Blood Product Transfusion Rates Research Articles

Transfusion Managament in Cardiac Surgery in British Columbia: Review of 8352 Patients.

AbstractAbstract 2277 Background:Transfusion of blood products remains an essential intervention during hospitalization for cardiac surgeries. Published data reveal significant variability in the patterns of transfusion of blood products among different centers. In addition, published data suggest that allogenic transfusions are associated with worse outcomes in cardiac surgery patients.This project was conducted to investigate for significant variability in transfusion practices in the management of cardiac surgery patients in the 4 cardiac surgery centers within the province of British Columbia (BC). Secondary objectives include assessing for correlation of specific patient and surgical characteristics with risk of transfusion, in addition to comparing one-year mortality in patients who received transfusions with those who did not. Methods:A retrospective review of data collected through the BC Cardiac Registry (BCCR) was performed. All adult patients who underwent cardiac surgery in BC between January 1,2008 to December 31,2010 were included. The following patients were excluded: Jehovah's witnesses, heart transplantation recipients and patients who underwent aortic aneurysm repair not including aortic valve surgery. In patients who underwent more that one surgery within 365 days, data were only collected for the first cardiac surgery.The following data were collected: age, gender, type of surgery, clinical urgency, institution, preoperative hemoglobin, preoperative eGFR, duration of cardio-pulmonary bypass and use of cell saver technology. Mortality data over 1 year post operatively and quantities of packed red blood cells (PRBCs), frozen plasma (FP), platelets and cryoprecipitate (cryo) transfused during surgery and within 30 days afterwards were also collected. Cardiac surgery centers were anonymized.Chi-square test and Fisher exact test were used to analyze variation in transfusion requirements. Kaplan-Meir curves will be created for estimation of survival. Multivariate regression analysis will be used to identify risk factors for transfusion. Results:After excluding patients as outlined above, 8352 patients were included in the analysis.A summary of transfusion rates of different blood products in different types of cardiac surgeries among different centers is summarized in table 1.Statistical analysis is currently in progress to assess for association between transfusion of blood products and survival, in addition to multivariate analysis to identify risk factors for transfusion. Conclusions:Significant differences are noted in transfusion requirement of PRBCs, FP and platelets during and within 30 days of cardiac surgery among the four different cardiac surgery centers in British Columbia. The differences are not accounted for by surgery type alone. Further research is required to identify factors to account for the observed variability. Consideration will be made for development of further measures for standardization of transfusion management in this patient group.Table 1:Rates of transfusion of different blood products classified by type of surgery and surgical center. Letters A-D represent anonymized surgical centers. CHD: Congenital heart diseaseSurgery type, number of patients (%)Blood productsPatients who received transfusions by surgical center %p-ValueABCDBCCABG, N= 5326 (63.8)PRBCs61.438.2927.2341.9742.79<0.0001FP11.052.7521.1820.1413.93<0.0001Platelets16.572.189.6319.6512.41<0.0001Cryo0.280.890.480.210.450.0459Pure valve, N=1376 (16.5)PRBCs57.7236.231.8333.5338.88<0.0001FP11.748.928.9827.4920.13<0.0001Platelets10.743.6814.0127.7914.17<0.0001Cryo1.341.530.241.211.020.1963CABG+valve, N=1121 (13.4)PRBCs79.2162.4153.9851.3361.82<0.0001FP18.288.2839.135.7425.16<0.0001Platelets17.924.8324.2239.5421.23<0.0001Cryo2.870.341.381.91.610.0919CABG+valve+other, N=137 (1.6)PRBCs95.2462.354.5545.4562.770.0041FP19.0511.4839.3927.2721.90.0160Platelets19.056.5618.1845.4517.520.0008503Cryo4.761.64001.460.4434Valve+other, N=230 (2.8)PRBCs67.6538.6742.1931.5842.170.0072FP17.655.335047.3730<0.0001Platelets20.591.3331.2540.3522.17<0.0001Cryo003-131.751.30.3441CHD repair N=162 (1.9)PRBCs5038.8928.5733.3335.190.2327FP13.3316.6730.1639.2228.40.0551Platelets3.335.5611.1127.4514.20.0107Cryo05.5603.921.850.1448 Disclosures:No relevant conflicts of interest to declare.

