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Does blood transfusion harm cardiac surgery patients?
Gavin J Murphy
BMC Medicine , 2009, DOI: 10.1186/1741-7015-7-38
Abstract: The development of modern blood services that enable large-scale allogenic red cell donation, storage and transfusion represents one of the greatest achievements of modern medicine. It has saved countless lives and is indispensable for the treatment of trauma patients and those with life-threatening haemorrhage. The early success of blood transfusion, occurring as it did during wartime, coupled with advances in storage techniques led to the widespread use of transfusion for indications where there is little, if any, evidence of efficacy. With the advent of evidence-based medicine over recent decades, coupled with the increasing prevalence of electronic prospective clinical databases, we have seen a large number of retrospective observational studies that appear to show an association between transfusion and adverse outcome in a range of clinical scenarios including cardiac surgery [1], general surgery [2], acute coronary syndromes [3] and in critical care [4], to name but a few. In fact, it would seem that, with very few exceptions [5] there is no evidence of efficacy beyond its use in haemorrhagic shock. The study by Rogers and colleagues, published this month in BMC Medicine, is a useful addition to the literature, and is strengthened by the large numbers of patients considered and the quality of the analysis performed [6]. In this case, transfusion was associated with a twofold increase in infection rates. Other studies have shown similar increases in cardiac, neurological and renal morbidity associated with transfusion in cardiac surgery [1,7].The question as to whether transfusion causes adverse outcome in cardiac surgery remains unanswered, however. The Rogers study suffers from the limitations of all retrospective studies in that it cannot adjust for unmeasured confounders, in this case the use of aprotinin, or a measure of left ventricular function, or for the likelihood that there will have been bias in the prescribing of allogenic blood, with patients who
The effect on coagulation parameters of the transfusion of cell saved blood after cardiac surgery
V Bates, JMT Pierce, RS Gill, D O'Shaughnessy
Critical Care , 2001, DOI: 10.1186/cc1035
Abstract: Following Regional Ethical Committee approval and written informed patient consent, 50 patients undergoing elective cardiac surgery were recruited. Cardiac anaesthesia, surgery and perfusion were conducted according to institutional protocols. CPB incorporated a Dideco D903 oxygenator (Dideco S.p.A., Modena, Italy) with integral heat exchanger primed with 2 l Hartmann's solution. IOCS was performed with a Dideco Compact Advanced Cell Saver. All shed mediastinal blood prior to heparinization and following protamine reversal was salvaged in addition to the CPB residue after the termination of CPB. Blood samples were drawn prior to incision (T1), 5 min after protamine reversal of heparin (T2) and 15 min after retransfusion of IOCS blood (T3), and analysed for ionised calcium, albumin, international normalized ratio, activated partial thromboplastin time ratio, factors VII and IX, fibrinogen, antithrombin, activated protein C, platelet count, haemoglobin, packed cell volume (PCV) and thromboelastogram. IOCS blood was analysed in five patients. Statistical analysis used the appropriate parametric and nonparametric tests. Significance was taken at the 5% level.Nine patients were given intraoperative blood or blood products and were excluded from further analysis. Of the remaining 41 patients (mean age 64.6 years and mean weight 84 kg), 35 were male. Mean CPB was 74 min and mean cross clamp was 46 min. The median volume of IOCS was 613 ml (7.3 ml/kg). There were almost undetectable amounts of coagulation factors present in IOCS blood. Table 1 presents the coagulation data.IOCS blood in routine cardiac surgical practice raises the PCV to a point at which red cell transfusion is not necessary. There are no deleterious effects on coagulation. We recommend its routine use. To minimize unnecessary exposure to blood products, where transfusion is protocol driven, coagulation studies should follow IOCS blood transfusion.This work was supported by a Haematology Educational Grant.
