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Journal of Gastrointestinal Surgery

, Volume 19, Issue 11, pp 1927–1937 | Cite as

Significant Variation in Blood Transfusion Practice Persists following Upper GI Cancer Resection

  • Christopher T. Aquina
  • Neil Blumberg
  • Christian P. Probst
  • Adan Z. Becerra
  • Bradley J. Hensley
  • James C. Iannuzzi
  • Maynor G. Gonzalez
  • Andrew-Paul Deeb
  • Katia Noyes
  • John R. T. Monson
  • Fergal J. Fleming
Original Article

Abstract

Purpose

Perioperative blood transfusions are costly and linked to adverse clinical outcomes. We investigated the factors associated with variation in blood transfusion utilization following upper gastrointestinal cancer resection and its association with infectious complications.

Methods

The Statewide Planning and Research Cooperative System was queried for elective esophagectomy, gastrectomy, and pancreatectomy for malignancy in NY State from 2001 to 2013. Bivariate and hierarchical logistic regression analyses were performed to assess the factors associated with receiving a perioperative allogeneic red blood cell transfusion. Additional multivariable analysis examined the relationship between transfusion and infectious complications.

Results

Among 14,875 patients who underwent upper GI cancer resection, 32 % of patients received a perioperative blood transfusion. After controlling for patient, surgeon, and hospital-level factors, significant variation in transfusion rates was present across both surgeons (p < 0.0001) and hospitals (p < 0.0001). Receipt of a blood transfusion was also independently associated with wound infection (OR = 1.68, 95% CI = 1.47 and 1.91), pneumonia (OR = 1.98, 95% CI = 1.74 and 2.26), and sepsis (OR = 2.49, 95% CI = 2.11 and 2.94).

Conclusion

Significant variation in perioperative blood transfusion utilization is present at both the surgeon and hospital level. These findings are unexplained by patient-level factors and other known hospital characteristics, suggesting that variation is due to provider preferences and/or lack of standardized transfusion protocols. Implementing institutional transfusion guidelines is necessary to limit unwarranted variation and reduce infectious complication rates.

Keywords

Blood transfusion Upper gastrointestinal tract Neoplasms Health services research 

Notes

Grant Support

None.

