What are the recommended transfusion thresholds for hemoderivatives, including red blood cells, and central venous saturation (ScvO2) 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. 1

Red Blood Cell Transfusion Thresholds

General Recommendations

• For hemodynamically stable patients undergoing HIPEC:
  • Maintain hemoglobin ≥ 7 g/dL for most patients 1, 2
  • Maintain hemoglobin ≥ 8 g/dL for patients with:
    • Pre-existing cardiovascular disease 3, 1
    • Those undergoing cardiac surgery 2
    • Orthopedic surgery patients 2

Special Considerations for HIPEC Patients

• Cancer patients undergoing HIPEC should generally follow the 7 g/dL threshold 1, 2
• Single-unit transfusion strategy should be employed with reassessment after each unit to avoid overtransfusion 1
• Brazilian trials suggested a potential benefit of liberal transfusion (9 g/dL threshold) in cancer patients after major abdominal surgery, but these studies had limited sample sizes and potential bias 3

Central Venous Saturation (ScvO2) Guidance

• Target ScvO2 ≥ 70% during HIPEC procedures 3
• Early goal-directed therapy protocols previously suggested maintaining hematocrit > 30% (Hb > 10.0 g/dL) to achieve ScvO2 targets 3
• However, more recent evidence from PROMISE, PROCESS, and ARISE trials showed no survival difference between interventional and control arms when targeting ScvO2 > 70% 3
• Important: ScvO2 should be considered alongside hemoglobin levels, not as an isolated trigger for transfusion

Clinical Decision-Making Beyond Numerical Thresholds

• Transfusion decisions should not be based exclusively on hemoglobin levels but must also consider 3, 1:
  • Patient's tolerance of anemia
  • Presence of active bleeding
  • Predicted decline in hemoglobin
  • Signs of tissue hypoxia or organ dysfunction
  • Symptoms of anemia (tachycardia, hypotension, shortness of breath)

Transfusion Management Algorithm for HIPEC

1. Initial Assessment:

   • Measure baseline hemoglobin and ScvO2
   • Assess cardiovascular status and comorbidities

2. Transfusion Triggers:

   • Hemoglobin < 7 g/dL in most patients
   • Hemoglobin < 8 g/dL in patients with cardiovascular disease
   • Consider transfusion at higher thresholds if symptomatic anemia present

3. Transfusion Protocol:

   • Transfuse one unit at a time
   • Reassess hemoglobin and clinical status after each unit
   • Avoid exceeding recommended thresholds (overtransfusion provides no additional benefit) 1

4. ScvO2 Monitoring:

   • If ScvO2 < 70% despite adequate hemoglobin levels, consider other causes of decreased oxygen delivery:
     • Cardiac output
     • Arterial oxygen saturation
     • Increased oxygen consumption

Evidence Quality and Pitfalls

• High-quality evidence supports restrictive transfusion strategies across multiple clinical contexts 4, 5
• Meta-analyses show restrictive strategies reduce transfusion exposure by approximately 40-43% without increasing mortality or morbidity 4, 5
• Caution: Patients with acute coronary syndrome may require higher thresholds, though evidence is limited 3
• Common pitfall: Transfusing based solely on hemoglobin numbers without considering clinical context and symptoms 1
• Potential risk: Higher incidence of acute coronary syndrome has been observed with restrictive strategies in patients with cardiovascular disease 3

Other Hemoderivatives During HIPEC

• For platelets: Maintain count > 50,000/μL 1
• For fibrinogen: Maintain levels > 120 mg/dL 1
• Evidence for plasma and platelet transfusion is moderate only in the context of massive blood transfusion 6

By following these evidence-based transfusion thresholds during HIPEC procedures, clinicians can minimize unnecessary blood product use while maintaining patient safety and optimizing outcomes.