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Ahmed A, Iribarne A. Heterogeneity Among Institutional Red Blood Cell Transfusion Rates With Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 116:1291. [PMID: 37839539 DOI: 10.1016/j.athoracsur.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Adham Ahmed
- School of Medicine, City University of New York, New York, New York
| | - Alexander Iribarne
- Department of Cardiothoracic Surgery, Staten Island University Hospital, Northwell Health, 501 Seaview Ave, Ste 202, Staten Island, NY 10305.
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Yıldız Z, Kayğın MA. Comparison of the effects of autologous and non-autologous blood transfusions on the advantages, disadvantages, extubation time and bleeding after coronary bypass. Heliyon 2023; 9:e17371. [PMID: 37383208 PMCID: PMC10293705 DOI: 10.1016/j.heliyon.2023.e17371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023] Open
Abstract
Purpose Blood transfusion; is considered an organ transplant. In coronary bypass surgery, large volumes of homologous blood transfusion may be required due to excessive bleeding. The large number of use of homologous blood transfusion in open heart surgery and the awareness of its various harmful effects have prompted researchers to conduct research on the use of autologous blood. With autologous transfusion, blood diseases, incompatibility, immunosuppression and organ damage can be prevented and the patient can be extubated earlier in the postoperative period. Methods Between January 2020 and January 2016, a total of 176 patients, 56 in the treatment group (with autologous blood transfusion) and 120 in the control group, whose information could be reached from hospital records were investigated retrospectively. Results No statistical difference was found between the mean intubation SO2 and PO2 values of the groups. On the contrary, considering the mean intubation times in the intensive care unit of both groups, the patients who underwent autologous blood transfusion were extubated at a statistically significant earlier time. Conclusion Autologous blood transfusion is a safe method in selected patients as well. Thanks to this method, patients are protected from complications associated with homologous blood transfusion. It is believed that performing autologous blood transfusion in selected patients undergoing open-heart surgery can decrease the number of postoperative transfusions, frequency of transfusion-related complications (especially in the lungs), and mean intubation times.
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Affiliation(s)
- Ziya Yıldız
- Corresponding author. Erzurum Regional Training and Research Hospital, Cardiovascular Surgery Clinic Çatyolu, Palandöken, 25040, Erzurum, Turkey.
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Machine learning-based prediction of massive perioperative allogeneic blood transfusion in cardiac surgery. Eur J Anaesthesiol 2022; 39:766-773. [PMID: 35852544 DOI: 10.1097/eja.0000000000001721] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Massive perioperative allogeneic blood transfusion, that is, perioperative transfusion of more than 10 units of packed red blood cells (pRBC), is one of the main contributors to perioperative morbidity and mortality in cardiac surgery. Prediction of perioperative blood transfusion might enable preemptive treatment strategies to reduce risk and improve patient outcomes while reducing resource utilisation. We, therefore, investigated the precision of five different machine learning algorithms to predict the occurrence of massive perioperative allogeneic blood transfusion in cardiac surgery at our centre. OBJECTIVE Is it possible to predict massive perioperative allogeneic blood transfusion using machine learning? DESIGN Retrospective, observational study. SETTING Single adult cardiac surgery centre in Austria between 01 January 2010 and 31 December 2019. PATIENTS Patients undergoing cardiac surgery. MAIN OUTCOME MEASURES Primary outcome measures were the number of patients receiving at least 10 units pRBC, the area under the curve for the receiver operating characteristics curve, the F1 score, and the negative-predictive (NPV) and positive-predictive values (PPV) of the five machine learning algorithms used to predict massive perioperative allogeneic blood transfusion. RESULTS A total of 3782 (1124 female:) patients were enrolled and 139 received at least 10 pRBC units. Using all features available at hospital admission, massive perioperative allogeneic blood transfusion could be excluded rather accurately. The best area under the curve was achieved by Random Forests: 0.810 (0.76 to 0.86) with high NPV of 0.99). This was still true using only the eight most important features [area under the curve 0.800 (0.75 to 0.85)]. CONCLUSION Machine learning models may provide clinical decision support as to which patients to focus on for perioperative preventive treatment in order to preemptively reduce massive perioperative allogeneic blood transfusion by predicting, which patients are not at risk. TRIAL REGISTRATION Johannes Kepler University Ethics Committee Study Number 1091/2021, Clinicaltrials.gov identifier NCT04856618.
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Digging Into Past HBOC Clinical Trials. Am J Ther 2022; 29:e338-e341. [PMID: 35446268 DOI: 10.1097/mjt.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Atasever AG, Eerens M, Van den Eynde R, Faraoni D, Rex S. Efficacy and safety of aprotinin in paediatric cardiac surgery: A systematic review and meta-analysis. Eur J Anaesthesiol 2022; 39:352-367. [PMID: 34783684 DOI: 10.1097/eja.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relicensing of aprotinin in Europe and Canada has stimulated discussions on its usefulness in paediatric cardiac surgery. OBJECTIVE To systematically evaluate the available evidence on the efficacy and safety of aprotinin in paediatric cardiac surgery. DESIGN Systematic review of all randomised and observational studies comparing aprotinin with tranexamic acid, epsilon aminocaproic acid, placebo or no drug in paediatric cardiac surgery. Meta-analyses were performed on efficacy and safety outcomes. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, Web of Science and Embase were searched from January 2000 to March 2021. ELIGIBILITY CRITERIA Studies that enrolled children under 18 years undergoing cardiac surgery with cardiopulmonary bypass. RESULTS Thirty-two studies enrolling a total of 63 894 paediatric cardiac procedures were included. Aprotinin significantly reduced total blood loss [mean difference -4.70 ml kg-1, 95% confidence interval (CI), -7.88 to -1.53; P = 0.004], postoperative transfusion requirements and the incidence of surgical re-exploration for bleeding [odds ratio (OR) 0.74, 95% CI, 0.56 to 0.97; P = 0.03]. Aprotinin had no effects on 30-day mortality (OR 1.02, 95% CI, 0.93 to 1.11; P = 0.73) and on other safety outcomes, except for the incidence of renal replacement therapy (RRT), which was significantly increased in patients given aprotinin (OR 1.29, 95% CI, 1.08 to 1.54; P = 0.006). Findings from observational and randomised controlled trials did not largely differ. A sub-group analysis in neonates showed that aprotinin significantly reduced packed red blood cell transfusions and the incidence of postoperative surgical re-exploration for bleeding and/or tamponade. When compared with lysine analogues, aprotinin was more effective at reducing bleeding and transfusion without increasing the risk of side effects. CONCLUSION This meta-analysis suggests that aprotinin is effective and well tolerated in paediatric cardiac surgery. Given the large heterogeneity of the results and the risk of selection bias in observational studies, large randomised controlled trials are warranted.
