The association of allogeneic blood transfusion and the recurrence of hepatic cancer after surgical resection

There is conflicting evidence whether allogeneic blood transfusion influences survival or cancer recurrence after resection of hepatocellular cancer. We followed up 1469 patients who had undergone hepatocellular resection for a median (IQR [range]) of 45 (21–78 [0–162]) months, of whom 626 (43%) had had blood transfusion within 7 days of surgery. Both disease-free survival and patient survival were measured using a proportional hazards regression model and inverse probability of treatment weighting. We used restricted cubic splines for the association of the number of packed red blood cell units transfused with cancer recurrence and survival. We found that peri-operative blood transfusion was independently associated with survival and cancer recurrence after resection of hepatocellular carcinoma. Adjusted hazard ratios (95%CI) for the association of blood transfusion with cancer recurrence and all-cause mortality were 1.3 (1.1–1.4) and 1.9 (1.6–2.3), p < 0.001 for both. With more units transfused cancer recurrence was more likely and survival was shorter. The association of the number of transfused units was non-linear for cancer recurrence and linear response for all-cause mortality.     

Intraoperative Allogeneic Red Blood Cell Transfusion in Ampullary Cancer Outcome after Curative Pancreatoduodenectomy: A Clinical Study and Meta-Analysis

BACKGROUND: Allogeneic blood transfusion (ABT) containing packed red blood cells (RBCs) has a known immunosuppressive effect that may affect cancer metastases and recurrence. This study examined whether intraoperative allogeneic RBC transfusion is an independent risk factor of adverse outcome in patients with ampullary carcinoma after curative pancreatoduodenectomy. METHODS: The clinical data of 67 patients with carcinoma of the ampulla of Vatar underwent pancreatoduodenectomy between 1999 and 2004 were analyzed, and long-term follow-up visits were made for all patients. Kaplan-Meier statistics and Cox proportional hazard methodology were used to perform univariate and multivariate analysis to identify independent risk factors for survival. For the meta-analysis, all English-language studies regarding blood transfusion from carcinoma of the ampulla of Vatar or ampullary carcinoma and prognostic factors or factors for survival from 1995 to 2007 were reviewed, and contingency tables were constructed from which a summary relative risk was calculated. RESULTS: There were 43 patients (64.2%) who received an intraoperative ABT. The amount of intraoperative ABT ranged from 2 to 13 (mean, 4.25) units; there were 18 patients transfused at 2 units, and 25 patients transfused >/=3 units. The follow-up ranged from 2 to 90 (mean, 49) months. Forty-five patients (67.2%) died as a result of tumor progression. For patients transfused >/=3 units, median and cumulative 3-year and 5-year survivals were poorer significantly than that of patients transfused with 2 units and/or nontransfused patients (P < 0.05). After multivariate analysis, except for presence of lymph node metastasis (P = 0.023) and pancreatic invasion (P = 0.024), the intraoperative ABT >/=3 units was found to be an independent poor prognostic factor for those with ampullary cancer after curative pancreatoduodenectomy either (relative risk, 2.082; 95% confidence interval (CI), 1.048-4.135; P = 0.036). Meta-analysis of 346 patients showed the summary relative risk of an adverse outcome after intraoperative ABT in these studies was 2.55 (95% CI, 1.59-4.1). CONCLUSIONS: The amount of intraoperative ABT is one of the important factors that adversely influenced survival in patients with ampullary cancer after curative pancreatoduodenectomy. Healing anemia preoperatively and careful dissection to minimize intraoperative bleeding as much as possible are mandatory for reducing risk of the intraoperative ABT.     

A simple mathematical approach to calculate blood loss in radical prostatectomy

INTRODUCTION: The aim of this study was to apply a simple mathematical approach to calculate blood loss in 126 patients undergoing radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Perioperative red blood cell loss (RBCL) was estimated by adding the difference in circulating red blood cells from before to after surgery to the allogeneic red blood cells transfused in the same period. RESULTS: Mean preoperative hematocrit was 45 +/- 4% and mean perioperative RBCL was 574 +/- 297 ml, corresponding to a mean equivalent whole blood loss (WBL) of 1,479 +/- 831 ml. Twenty of 126 patients (15.9%) received 42 units of allogeneic packed red blood cells (PRBC), for a mean of 2.1 +/- 1.2 U/patient. The transfusion rate was higher in patients with a preoperative hematocrit of 40% or less (45 vs. 13%, p = 0.014). CONCLUSIONS: Anatomical RRP is still associated with appreciable operative blood loss. Owing to the high preoperative hematocrit values, the allogeneic blood transfusion rate is low and the transfusion requirement of the majority of patients is limited to about 2 units of PRBC. Preoperative autologous blood augmentation strategies may not be routinely needed for patients with a basal hematocrit of >40%.     

