title: Safe application of a restrictive transfusion protocol in moderate-risk patients undergoing cardiac operations.
abstract: BACKGROUND
  Perioperative red blood cell transfusion is associated with adverse outcomes after cardiac operations. Although restrictive transfusion protocols have been developed, their safety and efficacy are not well demonstrated, and considerable variation in transfusion practice persists. We report our experience with a restrictive transfusion protocol.
  
  
  METHODS
  We analyzed the outcomes in 409 patients undergoing cardiac operations enrolled in a trial conducted at 30 centers worldwide. Blood products were administered on the basis of a transfusion algorithm applied across all centers, with a restrictive transfusion trigger of hemoglobin less than or equal to 6 g/dL. Transfusion was acceptable but not mandatory for hemoglobin 6 to 8 g/dL. For hemoglobin 8 to 10 g/dL, transfusion was acceptable only with evidence for end-organ ischemia.
  
  
  RESULTS
  The patient population was moderately complex, with 20.5% having combined procedures and 29.6% having nonelective operations. The mean EuroSCORE for the population was 4.3, which predicted a substantial incidence of morbidity and mortality. Actual outcomes were excellent, with observed mortality of 0.49% and rates of cerebrovascular accident, myocardial infarction, and acute renal failure 1.2%, 6.1%, and 0.98%, respectively. The frequency of red blood cell transfusion was 33.7%, which varied significantly by center. Most transfusions (71.9%) were administered for hemoglobin 6 to 8 g/dL; 21.4% were administered for hemoglobin 8 to 10 g/dL with evidence for end-organ ischemia; 65.0% of patients avoided allogeneic transfusion altogether.
  
  
  CONCLUSIONS
  A restrictive transfusion protocol can be safely applied in the care of moderate-risk patients undergoing cardiac operations. This strategy has significant potential to reduce transfusion and resource utilization in these patients, standardize transfusion practices across institutions, and increase the safety of cardiac operations.
authors.affiliation: Division of Cardiothoracic Surgery, Oregon Health & Science University, Portland, Oregon. Electronic address: songh@ohsu.edu.
authors.forename: Howard K
authors.initials: HK
authors.lastname: Song
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: von Heymann
authors.affiliation: Safety Surveillance, Global Safety, Novo Nordisk, Bagsværd, Denmark.
authors.forename: Christian M
authors.initials: CM
authors.lastname: Jespersen
authors.affiliation: Department of Anesthesia and Toronto General Research Institute, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Keyvan
authors.initials: K
authors.lastname: Karkouti
authors.affiliation: Center for Laboratory Medicine, St Gallen, Switzerland.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Korte
authors.affiliation: Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina.
authors.forename: Jerrold H
authors.initials: JH
authors.lastname: Levy
authors.affiliation: Department of Cardiothoracic-Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Ranucci
authors.affiliation: Biostatistics, Novo Nordisk A/S, Søborg, Denmark.
authors.forename: Trine
authors.initials: T
authors.lastname: Saugstrup
authors.affiliation: Department of Surgery, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island.
authors.forename: Frank W
authors.initials: FW
authors.lastname: Sellke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000379:methods* / Q000401:mortality; D002423:Cause of Death; D003029:Coagulants / Q000627:therapeutic use; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality*; D004311:Double-Blind Method; D017707:Erythrocyte Transfusion / Q000009:adverse effects* / Q000401:mortality / Q000592:standards*; D005176:Factor XIII / Q000627:therapeutic use; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods / Q000401:mortality; D006454:Hemoglobins / Q000032:analysis; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007391:International Cooperation; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D019990:Perioperative Care / Q000379:methods; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D012016:Reference Values; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D003029:Coagulants; D006454:Hemoglobins; D005176:Factor XIII