemia on red blood cell transfusion. Journal of Clinical Anesthesia. 2024;98:111560. \u003c/li\u003e\n\u003cli\u003eCzarnecka J, Neuschwander A, Aujoulat T, Balmier A, Belcour D, Boulanger B, et al. Red Blood Cell Transfusion Requirements Before and After Implementation of a Perioperative Patient Blood Management Program in Adult Patients Undergoing Cardiac Surgery. A Before and After Observational Study. J Cardiothorac Vasc Anesth. janv 2024;38(1):73‑9. \u003c/li\u003e\n\u003cli\u003eMekhail A, Clayton N, Rhadakrishnan K, Blakey A, Galvin S. Utilizing retrograde autologous priming for blood conservation in cardiac surgery. ANZ J Surg. oct 2023;93(10):2406‑10. \u003c/li\u003e\n\u003cli\u003eKleiner\u0026uuml;schkamp A, Meybohm P, Straub N, Zacharowski K, Choorapoikayil S. A model-based cost-effectiveness analysis of Patient Blood Management. Blood Transfus. janv 2019;17(1):16‑26. \u003c/li\u003e\n\u003cli\u003eGross I, Seifert B, Hofmann A, Spahn DR. Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion. mai 2015;55(5):1075‑81. \u003c/li\u003e\n\u003cli\u003eKei T, Mistry N, Curley G, Pavenski K, Shehata N, Tanzini RM, et al. Efficacy and safety of erythropoietin and iron therapy to reduce red blood cell transfusion in surgical patients: a systematic review and meta-analysis. Can J Anaesth. juin 2019;66(6):716‑31. \u003c/li\u003e\n\u003cli\u003eFriedman T, Dann EJ, Bitton-Worms K, Makhoul M, Glam R, Weis A, et al. Intravenous iron administration before cardiac surgery reduces red blood cell transfusion in patients without anaemia. Br J Anaesth. d\u0026eacute;c 2023;131(6):981‑8. \u003c/li\u003e\n\u003cli\u003ePeri V, Devlin P, Perry L, Richards T, Miles LF. Associations Between Nonanemic Iron Deficiency and Postoperative Outcomes in Cardiac Surgery: A Systematic Review and Meta-Analysis. Anesth Analg. 1 juill 2024;139(1):47‑57. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cardiac Surgical Procedures, Iron Deficiency, Anemia, Patient Blood Management, Blood Transfusion, Costs and Cost Analysis","lastPublishedDoi":"10.21203/rs.3.rs-7567325/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7567325/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nPreoperative anemia and iron deficiency are common in patients undergoing cardiac surgery and are associated with increased transfusion requirements, morbidity, mortality, and healthcare costs. The implementation of Patient Blood Management (PBM) strategies remains challenging in routine clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nWe conducted a single-center, retrospective before-and-after study including patients scheduled for elective on-pump cardiac surgery during one year before and one year after PBM implementation. The PBM protocol included preoperative anemia correction, reduction of intraoperative hemodilution, reinforcement of single-unit red blood cell (RBC) transfusion strategies, and postoperative iron supplementation. The primary outcome was the rate of RBC transfusion. Secondary outcomes included postoperative complications and cost analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nA total of 782 patients were included (377 pre-PBM and 411 post-PBM). Baseline characteristics were comparable, except for a lower preoperative hemoglobin level in the pre-PBM group (13.7 ± 1.7 vs. 14.0 ± 1.5 g/dL; p=0.03). RBC transfusion rate decreased significantly (33% vs. 26%, p=0.02), with a higher proportion of single-unit transfusions. The post-PBM group received less intraoperative fluids and maintained higher hemoglobin levels throughout hospitalization. In multivariable analysis, PBM implementation was independently associated with reduced transfusion risk (OR 0.58; 95% CI 0.40–0.86; p\u0026lt;0.01). The estimated annual cost savings were €67,454. There was no significant difference in postoperative complications, including acute kidney injury, stroke, new-onset atrial fibrillation, and hospital length of stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nImplementation of a pragmatic PBM program in cardiac surgery reduced RBC transfusions and healthcare costs without increasing postoperative complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration\u003c/strong\u003e: Not applicable.\u003c/p\u003e","manuscriptTitle":"Implementation of a Personalized Blood Management Program in Cardiac Surgery: A Single-Center, Retrospective Before-and-After Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-31 10:47:03","doi":"10.21203/rs.3.rs-7567325/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-24T18:06:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-08T04:03:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195239866300468580506412629958175315492","date":"2026-01-03T03:44:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-29T16:41:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-09T11:25:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-09T11:24:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-09-08T20:03:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d47f3d8d-35d3-4eeb-95d3-528ead8a2e69","owner":[],"postedDate":"December 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-03-24T18:09:45+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-31 10:47:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7567325","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7567325","identity":"rs-7567325","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}