109 The Impact of Differences in Practice Patterns on Rates of Blood Product Transfusion Following Cardiac Surgery

109 The Impact of Differences in Practice Patterns on Rates of Blood Product Transfusion Following Cardiac Surgery

Safety of cardiac surgery without blood transfusion: a retrospective study in Jehovah’s Witness patients

We read with interest the experience of El Azab et al. [1] of providing a cardiac surgery service to Jehovah’s Witness patients. We agree that patients who refuse allogeneic blood products present both moral and ethical challenges, especially in cardiac surgery where significant blood loss and allogeneic blood product transfusion are common. We noted that the pre-operative haemoglobin concentrations were very similar in both groups, despite 3 weeks' treatment with erythropoietin, and the number of patients in the control group who received blood product transfusion was very high. We work in a busy cardiothoracic centre with a blood product transfusion rate of 20–25% compared to 65% in the control group in their article. Knowledge of their patients’ postoperative haemoglobin concentrations would have been interesting, but this information was not provided. Cell salvage and autologous transfusion is an important component of blood conservation, but this was not part of this hospital’s protocol for managing Jehovah’s Witness patients. Cell salvage is usually acceptable to Jehovah’s Witnesses, but consent needs to be obtained on an individual basis. The 2009 Association of Anaesthetists of Great Britain and Ireland guidelines recommend the use of cell salvage in cases where patients have objections to receiving allogeneic blood product transfusions [2]. In cardiac surgery cell salvage can be used both intra- and postoperatively. The benefits of intra-operative cell salvage are the salvage of blood before and after cardiopulmonary bypass and reduction of the volume of cardiotomy blood that is returned to the patient. The re-infusion of cardiotomy blood has been implicated with the development of a coagulopathy and increased blood loss [3], increased incidence of postoperative neurocognitive dysfunction [4] and the development of systemic inflammatory response syndrome [5]. Blood can also be salvaged postoperatively from surgical drains. We feel that cell salvage is an essential component of blood conservation and should be used in all Jehovah’s Witness patients who consent to its use. No external funding and no competing interests declared. Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.

Activated recombinant factor VII for refractory bleeding during extracorporeal membrane oxygenation*

To determine the frequency of adverse events with the use of activated recombinant factor VII during extracorporeal membrane oxygenation support and to quantify the effect on bleeding parameters. Retrospective case series from January 1999 to August 2006. Pediatric intensive care unit at a tertiary academic children's hospital. Seventeen patients received a total of 26 doses of activated recombinant factor VII while supported on extracorporeal membrane oxygenation or within 3 hrs of initiation of extracorporeal membrane oxygenation support from February 2003 to August 2006, and 23 historical controls from January 1999 to December 2002 with bleeding complications reported to the Extracorporeal Life Support Organization database while supported on extracorporeal membrane oxygenation before the use of activated recombinant factor VII. None. No significant difference in the rate of thromboembolic complications, extracorporeal membrane oxygenation circuit failures, or mortality was found between the patients and historical controls. No trend toward increased survival was found, and a significant number of circuit complications was seen in both groups. In patients treated with activated recombinant factor VII, a significant reduction in chest tube output and blood product transfusion rates was seen within 5 hrs of activated recombinant factor VII administration. Activated recombinant factor VII administration during extracorporeal membrane oxygenation support was associated with a decrease in bleeding severity (indicated by chest tube output and blood product transfusion rates) and was not associated with an increased rate of thromboembolic complications.

