The September issue of Anesthesia and Analgesia was devoted to patient blood management (PBM). The authors define PBM as “a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving a patient’s own blood, while promoting patient safety and empowerment.”[1] Today’s article asks the question: Is blood transfusion good for the patient, particularly if only one unit is given?[2] I’ve asked Dr. Genie Heitmiller, the division chief at Children’s National Medical Center in Washington DC to assist me. For those of you who don’t know her, Genie was a recent SPA lifetime achievement award winner who spent a large part of her career focused on anesthesia quality and patient safety issues. One of her passions involved blood transfusion and blood wastage in the operating rooms. At a Hopkins M&M I vividly remember, one of my posterior spinal fusion cases was reviewed because I transfused only one unit of blood. I actually thought I did a great job because I only used one rather than 2 or more units and said, “one unit blood transfusions may be bad for the patient and the hospital’s bottom line …unless of course the patient is bleeding”. I also discovered that despite my attempts to limit blood transfusions in the OR, the medical and surgical teams treating the patient postoperatively transfused an additional 2 units in the 48 hours after surgery. My lesson is best summed up by Van Morrison. Myron Yaster MD
Original article
Trentino KM, Leahy MF, Erber WN, Mace H, Symons K, Budgeon CA, Murray K. Hospital-Acquired Infection, Length of Stay, and Readmission in Elective Surgery Patients Transfused 1 Unit of Red Blood Cells: A Retrospective Cohort Study. Anesth Analg. 2022 Sep 1;135(3):586-591 PMID: 35977367
Today’s PAAD “aimed to compare hospital-acquired infection, length of stay, and readmissions in elective ADULT surgery patients transfused 1 unit of red blood cells throughout their entire admission to those not transfused”.[2] Cutting to the chase: They found that “Patients transfused 1 unit of red blood cells during their hospital admission had greater odds of hospital-acquired infection, increased length of stay, and all-cause emergency readmission within 28 days.”[2] Keep in mind: The authors were not looking at massive transfusion scenarios, trauma, and emergency surgery, rather the more common elective situations in which < 1-2 units of red blood cells were transfused to adult patients.
Fundamentally, and the reason we chose today’s article: Can a significant number of blood transfusions in PEDIATRIC PATIENTS be avoided by implementing strategies aimed at “managing and preserving a patient’s own blood”?[2, 3] AND we are not limiting this question to the operating room but to the duration of the hospital admission.[4] Based on previous studies in surgical and PICU patients, the answer is YES! [5 - 8]
The 3 pillars of blood transfusion therapy in the perioperative period are 1) the level of preoperative anemia, (2) the volume of perioperative blood loss, and (3) the transfusion threshold. [4] Are single red cell unit transfusions (or the equivalent amount for the smaller child) predictable and avoidable in pediatric patients? What is the transfusion threshold and why? There is to the best of our knowledge no data if single unit transfusions are more likely to be associated with adverse outcomes in children, so shouldn’t this be a priority for research in our specialty? We think so, and since our leadership time in the specialty is coming to an end, we are throwing down the gauntlet. Who is going to pick it up? Write us with your thoughts and I (MY) will publish in a readers’ response.
PS from Myron: As Jim DiNardo always reminds us: Association is not the same thing as Causation. The associations found in this study may have been caused by underlying medical and surgical conditions that necessitated the transfusions rather than the other way around.
References
1. Goobie, S.M., Patient Blood Management Is a New Standard of Care to Optimize Blood Health. Anesth Analg, 2022. 135(3): p. 443-446.
2. Trentino, K.M., et al., Hospital-Acquired Infection, Length of Stay, and Readmission in Elective Surgery Patients Transfused 1 Unit of Red Blood Cells: A Retrospective Cohort Study. Anesth Analg, 2022. 135(3): p. 586-591.
3. Trentino, K.M., et al., Appropriate red cell transfusions are often avoidable through Patient Blood Management. Blood Transfus, 2021. 19(2): p. 177-178.
4. Roubinian, N.H., et al., Predicting red blood cell transfusion in hospitalized patients: role of hemoglobin level, comorbidities, and illness severity. BMC Health Serv Res, 2014. 14: p. 213.
5. Goel R, et al. Pediatric patient blood management programs: not just transfusing little adults. Transfusion Medicine Reviews 2016. 30: p. 235–241.
6. Faraoni D, et al. Patient blood management for neonates and children undergoing cardiac surgery: 2019 NATA guidelines. J Cardiothorac Vasc Anesth 2019. 33: p.3249-3263
7. Long TR, et al. Changes in red blood cell transfusion practice during the past quarter century: a retrospective analysis of pediatric patients undergoing elective scoliosis surgery using the Mayo database. The Spine Journal 2012. 12: p. 455–462
8. Doctor A., et al. Recommendations on red blood cell transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med. 2018 September; 19(9): S98–S113