Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery

Safety of recombinant activated factor VII in randomized clinical trials

BACKGROUND

The use of recombinant activated factor VII (rFVIIa) on an off-label basis to treat life-threatening bleeding has been associated with a perceived increased risk of thromboembolic complications. However, data from placebo-controlled trials are needed to properly assess the thromboembolic risk. To address this issue, we evaluated the rate of thromboembolic events in all published randomized, placebo-controlled trials of rFVIIa used on an off-label basis.

METHODS

We analyzed data from 35 randomized clinical trials (26 studies involving patients and 9 studies involving healthy volunteers) to determine the frequency of thromboembolic events. The data were pooled with the use of random-effects models to calculate the odds ratios and 95% confidence intervals.

RESULTS

Among 4468 subjects (4119 patients and 349 healthy volunteers), 401 [corrected] had thromboembolic events (9.0%). [corrected] Rates of arterial thromboembolic events among all 4468 subjects were higher among those who received rFVIIa than among those who received placebo (5.5% vs. 3.2%, P=0.003). Rates of venous thromboembolic events were similar among subjects who received rFVIIa and those who received placebo (5.3% vs. 5.7%). Among subjects who received rFVIIa, 2.9% had coronary arterial thromboembolic events, as compared with 1.1% of those who received placebo (P=0.002). Rates of arterial thromboembolic events were higher among subjects who received rFVIIa than among subjects who received placebo, particularly among those who were 65 years of age or older (9.0% vs. 3.8%, P=0.003); the rates were especially high among subjects 75 years of age or older (10.8% vs. 4.1%, P=0.02).

CONCLUSIONS

In a large and comprehensive cohort of persons in placebo-controlled trials of rFVIIa, treatment with high doses of rFVIIa on an off-label basis significantly increased the risk of arterial but not venous thromboembolic events, especially among the elderly. (Funded by Novo Nordisk.).

Video-Assisted Minimally Invasive Mitral Valve Surgery External Aortic Clamp versus Endoclamp Techniques

Objective

Video-assisted minimally invasive mitral valve surgery can be performed through different approaches. The aim of the study was to report our early results and compare the external transthoracic aortic clamping with the endoaortic balloon occlusion techniques according to our experience.

Methods

Between January 2000 and March 2010, 138 patients (103 women, aged 58.4 ± 10.2 years) underwent video-assisted mitral valve surgery through a right thoracotomy. Cardiopulmonary bypass was instituted by femoral arterial and bicaval cannulation with active venous drainage and normothermia; cardioplegic arrest achieved with intermittent blood cardioplegia. In group A (93 patients, 68 women, aged 58.8 ± 7.8 years, 72 MV replacement, 21 MV repair), aortic clamping was achieved using the external transthoracic aortic clamp. In group B (45 patients, 35 women, aged 58.1 ± 11.4 years, 33 MV replacement, 12 MV repair), aortic clamping was achieved with endoaortic balloon occlusion.

Results

Intraoperative procedure-associated problems were experienced in one patient (0.7%) in group A (one conversion to sternotomy for pleural adhesions and bad exposure). At a mean follow-up of 36 ± 18 months, 135 patients (97.8%) were in New York Heart Association class I to II, with satisfactory echocardiographic follow-up. In group A, two patients had noncardiac-related deaths. No perioperative deaths were observed in both groups. There were four (2.8%) transient ischemic attacks and one (0.7%) peripheral ischemic event (group A) during the early postoperative period. Mitral valve repair patients had a 5-year freedom from reoperation of 100% in both groups. There was no significant difference between the two groups regarding preoperative variables, such as age, sex, New York Heart Association class, and left ventricular ejection fraction (P ≥ 0.05). Postoperative levels of myocardial cytonecrosis enzymes (MB fraction, creatine kinase, and troponine I) as well as operative time, extracorporeal circulation, and aortic cross-clamping times or ventilation and intensive care unit times were not significantly different between the two groups (P ≥ 0.05). More microembolic events were observed in group A than in group B (total 143.4 ± 30.6 per patient vs 78.9 ± 28.6 per patient) by means of continuous automated intraoperative transcranial Doppler evaluations (P < 0.05) applied to part of population.

Conclusions

Both techniques proved safe and comparable with low risk of morbidity and mortality. Patients undergoing endoclamp technique resulted to be less subject to embolism.

Transfusion practice in hip arthroplasty--a nationwide study

BACKGROUND AND OBJECTIVES

The optimal transfusion strategy in hip arthroplasty remains controversial despite existing guidelines. The aim of this study was to evaluate the transfusion practice in patients undergoing primary total hip arthroplasty (THA) or revision total hip arthroplasty (RTHA) in Denmark.

