Skip to main content
SpringerLink
Log in

Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures.

Methods

Patients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity.

Results

Among 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3–4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98–1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88–1.22; P = 0.65).

Conclusions

Liberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Greenblatt DY, Kelly KJ, Rajamanickam V, et al. Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy. Annals of surgical oncology. Aug 2011;18(8):2126-2135.

  2. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine. Jan 29 2009;360(5):491-499.

  3. Shapiro M, Swanson SJ, Wright CD, et al. Predictors of major morbidity and mortality after pneumonectomy utilizing the Society for Thoracic Surgeons General Thoracic Surgery Database. The Annals of thoracic surgery. Sep 2010;90(3):927-934; discussion 934-925.

  4. Pinheiro de Almeida J, Vincent JL, Barbosa Gomes Galas FR, et al. Transfusion requirements in surgical oncology patients: a prospective, randomized controlled trial. Anesthesiology. Jan 2015;122(1):29-38.

  5. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. The New England journal of medicine. Dec 29 2011;365(26):2453-2462.

  6. Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM. Identifying variations in blood use based on hemoglobin transfusion trigger and target among hepatopancreaticobiliary surgeons. Journal of the American College of Surgeons. Aug 2014;219(2):217-228.

  7. Whitaker BI. Report of the US Department of Health and Human Services. The 2011 National Blood Collection and Utilization Survey Report. 2011; http://www.hhs.gov/ash/bloodsafety/2011-nbcus.pdf, February 15, 2015.

  8. Bueter M, Thalheimer A, Schuster F, et al. Transfusion-related acute lung injury (TRALI)--an important, severe transfusion-related complication. Langenbeck's archives of surgery / Deutsche Gesellschaft fur Chirurgie. Sep 2006;391(5):489-494.

  9. Popovsky MA, Chaplin HC, Jr., Moore SB. Transfusion-related acute lung injury: a neglected, serious complication of hemotherapy. Transfusion. Jul-Aug 1992;32(6):589-592.

  10. Roberson RS, Bennett-Guerrero E. Impact of red blood cell transfusion on global and regional measures of oxygenation. The Mount Sinai journal of medicine, New York. Jan-Feb 2012;79(1):66-74.

  11. Ejaz A, Spolverato G, Kim Y, et al. Impact of Blood Transfusions and Transfusion Practices on Long-Term Outcome Following Hepatopancreaticobiliary Surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. Feb 24 2015.

  12. Komatsu Y, Orita H, Sakurada M, Maekawa H, Hoppo T, Sato K. Intraoperative blood transfusion contributes to decreased long-term survival of patients with esophageal cancer. World journal of surgery. Apr 2012;36(4):844-850.

  13. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA : the journal of the American Medical Association. Oct 13 2010;304(14):1559-1567.

  14. Hebert PC, Carson JL. Transfusion threshold of 7 g per deciliter--the new normal. The New England journal of medicine. Oct 9 2014;371(15):1459-1461.

  15. Holst LB, Wetterslev J, Perner A. Hemoglobin threshold for transfusion in septic shock. The New England journal of medicine. Jan 1 2015;372(1):91-92.

  16. Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. The New England journal of medicine. Apr 19 2007;356(16):1609-1619.

  17. Robertson CS, Hannay HJ, Yamal JM, et al. Effect of erythropoietin and transfusion threshold on neurological recovery after traumatic brain injury: a randomized clinical trial. JAMA : the journal of the American Medical Association. Jul 2 2014;312(1):36-47.

  18. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. The New England journal of medicine. Jan 3 2013;368(1):11-21.

  19. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Annals of internal medicine. Jul 3 2012;157(1):49-58.

  20. Carson JL, Hill S, Carless P, Hebert P, Henry D. Transfusion triggers: a systematic review of the literature. Transfusion medicine reviews. Jul 2002;16(3):187-199.

  21. Carson JL, Brooks MM, Abbott JD, et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. American heart journal. Jun 2013;165(6):964-971 e961.

  22. Frank SM, Wick EC, Dezern AE, et al. Risk-adjusted clinical outcomes in patients enrolled in a bloodless program. Transfusion. Oct 2014;54(10 Pt 2):2668-2677.

  23. Frank SM, Resar LM, Rothschild JA, Dackiw EA, Savage WJ, Ness PM. A novel method of data analysis for utilization of red blood cell transfusion. Transfusion. Dec 2013;53(12):3052-3059.

  24. Frank SM, Savage WJ, Rothschild JA, et al. Variability in blood and blood component utilization as assessed by an anesthesia information management system. Anesthesiology. Jul 2012;117(1):99-106.

  25. Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM. Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery. The British journal of surgery. Oct 2014;101(11):1424-1433.

  26. Munoz M, Leal-Noval SR. Restrictive transfusion triggers in major orthopaedic surgery: effective and safe? Blood transfusion=Trasfusione del sangue. Apr 2013;11(2):169-171.

