Evaluation of Red Blood Cell Transfusion Practice and Knowledge Among Cancer Surgeons

Abstract

Background

Transfusion of blood products has a negative impact on surgical and cancer outcomes. The objective of the current study was to evaluate surgeons’ practice and knowledge of red blood cell transfusion for surgical patients.

Methods

A survey of residents, fellows, and faculty surgeons at the Ohio State University Wexner Medical Center and surgeons who identified as taking care of cancer patients nationally was conducted. Four domains were addressed including perceived preoperative assessment and management of anemia, perceived use of transfusion alternatives, perceived use of and factors influencing packed red blood cell administration, and transfusion practice knowledge.

Results

Among 158 respondents, 87 (64.5%) were surgeons on faculty at an academic medical center, 26 (19%) were surgeons in private practice, and 24 (15.2%) were surgical residents or fellows. The majority of respondents were surgical oncologists or hepatobiliary surgeons (N = 83, 62.0%) and had been in practice > 10 years (> 10–15 N = 28, 20.6%) and > 15 years N = 59, 43.4%). Only thirteen (N = 13, 8.2%) surgeons reported that they routinely complete a preoperative anemia workup. The majority of providers reported that they rarely or never use alternatives to transfusion such as erythropoietin (N = 135, 91.8%), tranexamic acid (N = 140, 94.6%), autologous blood transfusion (N = 141, 95.3%), or cell saver for benign (N = 107, 72.3%) or malignant cases (N = 133, 90.4%). Provider transfusion knowledge was variable.

Conclusions

Surgeons varied widely in their transfusion practice and knowledge. Further education of surgeons regarding transfusion medicine and practice, as well as use of transfusion alternatives, could lead to improved patient outcomes. Patient blood management programs may help inform individual surgeon practices.

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Appendix 1. Survey Instrument, Evaluation of Red Blood Cell Transfusion Practice, and Knowledge in US Physicians

Appendix 1. Survey Instrument, Evaluation of Red Blood Cell Transfusion Practice, and Knowledge in US Physicians

This survey seeks to learn about surgeons’ practices related to red blood cell transfusion. Please consider the scenarios below and select the response option that best fits with what you typically do.

Preoperative Assessment and Management

Do you routinely order an anemia workup (iron, ferritin, total iron-binding capacity) for patients when you see them preoperatively?

  1. A.

    Yes

  2. B.

    No

During the preoperative workup of patients undergoing elective surgery, indicate how likely you would conduct an anemia workup (iron, ferritin, total iron-binding capacity) in the following situations.

  Very unlikely to conduct Unlikely to conduct Likely to conduct Very likely to conduct
Anemia (Hg < 13.0 g/dL)     
Documented or suspected bleeding disorder     
Colorectal resection     
Gastric resection     
HPB resection     
Small bowel resection     
Open approach     
Laparoscopic approach     
Robotic approach     
Surgery in less than 3 weeks     

In the preoperative period, indicate how likely you would order the following in preparation for a 55-year-old male, with no significant comorbidities, undergoing total gastrectomy, who presented with a hemoglobin of 10.5 g/dL 4 weeks prior to surgery.

  Very unlikely to conduct Unlikely to conduct Likely to conduct Very likely to conduct
Referral to preadmission clinic     
Referral to consultant (internal medicine or hematology)     
Type and screen     
Type and cross     
Packed red blood cells on call to OR     
PO iron supplementation     

At your institution, who is responsible for assessing and managing preoperative anemia?

  1. A.

    Anesthesiology

  2. B.

    Surgery

  3. C.

    Preadmission clinic

  4. D.

    Others, please specify: _______________

Practice

In your opinion, do packed red blood cell transfusions increase or decrease the risks of the following outcomes?

  Strongly decreases Decreases Neither increases nor decreases Increases Strongly increases
Postoperative morbidity      
Postoperative mortality      
Cancer recurrence after oncologic surgical resection      
Survival after oncologic surgical resection      

Indicate to what extent you agree or disagree with the following statements.

  Strongly disagree Disagree Agree Strongly agree
PRBC should be transfused to a target hemoglobin of 7.0 g/dL in the non-bleeding asymptomatic patient without cardiac comorbidity     
PRBC should be transfused to a target hemoglobin of 8.0 g/dL in the non-bleeding asymptomatic patient with a known or suspected cardiac comorbidity     
PRBC should be transfused one unit at a time in the non-bleeding patient     

After undergoing an elective total gastrectomy, a 55-year-old male has a hemoglobin of 6.4 g/dL. He is not bleeding and is hemodynamically stable. When you order an RBC transfusion, indicate how the followings reflect your management.

  Never Rarely Often Always
I order 1 unit of packed red blood cells to transfuse     
I order 2 units of packed red blood cells to transfuse     

In the postoperative period, please indicate the hemoglobin level below at which you would order a packed red blood cell transfusion (your “transfusion trigger”). For each scenario, use the following patient: 55-year-old male underwent elective total gastrectomy, is not bleeding, and is hemodynamically stable.

