Transfusion Trigger After Operations in High Cardiac Risk Patients

Prior treatment

• Veteran with prior history of adverse reaction to blood administration, such as fever, rash, or hemolysis
• Prior randomization in the CSP#599
• Patients who are known to have tested positive for COVID-19 and have not recovered prior to consent will not be consented. Any participant who is known to have a positive COVID-19 test during the screening process and has not recovered will be excluded prior to randomization.

Other illness

• Veteran with known history of hereditary anemias such as Thalassemia or Sickle cell disease
• Veteran with known history of hereditary bleeding disorders, such as factor VIII or factor IX deficiency

Other

• Veteran unable to consent
• Veteran unwilling to follow protocol (such as Jehovah's witnesses)
• Veteran does not speak or understand English
• Veteran hemodynamically unstable or in cardiogenic shock for \>48 hours after the index procedure
• Veteran participating in another interventional trial whose objective is to evaluate the effect of transfusion on outcomes
• Pregnancy in female Veterans
• Veteran is a prisoner or in custody of law enforcement

• Males and females older than 18 years of age who have postoperative Hb \< 10gm/dl within 15 days after the index operation
• Patients who undergo an operation in either one of the three following categories:
  • Veterans who undergo PAD - related operations including but not limited to the following:
  • aortobifemoral or aortobiiliac bypass
  • open abdominal aortic aneurysm repair with simultaneous repair of aortoiliac occlusive disease
  • visceral bypass
  • iliofemoral bypass
  • femoral bypass or endarterectomy
  • infrainguinal bypass
  • thromboembolectomy
  • supra-aortic trunk bypass or endarterectomy
  • carotid endarterectomy
  • major lower extremity amputations (transfemoral, through the knee, or transtibial)
  • Veterans with past medical history of ischemic stroke or IHD or PAD who undergo the following general surgery procedures, defined as:
  • known prior MI
  • ECG findings consistent with prior MI
  • prior percutaneous coronary intervention
  • prior coronary artery bypass surgery
  • history of angina for which the patient is currently receiving treatment
  • stress test indicating myocardial ischemia
  • who undergo the following General Surgery operations:
  • Open cholecystectomy or other complex biliary reconstruction
  • such as open common bile duct exploration for stones
  • reconstruction as part of oncologic operations such as palliative pancreatic cancer procedures)
  • small bowel resection
  • pancreatectomy
  • colon resection
  • rectal resection
  • splenectomy
  • transhiatal esophagectomy
  • liver resection
  • gastric resection
  • open ventral hernia repair
  • Colostomies (reversals and takedowns)
  • Intestinal anastomosis takedowns and revisions
  • Gastric bypass
  • Adrenalectomies
  • Major diaphragmatic hiatal hernia repairs
  • Veterans with past medical history of ischemic stroke or IHD or PAD who undergo the following Vascular Surgery operations:
  • Open aneurysm repair, including but not limited to:
  • carotid
  • subclavian
  • abdominal aortic
  • iliac
  • femoral
  • popliteal aneurysms
  • and complex endovascular aneurysm repair, defined as:
  • fenestrated endograft
  • or endograft with need for iliac conduit
  • or endovascular aneurysm repair with simultaneous femoral artery reconstruction or bypass
  • Subclavian/vertebral bypasses and transpositions
• Patients undergoing the above procedures will be included in the study regardless of their preoperative Hb level, and regardless of preoperative or intraoperative transfusion they might have received.