The variability of transfusion practice in coronary artery bypass surgery. Transfusion Medicine Academic Award Group

We audited 540 patients undergoing elective first-time coronary artery bypass grafts at 18 institutions. The purposes of the study were to describe the variability in transfusions among institutions and to determine factors that may account for variability. Mean homologous red blood cell use per patient was 2.9(+/- 0.1) U (institutional range, 0.4 to 6.3 U). One hundred seventy-seven patients (32%) received plasma (institutional range, 0% to 97%), and 119 (22%) received platelets (institutional range, 0% to 80%). After controlling for patient and surgical practice variables, transfusion practice factors still accounted for variation in red blood cell transfusions. Variation in patients receiving plasma and platelet transfusions among institutions was determined in part by prophylactic transfusions. We conclude that blood component usage for coronary artery bypass grafts differs widely among institutions. The variability in use of these components is accounted for in part by unnecessary transfusions in otherwise routine, uncomplicated coronary artery bypass graft procedures.     

Transfusion practices among patients who did and did not predonate autologous blood before elective cardiac surgery

BACKGROUND: Preoperative autologous blood donation is commonly used to reduce exposure to allogeneic transfusions among patients undergoing elective cardiac surgery. However, this technique is associated with an overall increase in transfusions (allogeneic or autologous). The authors assessed the impact of transfusion decision-making on the effectiveness of preoperative autologous donation in reducing the frequency of allogeneic transfusions, and its impact on the increased transfusion rate associated with preoperative autologous donation in cardiac surgery. METHODS: This retrospective analysis compared transfusion practices among 176 patients who predonated autologous blood before elective cardiac surgery and 176 matched cardiac surgery patients who did not predonate blood. The impact of decision-making on transfusion exposure was determined using multivariate analyses to account for major perioperative interventions and complications. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for exposure to allogeneic blood transfusion or any transfusion, before and after exclusion of transfusions not conforming with selected transfusion criteria. RESULTS: Exposure to allogeneic transfusion was more likely among patients who did not predonate blood than among those who did predonate blood (OR 14.0, 95% CI 5.8-33.8). This finding was still true after exclusion of transfusions not meeting the transfusion criteria (OR 19.3, 95% CI 6.7-55.7). The autologous blood donors were more likely than the nondonors to receive any transfusion (OR 10.8, 95% CI 5.7-20.3). However, this association was substantially attenuated after exclusion of transfusions not meeting the transfusion criteria (OR 1.9, 95% CI 1.1-3.2). INTERPRETATION: Patients who predonated blood before elective cardiac surgery were at lower risk of receiving allogeneic transfusions than the nondonors. This was not because of a deliberate withholding of allogeneic transfusions from autologous donors. However, more liberal transfusion criteria for autologous blood were largely responsible for the increased transfusion rate among the autologous donors.     

Autologous blood donation for elective surgery. Effect on physician transfusion behavior

The hospital records of 69 autologous blood donors undergoing elective surgical procedures and those of matched controls were reviewed in an effort to assess whether autologous blood donation altered physician transfusion behavior. Physicians tolerated significantly lower admission (0.372 vs 0.437 [37.2% vs 43.7%]), nadir (0.304 vs 0.334 [30.4% vs 33.4%]), and discharge (0.326 vs 0.358 [32.6% vs 35.8%]) hematocrits in patients with autologous blood predeposits compared with matched controls. Additionally, 44 patients undergoing orthopedic procedures stored insufficient blood to prevent homologous blood exposure; ten of 17 patients could have avoided homologous blood if 4 U of autologous blood had been stored. Twenty-five patients undergoing nonorthopedic procedures stored an insufficient volume of blood to satisfy an unexpected transfusion need but were given transfusions of more than needed amounts of their own blood when transfusion was not clinically indicated. Future studies designed to maximize procurement of autologous blood are needed; a salutary effect on physician transfusion behavior would then be coupled with an autologous blood inventory that could eliminate homologous blood exposure in these patients.     