MATERIALS AND METHODS

We performed a retrospective cohort study of all patients undergoing THA or RTHA in Denmark in 2008. Primary outcomes were intercentre variation in red blood cell (RBC) transfusion rates and the timing of transfusion related to surgery.

RESULTS

Six thousand nine hundred thirty-two THA patients and 1132 RTHA patients were included for analysis of which 1674 (24%) THA and 689 (61%) RTHA patients received RBC transfusion. Of these, 47% of THA and 73% of RTHA patients received transfusion on the day of surgery. Transfusion rates between centres varied from 7 to 71% and between 26 and 85% in THA and RTHA patients, respectively. Patients receiving RBC transfusion had longer length of stay and for THA patients an increased odds-ratio (5·5) of death within 90 days.

CONCLUSION

Despite established guidelines, RBC transfusion practice in hip arthroplasty remains highly variable between Danish hospitals. The effect of RBC transfusion on outcome after hip arthroplasty should be established in prospective randomized controlled trials.

Association of allogeneic red-blood cell transfusion with surgeon case-volume

BACKGROUND

Surgeon case-volume predicts a variety of patient outcomes. We hypothesize that surgeon case-volume predicts RBC transfusion across different surgical procedures.

METHODS

We performed a cohort study of 372,670 in-patient surgical cases in the 52 non-federal hospitals in Maryland between 2004 and 2005. The main outcome measure was relative risk of receiving a transfusion.

RESULTS

Overall, 13.9% of patients received a transfusion. Patients seen by the highest case-volume surgeons (>161 cases/y) were more likely to receive a transfusion (16% versus 11%, P < 0.01) compared with middle case-volume surgeons (89-161 cases/y). After adjusting for confounders, the highest case-volume patients were still at increased risk of transfusion [relative risk (RR) 1.10, 1.07-1.14]. This result was true across many surgery types.

CONCLUSIONS

Surgeon case-volume is independently associated with the likelihood of RBC transfusion across a broad range of surgical procedures. Future efforts should be directed towards studying and standardization of transfusion practices.

Off-pump Coronary Artery Bypass is a Safe Option in Patients Presenting as Emergency

Introduction: The applicability of off-pump coronary-artery bypass (OPCAB) in patients who present as emergency remains controversial. Herein, we explore the efficacy and safety of OPCAB in patients who were indicated for emergency surgery. Materials and Methods: Between 2002 and 2007, a total of 282 patients underwent OPCAB, of which 68 were presented as emergency. This cohort (group A) was compared to 68 patients who had traditional on-pump coronary artery bypass grafting (CABG, group B) under emergency indications during the same period of time. Baseline demographics, intraoperative data and postoperative outcomes were analysed. Results: Preoperative demographics were comparable in both groups. Mortality during the first 30 days was comparable in both groups and no stroke occurred in the whole series. Patients in group A had significantly less pulmonary complications (4.4% vs 14.7%, P= 0.04), less ventilation time (30.3 ± 33.6 hours vs 41.5 ± 55.4 hours, P = 0.18) and were less likely to have prolonged ventilation, (19.1% vs 35.3%, P = 0.03). Similarly, OPCAB patients had less postoperative renal-failure/dysfunction (5.9% vs 8.8%, P = 0.51) and required less inotropic support (66.2% vs 88.2%, P = 0.002), bloodtransfusions (23% vs 86.8%, P <0.0001), and atrial- (17.6% vs 35.3%, P = 0.02) or ventricular-pacing (17.6% vs 41.2%, P = 0.002). Although the number of diseased vessels was comparable in both groups, patients in group A received less distal anastomoses. (2.78 ± 1.19 vs 3.41 ± 0.89, P = 0.002). Similarly, complete revascularisation was achieved less frequently in group A (76.5% vs 94.1%, P = 0.004). Conclusion: OPCAB strategy is a safe and efficient in emergency patients with reasonable good short-term postoperative outcomes. Keywords: Cardiac surgery, Coronary artery disease, Off-pump coronary-artery bypass

State-of-the-Art Review: Hemostats, Sealants, and Adhesives II: Update As Well As How and When to Use the Components of the Surgical Toolbox

The goal of this submission is to describe how and when to best use hemostats, sealants, and adhesives as well as to compare their characteristics and to update the surgical toolbox with respect to any new products approved by the Food and Drug Administration (FDA) as of this date (November 2009). The materials will be presented in 3 major groups each containing specific categories: (1) hemostats; mechanical, active, flowable, and fibrin sealant, (2) sealants; fibrin sealant, polyethylene glycol polymer, and albumin and glutaraldehyde, (3) adhesives; cyanoacrylate, albumin and glutaraldehyde, and fibrin sealant. The categories will be used for comparisons based on safety, efficacy, usability, and cost. Recommendations with respect to how and when to best use these materials will be presented. A review of the recent literature is also provided with respect to the most recent uses of these materials in specific surgical specialties.

