Effects of a Goal Directed Transfusion Protocol on Severe Primary Graft Dysfunction after Lung Transplantation

Purpose Transfusion during lung transplantation (LT) is linked to primary graft dysfunction (PGD) and worsened outcomes. Goal-directed protocols have improved outcomes in cardiac surgical populations and decreased transfusions in LT on cardiopulmonary bypass. We propose that the implementation of goal-directed transfusion protocol for LT would reduce the rate of transfusion and PGD grade 3 at 72hrs. Methods We included adult LT patients performed on and off mechanical circulatory support (MCS) between March 1, 2017 and February 28, 2019. Patients undergoing multi-organ transplant, preoperative MCS, or who received preoperative transfusions were excluded. A ROTEM-guided transfusion algorithm was implemented February 28, 2018. Demographic and procedural characteristics of patients were compared pre- and post-protocol. The primary outcome was PGD grade 3 at 72hrs, as defined by 2016 ISHLT criteria. PGD was trended by month before and after implementation. Adherence was defined as the presence of intraoperative ROTEM results. Results 188 patients were included, and grouped by time period either into pre-protocol (N=101) or post-protocol (N=87). There were no statistically significant  differences in procedural or demographic characteristics between groups (Table 1). While the PGD rate decreased from 27.7% (n=28) in the pre-period to 20.7% (n=18) in the post-period, this was a not statistically significant (p=0.26). Intraoperative protocol labs were sent in in 77% (n=67) of the post-protocol patients. PGD during the post-period was 25% in the non-adherent protocol cases and 19% in the protocol adherent cases (p=0.54). Conclusion While we previously described a consistent reduction of median RBC units transfused post-protocol over 12 months, this protocol did not result in a consistently reduced severe PGD rate. Over 12 months, we observed a trend in reduced PGD rates after implementing our transfusion protocol. Teams should consider goal-directed transfusion protocols for LT.