Caroline Helwick

October 22, 2014

NEW ORLEANS — Patients having surgery who refuse blood transfusions and are instead treated with blood conservation measures have outcomes that are comparable to or better than patients who receive transfusions, according to a new study.

"The use of appropriate blood conservation measures for patients who do not accept transfusions results in similar or better outcomes and is associated with equivalent or lower costs," said Steven Frank, MD, associate professor of anesthesiology and director of the Center for Bloodless Medicine and Surgery at Johns Hopkins Medical Institutions in Baltimore. "This specialized care may be beneficial even for patients who accept transfusions."

Dr Frank presented the study results here at Anesthesiology 2014.

"Although clinical outcomes have been reported for patients who do not accept transfusions, most studies lack a control group, fail to use risk adjustment, and focus exclusively on cardiac surgery," he said. "Having recently opened our Center for Bloodless Medicine and Surgery, we analyzed our clinical outcomes in a risk-adjusted fashion."

The 294 patients in the bloodless group, all Jehovah's Witnesses, received multidisciplinary specialized care to conserve blood and optimize clinical outcomes. They were matched with 1157 patients who received transfusions.

The investigators assessed hemoglobin concentrations, mortality, morbid outcomes (including infection), myocardial infarction, thrombotic, renal, and respiratory complications, hospital charges, and costs.

Demographic differences between the groups were minimal, and hemoglobin values were not different at baseline.

"Each patient in the bloodless group was treated individually, according to the particular clinical situation," Dr Frank explained.

Bloodless surgery does not take any longer to perform.

Specialist care included the treatment of preadmission anemia, efforts to reduce intraoperative and iatrogenic blood loss, autologous blood salvage, the selective use of intraoperative autologous normovolemic hemodilution, the tolerance of lower than usual hemoglobin concentrations, and the use of intravenous iron and erythropoietin.

Conscientious attention to blood loss typically pays off. "For instance, say that we expect blood loss for a Whipple procedure to be 800 cc. It will be half as much if that patient is a Jehovah's Witness," Dr Frank reported. "We see this all the time. And in our preliminary analyses, bloodless surgery does not take any longer to perform."

Another place to conserve blood is through the restriction in laboratory testing. "ICU patients will lose about 1% of blood volume a day due to routine lab testing, which is enough to cancel out any erythropoiesis. Using neonatal phlebotomy tubes that hold 0.5 cc instead of 5.0 cc, we can reduce blood loss by about 90%," he reported.

Comparable Outcomes

Discharge hemoglobin concentrations were similar in the bloodless and transfusion groups (10.8 vs 10.9 g/dL), but overall mortality was lower in the bloodless group (0.7% vs 2.7%; P = .046). "Mortality risk was about three times higher in patients who accepted transfusion," said Dr Frank.

After risk adjustment, bloodless care was not an independent predictor of the composite adverse outcome, which was death or any morbid event (odds ratio, 1.02; P = .91).

Total hospital costs were 12% lower in the bloodless group (P = .02), and direct hospital costs were 18% lower (P = .02).

These differences were primarily observed in the surgical subgroup, not the medical subgroup.

Surgeons can be particularly skeptical about not giving blood to patients whose hemoglobin levels concern them. "We are often fighting surgeons who want to transfuse patients with hemoglobins above 9 or 10 g/dL," Dr Frank explained. He said the results of several landmark trials support a more restrictive transfusion strategy. "We need to use evidence-based transfusion criteria."

"Once you see a few patients walk out the door with a hemoglobin level of 6.5 g/dL and come back in a month with 9.0 g/dL, this changes your whole perspective," he said. "You won't automatically want to transfuse the next patient with a 6.5, especially if he is healthy."

"I always say that treating preoperatively with a $5 iron pill is a lot better than treating with $500 worth of blood," he added.

Dr Frank and his team like to use a single 1 g dose of low-molecular-weight iron dextran, which requires only one visit to the infusion center and carries almost no risk for anaphylaxis.

Pratik Pandharipande, MD, from Vanderbilt Medical Center in Nashville, Tennessee, reported that his institution manages many bloodless cases, and they do so in a manner similar to that described by Dr Frank, although not in a focused program. The surgeons generally understand when there is a need for blood conservation, "even though this is not always spelled out," he told Medscape Medical News.

The findings from the Hopkins program are "provocative and interesting," and "raise a lot of good questions about the best practices for patients in the hospital," said Hannah Wunsch, MD, from the University of Toronto.

"It's great to have data to see the impact of these choices," she told Medscape Medical News. Because the bloodless population is generally a small group, to have data on almost 300 patients is of great interest, she added.

Dr Frank, Dr Pandharipande, and Dr Wunsch report no relevant financial relationships.

Anesthesiology 2014 from the American Society of Anesthesiologists (ASA): Abstract A2013. Presented October 12, 2014.


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