Intraop Transfusion - help me change my mind

[Soparklion]

My neurosurgeons (cranis and spines) believe that a HCT below 30% is basically an ischemic event and that all patients should have a postop INR <=1.4 with fibrinogen >250 and plts >150k.

I'd feel more job satisfaction if I had some rationale behind these parameters. Please tell me about the risk of coagulopathies, horrible hematomas/hemorrhages, etc.

TIA

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[pgg]

What, are they suggesting platelet transfusions for a PLT count of 135? Cryo for fibrinogen <250? This all sounds ridiculous.

Do they have a financial stake in a for-profit blood bank? (Actually sort of a serious question - I assume you're in the USA, but you never know, and I did some work overseas where the spine surgeons would transfuse everyone 2 units prior to lumbar lamis, no matter if their starting Hb was 15.)

 

[vector2]

My neurosurgeons (cranis and spines) believe that a HCT below 30% is basically an ischemic event and that all patients should have a postop INR <=1.4 with fibrinogen >250 and plts >150k.

I'd feel more job satisfaction if I had some rationale behind these parameters. Please tell me about the risk of coagulopathies, horrible hematomas/hemorrhages, etc.

TIA

There is no appreciably greater risk at those outlandishly high transfusion targets. They are out of touch dinosaurs who haven't kept up with the latest evidence.

 

[nimbus]

Maybe they’re reacting/overreacting to all the patients on XA inhibitors nowadays.

 

[pocafx]

Not on topic at all but yesterday the spine surgeon injected exparel into the back. I don’t know where exactly, but it was after a decompression. I can’t get the drug myself tho

 

[DirtDocMD]

Is there some sort of “utilization committee” at your facility??Wasteful from a financial standpoint, not to mention, wasteful of a limited resource that could save someone else’s life.

On top of that, who knows when another “mystery disease” (HIV) is going to come down the pike. You really wanna infect some pt with something, not to save their life, but because of some surgeon’s ego???

 

[woopedazz]

Don't they get audited on transfusion rates, etc? Higher normally being worserer

 

[bigdan]

There is no data that I know of to support the transfusion practices that you describe.

You may elect to take an alternate angle to instill a modicum of sensibility to their transfusion strategies, although in my short career I’ve noticed that some surgeons hold their transfusion beliefs right next to their opinions on death penalty, abortion, and religion, so it may be an uphill climb if you’re trying to “change their minds”.

You may elect to focus on the deleterious effects of transfusions (as opposed to focus on transfusion targets/“need”); there is a lot of published data on the unintended consequences of product transfusion. A recent edition of A&A was dedicated to patient blood management, and would be a reasonable single-source place to start. If you elect to really get into the weeds on this issue - especially if your hospital has a high enough volume of these cases - you could focus study on these surgeons’ infection rates, postoperative respiratory complications/TRALI, and length of stay. Those things should matter to the surgeons but will definitely matter to hospital administrators, as they cost money to the hospital. Lastly, the more blood you order, the more you’ll waste. That is a massive expense of a limited resource.

G’luck

 

[kidthor]

Speaking of inane blood requests/demands, I worked with a couple of vascular surgeons who insisted on FFP infusions to be run continuously for 24-48 hrs post op.

 

[forchinet121]

Do what’s best for the patient and talk with them/get someone else involved if they don’t listen

 

[Arch Guillotti]

Do what’s best for the patient

This strategy is dubious at best when dealing with surgeons that are giving "orders".

 

[anaesthetic]

I may be going against the grain here, but I usually don’t care if they want to “give a unit” or not, the caveat being that we are a level I trauma center with complex cardiothoracic cases/transplants.

I think a transfusion trigger of Hgb 10 is ridiculous, but if the Hgb is 7.5-8.0 with ongoing, unquantifiable oozing/bleeding and hypotension, I’m probably hanging stuff despite the “evidence” saying our trigger should always be <7. Same with platelets <135k (quantity does not equal quality) and fibrinogen levels (i.e., ongoing bleeding despite “normal” levels at the time of measurement).

At the end of the day, the surgeon is the one that deals with the patient on the floor/in the ICU postoperatively. If they want blood products for the patient, the patient will get blood products, if not in the OR, then certainly afterwards. The only thing that changes is where they place the blame.

Fortunately, we are respected where I work, so it’s not often that this is even an issue. I do find it amusing that there are suggestions about quoting articles or data to surgeons… that’s a good one.