Aortic Surgery Using Total Miniaturized Cardiopulmonary Bypass

Few centers have attempted aortic surgery using miniaturized cardiopulmonary bypass (MCPB) systems due to concerns of air handling. The extra corporeal circuit optimized (ECCO) total MCPB system uses a venous air removal device and a parallel soft-shell reservoir that allows for venting of the heart. At our institution, total MCPB is used for all coronary artery bypass graft patients. Our objective was to assess the suitability of the ECCO total MCPB system during aortic surgery. Fifty consecutive and unselected aortic procedures using the ECCO system were undertaken. Surgical feasibility, air removal ability, and blood transfusion requirements were audited to determine the efficacy of this technique. The bypass time was 81.6 +/- 28.0 minutes and the ischemic time was 56.7 +/- 18.9 minutes. Total MCPB handled 1,910 +/- 404 mL of vented blood with 96 venous air removal device activations noted. The blood product transfusion rate was 12%, which was below the surgical transfusion rate for our unit. There were no complications. Aortic surgery can be undertaken safely and effectively using the ECCO total MCPB system.

Outcome Analysis of Blood Product Transfusion in Trauma Patients: A Prospective, Risk‐Adjusted Study

Studies have confirmed adverse outcome associated with transfusion of packed red blood cells (PRBCs) in trauma; however, little data are available regarding other blood product transfusion, such as fresh frozen plasma (FFP) and platelets. The objective of this study was to examine risk-adjusted outcome in trauma with stratification by blood product type. Prospective data were collected daily for 1,172 consecutive trauma patients admitted to the intensive care unit (ICU) during a 2-year period, including transfusion rates of blood products (PRBCs, FFP, platelets). Outcome assessment included infection rate, ventilator days (Vdays), ICU and hospital length of stay (LOS), and mortality. Blood products were transfused in 786 (67%) patients. The study cohort had a mean age of 43 +/- 21 years and Injury Severity Score (ISS) of 24 +/- 13. Although the majority of patients were men, women were more likely to be transfused (p < 0.001). Mean transfusion rates of PRBCs (5.5 +/- 9.6 U), FFP (5.4 +/- 11.4), and platelets (3.7 +/- 11.1) were high. Univariate analysis identified that blood product transfusion (any type) was associated with a significantly greater infection rate (34% vs. 9.4%; p < 0.001), hospital LOS (18.6 vs. 9 days; p < 0.001), ICU LOS (13.7 vs. 7.4 days; p < 0.001), Vdays (12.9 vs. 6.3 days; p < 0.001), and mortality (19% vs. 8.3%; p < 0.001). Multivariate analysis (risk-adjusted for severity of injury by ISS, age, sex, and race, and stratified by blood product type) confirmed that risk of infection increased by 5%, and hospital LOS, ICU LOS, and Vdays increased by 0.64, 0.42, and 0.47 days, respectively, for every unit of PRBCs given. Risk of death increased by 3.5% for every unit of FFP transfused. There is a dose-dependent correlation between blood product transfusion and adverse outcome (increased mortality and infection) in trauma patients.

Prevalence of claustrophobia and magnetic resonance imaging after coronary artery bypass graft surgery

The purpose of this study was to determine the prevalence of claustrophobia in patients undergoing magnetic resonance imaging (MRI) after coronary artery bypass graft (CABG) surgery. After IRB approval, we conducted a substudy of a prospective randomized controlled clinical trial of 311 patients evaluating administration of tranexamic acid and early saphenous vein graft patency with MRI after conventional CABG surgery. Chest tube drainage was measured at 6, 12, and 24 hours after surgery. The rate of transfusion and the amount of red blood cells (RBC), fresh frozen plasma (FFP), and platelets transfused were recorded. A total of 237(76%) patients underwent MRI after surgery. 39 (14%, [95% CI, 10.2 to 18.0]) patients experienced severe anxiety caused by a fear of enclosed space in the MRI coil necessitating termination of the procedure. Patients with claustrophobia were on average 5 years younger. They were more likely to have diabetes mellitus and hypertension. Patients with claustrophobia had increased chest tube drainage during the postoperative period. The rate of blood product transfusion was similar between the two groups but patients with claustrophobia who were transfused received significantly more RBC and FFP than patients without claustrophobia. Postoperative claustrophobia and anxiety, leading to inability to undergo MRI, may be more common than previously described.