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Affiliation(s)
- Ayse Gulsah Atasever
- From the Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat, Leuven, Belgium (AGA, ME, RVdE, SR). Arthur S. Keats Division of Paediatric Cardiovascular Anesthesia. Department of Anesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA (DF). And Department of Cardiovascular Sciences, KU Leuven, Herestraat, Leuven, Belgium (SR)
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Abstract
Emerging evidence suggests surgical outcomes of patients undergoing cardiovascular surgery that refuse autologous transfusion is comparable to those who accept whole blood product transfusions. There are several methods that can be used to minimize blood loss during cardiovascular surgery. These methods can be categorised into pharmacological measures, including the use of erythropoietin, iron and tranexamic acid, surgical techniques, like the use of polysaccharide haemostat, and devices such as those used in acute normovolaemic haemodilution. More prospective studies with stricter protocols are required to assess surgical outcomes in bloodless cardiac surgery as well as further research into the long-term outcomes of bloodless cardiovascular surgery patients. This review summarizes current evidence on the use of pre-, intra-, and post-operative strategies aimed at the subset of patients who refuse blood transfusion, for example Jehovah's Witnesses.
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Werner RS, Lipps C, Waldhans S, Künzli A. Blood consumption in total arterial coronary artery bypass grafting. J Cardiothorac Surg 2020; 15:23. [PMID: 31952527 PMCID: PMC6969432 DOI: 10.1186/s13019-020-1053-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/03/2020] [Indexed: 11/10/2022] Open
Abstract
Background Accumulating evidence consistently demonstrates that blood transfusion in cardiac surgery is related to decreased short- and long-term survival. We aimed to evaluate periprocedural blood loss and transfusion rates in elective, isolated total arterial coronary artery bypass grafting (CABG) using exclusively skeletonized bilateral internal mammary arteries (IMAs). Methods We identified 1011 consecutive patients with coronary artery disease who underwent CABG between 1/2007 and 12/2014. Of them, 595 patients who presented preoperative hemoglobin levels >9md/dl and underwent elective, isolated CABG for multi-vessel coronary artery disease were included in the study population. 419 patients (70.4%) received total arterial CABG using skeletonized bilateral IMAs, in 176 patients (29.6%) mixed CABG (single IMA & saphenous vein) was performed. Propensity score adjustment using 16 variables was applied to control for treatment effect. Results In patients undergoing total arterial CABG, heterologous blood transfusion could be avoided in 87.8% of all cases. Propensity score adjusted results showed a significantly lower incidence of erythrocyte concentrate transfusion in patients undergoing total arterial CABG compared to mixed CABG (odds ratio 2.74, 95% confidence interval 1.38–5.43, P = 0.004). There were no statistically significant differences in the rates of thrombocyte concentrate (P = 0.39) and fresh frozen plasma transfusions (P = 0.07). Conclusions In this study, patients who underwent elective, isolated total arterial CABG using exclusively skeletonized bilateral IMAs showed reduced transfusion rates of erythrocyte concentrates compared to mixed CABG using a combination of single IMA and saphenous vein grafts. No evidence for a higher incidence of complications was found with a total arterial approach.
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Affiliation(s)
- Raphael Sven Werner
- Department of Thoracic Surgery, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland. .,Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland.
| | - Christoph Lipps
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
| | - Stefan Waldhans
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
| | - Andreas Künzli
- Department of Cardiovascular Surgery, Herzzentrum Bodensee, Kreuzlingen, Switzerland
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Li C, Zhao Q, Yang K, Jiang L, Yu J. Thromboelastography or rotational thromboelastometry for bleeding management in adults undergoing cardiac surgery: a systematic review with meta-analysis and trial sequential analysis. J Thorac Dis 2019; 11:1170-1181. [PMID: 31179059 DOI: 10.21037/jtd.2019.04.39] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Severe bleeding and massive transfusion of blood products may be associated with increased morbidity and mortality of cardiac surgery. A transfusion algorithm incorporating thromboelastography (TEG) or rotational thromboelastometry (ROTEM) can help to determine the appropriate time and target for the use of hemostatic blood products, which may thus reduce the quantity of blood loss as well as blood products transfused. Methods We conducted meta-analysis and trial sequential analysis to evaluate the effects of TEG or ROTEM-guided transfusion algorithms vs. standard treatments for patients undergoing cardiac surgery with cardiac pulmonary bypass. Results Nineteen studies with a total of 15,320 participants, including 13 randomized controlled trials (RCTs), were included. All-cause mortality was not reduced either in overall studies or in RCTs. Blood loss volume was reduced by 132 mL in overall studies [mean difference (MD): -132.46, 95% CI: -207.49, -57.43; I2 =53%, P<0.01], and by 103 mL in RCTs (MD: -103.50, 95% CI: -156.52, -50.48; I2 =0%, P<0.01). The relative risks (RRs) in RCTs were 0.89 (95% CI: 0.80-0.98; I2 =0%, P=0.02) for red blood cells transfusion, 0.59 (95% CI: 0.42-0.82; I2 =55%, P<0.01) for fresh frozen plasma transfusion, and 0.81 (95% CI: 0.74-0.90; I2 =0%, P<0.01) for platelet transfusion, respectively. Trial sequential analysis of continuous data on blood loss and dichotomous outcomes on transfusion of blood products suggested the benefits of a TEG/ROTEM-guided algorithm. Conclusions TEG or ROTEM-guided transfusion strategies may reduce blood loss volume and the transfusion rates in adult patients undergoing cardiac surgery.