The use of percutaneous ECMO support as a 'bridge to bridge' in heart failure patients: a case report

A 65-year-old male with a known history of ischemic cardiomyopathy was admitted to the intensive care unit in cardiogenic shock. Cardiac catheterization revealed bi-ventricular hypokinesis, with an estimated ejection fraction of 15%. Despite moderate inotropic support, the patient's liver enzymes, international normalization ratio (INR), and creatinine became grossly elevated, indicating multi-organ injury from hypoperfusion. Due to the patient's state of shock and probable bleeding complications, a full sternotomy and emergent biventricular assist device insertion was deemed very high risk. In order to achieve hemodynamic stability, a decision was made for extracorporeal membrane oxygenation (ECMO) support. ECMO support was quickly initiated by percutaneous cannulation of the femoral vein and artery. The ECMO circuit was comprised of a Centrimag blood pump and Quadrox-D Safeline-coated membrane oxygenator. With successful perfusion and organ resuscitation, abnormal liver function tests, INR, and creatinine all returned to normal in less than one week. With normal organ function, especially the liver, the patient successfully underwent an implantable left ventricular assist device, HeartMate II LVAD, without requiring mechanical right heart support. Prior to ECMO, the patient was at very high risk of needing biventricular support. Thus, the temporary use of ECMO allowed for a safer and more durable bridge to transplantation. The use of percutaneous ECMO has many advantages, including improving the patient condition and allowing for time to evaluate fully the LVAD patient.

Operative blood loss, blood transfusion, and 30-day mortality in older patients after major noncardiac surgery

OBJECTIVE

Anemia and operative blood loss are common in the elderly, but evidence is lacking on whether intraoperative blood transfusions can reduce the risk of postoperative death.

METHODS

We analyzed retrospective data from 239,286 patients 65 years of older who underwent major noncardiac surgery in 1997 to 2004 at veteran hospitals nationwide. Propensity-score matching was used to adjust for differences between patients who received intraoperative blood transfusions (9.4%) and those who did not, and data were used to determine the association between intraoperative blood transfusion and 30-day postoperative mortality.

RESULTS

After propensity-score matching, intraoperative blood transfusion was associated with mortality risk reductions in patients with preoperative hematocrit levels of <24% (odds ratio: 0.60, 95% CI: 0.41-0.87), and in patients with hematocrit of 30% or greater when there is substantial (500-999 mL) blood loss (odds ratio: 0.35, 95% CI: 0.22-0.56 for hematocrit levels between 30%-35.9% and 0.78, 95% CI: 0.62-0.97 for hematocrit levels of 36% or greater). When operative blood loss was <500 mL, transfusion was not associated with mortality reductions for patients with hematocrit levels of 24% or greater, and conferred increased mortality risks in patients with preoperative hematocrit levels between 30% to 35.9% (odds ratio 1.29, 95% CI: 1.04-1.60).

CONCLUSIONS

Intraoperative blood transfusion is associated with a lower 30-day postoperative mortality among elderly patients undergoing major noncardiac surgery if there is substantial operative blood loss or low preoperative hematocrit levels (<24%). Transfusion is associated with increased mortality risks for those with preoperative hematocrit levels between 30% and 35.9% and <500 mL of blood loss.

Outcomes in perioperative care

PURPOSE OF REVIEW

The present review examines the trends and controversies on how perioperative care can influence outcome after anesthesia and surgery.

RECENT FINDINGS

Recent studies indicate that anesthesia and perioperative care may have a major impact on long-term postoperative mortality and major complications in surgical patients by decreasing the rate of individual decisions. The use of a surgical checklist in the operating room improves postoperative mortality by decreasing the rate of individual decisions and facilitating communication between anesthesiologists, surgeons and intensivists. Antiplatelet therapy should not be discontinued routinely before elective surgery in patients with coronary or vascular occlusive disease. Attenuation of the surgical stress response by beta-blockers decreases long-term major adverse cardiac events, but may increase the incidence of postoperative stroke. The long-term impact on outcome of tight glycemic control and intraoperative hemodynamic optimization requires further investigation.

