Clinical and economic outcomes associated with blood transfusions among elderly Americans following coronary artery bypass graft surgery requiring cardiopulmonary bypass

Perioperative Transfusions in Veterans Following Noncardiac Procedures

Background: Perioperative blood transfusions are associated with increased morbidity and mortality. Each surgical specialty is associated with unique operative variables. Moreover, transfusion rates vary across specialty. This article seeks to elucidate variables both common and unique to surgical specialties. Materials and Methods: This study was a retrospective review of 5344 patients from the prospectively maintained Veterans Affairs Surgical Quality Improvement Project at a single-level 1A tertiary Veterans Affairs Medical Center. Data collected included demographic information, preoperative clinical variables, postoperative outcomes, and perioperative transfusion (within 72 hours of procedure). Patients were stratified based on whether they received a transfusion. Univariate and multivariate analyses were performed. P values <.05 were significant. Results: Of the 5344 patients included in the study, 153 required perioperative transfusion of at least one unit of packed red blood cells. Patients who underwent transfusion were more likely to be men, have an underlying bleeding disorder, and have more preoperative risk factors. Although unique risk factors were found within most specialties, there was no statistically significant difference in postoperative complications between surgical specialties. Patients requiring transfusion had higher rates of morbidity and mortality. Elevated preoperative hematocrit was significantly protective against requiring transfusion across most specialties. Conclusions: Specialty-based differences in transfusion requirement may be due to the proportion of older and more frail patients, hospital transfusion thresholds, and surgical complexity. Hematocrit, however, could be an effective target for mitigating cost and morbidity associated with transfusion. Preoperative hematocrit optimization through B12, folate, iron dosing, and erythropoietin supplementation could be a useful strategy.

Factors Associated with Perioperative Transfusions in Veterans

Background: Private sector literature demonstrates an association between perioperative transfusions and poor clinical outcomes. Hemostatic agents, surgeon training, and patient blood management programs (PBMPs) may mitigate perioperative bleeding. This study attempts to identify preoperative risk factors associated with perioperative transfusions in Veterans. Study Design and Methods: This study is a retrospective review of the prospectively maintained Veterans Affairs Surgical Quality Improvement Project database. Included patients were older than 18 years and underwent noncardiac surgery between April 1, 2016, and March 31, 2021. Data collected included demographics, surgery variables, preoperative clinical variables, postoperative outcomes, and perioperative transfusions. Cohorts were created based on transfusion status. Univariate and multivariate analyses were performed to characterize the similarities, differences, and potential predictors of perioperative transfusion. Results: Of 6108 patients included, 153 patients received perioperative transfusions. The risks for transfusion included older age, male sex, black race, smoking, and low body mass index (BMI). The highest percent of transfused patients underwent vascular (43.4%), orthopedic (22%), and general surgeries (20%). Transfusion increased risk for postoperative cerebral vascular accident (P = .041) and 30-day mortality (P < .001). Multivariate regression analysis revealed American Society of Anesthesiology class, chemotherapy within 30 days, increased age, tobacco smoking, and decreased BMI were predictive of perioperative transfusions. Discussion: Perioperative transfusions are associated with increased morbidity and mortality in the Veteran population. These retrospective data describe the complex relationships between perioperative transfusions and outcomes after noncardiac surgery. These results serve as a foundation to create predictive models and PBMP within the veteran population to decrease transfusion requirements and associated complications.

A randomized, double-blinded trial comparing the effectiveness of tranexamic acid and epsilon-aminocaproic acid in reducing bleeding and transfusion in cardiac surgery

Objectives:

To compare the effectiveness of epsilon aminocaproic acid (EACA) to tranexamic acid (TA) in reducing blood loss and transfusion requirements in patients undergone cardiac surgery under cardiopulmonary bypass.

Design:

Randomized, double blinded study. Outcome variables collected included; baseline demographic characteristics, type of surgery, amount of 24 hour chest tube drainage, amount of 24 hour blood products administered, 30 day mortality and morbidity and length of stay. We analyzed the data using parametric and non-parametric tests as appropriate.

Setting:

Single center tertiary-care university hospital setting.

Participants:

114 patients who had undergone cardiac surgery under cardiopulmonary bypass.

Interventions:

Standard dose of intra-operative EACA or TA was compared in patients undergone cardiac surgery under cardiopulmonary bypass.

Results:

There was no statistically significant difference between groups when analyzing chest tube drainage. However, there was a significant difference in the administration of any transfusion (PRBC's, FFP, platelets) intra-operatively to 24 hours postoperatively, with less transfusion in patients receiving EACA compared to TA (25% vs. 44.8%, respectively P = 0.027). Additionally, there was no significant difference in terms of adverse events during the one month follow up period.

Conclusion:

The findings of this study suggest that EACA and TA have similar effects on chest tube drainage but EACA is associated with fewer transfusions in CABG alone surgeries. Our results suggest that EACA can be used in a similar fashion to TA which may result in a cost and morbidity advantage.