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Affiliation(s)
- Caie Li
- Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Qiming Zhao
- Department of Cardiac Surgery ICU, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Kun Yang
- Department of Cardiac Surgery ICU, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Luxia Jiang
- Department of Cardiac Surgery ICU, Lanzhou University Second Hospital, Lanzhou 730030, China
| | - Jing Yu
- Department of Cardiology, Lanzhou University Second Hospital, Lanzhou 730030, China
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Mirzaei S, Hershberger PE, DeVon HA. Association Between Adverse Clinical Outcomes After Coronary Artery Bypass Grafting and Perioperative Blood Transfusions. Crit Care Nurse 2019; 39:26-35. [DOI: 10.4037/ccn2019589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background
Bleeding is a serious complication of coronary artery bypass grafting that often leads to blood transfusion. Approximately 50% of patients who have the surgery receive blood products, and blood transfusions play a role in adverse outcomes after the surgery.
Objective
To examine the association between perioperative blood transfusion and postoperative adverse outcomes in patients undergoing coronary artery bypass grafting.
Methods
A systematic review of the literature, via the matrix method of quality evaluation, was conducted. PubMed, CINAHL, and Science Direct databases for 2000 through 2016 were searched. Inclusion criteria were articles published in English and original research related to clinical outcomes of blood transfusion after coronary artery bypass grafting. Seventeen articles were included in the review.
Results
Mortality, both short- and long-term, was significantly higher in transfusion patients than in nontransfusion patients. Patients with transfusion of red blood cells had higher resource utilization and more complications, including infection, pneumonia, renal failure, graft occlusion, and atrial fibrillation, than did nontransfusion patients.
Conclusion
An association exists between red blood cell transfusions and adverse clinical outcomes for patients undergoing coronary artery bypass grafting. Transfusion of red blood cells is sometimes unnecessary, may be injurious, and should be used cautiously. Even a single-unit increase in perioperative red blood cell transfusions can have a significant adverse impact on outcomes. Individual benefits and risks should be weighed before transfusion to avoid adverse outcomes. Transfusion guidelines should be reviewed to include the latest evidence to guarantee the most appropriate use of blood products.
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Affiliation(s)
- Sahereh Mirzaei
- Sahereh Mirzaei is a doctoral student at the University of Illinois at Chicago, and a clinical practitioner in the open heart intensive care unit, University of Illinois at Chicago, College of Nursing, Chicago, Illinois
| | - Patricia E. Hershberger
- Patricia Hershberger is the doctoral instructor for the Developing Literature Reviews course at the University of Illinois at Chicago
| | - Holli A. DeVon
- Holli DeVon is the doctoral instructor for the Philosophy of Science and Evidence-Based Practice courses at the University of Illinois at Chicago
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Kaiser A, Miller K, Tian G, Moore RH, Guzzetta NA. Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass. Paediatr Anaesth 2018; 28:795-802. [PMID: 30079485 DOI: 10.1111/pan.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass. METHODS After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10 kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared. RESULTS Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24 hours postoperatively. DISCUSSION The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.
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Affiliation(s)
- Ania Kaiser
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kati Miller
- Department of Clinical Research, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ganzhong Tian
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Reneé H Moore
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
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Camaj A, Zahuranec DB, Paone G, Benedetti BR, Behr WD, Zimmerman MA, Zhang M, Kramer RS, Penn J, Theurer PF, Paugh TA, Engoren M, DeLucia A, Prager RL, Likosky DS. Organizational Contributors to the Variation in Red Blood Cell Transfusion Practices in Cardiac Surgery: Survey Results From the State of Michigan. Anesth Analg 2017; 125:975-980. [PMID: 28719425 DOI: 10.1213/ane.0000000000002277] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND While large volumes of red blood cell transfusions are given to preserve life for cardiac surgical patients, indications for lower volume transfusions (1-2 units) are less well understood. We evaluated the relationship between center-level organizational blood management practices and center-level variability in low volume transfusion rates. METHODS All 33 nonfederal, Michigan cardiac surgical programs were surveyed about their blood management practices for isolated, nonemergent coronary bypass procedures, including: (1) presence and structure of a patient blood management program, (2) policies and procedures, and (3) audit and feedback practices. Practices were compared across low (N = 14, rate: 0.8%-10.1%) and high (N = 18, rate: 11.0%-26.3%) transfusion rate centers. RESULTS Thirty-two (97.0%) of 33 institutions participated in this study. No statistical differences in organizational practices were identified between low- and high-rate groups, including: (1) the membership composition of patient blood management programs among those reporting having a blood management committee (P= .27-1.0), (2) the presence of available red blood cell units within the operating room (4 of 14 low-rate versus 2 of 18 high-rate centers report that they store no units per surgical case, P= .36), and (3) the frequency of internal benchmarking reporting about blood management audit and feedback practices (low rate: 8 of 14 versus high rate: 9 of 18; P= .43). CONCLUSIONS We did not identify meaningful differences in organizational practices between low- and high-rate intraoperative transfusion centers. While a larger sample size may have been able to identify differences in organizational practices, efforts to reduce variation in 1- to 2-unit, intraoperative transfusions may benefit from evaluating other determinants, including organizational culture and provider transfusion practices.