A survey of blood transfusion practice in UK cardiac surgery units
SF Moise, MJ Higgins, AD Colquhoun
Critical Care , 2001, DOI: 10.1186/cc982
Abstract: Glasgow Royal Infirmary data were analyzed on the basis of percentage of unnecessary transfusions performed. An unnecessary transfusion was defined as having occurred in patients with a discharge haemoglobin of = 11 g/dl transfused one unit of blood or with a discharge haemoglobin of = 12 g/dl transfused two or more units. The questionnaire was sent, in the form of an electronic document, to 41 cardiac units. Only paediatric units were then excluded. Units were also requested to supply data sets on 20 first time coronary artery bypass grafts (CABGs). This was the number thought to be achievable by most units.At the Glasgow Royal Infirmary, by fiscal year from April 1996 to March 1999, 79, 81 and 80% of all cardiac surgery patients received blood and 26, 22 and 26% of those transfused received unnecessary units of blood. The response to the questionnaire was 43.6% (17 out of 39) of units; 31% (12 out of 39) supplied data sets. Twelve out of 17 units have blood transfusion guidelines; these were sometimes followed in seven and usually followed in five units. Eight out of 17 units have audit, and three of these felt that this had resulted in a reduction in blood use. Seven out of 17 hospitals have guidelines but do not have ongoing audit. The percentage of CABGs transfused ranged between 20 and 95%. Units agreed that there was no evidence on which to base transfusion triggers, but most units accept haemoglobin above 8-9 g/dl during and after intensive care unit treatment. In the data sets, there was no significant difference between units in age, weight and height of patients. For haemoglobin at admission and discharge, there were significant differences between units (P = 000.1 and P = 0.00004, respectively, by analysis of variance). The average haemoglobin at admission ranged between 12.4 and 14.8 g/dl, and at discharge it ranged between 9.8 and 11.4 g/dl. Combining the 11 groups for which discharge haemoglobin was supplied (ie 220 patients), 52% of all patients rece
Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery  [cached]
Scott Bharathi,Seifert Frank,Grimson Roger
Annals of Cardiac Anaesthesia , 2008,
Abstract: The purpose of the present investigation was to examine the impact of blood transfusion on resource utilisation, morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery at a major university hospital. The resources we examined are time to extubation, intensive care unit length of stay (ICULOS) and postoperative length of stay (PLOS). We further examined the impact of number of units of packed red blood cells (PRBCs) transfused during PLOS. This is a retrospective observational study and includes 1746 consecutive male and female patients undergoing primary CABG (on- and off-pump) at our institution. Of these, 1067 patients received blood transfusions, while 677 did not. The data regarding the demography, blood transfusion, resource utilisation, morbidity and mortality were collected from the records of patients undergoing CABG over a period of three years. The mean time to extubation following surgery was 8.0 h for the transfused group and 4.3 h for the nontransfused group ( P ≤ 0.001). The mean ICULOS for the transfused group was 1.6 d and 1.2 d for the nontransfused group ( P < 0.001). The PLOS was 7.2 d for the transfused group and 4.3 d for no-transfused cohorts ( P ≤ 0.001). In all patients and in patients with no preoperative morbidity, partial correlation coefficients were used to examine the effects of transfusion on mortality, time to extubation, ICULOS and PLOS. Linear regression model was used to assess the effect of number of PRBC units transfused on PLOS. We noted that PLOS increased with the number of PRBCs units transfused. Transfusion is significantly correlated with the increased time to extubation, ICULOS, PLOS and mortality. The transfused patients had significantly more postoperative complications than their nontransfused counterparts ( P ≤ 0.001). The 30-day hospital mortality was 3.1% for the transfused group with no deaths in the nontransfused group ( P ≤ 0.001). We conclude that the CABG patients receiving blood transfusion have significantly longer time for tracheal extubation, ICULOS, PLOS and higher morbidity and 30-day hospital mortality. Blood transfusion was an independent predictor of increased resource utilisation, postoperative morbidity and mortality.
