Weve done numerous columns on the benefits and safety of more restrictive transfusion policies. Most studies comparing restrictive vs. liberal transfusion policies have been conducted in patients undergoing non-cardiac surgery. The question has been unanswered in patients undergoing cardiac surgery. Until now, that is. The recently completed Transfusion Requirements in Cardiac Surgery (TRICS) III trial demonstrated that even for those patients undergoing cardiac surgery who are at moderate-to-high risk for death a restrictive transfusion strategy is noninferior to a liberal strategy with respect to the composite outcome of death from any cause, myocardial infarction, stroke, or new-onset renal failure with dialysis (Mazer 2017).
Patients were randomized to either a restrictive red-cell transfusion threshold (transfuse if hemoglobin level was <7.5 g per deciliter, starting from induction of anesthesia) or a liberal red-cell transfusion threshold (transfuse if hemoglobin level was <9.5 g per deciliter in the operating room or intensive care unit [ICU] or was <8.5 g per deciliter in the non-ICU ward).
Red-cell transfusion occurred in 52.3% of the patients in the restrictive-threshold group, as compared with 72.6% of those in the liberal-threshold group Mortality was 3.0% in the restrictive-threshold group and 3.6% in the liberal-threshold group. The percentage of patients who had a primary composite outcome event was 11.4% in the restrictive-threshold group, as compared with 12.5% in the liberal-threshold group.
So the restricted transfusion strategy was as good as a more liberal one from a patient safety perspective and resulted in far fewer transfusions. This should answer that last unanswered question. It is clear that a restrictive transfusion strategy is safe and effective in all types of surgical patients, even those undergoing cardiac surgery.
Also timely in this regard are recommendations from researchers at Johns Hopkins for a patient blood management program to promote high-value care and reduce unnecessary transfusions (Sadana 2017). They note that 3 recommendations summarize evidence-based RBC transfusion practices, derived from the AABB clinical practice guidelines and Choosing Wisely aims:
They offer the following blueprint for a patient blood management program:
Step 1: Organization and Support
Step 2: Transfusion Guidelines
Step 3: Education and Clinical Decision Support
Step 4: Data Dashboards, Audits, and Reports
Step 5: Other Blood Conservation Methods
They note the importance of multidisciplinary representation from multiple departments (medicine, surgery, pediatrics, blood bank/transfusion medicine, anesthesiology, critical care, nursing, pharmacy, quality/safety, and IT) for developing buy-in and ensuring compliance. The initiative should be adequately funded, with the savings from blood resource utilization justifying the funding. The guidelines can include blood products other than just RBCs (eg. plasma, platelets, etc.). Education should be targeted but supplemented by clinical decision support (CDS) in the EMR. The CDS alerts should include reasons for bypassing alerts (eg. active bleeding). Data with feedback should include peer-to-peer comparisons. Each clinical service should have a champion or leader who reviews the reports and provides feedback to service members. Other blood conservation methods include treating anemia before surgery, using antifibrinolytic medications, autologous blood salvage, preoperative autologous blood donation, avoiding excessive phlebotomy, etc.
While transfusions may be lifesaving, they also have several potential harms and downsides. An effective blood transfusion management program is essential for patient safety and will likely produce considerable financial savings for every hospital or ambulatory surgery center.
Prior columns on potential detrimental effects related to red blood cell transfusions:
Mazer CD, Whitlock RP, Fergusson DA, et al. for the TRICS Investigators and Perioperative Anesthesia Clinical Trials Group. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery. NEJM 2017; November 12, 2017
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