References

  1. 1.
    The 2011 National Blood Collection and Utilization Survey Report. Washington, DC: US Department of Health and Human Services; 2011.Google Scholar
  2. 2.
    Napolitano LM, Kurek S, Luchette FA, Corwin HL, Barie PS, Tisherman SA, Hebert PC, Anderson GL, Bard MR, Bromberg W, Chiu WC, Cipolle MD, Clancy KD, Diebel L, Hoff WS, Hughes KM, Munshi I, Nayduch D, Sandhu R, Yelon JA, American College of Critical Care Medicine of the Society of Critical Care M, Eastern Association for the Surgery of Trauma Practice Management W. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med. 2009 Dec;37(12):3124–57.Google Scholar
  3. 3.
    Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J Am Coll Surg. 2009 May;208(5):931–7, 7 e1-2; discussion 8–9.Google Scholar
  4. 4.
    Grimshaw K, Sahler J, Spinelli SL, Phipps RP, Blumberg N. New frontiers in transfusion biology: identification and significance of mediators of morbidity and mortality in stored red blood cells. Transfusion. 2011 Apr;51(4):874–80.Google Scholar
  5. 5.
    Glance LG, Dick AW, Mukamel DB, Fleming FJ, Zollo RA, Wissler R, Salloum R, Meredith UW, Osler TM. Association between intraoperative blood transfusion and mortality and morbidity in patients undergoing noncardiac surgery. Anesthesiology. 2011 Feb;114(2):283–92.Google Scholar
  6. 6.
    Al-Refaie WB, Parsons HM, Markin A, Abrams J, Habermann EB. Blood transfusion and cancer surgery outcomes: a continued reason for concern. Surgery. 2012 Sep;152(3):344–54.Google Scholar
  7. 7.
    Ferraris VA, Davenport DL, Saha SP, Austin PC, Zwischenberger JB. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg. 2012 Jan;147(1):49–55.Google Scholar
  8. 8.
    Cata JP, Wang H, Gottumukkala V, Reuben J, Sessler DI. Inflammatory response, immunosuppression, and cancer recurrence after perioperative blood transfusions. Br J Anaesth. 2013 May;110(5):690–701.Google Scholar
  9. 9.
    Carson JL, Grossman BJ, Kleinman S, Tinmouth AT, Marques MB, Fung MK, Holcomb JB, Illoh O, Kaplan LJ, Katz LM, Rao SV, Roback JD, Shander A, Tobian AA, Weinstein R, Swinton McLaughlin LG, Djulbegovic B, Clinical Transfusion Medicine Committee of the A. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med. 2012 Jul 3;157(1):49–58.Google Scholar
  10. 10.
    Goodnough LT, Johnston MF, Toy PT. The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group. JAMA. 1991 Jan 2;265(1):86–90.Google Scholar
  11. 11.
    Stover EP, Siegel LC, Parks R, Levin J, Body SC, Maddi R, D’Ambra MN, Mangano DT, Spiess BD. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology. 1998 Feb;88(2):327–33.Google Scholar
  12. 12.
    Snyder-Ramos SA, Mohnle P, Weng YS, Bottiger BW, Kulier A, Levin J, Mangano DT, Investigators of the Multicenter Study of Perioperative I, Group MR. The ongoing variability in blood transfusion practices in cardiac surgery. Transfusion. 2008 Jul;48(7):1284–99.Google Scholar
  13. 13.
    Surgenor DM, Wallace EL, Churchill WH, Hao SH, Chapman RH, Poss R. Red cell transfusions in total knee and total hip replacement surgery. Transfusion. 1991 Jul-Aug;31(6):531–7.Google Scholar
  14. 14.
    Churchill WH, McGurk S, Chapman RH, Wallace EL, Bertholf MF, Goodnough LT, Kao KJ, Olson JD, Woodson RD, Surgenor DM. The Collaborative Hospital Transfusion Study: variations in use of autologous blood account for hospital differences in red cell use during primary hip and knee surgery. Transfusion. 1998 Jun;38(6):530–9.Google Scholar
  15. 15.
    Audet AM, Andrzejewski C, Popovsky MA. Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis. Orthopedics. 1998 Aug;21(8):851–8.Google Scholar
  16. 16.
    Aquina CT, Kelly KN, Probst CP, Iannuzzi JC, Noyes K, Langstein HN, Monson JR, Fleming FJ. Surgeon volume plays a significant role in outcomes and cost following open incisional hernia repair. J Gastrointest Surg. 2015 Jan;19(1):100–10; discussion 10.Google Scholar
