Perioperative blood transfusions: indications and options

Cardiac Surgery and Blood-Saving Techniques: An Update

Cardiac surgery is typically attributed with a significant risk of intraoperative blood loss and allogeneic blood transfusions. Intraoperative blood loss, allogenic blood transfusions, high dose anticoagulation requirement, and interactions with cardiopulmonary bypass (CPB) have all been linked to cardiac surgeries. To reduce unnecessary transfusions and their negative effects, it is recommended to follow evidence-based multidisciplinary strategies, which are collectively termed patient blood management (PBM). This review highlights the most recent blood conservation strategies in adult cardiac surgery, which can be employed pre-operatively, intra-operatively, and postoperatively, to enhance red cell mass and attenuate the utilization of packed red blood cells (PRBCs) and other blood products.

Sodium (23Na) MRI of the Kidney: Basic Concept

The handling of sodium by the renal system is a key indicator of renal function. Alterations in the corticomedullary distribution of sodium are considered important indicators of pathology in renal diseases. The derangement of sodium handling can be noninvasively imaged using sodium magnetic resonance imaging (²³Na MRI), with data analysis allowing for the assessment of the corticomedullary sodium gradient. Here we introduce sodium imaging, describe the existing methods, and give an overview of preclinical sodium imaging applications to illustrate the utility and applicability of this technique for measuring renal sodium handling.This chapter is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers. This introduction chapter is complemented by two separate chapters describing the experimental procedure and data analysis.

Perfusion technique for nonhaemic cardiopulmonary bypass prime in neonates and infants under 6 kg body weight

Background: Cardiopulmonary bypass (CPB) in neonates and infants is associated with significant haemodilution when priming of the CPB circuit is accomplished without transfusion of homologous blood components. The degree of haemodilution and, thus, the requirements for blood transfusion may be reduced when the CPB circuit is miniaturized without compromising patient safety.

Method: Between January 2002 and October 2003, selected neonates and small infants were operated on using a nonhaemic prime extracorporeal circuit. CPB priming volume could be reduced from 300 mL to 190 mL by using a dedicated neonatal CPB console with mast-mounted roller pump heads. Reduction of priming volume resulted from shortening of all CPB lines to the minimum, downsizing of all CPB lines, exclusion of unused CPB components, use of vacuum-assisted venous drainage and from close co-operation between the perfusionist, cardiac surgeon and anaesthesiologist. The reduction in priming volume was achieved without eliminating the arterial line filter as safety device.

Results: A total of nine patients weighing between 3.2 and 5.9 kg (mean 4.7 kg) and with a body surface area of 0.22 - 0.35m2 (mean 0.29m2) were operated on with the use of the modified neonatal CPB circuit and a nonhaemic prime. Bypass time varied from 38 to 167 min (mean 96 min). The mean haematocrit on CPB was 22.5% with a range of 17 - 29%. The postoperative course of all patients was uneventful.

Conclusion: A significant reduction in CPB priming volume makes nonhaemic prime CPB in neonates and small infants undergoing complex repair of congenital heart defects possible.

Blood Transfusions May Have Limited Effect on Muscle Oxygenation After Total Knee Arthroplasty

BACKGROUND

Traditionally, blood transfusions in the perioperative setting are used to maintain adequate delivery of nutrients and oxygen to organs. However, the effect of blood administration on tissue oxygenation in the perioperative setting remains poorly understood.

QUESTIONS/PURPOSES

The aim of this study was to determine changes in muscle tissue oxygenation saturation (SmO2) in response to perioperative blood transfusions.

PATIENTS AND METHODS

Patients undergoing total knee arthroplasty were enrolled. SmO2, continuous hemoglobin (SpHb), stroke volume (SV), cardiac index, and standard hemodynamic parameters including heart rate (HR), mean arterial blood pressure (MAP), and arterial oxygen saturation (SO2) were recorded. To assess fluid responsiveness, a passive leg raise (PLR) test was performed before the transfusions were started.