体外循环心内直视手术减少异体输血的探讨

目的 探讨体外循环心内直视手术少输或不输异体血的方法.方法 对体外循环心内直视手术病人应用术前自体储血,血液回收机回收术中失血以及术前应用促红细胞生成素等综合血液保护方法.结果 实行血液保护措施病人输异体血量为0～2 400mL,平均185 mL/例,对照组输异体血量为300～3 600mL,平均520mL/例,差异有显著性（P＜0.05）.实行血液保护措施病人中41.3%不输异体血,对照组为12%,差异有显著性（P＜0.05）.结论 通过多种血液保护方法可明显减少体外循环心内直视手术的异体输血量.     

Patterns of red blood cell use in southeastern Wisconsin

We conducted a retrospective study of red blood cell use in southeastern Wisconsin to characterize transfusion practices and provide data for designing educational programs. Charts of 533 patients who received 3,006 units of blood at ten hospitals were reviewed. Demographic, diagnostic, surgical, and laboratory data and indications for transfusion were obtained. Mean blood use per patient (U/pt) was 5.6, 7.2, and 4.1 units for all patients, surgical and non-surgical, respectively. Fifty percent of the patients underwent surgery, used 64% of the blood, and required more postoperatively (4.2 U/pt) than intraoperatively (2.8 U/pt). Open-heart surgeries required 32% of all blood. Eighty-two percent of postoperative transfusions occurred when the hematocrit was less than or equal to 30%. Only 2.8% of eligible elective surgery patients made pre-deposit autologous donations and contributed 1% of the total blood used.     

晶体停搏液与氧合血停搏液结合应用于重症心脏病手术心肌保护的临床观察

目的回顾分析66例成人重症心脏病手术病人采用晶体停搏液与氧合血停搏液联合应用心肌保护的临床效果。方法对66例采用晶体停搏液与氧合血停搏液联合心肌灌注方法的成人重症心脏病手术病人的体外循环的资料,包括体外循环时间,主动脉阻断时间,自动复跳率,心脏停搏时间,主动脉开放后心肌复跳时间等指标进行回顾性分析。结果全组病例体外循环时间为63～268 min,平均（131.5±47.8）min,主动脉阻断时间为38～146 min,平均（88.4±45.1）min,自动复跳64例（97%）,心脏停搏时间15～220 min,平均（87.9±63.1）min。主动脉开放后心肌复跳时间5～700 s,平均（181±159）s。电击复跳2例（3%）。转中尿量300～800 ml,平均（422±110）ml。转中常规超滤及零平衡超滤,超滤液1 200～2 500 ml,平均（1 600±420）ml。术中出血量300～1550 ml,平均（630±240）ml,术中输血量600～1 200 ml,平均（840±230）ml。术后死亡1例（1.5%）,死于低心排出量综合征。其余患者顺利出院。结论采用晶体停搏液与氧合血停搏液联合应用于重症心脏病手术心肌保护方法临床效果良好。     

心脏外科主要手术出血患者输血模式

目的 了解心脏外科主要手术出血患者的围手术期输血模式,为促进临床合理、规范用血提供数据参考。方法 从2015至2016年开展的全国多中心(4家医院)调查中,纳入大血管手术、冠状动脉旁路移植手术、心脏瓣膜手术和先天性心脏病手术患者(≥18岁),描述患者特征及术后结局,探讨其出血情况,围手术期自体、异体血(红细胞、血浆、血小板)的输注模式(比例、输注量及组合方式)。结果 术中心脏瓣膜手术自体血输注比例最高(58.84%),而大血管手术自体血输注量最大(722 ml),且异体血术中输注比例(53.28%)尤其是血小板输注比例(39.34%)显著高于其他手术患者。相对异体红细胞,其他成分在各类手术中的输注时机较为集中,其中单独输注血浆比例在术后1 d最高。随着出血量增加,成分联合输注比例逐渐上升为主要的输血方式。结论 不同心脏手术类型、围手术期阶段或出血量下,患者的输注模式存在差异,需要在了解现况的基础上进一步研究有针对性的输血实践方案,节约血液并提高患者输血安全。     

