Keywords
transfusion - free flap - hematocrit - head and neck
I would like to thank Dr. Kadakia and Dr. Wimalawansa for inviting me to submit a
manuscript on taking an idea from inception to innovation. Perhaps the most complex
part of deciding how to approach this subject was reflecting on what significant changes
I have introduced into my practice that were not just subjective and anecdotal but
were evidenced-based and had the potential to affect patient care; perhaps even instituting
a paradigm shift in the management of not only my patients, but also all of our patients.
Over the course of a long career, the mark of a successful surgeon is the ability
to recognize needed change and to institute that change in one's practice. Oftentimes
incremental changes are adapted over a long period. When I reflect on what I did 20
to 30 years ago and what I am doing now, there is a vast difference in many areas.
It is the mark of our specialties' continued interest in education and pursuit of
excellence that we adapt small incremental changes over time. So when examined in
a retrospective nature the change is substantial. It is only after self-reflection
and Pittsburgh Sleep Quality Index (PSQI) evaluations that one can look back to see
how one's practice parameters have evolved. Dr. Ashok Shaha in the early days of my
career cemented that the first 10 years of one's career are spent in learning how
to do the procedure, the second 10 years are spent in learning when to do the procedure,
and the final 10 years are spent learning when not to do the procedure.
I have chosen to address the role of transfusion in head and neck oncologic and reconstructive
surgery. I will describe how this has evolved over time in my practice with self-reflection,
PSQI, and finally to the ability to be open to change and listen to those who are
junior to oneself. The process of initiating a change and following through on that
change so it is integrated into one's practice is translatable into almost any process
or protocols that we utilize. While I have chosen to discuss transfusion criteria,
the same process is applicable to multiple other changes instituted over the years.
Transfusion Criteria in the Early Days
Head and neck ablative and reconstructive surgery is oftentimes associated with blood
loss that warrants transfusion. The exact level at which patients require transfusion
remains controversial. Early in my career, I established that a hematocrit level below
30% or a hemoglobin level below 10 g/dL warranted transfusion. I based this decision
on data from animal research dating back to the 1970s. In 1988, the National Institutes
of Health consensus statement confirmed that “modern surgical and anesthetic practice”
has been guided by the belief that a hemoglobin value of less than 10 g/dL or hematocrit
value of less than 30% indicates the need for perioperative red blood cell transfusion.[1] It was my belief that establishing a firm cutoff for transfusion was better than
attempting to evaluate on an individual patient basis. While there was much literature
in animal models that demonstrated that various cutaneous, fasciocutaneous, and myocutaneous
flaps had improved survival when anemic, the translation of this information to the
human model was lacking.[2]
[3]
[4] Complications from red blood cell transfusions, while uncommon, can be devastating
from both an infectious and an noninfectious process. Resource utilization is also
a factor to take into account in our current health care model.
In 2007, a resourceful resident Dr. Zachary Solar undertook a literature review following
an intensive care unit (ICU) rotation, which demonstrated that blood transfusions
were associated with increased rates of infection, longer hospital stays, and increased
mortality in critically ill patients.[5]
[6]
[7] The increased threshold for transfusion in the ICU setting for these critically
ill patients prompted an in-depth evaluation of our practice. All microvascular reconstructive
surgeons are leery of a change in protocol or technique. The downside of a dead flap
is a fear that oftentimes makes us dogmatic and unaccepting of change. To evaluate
a change in our transfusion protocol, we analyzed in a retrospective fashion what
the impact would be if we modified our transfusion threshold. We reviewed 54 free-flap
patients transfused over the previous year and a half. Eighty percent of transfusions
went to patients with hematocrit levels between 25 and 30%. Multiple joint discussions
with trauma surgeons, intensivists, and other faculty were undertaken. A consensus
decision to decrease the transfusion criteria to a hematocrit level of 25% was made.
The nonotolaryngology transfusion literature supported that the morbidity may in fact
be less. Survival of free flaps in animal models supported the move and our retrospective
analysis supported that it would be highly impactful on patient care and resource
utilization.[8]
[9]
[10]
We then collected data over the next year and a half on patients with our new transfusion
level. We compared these data with the data of immediate previous year and a half
to evaluate the clinical significance, the number of units of blood not transfused,
and the number of patients who did not receive a transfusion based on the new protocol.
We were able to demonstrate that a restrictive transfusion protocol significantly
lowered the transfusion rate without increasing complication rates. The only difference
was a higher rate of fistulas and respiratory failure in the group that more liberally
transfused.[11] This transfusion protocol then became the paradigm for the next decade. During this
time, transfusion protocols were not a topic of interest in the literature or at national
meetings.
Almost 10 years later, Dr. James Azzi started his facial plastic and reconstructive
microvascular fellowship in our department. During rounds, he remarked that at the
institution where he completed his residency, the transfusion criteria were more restrictive,
using a hematocrit level of 21 g/dL to determine transfusion needs. This prompted
much discussion and thought. Having already changed our transfusion criteria with
no adverse effects and improvements in decreasing units of blood transfused, we reevaluated
our protocol. We followed the same steps by examining the previous 2-year history
of transfusions. We reviewed what the theoretical effect of a more restrictive transfusion
level of 21% would have on the number of units and patients transfused. Forty-five
percent of patients had a hematocrit less than 25% and received a transfusion. Of
these, 80% of patients transfused never had a hematocrit less than 21%. The potential
impact was clinically significant for both the patients as well as the hospital system.
Meetings were held between intensivists, trauma surgeons, and the department.
In March 2018, almost a decade after our first change, we again instituted a more
restrictive transfusion protocol. The new hematocrit level was 21%. Data were collected
on 142 patients undergoing free tissue transfer and morbidity assessed. We were able
to demonstrate that there was no increase in flap loss, fistula formation, pulmonary
complications, or other patient morbidities. Only 23% of patients were transfused
under our new restrictive guidelines. This was half the number that would have been
transfused under our old criteria. Overall our transfusion rate for patients undergoing
free tissue transfer evolved from approximately 75% of patients receiving a transfusion
to 25% with a restrictive protocol. Our new restrictive guidelines have remained in
place since then.
I have used this incorporation of increasingly restrictive transfusion criteria in
a microvascular reconstructive practice to demonstrate how one can alter the paradigm
of one's practice. Ideas for innovative approaches to patient care can arise on many
levels. The ability to integrate the information from different sources and evaluate
how it can influence one's practice is important. Analyzing what is currently being
done and evaluating through multispecialty consultation which changes can be instituted,
a plan to provide an innovative new management paradigm can be instigated. It is important
to keep an open mind to ideas from those less experienced and perhaps most importantly
from other specialties. An important first step is to analyze the data and evaluate
if the paradigm shift in fact has been helpful or not. In our setting over the course
of two decades, we have been able to alter our transfusion rate by greater than 60%
in our patient population. The benefits to the patients in the system are significant.
We have utilized this model to look at multiple other clinical and practice issues.
These range from vasopressor use to ICU stays and many others.