RESULTS

Twenty-eight patients were included in the analysis. Mean (±SD) SmO2 before transfusion was 63.18 ± 10.04%, SpHb was 9.27 ± 1.16 g/dl, and cardiac index was 2.62 ± 0.75 L/min/m(2). A significant increase during the course of blood transfusion was found for SmO2 (+3.44 ± 5.81% [95% confidence interval (CI) 1.04 to 5.84], p = 0.007), SpHb (0.74 ± 0.92 g/dl [95% CI 0.35 to 1.12], p < 0.001), and cardiac index (0.38 ± 0.51 L/min/m2 [95% CI 0.15 to 0.60], p = 0.002), respectively. However, the correlation between SmO2 and SpHb over the course of the transfusion was negligible (ρ = 0.25 [95% CI -0.03 to 0.48]). A similar lack of correlation was found when analyzing data of those patients who showed a positive leg raise test before the start of the transfusion (ρ = 0.37 [95% CI -0.11 to 0.84]).

CONCLUSION

We detected a statistically significant increase in SmO2 during the course of a single unit blood transfusion compared to baseline. However, there was no evidence of a correlation between longitudinal SmO2 and SpHb measurements.

The effects of non-leukoreduced red blood cell transfusions on microcirculation in mixed surgical patients

BACKGROUND

The impact of the storage process on oxygen-carrying properties of red blood cells and the efficacy of red blood cell (RBC) transfusions concerning tissue oxygenation remain an issue of debate in transfusion medicine. Storage time and leukocyte content probably interact since longer storage duration is thought to cause greater accumulation of leukocyte-derived cytokines and red blood cell injury.

OBJECTIVES

The aim of this study was to investigate the effects of storage and the efficacy of fresh (stored for less than 1 week) versus aged (stored for more than 3 weeks) non-leukoreduced RBC transfusions on sublingual microvascular density and flow in mixed surgical patients.

METHODS

Eighteen surgical patients were included in this study. Patients were randomly assigned into two groups receiving fresh (Group A) and aged (Group B) RBC transfusions. Sublingual microcirculatory functional capillary density (FCD) and microvascular flow index (MFI) were assessed using orthogonal polarization spectral (OPS) imaging. Measurements and collection of blood samples were performed after induction of general anesthesia, before RBC transfusion and 30 min after the RBC transfusion ended.

RESULTS

In both groups RBC transfusions caused an increase in hemoglobin concentration (p<0.001). RBC transfusions increased FCD in Group A (p<0.001), while FCD remained unaffected in Group B. Changes in MFI following RBC transfusion in both groups remained unaltered.

CONCLUSIONS

Fresh non-leukoreduced RBC transfusions but not RBCs stored for more than 3weeks, were effective in improving microciruculatory perfusion by elevating the number of perfused microvessels in mixed surgical patients.

THREAT helps to identify epistaxis patients requiring blood transfusions

Objective

To analyze the characteristics of patients who needed a blood transfusion due to epistaxis-caused anemia and to define potential risk factors.

Design

Retrospective cohort study.

Setting

A total cohort of 591 epistaxis patients, prospectively included between March 2007 and April 2008 at the ENT department of the University Hospital of Zurich, was evaluated concerning the need for blood transfusions.

Methods

The clinical charts and medical histories of these patients were evaluated.

Main outcome measures

Common parameters that increase the risk for severe anemia due to epistaxis.

Results

Twenty-two patients required blood transfusions due to their medical condition. 22.7% suffered from traumatic nosebleeds. Another 27.3% had a known medical condition with an increased bleeding tendency. These proportions were significantly higher than in the group of patients without need of blood transfusion. The odds ratio for receiving a blood transfusion was 14.0 in patients with hematologic disorders, 4.3 in traumatic epistaxis and 7.7 in posterior bleeders. The transfusion-dependent epistaxis patients suffered significantly more often from severe posterior nosebleeds with the need for a surgical therapeutic approach.

Conclusions

Patients with severe nosebleeds either from the posterior part of the nose or with known hematologic disorders or traumatic epistaxis should be closely monitored by blood parameter analyses to evaluate the indication for hemotransfusion. The acronym THREAT (Trauma, Hematologic disorder, and REAr origin of bleeding → Transfusion) helps to remember and identify the factors associated with an increased risk of receiving blood transfusion.

