Benchmark for blood use in open heart and valve replacement surgeries

A California blood banker reports that her facility compiles statistics on blood usage for various open heart and valve replacement surgeries. The benchmark they are striving to achieve is to transfuse no more than 2 units of RBCs per patient. The inquiring blood banker wants to know if anyone uses a different benchmark for blood use in open heart and valve replacement surgeries, and if so, upon what is the benchmark based and what is your compliance with achieving the benchmark? Are there recent publications that might be useful for determining such a benchmark? She also wants to know if anyone correlates the type of surgical procedure and its blood usage according to pre-surgical risk factors such as the patient receiving dialysis, being diabetic, or performing the procedure off-pump versus on bypass, etc?

The following responses were submitted:

1. A New York blood bank physician reports that they attained their benchmark of 2.0-2.4 units/case of donor RBC's for CT surgery in several stages. The above usage includes postoperative transfusions. First, they established the statistical mean of usage of the various surgeons. Once this was determined, they reviewed the appropriateness of that use for each individual case and determined the number of units that were inappropriately administered. Once the usage and inappropriate usage data were collected, they shared the data with their surgical team and determined a target usage which was somewhat higher that the minimal use, but less than the current practice. Within 7 months their goal of 2.0-2.4 units of donor RBCs per case was realized. The New Yorker adds that it is important to consider several factors: The clinical condition of these patients and the precise patient mix (AVR Tricuspid repair and replacement which is at times more consuming of blood products than other surgeries, the number of "redo's, etc.) as well as the postoperative management and the trigger point at which patients are being taken back to the OR to correct bleeding that is correctable by placement of a suture. 
   
   
2. A California blood banker reports that when they examined their institutional transfusion practice, they found several factors that could influence blood usage data, including variability of blood use between individual surgeons and variability in case mix, including treatment with or without PTCA/Cardiac Cath, and primary vs.  redo surgery.  The responding blood banker cautions that different "guidelines" may be necessary for each of the foregoing factors.  The responding blood banker reports that the following studies were helpful in benchmarking their data: 
   • Surgenor WH, et al.  The specific hospital significantly affects red cell and component transfusion practice in coronary artery bypass graft surgery: a study of five hospitals.  Transfusion 1998;38:122-134. 
   • Goodnough LT, Johnston FM, Pearl TC, Toy Y.  The variability of transfusion practice in coronary artery bypass surgery.  JAMA 1991;265: 86-90. 
   • Goodnough LT, et al.  Guidelines for transfusion support in patients undergoing coronary artery bypass grafting.  Ann.  Thorac Surg 1990;50:675-83. 

ADDENDA April 11, 2002 

3. A very experienced surgeon wrote that the field of transfusion in cardiac surgery has generated a lot of literature, much of which is anecdotal.  However, several sources of information may be of help to e-network subscribers: 
   • DeFoe GR et al.  Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting.  Northern New England Cardiovascular Disease Study Group.  Ann Thorac Surg.  2001 Mar;71(3):769-76.  This article analyzes the impact of Hct on outcome from the large Northeastern New England Cardiac Surgery database.  It points out that women with small body mass are much more likely to be transfused than men.
   • Magovern JA et al.   A model for predicting transfusion after coronary artery bypass grafting.  Ann Thorac Surg.  1996 Jan;61(1):27-32.  The Magoverns model for predicting transfusion need has stood the test of time.  It may be helpful to others in benchmarking their transfusion practices. 
   • Helm RE et al.   Comprehensive multimodality blood conservation: 100 consecutive CABG operations without transfusion.  Ann Thorac Surg.  1998 Jan;65(1):125-36 
   • Van der Linden P et al. A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiac surgery.  Can J Anaesth.  2001 Oct;48(9):894-901.  Both Todd Rosengart, a cardiac surgeron, and Phillipe van der Linden, an anesthesiologist, have shown that a combined, multimodality program of alternatives can reduce the use of transfusion in cardiac surgery. 
   The responding surgeon's group is currently completing an in-hospital review of cardiac surgery transfusion practices based on 550 patients. He volunteered to share the information when they complete their analysis. The main investigator has on an ongoing study that is gathering information on transfuions and cardiac surgery. This data set will include over 1,200 patients and should be published within the next 12 months.

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