The real-world outcomes of off-pump coronary artery bypass surgery in a public health care system

The population-based results of off-pump coronary artery bypass surgery (OPCAB) in a public health care system have not been reported. The study objective was to compare the one-year outcomes of OPCAB with those of the standard on-pump coronary artery bypass surgery (ONCAB) in the province of Ontario. The present study was a retrospective, population-based study (n=15,172, with 1660 OPCAB patients) undertaken in fiscal years 2000 and 2001 using clinical and administrative data. Multivariate regression modelling for risk adjustment and propensity matching were used to compare OPCAB with ONCAB for one-year outcomes, including death, repeat revascularization and cardiac readmission. The rate of OPCAB was 11%, with institutional rates ranging from 3% to 51%. OPCAB patients were more likely to be female and older than 79 years of age, with peripheral vascular disease and higher socioeconomic status. OPCAB patients were less likely to have surgically significant coronary disease, poor left ventricular function, an urgent status, congestive heart failure and diabetes. The risk-adjusted one-year composite outcome was higher for OPCAB (11.8%, 95% CI 10.40% to 13.29%) than ONCAB (10.8%, 95% CI 10.23% to 11.27%); however, this difference was eliminated with propensity matching. OPCAB patients had shorter hospital lengths of stay and lower blood product transfusion rates than ONCAB patients. Despite the minimal use of OPCAB in Canada's public health care system, outcome rates are similar to those of ONCAB. The benefits of OPCAB observed in randomized trials, including shorter hospital lengths of stay and lower transfusion rates, remained true in the investigators' real-world experience. The results OPCAB were at least equivalent to those of ONCAB.

Tranexamic Acid Infusion Reduces the Rate of Human Blood Product Transfusion during Skull Base Tumor Surgery

Tranexamic Acid Infusion Reduces the Rate of Human Blood Product Transfusion during Skull Base Tumor Surgery

Effect of Clopidogrel Premedication in Off-Pump Cardiac Surgery

Premedication with clopidogrel has reduced thrombotic complications after percutaneous coronary revascularization procedures. However, because of the enhanced and irreversible platelet inhibition by clopidogrel, patients requiring surgical revascularization have a higher risk of bleeding complications and transfusion requirements. A principal benefit of surgical coronary revascularization without cardiopulmonary bypass is its lower hemorrhagic sequelae. The purpose of this study was to evaluate the effect of preoperative clopidogrel administration in the incidence of hemostatic reexploration, blood product transfusion rates, morbidity, and mortality in patients undergoing off-pump coronary artery bypass graft surgery using a large patient sample and a risk-adjusted approach. Two hundred eighty-one patients (17.9%) did and 1291 (82.1%) did not receive clopidogrel before their surgery, for a total of 1572 patients undergoing isolated off-pump coronary artery bypass graft surgery between January 2000 and June 2002. Risk-adjusted logistic regression analyses and a matched pair analyses by propensity scores were used to assess the association between clopidogrel administration and reoperation as a result of bleeding, intraoperative and postoperative blood transfusions received, and the need for multiple transfusions. Hemorrhage-related preoperative risk factors identified in the literature and those found significant in a univariate model were used. The clopidogrel group had a higher likelihood of hemostatic reoperations (odds ratio [OR], 5.1; 95% confidence interval [CI], 2.47 to 10.47; P<0.01) and an increased need in overall packed red blood cell (OR, 2.6; 95% CI, 1.94 to 3.60; P<0.01), multiple unit (OR, 1.6; 95% CI, 1.07 to 2.48; P=0.02), and platelet (OR, 2.5; 95% CI, 1.77 to 3.66; P<0.01) transfusions. Surgical outcomes and operative mortality (1.4% versus 1.4%; P=1.00) were not statistically different. Clopidogrel administration in the cardiology suite increases the risk for hemostatic reoperation and the requirements for blood product transfusions during and after off-pump coronary artery bypass graft surgery.

