Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery (original) (raw)
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Journal of the American College of Surgeons, 2014
BACKGROUND: Transfusion practice among surgeons varies despite several trials supporting the restrictive use of blood products. We sought to define the variation in surgeon transfusion hemoglobin (Hb) triggers and targets among patients undergoing hepatopancreaticobiliary (HPB) procedures, as well as assess perioperative outcomes among patients receiving transfusions under a restrictive vs liberal transfusion strategy. STUDY DESIGN: Using prospectively collected data, variations in transfusion Hb triggers, targets, and overall use of blood were examined among 1,554 patients undergoing an HPB procedure by 1 of 11 surgeons at Johns Hopkins Hospital between 2009 and 2013. Perioperative outcomes were compared among patients treated with a restrictive (Hb < 8 g/dL) vs liberal (Hb ! 8 g/dL) transfusion strategy.
Targeting Perioperative Hemoglobin in Major Abdominal Surgery
Journal of Anesthesia and Clinical Research, 2012
Background: Perioperative transfusion optimization may result in blood saving and minimization of complications associated with blood transfusions. The study aimed to compare units transfused, cytokines and patient outcome in a restrictive versus a liberal transfusion strategy. Materials and methods: We conducted a randomized-controlled study, in a single center, from December 2004 to May 2007. Of the 75 patients scheduled for major abdominal surgery and assessed for eligibility, 58 were randomized and 52 completed the study. Preoperatively, patients were randomly assigned to the Hb 7.7 g dL-1 (restrictive) or to the Hb 9.9 g dL-1 (liberal) group to receive blood transfusion intraoperatively and postoperatively if hemoglobin was below 7.7 g dL-1 or Hb 9.9 g dL-1 respectively. The follow-up for hemoglobin and intervention lasted five days, for cytokine measurements three days and for complications till discharge from the hospital. Units of red blood cells (RBC) per patient and the incidence of transfused patients in each group were the main outcome measure. Results: Median RBC transfused (units/patient) was 0 [interquartile range 0,2] in the restrictive versus 1 [0,3] in the liberal group (p=0.013), and the percentage of patients transfused 36% versus 70% respectively (p=0.027). Postoperative IL-10 levels were higher in the liberal transfusion group 24 h postoperatively (p<0.05). Pooled peak postoperative IL-10 levels correlated with the overall number of units of blood transfused (r2 = 0.38, p = 0.032) as well as with the overall mean duration of storage of blood transfused (in days) (r2 = 0.52, p = 0.007). Complications or time to discharge from hospital did not differ between the groups. Conclusion: In major abdominal surgery, restrictive transfusion decreases RBC requirements and IL-10 levels. The association between IL-10 and transfusion variables indicates that IL-10 may play a role in transfusionassociated immunomodulation. J o u rn al of A n e s th es ia & C li n ic a l Resea rc h
Trends in Anaesthesia and Critical Care, 2019
Background: Lack of consensus on hemoglobin threshold and transfusion strategies have led to a wide variation in transfusion practices and inappropriate use of blood. This may result in over ordering of blood with minimal utilization or unnecessary allogenic blood transfusion. This may lead to financial crisis due to costs for blood handling, laboratory tests and blood administration. So, saving of blood and resources are required by rationalizing blood transfusion indications based on evidence-based hemoglobin threshold and clinical predictive factors in resource limiting setup. Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol was used to conduct this study. PubMed, Google Scholar and Cochrane Library search engines were used to find evidences that help to draw recommendations and conclusions. Discussion: Half of clinical specialties used red blood cell transfusion with 7 g/dl threshold and the other half used 8 g/dl to 9 g/dl. Restrictive strategy of blood transfusion is as effective as liberal transfusion strategy in critically ill patients except in patients with cardiovascular diseases. Conclusions: Transfusion is required at hemoglobin levels <7 g/dl. Recent guidelines and literatures have consistently expressed the transfusion threshold between 7 and 10 g/dl with clinical indicators further defining the need for allogenic transfusion in between.
Scandinavian Journal of Surgery, 2020
Background: Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations. Methods: Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time. Results: The study included 1596 patients, of which 785 underwent pancreatoduodenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L...