A large-scale autologous blood program in a community hospital. A contribution to the community's blood supply

In an attempt to eliminate the hazards of homologous blood transfusions during major orthopedic surgical procedures, 1672 patients donated 6615 units of autologous blood in a ten-year period. Most of the blood components were stored frozen. The autologous units were later used in 1938 surgical procedures. Intraoperative blood salvage yielded 125,105 mL of blood with an average hematocrit of 80% (0.80), which was reinfused into 934 patients. Autologous blood components accounted for 95% of the transfusion requirements. Thus, the risks of homologous transfusions were avoided in the vast majority of the procedures. Ninety-one percent of the donors were older than 50 years of age and 8.4% were between 80 and 91 years of age. The large-scale use of autologous blood has been feasible, practical, and cost efficient, has contributed to the community's blood supply, and provides the patient with the safest blood available--his own blood.     

心脏退行性瓣膜病合并冠心病同期手术治疗

目的:总结老年退行性瓣膜手术和冠状动脉旁路移植术(CABG)同期施行的效果和临床经验。方法:2011年1月-2012年12月同期行退行性瓣膜手术与冠状动脉旁路移植术的老年患者63例,其中男37例,女26例,年龄60～72岁,平均年龄(65±4)岁。退行性瓣膜疾病合并冠心病42例,冠心病合并退行性瓣膜病21例。同期行冠状动脉旁路移植术合并瓣膜置换58例,其中双瓣膜置换5例,合并三尖瓣成形术15例,合并带瓣人工血管置换(Bentall)手术1例,合并室壁瘤切除术1例,合并左房血栓清除术2例;合并单瓣膜成形术7例。冠状动脉造影显示单支血管病变15例,双支16例,多支32例。结果:本组早期病死3例(4.8%),共出现并发症8例(12.7%);患者中2例死于重症感染引发的多器官功能衰竭,1例死于低心排综合征。低心排综合征2例,再次开胸止血3例,呼吸衰竭2例,室颤1例,脑栓塞2例均治愈。手术后随访43例,随访时间1～60个月,随访期间无死亡,患者生活质量明显改善。结论:老年患者退行性瓣膜手术及冠状动脉旁路移植术同期施行手术效果满意,具有安全可行性。     

Emergency off-pump coronary artery surgery

Background Off-pump coronary artery bypass grafting is fast-becoming a procedure of choice for elective revascularization in high-risk patients with multi-vessel coronary artery disease. However, the role of off-pump coronary artery bypass grafting for patients with acute coronary syndromes requiring emergency revascularization still requires validation. We present our experience to show the feasibility of off-pump coronary artery surgery as an emergency revascularization technique. Methods From April 2001 to September 2003, emergency (operation within 24 hours after hospitalization) coronary artery bypass grafting without cardiopulmonary bypass (CPB) was performed in 66 patients with a mean age of (66.9±5.4) years (range 49-72 years). They presented acute coronary syndromes with 38 patients on platelet glycoprotein Ⅱb/Ⅲa receptor antagonists. All patients underwent off-pump coronary artery bypass surgery via sternotomy with the intention of complete coronary revascularization.Results An average of 2.9 grafts per patient were performed and the posterior descending artery and marginal branches of the circumflex artery were grafted in 83.3% of the patients. There were 4 events of intraoperative cardiac instability, precipitated by occlusion of right coronary artery or positioning of a cardiomegaly heart, leading to immediate conversion to CPB. The mortality rate was 3% (2/66). Two patients suffered postoperative stroke while three needed hemofiltration for acute renal failure. Post surgery elective coronary angiography (n=46) showed no significant stenosis.Conclusion Emergency off-pump coronary artery surgery with complete revascularization is feasible in patients with acute coronary syndrome with low morbidity and mortality and excellent early results.     

