Commentary: Like politics, transfusion practice is local

Abstract

Central MessageWide center-level variability exists in the RBC transfusion practices after CABG surgery which is independent of patient characteristics. Further studies might explain this variation between institutions.See Article page 1015. Wide center-level variability exists in the RBC transfusion practices after CABG surgery which is independent of patient characteristics. Further studies might explain this variation between institutions. See Article page 1015. Ever growing numbers of studies have demonstrated an association between red blood cell (RBC) transfusion and adverse surgical outcomes and increasing costs after cardiac surgery.1Habib R.H. Zacharias A. Schwann T.A. Riordan C.J. Engoren M. Durham S.J. et al.Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome.Crit Care Med. 2005; 33: 1749-1756Crossref PubMed Scopus (240) Google Scholar, 2Reeves B.C. Pike K. Rogers C.A. Brierley R.C. Stokes E.A. Wordsworth S. et al.A multicentre randomised controlled trial of transfusion indication threshold reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2).Health Technol Assess. 2016; 20: 1-260Crossref Scopus (31) Google Scholar, 3Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1003) Google Scholar Initiatives to reduce blood transfusions in cardiac surgery patients have included blood conservation practice guidelines from the Society of Thoracic Surgeons, Society of Cardiovascular Anesthesiologists, and European Association for Cardio-Thoracic Surgery/European Association of Cardiothoracic Anaesthesiology.4Ferraris V.A. Brown J.R. Despotis G.J. Hammon J.W. Reece T.B. Saha S.P. et al.Society of Thoracic Surgeons Blood Conservation Guideline Task Force2011 Update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.Ann Thorac Surg. 2011; 91: 944-982Abstract Full Text Full Text PDF PubMed Scopus (988) Google Scholar,5Boer C. Meesters M.I. Milojevic M. Benedetto U. Bolliger D. von Heymann C. et al.Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA)2017 EACTS/EACTA guidelines on patient blood management for adult cardiac surgery.J Cardiothorac Vasc Anesth. 2018; 32: 88-120Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar Liberal and restrictive transfusion approaches have been studied widely in cardiac surgery. The TRICS trial randomized 5243 moderate- to high-risk adult cardiac surgery patients to liberal and restrictive strategies. The results showed that the liberal approach was noninferior to the restrictive strategy regarding a composite endpoint of death, myocardial infarction, stroke, renal failure requiring dialysis, and fewer blood transfusions.6Mazer C.D. Whitlock R.P. Fergusson D.A. Hall J. Belley-Cote E. Connolly K. et al.Restrictive or liberal red-cell transfusion for cardiac surgery.N Engl J Med. 2017; 377: 2133-2144Crossref PubMed Scopus (388) Google Scholar The TITRe2 investigators also evaluated both transfusion strategies. The primary outcomes of a serious infection or an ischemic event between both groups showed no differences. However, more deaths occurred in the restrictive group. The authors concluded that the restrictive transfusion threshold was not superior to the liberal approach concerning morbidity and health care costs.7Murphy G.J. Pike K. Rogers C.A. Wordsworth S. Stokes E.A. Angelini G.D. et al.Liberal or restrictive transfusion after cardiac surgery.N Engl J Med. 2015; 372: 997-1008Crossref PubMed Scopus (533) Google Scholar In contrast to previous reports,3Murphy G.J. Reeves B.C. Rogers C.A. Rizvi S.I.A. Culliford L. Angelini G.D. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.Circulation. 2007; 116: 2544-2552Crossref PubMed Scopus (1003) Google Scholar that study indicated that liberal transfusion resulted in lower mortality.7Murphy G.J. Pike K. Rogers C.A. Wordsworth S. Stokes E.A. Angelini G.D. et al.Liberal or restrictive transfusion after cardiac surgery.N Engl J Med. 2015; 372: 997-1008Crossref PubMed Scopus (533) Google Scholar At present, the restrictive transfusion approach remains the predominant practice, as reflected in the European guidelines.5Boer C. Meesters M.I. Milojevic M. Benedetto U. Bolliger D. von Heymann C. et al.Task Force on Patient Blood Management for Adult Cardiac Surgery of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Cardiothoracic Anaesthesiology (EACTA)2017 EACTS/EACTA guidelines on patient blood management for adult cardiac surgery.J Cardiothorac Vasc Anesth. 2018; 32: 88-120Abstract Full Text Full Text PDF PubMed Scopus (202) Google Scholar These guidelines have been effective, as demonstrated by the National Blood Collection and Utilization Survey, which showed a 6.1% decrease in the units of RBCs transfused in the United States in 2017 compared with 2015.8Jones J.M. Sapiano M.R.P. Savinkina A.A. Haass K.A. Baker M.L. Henry R.A. et al.Slowing decline in blood collection and transfusion in the United States – 2017.Transfusion. 2020; 60: 51-59Crossref Scopus (69) Google Scholar In their report, Fitzgerald et al9Fitzgerald D.C. Simpson A.N. Baker R.A. Wu X. Zhang M. Thompson M.P. et al.Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgery.J Thorac Cardiovasc Surg. 2022; 163: 1015-1024.e1Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar reviewed 22,272 patients undergoing isolated coronary artery bypass graft surgery. One third had required ≥1 U of RBC transfusion. The authors used multilevel regression models of patient characteristics, preoperative risks, and intraoperative blood conservation approaches to explain the center-level transfusion variability.9Fitzgerald D.C. Simpson A.N. Baker R.A. Wu X. Zhang M. Thompson M.P. et al.Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgery.J Thorac Cardiovasc Surg. 2022; 163: 1015-1024.e1Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This premise is grounded in their previous work. The patients in the blood transfusions group were older, more often women, and more often undergoing nonelective procedures, with a greater prevalence of preoperative dialysis and anticoagulant therapy. However, the variability in RBC transfusions across the various centers could not be explained. One limitation of an observational registry is the inability to discern the institutional factor, including organizational culture and provider level variability, which could have contributed to the decisions regarding blood transfusions. The trigger for blood transfusion in these patients is clearly not limited to the patient-related factors. However, we applaud the authors in their attempt to answer this important question in cardiac surgery. Although it might be considered a negative study, the lack of uniformity in the use of blood transfusions across institutions is clear. Although with current evidence and societal guidelines, the restrictive blood transfusion strategy in cardiac surgery has gained traction, better patient care can only be provided by focusing on changing institutional cultures, the implementation of guidelines and, most importantly, if all providers—including surgeons, anesthesiologists, perfusionists, and intensivists—follow the guidelines. Potentially unwanted RBC transfusion of cardiac surgery patients can be reduced only by further education, followed by improved communication among the team members to minimize the unneeded RBC transfusions. Determinants of hospital variability in perioperative red blood cell transfusions during coronary artery bypass graft surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 3PreviewTo identify to what extent distinguishing patient and procedural characteristics can explain center-level transfusion variation during coronary artery bypass grafting surgery. Full-Text PDF