Use of Restrictive Transfusion in Abdominal Surgery: Should Evidence-Based Medicine Replace Art of Medicine?

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Ejaz et al1 elegantly demonstrated in a single-institution study that significant monetary savings may be realized if surgeons were to adhere to a restrictive transfusion policy based on concrete intraoperative and postoperative hemoglobin values. There is little doubt that blood transfusion exposes patients to potential risks of bloodborne pathogens.2 Studies have also demonstrated worse short-term outcomes attributable to blood transfusion itself in critically ill patients.3 Recently, a multicenter, prospective, randomized clinical trial demonstrated no long-term mortality difference between liberal and restrictive transfusion strategies.4 In light of the current controversy and changing climate of health care reform, Ejaz and colleagues are to be commended for spearheading this timely and provocative study. However, many such studies are retrospective in nature, using administrative databases, and have thus suffered from selection bias and lack of clinical granularity.While the transfusion trigger usinghemoglobin levelsmayguide theneed for transfusion, these guidelines should be takenwith some caution and surgeons must use all clinical data to make the final determination on the need for transfusion. At the same time, liberal transfusion strategies based solely on relatively lowhemoglobin levels in completely asymptomatic healthy patients may expose them to unnecessary risks and possibly worse outcomes. Because it is nearly impossible to design a prospective randomizedclinical trial of blood transfusion triggers incorporating all possible clinical scenarios owing to ethical concerns, surgeons should carefullyweighall the risks and benefits of blood transfusionguidedbyevidenceanduse their best clinical judgment. Ultimately, evidence-basedmedicine should complement, not replace, the art of medicine.