Autologous versus allogeneic transfusion: patients'' perceptions and experiences

BACKGROUND: Preoperative autologous donation is one way to decrease a patient's exposure to allogeneic blood transfusion. This study was designed to determine patients' perceptions about the autologous blood donation process and their experiences with transfusion. METHODS: To assess patient perception, a questionnaire was administered a few days before surgery to patients undergoing elective cardiac and orthopedic surgery in a Canadian teaching hospital. All patients attending the preoperative autologous donation clinic during a 10-month period were eligible. A convenience sample of patients undergoing the same types of surgery who had not predonated blood were selected from preadmission clinics. Patient charts were reviewed retrospectively to assess actual transfusion practice in all cases. RESULTS: A total of 80 patients underwent cardiac surgery (40 autologous donors, 40 nondonors) and 73 underwent orthopedic surgery (38 autologous donors, 35 nondonors). Of the autologous donors, 75 (96%) attended all scheduled donation appointments, 73 (93%) said that they were "very likely" or "likely" to predonate again, and 75 (96%) said that they would recommend autologous donation to others. There was little difference in preoperative symptoms between the autologous donors and the nondonors, although the former were more likely than the latter to report that their overall health had remained the same during the month before surgery (30 [75%] v. 21 [52%] for the cardiac surgery patients and 30 [79%] v. 18 [51%] for the orthopedic surgery patients). When the autologous donors were asked what they felt their chances would have been of receiving at least one allogeneic blood transfusion had they not predonated, the median response was 80%. When they were asked what their chances were after predonating their own blood, the median response was 0%. The autologous donors were significantly less likely to receive allogeneic blood transfusions (6 [15%] for cardiac surgery and 3 [8%] for orthopedic surgery) than were the nondonors (14 [35%] for cardiac surgery and 16 [46%] for orthopaedic surgery). They were, however, more likely to receive any transfusion (autologous or allogeneic) than were the nondonors (25 [63%] v. 14 [35%] for cardiac surgery and 31 [81%] v. 16 [46%] for orthopedic surgery). INTERPRETATION: Patients who underwent preoperative autologous blood donation were positive about the experience and did not report more symptoms than patients who did not donate blood preoperatively. Autologous donors overestimated their chances of receiving allogeneic blood transfusions had they not predonated and underestimated their chances after they had predonated. They were less likely to receive allogeneic transfusions, but more likely to receive any type of transfusion, than were patients who did not predonate.     

非体外循环与常规体外循环冠状动脉旁路移植术早期疗效的评价

目的 :评价非体外循环下冠状动脉 (冠脉 )旁路移植术 (OPCABG)与常规体外循环下冠脉旁路移植术 (CCABG)相比是否具有优越性。方法 :将 36 2例行单纯冠脉旁路移植术的患者分为 OPCABG组 (n=1 5 2 )和 CCABG组 (n=2 1 0 ) ,分别在非体外循环心脏不停跳下 ,或建立常规体外循环 ,心脏停跳下完成冠脉旁路移植术。围术期应用肺动脉漂浮导管监测血流动力学 ,对两组患者的术前和术后各项指标进行对比分析。 结果 :两组患者术前一般情况、手术时间、血管桥数无差别 ,OPCABG组术后低心排血量综合征、房颤和肺不张的发生率显著低于 CCABG组 (P<0 .0 5 ) ,呼吸机支持时间、监护时间和住院时间也显著低于 CCABG组 (P<0 .0 5 ) ,两组患者术后早期出血量、输血量和其他并发症的发生率及死亡率无显著差异。 结论 :OP-CABG可减少术后并发症的发生 ,可缩短术后呼吸机支持时间、监护时间和住院时间     