SUMMARY

The use of a surgical checklist may reduce postoperative mortality and complications in surgical patients. The optimal dosing and timing of perioperative beta-blockade should decrease the incidence of postoperative stroke. However, to date, the long-term risk:benefit balance of attenuation of the perioperative stress response remains controversial. Red cell transfusion is unavoidable in some cases, but is associated with worsened outcome in various surgical situations. Future research should focus on the risk:benefit balance of anesthesia and surgery. This will contribute to promoting the role of anesthesiologists as physicians of the perioperative period.

Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) accounts for 14% of RBC units transfused in the UK. In exsanguinating AUGIB the value of RBC transfusion is self evident, but in less severe bleeding its value is less obvious.

AIM

To examine the relationship between early RBC transfusion, re-bleeding and mortality following AUGIB, which is one of the most common indications for red blood cell (RBC) transfusion.

METHOD

Data were collected on 4441 AUGIB patients presenting to UK hospitals. The relationship between early RBC transfusion, re-bleeding and death was examined using logistic regression.

RESULTS

44% were transfused RBCs within 12 hours of admission. In patients transfused with an initial haemoglobin of <8 g/dl, re-bleeding occurred in 23% and mortality was 13% compared with a re-bleeding rate of 15%, and mortality of 13% in those not transfused. In patients transfused with haemoglobin >8 g/dl, re-bleeding occurred in 24% and mortality was 11% compared with a re-bleeding rate of 6.7%, and mortality of 4.3% in those not transfused. After adjusting for Rockall score and initial haemoglobin, early transfusion was associated with a two-fold increased risk of re-bleeding (Odds ratio 2.26, 95% CI 1.76-2.90) and a 28% increase in mortality (Odds ratio 1.28, 95% CI 0.94-1.74).

CONCLUSIONS

Early RBC transfusion in AUGIB was associated with a two-fold increased risk of re-bleeding and an increase in mortality, although the latter was not statistically significant. Although these findings could be due to residual confounding, they indicate that a randomized comparison of restrictive and liberal transfusion policies in AUGIB is urgently required.

Perfusion vs. oxygen delivery in transfusion with "fresh" and "old" red blood cells: the experimental evidence

We review the experimental evidence showing systemic and microvascular effects of blood transfusions instituted to support the organism in extreme hemodilution and hemorrhagic shock, focusing on the use of fresh vs. stored blood as a variable. The question: "What does a blood transfusion remedy?" was analyzed in experimental models addressing systemic and microvascular effects showing that oxygen delivery is not the only function that must be addressed. In extreme hemodilution and hemorrhagic shock blood transfusions simultaneously restore blood viscosity and oxygen carrying capacity, the former being critically needed for re-establishing a functional mechanical environment of the microcirculation, necessary for obtaining adequate capillary blood perfusion. Increased oxygen affinity due to 2,3 DPG depletion is shown to have either no effect or a positive oxygenation effect, when the transfused red blood cells (RBCs) do not cause additional flow impairment due to structural malfunctions including increased rigidity and release of hemoglobin. It is concluded that fresh RBCs are shown to be superior to stored RBCs in transfusion, however increased oxygen affinity may be a positive factor in hemorrhagic shock resuscitation. Although experimental studies seldom reproduce emergency and clinical conditions, nonetheless they serve to explore fundamental physiological mechanisms in the microcirculation that cannot be directly studied in humans.

Surgical site infection after osteotomy of the adult spine: does type of osteotomy matter?

BACKGROUND CONTEXT

Surgical site infection after spinal surgery is frequently seen. It occurs between 0.7% and 12% of patients, leading to higher morbidity, mortality, and health-care costs. Osteotomy procedures are known to have increased blood losses and surgical times when compared with other spinal surgeries. Both of these factors have previously been identified as significant risk factors for SSI. We performed a cohort study of this high-risk population to identify risk factors and rates of SSI after spinal osteotomy surgery and identify difference in risk between different types of osteotomies.

PURPOSE

The objective of the study was to assess the incidence and identify significant risk factors for surgical site infection (SSI) after spinal osteotomy.

STUDY DESIGN

Retrospective review of all adult patients who underwent spinal osteotomy surgery for deformity by an orthopedic surgeon in our university.

METHODS

All electronic records of adult orthopedic patients whom underwent a spinal osteotomy procedure at our department between January 1998 and December 2005 (n=363) were abstracted. During surgery, a pedicle subtraction osteotomy (transpedicular wedge resection), anterior spine osteotomy (resection of anterior and middle columns), posterior Smith-Petersen osteotomy (resection of a portion of the superior and inferior lamina, ligamentum flavum, and the inferior and superior articular processed), or a combined anterior and posterior osteotomy (vertebral column resection [VCR]) (circumferential resection of the vertebrae via either a combined anterior/posterior or posterior-only approach) was performed. Primary outcome measurement was SSI. Subanalysis to deep and superficial SSI was performed.

