The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis

Patient Blood Management in intensive care patients

PURPOSE OF REVIEW

Patients admitted to ICUs are a heterogeneous group, displaying multiple anaemia risk factors and comorbidities. Clinicians should therefore take all possible measures to identify modifiable risks. Patient Blood Management (PBM) is an approach promoting the timely application of evidence-based interventions designed to maintain patients own blood mass.

RECENT FINDINGS

Within ICU-patients, anaemia is highly prevalent. Generally, anaemia is associated with impaired outcome and need of blood transfusion. Currently, with ICUs working at full capacity and the global blood reserves exhausted, the SARS-CoV-2 pandemic reinforces the need for PBM implementation. For instance, implementation of a comprehensive coagulation management and measures to avoid iatrogenic blood loss may prevent bleeding-associated complications and adherence to blood transfusion guidelines may reduce adverse events associated with transfusion.

SUMMARY

Critically ill patients display various morbidities often requiring individualized treatment. PBM offers patient-centred measures to improve outcome any time during hospital stay.

Number and Type of Blood Products are Negatively Associated With Outcomes Following Cardiac Surgery

BACKGROUND

The association between blood transfusion and adverse outcome is documented in cardiac surgery. However, the incremental significance of each unit transfused, whether red blood cell (RBC) or non-RBC, is uncertain. This study examined the relationship of patient outcomes with type and number of blood product units transfused.

METHODS

Statewide data from adult cardiac surgery patients were included (N=24,082). Relationship with blood transfusion was assessed for morbidity and 30-day mortality using total number of RBC and non-RBC units transfused, specific type of non-RBC units, and different combinations of transfusion (only RBC, only non-RBC, RBC+non-RBC). Multivariable logistic regressions examined these associations.

RESULTS

Median age was 66 years (30% female) with 51% of patients transfused (31%-66% across hospitals). Risk-adjusted analyses found each blood product unit associated with 9%, 7%, and 4% greater odds for 30-day mortality, major morbidity, and minor morbidity (all P<0.001). Odds for 30-day mortality were 13% greater with each RBC unit (P<0.001) and 6% greater for each non-RBC unit (P<0.001). Each unit of fresh frozen plasma (P<0.001) and platelets (P<0.001) increased odds for 30-day mortality, but no effect for cryoprecipitate (P=0.725). Odds for 30-day mortality were lower for non-RBC only (OR=0.52, P=0.030) and greater for RBC+non-RBC (OR=2.98, P<0.001) compared to RBC only transfusion.

CONCLUSIONS

Independent of center variability on transfusion methods, each additional unit transfused was associated with increased odds for complications, with RBC transfusion carrying greater risk compared to non-RBC. Comprehensive evidence-based clinical approaches and coordination are needed to guide each blood transfusion event following cardiac surgery.

Effect of Blood Product Transfusion on Perioperative Outcomes After Heart Transplantation

OBJECTIVE(S)

The objective of this study was to identify transfusion-related in-hospital outcomes in orthotopic heart transplantation (OHT) recipients.

DESIGN

Retrospective chart review.

SETTING

Tertiary care hospital.

PARTICIPANTS

Adult OHT recipients undergoing transplantation between January 2010 and December 2016.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary composite outcome was occurrence of any of the following events during admission for OHT: (1) graft dysfunction requiring mechanical circulatory support (MCS); (2) respiratory failure requiring tracheostomy; (3) renal failure requiring hemodialysis; (4) 30-day mortality; (5) complication requiring readmission to intensive care unit; (6) sepsis; and (7) stroke. The authors evaluated these outcomes in relation to all blood component transfusions received intraoperatively and in the first 24 hours postoperatively. The study included 197 patients and the primary composite outcome was present in 72 (36.6%). After adjusting for propensity score, red blood cell (RBC) transfusion was associated with composite outcomes (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.05-1.31, p = 0.004), postoperative MCS use (OR 1.36, 95% CI 1.18-1.58, p < 0.001), acute renal failure requiring hemodialysis (OR 1.21, 5% CI 1.06-1.38, p = 0.004), and 30-day mortality (OR 1.29, 95% CI 1.05-1.59, p = 0.02). Fresh frozen plasma was associated with composite outcome (OR 1.07, 95% CI [1.003-1.15], p = 0.042) and renal failure (OR 1.08, 95% CI 1.08 [1.002-1.17], p = 0.04).

CONCLUSIONS

Intra- and postoperative transfusions (first 24 hours) of RBC and FFP were associated with adverse postoperative composite outcomes in patients undergoing OHT.

Blood management in a patient with anti-Oka antibody who underwent cardiac surgery using cardiopulmonary bypass: a case report

Background

Cardiac surgery under cardiopulmonary bypass (CPB) is often associated with massive bleeding and blood transfusion. For patients requiring specific blood products, meticulous blood management is critical to reduce blood loss, as well as the need for transfusion. Here, we have described the intraoperative blood management in a patient with anti-Ok^a antibody, who underwent cardiac surgery with CPB.

Case presentation

A 79-year-old woman was scheduled for open aortic valve replacement and tricuspid valve annuloplasty under hypothermic CPB. Her blood type was A RhD(+) Ok(a−), and anti-Ok^a, an extremely rare antibody against erythrocyte antigen, was detected. Eight units of Ok(a−) frozen thawed red cells (FTRCs), and six units of red blood cells donated by three Ok(a−) individuals were collected just prior to surgery. Although she was anemic, acute normovolemic hemodilution was conducted after anesthesia induction to preserve the autologous whole blood. Four units of FTRCs were loaded in the CPB priming solution, and modified ultrafiltration was adopted during CPB to prevent further hemodilution. After CPB termination, two units of FTRCs, four units of fresh frozen plasma, and ten units of platelet concentrate were intensively transfused, facilitating surgical hemostasis and stable hemodynamics. The autologous whole blood was returned to the patient in the intensive care unit. Since the hemoglobin and hematocrit levels were maintained postoperatively, no additional transfusion was required throughout her hospital stay.

Conclusions

Multidisciplinary intraoperative blood management in a patient with anti-Ok^a antibody facilitated successful cardiac surgery using CPB, along with effective use of limited blood products.