The use of specific anti-growth factor antibodies to abrogate the oncological consequences of transfusion in head & neck squamous cell carcinoma: an in vitro study

Introduction

Perioperative blood transfusion is associated with reduced prognosis in a number of solid malignancies. We investigate its role in a head & neck squamous cell cancer (HNSCC) cell lines. Growth of these cell lines was analogous to endothelial growth. Direct exposure to transfusion products exaggerated this effect. It was logical therefore to assess the effects of anti-endothelial antibodies on this interaction.

Materials and methods

Control (HUVEC) and tumour cell lines were exposed to transfusion products. The pre-incubation of the transfusion product with anti-endothelial growth factors was assessed by a growth assay. Where appropriate cells were pre-incubated for 1 hour with 10 μl of a mixture of 100 μl of each and anti-ligand antibodies, the corresponding blood product supplement was incubated with 10 μl of a mixture of 100 μl each of anti-ligand antibodies 1 hour before supplementation to the appropriate cell line. All results are representative of at least two independent experiments carried out in triplicate.

Results

The antibody did not directly reduce growth in the tumour cell line, however there was a significant reduction (p < 0.001) in tumour cell line vascular mimicry caused by transfusion products pre-incubation with anti-endothelial growth factor antibody. This was found in several other tumours.

Conclusion

Perioperative blood transfusion is associated with reduced prognosis in a number of solid malignancies including HNSCC. However this phenomenon is abrogated by the use of anti-endothelial growth factor antibodies. This suggests that the original effect was mediated by the endothelial growth factor family.

In vitro and in vivo evaluation of Dideco’s paediatric cardiopulmonary circuit for neonates weighing less than five kilograms

The neonate cardiopulmonary bypass (CPB) circuit, including a KIDS D100 oxygenator (The Sorin Group, Mirandola, Italy) and a D130 arterial filter (The Sorin Group), was evaluated in vitro with respect to the removal of free micro gas bubbles. No gas bubbles > 40µm were measured after the arterial filter D130 upon manual introduction of 10 ml of air into the venous line or during the use of vacuum-assisted venous drainage (VAVD). The D130 arterial filter removed 88 % of gas bubbles < 40 µm during manual introduction of air into the venous line; however, only 50 % of gas bubbles < 40 µm were removed during the use of VAVD.

The same CPB circuit was evaluated in vivo to compare with another CPB circuit, including a D901 oxygenator (The Sorin Group) and arterial filter D736 (The Sorin Group), in 155 neonates weighing ≤5 kg. The D100 circuit required significantly less priming volume than the D901 circuit. Postoperative haemoglobin was significantly higher, artificial ventilation time was significantly shorter and postoperative bleeding was significantly less in the D100 group. This neonate CPB circuit effectively removed the gas bubbles and required up to 37% less priming volume and, thus, decreased the need for blood transfusion.

Is cell salvage safe in liver resection? A pilot study

STUDY OBJECTIVE

To investigate the quality of cell salvaged (CS) blood in patients undergoing hemihepatectomy (study group) and compare it with CS-blood from aortic surgery (control group).

DESIGN

Observational study.

SETTING

Operating room in a university hospital.

MEASUREMENTS

6 patients undergoing hemihepatectomy or aortobifemoral bypass with intraoperative blood loss of more than 800 mL. Samples were drawn from the central venous catheter, from the reservoir of a CS recovery system, and from the processed blood in each patient to determine interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF), complement C3a, and the terminal complement complex C5b-9. Microbiological analysis included colony count after cultivation in aerobic and anaerobic medium as well as enrichment culture for 6 days.

MAIN RESULTS

In the hemihepatectomy group, levels of IL-6, C3a, and C5b-9 were significantly higher in the reservoir than in samples obtained from the central venous catheter. After the washing procedure, levels of IL-6, C3a, and C5b-9 were lower in the liver resection group than in each patient's own plasma levels. In all patients undergoing aortobifemoral bypass and in 5 patients undergoing hemihepatectomy, blood samples were sterile or showed growth of commensal skin microflora in low numbers (coagulase-negative staphylococci or propionibacteria). In one patient in the liver resection group, we could not exclude contamination with intestinal flora.

CONCLUSION

Cell salvaged blood in liver resection seems to be safe for retransfusion with respect to cytokine release and complement activation, but requires further investigation in regard to bacterial contamination.