影响70岁以上老年人冠脉搭桥远期预后独立因素分析

目的探讨70岁以上老年人冠脉搭桥远期死亡率的独立影响因素。方法前瞻性分析2005年1月～2011年5月70～86岁(平均74岁)接受冠脉搭桥术(不合并其他手术)的345例患者术前、术中及术后临床资料,并进行远期随访。按照随访结局不同,将患者分为随访死亡组(n=45)和随访存活组(n=300),比较两组患者术前,术中及术后临床资料的数据,筛选P<0.05的因素进入Cox多元回归分析,分析影响70岁以上老年人冠脉搭桥远期死亡率的独立影响因素。结果接受体外循环冠脉搭桥术患者74例,非体外循环冠脉搭桥术患者219例及体外循环辅助下心脏不停跳搭桥术患者52例,院内死亡15例,死亡率4.35%,随访72个月[1～72个月,中位随访时间68个月;平均随访(62.557±1.282)个月],随访率100%;累计死亡45例,累计死亡率13.04%;经过Cox多元回归分析(向前LR法)后,共筛选出5个因素为70岁以上老年人冠脉搭桥远期死亡率的独立影响因素:插管时间RR:1.002,95%CI(1.001-1.003);术后肾功能不全RR20.59,95%CI(6.131-69.154);术前合并CVDRR4.605,95%CI(1.796-11.806);术后规律服用他汀类药物RR0.334,95%CI(0.158-0.706);术后血压控制良好RR0.135,95%CI(0.047-0.385)。结论术后插管时间、术后肾功能不全、术前合并CVD为危险因素,术后规律服用他汀类药物、术后血压控制良好为改善70岁以上老年人冠脉搭桥远期预后的保护因素,该结果对今后改善70岁以上老年冠脉搭桥患者长期预后有一定的指导意义。     

IABP在术后危重心脏病患者中的临床应用

目的 报告应用主动脉内球囊反搏(IABP)治疗术后危重心脏病患者的疗效.方法 对12例心脏手术后并发心源性休克及低心排的患者应用IABP治疗.其中双瓣置换术3例,二尖瓣置换加冠状动脉搭桥术2例,主动脉瓣置换加冠状动脉搭桥术1例,单纯冠状动脉搭桥术6例.结果 9例顺利脱离IABP,成功率为75%(9/12).结论 IABP是抢救危重心脏病患者的有效措施,对危重心脏病有适应证者应及早使用.     

不输库血体外循环心内直视手术40例报道

报道 ４０例体外循环心内直视手术不输库血的临床经验。认为术前血红蛋白≥１１５ ｇ／Ｌ、红细胞压积比≥０． ３４的心脏病患者,通过严格的血液保护措施可以在其施行体外循环心内直视手术时做到不输库血。成功的血液保护措施有;严格控制输血指征;体外循环采用血液中度稀释;血液自体回输;术中保持足够的麻醉深度及术中严密止血等。用综合措施开展血液保护,安全、可行、有效,既节省了费用又避免了输库血而可能感染的传染性疾病。     

IABP在术后危重心脏病患者中的临床应用

目的 报告应用主动脉内球囊反搏（IABP）治疗术后危重心脏病患者的疗效。方法 对12例心脏手术后并发心源性休克及低心排的患者应用IABP治疗。其中双瓣置换术2例，二尖瓣置换加冠状动脉搭桥术1例，单纯冠状动脉搭桥术8例，冠状动脉搭桥术加左室室壁瘤切除重建术1例。结果 8例顺利脱离IABP，成功率为66．7％（8／12）。结论 IABP是抢救重心脏病患者的有效措施，对危重心脏病有适应证者应及早使用。     

