Every experienced surgeon has a patient whose life was saved by a blood transfusion (the “good”). In contrast, an overwhelming amount of evidence suggests that perioperative blood transfusion can be associated with adverse surgical outcomes (the “bad”). We wondered what patient characteristics, if any, can explain this clinical dichotomy with certain patients benefiting from transfusion, whereas others are harmed by this intervention.
We queried the American College of Surgeons National Surgical Quality Improvement Project database containing patient information entered between 2010 and 2012 to identify differences in mortality and morbidity among patients receiving blood transfusion within 72 hours of their operative procedure compared with those who did not receive any blood. We calculated the relative risk of developing a serious complication or of operative mortality in propensity-stratified patients with equivalent predicted risk of developing a serious complication or operative mortality.
There were 470,407 patients in the study group. Of these, 32,953 patients (7.0%) received at least a single blood transfusion within 72 hours of operation. The percent of transfused patients who died or developed serious morbidity was 11.3% and 55.4% compared with 1.3% and 6.1% in nontransfused patients (both P < .001). Operative mortality, rates of failure to rescue, and serious postoperative complications are increased in patients who receive a postoperative transfusion, both in unadjusted comparisons and in propensity-matched comparisons. Dividing patients into regression-stratified deciles with equal numbers of deaths in each group found that patients at the greatest risk for development of death or serious complications had nonsignificant risk of harm from blood transfusion, whereas patients in the least risk deciles had between an 8- and 12-fold increased risk of major adverse events associated with transfusion.
We found that high-risk patients do not have a significant risk from blood transfusion, but low-risk patients have between an 8- and 10-fold excess risk of adverse outcomes when they receive a blood transfusion. We speculate that careful preoperative assessment of transfusion risk and intervention based on this assessment could minimize operative morbidity and mortality, especially because the patients at least risk are more likely to undergo elective operations and provide time for therapeutic interventions to improve transfusion risk profiles.
To read this article in full you will need to make a payment
Purchase one-time access:Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
One-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:Subscribe to Surgery
Already a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
- Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis.Interact Cardiovasc Thorac Surg. 2013; 17: 96-102
- Transfusion triggers for guiding RBC transfusion for cardiovascular surgery: a systematic review and meta-analysis*.Crit Care Med. 2014; 42: 2611-2624
- Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention.Blood. 2009; 113: 3406-3417
- Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature.Crit Care Med. 2008; 36: 2667-2674
- Blood transfusion in critically injured patients: a prospective study.Injury. 2006; 37: 455-465
- Red blood cell transfusion and mortality in trauma patients: risk-stratified analysis of an observational study.PLoS Med. 2014; 11: e1001664
- Review article: risks of anemia and related management strategies: can perioperative blood management improve patient safety?.Can J Anaesth. 2013; 60: 168-175
- What is really dangerous: anaemia or transfusion?.Br J Anaesth. 2011; 107: i41-i59
- Anemia and perioperative red blood cell transfusion: a matter of tolerance.Crit Care Med. 2006; 34: S102-S108
- Reducing Bleeding in Cardiac Surgery I. Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study.Circulation. 2008; 117: 478-484
- The impact of anemia in patients with respiratory failure.Chest. 2005; 128: 576S-582S
- The relationship between intraoperative blood transfusion and postoperative systemic inflammatory response syndrome.Am J Surg. 2013; 205: 457-465
- Intraoperative transfusion of small amounts of blood heralds worse postoperative outcome in patients having noncardiac thoracic operations.Ann Thorac Surg. 2011; 91: 1674-1680
- Comparing apples and oranges.J Thorac Cardiovasc Surg. 2002; 123: 8-15
- Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.Stat Med. 2009; 28: 3083-3107
- Thoracic surgery in the real world: does surgical specialty affect outcomes in patients having general thoracic operations?.Ann Thorac Surg. 2012; 93: 1041-1047
- The treatment of bleeding is to stop the bleeding! Treatment of trauma-related hemorrhage.Transfusion. 2009; 49: 240S-247S
- Diluting the benefits of hemostatic resuscitation: a multi-institutional analysis.J Trauma Acute Care Surg. 2013; 75: 76-82
- Revisiting early postinjury mortality: are they bleeding because they are dying or dying because they are bleeding?.J Surg Res. 2013; 179: 5-9
- Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients.J Am Coll Surg. 2009; 208: 931-937
- Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care.J Trauma Acute Care Surg. 2013; 75: S238-S246
- Potential value of protocols in substantially bleeding trauma patients.Curr Opin Anaesthesiol. 2013; 26: 215-220
- Risk factors and outcome of increased red blood cell transfusion in cardiac surgical patients aged 65 years and older.Thorac Cardiovasc Surg. 2015; 63: 39-44
- Anemia, bleeding, and blood transfusion in the intensive care unit: causes, risks, costs, and new strategies.Am J Crit Care. 2013; 22: eS1-eS13
- Variation in use of blood transfusion in coronary artery bypass graft surgery.JAMA. 2010; 304: 1568-1575
- Identifying variations in blood use based on hemoglobin transfusion trigger and target among hepatopancreaticobiliary surgeons.J Am Coll Surg. 2014; 219: 217-228
- Red blood cell transfusion practices in two surgical intensive care units: a mixed methods assessment of barriers to evidence-based practice.Transfusion. 2014; 54: 2658-2667
- 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982
- 2012 update to the Society of Thoracic Surgeons guideline on use of antiplatelet drugs in patients having cardiac and noncardiac operations.Ann Thorac Surg. 2012; 94: 1761-1781
Published online: May 29, 2015
Accepted: February 27, 2015
The authors have made the following disclosures: Victor A. Ferraris—CMEology/Baxter Healthcare (CME event), NovoNordisk (unpaid consultant); Sibu P. Saha—CVRx and Baxter HealthCare (research trials).
Published by Elsevier Inc.