Bloodless cardiac surgery: not just possible, but preferable

Blood transfusions after cardiac surgery are very common, and the rates are highly variable among institutions. Transfusion carries the risk of infectious and noninfectious hazards and is often clinically unnecessary. This article discusses the history of bloodless cardiac surgery, the hazards of transfusion, the benefits of reducing or eliminating transfusion, and strategies to conserve blood. It also provides a list of resources for those who are interested in learning more about bloodless care.

Anemia in critical care patients: incidence, etiology, impact, management, and use of treatment guidelines and protocols

PURPOSE

The incidence, etiology, impact, and management of anemia in critical care patients and the development of treatment guidelines and protocols for the management of anemia in this patient population are discussed.

SUMMARY

Most patients in intensive care units develop anemia as a result of blood losses, nutritional deficiencies, hemolysis, myelosuppression, renal insufficiency, inflammation, infection, or another disease process. Anemia can have an adverse impact on critically ill patients with severe ischemic heart disease or cerebrovascular disease and patients undergoing surgery. The use of blood conservation measures and restrictive blood transfusion strategies can circumvent problems associated with transfusion. Epoetin alfa increases hemoglobin concentrations and reduces the need for transfusion in critical care patients, including surgical patients with large anticipated blood losses. Epoetin alfa also appears to be effective for managing anemia in patients with multiple organ dysfunction syndrome. Iron supplementation is needed by most patients receiving erythropoietic therapy. Iron supplementation without erythropoietic therapy is inadequate to correct anemia unrelated to iron deficiency. Concerns have been raised about a possible increased risk for infection when parenteral iron therapy is used in critical care patients. Developing treatment guidelines or protocols for managing anemia in critical care patients can minimize the need for transfusions and improve prescribing of erythropoietic therapy.

CONCLUSION

Epoetin alfa can play an important role in managing anemia in critical care patients, thereby minimizing patient exposure to transfusion-related risks and optimizing the use of the limited blood supply. There is currently no data available for use of darbepoetin in this manner.

Definition and management of anemia in patients infected with hepatitis C virus

Chronic infection with hepatitis C virus (HCV) can progress to cirrhosis, hepatocellular carcinoma, and end-stage liver disease. The current best treatment for HCV infection is combination therapy with pegylated interferon and ribavirin. Although this regimen produces sustained virologic responses (SVRs) in approximately 50% of patients, it can be associated with a potentially dose-limiting hemolytic anemia. Hemoglobin concentrations decrease mainly as a result of ribavirin-induced hemolysis, and this anemia can be problematic in patients with HCV infection, especially those who have comorbid renal or cardiovascular disorders. In general, anemia can increase the risk of morbidity and mortality, and may have negative effects on cerebral function and quality of life. Although ribavirin-associated anemia can be reversed by dose reduction or discontinuation, this approach compromises outcomes by significantly decreasing SVR rates. Recombinant human erythropoietin has been used to manage ribavirin-associated anemia but has other potential disadvantages. Viramidine, a liver-targeting prodrug of ribavirin, has the potential to maintain the virologic efficacy of ribavirin while decreasing the risk of hemolytic anemia in patients with chronic hepatitis C.

Collection of autologous blood for bone marrow donation: how useful is it?

The hospital charts of 495 adult bone marrow (BM) donors to adult patients were reviewed to determine how necessary it is to collect autologous blood for marrow donation. An autologous transfusion was given to 79% of the donors. The median total volume of marrow harvested was 900 ml (range 450-1350 ml). The median number of nucleated cells harvested was 3.2 x 10(8)/kg patient weight (range 0.9-7.4 x 10(8)/kg patient weight). On the morning following the harvest, the median haemoglobin (Hb) concentrations were 104 g/l (79-135 g/l) in the female and 122 g/l (89-151 g/l) in the male donors autotransfused, and 96 g/l (75-127 g/l) in the female and 119 g/l (88-141 g/l) in the male donors not autotransfused. The post-donation Hb was lower than 85 g/l in four and lower than 90 g/l in 25 donors. Of the 25 donors with post-harvest Hb lower than 90 g/l, 23 were females and 14 had received an autologous transfusion. This study shows that, with a few exceptions, it is not necessary to collect autologous blood from healthy BM donors before the marrow harvest. The post-donation Hb concentrations do not decrease to levels detrimental to healthy persons whether autologous blood is transfused or not.

