Blood conservation strategies in cardiac surgery

Implementation of an electronic identification system in the setting of perioperative autologous cell salvage transfusion: Experience at a university hospital

Perioperative autologous cell salvage (PACS) is one of the effective strategies in patient blood management (PBM). However, mistransfusion, in which the wrong blood is transfused to the wrong patient, of PACS units has been reported. In this study, we implemented a bar code-based electronic identification system (EIS) for blood transfusion in the setting of PACS transfusion. Between February 2009 and December 2020, a total of 12341 surgical patients (9% of whom received surgical interventions) received blood transfusion, among whom 6595 (54 %) received autologous blood transfusion alone, 2877 (23 %) both autologous and allogeneic blood transfusions, and 2869 (23 %) allogeneic blood transfusion alone. Among autologous blood conservation techniques, PACS units were transfused to 7873 patients (83 %) without a single mistransfusion. Rates of overall compliance with the electronic pre-transfusion check at the bedside for all autologous units and PACS units were 98.8 and 98.5 %, respectively. Our observations suggest that a bar code-based EIS can be successfully applied to PACS transfusion, as well as allogeneic blood transfusion in operating rooms.

Outcomes from cardiac surgery in Jehovah's witness patients: experience over twenty-one years

BACKGROUND

Cardiac surgery in Jehovah's Witnesses may be challenging during the operation and postoperative period given their refusal of blood products. The aim of this study was to document our center's experience with Jehovah's Witnesses undergoing major cardiac surgery and to compare surgical outcomes with a matched control group.

METHODS

We retrospectively reviewed the demographic, perioperative, and in-hospital postoperative data for 31 Jehovah's Witness patients undergoing surgery from 1991 to 2012 and compared findings with a control group of 62 patients of the same sex and age, who underwent the same type of operations in the same period. Early mortality, major in-hospital morbidity, laboratory findings, and hospital stays were compared between groups.

RESULTS

Demographic data were similar between groups, except that more patients in the Jehovah's Witness group had extracardiac arteriopathy compared with controls (p = 0.04). There was no difference in predicted mortality, calculated by the Euroscore II, between groups (2.8 ± 3.3 in study group versus 2.4 ± 2.2 in control group, p = 0.469). For postoperative outcomes, there were no differences between Jehovah's Witnesses versus controls in hospital mortality (3 % versus 2 %, p = 0.548), total drain loss (847 ± 583 mL versus 812 ± 365 mL, p = 0.721), mechanical ventilation time (1.26 ± 2.24 versus 0.89 ± 0.55 days, p = 0.218), intensive care unit stay (4.3 ± 3.9 versus 3 ± 1.4 days, p = 0.080), and hospital stay (12.9 ± 7.6 versus 10.9 ± 6.6 days, p = 0.223).

CONCLUSIONS

Outcomes after cardiac surgery are similar between Jehovah's Witnesses and general population, in centers applying rigorous blood patient management protocols.

Safety and efficacy of caproamin fides and tranexamic Acid versus placebo in patients undergoing coronary artery revascularization

Introduction: Excessive fibrinolysis contributes to post-cardiopulmonary bypass bleeding. Tranexamic Acid (TXA) and Caproamin Fides are synthetic lysine analogues that inhibit plasminogen-fibrin binding. The present study aimed to compare TXA and Caproamin Fides versus placebo in patients undergoing elective coronary artery revascularization.

Methods: We analyzed perioperative data of 300 adult patients undergoing coronary artery revascularization. Patients were randomly allocated to receive TXA (n=100), Caproamin Fides (n=100) or placebo (n=100) during perioperative time. Mediastinal bleeding during the first 24 hours post-operation, transfusion requirement and post-surgical complications were assessed.