RESULTS

Twenty patients (5.5%) were found to have an SSI, with nine (2.5%) having deep SSI. Analysis showed that patients undergoing VCR (p=.042) had a significant increased risk for deep SSI (11.1%). Obese patients had a significant increased risk (p=.045) for superficial SSI.

CONCLUSIONS

Vertebral column resection has a significant increased risk for SSI (11.1%) compared with other types of osteotomies (4.1%). When possible, osteotomy techniques that involve less extensive exposures and soft-tissue dissection should be chosen to minimize deep SSI risk. Obese patients should be counseled on weight loss to try minimizing superficial SSI risk.

Red blood cell storage duration and mortality in patients undergoing percutaneous coronary intervention

BACKGROUND

Blood transfusion has been associated with an increased mortality in patients undergoing percutaneous coronary intervention (PCI). Although the reasons for this remain unclear, it may be related to the structural and functional changes occurring within red blood cells (RBCs) during storage. We investigated whether RBC storage duration was associated with mortality in patients requiring transfusion after PCI.

METHODS

We collected data on all RBC transfusions occurring within 10 days of PCI (excluding those related to cardiac surgery) using the British Columbia Cardiac Registry and Central Transfusion Registry. Transfusion details were analyzed according to 30-day survival.

RESULTS

From a total of 32,580 patients undergoing PCI, 909 (2.8%) patients received RBCs with a mean storage duration of 25 +/- 10 days. In these 909 patients, mean transfusion volumes were lower in survivors (2.8 +/- 2.1 vs 3.8 +/- 2.9 U, P = .002) than those who died within 30 days. In a multivariate analysis to adjust for baseline risk, mean RBC storage age (HR 1.02 [95% CI 1.01-1.04], P = .002) and transfusion volume (HR 1.26 [95% CI 1.18-1.34], P < .001) both predicted 30-day mortality. Transfused patients who received only older blood (RBC min age >28 days) appeared to be at greater risk of death (HR 2.49 [95% CI 1.45-4.25], P = .001).

CONCLUSION

Red blood cell transfusion is associated with increased 30-day mortality in patients undergoing PCI. Although current transfusion practice permits RBC storage for up to 42 days, the use of older red cells may pose an additional hazard to this patient group.

Blood still kills: six strategies to further reduce allogeneic blood transfusion-related mortality

After reviewing the relative frequency of the causes of allogeneic blood transfusion-related mortality in the United States today, we present 6 possible strategies for further reducing such transfusion-related mortality. These are (1) avoidance of unnecessary transfusions through the use of evidence-based transfusion guidelines, to reduce potentially fatal (infectious as well as noninfectious) transfusion complications; (2) reduction in the risk of transfusion-related acute lung injury in recipients of platelet transfusions through the use of single-donor platelets collected from male donors, or female donors without a history of pregnancy or who have been shown not to have white blood cell (WBC) antibodies; (3) prevention of hemolytic transfusion reactions through the augmentation of patient identification procedures by the addition of information technologies, as well as through the prevention of additional red blood cell alloantibody formation in patients who are likely to need multiple transfusions in the future; (4) avoidance of pooled blood products (such as pooled whole blood-derived platelets) to reduce the risk of transmission of emerging transfusion-transmitted infections (TTIs) and the residual risk from known TTIs (especially transfusion-associated sepsis [TAS]); (5) WBC reduction of cellular blood components administered in cardiac surgery to prevent the poorly understood increased mortality seen in cardiac surgery patients in association with the receipt of non-WBC-reduced (compared with WBC-reduced) transfusion; and (6) pathogen reduction of platelet and plasma components to prevent the transfusion transmission of most emerging, potentially fatal TTIs and the residual risk of known TTIs (especially TAS).

Dual antiplatelet therapy in patients requiring urgent coronary artery bypass grafting surgery: a position statement of the Canadian Cardiovascular Society

Acute coronary syndrome (ACS) guidelines recommend that most patients receive dual antiplatelet therapy with clopidogrel and acetylsalicylic acid (ASA) at the time of presentation to prevent recurrent ischemic events. Approximately 10% of ACS patients require coronary artery bypass grafting surgery (CABG) during the index admission. Most studies show that patients who receive ASA and clopidogrel within five days of CABG have an increase in operative bleeding. Current consensus guidelines recommend discontinuation of clopidogrel therapy at least five days before planned CABG to reduce bleeding-related events. However, high-risk individuals may require urgent surgery without delay, to reduce the risk of potentially fatal ischemic events. The present multidisciplinary position statement provides evidence- based recommendations for the optimal use of dual antiplatelet therapy to balance ischemic and bleeding risks in patients with recent ACS who may require urgent CABG.

