1. Surgical ICU, Heart Institute University of São Paulo
Ludhmila Hajjar, MD, PhD
Surgical ICU, Heart Institute
University of São Paulo

2. Mayo Clinic and the Origins of Blood Banking
John Lundy, 1934: first blood banking (Mayo Clinic)
Transfusion trigger (1942): hemoglobin of 10g/dL would be the goal in high risk patients
1970/1980’s: transfusion-related hepatitis in 45% of patients
1987: HIV infection – risks and benefits of transfusion (60% of critically ill patients)
Lundy JS. Blood transfusion. Surg Clin North Am. 1934;14:721-7.
Rabbitts JA, et al. Mayo Clinic and the origin of blood banking. Mayo Clin Proc. 2007;82(9):

3. RISKS OF BLOOD TRANSFUSION
Incompatibility reactions
Early and late transfusional reactions
Imunossupression
Infections (bacterial, viral and prions)
GVHD
Imunommodulation
Systemic inflammatory response syndrome
Metabolic disorders (acidosis, hyperkalemia, hipothermy)
Storage lesion
Transfusion related acute lung injury (TRALI)
Transfusion acute circulatory overload (TACO)
Increased morbidity and mortality in medical and surgical patients
Hajjar LA, Auler Jr JO, Galas F et al.
Blood transfusion in critically ill patients: state of the art. Clinics. 2007;62(4):
Goodnough LT. Anesthesiology Clin N Am. 2005;23:

4. The challenge of identifying the critical point
Hébert P et al. Crit Care Clinics. 2004;20:
Hébert P et al. Crit Care Clinics. 2004;20:

5. Liberal strategy: RBC transfusion when Hb < 10g/dL
Restrictive strategy: RBC transfusion when Hb < 7g/dL
n = 418
n = 420
DOUBTS ON TRANSFUSIONAL PRACTICE – trigger or individual-based 
Hébert PC et al. N Engl J Med. 1999;340:
N Engl J Med. 1999;340:

6. Cardiac Surgery and Red Blood Cell Transfusion
Estratégias liberal vs. restritiva em cirurgia cardíaca
Major cause of RBC transfusion
Occurrence: 40 to 95%
Aged patients, high percent of comorbidities, antiplatelet and anticoagulants use
RBC transfusion rates with high variability – institutional “guidelines”
Not standard indications
Steiner ME et al. Transfusion algorithms and how they apply to blood conservation.
Hematol Oncol Clin N Am 2007;21:
Reeves BC and Murphy GJ. Current Opinion in Cardiology. 2008; 23:

7. 11.963 patients (on pump CABG)
RBC transfusion: increase in morbidity and mortality
Koch CG et al. Crit Care Med. 2006;34:

8. DESIGN
Prospective and randomized controlled trial
February 2009 to February 2010
Heart Institute, University of São Paulo
HYPOTHESIS
A restrictive strategy of RBC transfusion is as safe as a liberal one in
cardiac surgery

9. Primary outcome:
Composite end point that included 30-day
all cause mortality and severe morbidity
(cardiogenic shock, ARDS, or acute renal
injury requiring dyalisis or hemofiltration)
Secondary outcomes:
All clinical complications during hospital stay,
ICU and hospital lengths of stay
Predictive factors for RBC transfusions
Effects of transfusion on patient outcomes

12. Porcentage of patients who received RBC transfusion

13. Median levels of total transfused RBC units in liberal and
restrictive-strategy groups

16. Kaplan-Meier Estimates of 30-Day Survival by Transfusion Strategy

17. PREDICTIVE FACTORS FOR RBC TRANSFUSION

18. PREDICTIVE FACTORS FOR COMPLICATIONS

19. PREDICTIVE FACTORS FOR DEATH AT 30 DAYS
Hajjar, L. A. et al. JAMA 2010;304:

20. Kaplan-Meier Estimates of 30-Day Survival Based on Number of Red Blood Cell (RBC) Units Transfused
Hajjar, L. A. et al. JAMA 2010;304:

21. CONCLUSIONS
The restrictive-strategy patients received fewer RBC units and
did not present higher incidence of clinical complications
In our study, independent of treatment strategy, patients who
received na RBC transfusion had higher rates of complications
after surgery, including 30-day mortality
The number of transfused RBC units was a predictive factor
for 30-day mortality
Using a noninferiority margin of -8%, the use of a restrictive transfusion strategy
resulted in noninferior rates of the combined outcome of 30-day all-cause
mortality and severe morbidity.

22. The study by Hajjar et al is a notable addition to the existing body of evidence on the narrow benefits of RBC transfusion and its effect on outcomes in patients without hemorrhage. These studies have suggested that reduction or avoidance of transfusion in cardiac patients is associated with improved outcomes.
When evaluating a hemoglobin level, treating physicians must resist the temptation to "first do something" and temper this temptation with a philosophy of "first do no harm" to achieve the optimal balance of providing the best risk-benefit and cost-effective outcomes of transfusion therapy for patients.
JAMA. 2010;304(14):