Outcome of patients who refuse transfusion after cardiac surgery: a natural experiment with severe blood conservation

Arch Intern Med. 2012 Aug 13;172(15):1154-60. doi: 10.1001/archinternmed.2012.2449.

Abstract

Background: Jehovah's Witness patients (Witnesses) who undergo cardiac surgery provide a unique natural experiment in severe blood conservation because anemia, transfusion, erythropoietin, and antifibrinolytics have attendant risks. Our objective was to compare morbidity and long-term survival of Witnesses undergoing cardiac surgery with a similarly matched group of patients who received transfusions.

Methods: A total of 322 Witnesses and 87 453 non-Witnesses underwent cardiac surgery at our center from January 1, 1983, to January 1, 2011. All Witnesses prospectively refused blood transfusions. Among non-Witnesses, 38 467 did not receive blood transfusions and 48 986 did. We used propensity methods to match patient groups and parametric multiphase hazard methods to assess long-term survival. Our main outcome measures were postoperative morbidity complications, in-hospital mortality, and long-term survival.

Results: Witnesses had fewer acute complications and shorter length of stay than matched patients who received transfusions: myocardial infarction, 0.31% vs 2.8% (P = . 01); additional operation for bleeding, 3.7% vs 7.1% (P = . 03); prolonged ventilation, 6% vs 16% (P < . 001); intensive care unit length of stay (15th, 50th, and 85th percentiles), 24, 25, and 72 vs 24, 48, and 162 hours (P < . 001); and hospital length of stay (15th, 50th, and 85th percentiles), 5, 7, and 11 vs 6, 8, and 16 days (P < . 001). Witnesses had better 1-year survival (95%; 95% CI, 93%-96%; vs 89%; 95% CI, 87%-90%; P = . 007) but similar 20-year survival (34%; 95% CI, 31%-38%; vs 32% 95% CI, 28%-35%; P = . 90).

Conclusions: Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.

Publication types

  • Comparative Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anemia* / ethnology
  • Anemia* / etiology
  • Anemia* / psychology
  • Anemia* / therapy
  • Antifibrinolytic Agents / therapeutic use
  • Blood Transfusion* / psychology
  • Blood Transfusion* / statistics & numerical data
  • Cardiac Surgical Procedures* / adverse effects
  • Cardiac Surgical Procedures* / mortality
  • Erythropoietin / therapeutic use
  • Female
  • Hematinics / therapeutic use
  • Humans
  • Jehovah's Witnesses / psychology*
  • Length of Stay
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care
  • Perioperative Care / methods
  • Perioperative Care / psychology
  • Postoperative Complications* / ethnology
  • Postoperative Complications* / psychology
  • Postoperative Complications* / therapy
  • Research Design
  • Survival Analysis
  • Time Factors
  • Transfusion Reaction
  • Treatment Refusal* / ethnology
  • Treatment Refusal* / psychology
  • Treatment Refusal* / statistics & numerical data
  • United States / epidemiology
  • United States / ethnology

Substances

  • Antifibrinolytic Agents
  • Hematinics
  • Erythropoietin