Perioperative Blood Transfusion Is Associated with Decreased Survival in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Adenocarcinoma: a Multi-institutional Study

Introduction

In this multi-institutional study of patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma, we sought to identify factors associated with perioperative transfusion requirement as well as the association between blood transfusion and perioperative and oncologic outcomes.

Methods

The surgical databases across six high-volume institutions were analyzed to identify patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 2005 to 2010. For statistical analyses, patients were then stratified by transfusion volume according to whether they received 0, 1–2, or >2 units of packed red blood cells.

Results

Among 697 patients identified, 42 % required blood transfusion. Twenty-three percent received 1–2 units, and 19 % received >2 units. Factors associated with an increased transfusion requirement included older age, heart disease, diabetes, longer operative time, higher blood loss, tumor size, and non-R0 margin status (all p?p?=?0.02) and overall survival (14.0 vs. 21.0 months, p?2 units (hazard ratio, 1.92, p?=?0.009) and postoperative transfusions as independent factors associated with decreased disease-free survival.

Conclusions

This multi-institutional study represents the largest series to date analyzing the effects of perioperative blood transfusion on patient outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma. While blood transfusion was not associated with increased rate of infectious complications, allogeneic blood transfusion did confer a negative impact on disease-free and overall survival.     

Autologous Versus Allogeneic Transfusions: No Difference in Perioperative Outcome After Partial Hepatectomy

Blood transfusion is often necessary in patients undergoing liver resection. Because of the risks associated with allogeneic blood products, preoperative autologous blood donation has been advocated, but its benefit with respect to perioperative outcome remains unclear. This study compares perioperative outcome in patients transfused only with autologous blood to a matched cohort receiving only allogeneic blood. All patients subjected to hepatic resection and given only perioperative autologous red cell transfusions were identified from a prospective database of 2,123 patients and reviewed retrospectively. This group was matched to patients transfused only with a comparable number of allogeneic red cell units and to a control group that received no blood products. All patients in the autologous or allogeneic group received either 1 or 2 U. Matching was based on age, comorbidity, extent of hepatic resection, and estimated blood loss. Matched pair analysis was performed using the paired t test, McNemar and Stuart–Maxwell tests. From December 1991 to May 2003, 124 patients undergoing hepatic resection received perioperative autologous blood only, for which optimal matching was possible in 104. The groups were similar with respect to age, comorbidities, and blood loss; the proportions receiving preoperative chemotherapy, requiring a major resection (≥3 segments) or a complex procedure (concomitant major procedure in addition to the principal hepatic resection) were also similar. There were no differences between the autologous and allogeneic groups in length of hospitalization, complications, and operative mortality. In patients undergoing hepatic resection, autologous blood transfusion did not demonstrably improve perioperative outcome when compared to a matched cohort of patients receiving a similar number of allogeneic units. To be presented at the 47th Annual Meeting of the Society of Surgery of the Alimentary Tract, May 20–24, 2006, Los Angeles, California.     

Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.     

Intraoperativer Fremdblutverbrauch und Eigenbluttransfusion in der Kardioanästhesie Datenanalyse von 7729 Patienten aus 12 herzchirurgischen Kliniken