How low is too low? Cardiac risks with anemia

Despite the increasing availability of data supporting more restrictive transfusion practices, the risks and benefits of transfusing critically ill patients continue to evoke controversy. Past retrospective and observational studies suggested that liberal transfusion strategies were more beneficial in patients whose hematocrit levels fell below 30%. An expanding body of literature suggests that an arbitrary trigger for transfusion (the '10/30 rule') is ill advised. A recent randomized controlled trial provided compelling evidence that similar, and in some cases better, outcomes result if a restrictive transfusion strategy is maintained. The impact of this accumulating evidence on clinical practice is evident in large reports, which show that the average transfusion trigger in critically ill patients was a hemoglobin level in the range 8–8.5 g/dl. Based on the available evidence, transfusion in the critically ill patient without active ischemic heart disease should generally be withheld until the hemoglobin level falls to 7 g/dl. Transfusions should be administered as clinically indicated for patients with acute, ongoing blood loss and those who have objective signs and symptoms of anemia despite maintenance of euvolemia. The hemoglobin level at which serious morbidity or mortality occurs in critically ill patients with active ischemic heart disease is a subject of continued debate but it is likely that a set transfusion trigger will not provide an optimal risk–benefit profile in this population.

Blood transfusion in the perioperative period

In the perioperative period, blood transfusions are most commonly administered to address acute blood loss resulting from trauma, neoplasia, or surgery. In this setting, transfusions may be life saving, allowing time for clotting or surgical hemostasis. In recent years, however, there is a growing awareness that the administration of blood products may not be a benign treatment. In addition to the more commonly cited complications such as transfusion reactions, disease transmission, and electrolyte disturbances, blood transfusions have also been linked to poor surgical outcomes, increased risk of infection, cancer recurrence, and acute lung injury. The recognition of these problems has lead to more conservative transfusion strategies, and questioning of what constitutes an appropriate transfusion trigger. In this section, we will discuss the pathophysiology of acute blood loss, the benefits and risks of transfusions in surgical patients, management of perioperative blood transfusions, and alternative strategies to minimize the need for blood products.

Blood-transfusion requirements and blood salvage in donors undergoing right hepatectomy for living related liver transplantation

Living related liver donation for liver transplantation in adults including its risks is receiving increased attention. We present data from 44 liver donors focusing on transfusion requirements and avoidance of heterologous transfusion. The volume of blood transfused (both autologous from preoperative donation and heterologous) was assessed including that derived from intraoperative isovolemic hemodilution, cell-saver salvaged, and retransfused blood. Hemoglobin concentration and central venous pressure were measured at specified time points before and during surgery. Intraoperative blood loss was calculated and correlated to the duration of parenchymal transsection, liver volume resected, and central venous pressure. There were no specific anesthesia-evoked complications. In 4 donors, major bleeding (>2000 mL) occurred. Blood loss averaged 902 +/- 564 mL (SD), yielding a minimal mean hemoglobin concentration of 8.1 +/- 1.2 g/dL. One donor received 3 U of heterologous blood and 30 donors received autologous blood from their preoperative donation. An average of 592 +/- 112 mL of blood derived from perioperative acute isovolemic hemodilution was retransfused as was 421 +/- 333 mL of washed red cells from the cell-saving system. Avoidance of heterologous blood transfusion, application of blood-saving techniques, and efficient pain management are crucial for adult living liver donors. Transfusion of banked blood can be avoided in most patients when intraoperative cell salvage, preoperative autologous blood donation, and intraoperative hemodilution are combined.

Blood-transfusion requirements and blood salvage in donors undergoing right hepatectomy for living related liver transplantation

Living related liver donation for liver transplantation in adults including its risks is receiving increased attention. We present data from 44 liver donors focusing on transfusion requirements and avoidance of heterologous transfusion. The volume of blood transfused (both autologous from preoperative donation and heterologous) was assessed including that derived from intraoperative isovolemic hemodilution, cell-saver salvaged, and retransfused blood. Hemoglobin concentration and central venous pressure were measured at specified time points before and during surgery. Intraoperative blood loss was calculated and correlated to the duration of parenchymal transsection, liver volume resected, and central venous pressure. There were no specific anesthesia-evoked complications. In 4 donors, major bleeding (>2000 mL) occurred. Blood loss averaged 902 +/- 564 mL (SD), yielding a minimal mean hemoglobin concentration of 8.1 +/- 1.2 g/dL. One donor received 3 U of heterologous blood and 30 donors received autologous blood from their preoperative donation. An average of 592 +/- 112 mL of blood derived from perioperative acute isovolemic hemodilution was retransfused as was 421 +/- 333 mL of washed red cells from the cell-saving system. Avoidance of heterologous blood transfusion, application of blood-saving techniques, and efficient pain management are crucial for adult living liver donors. Transfusion of banked blood can be avoided in most patients when intraoperative cell salvage, preoperative autologous blood donation, and intraoperative hemodilution are combined.

