Perioperative Allogenic Red Blood Cell Transfusion: Available Guidance and Audit of Appropriateness in Liver Resection

Abstract

Red blood cells are commonly administered during the perioperative period, however our understanding of available guidance informing transfusion decisions as well as appropriateness of current practice is not well understood. Blood transfusions are associated with post-operative morbidity and possibly worse long-term outcomes. Furthermore, they are a costly and limited resource. They should therefore be used sparingly. The objective of this thesis was to further our understanding of guidance available for administration of intraoperative red blood blood cell transfusion, as well as conduct an audit of the appropriateness of transfusions administered during the perioperative period. This thesis is composed of both a systematic review as well as a retrospective review of a prospectively maintained database. The systematic review of identified 10 guidelines published between 1992-2018 that included indications for intraoperative transfusions. Six provided objective clearly defined criteria for transfusion based on hemoglobin triggers (range 60-100g/L) or hematocrit (<30%); one stated a specific clinical situation for which transfusion would be appropriate (ST changes). The evidence supporting intraoperative recommendations was extrapolated primarily from the non-operative setting. Retrospective review of a single centre revealed 19% of patients underging liver resection were transfused a mean of 2.6 units during the perioperative period. A total of 22% to 63% of transfusions administered during the intraoperative period were considered inappropriate based on the application of three different instruments. In contrast, 38% to 67% of transfusions administered during the postoperative period were considered inappropriate. Patients considered to have been inappropriately transfused during the intraoperative period were at increased risk of developing a major postoperative adverse event (Clavien-Dindograde 3) compared to those who did not receive a transfusion (OR 4.2; 95% CI 1.1-15.6). In conclusion, this thesis demonstrates evidence-based, practitioner oriented, intraoperative transfusion guidance for clinicians is lacking. Furthermore, a significant proportion of patients continue to be exposed to unnecessary transfusion. Further work in this area is warranted to clarify indications for intraoperative transfusion and subsequently minimize the administration of unnecessary transfusion.