RECOMMENDATIONS

1. All ACS patients should be considered for dual antiplatelet therapy with ASA and clopidogrel at the earliest opportunity, despite the possibility of a need for urgent CABG. 2. For patients who have received clopidogrel and ASA, and require CABG: * Those at high risk of an early fatal event (eg, with refractory ischemia despite optimal medical treatment, and with high-risk coronary anatomy (eg, severe left main stenosis with severe right coronary artery disease), should be considered for early surgery without discontinuation of clopidogrel. * In patients with a high bleeding risk (eg, previous surgery, complex surgery) who are also at high risk for an ischemic event, consideration should be given to discontinuing clopidogrel for three to five days before surgery. * Patients at a lower risk for ischemic events (most patients) should have clopidogrel discontinued five days before surgery. 3. For patients who have CABG within five days of receiving clopidogrel and ASA, the risk of major bleeding and transfusion can be minimized by applying multiple strategies before and during surgery. 4. Patients who receive clopidogrel pre-CABG for a recent ACS indication should have clopidogrel restarted after surgery to decrease the risk of recurrent ACS. 5. For patients with a recent coronary stent, the decision to continue clopidogrel until the time of surgery or to discontinue will depend on the risk and potential impact of stent thrombosis. Restarting clopidogrel after CABG will depend on whether the stented vessel was revascularized, the type of stent and the time from stent implantation. Clopidogrel should be restarted when hemostasis is assured to prevent recurrent acute ischemic events.

Survival and length of stay following blood transfusion in octogenarians following cardiac surgery

Our aim was to assess if peri-operative blood transfusion is an independent risk factor for mortality and morbidity in the elderly. We report the results of a cohort study of all patients aged 80 or more on the day of their emergency or elective cardiac surgery (n = 874), using routinely collected data from January 2003 to November 2007. The primary outcome was all-cause mortality in hospital. The secondary outcomes were duration of stay in the intensive care unit (ICU) and overall hospital stay. Confounding variables were used to build up a risk model using a multivariable logistic regression analysis, and blood transfusion was added to assess whether it had additional predictive value for hospital mortality. Patients were divided into three groups: (i) transfusion of 0-2 units of red blood cells; (ii) transfusion of > 2 units of red blood cells and (iii) transfusion of red blood cells plus other clotting products. The strongest independent predictors of hospital death were logistic EuroSCORE and body mass index. After inclusion of these two variables, the odds ratio for transfusion remained significant. Relative to 0-2 units, the odds ratio for > 2 units was 6.80 (95% CI 2.46-18.8), and for other additional blood products was 14.4 (95% CI 5.34-37.3), with a p value of < 0.001. Duration of stay in the ICU was significantly associated with the amount of blood products administered (median (IQR [range]) ICU stay 1 (1-2 [0-15]) day if transfused 0-2 units of red blood cells, 2 (1-6 [0-128]) days if transfused > 2 units of red blood cells and 3 (1-76 [0-114]) days if other clotting products were used; p value < 0.001). Hospital stay was also associated with the amount of red cells used (p < 0.001).

Blood transfusion is associated with increased morbidity and mortality after lower extremity revascularization

BACKGROUND

Little is known about the significance of blood transfusion in patients with peripheral arterial disease. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to examine the effect of intraoperative blood transfusion on the morbidity and mortality in patients who underwent lower extremity revascularization.

METHODS

We analyzed data from the participant use data file containing vascular surgical cases submitted to the ACS NSQIP in 2005, 2006, and 2007 by 173 hospitals. Current procedural terminology codes were used to select lower extremity procedures that were grouped into venous graft, prosthetic graft, or thromboendarterectomy. Thirty-day outcomes analyzed were (1) mortality, (2) composite morbidity, (3) graft/prosthesis failure, (4) return to the operating room within 30 days, (5) wound occurrences, (6) sepsis or septic shock, (7) pulmonary occurrences, and (8) renal insufficiency or failure. Intraoperative transfusion of packed red blood cells was categorized as none, 1 to 2 units, and 3 or more units. Outcome rates were compared between the transfused and nontransfused groups using the chi(2) test and multivariable regression adjusting for transfusion propensity, comorbid and procedural risk.

