Transfusion

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chmd

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80 yo woman for open repair of a large colovaginal fistula from diverticilar abscess. PMH includes DM2. HTN, and CKD III. EKG is nsr with TWI in anterior leads and LVH with repol abn. Pt can do 4 mets but gets winded. She is typed and screened and cards has seen her and said she needs surgery and is higher risk. Her hgb DOS is 9.2. My question is what is your transfusion threshold and when do you give blood. My plan was to get blood In OR and give 1 unit. My partner suggested crossing for 2 and waiting. Surgeon wanted just the screen and to wait for blood loss. All are fine in sure. But what's right?
 
Agree with above. 9.2 isn't awful unles you feel that she's severely hemoconcentrated. I would have a type and cross ready and proceed with the case. I think a type and screen is a little too minimal. Though you can probably get away with screened blood in the majority of cases, I'd also not want to be the one to find the exception during an urgent case.

Type and cross. Wait and see. Transfuse per your clinical recommendations during the case. Evidence points to lower transfusion thresholds nowadays even in cardiac patients, but the OR can be a little different.
 
chmd said:
80 yo woman for open repair of a large colovaginal fistula from diverticilar abscess. PMH includes DM2. HTN, and CKD III. EKG is nsr with TWI in anterior leads and LVH with repol abn. Pt can do 4 mets but gets winded. She is typed and screened and cards has seen her and said she needs surgery and is higher risk. Her hgb DOS is 9.2. My question is what is your transfusion threshold and when do you give blood. My plan was to get blood In OR and give 1 unit. My partner suggested crossing for 2 and waiting. Surgeon wanted just the screen and to wait for blood loss. All are fine in sure. But what's right?
Click to expand...

If the patient was you, would you want to be preemptively transfused?
 
I would be ok with all three plans. If you screen the pt then it only takes a few minutes to cross match assuming no antibodies. I can't remember the last time I had to give blood in a case like this. I'm sure it wasn't all that long ago but it is still rare. I just did this exact case about 5 days ago. I generally try to get thru the case without giving blood. But I placed an epidural and had to run some low dose neo the entire case (not unusual). Also did a spine case the other day that started with a low H&H. Had to support the BP the entire case thinking it might return to normal once I woke her up. We lost virtually no blood but she remained soft in BP so we gave 1 or 2 units postop for a couple reasons, to increase her BP and to keep,the nurses from calling all night cuz her BP was low. That's not a reason to transfuse but it does add to the situation whether you like it or not.
 
G-Man82 said:
Evidence points to lower transfusion thresholds nowadays even in cardiac patients, but the OR can be a little different.
Click to expand...
Just to be clear, you are saying evidence is supporting earlier transfusion at higher H&H levels?
 
Noyac said:
Just to be clear, you are saying evidence is supporting earlier transfusion at higher H&H levels?
Click to expand...

Nope. I hate to bring up the magic number 7, but unless this patient came to me with a hgb < 7, I wouldn't transfuse unless she was hypotensive and wasn't responding to fluid boluses (as one example). Intraop however, if there's ongoing bleeding we can't really rely on the hemoglobin number. Then it becomes clinical.

I like these because it shows where ICU practice and OR Anesthesia practice diverge some. Makes it interesting for me.
 
^^^thats why I asked. In your original post it was worded poorly. The way I read it, you said lower transfusion thresholds rather than lower lab numbers. Lower threshold to me means you would transfuse sooner. I don't think evidence is supporting this.
 
Magic number in the OR is 8-9. For moderate risk patients I use a Hgb of around 8. For high risk patients and those with cancer I prefer 8.5-9 Hgb. This is backed up by a lot of data including a recent study in Anesthesiology.

