Utilisation of blood and blood products during open heart surgery in a low-income country: our local experience in 3 years

Intraoperative use of cell saver devices decreases the rate of hyperlactatemia in patients undergoing cardiac surgery

Objective

This study was aimed to elucidate the effect of the intraoperative cell saver (CS) on hyperlactatemia of patients who underwent cardiac surgery.

Design

A sub-analysis of the CS was performed, which is a historial control trial of patients undergoing cardiac surgery.

Setting

This was a retrospective single-center and not blinded study.

Participants

We examined the occurrence of hyperlactatemia retrospectively in patients of CS group (n = 78) who were included in prospective trial and received valvular surgery, where CS was used during the procedure. Patients subjected to valvular surgery before February 2021 were adopted in control group (n = 79).

Interventions

Arterial blood was sampled (1) before cardiopulmonary bypass, (2) during bypass (3) immediately after bypass, (4) on ICU admission and (5) every 4 h up to 24 h postoperatively.

Measurements and main results

A lower incidence of hyperlactatemia (32.1% vs. 57.0%; P = 0.001) was observed in patients from the CS group. Furthermore, the blood lactate concentration was higher in control group than in CS group during CPB, post CPB, on ICU admission and lasted until 20 h after the operation. Multivariable analysis revealed that intraoperative use of CS was expected to be a protective factor against hyperlactatemia in this study (OR = 0.31, 95% CI 0.15-0.63, P = 0.001).

Conclusion

Intraoperative use of a CS device was associated with a lower incidence of hyperlactatemia. Whether such device use is valuable to limiting hyperlactatemia in cardiac patients after surgery requires further evaluation in larger prospective studies.

Risk factors associated with positive bacterial culture in salvaged red blood cells during cardiac surgery and postoperative infection incidence: A prospective cohort study

Background

This study was designed to explore factors associated with the incidence of positive bacterial culture of salvaged red blood cells (sRBCs) recovered with a Cell Saver instrument during cardiac surgery and the impact of such positive outcomes on postoperative infection-related morbidity.

Methods

The cohort study enrolled 204 patients scheduled for cardiac surgery with intraoperative blood cell salvage and retransfusion from July 2021 to July 2022. These patients were stratified into two groups based on intraoperative sRBCs bacterial culture results: culture (+) and culture (-) groups. Preoperative and intraoperative variables were compared between these groups aim to detect possible predictors of positive culture in sRBCs. In addition, differences in postoperative infection-related morbidity and other clinical outcomes were compared between these groups.

Results

Of these patients, 49% were sRBCs culture (+), with Staphylococcus epidermidis as the most commonly identified pathogen. Risk factors independently associated with the risk of positive culture in sRBCs included BMI ≥25 kg/m², a history of smoking, an operative duration ≥277.5 min, the higher number of staff in the operating room and higher surgical case order. Patients in the sRBCs culture (+) group exhibited a longer average ICU stay [3.5 days (2.0-6.0) vs. 2 days (1.0-4.0), P < 0.01], a longer duration of ventilation [20.45 h (12.0-17.8) vs. 13 h (11.0-17.0, P = 0.02)], underwent more allogeneic blood transfusions, exhibited higher transfusion-related costs [2,962 (1,683.0-5,608.8) vs. 2,525 (1,532.3-3,595.0), P = 0.01], and had higher rates of postoperative infections (22 vs. 9.6%, P = 0.02) as compared to patients in the sRBCs culture (-) group. In addition, culture (+) in sRBCs was an independent risk factor for postoperative infection (OR 2.62, 95% CI 1.16-5.90, P = 0.02).

Conclusion

Staphylococcus epidermidis was the most common pathogen detected in sRBCs in the culture (+) group in this study, identifying it as a potential driver of postoperative infection. Positive sRBCs culture may contribute to postoperative infection and its incidence was significantly associated with patient BMI, history of smoking, operative duration, the number of staff in the operating room and surgical case order.

Intravenous transfusion of iron sucrose reduces blood transfusions and improves postoperative anaemia after a second thoracotomy: a propensity-score matching study

Objective

To evaluate the efficacy of intravenous iron sucrose (IS) in the perioperative period of a second thoracotomy after open-heart surgery.

Methods

This study enrolled patients that underwent a second thoracotomy after previous open-heart surgery. Propensity-score matching was used to match patients that received oral iron therapy with those that received IS after admission. The baseline demographic and clinical characteristics, perioperative data and adverse outcomes were compared between these two matched groups.

Results

The study enrolled 447 patients: of these, 148 received oral iron therapy and effective dietary guidance; and 299 patients received 300 mg IS per week. After matching the propensity scores, there were no significant differences between the two groups in terms of age, sex, smoking history, incidence of major cardiac adverse events, Euro-score, time between the two thoracotomies, application of recombinant erythropoietin, haemoglobin (Hb) on admission and red blood cell (RBC) count on admission. The differences between the two groups after propensity-score matching in terms of the amount of RBC input and Hb after the operation were significant.

Conclusion

The administration of IS might be useful for improving postoperative Hb levels and reducing intraoperative RBC input in patients undergoing a second thoracotomy.

Establishing a sustainable open heart surgery programme in Nigeria, a low-income country: which is the best model?

BACKGROUND

In any country, the development of open heart surgery programme parallels stable political climate, economic growth, good leadership, and prudent fiscal management. This is lacking in a country like Nigeria without a functional cardiac hospital.

OBJECTIVE

To review and compare the various models being adopted towards establishing a sustainable open heart surgery programme in Nigeria.

MATERIALS AND METHODS

For ethnic and cultural reasons, Nigeria is divided into six geopolitical regions. Each region has one or more Federal Teaching Hospitals including medical centres. The hospitals have trained cardiothoracic surgeons and cardiologists as well as other auxiliary staff. After attainment of democratic rule in 1999, individual hospitals have devised various models to establish sustainable open heart surgery programme. The number of hospitals in each region, the models devised, and the limitations including the outcome were studied and analysed.

RESULTS

Each geopolitical zone has about three to four centres, either public or private, trying to establish the programme. There are six different models. Each centre has been trying the different models since the year 2000. The oldest of the model is cardiac mission and the newest is employment of highly skilled retired expatriate consultant cardiac surgeon to help develop the local team. Inadequate funds, lack of governmental support, and brain drain syndrome have largely affected the programme.