title: Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion.
abstract: BACKGROUND
  Guidelines for allogeneic transfusion emphasize minimizing use to avoid transmission of serious illness. However, there is little information on the risks associated from withholding transfusion.
  
  
  METHODS
  A retrospective cohort study of patients who declined RBC transfusions for religious reasons was performed. This analysis was restricted to consecutive patients > or = 18 years old, who underwent surgery in the operating room from 1981 to 1994 and had a postoperative Hb count of 8 g per dL or less. The primary outcome was defined as any inhospital death occurring within 30 days of the surgery. Secondary outcome was 30-day mortality or in-hospital 30-day morbidity. Morbidity was defined as myocardial infarction, arrhythmia, congestive heart failure, or infection.
  
  
  RESULTS
  Of 2083 eligible patients, 300 had postoperative Hb counts of 8 g per dL or less. The study population was predominantly female (70.3%) with a mean age of 57 years (SD, +/- 17.7). In patients with a postoperative Hb level of 7.1 to 8.0, 0 died (upper 95% CI, 3.7%), and 9.4 percent (95% CI, 4.4-17.0%) had a morbid event. In patients with a postoperative Hb level of 4.1 to 5.0, 34.4 percent (95% CI, 18.6-53.2%) died and 57.7 percent (95% CI, 36.9-76.6%) had a morbid event or died. After adjusting for age, cardiovascular disease, and Acute Physiology and Chronic Health Evaluation II score, the odds of death in patients with a postoperative Hb level of < or = 8 g per dL increased 2.5 times (95% CI, 1.9-3.2) for each gram decrease in Hb level.
  
  
  CONCLUSIONS
  The risk of death was low in patients with postoperative Hb levels of 7.1 to 8.0 g per dL, although morbidity occurred in 9.4 percent. As postoperative blood counts fall the risk of mortality and/or morbidity rises and becomes extremely high below 5 to 6 g per dL.
authors.affiliation: Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, USA. carson@umdnj.edu
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Carson
authors.forename: Helaine
authors.initials: H
authors.lastname: Noveck
authors.forename: Jesse A
authors.initials: JA
authors.lastname: Berlin
authors.forename: Steven A
authors.initials: SA
authors.lastname: Gould
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001803:Blood Transfusion / Q000523:psychology; D015331:Cohort Studies; D005260:Female; D006331:Heart Diseases / Q000097:blood / Q000209:etiology / Q000401:mortality; D006454:Hemoglobins / Q000032:analysis*; D017052:Hospital Mortality; D006801:Humans; D007239:Infections / Q000097:blood / Q000209:etiology / Q000401:mortality; D007430:Intraoperative Care; D033221:Jehovah's Witnesses; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D011183:Postoperative Complications / Q000097:blood* / Q000209:etiology / Q000401:mortality*; D012189:Retrospective Studies; D013514:Surgical Procedures, Operative / Q000401:mortality; D016312:Treatment Refusal
chemical_list: D006454:Hemoglobins