Perioperative transfusion practice in patients undergoing lung transplantation – experience from a 7-year period

Abstract

Introduction Perioperative allogenic blood product transfusion is common in lung transplantation (LTx), particularly after an increased utilization of extracorporeal membrane oxygenation (ECMO) throughout the peritransplant period. The risks of massive transfusion of blood products are well-known, and may negatively influence LTx outcomes (1). We analyzed perioperative transfusion practice among the LTx recipients at our institution. Methods All consecutive patients who underwent LTx at Harefield Hospital between January 2012 and December 2018 were analyzed. Patients bridged to LTx with ECMO and preoperatively mechanically ventilated were included. Data were extracted from our institutional electronic system. The use of red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLT) intraoperatively and postoperatively within the first 48 hours was investigated. Transfusion of >10 units of RBCs was considered as massive transfusion. Results A total of 304 LTx recipients (male gender 54.9%, mean age 45.9±12.3 years) underwent bilateral sequential single LTx (97.4%) or single LTx (2.6%). The most common diagnosis was cystic fibrosis (CF; 42.4%). Re-transplantation was performed in 3.3%. The percentage of recipients bridged to LTx with ECMO was 9.2% (20 patients with veno-venous [VV] ECMO, 5 with veno-arterial [VA] ECMO and 3 with Novalung). Intraoperative ECMO was required in 30 (9.9%) patients (11 VV ECMO/19 VA ECMO) and cardiopulmonary bypass (CPB) in 107 (35.2%), whereas 167 (54.9%) patients were operated off-pump. Postoperatively, ECMO was utilized in 35 (11.5%) patients (24 VA ECMO/10 VV ECMO/1 Novalung). Of these, 26 (74.3%) patients required conversion to ECMO following unsuccessful weaning from CPB, 6 (17.1%) continued to be supported after intraoperative ECMO, and 3 (8.6%) were initially operated off-pump. The median number of RBCs in the first 48 hours was 4 (0-71) units, FFP 2 (0-37) and PLT 1 (0-21). The overall incidence of patients requiring >10 units of RBCs in the first 48 hours was 22.1%, including all patients with idiopathic pulmonary arterial hypertension (IPAH), 50% of patients who underwent re-transplantation, and 31.8% of patients with CF. Patients who needed intraoperative MCS support had a higher incidence of massive transfusion (43% in the CPB group vs. 40% in the ECMO group vs. 5.4% in the off-pump group). The overall 30-day mortality rate was 6.9%, which increased to 23.9% among patients with massive transfusion. Discussion We performed a descriptive analysis of perioperative transfusion practice in a tertiary centre over a 7-year period and showed that MCS, IPAH, re-transplantation, and CF were associated with massive transfusion. Overall, we demonstrated a reasonably low incidence of perioperative blood transfusion and excellent 30-day survival. Further analysis is needed to investigate which perioperative factors may help minimize allogenic blood product usage in LTx and improve postoperative outcomes.