 

[forchinet121]

This strategy is dubious at best when dealing with surgeons that are giving "orders".

I’m not sure how doing what’s best for the patient is considered a strategy, it’s what you should be doing all the time when possible it’s not really a strategy

 

[PainDrain]

There is no appreciably greater risk at those outlandishly high transfusion targets. They are out of touch dinosaurs who haven't kept up with the latest evidence.

One thing I would also bring up is that transfusion is associated with immune dysfunction and an increased risk of post op wound infection. Never mind risks of TRALI and TACO.

 

[Onefellswoop87]

Maybe try to change their practice by shame? Offer to present a grand rounds on education about and risks/benefits of intraoperative transfusions and throw a slide in where you break down average unit transfused (in non emergent setting) first by ASA status and then by department. Don’t even need to name names but when the neurosurgery department is statistically above others and the only indication is “surgical bleeding,” force some introspection on them

 

[Radetzky]

I may be going against the grain here, but I usually don’t care if they want to “give a unit” or not, the caveat being that we are a level I trauma center with complex cardiothoracic cases/transplants.

I think a transfusion trigger of Hgb 10 is ridiculous, but if the Hgb is 7.5-8.0 with ongoing, unquantifiable oozing/bleeding and hypotension, I’m probably hanging stuff despite the “evidence” saying our trigger should always be <7. Same with platelets <135k (quantity does not equal quality) and fibrinogen levels (i.e., ongoing bleeding despite “normal” levels at the time of measurement).

Is there some new evidence saying it should “always” be 7? I only up to date with evidence in stable, non bleeding pts.

The discussion reminds me of the gomerblog article “surgeon successfully transfuses patient to 100% hematocrit”

 

[zizzer]

I'm pretty sure I remember the ASA guidelines for RBC transfusion to be very vague, something like Hbg 7-10 allowing for much individualization in the OR, weighing comorbidities and ongoing losses.

 

[deleted875186]

My neurosurgeons (cranis and spines) believe that a HCT below 30% is basically an ischemic event and that all patients should have a postop INR <=1.4 with fibrinogen >250 and plts >150k.

I'd feel more job satisfaction if I had some rationale behind these parameters. Please tell me about the risk of coagulopathies, horrible hematomas/hemorrhages, etc.

TIA

Perhaps expand on how often your transfusing certain products. FFP cannot get you lower than an INR of 1.5, and platelet of 150 is a very high threshold. And why are checking labs intraop so often?? Is it mostly transfusion of PRBC based off blood gas HCTs?

 

[bigdan]

Fortunately, we are respected where I work, so it’s not often that this is even an issue. I do find it amusing that there are suggestions about quoting articles or data to surgeons… that’s a good one.

Different strokes for different folks, I guess.

Our group (caveat: it’s a level 1 trauma center doing CV & transplant) was able to engender meaningful change in transfusion practices by discussing actual data with our surgeons. It worked in part because, fortunately, we are respected where I work, so it’s not often an issue.

 

[anaesthetic]

Different strokes for different folks, I guess.

Our group (caveat: it’s a level 1 trauma center doing CV & transplant) was able to engender meaningful change in transfusion practices by discussing actual data with our surgeons. It worked in part because, fortunately, we are respected where I work, so it’s not often an issue.

Fortunately, where I work, we have people who realize when something is tongue-in-cheek and when something isn’t.

Different strokes, I guess.

 

[2Fast2Des]

I don't take orders from a surgeon, I collaborate and discuss what is best. I work with anesthesiologists who are spineless and will do whatever gymnastics they are told. I worked with a urologist who demanded blood be given for a kidney transplant case, and the nurses called up the blood bank and gave me 3 units to hang. I refused to do it, on 1) I didn't ask for it 2) just had sent off a blood gas that resulted not less than few minutes ago that showed hgb of 10 3)pt was not unstable. When I told the surgeon that it made no sense to give blood, he muttered a little bit and that was the end of that. But the culture in the institution was that surgeon demands blood, anesthesia gives blood, no questions asked. We should determine what is appropriate resuscitation intraoperatively. Surgeon can manage post op whatever they have to, that's their calls.

 

[Iso4ane]

The liver transplant surgeons have less strict transfusion goals.