  17. 17.
    Aquina CT, Probst CP, Kelly KN, Iannuzzi JC, Noyes K, Fleming FJ, Monson JR. The pitfalls of inguinal herniorrhaphy: Surgeon volume matters. Surgery. 2015 May 30.Google Scholar
  18. 18.
    Silber JH, Romano PS, Rosen AK, Wang Y, Even-Shoshan O, Volpp KG. Failure-to-rescue: comparing definitions to measure quality of care. Med Care. 2007 Oct;45(10):918–25.Google Scholar
  19. 19.
    Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998 Jan;36(1):8–27.Google Scholar
  20. 20.
    Rubin DB. Estimating causal effects from large data sets using propensity scores. Ann Intern Med. 1997 Oct 15;127(8 Pt 2):757–63.Google Scholar
  21. 21.
    Kelly KN, Iannuzzi JC, Rickles AS, Garimella V, Monson JR, Fleming FJ. Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications. Surg Endosc. 2014 Jan;28(1):65–73.Google Scholar
  22. 22.
    Kelly KN, Fleming FJ, Aquina CT, Probst CP, Noyes K, Pegoli W, Monson JR. Disease severity, not operative approach, drives organ space infection after pediatric appendectomy. Ann Surg. 2014 Sep;260(3):466–71; discussion 72–3.Google Scholar
  23. 23.
    Iannuzzi JC, Rickles AS, Kelly KN, Rusheen AE, Dolan JG, Noyes K, Monson JR, Fleming FJ. Perioperative pleiotropic statin effects in general surgery. Surgery. 2014 Mar;155(3):398–407.Google Scholar
  24. 24.
    Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Missed opportunity: Laparoscopic colorectal resection is associated with lower incidence of small bowel obstruction compared to an open approach. Annals of Surgery. 2015;(In Press).Google Scholar
  25. 25.
    Practice strategies for elective red blood cell transfusion. American College of Physicians. Ann Intern Med. 1992 Mar 1;116(5):403–6.Google Scholar
  26. 26.
    Bennett-Guerrero E, Zhao Y, O’Brien SM, Ferguson TB, Jr., Peterson ED, Gammie JS, Song HK. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA. 2010 Oct 13;304(14):1568–75.Google Scholar
  27. 27.
    Qian F, Osler TM, Eaton MP, Dick AW, Hohmann SF, Lustik SJ, Diachun CA, Pasternak R, Wissler RN, Glance LG. Variation of blood transfusion in patients undergoing major noncardiac surgery. Ann Surg. 2013 Feb;257(2):266–78.Google Scholar
  28. 28.
    Ejaz A, Spolverato G, Kim Y, Frank SM, Pawlik TM. Variation in triggers and use of perioperative blood transfusion in major gastrointestinal surgery. Br J Surg. 2014 Oct;101(11):1424–33.Google Scholar
  29. 29.
    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. J Am Coll Surg. 2014 Aug;219(2):217–28.Google Scholar
  30. 30.
    Ejaz A, Frank SM, Spolverato G, Kim Y, Pawlik TM. Potential Economic Impact of Using a Restrictive Transfusion Trigger Among Patients Undergoing Major Abdominal Surgery. JAMA Surg. 2015 May 6.Google Scholar
  31. 31.
    Society of Thoracic Surgeons Blood Conservation Guideline Task F, Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Society of Cardiovascular Anesthesiologists Special Task Force on Blood T, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, International Consortium for Evidence Based P, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011 Mar;91(3):944–82.Google Scholar
  32. 32.
    Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999 Feb 11;340(6):409–17.Google Scholar
  33. 33.
    Lacroix J, Hebert PC, Hutchison JS, Hume HA, Tucci M, Ducruet T, Gauvin F, Collet JP, Toledano BJ, Robillard P, Joffe A, Biarent D, Meert K, Peters MJ, Investigators T, Canadian Critical Care Trials G, Pediatric Acute Lung I, Sepsis Investigators N. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007 Apr 19;356(16):1609–19.Google Scholar
  34. 34.
    Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, Fukushima J, Kalil Filho R, Sierra DB, Lopes NH, Mauad T, Roquim AC, Sundin MR, Leao WC, Almeida JP, Pomerantzeff PM, Dallan LO, Jatene FB, Stolf NA, Auler JO, Jr. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA. 2010 Oct 13;304(14):1559–67.Google Scholar
