Blood transfusion in major non-emergency surgery: The urgent necessity to significantly decrease its indication

Lammi JP et al.14 studied the use of blood transfusions in 1404 patients undergoing pancreatic resections in Finland. The authors tried to improve and unify blood transfusion (BT) policies in order to decrease and optimize the use of blood products. They found no differences among high, medium and, low-volume centers in BT utilization, trigger points or the use of reserved blood units after pancreatoduodenectomy or total pancreatectomy. Although, only minor changes in BT trends were found, the lowering of the transfusion trigger point and the best use of reserved blood units occurred only in high-volume centers.14 This is already a plausible finding since there is compelling evidence indicating that BT is excessive and sometimes unnecessary worldwide. Nearly 14million units of blood are donated annually in the USA, and about 4million people receive BT every year.15,16 Blood transfusion administration in surgical and critical care settings varies between 30-100% of patients. Lammi JP et al.14 observed that 65.9% of their study patients received BT. The mean number of red BT units was 5.22/patient (1.9–8.76). The mean trigger point for BT was an Hb level of 8.6g/dL. The mean percentage of blood units used out of the reserved red blood was 63.4%. We can see that the percentage of BT is still elevated, the trigger Hb level and the utilization of reserved blood units is also high. Although, the authors did not mention BT related complications in their study, the utilization of reserved blood is strongly associated to ischemic complications. Stored red blood cells are known to have decreased 2,3 DPG in the cell membrane, hence, they are less deformable, less likely to deliver oxygen to the tissues, and with greater tendency to produce capillary obstruction.16 On the other hand, the mechanisms responsible for the increased incidence of infectious complications are due to the immunosuppressive effects of BT. Administration of blood products causes profound negative effects on the human immune system, a condition termed transfusion-related immune modulation.17 Another reason to decrease BT is the fact that blood donations have significantly diminished mainly because of decreasing number of qualified donors.18 This fact has resulted in a shortage of blood supply in blood banks worldwide which makes it necessary to seek out new treatment options.19 Although, alternatives to BT and other treatment options exist, they are seldom utilized.