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Affiliation(s)
- Anton Camaj
- From the *Michigan Medicine, Ann Arbor, Michigan; †Department of Neurology, University of Michigan, Ann Arbor, Michigan; ‡Division of Cardiac Surgery, Henry Ford Hospital, Detroit, Michigan; §Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Michigan; ‖Blood Management and Conservation, Bronson Methodist Hospital, Kalamazoo, Michigan; ¶Department of Health Behavior and Health Education, School of Public Health and #Department of Biostatistics, University of Michigan, Ann Arbor, Michigan; **Division of Cardiothoracic Surgery, Maine Medical Center, Portland, Maine; ††Department of Perfusion, Bronson Methodist Hospital, Kalamazoo, Michigan; ‡‡Department of Cardiac Surgery and §§Department of Anesthesiology, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan; and ‖‖Department of Cardiothoracic Surgery, Bronson Methodist Hospital, Bronson, Michigan
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Fahrendorff M, Oliveri RS, Johansson PI. The use of viscoelastic haemostatic assays in goal-directing treatment with allogeneic blood products - A systematic review and meta-analysis. Scand J Trauma Resusc Emerg Med 2017; 25:39. [PMID: 28403868 PMCID: PMC5390346 DOI: 10.1186/s13049-017-0378-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/21/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Management of the critically bleeding patient can be encountered in many medical and surgical settings. Common for these patients is a high risk of dying from exsanguination secondary to developing coagulopathy. The purpose of this meta-analysis was to systematically review and assess randomised controlled trials (RCTs) performed on patients in acute need for blood transfusions due to bleeding to evaluate the effect of viscoelastic haemostatic assay (VHA) guidance on bleeding, transfusion requirements and mortality. METHODS PubMed and EMBASE were searched for RCTs that 1) randomised patients into receiving transfusions based on either a VHA-guided (thromboelastography [TEG] or rotational thromboelastometry [ROTEM]) algorithm (intervention group) or at the clinician's discretion and/or based on conventional coagulation tests (control group) and 2) adequately reported on the outcomes bleeding and/or transfusions and/or mortality. Data on bleeding, transfusions and mortality were extracted from each trial and included in a meta-analysis. RESULTS Fifteen RCTs (n = 1238 patients) were included. Nine trials referred to cardiothoracic patients, one to liver transplantation, one to surgical excision of burn wounds and one to trauma. One trial was conducted with cirrhotic patients, one with patients undergoing scoliosis surgery while one trial randomised treatment in post-partum females presenting with bleeding. The amount of transfused red blood cells (RBCs), fresh frozen plasma (FFP) and bleeding volume was found to be significantly reduced in the VHA-guided groups, whereas no significant difference was found for platelet transfusion requirements or mortality.
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Affiliation(s)
- Mathilde Fahrendorff
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
| | - Roberto S. Oliveri
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK–2100 Copenhagen, Denmark
- Department of Surgery, Centre for Translational Injury Research, UT Health, University of Texas Health Science Center at Houston, Houston, TX USA
- Center for Systems Biology. The School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
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Solov'eva IN, Trekova NA, Krapivkin IA. [Transfusion supply optimization in multiple-discipline surgical hospital]. Khirurgiia (Mosk) 2016:55-60. [PMID: 26977612 DOI: 10.17116/hirurgia2016155-60] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIM To define optimal variant of transfusion supply of hospital by blood components and to decrease donor blood expense via application of blood preserving technologies. MATERIAL AND METHODS Donor blood components expense, volume of hemotransfusions and their proportion for the period 2012-2014 were analyzed. RESULTS Number of recipients of packed red cells, fresh-frozen plasma and packed platelets reduced 18.5%, 25% and 80% respectively. Need for donor plasma decreased 35%. Expense of autologous plasma in cardiac surgery was 76% of overall volume. Preoperative plasma sampling is introduced in patients with aortic aneurysm. Number of cardiac interventions performed without donor blood is increased 7-31% depending on its complexity.
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Affiliation(s)
- I N Solov'eva
- Acad. B.V. Petrovsky Russian Research Surgery Center, Moscow
| | - N A Trekova
- Acad. B.V. Petrovsky Russian Research Surgery Center, Moscow
| | - I A Krapivkin
- Acad. B.V. Petrovsky Russian Research Surgery Center, Moscow
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Yaffee DW, DeAnda A, Ngai JY, Ursomanno PA, Rabinovich AE, Ward AF, Galloway AC, Grossi EA. Blood Conservation Strategies Can Be Applied Safely to High-Risk Complex Aortic Surgery. J Cardiothorac Vasc Anesth 2015; 29:703-9. [DOI: 10.1053/j.jvca.2014.10.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Indexed: 11/11/2022]
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Szelkowski LA, Puri NK, Singh R, Massimiano PS. Current trends in preoperative, intraoperative, and postoperative care of the adult cardiac surgery patient. Curr Probl Surg 2015; 52:531-69. [DOI: 10.1067/j.cpsurg.2014.10.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Yaffee DW, Smith DE, Ursomanno PA, Hill FT, Galloway AC, DeAnda A, Grossi EA. Management of Blood Transfusion in Aortic Valve Surgery: Impact of a Blood Conservation Strategy. Ann Thorac Surg 2014; 97:95-101. [DOI: 10.1016/j.athoracsur.2013.09.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 09/17/2013] [Accepted: 09/23/2013] [Indexed: 01/07/2023]
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17
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Brauer SD, Applegate RL, Jameson JJ, Hay KL, Lauer RE, Herrmann PC, Bull BS. Association of Plasma Dilution With Cardiopulmonary Bypass-Associated Bleeding and Morbidity. J Cardiothorac Vasc Anesth 2013; 27:845-52. [DOI: 10.1053/j.jvca.2013.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Indexed: 11/11/2022]