Predictive factors for perioperative blood transfusions in laparoscopic colorectal surgery
International Journal of Colorectal Disease, 2014
Background: Allogeneic perioperative blood transfusions (PBT) have been associated with higher rates of postoperative complications and tumour recurrence in a number of malignancies. This study evaluates the risk factors for PBT in patients undergoing partial nephrectomy (PN), in order to identify patients who could benefit from alternatives to allogenic blood. Methods: Data on 822 patients who underwent elective PN between 1988 and 2013 were analysed. Patient demographics and clinicopathologic variables were collected retrospectively. PBT was defined as transfusion of allogeneic red blood cells during PN (in the operating-room) or postoperative hospitalization. Results: Of the 822 patients, 122 (14.8%) received PBT. Of these, 45.9% were transfused intraoperatively and 47.5% in the postoperative period. Only 14.3% of the patients who were transfused intraoperatively required additional postoperative transfusions. On multivariable analysis, age !65 (P < 0.01), lower preoperative haemoglobin levels (P < 0.001), larger renal masses (P < 0.001), central lesions (P < 0.01) and cumulative surgical experience (P < 0.001) were found to be associated with higher rate of PBT. Conclusions: Age, low preoperative haemoglobin level, lesion size, surgeons' experience and central renal lesions are independent pre-operative risk factors for PBT in patients undergoing PN. Evaluation of these risk factors prior to surgery may be helpful in constituting guidelines for a more responsible use of allogeneic blood and its alternatives.
World Journal of Surgery, 1999
In a double-blind placebo-controlled study we investigated the effect of recombinant human erythropoietin (r-HuEPO), on the perioperative hemoglobin concentration and the use of blood transfusions in patients undergoing elective colorectal surgery with a preoperative hemoglobin level <8.5 mmol/L. Altogether 100 were included, and 81 patients could be evaluated. A total of 38 patients received r-HuEPO in a dose of 300 IU/kg body weight on day 4 before surgery and 150 IU/kg daily for the following 7 days; 43 patients received placebo. In addition, all patients received daily doses of 200 mg iron orally for 4 days before surgery. There were no differences between the two groups with regard to sex, height, weight, serum electrolytes, and liver function tests at study entry. The preentry hemoglobin concentration was similar in the two groups, with a median value of 7.9 (range 5.3-8.5) mmol/L in the erythropoietin group and 7.6 (5.1-8.5) mmol/L in the placebo group. On the day of surgery the median hemoglobin concentration was 7.8 (5.3-9.2) mmol/L in the erythropoietin group and 7.2 (4.6-8.5) mmol/L in the placebo group (p < 0.05). On postoperative days 3 and 7 the values were 7.2 (5.3-8.2) and 7.5 (5.4-9.4) mmol/L, respectively, in the erythropoietin group compared to 6.7 (5.2-7.8) and 6.9 (5.1-8.6) mmol/L in the placebo group (p < 0.01). At discharge the hemoglobin concentration was 7.8 (5.9-8.8) mmol/L in the erythropoietin group and 7.2 (5.4-8.6) mmol/L in the placebo group (p < 0.002). The blood loss during operation was similar in the two groups. In the erythropoietin group the median value was 280 ml (range 25-2000 ml), with the lower and upper quartiles 150 and 500 ml, respectively. In the placebo group the blood loss was median 300 ml (range 50-1800 ml), with the lower and upper quartiles 200 and 750 ml, respectively. The number of blood transfusions given was significantly lower in the erythropoietin group, with a mean of 0.3 (range 0-6) units compared to 1.6 (0-9) units in the control group (p < 0.05). In conclusion, the hemoglobin concentration at the time of surgery and during the week following surgery was significantly higher in the group of patients receiving r-HuEPO perioperatively compared to the placebo group together with a significant lower use of blood transfusions in the r-HuEPO group. However, the clinical implications of these findings has yet to be proven.