Transfusion triggers for blood components

Whereas there are general guidelines for acceptable transfusion therapy, optimal transfusion therapy has not been determined for most clinical settings. Recent research has focused on controlled studies of red cell transfusion in specific clinical settings. Better determinations of oxygen delivery and consumption are needed to guide clinicians in determining whether transfusion is justified for patients during the perioperative period, those with coronary artery disease, and those in intensive care units. For sickle cell disease, the role of transfusion for acute complications can be life saving; however, the role of chronic transfusion regimens awaits further research into efficacy. Finally, whereas criteria for the prophylactic transfusion of platelets in hematologic diseases are well described, relatively little information is available on the value of platelet transfusion where the absolute count is less than 100,000 but greater than 50,000. The value of fresh frozen plasma components, both standard and sterilized, also requires elucidation.

When to give blood

With increased public awareness of the risks of blood transfusion and the decreased availability of blood products, the decision to transfuse a patient should be considered carefully. Most patients require a blood transfusion when haemoglobin levels fall below 8 g=dl or when there is greater than 30% loss of blood volume. However, the main indication for transfusing a patient is to increase their oxygen-carrying capacity and through invasive monitoring provide evidence of inadequate tissue oxygenation. Blood transfusions should be based on the patient’s risks of developing complications of inadequate oxygenation rather than on a single haemoglobin ‘trigger’.

Recombinant human erythropoietin administration in cardiac surgery

OBJECTIVE

Postoperative anemia and multiple blood transfusions are still important problems in cardiac surgery. During the past few years, there have been some reports indicating that multiple recombinant human erythropoietin infusions starting at least 2 weeks before the operation induced erythropoiesis. We aimed to reduce the risk of adverse reactions of high doses of recombinant human erythropoietin and reduce the period of hospitalization by using it only once, 4 days before the operation.

METHODS

Twenty-five patients received recombinant human erythropoietin 4 days before the operation, and 28 patients comprised the control group. All the hematologic parameters of the patients are measured on the day of admission, the day before the operation (fourth day), the first day after the operation, and 1 week later.

RESULTS

In the recombinant human erythropoietin group the mean hemoglobin concentration increased on the morning of the operation (14.5 +/- 0.52 g/dL in the recombinant human erythropoietin group and 12.4 +/- 0.65 in the control group, P <.05). To maintain hemoglobin levels at greater than 8.5 g/dL, 330 +/- 33 mL of homologous transfusion was required in the recombinant human erythropoietin group, whereas 680 +/- 75 mL was required in the control group (P <.01).

CONCLUSION

Recombinant human erythropoietin induces erythropoiesis rapidly, even when it is used with a low single dose just 4 days before the operation. No adverse reactions were seen with this kind of recombinant human erythropoietin treatment.

A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks

In many patients, a 'type and screen' procedure is routinely performed before surgery. However, most patients are not transfused after all. Can we predict, which surgical patients will and will not be transfused, to reduce the number of these investigations? We studied 1482 consecutive surgical patients with intermediate risk for transfusion. Multivariate logistic regression modelling and the area under the Receiver Operating Characteristic curve (ROC area) were used to quantify how well age, gender, surgical procedure, emergency or elective surgery and anaesthetic technique predicted transfusion, and whether the preoperative haemoglobin concentration had added predictive value. Gender, age > or =70 yr, and type of surgery were independent predictors of transfusion, with a ROC area of 0.75 (95% CI: 0.72-0.79). Validating this model with an easily used prediction rule in a second patient population yielded a ROC area of 0.70 (95% CI: 0.63-0.77). With this rule type and screen could correctly be withheld in 35% of these patients. In the remaining 65% of the patients, a further reduction in type and screen investigations of 15% could be achieved using the preoperative haemoglobin concentration. Using a simple prediction rule, preoperative type and screen investigations in patients who have to undergo surgery procedures with intermediate transfusion risk can be avoided in about 50%. This may reduce patient burden and hospital costs (on average: 3 million US$ per 100 000 procedures).