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Shaw RE, Johnson CK, Ferrari G, Brizzio ME, Sayles K, Rioux N, Zapolanski A, Grau JB. Blood transfusion in cardiac surgery does increase the risk of 5-year mortality: results from a contemporary series of 1714 propensity-matched patients. Transfusion 2013; 54:1106-13. [DOI: 10.1111/trf.12364] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/24/2013] [Accepted: 06/26/2013] [Indexed: 12/15/2022]
Affiliation(s)
- Richard E. Shaw
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Christopher K. Johnson
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Giovanni Ferrari
- University of Pennsylvania School of Medicine; Glenolden Pennsylvania
| | - Mariano E. Brizzio
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Kathleen Sayles
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Nancy Rioux
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Alex Zapolanski
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
| | - Juan B. Grau
- The Valley Columbia Heart Center; Columbia University College of Physicians and Surgeons; Ridgewood New Jersey
- University of Pennsylvania School of Medicine; Glenolden Pennsylvania
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Shaw RE, Johnson CK, Ferrari G, Zapolanski A, Brizzio M, Rioux N, Edara S, Sperling J, Grau JB. Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis. Interact Cardiovasc Thorac Surg 2013; 17:96-102. [PMID: 23537850 DOI: 10.1093/icvts/ivt124] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prior studies have found that cardiac surgery patients receiving blood transfusions are at risk for increased mortality and morbidity following surgery. It is not clear whether this increased risk occurs across all haematocrit (HCT) levels. The goal of this study was to compare operative mortality in propensity-matched cardiac surgery patients based on stratification of the preoperative HCT levels. METHODS Between 1 August 2004 and 30 June 2011, 3516 patients had cardiac surgery. One thousand nine hundred and twenty-two (54.5%) required blood transfusion during or after surgery. A propensity score for transfusion was developed based on 22 baseline variables. One thousand seven hundred and fourteen patients were matched: 857 in the transfusion group (TG) and 857 in the non-transfused control group (CG). Univariate analyses demonstrated that, after propensity matching, the groups did not differ on any baseline factors included in the propensity model. Operative mortality was defined as death within 30 days of surgery. Preoperative HCT was stratified into four groups: <36, 36-39, 40-42 and ≥ 43. RESULTS For HCT <36%, 30-day mortality was higher in the TG than that in the CG (3.0 vs 0.0%). For HCT 36-39, operative mortality was similar between TG (1.1%, N = 180) and CG (0.8%, N = 361; P = 0.748). For HCT 40-42, operative mortality was significantly higher in the TG compared with that in the CG (1.9 vs 0%, N = 108 and 218, respectively; P = 0.044). For HCT of ≥ 43, there was a trend towards higher operative mortality in the TG vs the CG (2.0 vs 0%, N = 102 and 152, respectively; P = 0.083). Other surgical complications followed the same pattern with higher rates found in the transfused group at higher presurgery HCT levels. HCT at discharge for the eight groups were similar, with an average of 29.1 ± 1.1% (P = 0.117). CONCLUSIONS Our study indicates that a broad application of blood products shows no discernible benefits. Furthermore, patients who receive blood at all HCT levels may be placed at an increased risk of operative mortality and/or other surgical complications. Paradoxically, even though patients with low HCTs theoretically should benefit the most, transfusion was still associated with a higher complication and mortality rate in these patients. Our results indicate that blood transfusion should be used judiciously in cardiac surgery patients.
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Affiliation(s)
- Richard E Shaw
- Valley Columbia Heart Center, Columbia University College of Physicians and Surgeons, Ridgewood, NJ 07450, USA
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Sá MPBDO, Soares EF, Santos CA, Figueiredo OJ, Lima ROA, Rueda FGD, Escobar RRD, Soares AMMN, Lima RDC. Predictors of transfusion of packed red blood cells in coronary artery bypass grafting surgery. Braz J Cardiovasc Surg 2012; 26:552-8. [PMID: 22358269 DOI: 10.5935/1678-9741.20110044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Accepted: 09/16/2011] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Finding predictors of blood transfusion may facilitate the most efficient approach for the use of blood bank services in coronary artery bypass grafting procedures. The aim of this retrospective study is to identify preoperative and intraoperative patient characteristics predicting the need for blood transfusion during or after CABG in our local cardiac surgical service. METHODS 435 patients undergoing isolated first-time CABG were reviewed for their preoperative and intraoperative variables and analyzed postoperative data. Patients were 255 males and 180 females, with mean age 62.01 ± 10.13 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of blood transfusion. RESULTS Blood transfusion was used in 263 patients (60.5%). The mean number of transfused blood products units per patient was 2.27 ± 3.07 (0-23) units. The total number of transfused units of blood products was 983. Univariate analysis identified age >65 years, weight <70 Kg, body mass index <25 Kg/m2, hemoglobin <13mg/dL, hematocrit < 40% and ejection fraction <50%, use of cardiopulmonary bypass (CPB), not using an internal thoracic artery as a bypass, and multiple bypasses as significant predictors. The strongest predictors using multivariate analysis were hematocrit < 40% (OR 2.58; CI 1.62-4.15; P<0.001), CPB use (OR 2.00; CI 1.27-3.17; P=0.003) and multiple bypasses (OR 2.31; CI 1.31-4.08; P=0.036). CONCLUSIONS The identification of these risk factors leads to better identification of patients with a greater probability of using blood, allocation blood bank resources and cost-effectiveness use of blood products.
