Press Room: Press Releases

New Studies Report Excess Complications Surrounding Blood Transfusions

Blood Product Utilization Suggested Only for Patients with Demonstrated Physical Need

(DES PLAINES, Ill. June 1, 2006) — Blood transfusions may be more of a risk to recovery than previously suspected, according to two articles in the June issue of Critical Care Medicine, the journal of the Society of Critical Care Medicine.

“Surgery associated red blood cell transfusion is the single largest factor associated with increased risk of post-surgical complications following coronary bypass,” says lead author Colleen Gorman Koch, M.D., M.S., from the Cleveland Clinic Foundation.  “Our results suggest that transfusions should be avoided whenever possible.”

According to background information in the article, administration of packed red blood cells is associated with medical and surgical mortality.  Transfusions are associated with transmission of infectious agents, infectious complications following surgery, wound infection, post-surgical pneumonia, kidney dysfunction, diminished lung function, multiple organ failure, increased length of stay in the hospital or ICU, and generally increased short and long-term mortality.

This is the first large-scale study to examine heart surgery-related transfusion and outcomes closely.

The researchers studied 11,963 Cleveland Clinic patients who had coronary bypass transfusions to analyze the probability of in-hospital illness and death as a function of transfusion of red blood cells and blood components. 

In addition to the main finding that red blood transfused is the single factor most reliably associated with increased risk of bypass related post-surgical illness, the researchers found that each unit of red blood transfused incrementally increases risk for adverse outcome.

Transfusion of red blood cells was associated with an increased risk of all post-surgical events, including death (77% higher risk), kidney failure (double), prolonged ventilatory support (72% higher risk), serious infection (76% higher risk), cardiac complications (55% higher risk) and neurological events (37% higher risk).

“More than 25 years ago, the Cleveland Clinic, one of the busiest heart centers in the world, recognized the need to implement blood conservation strategies for patients undergoing heart surgery,” comments Dr. Koch.  “We have made every effort to avoid transfusion of red blood cells whenever possible. We administer medications to help decrease bleeding on every patient undergoing heart surgery and make adjustments in the heart lung machine so that the patient’s blood is not diluted with clear fluids. However, it is likely that bloodconservation can be pushed further, to possibly prevent adverse events.

According to Dr. Koch, red blood cells are a limited resource with an expiration date set once donated. There is a balance between the ability of red blood cells to save the lives of bleeding patients and the increased risk of complications.  “We don’t have definitive answers as to exactly how low your hemoglobin can go before you have side effects and at which a transfusion would be indicated,” she explains.  “We have recently designed a study to specifically address this question.”

EDITORIAL: Blood Product Transfusion in Association with CABG - Proceed with Caution

The accompanying editorial notes that the study by Koch study is important because it provides data on a controversial therapy in a challenging segment of the ICU patient population.  “The correlation between blood use and poor outcome in [coronary artery bypass grafting] surgery is strong; therefore decisions to utilize transfusion must be made carefully,” says lead editorialist Debra L. Malone, M.D., F.A.C.S., from the University of Maryland School of Medicine in Baltimore. “We can save lives by being frugal in our use of blood. We can save lives by improving [coronary artery bypass grafting] surgery. We can save lives by improving the quality of blood products. We all have work to do.”

Blood Transfusions Risky for Burn Patients

In a related article in the same issue, the researchers associated the number of blood transfusions received with death and infectious episodes in patients with major burns. The authors suggest that the utilization of blood products in the treatment of major burn injuryshould be reserved for patients with a demonstrated physiologic need. 

The researchers studied data on 666 acutely burned patients with burns involving more than 20% of their bodies to delineate blood transfusion practices and outcomes in patients with major burn injury. Mortality was related to patient age, the total body surface area that was burned, inhalation injury, number of blood units transfused outside the operating room, and total number of transfusions. They found that the number of infections per patient increased with each unit of blood transfused.

“Although blood transfusion is ubiquitous in the treatment of major burn injury (≥20% [total body surface area] burn), appropriate indications for transfusion in burns remain elusive,” states lead author Tina L. Palmieri, M.D., F.A.C.S., from the Shriners Hospital for Children Northern California and the University of California Davis Medical Center in Sacramento. “This study suggests that mortality and infectious complications may be related to the number of blood transfusions received. The amount of blood received outside the operating room, a situation in which burn intensivists have control of therapy, has the greatest association with survival.”

The authors suggest a prospective, randomized, multicenter study to determine the appropriate indications for blood transfusion in burn patients. “In the interim the use of blood transfusions in the treatment of patients with major burn injury should be reserved for patients with a demonstrated physiologic need,” the researchers conclude.

Editorial:  Blood Transfusion in Burns: benefit or risk?

The accompanying editorial suggests that the amount of blood transfusion should be reduced for burn patients.  They have several suggestions, including lowering the hematocrit and hemoglobin thresholds, developing new surgical techniques, and implementing strict wound management techniques.

“We suggest that the next step would be to initiate a large prospective clinical trial to determine the threshold for blood transfusions and possibly new methods to limit blood loss during surgery,” editorialists Marc G. Jeschke, M.D., Ph.D., and David N. Herndon, M.D., comment.  “This prospective randomized study should address these issues and answer these questions before recommendations can be made to change clinical practice.”  Drs. Jeschke and Herndon are from the Shriners Burn Hospital in Galveston, TX.

“As the caretakers to the critically ill, our profession is continually seeking evidenced-based solutions to improve patient care,” says Joseph E. Parrillo, M.D., editor-in-chief of Critical Care Medicine.  “The research supporting prudent use of blood transfusions is continuing to grow.”

Critical Care Medicine is the official journal of the Society of Critical Care Medicine. It is the premier peer-reviewed, scientific publication in critical care medicine. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.

The Society of Critical Care Medicine is the leading professional organization dedicated to ensuring excellence and consistency in the practice of critical care medicine. With more than 13,000 members worldwide, the Society is the only professional organization devoted exclusively to the advancement of multiprofessional intensive care through excellence in patient care, professional education, public education, research and advocacy. Members of the Society include intensivists, critical care nurses, critical care pharmacists, clinical pharmacologists, respiratory care practitioners and other professionals with an interest in critical care, including physician assistants, social workers and dietitians.

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