Con: whole blood transfusions are not useful in patients undergoing cardiac surgery

Lack of effect of unrefrigerated young whole blood transfusion on patient outcomes after massive transfusion in a civilian setting

BACKGROUND

Warm fresh whole blood has been advocated for critical bleeding in the military setting. This study assessed whether unrefrigerated young whole blood transfusion, from donation to transfusion less than 24 hours, could reduce mortality of patients with critical bleeding in a civilian setting.

STUDY DESIGN AND METHODS

A linked data cohort study was conducted on a total of 353 consecutive patients requiring massive transfusion, defined as 10 units or more of red blood cells or whole blood transfusion within 24 hours, in a quaternary health care center in Australia.

RESULTS

Of the 353 patients with massive blood transfusion in the study, 77 received unrefrigerated young whole blood transfusion (mean, 4.0 units; interquartile range, 2-6). The diagnosis, severity of acute illness, age, sex, and ABO blood group were not significantly different between the patients who received unrefrigerated young whole blood and those who did not. Unrefrigerated young whole blood transfusions were associated with a slightly improved coagulation profile (lowest fibrinogen concentrations 1.7g/L vs. 1.4g/L, p=0.006; worst international normalization ratio, 2.4 vs. 2.8, p=0.05) but did not reduce the total utilization of allogeneic blood products and subsequent use of recombinant Factor VIIa (27% vs. 22%, p=0.358). Thirty-day mortality and 8-year survival after hospital discharge (hazard ratio, 1.05; 95% confidence interval, 0.41-2.65; p=0.93) were also not different after the use of unrefrigerated young whole blood transfusion.

CONCLUSIONS

Unrefrigerated young whole blood transfusion was not associated with a reduced mortality of patients requiring massive transfusion in a civilian setting when other blood products were readily available.

Blood component therapy

The blood component support in pediatric patients is more challenging as compared to adult patients, as such, a thorough understanding of various blood components and indications for each is critical when making the decision for transfusion. Transfusion needs in pediatric group parallel the changes that accompany the transitions from fetus to neonate, neonate to infant, and throughout childhood. Modified or unmodified blood components viz. red blood cells, platelets, granulocytes, fresh frozen plasma and cryoprecipitate are required for transfusion support in pediatric population. In general, fetuses and infants younger than 4 months of age have specialized transfusion requirements whereas transfusion of infants older than 4 months and children parallels those for adults. Transfusion practices differ widely among pediatric care units depending upon individual preferences, hospital transfusion policy and resource availability. There is a need to implement best transfusion practices and despite the lack of firm evidences, existing pediatric transfusion guidelines can help pediatric care providers in their decisions related to component transfusion.

Hemostatic Abnormalities in Cardiopulmonary Bypass: Pathophysiologic and Transfusion Considerations

Cardiac surgical procedures typically use cardiopulmo nary bypass (CPB), a technique that diverts blood from the heart and lungs, where it is oxygenated and pumped back into the circulation. CPB is associated with significant pathophysiologic changes leading to an increased bleeding risk. Bleeding during CPB occurs for multiple reasons; the primary reason is the expo sure of blood to the material components of the CPB system, with intense systemic coagulation and platelet, fibrinolytic, and endothelial activation. To counteract the coagulation activation, extremely high levels of heparin anticoagulation are required to prevent sys temic thrombosis. Thrombin generation through tissue factor pathway activation is now thought to be the predominant mechanism of coagulation activation in CPB. The stimulus for tissue factor exposure to blood is thought to be a systemic activation of tissue factor on monocytes and endothelial cells caused by comple ment activation by the CPB materials and circulating inflammatory mediators. Despite improvements in the CPB system, surgical techniques, and blood conserva tion methods, the demand for blood in such procedures remains sustantial. Optimal blood use can be achieved by combining blood conservation measures with the transfusion of blood components according to strict guidelines. Blood is a limited resource and must be used wisely and cautiously. The risks and costs associ ated with transfusion are compelling reasons to mini mize unnecessary exposure to blood. However, the bene fits of transfusion are well established, and the risks are reasonably low. New developments in the surfaces of the CPB system, use of established and new protease inhibitors, and new blood conservation measures offer promise in decreasing the bleeding risk associated with CPB.