Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality


To determine the effect of implementing an algorithm of fluid and blood administration based on continuous monitoring of hemoglobin (SpHb) and PVI (plethysmography variability index) on mortality and transfusion on a whole hospital scale. This single-center quality program compared transfusion at 48 h and mortality at 30 days and 90 days after surgery between two 11-month periods in 2013 and 2014 during which all the operating and recovery rooms and intensive care units were equipped with SpHb/PVI monitors. The entire team was trained to use monitors and the algorithm. Team members were free to decide whether or not to use devices. Each device was connected to an electronic wireless acquired database to anonymously acquire parameters on-line and identify patients who received the monitoring. All data were available from electronic files. Patients were divided in three groups; 2013 (G1, n = 9285), 2014 without (G2, n = 5856) and with (G3, n = 3575) goal-directed therapy. The influence of age, ASA class, severity and urgency of surgery and use of algorithm on mortality and blood use were analyzed with cox-proportional hazard models. Because in 2015, SpHb/PVI monitors were no longer available, we assessed post-study mortality observed in 2015 to measure the impact of team training to adjust vascular filling on a patient to patient basis. During non-cardiac surgery, blood was more often transfused during surgery in G3 patients as compared to G2 (66.6% vs. 50.7%, p < 0.001) but with fewer blood units per patient. After adjustment, survival analysis showed a lower risk of transfusion at 48 h in G3 [OR 0.79 (0.68–0.93), p = 0.004] but not in G2 [OR 0.90 (0.78–1.04) p = 0.17] as compared to G1. When adjusting to the severity of surgery as covariable, there was 0.5 and 0.7% differences of mortality at day 30 and 90 whether patients had goal directed therapy (GDT). After high risk surgery, the mortality at day 30 is reduced by 4% when using GDT, and 1% after intermediate risk surgery. There was no difference for low risk surgery. G3 Patients had a lower risk of death at 30 days post-surgery [OR 0.67 (0.49–0.92) p = 0.01] but not G2 patients [OR 1.01, (0.78–1.29), p = 0.96]. In 2015, mortality at 30 days and 90 days increased again to similar levels as those of 2013, respectively 2.18 and 3.09%. Monitoring SpHb and PVI integrated in a vascular filling algorithm is associated with earlier transfusion and reduced 30 and 90-day mortality on a whole hospital scale.

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Dr Sébastien Ponsonnard. Jeanne Moreau for translation assistance.


Masimo society provided all monitors to the hospital for 1 year. Six hundred disposable (Rainbow® ReSposable™ SpHb) sensors were purchased by the hospital. The remaining sensors were donated by the manufacturer.

In exchange the CHU of Limoges agreed to give access to anonymous data collected by the wireless acquired data base of Rainbow monitoring (“Safety net™”).

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Correspondence to Jérôme Cros or Nathalie Nathan.

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Surgery severity criteria

Minor procedures

  • Inguinal hernia

  • Diagnostic videoscopy of any part of the body (knee, thorax) except mediastinoscopy

  • Simple cholecystectomy

  • Appendectomy

  • Soft tissue abscess

  • Thyroidectomy

  • Varicose vein surgery

  • Finger amputation

  • Bone fracture reduction/osteosynthesis

  • Cesarean section

  • Lumpectomy

  • Trans-urethral bladder resection

  • Transurethral prostatic resection by laser

Moderately to significant invasive procedure

  • Transurethral prostatic or bladder resection (except laser)

  • Hip or knee replacement (first procedure) + shoulder replacement

  • Open long bone (femur, humerus) or pelvic osteosynthesis

  • Hysterectomy, myomectomy regardless of the route (open or laparoscopy)

  • Radical mastectomy

  • Nephrectomy

  • Laparoscopic radical prostatectomy

  • Cystectomy and ileal reconstruction

  • Appendectomy with complications

  • Open cholecystectomy with principal biliary duct exploration

  • Reconstructive surgery of digestive tract

  • Gynecologic exploration for postpartum hemorrhage

  • Cesarean section for multiple gestation or scarred uterus or abnormal placental insertion (except placenta accreta)

  • Mediastinoscopy

  • Peripheral arterial vascular surgery

  • Amputation of foot or leg

  • Peritonitis

Highly invasive surgeries

  • Partial or total pneumonectomy

  • Major orthopedic surgery (scoliosis or redux hip or knee prosthesis)

  • Open radical prostatectomy

  • Complex pelvectomy

  • Complex digestive tract surgery, pancreatectomy, gastrectomy, esophagectomy

  • CHIP surgery

  • Aortic vascular surgery

  • Renal graft

  • Cardiac surgery

  • Complete amputation of leg or arm

  • Cesarean section with placenta accreta

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Cros, J., Dalmay, F., Yonnet, S. et al. Continuous hemoglobin and plethysmography variability index monitoring can modify blood transfusion practice and is associated with lower mortality. J Clin Monit Comput 34, 683–691 (2020).

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  • Hemoglobin
  • Volemia
  • Mortality
  • Transfusion
  • Plethysmography variability index