S. Bennett1,10, A. Tinmouth2,10, D. I. McIsaac3,10, S. English2,10, P. C. Hébert4, P. J. Karanicolas5, L. McIntyre2,10, A. F. Turgeon7, J. Barkun8, T. M. Pawlik9, D. Fergusson10, G. Martel1,10 1University Of Ottawa,Department Of Surgery,Ottawa, Ontario, Canada 2University Of Ottawa,Department Of Medicine,Ottawa, Ontario, Canada 3University Of Ottawa,Department Of Anesthesiology,Ottawa, Ontario, Canada 4Centre Hospitalier De L’Université De Montréal,Department Of Medicine,Montréal, QUEBEC, Canada 5University of Toronto,Department Of Surgery,Toronto, Ontario, Canada 6Université Laval,Department Of Anesthesiology,Quebec City, QUEBEC, Canada 7Université Laval,Department Of Anesthesiology,Quebec City, QUEBEC, Canada 8McGill University,Department Of Surgery,Montreal, QUEBEC, Canada 9Ohio State University,Department Of Surgery,Columbus, OH, USA 10Ottawa Hospital Research Institute,Ottawa, ONTARIO, Canada
Introduction: Hepatectomy is associated with a high prevalence of blood transfusions. A transfusion can be a life-saving intervention in the appropriate patient, but is associated with important adverse effects. Given the prevalence of transfusions, their potential for great benefit and harm, and the difficulty in conducting clinical trials, this topic is well-suited for a study of appropriateness. Using the RAND/UCLA Appropriateness Method, the objective of this study was to determine the indications for which the expected health benefits of a transfusion exceed expected negative consequences in patients undergoing hepatectomy.
Methods: An international, multidisciplinary panel of eight experts in hepatobiliary surgery, surgical oncology, anesthesiology, transfusion medicine, and critical care were identified. The panelists were sent a recently conducted systematic review and asked to rate a series of 468 intraoperative and postoperative scenarios for the appropriateness of a blood transfusion using a validated, 1-9 ordinal scale. The scenarios were rated in two stages: individually, followed by an in-person moderated panel session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.
Results: 48% of scenarios were rated appropriate, 28% inappropriate, and 24% uncertain. Level of agreement increased significantly after the in-person session. Based on the scenario ratings, there were five key recommendations.
Intraoperative:
1) It is never inappropriate to transfuse for significant bleeding or ST segment changes.
2) It is never inappropriate to transfuse for a hemoglobin value of 75 g/L or less.
3) Without major indications (excessive bleeding or ST changes), it is inappropriate to transfuse at a hemoglobin of 95 g/L, and transfusion at 85 g/L requires strong justification.
Postoperative:
1) In a stable, asymptomatic patient an appropriate transfusion trigger is 70g/L (without coronary artery disease) or 80 g/L (with coronary artery disease).
2) It is appropriate to transfuse for a hemoglobin of 75 g/L or less in the recovery unit immediately post-operative, or later with a significant hemoglobin drop (>15 g/L).
Factors that increased the likelihood of a transfusion being inappropriate included no history of coronary artery disease, normal hemodynamics, and good postoperative functional status. Patient age did not affect the rating significantly.
Conclusion: Based on the best available evidence and expert opinion, criteria for the appropriate use of perioperative blood transfusions in hepatectomy were developed.These criteria provide clinical guidance for those involved in perioperative blood management. In addition, the areas of uncertainty and disagreement can inform the direction of future clinical trials.