A propensity score case‐control comparison of aprotinin and tranexamic acid in high‐transfusion‐risk cardiac surgery

Cardiac surgery with cardiopulmonary bypass may result in excessive fibrinolysis and platelet (PLT) dysfunction, resulting in impaired hemostasis and excessive blood loss. Prophylactic use of the antifibrinolytic drugs aprotinin and tranexamic acid is thought to prevent these hemostatic defects. Their relative clinical utility and safety in high-transfusion-risk cardiac surgery, however, is not known. Using propensity scores, 449 patients who received aprotinin for high-transfusion-risk cardiac surgery were matched to 449 patients who received tranexamic acid from a pool of 10,870 consecutive patients who underwent cardiac surgery at a single center, 586 of whom received aprotinin and the remainder of whom received tranexamic acid. The two matched groups were well balanced in terms of measured perioperative variables. Blood product transfusion rates were similar in the aprotinin and tranexamic acid groups: red blood cells, 79 percent versus 76 percent (p = 0.3); PLTs, 56 percent versus 50 percent (p = 0.06); and plasma, 66 percent versus 61 percent (p = 0.1). Adverse events rates were comparable in the two groups, except for renal dysfunction (defined as a greater than 50% increase in creatinine concentration during the first postoperative week to >100 micromol/L in women and >110 micromol/L in men or a new requirement for dialysis support), which occurred in 24 percent (107/449) of aprotinin patients and 17 percent (75/449) of tranexamic acid patients (p = 0.01). Aprotinin and tranexamic acid have similar hemostatic effectiveness in high-transfusion-risk cardiac surgery. Within the confines of propensity score matching, our results suggest that aprotinin may be associated with renal dysfunction.

Tranexamic acid and early saphenous vein graft patency in conventional coronary artery bypass graft surgery: A prospective randomized controlled clinical trial

Use of antifibrinolytic agents reduces the risk of bleeding and decreases the need for blood product use in patients undergoing cardiac surgery. The purpose of this study was to determine whether perioperative use of tranexamic acid decreases the rate of saphenous vein graft patency in the early postoperative period after conventional coronary artery bypass grafting surgery. A total of 312 patients scheduled for elective coronary artery bypass grafting surgery with cardiopulmonary bypass were randomized to receive either tranexamic acid 100 mg/kg (n = 147) or placebo (n = 165) in a double-blinded fashion before the initiation of cardiopulmonary bypass. Saphenous vein graft patency was assessed with magnetic resonance imaging 5 to 30 days after surgery. Both groups were comparable with respect to baseline demographic data and surgical characteristics. A total of 237 (76%) patients underwent magnetic resonance imaging assessment. A total of 297 saphenous vein grafts were performed and 253 (85.2%; 95% confidence interval, 83.5%-86.9%) were seen in the tranexamic acid group, and 265 saphenous vein grafts were performed and 231 (87.2%; 95% confidence interval, 85.5%-88.9%) were seen in the placebo group (P = .4969). The blood loss and blood product transfusion rates in the tranexamic acid group were significantly lower than in the placebo group. There was no difference between groups with respect to postoperative morbidity and mortality. The administration of tranexamic acid before cardiopulmonary bypass did not seem to compromise early venous graft patency rates but reduced perioperative blood product transfusion rates. Consequently, tranexamic acid could be advocated for routine use in patients undergoing conventional coronary artery bypass grafting surgery.

