Elective Surgery without Transfusion: Influence of Preoperative Hemoglobin Level and Blood Loss on Mortality Richard K. Spence, MD, Jeffrey A. Carson, MD, Roy Poses, MD, Camden, New Jersey, Sue McCoy, MD, Job~ Tennessee,Mark Pello, MD, James Alexander, MD, Joseph Popovich, MD, Edward Norcross, MD, Rudolph C. Camishion, MD, Camden.NewJersey
To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 2 0 had preoperative hemoglobin levels between 6 to 10 g/dL.Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g / d E mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p < 0 . 0 2 5 ) . More importantly, there was n o mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: ( 1 ) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and ( 2 ) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.
City,
he ready availability of blood, the belief that complications of transfusion occurred infrequently and were usually benign, and the acceptance of the tradition that patients must have a hemoglobin level of 10 g/dL for surgery to be safe all contributed to our routine use of blood transfusion in the past [I]. Current concerns about increasingly scarce supplies, escalating costs, and the potential for transmitting fatal disease compel us to reconsider our transfusion practices [2,3]. Surgeons frequently transfuse blood to attain a hemoglobin level of 10 g/dL preoperatively, even in the absence of demonstrable physiologic need for better oxygen delivery or more red blood cells. Questions about the influence of the preoperative hemoglobin level on surgical outcome have been difficult to answer in clinical studies because of our understandable reluctance to operate on anemic patients. We have previously suggested that there may be little or no increment of postoperative risk for some surgical patients with preoperative hemoglobin values below 10 g/ dL [4]. In this study, we focused on elective surgical patients. Because we treat a large population of Jehovah's Witnesses, we have had the unique opportunity to study prospectively the influence of preoperative hemoglobin level and operative blood loss on survival following elective surgery in patients who refuse blood transfusion.
T
PATIENTS AND M E T H O D S Between 1981 and 1986, we performed 113 elective surgical procedures on 107 consecutive Jehovah's Witness patients. There were 41 males and 72 females. Ages ranged between 8 and 88 years, with a mean age of 47 years. Preoperative hemoglobin levels ranged between 6.0 and 16.7 g / d E with a mean of 11.4 g/dL. Blood loss and/or anemia had existed in all patients for at least 2 weeks. All patients were Jehovah's Witnesses and refused blood for religious reasons. Sixty-five of these patients had been part of our previous study [4]. Operations were performed on the basis of need, regardless of preoperative hemoglobin level. The only major contraindication to surgery was a recent myocardial infarction (Table I). Ninety-three patients had a preoperative hemoglobin level greater than 10 g/dL. In 20 patients, the preoperative From the Departmentsof Surgery(RKS, MP, JA, JP, EN, RCC) and hemoglobin level was between 6 and 10 g/dL. All paMedicine (JAC, RP), Cooper Hospital/UniversityMedical Center, Robert WoodJohnsonSchoolof Medicine,Universityof Medicineand tients were normovolemic prior to surgery as judged by Dentistryof New Jersey,Camden,New Jersey,and the Departmentof clinical examination and/or measurement of central veSurgery (SMcC), East TennesseeState University,Quillen-Dishner nous and arterial pressures. Estimated blood loss ranged Collegeof Medicine,JohnsonCity,Tennessee. from 0 to 5,600 mL, with a median loss of 500 mL and a Requests for reprints should be addressed to Richard K. Spenee, mean loss of 750 4- 93 mL. Estimated blood loss was MD, 3 CooperPlaza, Suite 41 l, Camden, New Jersey08103. Manuscript submitted August 26, 1988,revisedMarch 21, 1989, below 500 mL in 59 patients (52%) and below 1,000 mL in 88 patients (78%). Volume resuscitation given during and acceptedApril 5, 1989. 320
THE AMERICAN JOURNALOF SURGERY VOLUME159 MARCH 1990
ELECTIVE SURGERY WITHOUT TRANSFUSION
TABLE 11
TABLE I
Mortality, Preoperative Hemoglobin Level, and Blood Loss
Types of Operations Performed without Transfusion Operation
n
Total abdominal hysterectomy 13 11 Heminephrectomy/radical nephrectomy 10 Open reduction/internal
Operation
Joint replacement Oophorectomy/myomectomy
7 8
Hemicolectomy Cesarean section Laminectomy/spinal fusion Coronary artery bypass graft Craniotomy Exploratory laparotomy/lysis of adhesions Aortic valve replacement Portacaval shunt Incisional hernia repair Below knee amputation
5 5 4 4 4 4
Subtotal gastrectomy Modified radical mastectcmy/ reduction mammoplasty Prostatectomy Gynecologic procedures Vaginal hysterectomy Choledochojejunostomy/ gastrojejunostomy Carotid endarterectomy Cholecystectomy Vagotomy/pyloroplasty Resection of chest wall mass Myocutaneous flap Right upper lobe Iobectomy
3 3 3 1
Retroperitoneal lymph node dissection Splenectomy Nephrostomy
fixation
n
3 3
1
3 3 2 2 2 2 2 1 1 1
No./Total (%) Preoperative hemoglobin* > t0 g/dL 6-10 g/dL Blood loss t >500 mL 10 g/dL + >500 mL >10 g/dL -I- 500 mL 6-10 g/dL + 0.25. t p
To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 2 0 had preoperative hemoglobin levels between 6 to 10 g/dL.Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g / d E mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p < 0 . 0 2 5 ) . More importantly, there was n o mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: ( 1 ) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and ( 2 ) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.
