Restrictive blood transfusion protocol in liver resection patients reduces blood transfusions with no increase in patient morbidity

Abstract

Background Management of anemia in surgical oncology patients remains one of the key quality components in overall care and cost. Continued reports demonstrate the effects of hospital transfusion, which has been demonstrated to lead to a longer length of stay, more complications, and possibly worse overall oncologic outcomes. The hypothesis for this study was that a dedicated restrictive transfusion protocol in patients undergoing hepatectomy would lead to less overall blood transfusion with no increase in overall morbidity. Methods A cohort study was performed using our prospective database from 1/2000 to 6/2013. September of 2011 served as the separation point for the date of operation criteria because this marked the implementation of more restrictive blood transfusion guidelines. Results a total of 186 patients undergoing liver resection were reviewed. The restrictive blood transfusion guidelines reduced the percentage of patients that received blood from 31.0% before 09/01/2011 to 23.3% after this date (p=0.03). The liver procedure that was most consistently associated with higher levels of transfusion was a right lobectomy (16%). Prior surgery and endoscopic stent were the two preoperative interventions associated with receiving blood. Patients who received blood before and after the restrictive period had similar predictive factors: Major hepatectomies, higher intra-operative blood loss, lower pre-operative hemoglobin, older age, prior systemic chemotherapy, and lower pre-operative nutritional parameters (all P<0.05). Patients who received blood did not have worse overall progression free survival or overall survival. Conclusion A restrictive blood transfusion protocol reduces the incidence of blood transfusions and the number of packed red blood cells transfused. Patients who require blood have similar pre-operative and intra-operative factors that cannot be mitigated in oncology patients. Restrictive use of blood transfusions can reduce cost and does adversely effects patients undergoing liver resection.

Preoperative anemia is associated with increased use of hospital resources in patients undergoing elective hepatectomy

“…40 Restrictive protocols for blood transfusion in patients undergoing elective hepatectomy have also been shown recently to decrease blood transfusions without increases in morbidity or mortality. 46 With regard to blood-saving measures for hepatectomy, several therapies and technical maneuvers have been examined. One single-institution, randomized controlled trial from Asia suggested that perioperative administration of tranexamic acid may decrease blood loss and eliminate the need for blood transfusion after hepatectomy.…”

Blood transfusion is an independent predictor of morbidity and mortality after hepatectomy

“…In addition, the revised 72-hour NSQIP-reported blood transfusion variable allows for improved data recording and outcome estimates compared to the pre-2010 variable, which only captured blood transfusions greater than 4 units. The interaction between extent of resection and blood transfusion has been proposed previously [8]. In addition, other surrogates of more extensive operation including intraoperative management, tumor size, and associated resections have been described [14, 15].…”

“…Blood transfusion is associated with higher costs and increased risk of associated morbidity. Multiple recent studies have suggested worse oncologic outcomes most notably in patients with primary or metastatic malignancies leading to proposals for transfusion restrictions in patients undergoing hepatectomy [8, 9]. …”

A commentary on “Red blood cell transfusion practice in elective liver resection: Single center scenario” by Dr Andreas Vogt

“…Some limitations for their conclusion have to be mentioned: a) unbalanced group size (no transfusion in 151 patients vs. transfusion in 8 patients); b) important confounding variables are not reported e.g. preoperative haemoglobin, type of surgery (open vs. laparoscopic) and haemostatic management.The risk of allogenic red blood cell transfusion might be associated with major liver resection, preoperative anaemia and female sex [3,4]. Recently the concept of a multidisciplinary patient blood management in order to enhance efficacy and safety of perioperatively used blood products emerged in literature [5,6].…”

“…The risk of allogenic red blood cell transfusion might be associated with major liver resection, preoperative anaemia and female sex [3,4]. Recently the concept of a multidisciplinary patient blood management in order to enhance efficacy and safety of perioperatively used blood products emerged in literature [5,6].…”