 

[kidthor]

I don't take orders from a surgeon, I collaborate and discuss what is best. I work with anesthesiologists who are spineless and will do whatever gymnastics they are told. I worked with a urologist who demanded blood be given for a kidney transplant case, and the nurses called up the blood bank and gave me 3 units to hang. I refused to do it, on 1) I didn't ask for it 2) just had sent off a blood gas that resulted not less than few minutes ago that showed hgb of 10 3)pt was not unstable. When I told the surgeon that it made no sense to give blood, he muttered a little bit and that was the end of that. But the culture in the institution was that surgeon demands blood, anesthesia gives blood, no questions asked. We should determine what is appropriate resuscitation intraoperatively. Surgeon can manage post op whatever they have to, that's their calls.

One of my wisest attendings in residency highlighted something I’ll never forget (because she was right)…

When the surgeons start repeatedly asking “what’s the blood pressure”, “how’s he doing”, “give more blood”, and the like - it’s because they’ve lost or can’t control whatever’s going on in the field… so they try to latch onto something else they think they can control to make up for it.

In my current practice I’ve noticed this to be right in both the micro and macro sense. I had a very good surgeon encounter uncontrolled bleeding then he kept obsessing about the above anesthesia-domain questions. I have another surgeon who’s notoriously bad and mucks around for ages with no particular plan then insists on transfusing at random points because “the patient really needs it I can tell”.

 

[2Fast2Des]

The liver transplant surgeons have less strict transfusion goals.

Working on cases where bleeding is expected I am more apt to listen to the surgeon, like when the liver transplant surgeon says get ready to lose because I know I'll fall behind very very quickly and I get 2 units in the Belmont running hot, those are different stories

 

[Iso4ane]

Working on cases where bleeding is expected I am more apt to listen to the surgeon, like when the liver transplant surgeon says get ready to lose because I know I'll fall behind very very quickly and I get 2 units in the Belmont running hot, those are different stories

I should clarify, when I said less restrictive, I mean, the cutoff to start transfusing would start later than the limits set above.

 

[Soparklion]

we are respected where I work, so it’s not often an issue.

Where? Are you hiring?

 

[Soparklion]

I don't take orders from a surgeon, I collaborate and discuss what is best. I work with anesthesiologists who are spineless and will do whatever gymnastics they are told. I worked with a urologist who demanded blood be given for a kidney transplant case, and the nurses called up the blood bank and gave me 3 units to hang. I refused to do it, on 1) I didn't ask for it 2) just had sent off a blood gas that resulted not less than few minutes ago that showed hgb of 10 3)pt was not unstable. When I told the surgeon that it made no sense to give blood, he muttered a little bit and that was the end of that. But the culture in the institution was that surgeon demands blood, anesthesia gives blood, no questions asked. We should determine what is appropriate resuscitation intraoperatively. Surgeon can manage post op whatever they have to, that's their calls.

I'm usually running 3 rooms and give-in to the HOP wanting to have blood in the OR... Then the surgeon prompts transfusion regardless of HCT or hemodynamics.

 

[Soparklion]

What, are they suggesting platelet transfusions for a PLT count of 135? Cryo for fibrinogen <250? This all sounds ridiculous.

Do they have a financial stake in a for-profit blood bank? (Actually sort of a serious question - I assume you're in the USA, but you never know, and I did some work overseas where the spine surgeons would transfuse everyone 2 units prior to lumbar lamis, no matter if their starting Hb was 15.)

They are not financially involved with the BB.

 

[Soparklion]

I do find it amusing that there are suggestions about quoting articles or data to surgeons… that’s a good one.

 

[Soparklion]

There is no appreciably greater risk at those outlandishly high transfusion targets. They are out of touch dinosaurs who haven't kept up with the latest evidence.

Thank you, I feel like I judge myself on the postop HCT... without a major intraop incident, I feel that anything above 33% is a moderate fail - given the prescribed HCT of 30%.

 

[Soparklion]

Perhaps expand on how often your transfusing certain products. FFP cannot get you lower than an INR of 1.5, and platelet of 150 is a very high threshold. And why are checking labs intraop so often?? Is it mostly transfusion of PRBC based off blood gas HCTs?

FFP can get you below 1.5 if you use Lasix so that the kidneys concentrate it... LOL

 

[Soparklion]

Different strokes for different folks, I guess.

Our group (caveat: it’s a level 1 trauma center doing CV & transplant) was able to engender meaningful change in transfusion practices by discussing actual data with our surgeons. It worked in part because, fortunately, we are respected where I work, so it’s not often an issue.

I had the Chair of Surgery tell me to transfuse a very healthy guy after post-trauma splenectomy (lone injury) when he was normotensive, making ample urine and had a HCT of 35%... he told me that splenectomy patients do better when they get blood.