Blood transfusion during cardiac surgery is associated with inflammation and coagulation in the lung: a case control study
Pieter R Tuinman, Alexander P Vlaar, Alexander D Cornet, Jorrit J Hofstra, Marcel Levi, Joost CM Meijers, Albertus Beishuizen, Marcus J Schultz, AB Johan Groeneveld, Nicole P Juffermans
Critical Care , 2011, DOI: 10.1186/cc10032
Abstract: We performed a case control study in a mixed medical-surgical intensive care unit of a university hospital in the Netherlands. Cardiac surgery patients (n = 45) were grouped as follows: those who received no transfusion, those who received a restrictive transfusion (one two units of blood) or those who received multiple transfusions (at least five units of blood). Nondirected bronchoalveolar lavage fluid (BALF) and blood were obtained within 3 hours postoperatively. Normal distributed data were analyzed using analysis of variance and Dunnett's post hoc test. Nonparametric data were analyzed using the Kruskal-Wallis and Mann-Whitney U tests.Restrictive transfusion increased BALF levels of interleukin (IL)-1β and D-dimer compared to nontransfused controls (P < 0.05 for all), and IL-1β levels were further enhanced by multiple transfusions (P < 0.01). BALF levels of IL-8, tumor necrosis factor α (TNFα) and thrombin-antithrombin complex (TATc) were increased after multiple transfusions (P < 0.01, P < 0.001 and P < 0.01, respectively) compared to nontransfused controls, but not after restrictive transfusions. Restrictive transfusions were associated with increased pulmonary levels of plasminogen activator inhibitor 1 compared to nontransfused controls with a further increase after multiple transfusions (P < 0.001). Concomitantly, levels of plasminogen activator activity (PAA%) were lower (P < 0.001), indicating impaired fibrinolysis. In the systemic compartment, transfusion was associated with a significant increase in levels of TNFα, TATc and PAA% (P < 0.05).Transfusion during cardiac surgery is associated with activation of inflammation and coagulation in the pulmonary compartment of patients who do not meet TRALI criteria, an effect that was partly dose-dependent, suggesting transfusion as a mediator of acute lung injury. These pulmonary changes were accompanied by systemic derangement of coagulation.Blood transfusion can be a lifesaving intervention. However, it is in
Red blood cell transfusion after cardiac surgery does not result in improvement of tissue perfusion in adult patients
F Galas, JL Vincent, J Fukushima, R Nakamura, R Kalil Filho, F Jatene, JOC Auler, L Hajjar
Critical Care , 2011, DOI: 10.1186/cc10154
Abstract: From February 2009 to February 2010, a total of 502 patients underwent cardiac surgery with cardiopulmonary bypass at InCor - University of S?o Paulo. Arterial lactate, standard base deficit (SBD), arterial bicarbonate and oxygen central venous saturation (ScVO2) were collected immediately at the beginning and end of the procedure, immediately postoperative (POI), after 24 hours (1PO), 48 hours (2PO), 72 hours (3PO) and at ICU discharge. Mean values of these above-mentioned parameters were compared in patients exposed to RBC transfusions and patients not exposed through repeated-measures variance analysis.Hemoglobin values were different between groups since before surgery until just before ICU discharge and in all periods, the group not exposed to RBC transfusions presented higher values compared with the exposed group (see Figure 1 overleaf).In this prospective study, red blood transfusion did not result in improvement of tissue perfusion parameters. This finding brings to discussion the real role of blood transfusion in cardiac patients.
Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial
George Vretzakis, Athina Kleitsaki, Konstantinos Stamoulis, Metaxia Bareka, Stavroula Georgopoulou, Menelaos Karanikolas, Athanasios Giannoukas
Journal of Cardiothoracic Surgery , 2010, DOI: 10.1186/1749-8090-5-7
Abstract: 192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups.137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion.Our data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients.NCT00600704, at the United States National Institutes of Health.Cardiac surgery is a major blood product consumer. Data from many studies suggest that blood transfusions are associated with increased morbidity and mortality in cardiac surgery [1,2]. Howev
Are antifibrinolytic drugs equivalent in reducing blood loss and transfusion in cardiac surgery? A meta-analysis of randomized head-to-head trials
Paul A Carless, Annette J Moxey, Barrie J Stokes, David A Henry
BMC Cardiovascular Disorders , 2005, DOI: 10.1186/1471-2261-5-19