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Muedra V, Delás F, Villalonga V, Gómez M, Sánchez F, Llopis JE. [Transfusion requirements, morbidity and mortality in cardiac surgery and the use of antifibrinolytic agents: a comparison of aprotinin and tranexamic acid]. ACTA ACUST UNITED AC 2011; 58:140-6. [PMID: 21534287 DOI: 10.1016/s0034-9356(11)70020-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate transfusion requirements, morbidity and mortality when 2 antifibrinolytic agents (aprotinin and tranexamic acid) were used in patients undergoing cardiac surgery. PATIENTS AND METHODS Comparison of the effects of 2 antifibrinolytic agents in 243 patients undergoing cardiac surgery between December 2006 and June 2008. We recorded the surgical procedures used, blood product transfusions required, complications (particularly renal), mortality, and length of hospital stay. RESULTS The patients were distributed into 2 groups to receive tranexamic acid (n = 144) or aprotinin (n = 99). The incidence of transfusion in the tranexamic acid group (31.94%) was nonsignificantly lower than in the aprotinin group (38.38%) (PF = .31). The mean (SD) number of units of packed red blood cells transfused was 0.67 (1.18) in the tranexamic acid group and 1.01 (1.54) in the aprotinin group (P = .07). The mean preoperative hemoglobin concentration in the tranexamic acid group (11.79 [1.71] mg/dL) was significantly lower than in the aprotinin group (12.35 [1.70] mg/dL) (P < .01). Incipient postoperative renal failure tended to occur more frequently in the aprotinin group (19.6% compared to 16%; P = .47). Mortality at 1 year was 9.02% in the tranexamic acid group (compared to 14.14% in the aprotinin group; PF-.21); the trend for mortality related to postoperative renal failure was similar (7.6% in the tranexamic acid group compared to 12.4% in the aprotinin group; P = .22). No significant differences were observed in postoperative complications or length of hospital stay. However, the lack of randomization and the small sample size do not allow for definitive conclusions. CONCLUSIONS This study, subject to the aforementioned limitations, shows that tranexamic acid is as effective as aprotinin for reducing transfusion requirements in cardiac surgery in Spain.
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Affiliation(s)
- V Muedra
- Departamento de Anestesiología-Reanimación y Terapéutica del Dolor, Hospital Universitario La Ribera, Alzira, Valencia.
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Comparison of Outcome in Jehovah's Witness Patients in Cardiac Surgery: An Australian Experience. Heart Lung Circ 2010; 19:655-9. [DOI: 10.1016/j.hlc.2010.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 07/13/2010] [Accepted: 07/14/2010] [Indexed: 11/22/2022]
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Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at four hospitals. Transfusion 2009; 50:753-65. [PMID: 20003061 DOI: 10.1111/j.1537-2995.2009.02518.x] [Citation(s) in RCA: 539] [Impact Index Per Article: 35.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Blood utilization has long been suspected to consume more health care resources than previously reported. Incomplete accounting for blood costs has the potential to misdirect programmatic decision making by health care systems. Determining the cost of supplying patients with blood transfusions requires an in-depth examination of the complex array of activities surrounding the decision to transfuse. STUDY DESIGN AND METHODS To accurately determine the cost of blood in a surgical population from a health system perspective, an activity-based costing (ABC) model was constructed. Tasks and resource consumption (materials, labor, third-party services, capital) related to blood administration were identified prospectively at two US and two European hospitals. Process frequency (i.e., usage) data were captured retrospectively from each hospital and used to populate the ABC model. RESULTS All major process steps, staff, and consumables to provide red blood cell (RBC) transfusions to surgical patients, including usage frequencies, and direct and indirect overhead costs contributed to per-RBC-unit costs between $522 and $1183 (mean, $761 +/- $294). These exceed previously reported estimates and were 3.2- to 4.8-fold higher than blood product acquisition costs. Annual expenditures on blood and transfusion-related activities, limited to surgical patients, ranged from $1.62 to $6.03 million per hospital and were largely related to the transfusion rate. CONCLUSION Applicable to various hospital practices, the ABC model confirms that blood costs have been underestimated and that they are geographically variable and identifies opportunities for cost containment. Studies to determine whether more stringent control of blood utilization improves health care utilization and quality, and further reduces costs, are warranted.
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Affiliation(s)
- Aryeh Shander
- The Institute for Patient Blood Management and Bloodless Medicine at Englewood Hospital and Medical Center, Englewood, New Jersey, USA.
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Krishnan S, Conner TM, Leslie R, Stemkowski S, Shander A. Choice of hemostatic agent and hospital length of stay in cardiovascular surgery. Semin Cardiothorac Vasc Anesth 2009; 13:225-30. [PMID: 19951982 DOI: 10.1177/1089253209351321] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemostatic agents (HAs) are efficacious in reducing blood loss during surgery, which may affect postoperative length of stay (LOS). The purpose of this study was to compare the expected and actual LOS by HA in cardiac procedures. Hospital claims data between 2003 and 2006 were extracted from a US service-level comparative database. Four cohorts for comparison were FLOSEAL, SURGICEL + thrombin, GELFOAM + thrombin, and other. Expected LOS was derived using 2006 Centers for Medicare and Medicaid LOS by diagnosis-related group, and 2-part regression models were created to assess outcome. A total of 36 950 discharges were included. FLOSEAL was associated with less likelihood of exceeding expected LOS compared with baseline (odds ratio = 0.791; P < .01). Among patients who did exceed expected LOS, FLOSEAL patients did so at a reduced rate (incidence rate ratio = 0.891; P < .01). Further assessment is warranted to distinguish products with favorable outcomes.
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Transfusion associated in-hospital mortality and morbidity in isolated Coronary Artery Bypass Graft surgery. Open Med (Wars) 2009. [DOI: 10.2478/s11536-009-0044-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AbstractTransfusion after cardiac surgery is very common. This rate varies between institutions and has remained high despite established transfusion guidelines. We analyzed our database of patients who underwent isolated CABG (Coronary Artery Bypass Graft) to determine the predictive factors of homologous transfusion and associated postoperative morbidity, mortality and resource utilization. All 14,152 patients who underwent first-time isolated CABG, with or without cardiopulmonary bypass (CPB) who had postoperative homologous transfusion between February 2002 and March 2008 in Tehran Heart Center, were evaluated retrospectively. Overall, 16.5% of patients received transfusion. Transfused patients demonstrated a significantly higher incidence of postoperative complications (cardiac, infectious, ischemic, reoperation) and mortality (p<0.001). Homologous blood transfusion effect on mortality, morbidity and resource utilization. By Multivariable logistic regression analysis adjusted for confounders: Homologous blood transfusion effect on Mortality (30-days) (OR=3.976, p<0.0001), Prolonged ventilation hours (OR=4.755, p<0.0001), Total ICU hours (β =14.599, p<0.0001), Hospital length of stay (β =1.141, p<0.0001), Post surgery length of stay (β =0.955, p<0.0001). We conclude that the isolated CABG patients receiving blood transfusion have significantly higher mortality, morbidity and resource utilization. Homologous blood transfusion is an independent factor of increased resource utilization, morbidity and mortality.
