Age of Transfused Blood Impacts Perioperative Outcomes Among Patients Who Undergo Major Gastrointestinal Surgery

Yuhree Kim, MD, MPH; Neda Amini, MD; Faiz Gani, MBBS; Doris Wagner, MD; Daniel J. Johnson, BS; Andrew Scott, BS; Aslam Ejaz, MD, MPH; Georgios A. Margonis, MD, PhD; Li Xu, MD; Stefan Buettner, BS; Jack O. Wasey, BM, BCh; Ruchika Goel, MD; Steven M. Frank, MD; Timothy M. Pawlik, MD, MPH, PhD


Annals of Surgery. 2017;265(1):103-110. 

In This Article

Abstract and Introduction


Objective: To evaluate the impact of transfused packed red blood cell (PRBC) age on perioperative morbidity among patients undergoing major gastrointestinal surgery.

Background: Patients undergoing major surgery often receive PRBC transfusions. The effect of PRBC age (ie, storage duration before transfusion) on perioperative surgical outcomes remains poorly defined.

Methods: In this study, 1365 patients were identified who underwent a hepato-pancreatic or colorectal resection and received ≥1 unit of PRBCs between 2009 and 2014 at the Johns Hopkins Hospital. Data regarding the storage duration of PRBCs, clinicopathologic characteristics, and perioperative outcomes were obtained and analyzed. Multivariable modified Poisson regression analyses were performed to assess the effect of PRBC age on perioperative morbidity.

Results: A total of 5901 PRBC units were transfused for a median of 2 (interquartile range 2–4) units transfused per patient. In all, 936 (68.6%) patients received only units of blood that had been stored for less than 35 days ("fresh" blood), whereas 429 (31.4%) patients received at least 1 unit of PRBC that had been stored for ≥35 days ("older" blood). Overall postoperative morbidity was 32.8%. The incidence of postoperative complications (42.7% vs 28.3%) was higher among patients who received "older" vs "fresh" blood (P < 0.001). After adjusting for confounders on multivariable analysis, transfusion of "older" blood remained independently associated with an increased risk of perioperative morbidity (Relative Risk 1.20, P = 0.03).

Conclusions: The use of "older" blood was an independent predictor of postoperative morbidity among patients undergoing hepato-pancreatic or colorectal procedures. Transfusion of "older" blood products may contribute to a higher risk of postoperative complications.


Blood is an important therapeutic agent commonly administered to hospitalized patients. According to the Department of Health and Human Services, it is estimated that over 13 million units of packed red blood cells (PRBCs) are utilized annually in the United States, with up to 70% of PRBCs administered within the surgical setting.[1,2] Despite the therapeutic benefits of blood transfusions that include improving oxygen delivery/tissue perfusion, and being a potentially lifesaving procedure for severely anemic or acutely bleeding patients, blood transfusions may be associated with adverse outcomes such as a diminished immune response and transfusion-related acute lung injury (TRALI).[3,4] Previous studies have also demonstrated that blood transfusions may be associated with an increased risk of postoperative morbidity and infections, resulting in longer hospitalizations, multiple organ failure, and a higher risk for mortality among certain surgical patient populations.[5–8] Although the underlying pathophysiology of these adverse outcomes associated with blood transfusion remains unclear, the time-dependent biochemical and morphologic changes of red blood cells during the storage process have been proposed as a plausible underlying mechanism.[9–11] These changes, collectively known as the "RBC storage lesion," may affect microcirculatory flow and increase the affinity of hemoglobin for oxygen, thereby inducing tissue ischemia.[9,11–13]

In the United States, PRBCs can be stored for a maximum of 42 days, with an average storage duration of approximately 18 days.[14] Given that blood banks typically provide oldest unit released first, red blood cell units that have been stored longer are more frequently transfused, particularly at larger centers.[15] Despite recent evidence demonstrating in vitro changes in red cell structural integrity and in vivo red cell recovery, there is a paucity of data to explain the functional alterations of red blood cells after a certain period of storage.[11] Furthermore, previous studies on the clinical effects of the duration of red blood cell storage have reported contradictory results.[7,16,17] Given the lack of data evaluating the age of red blood cells transfused on perioperative clinical outcomes, we sought to define the association between the age of red blood cells and perioperative outcomes among patients undergoing major abdominal surgery at a large tertiary healthcare center.