RESULTS

A total of 8799 patients underwent lower extremity revascularization between 2005 and 2007. Mean age was 66.8 +/- 12.0 years and 5569 (63.3%) were male. Transfusion rates ranged from 14.5% in thromboendarterectomy patients to 27.1% in prosthetic bypass patients (P < .05). After adjustment for transfusion propensity and patient and procedural risks, transfusion of 1 or 2 units remained significantly predictive of mortality, composite morbidity, sepsis/shock, pulmonary occurrences, and return to the operating room. The adjusted odds ratios for 30-day mortality ranged from 1.92 (95% confidence interval [CI] 1.36-2.70) for 1 to 2 units to 2.48 (95% CI 1.55-3.98) for 3 or more units.

CONCLUSION

In a large number of patients undergoing lower extremity revascularization, we have found that there is a higher risk of postoperative mortality, pulmonary, and infectious complications after receiving intraoperative blood transfusion. Additional studies are necessary to better define transfusion triggers that balance the risk/benefit ratio for blood transfusion.

Is it the patient or the physician who cannot tolerate anemia? A prospective analysis in 1854 non-transfused coronary artery surgery patients

Background and objective: Low hematocrit level and transfusion may coexist during cardiopulmonary bypass and the actual impact of one on the outcome parameters may be counfounded or masked by the other. This study aims to determine the impact of the lowest hematocrit level during cardiopulmonary bypass on outcome parameters in non-transfused patients. Methods: Two thousand six hundred and thirty-two consecutive patients who underwent isolated coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass were evaluated prospectively:1854 (70.4%) patients who did not receive any red blood cells during hospital stay were included in the study. Perioperative data and outcome parameters were recorded. Outcomes were evaluated in 2 groups according to the lowest level of hematocrit (>21%: high hematocrit group, n= 1680, (91.6%) and ≤21%: low hematocrit group, n=174, (9.4%)) during cardiopulmonary bypass. Results: Overall mean lowest hematocrit level of patients was 27.7±4.4% (19.7±1.9% in the low hematocrit group, 28.5±4.1% in the high hematocrit group). The comparison of outcome parameters regarding the time on ventilator, duration of intensive care unit stay, intensive care unit re-admission, hospital re-admission, reoperation for bleeding or tamponade, low cardiac output, postoperative atrial fibrillation, stroke, creatinine level at hospital discharge, new onset renal failure, mediastinitis, pulmonary complication and mortality rates were similar in both groups. Conclusions: Our findings suggest that a lowest hematocrit level of ≤21% during cardiopulmonary bypass has no adverse impact on outcome after isolated coronary surgery in non-transfused patients.

Model for end-stage liver disease score predicts left ventricular assist device operative transfusion requirements, morbidity, and mortality

BACKGROUND

The Model for End-Stage Liver Disease (MELD) predicts events in cirrhotic subjects undergoing major surgery and may offer similar prognostication in left ventricular assist device candidates with comparable degrees of multisystem dysfunction.

METHODS AND RESULTS

Preoperative MELD scores were calculated for subjects enrolled in the University of Michigan Health System (UMHS) mechanical circulatory support database. Univariate and multiple regression analyses were performed to investigate the ability of patient characteristics, laboratory data (including MELD scores), and hemodynamic measurements to predict total perioperative blood product exposure and operative mortality. The ability of preoperative MELD scores to predict operative mortality was evaluated in subjects enrolled in the Interagency Registry of Mechanically Assisted Circulatory Support (INTERMACS), and results were compared with those from the UMHS cohort. The mean+/-SD MELD scores for the UMHS (n=211) and INTERMACS (n=324) cohorts were 13.7+/-6.1 and 15.2+/-5.8, respectively, with 29 (14%) and 19 (6%) perioperative deaths. In the UMHS cohort, median total perioperative blood product exposure was 74 units (25th and 75th percentiles, 44 and 120 units). Each 5-unit MELD score increase was associated with 15.1+/-3.8 units (beta+/-SE) of total perioperative blood product exposure. Each 10-unit increase in total perioperative blood product exposure increased the odds of operative death (odds ratio, 1.05; 95% confidence interval, 1.01 to 1.10). Odds ratios, measuring the ability of MELD scores to predict perioperative mortality, were 1.5 (95% confidence interval, 1.1 to 2.0) and 1.5 (95% confidence interval, 1.1 to 2.1) per 5 MELD units for the UMHS and INTERMACS cohorts, respectively. When MELD scores were dichotomized as >or=17 and <17, risk-adjusted Cox proportional-hazard ratios for 6-month mortality were 2.5 (95% confidence interval, 1.2 to 5.3) and 2.5 (95% confidence interval, 1.1 to 5.4) for the UMHS and INTERMACS cohorts, respectively.