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Westbrook AJ, Olsen J, Bailey M, Bates J, Scully M, Salamonsen RF. Protocol Based on Thromboelastograph (TEG) Out-Performs Physician Preference Using Laboratory Coagulation Tests to Guide Blood Replacement During and After Cardiac Surgery: A Pilot Study. Heart Lung Circ 2009; 18:277-88. [DOI: 10.1016/j.hlc.2008.08.016] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 07/03/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022]
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Abstract
Blood has been described as the most precious and personal substance in the world. Current directions in cardiac surgery are moving away from transfusing donor “Allogeneic” blood products, and towards improving methods of saving and preserving the patient's own “autologous” blood. Nothing else comes close to the natural healing abilities and homeostasis that one's own whole blood offers. No substitute, whether it is human or artificial, will ever work as well with fluid shifts, hemostasis and homeostasis. News reports today commonly feature severe blood shortages and research documenting recognized transfusion risks such as how older stored blood can put heart surgery patients at increased risk and others that point to the morbidity and mortality associated with its use. Therefore the medical community is moving towards more effective blood utilization by minimizing the exposure to donated blood. Current techniques are saving as much as possible of the patient's own blood that might otherwise be mismanaged or lost during surgery. Techniques, such as Ultrafiltration, that quickly concentrate and reinfuse whole blood back to the patient are the best choice. Admission to discharge hemovigilance requires a concerted multidisciplinary team effort with multimodal tools available in the coagulation armamentarium to effectively avoid this form of organ transplant. Improving outcomes and reducing morbidity and mortality in cardiac surgery takes place at the microcirculatory capillary level and with control of Hemostasis. Cardiac teams need to effectively communicate and minimize blood loss and hemodilution and reverse it, for state of the art blood management in Cardiac surgery.
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Maddux FW, Dickinson TA, Rilla D, Kamienski RW, Saha SP, Eales F, Rego A, Donias HW, Crutchfield SL, Hardin RA. Institutional Variability of Intraoperative Red Blood Cell Utilization in Coronary Artery Bypass Graft Surgery. Am J Med Qual 2009; 24:403-11. [DOI: 10.1177/1062860609339384] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Franklin W. Maddux
- Specialty Care Services Group, Nashville, Tennessee, and Hospital Clinical Services Group, Brentwood, Tennessee,
| | | | - Dirck Rilla
- Hospital Clinical Services Group, Brentwood, Tennessee
| | | | - Sibu P. Saha
- Dr Saha is from University of Kentucky, Lexington, Kentucky
| | - Frazier Eales
- Minnesota Thoracic Associates, Minneapolis, Minnesota
| | - Alfredo Rego
- South Florida Heart and Lung Institute, Aventura, Florida
| | - Harry W. Donias
- Cardiovascular Surgery of Southern Nevada, Las Vegas, Nevada
| | - Susan L. Crutchfield
- Specialty Care Services Group, Nashville, Tennessee, and Hospital Clinical Services Group, Brentwood, Tennessee
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Ak K, Isbir CS, Tetik S, Atalan N, Tekeli A, Aljodi M, Civelek A, Arsan S. Thromboelastography-Based Transfusion Algorithm Reduces Blood Product Use after Elective CABG: A Prospective Randomized Study. J Card Surg 2009; 24:404-10. [DOI: 10.1111/j.1540-8191.2009.00840.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jönsson H. The Rationale for Intraoperative Blood Salvage in Cardiac Surgery. J Cardiothorac Vasc Anesth 2009; 23:394-400. [DOI: 10.1053/j.jvca.2009.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Indexed: 11/11/2022]
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Elmistekawy EM, Errett L, Fawzy HF. Predictors of packed red cell transfusion after isolated primary coronary artery bypass grafting--the experience of a single cardiac center: a prospective observational study. J Cardiothorac Surg 2009; 4:20. [PMID: 19422707 PMCID: PMC2685128 DOI: 10.1186/1749-8090-4-20] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 05/07/2009] [Indexed: 11/16/2022] Open
Abstract
Background Preoperative patients' characteristics can predict the need for perioperative blood component transfusion in cardiac surgical operations. The aim of this prospective observational study is to identify perioperative patient characteristics predicting the need for allogeneic packed red blood cell (PRBC) transfusion in isolated primary coronary artery bypass grafting (CABG) operations. Patients and Methods 105 patients undergoing isolated, first-time CABG were reviewed for their preoperative variables and followed for intraoperative and postoperative data. Patients were 97 males and 8 females, with mean age 58.28 ± 10.97 years. Regression logistic analysis was used for identifying the strongest perioperative predictors of PRBC transfusion. Results PRBC transfusion was used in 71 patients (67.6%); 35 patients (33.3%) needed > 2 units and 14 (13.3%) of these needed > 4 units. Univariate analysis identified female gender, age > 65 years, body weight ≤ 70 Kg, BSA ≤ 1.75 m2, BMI ≤ 25, preoperative hemoglobin ≤ 13 gm/dL, preoperative hematocrit ≤ 40%, serum creatinine > 100 μmol/L, Euro SCORE (standard/logistic) > 2, use of CPB, radial artery use, higher number of distal anastomoses, and postoperative chest tube drainage > 1000 mL as significant predictors. The strongest predictors using multivariate analysis were CPB use, hematocrit, body weight, and serum creatinine. Conclusion The predictors of PRBC transfusion after primary isolated CABG are use of CPB, hematocrit ≤ 40%, weight ≤ 70 Kg, and serum creatinine > 100 μmol/L. This leads to better utilization of blood bank resources and cost-efficient targeted use of expensive blood conservation modalities.