Allogeneic blood requirement in cardiac surgery shows a wide variation even for comparable procedures. The aim of the present study was to compare the intraoperative allogeneic blood requirement in defined cardiac operations among 12 cardiac centers in Germany. Method: A data set with 25 variables concerning the intraoperative course in adult cardiac patients with myocardial revascularization, valve replacement (aortic or/and mitral valve) or combined procedures was distributed to the participating centers. The data of all patients between January 1^th 1998 and June 30^th 1998 were included. Besides demographic data, the intraoperative transfusion of allogeneic and autologous blood, fresh frozen plasma and the concomitant hematocrit values were registered. Data were analyzed for all centers and separated for each center. Results: The data of 7.729 patients were analyzed. The intraoperative allogeneic blood requirement was 0.6±1.3 units for all patients. It varied among the centers from 0.25±0.6 units to 0.97±1.6 units (P<0.05). The percentage of patients receiving allogeneic blood was 27% and differed among the centers from 17% to 35%. Female patients were transfused in 53% (36–39%) compared to male patients with 16% (9–20%) (P<0.05). The rate of autologous blood predonation varied from 0.5% to 23%. Patients without autologous predonation were transfused in 28% compared to 4% in patients with predonation (P<0.05). In patients with autologous predonation the intraoperative transfusion of allogeneic blood was significantly reduced (0.1±0.39 vs 0.6±1.4 units, P<0.05). However, some centers with a high percentage of autologous predonation also demonstrated a high rate of perioperative allogeneic transfusion. Conclusion: The incidence of allogeneic blood transfusion in cardiac surgery depends on the institution and not on the surgical procedure. A common threshold value of hemoglobin for the transfusion of blood trigger even for comparable procedures could not be detected among the centers. Especially in female patients, there was a wide variation in allogeneic blood transfusion. Autologous blood predonation reduces blood requirement significantly, however, it is practiced with variing intensity. The data set did not include information about transfusion regimen in the postoperative period, thus, these data do not allow to draw conclusions for the whole perioperative period.     

Platelet-rich plasma sequestration, with therapeutic platelet yields, reduces allogeneic transfusion in complex cardiac surgery

Platelet dysfunction is the most common cause of nonsurgical bleeding after cardiopulmonary bypass (CPB). We hypothesized that reinfusion of a therapeutic quantity of platelets sequestered before CPB would decrease the need for allogeneic platelet transfusion, as well as decrease bleeding and total allogeneic transfusion, in cardiac surgery patients at moderately high risk for bleeding. Fifty-five patients undergoing either reoperative coronary artery bypass (CABG) or combined CABG and valve replacement were randomized to control or platelet-rich plasma sequestration (pheresis) groups. All patients received intraoperative epsilon-aminocaproic acid infusions. There was no significant difference between groups with respect to preoperative characteristics, duration of CPB, or target postoperative hematocrit. Mean platelet yields were 6.2 +/- 2.1 units (3.1 x 10(11) platelets). Mean pheresis time was 44 min. Allogeneic platelets (range = 6-12 units) were transfused to 28% of control patients, compared with 0% of pheresis patients (P < 0.01). Allogeneic packed red blood cells were transfused to 45% of control patients (1.2 units per patient) versus 31% of pheresis patients (0. 7 unit per patient) (P = 0.35). Total allogeneic units transfused were significantly reduced in the pheresis group (P < 0.02). Mediastinal chest tube drainage was not significantly decreased in the pheresis group. In this prospective, randomized study, therapeutic platelet yields were obtained before CPB. In contrast with recent studies with low platelet yields, these data support the conclusion that platelet-rich plasma sequestration is effective in reducing allogeneic platelet transfusions and total allogeneic units transfused in cardiac surgery patients at moderately high risk for post-CPB coagulopathy and bleeding. IMPLICATIONS: Transfusion of allogeneic blood products, including platelets, is common during complex cardiac surgical procedures. In the present prospective, randomized study, a significant reduction in allogeneic platelet transfusion and total allogeneic units transfused was observed after the reinfusion of a therapeutic quantity of autologous platelets sequestered before cardiopulmonary bypass.     

The influence of perioperative blood transfusion on survival after esophageal resection for carcinoma

Background. There is evidence that perioperative blood transfusion may lead to immunosuppression. Our aim was to determine whether blood transfusion influenced survival after esophagectomy for carcinoma.

Methods. The study group comprised 234 consecutive patients (175 men and 59 women) with a mean age of 66 years who underwent esophagectomy for carcinoma by one surgeon between 1988 and 1998. The impact of 41 variables on survival was determined by means of univariate and multivariate analysis. Follow-up was complete (mean follow-up, 19.2 months; standard deviation, 16 months; range, 0 to 129 months).

