What’s New in the Patient Safety World

August 2018

Thromboembolism: Another Downside of Transfusions

The move in recent years toward more restrictive transfusion policies and practices has been fueled by increased recognition of untoward side effects of transfusions and controlled clinical trials demonstrating as good or better outcomes with the more restrictive practices in most cases (see the list of our prior columns at the end of today’s column).

Now, an additional risk associated with transfusion has been identified: venous thromboembolism. Goel and colleagues (Goel 2018) analyzed data from the American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) database, They found that perioperative RBC transfusion was associated with higher odds of venous thromboembolism (adjusted odds ratio 2.1), deep venous thrombosis (aOR 2.2), and pulmonary embolism (aOR 1.9), independent of various putative risk factors.

Moreover, they found a significant dose-response effect, with increased odds of VTE as the number of intraoperative and/or postoperative RBC transfusion events increased. The adjusted odds ratios were 2.1 for one event, 3.1 for 2 events, and 4.5 for 3 or more events compared to no intraoperative or postoperative RBC transfusion.

And the association between any perioperative RBC transfusion and postoperative VTE was statistically significant across all surgical subspecialties.

The Goel article goes on to discuss the putative mechanisms by which RBC transfusions might increase the risk of venous thromboembolism.

So the new study provides even more evidence to support restrictive transfusion practices in most cases. You’ll recall the AABB (American Association of Blood Banks) updated its guidelines in 2016 (see our November 2016 What's New in the Patient Safety World column “AABB Updates Transfusion Guidelines Again”) and recommended two tiers of hemoglobin level transfusion triggers (Carson 2016):

• 7 g/dL for hemodynamically stable adults, even those in critical care
• 8 g/dL for patients with preexisting cardiovascular disease or those undergoing cardiac or orthopedic surgery

But even the recommendation for orthopedic surgery has been challenged. Researchers at Johns Hopkins Bayview Medical Center looked at outcomes in orthopedic surgery patients before and after implementation of a blood management program (Gupta 2017). The program consisted of provider education, tranexamic acid, a new surgical blood order schedule, electronic best practice advisories, a “Why Give 2 When 1 Will Do?” campaign advocating single unit RBC transfusions, and audits with provider feedback for guideline compliance. They found, after implementation of the new program, a 38% decrease in percent of patients transfused, and a 25% decrease in mean RBC units per patient. Median length of stay was one day shorter in the post blood-management group with a statistically significant decrease in 30-day readmission rate and no difference in adverse outcomes. (Note that we discussed the Hopkins program (Sadana 2017) in our December 2017 What's New in the Patient Safety World column “Study Confirms Safety of Restrictive Transfusion Policy”.)

Increasing evidence suggests that more restrictive transfusion practices improve patient safety and outcomes and can lead to considerable financial savings, not only from reduced blood product costs but also from the savings seen with fewer complications, shorter lengths of stay, etc.

Prior columns on potential detrimental effects related to red blood cell transfusions:

• March 2011 “Downside of Transfusions in Surgery”
• August 2011 “CPOE Alerts Reduce Blood Transfusions in Children”
• January 2012 “Need for New Transfusion Criteria?”
• April 2012 “New Transfusion Guidelines from the AABB”
• February 2013 “More Evidence Favoring Restriction of Transfusions”
• June 2013 “Hopkins Blood Ordering Initiative”
• May 2014 “Blood Transfusion and Infection Risk”
• June 2015 “Economics and Blood Transfusion”
• November 2016 “AABB Updates Transfusion Guidelines Again”
• December 2017 “Study Confirms Safety of Restrictive Transfusion Policy”
• January 2018 “Transfusion in Cardiac Revision Surgery”

References:

Goel R, Patel EU, Cushing MM, et al. Association of Perioperative Red Blood Cell Transfusions with Venous Thromboembolism in a North American Registry. JAMA Surgery 2018; Published online June 13, 2018

https://jamanetwork.com/journals/jamasurgery/fullarticle/2683886?utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jamasurgery&utm_content=olf&utm_term=061318

Gupta PB, Scher LJ, Yang WW, et al. Impact of a Patient Blood Management Program on Blood Utilization and Clinical Outcomes in Orthopedic Surgery. ANESTHESIOLOGY 2017 Abstract A3101.

http://asaabstracts.com/strands/asaabstracts/abstract.htm?year=2017&index=15&absnum=4722

Carson JL, Guyatt G, Heddle NM, et al. Clinical Practice Guidelines from the AABB. Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016; Published online October 12, 2016

http://jamanetwork.com/journals/jama/article-abstract/2569055

Sadana D, Pratzer A, Scher LJ, et al. Promoting High-Value Practice by Reducing Unnecessary Transfusions with a Patient Blood Management Program. JAMA Intern Med 2017; Published online November 20, 2017

https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2663855

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