Results: Most descriptive and intra-operative parameters were well comparable between the 3 study groups. Except for mean number of packed red blood cell (PRBC) units transfused during ICU stay (P=0.01), patients in the Caproamin Fides and TXA groups did not show any statistically significant differences regarding transfusion of blood products during peri-operative period. There was no evidence of a significant difference in mediastinal blood loss during the first 24 hours post-operation between the patients receiving TXA or placebo, while patients in the Caproamin Fides group had significantly lower mediastinal bleeding than the other 2 groups (Caproamin Fides vs. placebo, P=0.002, <0.001 and <0.001 at 6, 12 and 24 hours post-operation; Caproamin Fides vs. TXA, P=0.009, 0.003, <0.001 at 6, 12 and 24 hours post-operation). The incidence of postoperative complications were comparable between Caproamin Fides and TXA groups (P>0.05).

Conclusion: In conclusion, Caproamin Fides seems to be superior to TXA regarding the blood saving effects in patients undergoing coronary artery revascularization.

Risk associated with preoperative anemia in cardiac surgery: a multicenter cohort study

BACKGROUND

Preoperative anemia is an important risk factor for perioperative red blood cell transfusions, which are associated with postoperative morbidity and mortality. Whether preoperative anemia also is an independent risk factor for adverse outcomes after cardiac surgery, however, has not been fully elucidated.

METHODS AND RESULTS

In this multicenter cohort study, data were collected on 3500 consecutive patients who underwent cardiac surgery during 2004 at 7 academic hospitals. The prevalence of preoperative anemia, defined as hemoglobin <12.5 g/dL, and its unadjusted and adjusted relationships with the composite outcome of in-hospital death, stroke, or acute kidney injury were obtained. The overall prevalence of preoperative anemia was 26%, with values ranging from 22% to 30% at the participating hospitals. After the exclusion of patients who had severe preoperative anemia (hemoglobin <9.5 g/dL) or preoperative kidney failure and those who underwent emergency surgery, the composite outcome was observed in 7.5% of patients (247 of 3286). The unadjusted odds ratio for the composite outcome in anemic versus nonanemic patients was 3.6 (95% confidence interval, 2.7 to 4.7). The risk-adjusted odds ratios, obtained by multivariable logistic regression and propensity-score matching to control for important confounders (including comorbidities, institution, surgical factors, and blood transfusion), were 2.0 (95% confidence interval, 1.4 to 2.8) and 1.8 (95% confidence interval, 1.2 to 2.7), respectively.

CONCLUSIONS

Preoperative anemia is independently associated with adverse outcomes after cardiac surgery. Future studies should determine whether therapies aimed at treating preoperative anemia would improve the outcomes of patients undergoing cardiac surgery.

Cardiac surgery with cardiopulmonary bypass: does aprotinin affect outcome?

BACKGROUND

Aprotinin, a non-specific serine protease inhibitor, has been used for two decades to reduce perioperative blood loss and the risk for allogeneic transfusion in cardiac surgery. This study evaluated the effects of aprotinin on outcome (mortality, cardiac events, renal failure, and cerebrovascular events) in such patients undergoing cardiac surgery with cardiopulmonary bypass.

METHODS

Data were obtained in patients who received a strict blood conservation protocol: no antifibrinolytic therapy when at low risk (n = 854) and aprotinin (n = 1210) when at high risk for blood transfusion. Relative risk of different pre- and intra-operative variables was calculated for the different outcome variables. Backward stepwise logistic regression analysis was used to identify the independent risk factors associated with the different outcome variables. Statistical significance was accepted at P < 0.01.

RESULTS

Postoperative mortality and morbidity were higher in the aprotinin group but this was related to an increased incidence of perioperative risk factors. Mortality was similar to that predicted by the Euroscore. Complex surgery was the only independent variable associated with postoperative cardiac events. Preoperative heart failure, preoperative creatinine > 1.5 mg dl(-1), urgent, and redo surgery were the independent variables associated with postoperative haemodialysis. Age > 70 yr was identified as the only independent variable associated with neurologic dysfunction.

CONCLUSIONS

In the present study, patients receiving aprotinin as part of a strict blood conservation strategy represent a population at high risk for postoperative complications. For the outcome variables studied, aprotinin administration was not identified as an independent risk factor.