Results. The operative mortality rate was 5.6% (13 deaths). Median operative blood loss was 700 mL (range, 150 to 7,000 mL). One hundred sixty-one patients (68.8%) received a blood transfusion postoperatively (mean transfusion, 2.6 units; range, 0 to 12 units). Overall actuarial 1-year, 3-year, and 5-year survival rates inclusive of operative mortality were 58.1%, 28.5%, and 16.1%, respectively. On univariate analysis, positive lymph nodes, pathological TNM stage, transfusion of more than 3 units of blood, incomplete resection, poor tumor cell differentiation, longer tumor, greater weight loss, male sex, and adenocarcinoma were significant (p < 0.05) negative factors for survival. On Cox proportional hazards regression analysis, after excluding operative mortality, lymph node involvement (p = 0.001), incomplete resection (p = 0.0001), poor tumor cell differentiation (p = 0.04), and transfusion of more than 3 units of blood (p = 0.04) were independent adverse predictors of late survival.

Conclusions. In addition to reaffirming the importance of completeness of resection and nodal involvement, this study demonstrates that blood transfusion (more than 3 units) may have a significant adverse effect on late survival after esophageal resection for carcinoma. Every effort should be made to limit the amount of transfused blood to the absolutely essential requirements.     

Transfusion practice in coronary artery bypass surgery in Denmark: a multicenter audit

Transfusion rates in coronary artery bypass grafting (CABG) continue to vary substantially, although guidelines for allogeneic transfusion have been developed. In order to evaluate ongoing transfusion practices, we performed a multicenter audit in four Danish hospitals regarding the use of allogeneic blood products among patients undergoing first-time CABG. Data on patient characteristics, peri- and postoperative factors were retrieved from 600 patient records (150 records per hospital). Substantial differences were seen regarding preoperative intake of antiplatelet drugs, perioperative use of antifibrinolytic drugs, use of cardiopulmonary bypass (CPB), cross-clamp time, time on CPB, lowest hemoglobin during CPB, and number of distal anastomoses. The percentage of patients transfused with allogeneic red blood cells ranged from 30.0% to 64.2%. Several patients (12.1-42.7%) transfused with red blood cells were discharged with a hemoglobin concentration >7 mmol/l, indicating inappropriate transfusions. The relative risk of receiving an allogeneic blood transfusion was 2.1 (95% CI: 1.6-2.7) in the hospital with the highest transfusion rate, after adjustment for patient-, drug-, and procedure-related factors. Interesting differences in transfusion rates exists in Danish hospitals and these differences may reflect true variations in transfusion practices. Audits create a basis for educational efforts among surgeons and anesthesiologists to standardize transfusion practices.     

Präoperative Eigenblutspende in der Herzchirurgie

BACKGROUND: Preoperative autologous blood donation is an effective method to reduce allogeneic transfusion requirement. However, this method is only rarely utilized in cardiac surgery. Besides economic concerns one essential argument against predonation is the lack of sufficient time due to the short waiting lists. The aim of the present study was to investigate the efficacy of autologous predonation to reduce allogeneic blood transfusion in routine cardiac surgery on a center without longer preoperative waiting lists. PATIENTS AND METHODS: A total of 2,626 cardiac surgery patients were included. Primary endpoint of the study was the perioperative incidence of allogeneic packed cell transfusion. If time between diagnosis and admission to the hospital was >10 days, predonation was offered to the patients. Data were stratified for preoperative risk score. Logistic and linear regression analysis tested the influence of different variables on the incidence of allogeneic blood transfusion and the total amount of allogeneic blood. RESULTS: Of all patients 267 (11.2%) underwent predonation. The incidence of allogeneic packed cell transfusion was reduced from 53% to 19% by autologous predonation (p<0.001). The total amount of allogeneic blood transfused was significantly different between the groups (2.2+/-4.2 vs. 0.84+/-6.3 units; p<0.001). DISCUSSION: Autologous predonation in cardiac surgery was effective in reducing blood transfusions even in the absence of longer preoperative waiting times. It is a safe and effective method to minimize blood transfusion in cardiac surgery.     