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Affiliation(s)
- Elsayed M Elmistekawy
- Division of Cardiovascular and Thoracic Surgery, St Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B1W8, Canada.
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32
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Napolitano LM. Transfusion Therapy. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bechtel JM, Detter C, Fischlein T, Krabatsch T, Osswald BR, Rieß FC, Scholz F, Schönburg M, Stamm C, Sievers HH, Bartels C. Cardiac Surgery in Patients on Dialysis: Decreased 30-Day Mortality, Unchanged Overall Survival. Ann Thorac Surg 2008; 85:147-53. [DOI: 10.1016/j.athoracsur.2007.08.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2007] [Revised: 08/19/2007] [Accepted: 08/22/2007] [Indexed: 01/04/2023]
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Whitson BA, Huddleston SJ, Savik K, Shumway SJ. Bloodless Cardiac Surgery is Associated With Decreased Morbidity and Mortality. J Card Surg 2007; 22:373-8. [PMID: 17803571 DOI: 10.1111/j.1540-8191.2007.00428.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blood transfusion with cardiac surgery accounts for 20% of transfusions in the United States. The effect of perioperative transfusion on cardiac surgery outcomes is unknown. We hypothesized that cardiac surgery with perioperative blood transfusion was associated with worse outcomes. METHODS A prospectively maintained (Society of Thoracic Surgeons) institutional database was analyzed from 2000 to 2005. All patients undergoing coronary artery bypass and/or valve operations were evaluated for the association of preoperative and intraoperative risk factors with blood transfusion. The association of transfusion with postoperative complications and mortality was evaluated. RESULTS During the study period, 2691 patients met inclusion criteria. Sixty-four percent received transfusions. Preoperative risk factors associated with transfusion (p < 0.05) were lung disease, elevated creatinine, peripheral vascular disease, and previous cardiac interventions. Patients requiring transfusion were older (mean 65.2 vs. 61.2 years, p < 0.001). Transfusion was associated with longer cross-clamp (median 78 vs. 88 minutes, p < 0.001) and perfusion times (median 114 vs. 128 minutes, p < 0.001). Perioperative blood transfusion was associated with increased postoperative complications (53.5% vs. 30.5%, p < 0.001). Significant transfusion-associated complications were renal failure, prolonged ventilation time, pneumonia, cardiac arrest, gastrointestinal complications, atrial fibrillation, stroke, myocardial infarction, and bleeding requiring reoperation. Blood transfusion was associated with an increased operative mortality (3.4% vs. 1.7%, p = 0.005) and length of stay after surgery (median 6 vs. 5 days p < 0.001). CONCLUSION Identification and management of risk factors associated with transfusion may reduce the transfusion requirement, minimize perioperative complications and improve outcomes. Bloodless cardiac surgery is associated with a decreased morbidity and mortality.
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Affiliation(s)
- Bryan A Whitson
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis, Minnesota 55455, USA
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Abstract
PURPOSE The practice of blood conservation is aimed at improving patient outcomes by avoiding allogeneic transfusions via a coordinated multidisciplinary, multipronged approach. The numerous blood conservation techniques and transfusion alternatives now available are described. SUMMARY Ongoing concerns exist regarding the availability of the nation's and the world's blood supply. In addition, the number of measures required to ensure blood safety has led to increases in the price of blood and blood products over the past 10-15 years. Moreover, blood transfusion carries inherent risks even under the most favorable circumstances. Investigations have established that injudicious transfusion is associated with development of ventilator-associated pneumonia, nosocomial infection, and organ dysfunction. Because most single blood-conservation techniques reduce blood usage by a mere 1-2 units, a series of integrated conservation approaches are required. These include preoperative autologous donation, use of erythropoietic agents, blood conservation techniques such as acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. Erythropoietic agents such as epoetin alfa have been used successfully to increase hemoglobin and decrease transfusion requirements, and are appropriate when used in advance of elective surgical procedures. Acquisition costs of erythropoietic stimulating agents versus costs of blood justify economic evaluation by hospitals to make the most cost-effective choice under current economic constraints. CONCLUSION Initiating a blood management program requires planning and support from those who are concerned about blood usage reduction and outcomes improvement. Launching a vigorous and ongoing educational program to raise awareness about the risks and hazards associated with blood transfusion is an important step in helping to reshape the medical staffs' attitudes about transfusion and the most cost-effective way to achieve clinical goals.
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Affiliation(s)
- David Jaspan
- Pharmacy Services, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001, USA.
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Abstract
PURPOSE OF REVIEW To outline the rationale, limitations, and execution of bloodless medical and surgical programs, highlighting characteristics that contribute to successful outcomes. RECENT FINDINGS Clinical experiences with patients who refuse blood transfusions for religious reasons have provided valuable lessons and raise intriguing questions about the necessity of routine blood transfusions. Healthcare centers with bloodless medicine and surgery programs feature a novel concept of patient care aimed at improving outcomes. A one-tiered approach to minimize blood usage for all patients, regardless of religious beliefs, is being successfully adopted at an increasing number of institutions. Since most single blood-conservation techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative, and postoperative conservation approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. SUMMARY The objectives of bloodless medicine and surgery programs are straightforward but require staff with expertise in transfusion medicine, intensive teamwork, patient-specific customization, careful planning, and integrated use of multimodal strategies.
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Affiliation(s)
- Aryeh Shander
- Department of Anesthesiology and Critical Care and Hyperbaric Medicine, New Jersey Institute for the Advancement of Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ 07631, USA.
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