ICU- medical. Hgb of 7.0
O. R. Surgery. Hgb of 8.0 (ASA 3 and 4)
High risk (ASA4) and Cancer patients in O.R. Hgb 9.0
 
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Anesthesiology. 2015 Jan;122(1):29-38. doi: 10.1097/ALN.0000000000000511.
Transfusion requirements in surgical oncology patients: a prospective, randomized controlled trial.
Pinheiro de Almeida J1, Vincent JL, Barbosa Gomes Galas FR, Pinto Marinho de Almeida E, Fukushima JT, Osawa EA, Bergamin F, Lee Park C, Nakamura RE, Fonseca SM, Cutait G, Inacio Alves J, Bazan M, Vieira S, Vieira Sandrini AC, Palomba H, Ribeiro U Jr, Crippa A, Dalloglio M, Del Pilar Estevez Diz M, Kalil Filho R, Costa Auler JO Jr, Rhodes A, Hajjar LA.
Author information

Abstract
BACKGROUND:
Several studies have indicated that a restrictive erythrocyte transfusion strategy is as safe as a liberal one in critically ill patients, but there is no clear evidence to support the superiority of any perioperative transfusion strategy in patients with cancer.

METHODS:
In a randomized, controlled, parallel-group, double-blind (patients and outcome assessors) superiority trial in the intensive care unit of a tertiary oncology hospital, the authors evaluated whether a restrictive strategy of erythrocyte transfusion (transfusion when hemoglobin concentration <7 g/dl) was superior to a liberal one (transfusion when hemoglobin concentration <9 g/dl) for reducing mortality and severe clinical complications among patients having major cancer surgery. All adult patients with cancer having major abdominal surgery who required postoperative intensive care were included and randomly allocated to treatment with the liberal or the restrictive erythrocyte transfusion strategy. The primary outcome was a composite endpoint of mortality and morbidity.

RESULTS:
A total of 198 patients were included as follows: 101 in the restrictive group and 97 in the liberal group. The primary composite endpoint occurred in 19.6% (95% CI, 12.9 to 28.6%) of patients in the liberal-strategy group and in 35.6% (27.0 to 45.4%) of patients in the restrictive-strategy group (P = 0.012). Compared with the restrictive strategy, the liberal transfusion strategy was associated with an absolute risk reduction for the composite outcome of 16% (3.8 to 28.2%) and a number needed to treat of 6.2 (3.5 to 26.5).

CONCLUSION:
A liberal erythrocyte transfusion strategy with a hemoglobin trigger of 9 g/dl was associated with fewer major postoperative complications in patients having major cancer surgery compared with a restrictive strategy.
 
Of course if the Hgb is 7.5 and the patient is stable I don't necessarily transfuse the patient. I've been involved with hundreds of renal failure patients with Hgb of 7.0-8.0 where no blood was given in the O.R. That said, once the blood letting begins I use 8.0 for most surgical cases (ASA3 and 4) and 9.0 for the highest risk patients and those with cancer undergoing a surgical procedure.
 
Well, obviously cancer pts and their surgeries are a bit different which has been shown in literature for years now.
But let's say it's not cancer related surgery. Maybe typical spine surgery in a pt with chronic anemia of unknown origin. Let's say this pt comes to surgery with a 6 mon history of Hb 9. How do you handle this?
 
T and C.
Proceed with surgery.
Did a L2-L5 emergent lami last week with <100 blood loss. 3 hour case. No blood.
 
Noyac said:
Well, obviously cancer pts and their surgeries are a bit different which has been shown in literature for years now.
But let's say it's not cancer related surgery. Maybe typical spine surgery in a pt with chronic anemia of unknown origin. Let's say this pt comes to surgery with a 6 mon history of Hb 9. How do you handle this?
Click to expand...

Hgb of 8.0 is my target if ASA 3 which I assume this patient is. Of course, I see your point about allowing a Hgb in the 7.0-8.0 range but with that level of anemia a transfusion is likely for a multi level lumbar fusion at my hospital even with a cell saver.
 
Other important points to consider in terms of the potential impact of anemia on postoperative outcomes are the patient’s age, rapidity of anemia onset, and the hemoglobin-duration deficit product (or duration below a critical hemoglobin value).6 Very low hemoglobin concentrations are generally well tolerated in young individuals, but older patients appear to be at a high risk for anemia-related mortality, possibly owing to age-associated limited organ reserve. The duration below a critical hemoglobin value also deserves attention because a delay in administering erythrocytes to improve oxygen delivery is directly related to mortality in patients whose hemoglobin concentrations are below 8 g/dl.7


Editorial Views | January 2015
Perioperative Anemia and Blood Transfusions in Patients with Cancer: When the Problem, the Solution, and Their Combination Are Each Associated with Poor Outcomes
Juan P. Cata, M.D.
 
