Changes in Red Blood Cell Transfusion Practice During the Turn of the Millennium: A Retrospective Analysis of Adult Patients Undergoing Elective Open Abdominal Aortic Aneurysm Repair Using the Mayo Database

Abstract

Conclusion: Change in transfusion practice, including the use of more autotransfusions and tolerance of lower perioperative hemoglobin levels, have not resulted in significant differences in perioperative morbidity or mortality in patients undergoing open abdominal aortic aneurysm (AAA) repair. Summary: The average cost of the transfusion of a red blood cell (RBC) unit is $153.68, and 14 million units of RBCs are transfused annually in the United States (Sullivan NT, et al. Transfusion 2007;47:385-94). Currently, there is also enthusiasm for reducing the number of transfused units because of reported increased morbidity and mortality with increased transfusions and reported increased infectious complications with increased transfusions. The authors sought to determine whether changes in transfusion practice during a two-decade study had any impact on perioperative morbidity and mortality in patients undergoing open elective AAA repair. The authors stratified patients undergoing open elective AAA repair into one of two transfusion-related groups. Early practice was defined as that between 1980 and 1982, and late practice was defined as between 2003 and 2006. Hemoglobin concentration and RBC transfusion were analyzed as continuous variables and compared between groups. Perioperative complications were compared, and data were age adjusted and analyses corrected for multiple comparisons. Patients in the late practice group compared with those in the early practice group had lower intraoperative (mean, 10 ± 1.4 vs 11.5 ± 1.5 g/dL), postoperative (mean, 11.9 ± 1.4 vs 13.4 ± 1.5 g/dL), and discharge hemoglobin levels (mean, 10.8 ± 1.2 vs. 12.5 ± 1.5 g/dL; P < .0001 for each variable). Fewer patients in the late practice group received intraoperative allogenic transfusions (46% vs 99%, P < .0001). There were also fewer total allogenic units transfused in the late practice group (mean, 1.7 vs 4.3, P < .0001). No patients in the early practice group had intraoperative autotransfusions, whereas intraoperative autotransfusions were used in 97% of the late practice patients (P < .0001). The incidence of perioperative morbidity and mortality was 40% (n = 119) in the late practice group and 35% (n = 106) in the early practice group (P = .27). Comment: RBC transfusion is associated with worse outcomes in cardiac surgery patients and in patients experiencing acute coronary syndrome (Murphy GJ, et al. Circulation 2007;116:2544-52; and Rao SV. JAMA 2004;292:1555-62). However, a randomized trial in critically ill patients comparing liberal vs conservative RBC transfusion found no difference in survival with the two treatment strategies (Hebert PC, et al. N Engl J Med 1999;340:409-47). The current study also found no difference in major morbidity or mortality in patients undergoing AAA repair with respect to a changing transfusion policy using more conservative thresholds for transfusion. However, the patients did no worse, and given the expense occurred with each unit transfused, a more conservative policy for patients undergoing open AAA repair is at least indicated financially if not medically.