Abstract: Studies were identified by searching electronic databases and bibliographies of published articles. Data from head-to-head trials were pooled using a conventional (Cochrane) meta-analytic approach and a Bayesian approach which estimated the posterior probability of TXA and EACA being equivalent to aprotinin; we used as a non-inferiority boundary a 20% increase in the rates of transfusion or re-operation because of bleeding.Peri-operative blood loss was significantly greater with TXA and EACA than with aprotinin: weighted mean differences were 106 mls (95% CI 37 to 227 mls) and 185 mls (95% CI 134 to 235 mls) respectively. The pooled relative risks (RR) of receiving an allogeneic red blood cell (RBC) transfusion with TXA and EACA, compared with aprotinin, were 1.08 (95% CI 0.88 to 1.32) and 1.14 (95% CI 0.84 to 1.55) respectively. The equivalent Bayesian posterior mean relative risks were 1.15 (95% Bayesian Credible Interval [BCI] 0.90 to 1.68) and 1.21 (95% BCI 0.79 to 1.82) respectively. For transfusion, using a 20% non-inferiority boundary, the posterior probabilities of TXA and EACA being non-inferior to aprotinin were 0.82 and 0.76 respectively. For re-operation the Cochrane RR for TXA vs. aprotinin was 0.98 (95% CI 0.51 to 1.88), compared with a posterior mean Bayesian RR of 0.63 (95% BCI 0.16 to 1.46). The posterior probability of TXA being non-inferior to aprotinin was 0.92, but this was sensitive to the inclusion of one small trial.The available data are conflicting regarding the equivalence of lysine analogues and aprotinin in reducing peri-operative bleeding, transfusion and the need for re-operation. Decisions are sensitive to the choice of clinical outcome and non-inferiority boundary. The data are an uncertain basis for replacing aprotinin with the cheaper lysine analogues in clinical practice. Progress has been hampered by small trials and failure to study clinically relevant outcomes.Excessive peri-operative bleeding during cardiac surgery involving c
Autologous Transfusion in Cardiac Surgery
Radmehr H,Mirkhani S H,Sanatkar Far M,Soltatii-Nia H
Tehran University Medical Journal , 2003,
Abstract: Preoperative autologous blood donation is commonly used to reduce exposure to homologous blood transfusions among patients undergoing elective cardiac surgery. The aim of this study was to evaluate the effect of autologous transfusion on patients' hematocryte value, intra and postoperative blood loss, hospitalization time, the development of infective complications and other factors. Materials and Methods: Between June 2001 to April 2002, 208 patients were underwent cardiac surgery in cardiac surgery ward in Imam Khomeini Medical Center. One or more blood units donate from 104 Patients before cardiopulmonary bypass and heparin injection, and transfused to them after CPB and Protamin injection (autologous Group, group 1). 104 patients underwent cardiac surgery routinely (control group, group 2)."nResults: Mean of age was 55.9±8.6 in group 1 and 56.6±9.3 in group 2 (P=NS). 73 male and 31 females were in group 1 and 79 males and 25 females were in group 2 (P=NS). Smoking, familial history, hyperlipidemia, diabetes mellitus, renal failure, hypertension, stroke, and history of myocardial infarction was similar in two groups."nSeverity of angina, urgency operation, number vessels disease, duration of cardiopulmonary bypass, duration of aortic cross clamp time, use of internal thoracic artery graft, and number of grafts was similar in both groups. Mean of bleeding post operation was 548 cc in group 1 and 803 cc in-group 2 (P=0.003). Bleeding that need to operation was 1.8% in group 1 and 8.6% in group 2 (P=0.002). Wound infection, mediastinitis, renal failure, ventilatory prolonged, stroke, need to Intra-aortic Balloon Pump (IABP), intraoperative bleeding, and hospital stay was similar in both groups. Mean of extubationt time was 10.2 hours in group 1 and 14.8 hours in group 2 (P=0.001)."nConclusion: Preoperative and intra-operative donations are safe and continue to contribute uniquely to blood conservation, providing important options in comprehensive blood conservation programs in current pediatric open-heart surgery."n"n"n"n"n"n"n
Blood Transfusion in Surgery in Africa
P Jani, A Howard
East and Central African Journal of Surgery , 2011,
Abstract: Many changes have occurred in transfusion practices in Africa and in Western countries since this topic was first reviewed in 2005. Blood transfusion remains a key component in the resuscitation of surgical patients suffering, whether from operative losses, trauma, GI bleeding, or obstetrics. Nothing has replaced the lifesaving potential of appropriate transfusion. Increased clinical evidence surrounding appropriateness of transfusion, increased understanding of the risks of transfusion, and better ways of managing these risks have been active topics of discussion in the literature since 2005 and will be addressed in this review.
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