Transfusion. 2002 Jul;42(7):812-8.
Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion.
Carson JL1, Noveck H, Berlin JA, Gould SA.
Author information

Abstract
BACKGROUND:
Guidelines for allogeneic transfusion emphasize minimizing use to avoid transmission of serious illness. However, there is little information on the risks associated from withholding transfusion.

STUDY DESIGN AND METHODS:
A retrospective cohort study of patients who declined RBC transfusions for religious reasons was performed. This analysis was restricted to consecutive patients > or = 18 years old, who underwent surgery in the operating room from 1981 to 1994 and had a postoperative Hb count of 8 g per dL or less. The primary outcome was defined as any inhospital death occurring within 30 days of the surgery. Secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Morbidity was defined as myocardial infarction, arrhythmia, congestive heart failure, or infection.

RESULTS:
Of 2083 eligible patients, 300 had postoperative Hb counts of 8 g per dL or less. The study population was predominantly female (70.3%) with a mean age of 57 years (SD, +/- 17.7). In patients with a postoperative Hb level of 7.1 to 8.0, 0 died (upper 95% CI, 3.7%), and 9.4 percent (95% CI, 4.4-17.0%) had a morbid event. In patients with a postoperative Hb level of 4.1 to 5.0, 34.4 percent (95% CI, 18.6-53.2%) died and 57.7 percent (95% CI, 36.9-76.6%) had a morbid event or died. After adjusting for age, cardiovascular disease, and Acute Physiology and Chronic Health Evaluation II score, the odds of death in patients with a postoperative Hb level of < or = 8 g per dL increased 2.5 times (95% CI, 1.9-3.2) for each gram decrease in Hb level.

CONCLUSIONS:
The risk of death was low in patients with postoperative Hb levels of 7.1 to 8.0 g per dL, although morbidity occurred in 9.4 percent. As postoperative blood counts fall the risk of mortality and/or morbidity rises and becomes extremely high below 5 to 6 g per dL.
 
19.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, Leão, WC, Almeida, JP, Pomerantzeff, PM, Dallan, LO, Jatene, FB, Stolf, NA, Auler, JOJr Transfusion Requirements After Cardiac Surgery: The TRACS randomized controlled trial.. JAMA. (2010). 304 1559–67 [Article] [PubMed]
20.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 FOCUS Investigators, Liberal or restrictive transfusion in high-risk patients after hip surgery.. N Engl J Med. (2011). 365 2453–62 [Article] [PubMed]
 
A relationship between anemia and postoperative mortality has been described in other studies.29–31 Carson et al.29 reported that pre- and postoperative anemia was independently associated with 30-day mortality, particularly in patients with cardiovascular disease. In a propensity score–matched retrospective study, Wu et al.31 showed that erythrocyte transfusion in patients with hematocrit levels less than 24% (approximately equal to hemoglobin concentrations of 8.0 g/dl) was associated with reduced 30-day postoperative mortality in elderly patients having major, noncardiac surgery. Similar findings were reported by Sakr et al.21 who conducted a large prospective study of 5,925 patients in a surgical ICU and reported that anemia (hemoglobin concentration <9.0 g/dl) was common and was associated with higher morbidity and mortality. In a further analysis, after propensity score matching and adjusting for possible confounders, higher hemoglobin concentrations and the receipt of a blood transfusion were independently associated with a lower risk of hospital mortality.21
 
Lancet. 2014 Dec 9. pii: S0140-6736(14)62286-8. doi: 10.1016/S0140-6736(14)62286-8. [Epub ahead of print]
Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial.
Carson JL1, Sieber F2, Cook DR3, Hoover DR4, Noveck H5, Chaitman BR6, Fleisher L7, Beaupre L8, Macaulay W9, Rhoads GG10, Paris B11, Zagorin A11, Sanders DW12, Zakriya KJ13, Magaziner J14.
Author information

Abstract
BACKGROUND:
Blood transfusion might affect long-term mortality by changing immune function and thus potentially increasing the risk of subsequent infections and cancer recurrence. Compared with a restrictive transfusion strategy, a more liberal strategy could reduce cardiac complications by lowering myocardial damage, thereby reducing future deaths from cardiovascular disease. We aimed to establish the effect of a liberal transfusion strategy on long-term survival compared with a restrictive transfusion strategy.