A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiac surgery

PURPOSE: Individual and institutional practices remain an independent predictor factor for allogeneic blood transfusion. Application of a standardized multidisciplinary transfusion strategy should reduce the use of allogeneic blood transfusion in major surgical patients. METHODS: This prospective non randomized observational study evaluated the effects of a standardized multidisciplinary transfusion strategy on allogeneic blood products exposure in patients undergoing non-emergent cardiac surgery. The developed strategy involved a standardized blood conservation program and a multidisciplinary allogeneic blood transfusion policy based mainly on clinical judgement, not only on a specific hemoglobin concentration. Data obtained in a first group including patients operated from September 1997 to August 1998 (Group pre: n=321), when the transfusion strategy was progressively developed, were compared to those obtained in a second group, including patients operated from September 1998 to August 1999 (Group post: n=315) when the transfusion strategy was applied uniformly. RESULTS: Patient populations and surgical procedures were similar. Patients in Group post underwent acute normovolemic hemodilution more frequently, had a higher core temperature at arrival in the intensive care unit and presented lower postoperative blood losses at day one. Three hundred forty units of packed red blood cells were transfused in 33% of the patients in Group pre whereas 161 units were transfused in 18% of the patients in Group post (P <0.001). Pre- and postoperative hemoglobin concentrations, mortality and morbidity were not different among groups. CONCLUSION: Development of a standardized multidisciplinary transfusion strategy markedly reduced the exposure of cardiac surgery patients to allogeneic blood.     

Predeposit self-transfusion (PDS) in a hepatobiliopancreatic surgery (HBPS) unit: preliminary data

Hepatobiliary pancreatic surgery (HBPS) has high morbility and mortality and frequently requires blood transfusion. Allogeneic transfusion may cause adverse sequelae. Predeposit self-transfusiÓn (PDS) minimizes allogeneic blood transfusion and avoids most adverse reactions. We present the preliminary data of our PDS experience (with recombinant human erythropoieting, r-HuEPO) in HBPS during the first year. We studied our first-year HBPS-PDS program by a retrospective review of the case histories and transfusion records in our Blood Bank. Sex, weight, underlying disease, packed red cell units (PRCUs) requested, drawn, and transfused, and hospital and ICU stays were analyzed. Nine patients were admitted in the PDS program. Of desired blood units, 83% was obtained, successfully in 77.8% of patients, and 63.2% were transfused with autologous blood transfusion. Only three patients needed allogeneic blood (33.3%). All complications occurred in patients who received allogeneic units. Also, we found stays were three times longer in those patients. PDS could be a valid and safe alternative for patients undergoing elective HBPS because it decreases allogeneic blood requirements, reduces overall complications, and also reduces hospital and ICU stays.     

Aprotinin in major orthopedic surgery: a systematic review of randomized controlled trials

Aprotinin therapy is a promising strategy for reducing blood loss and blood transfusion requirements. The efficacy and safety of aprotinin in orthopedic surgery, however, remain controversial. We searched electronic databases for randomized controlled trials on the efficacy and safety of the use of aprotinin in orthopedic surgery. Thirteen trials that included a total of 506 patients who underwent major orthopedic surgery were analyzed. The pooled intraoperative and perioperative blood loss was significantly less in the aprotinin-treated patients than in the control patients (weighted mean difference [WMD] for intraoperative blood loss = -229 mL, 95% confidence interval [CI] = -367 to -91 mL, P = 0.0011; WMD for perioperative blood loss = -557 mL; 95% CI = -860 to -254 mL; P < 0.0001). The pooled amounts of red blood cell (RBC) units (U) transfused intraoperatively and perioperatively were significantly less in the aprotinin-treated patients than in the control patients (WMD for intraoperative RBC U = -1.1 U; 95% CI = -1.7 to -0.4 U; P = 0.0001; WMD for perioperative RBC U = -1.1 U; 95% CI = -1.7 to -0.5 U; P < 0.0001). Aprotinin was not associated with an increased incidence of deep vein thrombosis (odds ratio = 0.39; 95% CI = 0.14 to 1.05, P = 0.061). The authors conclude that aprotinin reduces the intraoperative and perioperative blood loss and allogeneic blood transfusion requirement and may not be associated with increased risk of deep vein thrombosis in the presence of pharmacological or mechanical prophylaxis in patients undergoing major orthopedic surgery.     

Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty

Purpose

To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood.

Methods

We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 g·L^?1 were given erythropoietin, dosed by weight. Subjects with Hb 130-139 g·L^?1 underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb >139 g·L^?1 received no special intervention, unless they were aged >70 yr and weighed < 70 kg, in which case they received oral iron and folate supplementation.