Blood use in lung resection for carcinoma: perioperative elective anaemia does not compromise the early outcome

OBJECTIVE

Blood transfusion may adversely affect the prognosis following surgery for non-small cell lung carcinoma (NSCLC). Conventionally by most thoracic surgeons, a perioperative haemoglobin (Hb) less than 10 g/dl has been considered a transfusion trigger. In this prospective trial we have (a) evaluated the overall blood transfusion requirements and factors associated with an increased need for transfusion and (b) in a subsequent subset of patients, tested the hypothesis that elective anaemia after major lung resection may be safely tolerated in the early postoperative period.

METHODS

A total of 198 (M/F 179/10, mean age 61.2, range 32--85 years) patients suffering from NSCLC were submitted to pneumonectomy (n = 89), bilobectomy (n = 19) and lobectomy (n = 90). A rather strict protocol was used as a transfusion strategy. The transfusion requirements were analyzed and seven parameters (gender, age > 65, preoperative Hb < 11.5 g/dl, chest wall resection, history of previous thoracotomy, pneumonectomy and total blood loss) were statistically evaluated by univariate and logistic regression analysis. Subsequently, according to the perioperative Hb level during the first 48 h, patients were divided into group A (n = 49, Hb = 8.5--10) and group B (n = 149, Hb > 10) with a view to estimate the risks of elective perioperative anaemia. Groups were comparable in terms of age, sex, type of operation performed, preoperative Hb, creatinine level, FEV1, arterial blood gases and history of heart disease.

RESULTS

The overall transfusion rate was 16%. Univariate analysis revealed that preoperative Hb < 11.5 g/dl (P < 0.01) and total blood loss (P < 0.0001) were associated with increased need for transfusion, but only the total blood loss was identified as an independent variable in multivariate analysis. Statistical analysis between groups A and B showed no significant difference regarding postoperative morbidity and mortality: atelectasis (3 vs. 6), chest infection (2 vs. 9), sputum retention requiring bronchoscopy (5 vs. 12), admission to intensive care unit (5 vs. 7), ARDS (0 vs. 3), postoperative hospital stay (7.7 +/- 2.6 vs. 9.1 +/- 3.8 days) and deaths (1 vs. 3).

CONCLUSIONS

The use of a strict transfusion strategy could help in reducing overall blood transfusion. Furthermore, a perioperative Hb of 8.5--10 g/dl could be considered safe in elective lung resections for carcinoma.

Preoperative predictors of the need for allogeneic blood transfusion in lung cancer surgery

BACKGROUND

The use of blood-saving techniques in elective surgery can produce a favorable cost-benefit ratio only when there is a reasonable likelihood that transfusion will be required. To apply a targeted blood-sparing technique in lung cancer surgery, the patient's preoperative characteristics that predict the use of allogeneic blood transfusion (ABT) in this practice were investigated.

STUDY DESIGN AND METHODS

One hundred seventy-three consecutive patients who underwent primary lung cancer surgery were included in this retrospective study. Clinical and epidemiologic variables, lung tumor extension (TNM staging), and surgery type were analyzed by logistic regression to discover the preoperative predictors of ABT.

RESULTS

Thirty patients, 17.3 percent of all who underwent surgery and 19.9 percent of those who underwent resolvent surgery, received ABT. Excluding a patient who needed 18 units of RBCs, the number of ABT units required by transfused patients was 1. 93 +/- 0.88 (mean +/- SD). Extensive surgery, patient's age (< or =64 years), and elevated erythrocyte sedimentation rate (>45 mm/hour) were the preoperative variables that influenced the need for ABT. The definitive predictive model was able to recognize 82.3 percent of patients who received ABT and 95.6 percent of those who did not.

CONCLUSION

A predictive model can preoperatively identify patients at risk for needing ABT in lung cancer surgery. The model could be utilized to tailor blood-sparing intervention programs.