两种冠状动脉旁路移植术的临床效果及餐后血压和心率的比较

为了比较非体外循环冠状动脉旁路移植术(OCABG)和体外循环冠状动脉旁路移植术(CABG)术后患者的临床疗效及餐后血压和心率,回顾分析行冠状动脉旁路移植术患者181例的临床资料,其中,106例为非体外循环冠状动脉旁路移植术患者(OCABG组),75例为体外循环冠状动脉旁路移植术患者(CABG组)。结果显示,与CABG组比较,OCABG组总有效率显著增高(82.67% vs 95.28%); 与餐前相比,两组收缩压(SBP)、舒张压(DBP)和心率(HR)在餐后均有不同程度变化。结果说明,采用非体外循环冠状动脉旁路移植术治疗冠心病的临床效果更加显著,有利于维持患者餐后血压及心率的稳定。     

Autologous blood transfusion for elective surgery

Between September 1983 and June 1985, 336 patients were assessed by the Autologous Blood Transfusion Service; 267 men, mean age, 65 (range, 16-75) years, and 40 women, mean age, 63 (range, 40-70) years, participated in the programme (29 patients were excluded as unsuitable). Orthopaedic and vascular surgery accounted for 80% of the cases. Complications were minor even in this elderly group. Surgical and transfusion details for a one-month period were studied retrospectively. Of the surgical cases that required crossmatched blood, 50% were for "emergency" and "burn" surgery, and 50% for elective surgery. Forty-five per cent of this latter group were unsuitable as autologous donors, 21% had participated in the autologous blood transfusion programme, and an additional 34% were deemed to be suitable donors. The realistic upper limits of our autologous blood transfusion programme were determined as being 55% of elective cases that require crossmatched blood. To be efficient an autologous blood transfusion service must be incorporated into an existing homologous blood transfusion service and must complement, rather than replace, homologous blood transfusion.     

Autotransfusion of shed mediastinal blood after open heart surgery

Objective To determine the safety and effectiveness of autotransfusion of shed mediastinal blood after open heart surgery. Methods Sixty patients undergoing coronary artery bypass grafting (CABG) were selected randomly to receive either nonwashed shed mediastinal blood (Group 1, n=30) or banked blood (Group 2, n=30). Drainage and transfusion volume were determined after the operation. Hb, RBC, HCT and PLT were detected immediately before and after the operation, as well as 24 hours and 7 days after the operation. Data were analyzed using Fisher’s exact test. A P&lt;0.05 was considered significant. Results There were no significant differences in Hb, HCT, PLT or length of cardiopulmonary bypass (CPB) (P&gt;0.05). In the two groups, no significant difference in the mean blood loss was observed during 24 hours after the operation (660±300 ml in Group 1 and 655±280 ml in Group 2, P&gt;0.05). In Group 1, the mean volume autotransfused was 280±160 ml, and the patients required 360±80 ml banked blood compared with 660±120 ml in Group 2. In other words, the banked blood requirement in Group 1 was 40% lower. Conclusions Autotransfusion of shed mediastinal blood after an open heart operation is safe and effective.     

100例非体外循环冠状动脉搭桥术麻醉的循环管理分析

目的 通过对100例非体外循环冠状动脉搭桥术(OPCABG)麻醉回顾性分析,探讨OPCABG术中循环管理方法.方法 分析100例患者在吻合前降支(LAD)、右冠状动脉(RCA)、对角支(DIAG)、回旋支(CX)不同靶血管的血流动力学参数包括心率(HR)、平均动脉压(MAP)、平均肺动脉压(MPAP)、中心静脉压(CVP)、混合静脉血氧饱和度(SvO2)和心输出量(CO)的变化情况.结果 OPCABG患者术中吻合各冠脉分支时血流动力学参数均出现不同程度的变化,主要表现为MAP、CO下降,CVP升高,尤以远端吻合CX和RCA时变化明显.结论 OPCABG中血管吻合阶段常导致血流动力学的波动,尤其是吻合CX和RCA时,原因主要是受心脏固定器压迫和心脏位置改变造成右室舒张功能不全和血流动力学衰减,经过恰当处理均能保持血流动力学情况的基本稳定.