City,
he ready availability of blood, the belief that complications of transfusion occurred infrequently and were usually benign, and the acceptance of the tradition that patients must have a hemoglobin level of 10 g/dL for surgery to be safe all contributed to our routine use of blood transfusion in the past [I]. Current concerns about increasingly scarce supplies, escalating costs, and the potential for transmitting fatal disease compel us to reconsider our transfusion practices [2,3]. Surgeons frequently transfuse blood to attain a hemoglobin level of 10 g/dL preoperatively, even in the absence of demonstrable physiologic need for better oxygen delivery or more red blood cells. Questions about the influence of the preoperative hemoglobin level on surgical outcome have been difficult to answer in clinical studies because of our understandable reluctance to operate on anemic patients. We have previously suggested that there may be little or no increment of postoperative risk for some surgical patients with preoperative hemoglobin values below 10 g/ dL [4]. In this study, we focused on elective surgical patients. Because we treat a large population of Jehovah's Witnesses, we have had the unique opportunity to study prospectively the influence of preoperative hemoglobin level and operative blood loss on survival following elective surgery in patients who refuse blood transfusion.
T
PATIENTS AND M E T H O D S Between 1981 and 1986, we performed 113 elective surgical procedures on 107 consecutive Jehovah's Witness patients. There were 41 males and 72 females. Ages ranged between 8 and 88 years, with a mean age of 47 years. Preoperative hemoglobin levels ranged between 6.0 and 16.7 g / d E with a mean of 11.4 g/dL. Blood loss and/or anemia had existed in all patients for at least 2 weeks. All patients were Jehovah's Witnesses and refused blood for religious reasons. Sixty-five of these patients had been part of our previous study [4]. Operations were performed on the basis of need, regardless of preoperative hemoglobin level. The only major contraindication to surgery was a recent myocardial infarction (Table I). Ninety-three patients had a preoperative hemoglobin level greater than 10 g/dL. In 20 patients, the preoperative From the Departmentsof Surgery(RKS, MP, JA, JP, EN, RCC) and hemoglobin level was between 6 and 10 g/dL. All paMedicine (JAC, RP), Cooper Hospital/UniversityMedical Center, Robert WoodJohnsonSchoolof Medicine,Universityof Medicineand tients were normovolemic prior to surgery as judged by Dentistryof New Jersey,Camden,New Jersey,and the Departmentof clinical examination and/or measurement of central veSurgery (SMcC), East TennesseeState University,Quillen-Dishner nous and arterial pressures. Estimated blood loss ranged Collegeof Medicine,JohnsonCity,Tennessee. from 0 to 5,600 mL, with a median loss of 500 mL and a Requests for reprints should be addressed to Richard K. Spenee, mean loss of 750 4- 93 mL. Estimated blood loss was MD, 3 CooperPlaza, Suite 41 l, Camden, New Jersey08103. Manuscript submitted August 26, 1988,revisedMarch 21, 1989, below 500 mL in 59 patients (52%) and below 1,000 mL in 88 patients (78%). Volume resuscitation given during and acceptedApril 5, 1989. 320
THE AMERICAN JOURNALOF SURGERY VOLUME159 MARCH 1990
ELECTIVE SURGERY WITHOUT TRANSFUSION
TABLE 11
TABLE I
Mortality, Preoperative Hemoglobin Level, and Blood Loss
Types of Operations Performed without Transfusion Operation
n
Total abdominal hysterectomy 13 11 Heminephrectomy/radical nephrectomy 10 Open reduction/internal
Operation
Joint replacement Oophorectomy/myomectomy
7 8
Hemicolectomy Cesarean section Laminectomy/spinal fusion Coronary artery bypass graft Craniotomy Exploratory laparotomy/lysis of adhesions Aortic valve replacement Portacaval shunt Incisional hernia repair Below knee amputation
5 5 4 4 4 4
Subtotal gastrectomy Modified radical mastectcmy/ reduction mammoplasty Prostatectomy Gynecologic procedures Vaginal hysterectomy Choledochojejunostomy/ gastrojejunostomy Carotid endarterectomy Cholecystectomy Vagotomy/pyloroplasty Resection of chest wall mass Myocutaneous flap Right upper lobe Iobectomy
3 3 3 1
Retroperitoneal lymph node dissection Splenectomy Nephrostomy
fixation
n
3 3
1
3 3 2 2 2 2 2 1 1 1
No./Total (%) Preoperative hemoglobin* > t0 g/dL 6-10 g/dL Blood loss t >500 mL 10 g/dL + >500 mL >10 g/dL -I- 500 mL 6-10 g/dL + 0.25. t p