Blood Component Transfusion in Primary Coronary Artery Bypass Surgery in Kuwait

Objective: The aims of this study were to determine the rate of blood product transfusion, associated perioperative factors and cost of such blood product transfusion in primary coronary artery bypass surgery (CABG). Subjects and Methods:The medical records of 159 consecutive primary CABG patients (142 male, 17 female) from January 1, 2003 to June 30, 2003 at Chest Diseases Hospital, Kuwait, were reviewed. Urgent and emergency cases were included. Results: The mean age of the patients was 57.2 (range 36–77 years). Overall, 128 (80.5%) patients received blood product transfusion during primary CABG: 113 (70.5%) packed red blood cells (RBC), 54 (33.9%) fresh frozen plasma, and 13 (8%) platelets. Overall, 23 patients (12.6%) received more than two RBC transfusions intraoperatively. Significant factors for intraoperative RBC transfusion were: age >60 years, female gender, preoperative hemoglobin <12 g/dl, and 3 or more coronary bypass grafts constructed. One hundred and fifty-nine patients consumed 342 units of RBC at an average of 2.1 RBC units per patient. The cost per patient was 80 Kuwaiti dinar (KD; USD 240). Conclusion:The findings indicate a high rate of blood component transfusion in primary CABG patients in Kuwait that could expose the patients to the possible adverse effects, and such transfusions have high economic impact.

Identifying Patients at Risk of Intraoperative and Postoperative Transfusion in Isolated CABG: Toward Selective Conservation Strategies

Background Allogeneic blood product use during cardiac operation is often reported to exceed 40% despite published guidelines and costly blood conservation strategies. We developed a predictive model, based on eight preoperative risk factors, of allogeneic blood product transfusion rates in patients undergoing a cardiac procedure. Methods All 3,046 consecutive, isolated coronary artery bypass graft (CABG) procedures at a university hospital from 1995 to 1998 were included. A logistic regression model was created to identify independent predictors of allogeneic blood product transfusion. This model was validated using a prospective patient sample. Results Overall use of allogeneic blood products was 23% with a crude operative mortality of 2.1%. In isolated, elective, first-time CABG cases, 16.9% received allogeneic blood products. Independent predictors of blood product usage in CABG patients were preoperative hemoglobin 12.0 or less, emergent operation, renal failure, female sex, age 70 years or older, left ventricular ejection fraction 0.40 or less, redo procedure, and low body surface area. Prospective validation of this model on 2,117 consecutive isolated CABG patients demonstrated an observed-to-expected allogeneic blood product transfusion rate ratio of 1.06. Conclusions This internally validated logistic regression risk model is a sensitive and specific predictor of allogeneic blood product use in patients undergoing isolated CABG. Utilization of this model allows for preoperative risk stratification and may allow for more rational resource allocation of costly blood conservation strategies and blood bank resources.

Aprotinin for coronary bypass operations: Efficacy, safety, and influence on early saphenous vein graft patency

The purpose of this study was to evaluate the efficacy and safety of aprotinin in a U.S. population of patients undergoing coronary artery bypass grafting. Early vein graft patency rates were assessed by ultrafast computed tomography. A total of 216 patients at five centers were randomized to receive either high-dose aprotinin or placebo during the operation; 151 patients underwent primary operation, and 65 underwent repeat procedures. Total blood product exposures in the primary group were 2.2 per patient receiving aprotinin as compared with 5.7 per patient receiving placebo (p = 0.010). The repeat group had 0.3 exposures per patient receiving aprotinin as compared with 10.7 per patient receiving placebo (p = < 0.001). Consistent reductions in the percent of patients requiring donor red blood cells and in the number of units of platelets, fresh frozen plasma, and cryoprecipitate required were associated with the use of aprotinin in both primary and repeat groups. Mortality was 5.6% in the aprotinin group and 3.7% in the placebo group (p = 0.517). In the primary group, clinical diagnoses of myocardial infarction were made in 8.9% of patients receiving aprotinin as compared with 5.6% of the patients receiving placebo (p = 0.435). In the repeat group, infarctions occurred in 10.3% of patients receiving aprotinin and 8.3% of patients receiving placebo (p = 1.000). Secondary analysis of electrocardiograms and available enzyme data showed no significant difference in infarction rates between the treatment groups. There was no difference in clinically significant renal dysfunction. The early vein graft patency rates were 92.0% in the aprotinin group and 95.1% in the placebo group (p = 0.248). In this study, aprotinin was effective in reducing bleeding and blood product transfusion rates, and its use was not associated with an increase in complications. An adverse effect on early vein graft patency rates was not demonstrated, but the number of grafts assessed was insufficient for absolute conclusions in this regard.