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Ottawa Criteria for Appropriate Transfusions in Hepatectomy: Using the RAND/UCLA Appropriateness Method

Bennett, Sean, MD*,†,‡; Tinmouth, Alan, MD, FRCPC†,‡,§; McIsaac, Daniel, I., MD, FRCPC†,‡,¶; English, Shane, MD, FRCPC†,‡,§; Hébert, Paul, C., MD, FRCPC||; Karanicolas, Paul, J., MD, FRCSC, FACS**; Turgeon, Alexis, F., MD, FRCPC††,‡‡; Barkun, Jeffrey, MD, FRCSC, FACS§§; Pawlik, Timothy, M., MD, FACS¶¶; Fergusson, Dean, PhD*,†,‡; Martel, Guillaume, MD, FRCSC, FACS*,†,‡

doi: 10.1097/SLA.0000000000002205

Objective: Create practice guidelines for the appropriate use of red blood cell transfusions in hepatectomy.

Background: Hepatectomy is associated with a high prevalence of transfusions. A transfusion can be life-saving, but can be associated with important adverse effects. Given the prevalence, the potential for benefit and harm, and the difficulty in conducting clinical trials, transfusion in hepatectomy is well-suited for a study of appropriateness.

Methods: Using the RAND/UCLA appropriateness method, an international, multidisciplinary expert panel in hepatobiliary surgery, anesthesia, transfusion medicine, and critical care rated a series of 468 perioperative scenarios for transfusion appropriateness. Scenarios were rated individually, and again during an inperson group moderated session. Median scores and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or uncertain.

Results: Approximately, 47.4% of scenarios were rated as appropriate for transfusion, 28.2% were inappropriate, and 24.4% were uncertain. The key recommendations for intraoperative transfusion were (i) it is never inappropriate to transfuse for significant bleeding or ST segment changes; (ii) it is never inappropriate to transfuse for an intraoperative hemoglobin ≤75 g/L; and (iii) in the absence of significant bleeding or ST changes, transfusion for hemoglobin of ≥95 g/L is inappropriate, and transfusion for hemoglobin of ≥85 g/L requires strong justification. The key recommendations for postoperative transfusions were: (i) in a stable, asymptomatic patient, an appropriate transfusion trigger is 70 g/L (without coronary artery disease) or 80 g/L (with coronary artery disease) and (ii) it is appropriate to transfuse any patient for a hemoglobin of ≤75 g/L either immediately post-operative, or with a significant decrease from the previous day (>15 g/L).

Conclusions: Based on best available evidence and expert opinion, criteria for appropriate perioperative red blood cell transfusions in hepatectomy were determined.

*Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada

The Ottawa Hospital, Ottawa, Ontario, Canada

Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

§Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada

Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada

||Department of Medicine, Centre hospitalier de l’Université de Montréal, Montréal, Quebec, Canada

**Department of Surgery, University of Toronto, Toronto, Ontario, Canada

††Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Canada

‡‡Centre de reserche du CHU de Québec, Population Health and Optimal Health Practices Research Unit (Trauma, Emergency, Critical Care Medicine), Université Laval, Québec, Canada

§§Department of Surgery, McGill University, Montréal, Quebec, Canada

¶¶Department of Surgery, The Ohio State University, Columbus, OH.

Reprints: Guillaume Martel, MD, FRCSC, FACS, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, Ontario, Canada, K1H 8L6. E-mail:

Disclosure: AFT is the Canada Research Chair in Critical Care Neurology and Trauma. The authors declare no conflicts of interest.

Author Contributions: S.B. contributed in the conceptualization of the study, performed the systematic review, created the clinical scenarios, helped in data collection, data analysis, and writing the manuscript. A.T., P.C.H., D.I.M., P.J.K., A.F.T., J.B., T.M.P., D.F., and G.M. contributed in the conceptualization, critical edits for the systematic review, member of the expert panel, and critical review of the final manuscript.

S.E. contributed in the conceptualization, design, and critical review of the final manuscript.

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