CONCLUSIONS

The MELD score identified left ventricular assist device candidates at high risk for perioperative bleeding and mortality.

Hematomas of at least 5 cm and outcomes in patients undergoing elective percutaneous coronary intervention: insights from the SafeTy and Efficacy of Enoxaparin in PCI patients, an internationaL randomized Evaluation (STEEPLE) trial

BACKGROUND

Major bleeding significantly impacts outcomes in patients undergoing percutaneous coronary intervention (PCI). No uniform definitions exist for major and minor bleeding. Hematomas > or =5 cm at the femoral puncture site are considered major bleeding events in some trials and minor in others. Limited information is available on the incidence and clinical relevance of hematomas > or =5 cm in PCI patients.

METHODS

Data from the STEEPLE trial in patients undergoing elective PCI were used to assess the impact of hematomas > or =5 cm on ischemic outcomes (mortality, nonfatal myocardial infarction, or urgent target vessel revascularization) up to day 30 and all-cause 1-year mortality. Hematoma data were available for 3,342 of 3,528 patients in STEEPLE. Patients with (n = 103) and without (n = 3,239) hematomas > or =5 cm were evenly distributed across treatment groups.

RESULTS

No differences were observed in 30-day ischemic outcomes between patients with and without hematomas (5.8% vs 5.9%, respectively; P = .96). No transfusions were observed in patients with hematomas as compared with patients without hematomas (0% and 0.4%, respectively; P = .52). A greater reduction in hemoglobin was observed (pre- vs post-PCI) in patients with hematomas as compared with patients without hematomas (-0.84 vs -0.35 g/L, P < or = .001). No significant difference in all-cause 1-year mortality was observed between patients with and without hematomas (0.0% vs 1.7%, P = .98).

CONCLUSIONS

After PCI, hematomas > or =5 cm had no effect on 30-day ischemic events or 1-year mortality. Although there is no agreed classification for large hematomas, the lack of a relationship between hematomas > or =5 cm and clinical outcome after PCI justifies the classification of these hematomas as minor bleeds in STEEPLE.

Preoperative evaluation and preparation of the patient for cardiac surgery

Cardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use. This article outlines a system-based approach to preoperative evaluation and preparation of the patient undergoing cardiac surgery.

Patient blood management - a new paradigm for transfusion medicine?

The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropriate transfusion is still not sufficiently tangible for the public and many clinicians. This has to change. The medical, ethical, legal and economic evidence cannot be ignored. Patient blood management needs to be implemented as the standard of care for all patients.

Cardiac-surgery associated acute kidney injury requiring renal replacement therapy. A Spanish retrospective case-cohort study

Background

Acute kidney injury is among the most serious complications after cardiac surgery and is associated with an impaired outcome. Multiple factors may concur in the development of this disease. Moreover, severe renal failure requiring renal replacement therapy (RRT) presents a high mortality rate. Consequently, we studied a Spanish cohort of patients to assess the risk factors for RRT in cardiac surgery-associated acute kidney injury (CSA-AKI).

Methods

A retrospective case-cohort study in 24 Spanish hospitals. All cases of RRT after cardiac surgery in 2007 were matched in a crude ratio of 1:4 consecutive patients based on age, sex, treated in the same year, at the same hospital and by the same group of surgeons.

Results

We analyzed the data from 864 patients enrolled in 2007. In multivariate analysis, severe acute kidney injury requiring postoperative RRT was significantly associated with the following variables: lower glomerular filtration rates, less basal haemoglobin, lower left ventricular ejection fraction, diabetes, prior diuretic treatment, urgent surgery, longer aortic cross clamp times, intraoperative administration of aprotinin, and increased number of packed red blood cells (PRBC) transfused. When we conducted a propensity analysis using best-matched of 137 available pairs of patients, prior diuretic treatment, longer aortic cross clamp times and number of PRBC transfused were significantly associated with CSA-AKI.

Patients requiring RRT needed longer hospital stays, and suffered higher mortality rates.

Conclusion

Cardiac-surgery associated acute kidney injury requiring RRT is associated with worse outcomes. For this reason, modifiable risk factors should be optimised and higher risk patients for acute kidney injury should be identified before undertaking cardiac surgery.

Preoperative evaluation and preparation of the patient for cardiac surgery

Cardiac surgery is associated with significant morbidity, mortality, and socioeconomic costs. Preoperative assessment assists the clinician in identifying potential complications and facilitates discussion of these risks with the patient. Careful patient selection and preparation during preoperative evaluation may minimize morbidity, mortality, and resource use. This article outlines a system-based approach to preoperative evaluation and preparation of the patient undergoing cardiac surgery.