METHODS:
In the randomised controlled FOCUS trial, adult patients aged 50 years and older, with a history of or risk factors for cardiovascular disease, and with postoperative haemoglobin concentrations lower than 100 g/L within 3 days of surgery to repair a hip fracture, were eligible for enrolment. Patients were recruited from 47 participating hospitals in the USA and Canada, and eligible participants were randomly allocated in a 1:1 ratio by a central telephone system to either liberal transfusion in which they received blood transfusion to maintain haemoglobin level at 100 g/L or higher, or restrictive transfusion in which they received blood transfusion when haemoglobin level was lower than 80 g/L or if they had symptoms of anaemia. In this study, we analysed the long-term mortality of patients assigned to the two transfusion strategies, which was a secondary outcome of the FOCUS trial. Long-term mortality was established by linking the study participants to national death registries in the USA and Canada. Treatment assignment was not masked, but investigators who ascertained mortality and cause of death were masked to group assignment. Analyses were by intention to treat. The FOCUS trial is registered with ClinicalTrials.gov, number NCT00071032.

FINDINGS:
Between July 19, 2004, and Feb 28, 2009, 2016 patients were enrolled and randomly assigned to the two treatment groups: 1007 to the liberal transfusion strategy and 1009 to the restrictive transfusion strategy. The median duration of follow-up was 3·1 years (IQR 2·4-4·1 years), during which 841 (42%) patients died. Long-term mortality did not differ significantly between the liberal transfusion strategy (432 deaths) and the restrictive transfusion strategy (409 deaths) (hazard ratio 1·09 [95% CI 0·95-1·25]; p=0·21).

INTERPRETATION:
Liberal blood transfusion did not affect mortality compared with a restrictive transfusion strategy in a high-risk group of elderly patients with underlying cardiovascular disease or risk factors. The underlying causes of death did not differ between the trial groups. These findings do not support hypotheses that blood transfusion leads to long-term immunosuppression that is severe enough to affect long-term mortality rate by more than 20-25% or cause of death.

FUNDING:
National Heart, Lung, and Blood Institute.

Copyright © 2014 Elsevier Ltd. All rights reserved.
 
Interesting stuff regarding the CA pts. Blood Transfusion is pretty clearly immunosuppresive so I would typically try hard to limit transfusing CA pts but maybe time to reconsider. Don't really do many big CA whacks these days though.
 
I remember reading a while back an editorial from some transfusion / hemostasis guru recommending a transfusion "trigger" in hemodynamically stable patients that is half of whatever their baseline is.
That seemed to make sense at the time.
But in practice, it makes no sense.
I'm not gonna withhold transfusion in a chronically ill patient whose baseline is 11 until they hit 5.5...
Nor would I just to transfuse a (formerly) healthy trauma patient whose baseline is 14 and now they're chillin at 6.9...

To the OP, T+C for two and then wait and see is what I'd do.
 
fakin' the funk said:
I remember reading a while back an editorial from some transfusion / hemostasis guru recommending a transfusion "trigger" in hemodynamically stable patients that is half of whatever their baseline is.
That seemed to make sense at the time.
But in practice, it makes no sense.
I'm not gonna withhold transfusion in a chronically ill patient whose baseline is 11 until they hit 5.5...
Nor would I just to transfuse a (formerly) healthy trauma patient whose baseline is 14 and now they're chillin at 6.9...

To the OP, T+C for two and then wait and see is what I'd do.
Click to expand...