  35. 35.
    Carson JL, Terrin ML, Noveck H, Sanders DW, Chaitman BR, Rhoads GG, Nemo G, Dragert K, Beaupre L, Hildebrand K, Macaulay W, Lewis C, Cook DR, Dobbin G, Zakriya KJ, Apple FS, Horney RA, Magaziner J, Investigators F. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011 Dec 29;365(26):2453–62.Google Scholar
  36. 36.
    Villanueva C, Colomo A, Bosch A, Concepcion M, Hernandez-Gea V, Aracil C, Graupera I, Poca M, Alvarez-Urturi C, Gordillo J, Guarner-Argente C, Santalo M, Muniz E, Guarner C. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11–21.Google Scholar
  37. 37.
    Carson JL, Patel MS. Red blood cell transfusion thresholds: can we go even lower? Transfusion. 2014 Oct;54(10 Pt 2):2593–4.Google Scholar
  38. 38.
    Opelz G, Terasaki PI. Improvement of kidney-graft survival with increased numbers of blood transfusions. N Engl J Med. 1978 Oct 12;299(15):799–803.Google Scholar
  39. 39.
    Reddy SS, Leitman IM. Blood transfusions in the surgical patient: a gift of life, but at what cost? J Surg Res. 2013 May;181(2):216–8.Google Scholar
  40. 40.
    Blumberg N. Deleterious clinical effects of transfusion immunomodulation: proven beyond a reasonable doubt. Transfusion. 2005 Aug;45(2 Suppl):33S-9S; discussion 9S-40S.Google Scholar
  41. 41.
    Isbister JP, Shander A, Spahn DR, Erhard J, Farmer SL, Hofmann A. Adverse blood transfusion outcomes: establishing causation. Transfus Med Rev. 2011 Apr;25(2):89–101.Google Scholar
  42. 42.
    Hendrickson JE, Hillyer CD. Noninfectious serious hazards of transfusion. Anesth Analg. 2009 Mar;108(3):759–69.Google Scholar
  43. 43.
    Raghavan M, Marik PE. Anemia, allogenic blood transfusion, and immunomodulation in the critically ill. Chest. 2005 Jan;127(1):295–307.Google Scholar
  44. 44.
    Jensen LS, Kissmeyer-Nielsen P, Wolff B, Qvist N. Randomised comparison of leucocyte-depleted versus buffy-coat-poor blood transfusion and complications after colorectal surgery. Lancet. 1996 Sep 28;348(9031):841–5.Google Scholar
  45. 45.
    van de Watering LM, Hermans J, Houbiers JG, van den Broek PJ, Bouter H, Boer F, Harvey MS, Huysmans HA, Brand A. Beneficial effects of leukocyte depletion of transfused blood on postoperative complications in patients undergoing cardiac surgery: a randomized clinical trial. Circulation. 1998 Feb 17;97(6):562–8.Google Scholar
  46. 46.
    Tartter PI, Mohandas K, Azar P, Endres J, Kaplan J, Spivack M. Randomized trial comparing packed red cell blood transfusion with and without leukocyte depletion for gastrointestinal surgery. Am J Surg. 1998 Nov;176(5):462–6.Google Scholar
  47. 47.
    Thurer RL, Luban NL, AuBuchon JP, Silver H, McCarthy LJ, Dzik S, Stowell CP, Moore SB, Vamvakas EC, Armstrong W, Kanter MH, Jeter E, Becker J, Higgins M, Galel S, Kleinman S, Marshall CS, Newman R, Ocariz JA, Blackall D, Petz LD, Toy P, Oberman H, Siegel DL, Price TH, Slichter SJ. Universal WBC reduction. Transfusion. 2000 Jun;40(6):751–2.Google Scholar
  48. 48.
    Bernard A, Meier C, Ward M, Browning T, Montgomery A, Kasten M, Snow C, Manning E, Woodward J. Packed red blood cells suppress T-cell proliferation through a process involving cell-cell contact. J Trauma. 2010 Aug;69(2):320–9.Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2015

Authors and Affiliations

  • Christopher T. Aquina
    • 1
  • Neil Blumberg
    • 2
  • Christian P. Probst
    • 1
  • Adan Z. Becerra
    • 1
  • Bradley J. Hensley
    • 1
  • James C. Iannuzzi
    • 1
  • Maynor G. Gonzalez
    • 1
  • Andrew-Paul Deeb
    • 1
  • Katia Noyes
    • 1
  • John R. T. Monson
    • 1
  • Fergal J. Fleming
    • 1
  1. 1.Department of Surgery, Surgical Health Outcomes & Research Enterprise (SHORE)University of Rochester Medical CenterRochesterUSA
  2. 2.Department of Pathology and Laboratory MedicineUniversity of Rochester Medical CenterRochesterUSA

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