Last month (see our January 2012 What’s New in the Patient Safety World column “Need for New Transfusion Criteria?”) we reported on results of the FOCUS study (Carson 2011) which showed essentially no difference in outcomes between a restrictive transfusion policy and a liberal one in patients undergoing surgery for hip fracture. And in our March 2011 What’s New in the Patient Safety World column “Downside of Transfusions in Surgery” we discussed the mounting evidence that transfusions during surgery are associated with increased morbidity and mortality. We also noted that some performance improvement programs were successful in reducing the frequency of transfusions and resulted in considerable cost savings.
Now another new study (Ferraris 2012) demonstrates that transfusions have a dose-dependent adverse effect on outcomes in patients undergoing surgery. The study used data from the Amercian College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. They looked at patients who received intraoperative transfusion of one unit of packed RBC’s and those transfused with several units, and compared them to propensity-matched controls who were not transfused. They found that even those receiving just one unit of packed RBC’s (which they considered possibly “discretionary”) had increased mortality, morbidity, and resource use and adverse events increased in a dose-dependent manner with more transfusions given. There were increased wound problems, pulmonary complications, sepsis, and postoperative renal dysfunction in the transfused groups. Many of the adverse events were infectious complications.
The authors discuss potential reasons that transfusion may cause these adverse effects, including that transfusions have an immunosuppressive effect on the recipient. And they point out that there is little physiological rationale for using such “minimal” transfusions in these surgical patients.
There is now a substantial body of evidence showing harmful effects from transfusion and little evidence of benefit in patients undergoing surgery who are not “symptomatic” from their anemia. In particular, the practice of transfusing “minimal” amounts of blood during surgery is one that must be strongly reconsidered. Again, most hospitals have an opportunity here to both improve patient outcomes and save valuable resources at the same time.
Carson JL, Terrin ML, Noveck H, et al. Liberal or Restrictive Transfusion in High-Risk Patients after Hip Surgery. NEJM 2011; published online first December 14, 2011
Ferraris VA, Davenport DL, Saha SP, et al. Surgical Outcomes and Transfusion of Minimal Amounts of Blood in the Operating Room. Arch Surg 2012; 147(1): 49-55