Mortality:

•Hgb 7.1 to 8.0 (n = 99) – Zero percent

•Hgb 5.1 to 7.0 (n = 110) – 9 percent

•Hgb 3.1 to 5.0 (n = 60) – 30 percent

•Hgb ≤3.0 (n = 31) – 64 percent

If you decide NOT to transfuse your 40 year old, ASA 2 patient with a Hgb of 5.0 who is asymptomatic then perhaps a discussion about increased risk of mortality is warranted.

I can see withholding Blood until the Hgb falls below 6.0 but at some point the patient deserves to know the risks of NOT getting that unit of Prbcs.
Maybe, you want to wait until that ASA 1 patient drops to 4.9 before giving a unit but I'm not so sure that is the best decision.
 
http://www.aabb.org/pbm/Documents/C...s-Physicians-and-Patients-Should-Question.pdf

Once the Hgb drops below 6.0 we don't whether a unit of Prbcs is more helpful than harmful in asymptomatic patients. But, what about 5.0? I don't mind withholding the Prbc for low Hgb (less than 6.o in an asymptomatic ASA 1 or 2 patient) but the patient deserves to know that there may be increased risk by NOT getting that unit of Prbcs.
 
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So, we don’t need blood transfusions anymore?
Well, obviously, this was a special case. But patients can be kept alive at a very low Hb. For hours, maybe days. But eventually, it will kill them. They get organ failure. Of course, it’s hard to make good studies on extreme anaemia, but we do have one group that guinea pigs for this stuff. Jehova’s Witnesses. So some smart guys pooled all Jehova Witness patients in the States over the past years and looked at the ones with a post operative Hb<8 g/dL. 300 patients in all. How did they do? After trying to level the field by taking age, heart disease and APACHEII score into account, they found this relationship:

Hb 1-2: Mortality 100%
Hb 2-3: Mortality 54%
Hb 3-4: Mortality 27%
Hb 4-5: Mortality 34%
Hb 5-6: Mortality 9%
Hb 7-8: Mortality 0%

Not a surprising finding, but interesting to get an idea of where the cut-off is. Below 5 g/dL is not where you want to be.
 
How about looking at every patient as an individual and basing the transfusion decision on all the available clinical and lab data rather than memorizing stupid numbers?
 
Planktonmd said:
How about looking at every patient as an individual and basing the transfusion decision on all the available clinical and lab data rather than memorizing stupid numbers?
Click to expand...

Tell that to the family and their lawyer after your patient dies from a Hgb of 5.0 and you failed to inform them of the increased risk of death by not transfusing their loved one.

We live in a tough medico-legal climate so having numbers around to help guide the decision making process based on evidence makes good clinical sense. Nobody is saying you can't add your clinical judgement into the mix but rather look at the published evidence along with your judgement.

Bad outcome and over transfusion or under transfusion can lead to malpractice lawsuits which could be avoided.
 
My 2 cents (from IM perspective, may not apply to OR setting):

1) sepsis --> target hgb 7.0
2) trauma patient --> if still hypotensive, tachy after 2-3 L NS or massive bleeding, transfuse liberally
3) acute bleeding --> transfuse to symptoms relieve or expected blood loss until the underlying problem is fixing (e.g. waiting for GI to scope)
4) ESRD --> target hgb 10 (chronic setting, so can use venofer, aranesp)
5) sickle cell (pain crisis only)--> can tolerate much lower threshold. maybe 6-6.5
 
BLADEMDA said:
Tell that to the family and their lawyer after your patient dies from a Hgb of 5.0 and you failed to inform them of the increased risk of death by not transfusing their loved one.

We live in a tough medico-legal climate so having numbers around to help guide the decision making process based on evidence makes good clinical sense. Nobody is saying you can't add your clinical judgement into the mix but rather look at the published evidence along with your judgement.

Bad outcome and over transfusion or under transfusion can lead to malpractice lawsuits which could be avoided.
Click to expand...
These numbers you are throwing around will result in not transfusing patients who might clinically require transfusion.
So, while your chart might look good to a lawyer your patient might still die or suffer end organ damage, you might not get sued but that doesn't make you less guilty in that murder!
 
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