Results

The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group.

Conclusion

A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.     

Thromboelastography-Based Transfusion Algorithm Reduces Blood Product Use after Elective CABG: A Prospective Randomized Study

Abstract   Objective: Bleeding and allogeneic transfusion remain constant problems in cardiac surgical procedures. In this study, we aimed to test the role of a routine thromboelastography (TEG)-based algorithm on bleeding and transfusions in patients undergoing elective coronary artery bypass grafting (CABG). Methods: Patients (n = 224) undergoing elective CABG with cardiopulmonary bypass were prospectively randomized into two groups according to transfusion strategy: in group 1 (clinician-directed transfusion, n = 110) need for blood transfusion was based on clinician's discretion and standard coagulation tests and in group 2 (TEG algorithm group, n = 114) kaolin-activated (k) TEG-based algorithm-guided perioperative transfusion management. Transfusion, blood loss, and outcome data were recorded.  Results: There were no differences in consumption of packed cell units, blood loss, re-exploration for bleeding, and early clinical outcome between the groups. Patients in the TEG group had significantly lower median units of fresh frozen plasma and platelets compared with the other group (p = 0.001). The median number of total allogeneic units transfused (packed cells and blood products) was significantly reduced in the TEG group compared with the other group (median 2, range 1–3 units vs. median 3, range 2–4 units, respectively, p = 0.001). The need for tranexamic acid was significantly diminished in the TEG group compared with the other group (10.3% vs. 19%, respectively, p = 0.007). Conclusion: Our results show that routine use of a kTEG-guided algorithm reduces the consumption of blood products in patients undergoing elective CABG. Adopting such an algorithm into routine management of these patients may help to improve clinical outcome and reduce the potential risks of transfusion-related complications and total costs after CABG.     

Blood transfusion in critically injured patients: a prospective study

BACKGROUND: Despite evolving evidence that transfusion risks outweigh benefits in some patients, the critically injured continue to receive large quantities of blood. The present study evaluated patterns of red blood cell transfusions and risk factors for transfusions at various stages of admission in trauma patients. STUDY DESIGN: Prospective, observational study of transfusion practices in patients (n = 120) admitted to a single Level 1 academic trauma centre. Patients were expected to remain in the surgical intensive care unit for greater than 48 h. RESULTS: Patients had a mean age of 34.1+/- 16.0 years, a mean injury severity score (ISS) of 21.5 +/- 9.5, and were equally distributed by major injury type (48% blunt, 52% penetrating). One hundred and four patients (87%) received a total of 324 transfusions, 20 (6%) of which were given in the emergency room, 186 (57%) in the SICU, 22 (7%) post-SICU and 96 (30%) in the operating room. The mean volume of blood per patient transfused was 3144 +/- 2622 mL. One hundred and one patients received an allogeneic transfusion (mean volume 3126 +/- 2639 mL) and 10 patients received an autotransfusion (844 +/- 382 mL). The mean pre-transfusion Hb level was 9.1 +/- 1.4 g/dL. Transfusion volumes correlated with injury severity score (p = 0.011). Patients with an admission Hb < or =12 g/dL or age >55 years were at significant risk to receive increased transfusions (P < .001 and P = .035, respectively). An admission Hb < or =12 g/dL and any mention of long bone orthopedic operations or laparotomy or thoracotomy were associated with increased risk of blood transfusion during the first week of admission. Logistic regression analysis identified transfusion of >4 units of blood as a significant risk factor for SIRS. After 1 week of ICU stay, ISS > 20 and blunt injury were associated with increased risk of transfusion. CONCLUSIONS: Trauma patients are heavily transfused with allogeneic blood throughout the course of their hospital stay and transfusions are administered at relatively high pre-transfusion haemoglobin levels (mean of 9 g/dL). Transfusion of >4 units of blood is an independent risk factor for SIRS. Strategies to limit blood transfusions should be investigated in this population.     

