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Lower-Extremity Amputation & RBC Transfusion

Lower-Extremity Amputation & RBC Transfusion

Major lower-extremity amputation remains a commonly performed procedure in the United States, and studies estimate that the number of Americans who will be living with a major amputation will exceed 3.6 million by 2050, with the majority of these cases being attributable to vascular conditions. Amputation for lower-extremity arterial disease has been associated with substantial postoperative mortality and morbidity due to the inherent medical comorbidities. Risk factors associated with mortality after major amputation include older age, cardiac and pulmonary disease, renal insufficiency, steroid use, dependent functional status, and preoperative sepsis. “Research indicates that perioperative packed red blood cell (RBC) transfusions are often administered to patients with vascular disease, but the effect of this treatment on postoperative survival and outcomes among patients undergoing amputation is poorly understood,” says Tze-Woei Tan, MD, MBBS, FACS, RPVI. Despite its potential advantages in critically ill patients with acute cardiac events, RBC transfusions have been linked to higher mortality in patients undergoing various surgeries as well as perioperative wound infection and pneumonia. In patients undergoing lower-extremity bypass, RBC transfusion can increase risks for surgical site infections and early bypass graft thrombosis.   New Data For a study published in Surgery, Dr. Tan and colleagues evaluated the outcomes of patients undergoing major lower-extremity amputations who received perioperative packed RBC transfusions. The authors used the dataset of the National Surgical Quality Improvement Program (2005–2011) to examine more than 5,700 above-knee and over 6,700 below-knee amputations. Study participants were then stratified by perioperative RBC transfusion and assessed for outcomes, including perioperative mortality, myocardial infarction, thromboembolism, and duration of stay at the hospital. “Results showed that about 17% of...
Blood Transfusions & Infection Risk

Blood Transfusions & Infection Risk

Studies have shown that red blood cell (RBC) transfusions are commonly performed, with approximately 14 million units transfused in 2011 in the United States. RBC transfusions can modulate the immune system, which in turn may impact infection risk. One approach in blood management is to use a restrictive threshold transfusion strategy in which the hemoglobin thresholds at which RBC transfusions are indicated are lowered. “The restrictive strategy is recommended by guidelines, but only about 27% of hospitals report using them after surgery,” says Jeffrey M. Rohde, MD. In addition, only 31% of hospitals report having a blood management program in place to optimize the care of patients who might need a transfusion. A Systematic Review & Meta-Analysis Dr. Rohde and colleagues conducted a systematic review and meta-analysis of 21 randomized trials that compared restrictive and liberal RBC transfusion strategies. Published in JAMA, the article evaluated whether RBC transfusion thresholds were associated with risk of infection and whether these risks were independent of leukocyte reduction. The study included more than 8,700 patients who met eligibility criteria. All healthcare-associated infections reported after receiving donor blood in randomized trials were evaluated, including serious infections like pneumonia and bloodstream and wound infections. According to the results, a restrictive RBC transfusion strategy reduced the risk of healthcare-associated infections when compared with a liberal transfusion strategy. “The more RBCs that patients received, the greater their risk was for infection,” says Dr. Rohde. “The fewer the RBC transfusions, the less likely hospitalized patients were to develop infections.” He adds that these findings were most likely due to transfusion-associated immunomodulation. Overall, for every 38 hospitalized patients considered...
Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Examining a Protocol for Transfusing Plasma to Severely Injured Patients

Patients with a trauma-induced coagulopathy account for more than half of hemorrhagic deaths in the United States. About 25% of severely injured patients are already coagulopathic and thrombocytopenic upon arrival to trauma centers. Mortality rates have been shown to decrease in these patients when they receive higher ratios of plasma and platelets. “Early transfusion of red blood cells (RBCs) has been established as a core element of trauma resuscitation,” says Bryan A. Cotton, MD, MPH. “Most trauma centers store RBCs in their EDs, but few store plasma in their EDs. This makes it challenging to achieve high plasma-RBC ratios early during care, which in turn can worsen coagulopathy and increase patient mortality.” Expediting Plasma Delivery Over the past several years, more and more trauma centers have implemented massive transfusion (MT) protocols to ensure that severely injured patients receive higher plasma-RBC ratios early. “This was shown to markedly reduce the time to release of plasma, but the time to transfusion was still excessively long,” Dr. Cotton says. In an effort to expedite the delivery of plasma for patients requiring MT, some medical centers began keeping thawed plasma (TP) in their blood banks (BBs).   MT protocols vary throughout trauma centers in the U.S., but those reporting the most marked changes in survival are the ones that have implemented concurrent TP programs. Furthermore, trauma centers that develop TP programs concurrent with MT protocols have shown that they can reduce the time to first plasma transfusion and the overall number of blood components transfused. Testing a New Thawed Plasma Protocol In 2006, Dr. Cotton and colleagues began a TP program in their...
Wide Variation in Blood Transfusion Use

Wide Variation in Blood Transfusion Use

Current clinical guidelines from three medical societies suggest that the hemoglobin threshold for blood transfusions during surgery should be 7 g/dl or 8 g/dl. These guidelines also note that patients don’t need a transfusion when hemoglobin levels are above 10 g/dl. However, when hemoglobin levels fall between these thresholds, there is little consensus on the best course of action. Although four landmark studies published over the past 5 years suggest that it’s safe to wait until hemoglobin levels fall to 7 g/dl or 8 g/dl before transfusing, wide variation and excessive use of blood transfusions have been reported. Advances in viral testing in recent years have made blood transfusion safer, but risks still exist for these patients, including lung injury, immune suppression, and viral transmission. Blood is also in scarce supply and expensive. Wide Variation of Hemoglobin Thresholds In an issue of Anesthesiology, my colleagues and I had a study published that sought to confirm the wide range of hemoglobin thresholds used by surgeons and anesthesiologists. Over 18 months, we collected data on more than 48,000 surgical patients at Johns Hopkins Hospital. Within the institution, there was a variation of up to 3 g/dl in hemoglobin thresholds among surgeons and anesthesiologists, when compared with their peers. Virtually all providers used thresholds above the ones recommended in guidelines, and none used thresholds below the recommended range. Surprisingly, sicker patients—generally those under-going cardiac surgeries—had the lowest hemoglobin thresholds, whereas those undergoing surgery for pancreatic cancer, orthopedic issues, and aortic aneurysms received blood transfusions at higher thresholds. The amount of blood transfused did not correlate with how sick the patients were or...
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