title: Red Cell Transfusion Triggers and Postoperative Outcomes After Major Surgery.
abstract: BACKGROUND
  The effect of packed red blood cell (PRBC) transfusion on postoperative outcomes of patients undergoing major surgery remains unclear. We sought to determine the impact of blood utilization, as well as transfusion practices, on perioperative outcomes of patients undergoing cardiothoracic-vascular (CT-V) and gastrointestinal (GI) procedures.
  
  
  METHODS
  Patients who underwent major surgical procedures at Johns Hopkins Hospital between 2009 and 2014 were identified. Data on perioperative hemoglobin (Hb) and blood utilization were obtained; transfusion strategy was categorized as liberal (Hb trigger ≥7 g/dL) vs. restrictive (Hb trigger <7 g/dL). Risk-adjusted logistic regression models and propensity score matching were used to assess the association between transfusion triggers and perioperative morbidity.
  
  
  RESULTS
  Among 10,163 patients undergoing either CT-V (50.9 %) or GI (49.1 %) surgery, 4401 (43.3 %) patients received PRBCs. Of the 4401 patients transfused, 71.2 % were transfused using a liberal trigger (≥7 g/dL hemoglobin), while 28.8 % had a restrictive trigger (<7 g/dL). The median number of PRBCs transfused was 3 (restrictive 5 vs. liberal 2 units). While ischemic adverse events were more common among patients undergoing CT-V surgery (17.3 %), infection was the more common complication among patients undergoing GI surgery (11.9 %). American Society of Anesthesiologist (ASA) class 3-4, Charlson score ≥3, and total units of transfused PRBCs were independently associated with overall complications (all P < 0.05). Patients in the restrictive transfusion group did not have increased risk of complications compared with the liberal transfusion group on multivariable analysis (odds ratio (OR) 1.16, 95 % confidence interval (CI) 0.98-1.38; P = 0.08) or after propensity score matching (OR 1.04, 95 % CI 0.88-1.22; P = 0.65).
  
  
  CONCLUSIONS
  Liberal transfusion triggers after major surgery were more common than restrictive practice. Patients with restrictive transfusion trigger did not have increased risk for complications compared with patients transfused with a liberal trigger.
authors: Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA.
authors: Yuhree
authors: Y
authors: Kim
authors: Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA.
authors: Gaya
authors: G
authors: Spolverato
authors: Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA.
authors: Donald J
authors: DJ
authors: Lucas
authors: Department of Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA.
authors: Aslam
authors: A
authors: Ejaz
authors: Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA.
authors: Li
authors: L
authors: Xu
authors: Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA.
authors: Doris
authors: D
authors: Wagner
authors: Department of Anesthesiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors: Steven M
authors: SM
authors: Frank
authors: Department of Surgery, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 665, Baltimore, MD, USA. tpawlik1@jhmi.edu.
authors: Timothy M
authors: TM
authors: Pawlik
mesh_terms: D000328:Adult; D000368:Aged; D013505:Digestive System Surgical Procedures / Q000009:adverse effects*; D017707:Erythrocyte Transfusion; D005260:Female; D006454:Hemoglobins / Q000378:metabolism; D006801:Humans; D008297:Male; D008875:Middle Aged; D009017:Morbidity; D016017:Odds Ratio; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects*
chemical_list: D006454:Hemoglobins
keywords: Complications; Morbidities; Target; Transfusion; Trigger