Perioperative blood transfusions, with or without allogeneic leucocytes, relate to survival, not to cancer recurrence

BACKGROUND: Perioperative blood transfusions are reported to be related to cancer recurrence and reduced survival. Different underlying mechanisms have been proposed, and allogeneic leucocytes in transfused blood have been suggested to contribute to this phenomenon. METHODS: Packed red cells without buffy coat (PC group) were compared with filtered, leucoreduced, red cells (LD group) in a randomized trial of 697 patients with colorectal carcinoma. Five-year survival and cancer recurrence rates were determined, with special emphasis on the location of recurrence. RESULTS: The intention-to-treat analysis showed a survival rate of 63.6 per cent in the PC group and 65.3 per cent in the LD group (P = 0.69), with recurrence rates of 27.8 and 27.9 per cent respectively. The observational analysis showed a significant difference in survival between transfused and non-transfused patients (59.6 versus 72.9 per cent; P < 0.001). The difference in cancer recurrence rate between transfused and non-transfused patients was not statistically significant (29.8 versus 24.3 per cent; P = 0.13). Local recurrences were more frequent in transfused than non-transfused patients (11.9 versus 7.6 per cent; P = 0.09). CONCLUSION: Leucocyte depletion of perioperative transfused blood has no effect on long-term survival and/or cancer recurrence. Perioperative blood transfusions are associated with impaired survival, but not with cancer recurrence. The slight increase in local recurrence rate in transfused patients appears to be related to complicated, in particular rectal, surgery.     

Systematic review of the use of fibrin sealant to minimize perioperative allogeneic blood transfusion

BACKGROUND: Fibrin sealants have become popular in improving perioperative haemostasis and reducing the need for allogeneic red cell transfusion. METHODS: A systematic review of randomized controlled trials was conducted to examine the efficacy of fibrin sealants in reducing perioperative blood loss and allogeneic red blood cell transfusion. Studies were identified by computer searches of Medline, Embase, Current Contents, the Cochrane Library, manufacturer websites (to January 2001), and bibliographic searches of published articles. Trials were eligible for inclusion if they involved adult elective surgery and reported quantitative data on blood loss, the proportion of patients exposed to allogeneic red cell transfusion and/or the volume of blood transfused. RESULTS: Twelve trials met the criteria for inclusion. Fibrin sealants reduced the rate of allogeneic blood transfusion (relative risk 0.40 (95 per cent confidence interval (c.i.) 0.26 to 0.61); five trials with 275 subjects) and reduced blood loss (weighted mean difference--151.68 (95 per cent c.i. - 251.91 to - 51.46) ml; seven trials with 391 subjects). Generally, the trials were small and of poor methodological quality. CONCLUSION: Overall the results suggest that fibrin sealants are efficacious. Owing to lack of blinding, transfusion practices may have been influenced by knowledge of the patient's treatment status. This raises concern about blood transfusion practice as a response variable. Large methodologically rigorous trials of fibrin sealants with clinical outcomes are needed.     

Further evidence supporting a cause and effect relationship between blood transfusion and earlier cancer recurrence.

Studies of associations between perioperative blood transfusions and later recurrence of solid tumors have yielded conflicting results. A previous analysis of transfused patients suggested that recurrence was associated with transfusion of whole blood as opposed to red blood cell concentrates. Additional analyses were performed on patients with cancers of the colon, rectum, cervix, and prostate to determine if patients receiving whole blood, red blood cells only, or no transfusions had differing outcomes. Patients receiving 1 unit or more of whole blood had uniformly poor outcomes compared with nontransfused patients (p less than 0.001). In contrast, patients receiving only red blood cells had progressively worse recurrence and death rates with increasing numbers of transfusion, suggesting the presence of a dose-effect relationship. Employing multivariate techniques, blood transfusion of less than or equal to 3 units that included any whole blood were independently and significantly associated with earlier recurrence (p = 0.003) and death due to cancer (p = 0.02). Transfusions of less than or equal to 3 units of blood comprised solely of red blood cell concentrates were associated with no greater risk of recurrence than that seen in patients receiving no transfusion (p = 0.50). These results provide a potential explanation for the disparate results reported in studies of blood transfusion and cancer outcome. The marked difference in outcome seen between patients receiving a few units of red blood cells and comparable patients receiving even one unit of whole blood are consistent with the hypothesis that transfusion of stored blood plasma causes earlier tumor recurrence in some instances. Strategies for reducing these risks might include avoidance of whole blood transfusions when only 1-3 units are required, more conservative transfusion practice, use of autologous blood transfusions, and perhaps, use of red blood cells washed free of plasma and white cell debris. Clinical trials to test these hypotheses are urgently needed.