  6 g/dL 7 g/dL 8 g/dL 9 g/dL 10 g/dL Would not transfuse
Stable patient, no cardiac disease       
Stable patient. No chest pain. Prior cardiac comorbidity (e.g., myocardial infarction, congestive heart failure)       
Active cardiac disease       
Symptomatic anemia       
Suspected postoperative bleeding       
High intraoperative blood loss       

Indicate how often you would use the following alternative strategies to packed red blood cell transfusion for a 55-year-old male undergoing elective total gastrectomy with a hemoglobin of 10.5 g/dL.

  Never Rarely Often Always
Preoperative PO iron     
Erythropoietin     
Tranexamic acid     
Preoperative autologous blood transfusion     
Cell saver for benign cases     
Cell saver for malignant cases     

Knowledge

The following questions ask about your knowledge related to red blood cell transfusion.

How many grams of hemoglobin are contained in 1 unit of packed red blood cells obtained from the American Red Cross?

  1. A.

    20–50 grams

  2. B.

    50–80 grams

  3. C.

    80–110 grams

Approximately how many milligrams of iron are contained in 1 unit of packed red blood cells obtained from the American Red Cross?

  1. A.

    100 mg

  2. B.

    150 mg

  3. C.

    200 mg

  4. D.

    250 mg

  5. E.

    300 mg

Transfusion of 1 unit of packed red blood cells should increase hemoglobin and hematocrit by how much?

  1. A.

    Hemoglobin increased by 0.5 g/dL, hematocrit increased by 1%

  2. B.

    Hemoglobin increased by 1 g/dL, hematocrit increased by 3%

  3. C.

    Hemoglobin increased by 1.5 g/dL, hematocrit increased by 5%

In the setting of acute upper gastrointestinal bleed, which transfusion threshold has been shown to be associated with decreased bleeding and decreased 45-day mortality?

  1. A.

    Liberal (transfuse for < 9 g/dL)

  2. B.

    Restrictive (transfuse for < 7 g/dL)

AABB guidelines recommend the following transfusion threshold for hospitalized adult patients who are hemodynamically stable, including the critically ill?

  1. A.

    6 g/dL

  2. B.

    7 g/dL

  3. C.

    8 g/dL

  4. D.

    9 g/dL

  5. E.

    10 g/dL

Demographics

Please answer the following questions by selecting the most appropriate response option.

Which of the following BEST describes your current role?

  1. A.

    A surgeon on faculty at an academic medical center

  2. B.

    A surgeon in private practice or in a mixed private/academic setting

  3. C.

    A clinical surgical resident

  4. D.

    A clinical surgical fellow

  5. E.

    A surgical resident or fellow engaged in full-time research

  6. F.

    Others, please specify: ____

Which of the following do you feel BEST represents how you identify yourself?

  1. A.

    General surgeon

  2. B.

    Surgical oncologist or hepatobiliary surgeon

  3. C.

    Bariatric surgeon

  4. D.

    Thoracic or cardiac surgeon

  5. E.

    Trauma or acute care surgeon

  6. F.

    Burn surgeon

  7. G.

    Vascular surgeon

  8. H.

    Colorectal surgeon

  9. I.

    Surgical fellow

  10. J.

    Surgical resident

How many years have you been in practice, including residency?

  1. A.

    0–1 years

  2. B.

    > 1–5 years

  3. C.

    > 5–10 years

  4. D.

    > 10–15 years

  5. E.

    > 15 years

If you are a resident or fellow, what is your postgraduate year (PGY) level?

  1. A.

    PGY-1

  2. B.

    PGY-2

  3. C.

    PGY-3

  4. D.

    PGY-4

  5. E.

    PGY-5

  6. F.

    PGY-6

  7. G.

    PGY-7

  8. H.

    PGY-8

If you are a surgical oncologist, what are your primary areas of practice (select all that apply)?

  1. A.

    Esophagus or gastric

  2. B.

    Colon and rectal

  3. C.

    Hepatopancreatobiliary

  4. D.

    Endocrine

  5. E.

    Breast

  6. F.

    Sarcoma

  7. G.

    Melanoma

  8. H.

    Others, please specify: _____

A patient blood management program is a proactive, patient-centered, multidisciplinary approach to managing anemia. Does your institution have a patient blood management program?

  1. A.

    Yes

  2. B.

    No

  3. C.

    Unsure

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Beal, E.W., Tsung, A., McAlearney, A.S. et al. Evaluation of Red Blood Cell Transfusion Practice and Knowledge Among Cancer Surgeons. J Gastrointest Surg (2021). https://doi.org/10.1007/s11605-020-04899-7

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Keywords

  • Transfusion
  • Gastrointestinal
  • Cancer
  • Outcomes
  • Blood management