‘Fit to fly’: overcoming barriers to preoperative haemoglobin optimization in surgical patients
British Journal of Anaesthesia, 2015
In major surgery, the implementation of multidisciplinary, multimodal and individualized strategies, collectively termed Patient Blood Management, aims to identify modifiable risks and optimise patients' own physiology with the ultimate goal of improving outcomes. Among the various strategies utilized in Patient Blood Management, timely detection and management of preoperative anaemia is most important, as it is in itself a risk factor for worse clinical outcome, but also one of the strongest predisposing factors for perioperative allogeneic blood transfusion, which in turn increases postoperative morbidity, mortality and costs. However, preoperative anaemia is still frequently ignored, with indiscriminate allogeneic blood transfusion used as a 'quick fix'. Consistent with reported evidence from other medical specialties, this imprudent practice continues to be endorsed by non-evidence based misconceptions, which constitute serious barriers for a wider implementation of preoperative haemoglobin optimisation. We have reviewed a number of these misconceptions, which we unanimously consider should be promptly abandoned by health care providers and replaced by evidence-based strategies such as detection, diagnosis and proper treatment of preoperative anaemia. We believe that this approach to preoperative anaemia management may be a viable, cost-effective strategy that is beneficial both for patients, with improved clinical outcomes, and for health systems, with more efficient use of finite health care resources.
Anaesthesia, 2019
Few studies have investigated if, and how, red cell transfusion and anaemia interact. We analysed 60,955 admissions to three metropolitan hospitals in Western Australia between 2008 and 2017 to determine whether the relationship between red cell transfusion and outcomes in surgical patients differed by lowest (nadir) level of haemoglobin. At levels above 100 g.l À1 , in-hospital, 30-day and 1-year mortality were higher with transfusion, the adjusted odds ratios (ORs) (95%CI) being 8.80 (4.43-17.45) p < 0.001 and 3.68 (1.93-7.02) p < 0.001 and the adjusted hazard ratio (95%CI) being 1.83 (1.28-2.61) p = 0.001, respectively. Likewise, between 90 g.l À1 and 99 g.l À1 , in-hospital, 30-day and 1-year mortality were higher with transfusion, the adjusted odds ratio (95%CI) being 3.76 (2.23-6.34) p < 0.001 and 1.96 (1.23-3.12) p < 0.001 and the adjusted hazard ratio (95%CI) being 1.34 (1.05-1.70) p = 0.017, respectively. Length of stay was longer with transfusion at nadir haemoglobin levels above 100 g.l À1 and in the following ranges: 90-99 g.l À1 , 80-89 g.l À1 , 70-79 g.l À1 and 60-69 g.l À1 , the adjusted rate ratio (95%CI) being 1.
IntroductionPreoperative anemia is a common finding among surgical patients. It is associated with an increased risk of perioperative morbidity and mortality. Outcomes among emergency surgical patients are not established. This study aimed to assess the effect of preoperative anemia on perioperative outcomes among patients undergoing emergency surgery in selected Southern Ethiopia governmental teaching hospitals, Southern Ethiopia, 2022.MethodA multicenter prospective cohort study was conducted. Data were collected at selected hospitals, after obtaining ethical approval from the institutional review board. Descriptive statistics, cross-tabulation, and multivariable binary logistic regression analysis were performed. A P-value less than 0.05 were taken as statistically significant.ResultA total of 200 patients who underwent emergency surgery were grouped into the anemia group (100 patients) while the rest were in the non-anemia group. There was no statistically significant difference between the groups regarding socio-demographic and intraoperative patient characteristics. Based on multivariate logistic regression, anemia group had a significant risk of perioperative transfusion requirement (Relative Risk (RR) = 4.030, p < 0.001), developing postoperative complications (RR = 1.868, p = 0.017), occurring in-hospital mortality (RR = 5.763, p = 0.045), prolong the length of hospital stay (RR = 4.028, p < 0.001), and requiring postoperative intensive care unit admission (RR = 6.332, p = 0.003) compared with non-anemia groups.ConclusionPreoperative anemia was associated with a higher rate of perioperative transfusion requirements, along with increased postoperative complication, increased in-hospital mortality, increased Intensive Critical Care Unit admission rate, and prolonged length of hospital stay. We recommend adequate preoperative assessment and correction of hemoglobin concentrations to normal values to improve surgical outcomes and reduce complications.