 

[abolt18]

The liver transplant surgeons have less strict transfusion goals.

Except there is some potential benefit from transfusion in this population. Transfusion induced immunomodulation and reduced rejection. At least that's what I thought.

 

[zizzer]

My practice in OLTs is to basically only give blood products as fluids. They have so many things contributing to coagulopathy that I don't want dilution with albumin or crystalloids to be another. The vast majority all of the OLTs I've seen go south (by other people) are usually coagulopathy related.

 

[anbuitachi]

tell them no?

you arent there transfusion monkey. if they want blood, they can unscrub and transfuse themselves. or do it post op out of pacu

 

[Hoya11]

My neurosurgeons (cranis and spines) believe that a HCT below 30% is basically an ischemic event and that all patients should have a postop INR <=1.4 with fibrinogen >250 and plts >150k.

I'd feel more job satisfaction if I had some rationale behind these parameters. Please tell me about the risk of coagulopathies, horrible hematomas/hemorrhages, etc.

TIA

We once had an older lady come in with a knife sticking out of her abdomen. It had gone through her liver and was left in place by EMS.

She is initially tachy, hypotensive, on pressors from ER. Everyone freaking.

I start the massive transfusion protocol coolers coming up and start dumping the units in.

They call in the "liver specialist" who does hepatobiliary cancer surgeries.

"Patient needs volume, the IVC is flat" . Knife is still in place so I think fine Ill give some more product ahead of the removal or dissection of the knife. However she had stabilized clinically and labs were re-sent

"IVC is flat there is no volume!!"

I continue the massive transfusion protocol in anticipation of the labs.

HCT 32. "IVC is flat there is no volume"

I give one more cooler of product (4rbc, 2ffp, 1plt)

"IVC is flat are you listening to me?"

"Aline pressure is stable. BP is 140s off pressors. My last HCT was 32. I really think we are OK. Lets wait for labs."

"Oh wait sorry that wasnt the IVC, the IVC feels OK"

Next labs, HCT >50..

They remove the knife easily. Close up and go to ICU.

I was very embarassed. But this guy who was apparently a liver expert was yelling at me. It was in the heat of a moment of a massive transfusion where the patient probably needed 1 cooler but ended up getting 3.

Surgeons are *****s.

 

[DocVapor]

We once had an older lady come in with a knife sticking out of her abdomen. It had gone through her liver and was left in place by EMS.

She is initially tachy, hypotensive, on pressors from ER. Everyone freaking.

I start the massive transfusion protocol coolers coming up and start dumping the units in.

They call in the "liver specialist" who does hepatobiliary cancer surgeries.

"Patient needs volume, the IVC is flat" . Knife is still in place so I think fine Ill give some more product ahead of the removal or dissection of the knife. However she had stabilized clinically and labs were re-sent

"IVC is flat there is no volume!!"

I continue the massive transfusion protocol in anticipation of the labs.

HCT 32. "IVC is flat there is no volume"

I give one more cooler of product (4rbc, 2ffp, 1plt)

"IVC is flat are you listening to me?"

"Aline pressure is stable. BP is 140s off pressors. My last HCT was 32. I really think we are OK. Lets wait for labs."

"Oh wait sorry that wasnt the IVC, the IVC feels OK"

Next labs, HCT >50..

They remove the knife easily. Close up and go to ICU.

I was very embarassed. But this guy who was apparently a liver expert was yelling at me. It was in the heat of a moment of a massive transfusion where the patient probably needed 1 cooler but ended up getting 3.

Surgeons are *****s.

Why are you embarrassed? The liver surgeon didn't know what he was looking at.

 

[Iso4ane]

We once had an older lady come in with a knife sticking out of her abdomen. It had gone through her liver and was left in place by EMS.

She is initially tachy, hypotensive, on pressors from ER. Everyone freaking.

I start the massive transfusion protocol coolers coming up and start dumping the units in.

They call in the "liver specialist" who does hepatobiliary cancer surgeries.

"Patient needs volume, the IVC is flat" . Knife is still in place so I think fine Ill give some more product ahead of the removal or dissection of the knife. However she had stabilized clinically and labs were re-sent

"IVC is flat there is no volume!!"

I continue the massive transfusion protocol in anticipation of the labs.

HCT 32. "IVC is flat there is no volume"

I give one more cooler of product (4rbc, 2ffp, 1plt)

"IVC is flat are you listening to me?"