  27. Garraud O, Cognasse F, Hamzeh-Cognasse H, Laradi S, Pozzetto B, Muller JY. [Blood transfusion and inflammation]. Transfusion clinique et biologique : journal de la Societe francaise de transfusion sanguine. May 2013;20(2):231-238.

  28. Tuinman PR, Vlaar AP, Cornet AD, et al. Blood transfusion during cardiac surgery is associated with inflammation and coagulation in the lung: a case control study. Crit Care. 2011;15(1):R59.

    Article  PubMed Central  PubMed  Google Scholar 

  29. Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. The American journal of medicine. Feb 2014;127(2):124-131 e123.

  30. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. The New England journal of medicine. Feb 11 1999;340(6):409-417.

  31. Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. The Cochrane database of systematic reviews. 2012;4:CD002042.

    PubMed Central  PubMed  Google Scholar 

  32. McIntyre LA, Fergusson DA, Hutchison JS, et al. Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocritical care. 2006;5(1):4-9.

    Article  PubMed  Google Scholar 

  33. Zilberberg MD, Shorr AF. Effect of a restrictive transfusion strategy on transfusion-attributable severe acute complications and costs in the US ICUs: a model simulation. BMC health services research. 2007;7:138.

    Article  PubMed Central  PubMed  Google Scholar 

  34. Foss NB, Kristensen MT, Jensen PS, Palm H, Krasheninnikoff M, Kehlet H. The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion. Feb 2009;49(2):227-234.

  35. So-Osman C, Nelissen R, Brand R, et al. The impact of a restrictive transfusion trigger on post-operative complication rate and well-being following elective orthopaedic surgery: a post-hoc analysis of a randomised study. Blood transfusion = Trasfusione del sangue. Apr 2013;11(2):289-295.

  36. Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion. Oct 2014;54(10 Pt 2):2753-2759.

  37. Wang J, Bao YX, Bai M, Zhang YG, Xu WD, Qi XS. Restrictive vs liberal transfusion for upper gastrointestinal bleeding: a meta-analysis of randomized controlled trials. World journal of gastroenterology : WJG. Oct 28 2013;19(40):6919-6927.

  38. Chatterjee S, Wetterslev J, Sharma A, Lichstein E, Mukherjee D. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA internal medicine. Jan 28 2013;173(2):132-139.

  39. Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. The Cochrane database of systematic reviews. 2006(1):CD005033.

    PubMed  Google Scholar 

  40. Sun C, Wang Y, Yao HS, Hu ZQ. Allogeneic blood transfusion and the prognosis of gastric cancer patients: Systematic review and meta-analysis. International journal of surgery (London, England). Jan 2015;13:102-110.

  41. Acheson AG, Brookes MJ, Spahn DR. Effects of allogeneic red blood cell transfusions on clinical outcomes in patients undergoing colorectal cancer surgery: a systematic review and meta-analysis. Annals of surgery. Aug 2012;256(2):235-244.

  42. Patel SV, Kidane B, Klingel M, Parry N. Risks associated with red blood cell transfusion in the trauma population, a meta-analysis. Injury. Oct 2014;45(10):1522-1533.

  43. Carson JL, Altman DG, Duff A, et al. Risk of bacterial infection associated with allogeneic blood transfusion among patients undergoing hip fracture repair. Transfusion. Jul 1999;39(7):694-700.

  44. Houbiers JG, van de Velde CJ, van de Watering LM, et al. Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery: a prospective study. Transfusion. Feb 1997;37(2):126-134.

  45. Koval KJ, Rosenberg AD, Zuckerman JD, et al. Does blood transfusion increase the risk of infection after hip fracture? Journal of orthopaedic trauma. May 1997;11(4):260-265; discussion 265-266.

  46. Menis M, Anderson SA, Forshee RA, et al. Transfusion-related acute lung injury and potential risk factors among the inpatient US elderly as recorded in Medicare claims data, during 2007 through 2011. Transfusion. Sep 2014;54(9):2182-2193.

  47. Middelburg RA, van de Watering LM, van der Bom JG. Blood transfusions: good or bad? Confounding by indication, an underestimated problem in clinical transfusion research. Transfusion. Jun 2010;50(6):1181-1183.

Download references

Conflict of Interest

None

Author information

Authors and Affiliations

  1. Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA

    Yuhree Kim, Gaya Spolverato, Li Xu, Doris Wagner & Timothy M. Pawlik

  2. Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA

    Donald J. Lucas

  3. Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA

    Aslam Ejaz

  4. Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Steven M. Frank

Authors
  1. Yuhree Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gaya Spolverato
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Donald J. Lucas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Aslam Ejaz
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Li Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Doris Wagner
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Steven M. Frank
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Timothy M. Pawlik
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Timothy M. Pawlik.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 43 kb)

ESM 2

(DOCX 90 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, Y., Spolverato, G., Lucas, D.J. et al. Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery. J Gastrointest Surg 19, 2062–2073 (2015). https://doi.org/10.1007/s11605-015-2926-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-015-2926-9

Keywords

Search

Navigation