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Palmer Lecture: Why Give 2 when 1 Will Do?

John Palmer
John Palmer

Lorne Rotstein gave a delightful sketch of the character and career of Dr. John Palmer, who trained at the University of Toronto in General and Plastic Surgery, and then studied plastic surgery, surgical oncology and colorectal surgery at St. Marks. A superb technician, he was also somewhat of a maverick, an artist, and an antique shop owner. The lectureship was endowed by his friends and family.

Alan Okrainec introduced Palmer Lecturer Tim Pawlik who completed his undergraduate studies at Georgetown, medical school at Tufts, surgical residency at Michigan, and Ethics and Theology at Harvard. He serves on the Ethics Committee of the Johns Hopkins Hospital. He has published over 400 articles, given 250 talks, is the President of the Association for Academic Surgery, and the John Cameron Professor of Surgery at Hopkins.

Tim focused his lecture on the topic of perioperative transfusion. Five million patients receive transfusions in the United States, a total of 14 million units of blood per year. It is the number one overutilized therapy in the US, ahead of cardiac stents, polyethylene ear drainage tubes, and scheduled births. With his anaestheologist colleague and Head of Blood Bank Services Steve Frank, Tim has studied how to decrease unnecessary transfusions, save money and improved outcomes related to transfusion.

Most of the severe complications associated with transfusion, such as Hepatitis B, C and HIV are now rare, but other complications and cost can be associated with unnecessary blood transfusions. Immunological effects are more prevalent, including allergy and depression of the immune response, which has been linked to increases in cancer recurrence and metastasis. Data have shown an increase in wound infections, and perhaps even worse long-term survival among cancer patients who have received a transfusion.

Decreasing the use of transfusion among surgeons can be challenging. Pawlik noted that surgeons who give a lot of blood tend to say that they are doing bigger operations, have a different case mix, and sicker patients than those who give fewer. In order to avoid problems with individual surgeon case mix, Pawlik notes that transfusion utilization may be better understood in terms of hemoglobin triggers and targets. For example, the trigger for transfusion is ideally between 7-8 grams of hemoglobin. Those who trigger a transfusion above that level are viewed as liberal, and lower triggers reflect a restrictive practice. Randomized trials support the safe use of a more restrictive target.

Tim reported on Hopkins patients undergoing surgery for pancreatic, hepatic and colorectal disease from 2010- 2013. Among the eight surgeons in his division, there were some who used a liberal and some a restrictive trigger. In addition to provider level variation, factors associated with increased use of transfusions included older age, co-morbidities, male sex, and Whipple operations. Provider level variation, even after taking all these factors into account, was still considerable. In fact, Pawlik noted that there was overutilization in 25% of cases and a 3 gram variation among surgeons and anesthesiologists at Hopkins regarding what trigger was used to implement a transfusion. Of note, the C:T ratio - the ratio between the cross-matched and transfused blood, which should ideally be about 2, also varied considerably Some surgeons and anesthesiologists had a C:T ratio of 1, while other had a C:T as high as 6. The waste and cost of processing can be reduced by posting these results. The variation was similar in the use of “yellow blood” (i.e. fresh frozen plasma and platelets). A liberal hemoglobin trigger in the operating room was associated with liberal triggers in the postoperative period, suggesting the surgeon as the most important driver of transfusion behavior. Pawlik also described a spectrum in the use of crystalloid, as some surgeons were liberal and some restrictive in how much crystalloid fluids were given.

The effects of unnecessary transfusions are not inconsequential. Pawlik described how the immunological effects of transfusion can include more infections in patients treated with a liberal trigger. Complications also seem to be increased if the delta hemoglobin [the drop in hemoglobin from the admission level to the postoperative level] is 40% or greater. Oncologic outcomes also seem to be impacted by transfusions, as some reports have noted in increase in recurrent cancer among patients receiving more transfusions. Even when patients do need a transfusion the minimal amount necessary should be given. “The notion that we should always give 2 transfusions if we are going to give 1 is anachronistic. ‘Why give 2, when 1 will do?’ is the current recommendation. Furthermore, each unit costs $220 , with a total delivery cost of $760 to transfuse. The hepatobiliary group can save $100,000 per year by adopting a restrictive policy – a potential saving of $250, 000 if adopted by the entire Surgery Department.

group photo
left to right- Lorne Rotstein, Tim Pawlick, Alan Okrainec

“Some remedial steps to decrease transfusion include pre-habilitation - treating anemia with iron preoperatively, the use of minimally invasive access, the cell saver, reducing phlebotomy for blood tests and setting the threshold for transfusion at 7.5-8 grams for blood transfusion and 50,000 for platelets. In addition, implementing order entry system guidelines, which remind surgeons that they are recommending transfusion above the ideal threshold, can be helpful.” One of the most effective techniques that Tim describes was to provide unblinded data with the names of the surgeons and anesthesiologist identifying different providers’ transfusion utilization. By providing individual surgeons their specific data on transfusion, Tim noted how surgeons have changed their practice. In fact, the famed John Cameron has dramatically reduced his transfusion rate in the past 5 years by applying a more restrictive trigger.

Alan Okrainec asked about including the transfusion recommendations in the timeout prior to surgery. Tim says to the anaestheologists at that time: “Tell me if you are going to hang blood or pressors.” Jim Rutka asked if medico- legal fears lead to increased transfusions in the \US. Tim felt overuse was more cultural than medicolegal. Tom Waddell asked about real time feedback as this aggregated data does not return to the surgeon immediately following operations. Tim answered that feedback is given in personal conversations, but is not currently available on such a short time axis.

In conclusion, the variation is surgeon related. 25% of transfusions are unnecessary and there is no increase in complication when transfusions are restricted. A restrictive policy reduces risk, reduces cost, and improves outcome.


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