"Aline pressure is stable. BP is 140s off pressors. My last HCT was 32. I really think we are OK. Lets wait for labs."

"Oh wait sorry that wasnt the IVC, the IVC feels OK"

Next labs, HCT >50..

They remove the knife easily. Close up and go to ICU.

I was very embarassed. But this guy who was apparently a liver expert was yelling at me. It was in the heat of a moment of a massive transfusion where the patient probably needed 1 cooler but ended up getting 3.

Surgeons are *****s.

If that wasn’t the IVC, wtf was it? Like there’s not much back there that looks like the IVC.

 

[DocVapor]

If that wasn’t the IVC, wtf was it? Like there’s not much back there that looks like the IVC.

My guess?

Egg noodle.

 

[Iso4ane]

My guess?

Egg noodle.

Probably right, like a fettuccine and not a rigatoni.

 

[fakin' the funk]

I may be going against the grain here, but I usually don’t care if they want to “give a unit” or not, the caveat being that we are a level I trauma center with complex cardiothoracic cases/transplants.

I think a transfusion trigger of Hgb 10 is ridiculous, but if the Hgb is 7.5-8.0 with ongoing, unquantifiable oozing/bleeding and hypotension, I’m probably hanging stuff despite the “evidence” saying our trigger should always be <7. Same with platelets <135k (quantity does not equal quality) and fibrinogen levels (i.e., ongoing bleeding despite “normal” levels at the time of measurement).

At the end of the day, the surgeon is the one that deals with the patient on the floor/in the ICU postoperatively. If they want blood products for the patient, the patient will get blood products, if not in the OR, then certainly afterwards. The only thing that changes is where they place the blame.

Fortunately, we are respected where I work, so it’s not often that this is even an issue. I do find it amusing that there are suggestions about quoting articles or data to surgeons… that’s a good one.

This is an excellent post.

 

[Zekchar]

I may be going against the grain here, but I usually don’t care if they want to “give a unit” or not, the caveat being that we are a level I trauma center with complex cardiothoracic cases/transplants.

I think a transfusion trigger of Hgb 10 is ridiculous, but if the Hgb is 7.5-8.0 with ongoing, unquantifiable oozing/bleeding and hypotension, I’m probably hanging stuff despite the “evidence” saying our trigger should always be <7. Same with platelets <135k (quantity does not equal quality) and fibrinogen levels (i.e., ongoing bleeding despite “normal” levels at the time of measurement).

At the end of the day, the surgeon is the one that deals with the patient on the floor/in the ICU postoperatively. If they want blood products for the patient, the patient will get blood products, if not in the OR, then certainly afterwards. The only thing that changes is where they place the blame.

Fortunately, we are respected where I work, so it’s not often that this is even an issue. I do find it amusing that there are suggestions about quoting articles or data to surgeons… that’s a good one.

Agreed. They ask for blood. Give blood. Not the right hill to die on.

 

[abolt18]

Agreed. They ask for blood. Give blood. Not the right hill to die on.

Until the patient has a life-threatening reaction to the transfusion and people all "why did you give this blood when the Hgb was already 11?" And your only response can be "because the surgeon told me to."

 

[Planktonmd]

In many places the right answer is whatever the neurosurgeon says. This may bruise some egos but it's the hard cold reality.

 

[coffeebythelake]

Maybe try to change their practice by shame? Offer to present a grand rounds on education about and risks/benefits of intraoperative transfusions and throw a slide in where you break down average unit transfused (in non emergent setting) first by ASA status and then by department. Don’t even need to name names but when the neurosurgery department is statistically above others and the only indication is “surgical bleeding,” force some introspection on them

this seems like you are trying to shame the surgeons, but instead you are just making a lot of extra work for yourself

Agreed. They ask for blood. Give blood. Not the right hill to die on.

so in what situation would you actually take a stance? giving blood isn't a small deal, as so many others have pointed out

 

[coffeebythelake]

In many places the right answer is whatever the neurosurgeon says. This may bruise some egos but it's the hard cold reality.

I guess in a twisted way of thinking, if those units of blood aren't transfused intraop by you, it will still be transfused postop by the surgical team.

that being said i wouldn't do so without raising objections and pointing out why it is not a good idea.

i just don't want my name attached to an anesthetic record where a patient is transfused to a Hgb >12.

i wouldn't say it is a matter of ego, i would say it is a matter of what's best for the patient.