What are the thresholds for transfusion of hemoderivatives (blood, plasma, albumin) during Hyperthermic Intraperitoneal Chemotherapy (HIPEC)?

Transfusion Thresholds for Hemoderivatives During HIPEC

For patients undergoing Hyperthermic Intraperitoneal Chemotherapy (HIPEC), a restrictive transfusion strategy should be implemented with a hemoglobin threshold of 7 g/dL for most patients, and 8 g/dL for those with cardiovascular disease or undergoing cardiac surgery. 1, 2, 3

Blood Transfusion Thresholds

Red Blood Cell Transfusion

• Hemodynamically stable patients without cardiovascular disease: Transfuse when hemoglobin < 7 g/dL 1, 2, 3
• Patients with cardiovascular disease or undergoing cardiac surgery: Transfuse when hemoglobin < 8 g/dL 1, 2
• Cancer patients (including those undergoing HIPEC): Transfuse when hemoglobin < 7-8 g/dL 2, 3

Plasma Transfusion

• Transfuse based on coagulation parameters rather than prophylactically
• Consider plasma transfusion when:
  • INR > 1.5 with active bleeding
  • Before invasive procedures if INR > 2.0

Albumin Transfusion

• No specific threshold for albumin replacement during HIPEC
• Consider albumin administration when:
  • Serum albumin < 2.5 g/dL with clinical evidence of complications from hypoalbuminemia
  • Significant third-spacing or ascites

Special Considerations for HIPEC Patients

HIPEC patients represent a unique population with several factors that may influence transfusion decisions:

1. Cancer-related anemia: Many patients undergoing HIPEC have baseline anemia due to underlying malignancy
2. Surgical blood loss: Extensive cytoreductive surgery preceding HIPEC may cause significant blood loss
3. Fluid shifts: Hyperthermia during HIPEC can cause significant fluid shifts and hemodynamic changes

Clinical Decision-Making Algorithm

1. Assess baseline hemoglobin and coagulation status before HIPEC procedure
2. Monitor hemoglobin levels throughout the procedure and postoperatively
3. Apply appropriate threshold based on patient characteristics:
   • 7 g/dL for most patients
   • 8 g/dL for patients with cardiovascular disease
4. Consider symptoms of anemia in addition to hemoglobin levels 1
5. Transfuse one unit at a time with reassessment after each unit 2

Evidence Quality and Considerations

The evidence supporting restrictive transfusion strategies comes from multiple high-quality randomized controlled trials and meta-analyses. A 2016 Cochrane review of 31 trials with 12,587 participants found that restrictive transfusion strategies reduced the risk of receiving RBC transfusion by 43% without increasing mortality or morbidity 4.

Recent guidelines from the AABB (2023) strongly recommend a restrictive transfusion strategy with a hemoglobin threshold of 7 g/dL for most hospitalized patients 3. For patients undergoing surgery or with cardiovascular disease, a slightly higher threshold of 7.5-8 g/dL may be appropriate 3.

Common Pitfalls to Avoid

1. Overtransfusion: Transfusing to hemoglobin levels above 10 g/dL provides no additional benefit and may increase risks 2
2. Ignoring symptoms: While hemoglobin thresholds are important, symptoms of anemia should also guide transfusion decisions 1
3. Prophylactic plasma transfusion: Plasma should be transfused based on coagulation parameters and clinical bleeding, not prophylactically
4. Failure to reassess: Transfuse one unit at a time with reassessment after each unit 2

Conclusion

A restrictive transfusion strategy during HIPEC is supported by high-quality evidence and multiple guidelines. The hemoglobin threshold should be 7 g/dL for most patients and 8 g/dL for those with cardiovascular disease. Plasma and albumin transfusions should be guided by specific clinical parameters rather than prophylactic administration.