The effect of restrictive blood transfusion policy on patients undergoing major liver surgery

Abstract

Presenter: Jonathan DeLong MD | University of California, San Diego Background: Unrestricted transfusion practices expose patients to potentially harmful complications and are major cost drivers in critically ill patients. Our institution adopted a restrictive transfusion policy driven by education, a point of service BestPractice Advisory (BPA), and enhancements to the electronic order entry process starting Q3 2014, completed by Q2 2015, with additional electronic functionality and education completed by Q2 2017. We investigated whether these interventions altered transfusion practices following complex liver surgery, and whether restrictive transfusion practices affected outcomes. Methods: A retrospective review was performed of patients at an academic medical center undergoing major liver surgery at over a six-year period from 2013 to 2018. All patients undergoing total lobectomy, trisegmentectomy, and partial hepatectomy were included. There were 272 total liver resection cases in the entire cohort. Preintervention, transition period, and postintervention periods were considered. Results: Overall blood transfusion decreased from 42.4% preintervention to 21.7% during the intervention to 7.1% postintervention (p < 0.001). Adherence to best practice recommendations improved from 34.6% preintervention to 68.8% during the intervention period to 100% postintervention (p < 0.001). Absolute RBC transfusions were also decreased in the post intervention group (p = 0.006). There was no difference in liver resection type (lobectomy, trisegementectomy, partial lobectomy) between the groups (p = 0.095). There was no difference in major complications (defined as death, cardiac arrest, MI, CVA, and progressive renal failure requiring dialysis) between the three periods (p = 0.863). Infectious complications (defined as surgical site infections, urinary tract infection, or pneumonia) were not significantly different between the groups (p = 0.849). Similarly, there was no difference in bile leak and progression to liver failure (p = 0.251 and p = 0.480 respectively). Surgical take backs readmission rates were not statistically different between the 3 groups (p = 0.229 and p = 0.372). Conclusion: Implementing the institutional policy for restrictive blood transfusion reduced the rate of perioperative blood transfusion for major liver surgery by 35.3%. Adherence to best practice guidelines for blood transfusion improved by 65.4%. Restricting transfusion of RBCs did not result in a statistically significant difference in major post-operative complications, post-operative infections, bile leak, or progression to liver failure. Surgical take backs and readmissions were also unchanged. We conclude that restrictive RBC transfusion practices can safely be adopted in patients undergoing major liver surgery without increasing post-operative complications or exposing patients to unnecessary transfusion risks.