Multimodal Blood Sparing Concepts

 

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Infectious risks of transfusion, but also cost and resource efficiency considerations have triggered continuing efforts to reduce blood transfusion. Despite different national consensus guidelines, several American and European multicenter studies demonstrated a substantial variability in perioperative transfusion practice [1] [2] [3] [4] [5]. Even in a selected patient population at low risk for transfusion therapy, Stover et al demonstrated that the percentage of patients transfused and the median number of units transfused per patient varied considerably between institutions [3]. Evaluating blood products use in more than 40 teaching hospitals from 10 European countries, the SANGUIS study demonstrated that transfusion rates depend more on physicians than on type of procedure, patient population or hospital [4]. A recent study involving teaching and non-teaching hospitals found similar results [5]. Reasons for the large variability in transfusion practice remain elusive, but clinicians' practice and attitude may be entrenched and slow to change [6]. Application of a standardised multidisciplinary transfusion strategy might reduce the use of allogeneic blood transfusion in major surgical patients.

A multidisciplinary approach of blood transfusion strategy has been progressively developed in the department of cardiac surgery of our institution from 1997 [7]. The developed strategy involved a standardised blood conservation program and a multidisciplinary allogeneic blood transfusion policy. The transfusion trigger not only depended on the hemoglobin level, but also on the clinical status of the patient and on the relative risk of postoperative complications. All patients undergoing cardiac surgery over a two-year period were included. Procedures consisted of coronary artery revascularization, single or multiple valve replacement, and complex aortic operations. Emergency procedures were excluded. Data obtained in a first group including patients operated from September 97 to August 98 (group 1: N = 321), when the transfusion strategy was progressively developed, were compared to those obtained in a second group, including patients operated from September 98 to August 99 (group 2: N = 315) when the transfusion strategy was applied uniformly. Patient populations and surgical procedures were similar in both groups. The uniform application of the multidisciplinary blood transfusion strategy resulted in a 45 % reduction in the number of patients receiving allogeneic blood, and in a 53 % reduction in the number of allogeneic blood units transfused. These results were essentially related to a reduction in postoperative transfusion. Postoperative hemoglobin concentrations, mortality and morbidity were not different among groups.

Development of a standardized multidisciplinary approach to blood conservation markedly reduced the exposure of cardiac surgery patients to allogeneic blood. In view of these results, it might be suggested that the real efficacy of any novel blood conservation technique can only be evaluated when an institutional multidisciplinary approach of blood transfusion has been achieved previously.

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Prof. Dr. Philippe Van der Linden

Service d' Anesthésie Cardiaque C.H.U. de Charleroi,
Espace Santé
Site de Jumet

73 rue de Gosselies

6040 Jumet, Belgien