Allogenic blood transfusion does not predispose to infection after cardiac surgery

Background

Many retrospective studies report increased postoperative infection after allogenic blood transfusion. To investigate this phenomenon, we prospectively studied 232 patients undergoing cardiac surgery.

Methods

Patients were screened daily for evidence of culture positive infections. Wounds were examined daily and defined on the ASEPSIS score. Chest radiographs and white cell counts and differentials were recorded on days 1, 2, and 4. The use of blood products was monitored blindly and independently. Patients were grouped according to transfusion status and compared using χ² or Fisher's test. Logistic regression analyses were performed to identify predictors of transfusion and infection.

Results

Of 232 patients, 116 (50%) received blood product transfusion. Patients receiving blood had lower preoperative hemoglobin, were older, with a greater proportion of urgent/emergency or revision surgery, and were higher risk. Despite this, there were no differences in the frequency of chest infection (20% versus 15%, p = 0.38), urinary infection (3.5% versus 5.3%, p = 0 0.75), wound infection (3.5% versus 8.0%, p = 0.16), or overall infection (28% versus 30%, p = 0.89) comparing the transfused versus untransfused groups. There was no evidence to suggest that administration of blood products was associated with infection (odds ratio 0.92, p = 0.77).

Conclusions

The administration of blood per se did not lead to increased postoperative infection. Clinicians should reconsider withholding blood transfusion in patients solely owing to concerns of predisposition to infection.     

Indications for blood transfusion in cardiac surgery

In addition to its life-saving effect in hemorrhagic shock, transfusion of allogenic packed red blood cells can be beneficial in situations where a critically low hematocrit is contributing to a state of oxygen-supply dependency. These benefits are countered by the risks of transfusion-associated lung injury, transfusion-associated immunomodulation, and cellular hypoxia after RBC transfusion. The critical hematocrit is patient and organ specific, and varies intraoperatively according to the duration and temperature of bypass, as well as for a variable postoperative period. Future randomized studies must prospectively evaluate regional indicators of tissue oxygenation in transfusion algorithms.     

Effect of blood transfusion on survival after hip fracture surgery

Background

Our primary goal was to audit the incidence of erythrocyte blood transfusion (EBT) after hip fracture surgery and study the effects on perioperative complications and early and late mortality.

Methods

In a retrospective cohort study all patients 65 years old and above treated operatively for an acute hip fracture were included over a 48-month period with a 2-year follow-up period. Postoperative hemoglobin levels were used to investigate at what threshold EBT was used. The relation between EBT and perioperative complications and survival was analyzed with multivariate regression analysis. A propensity score for predicting the chance of receiving an EBT was calculated and used to differentiate between transfusion being a risk factor for mortality and other related confounding risk factors. Mortality was subdivided as in-hospital, 30-day, 1-year and 2-year mortality.

Results

Of the 388 included patients, 41% received a blood transfusion. The postoperative hemoglobin level was the strongest predictor for EBT. Patients who received EBT had a significant longer hospital stay and more postoperative cardiac complications, even after adjustment for confounders. Multivariate analysis for mortality showed that EBT was a significant risk factor for early as well as late mortality, but after adding the propensity score, EBT was no longer associated with increased mortality.

Conclusion

There was no effect of EBT on mortality after correction with propensity scoring for predictors of EBT. Transfusion in patients treated operatively for hip fracture should be evenly matched with their cardiovascular risk during the perioperative phase.

     

Pre-transplant blood transfusion and cyclosporin A induce long-term hamster cardiac xenograft survival in immunocompetent rats

BACKGROUND: In previous studies we have shown that pre-transplant hamster blood transfusion (HBT) can induce non-responsiveness in the T cell independent immunecompartment and result in tolerance towards hamster cardiac xenografts (Xgs) in T cell deficient athymic nude rats. In this study we test the combination of pre-transplant HBT with cyclosporin A (CSA) in immunocompetent Lewis rats. METHODS: Before transplantation of a hamster cardiac Xg, 1 ml hamster blood was administered to nude rats or Lewis rats. CSA dissolved in olive oil was given orally at varying doses. Anti-hamster antibodies were measured by flowcytometry. RESULTS: In nude rats HBT 3 days before transplantation resulted in 100% long-term survival >100 days (n=9). In Lewis rats, HBT resulted in hyperacute rejection (HAR) (n=6). Treatment of nude rats with CSA at doses varying from five to 20 mg/kg/day and treatment of Lewis rats with CSA five or 10 mg/kg/day did not effect Xg survival. However, treatment of Lewis rats with CSA 20 mg/kg/day led to long-term survival of five of nine Xgs (p <0.01). Combination of HBT with CSA 10 mg/kg/day in Lewis rats resulted in long-term survival of four of seven Xgs. HBT and CSA 20 mg/kg/day resulted in 100% long-term survival (n=9). Immunoglobulin M (IgM) increased after HBT and CSA in these Lewis rats, but decreased after transplantation and remained low over time. When CSA was discontinued, IgM increased and Xgs were rejected (n=3). CONCLUSIONS: This study confirms that pre-transplant HBT results in long-term survival of hamster cardiac Xgs in nude rats. HBT and CSA have strong synergistic effects in immunocompetent Lewis rats. Combination of HBT with CSA treatment leads to long-term Xg survival in Lewis rats, whereas HBT alone results in HAR. The presence of T cells has a dominant influence on Xg survival after pre-transplant blood transfusion.     

Effect of donor age on long-term survival following cardiac transplantation

BACKGROUND AND AIM: The current shortage of donor hearts has forced the criteria of organ procurement to be extended, leading to increased use of older donor hearts to bridge the gap between demand and availability. Our objective was to analyze the effect of donor age on outcomes after cardiac transplantation. METHODS: We retrospectively studied 864 patients who underwent cardiac transplantation at New York Presbyterian Hospital - Columbia University between 1992 and 2002. Patients were divided into two groups; donor age <40 years (Group A, n = 600) and donor age > or =40 years (Group B, n = 264). RESULTS: Characteristics including gender, body mass index, and cytomegalovirus (CMV) status were significantly different between the two donor age groups. Race, CMV status, toxoplasmosis status, left ventricular assist device prior to transplant, diabetes mellitus, and retransplantation were similar in both the recipient groups, while age, gender, and BMI were different. Early mortality was lower in Group A, 5%, versus 9.5% in Group B. Multivariate analysis revealed recipient female gender (odd ratio (OR) = 1.71), retransplantation (OR = 1.63), and increased donor age (OR = 1.02) as significant predictors of poor survival in the recipient population. Actuarial survival at 1 year (86.7% vs 81%), 5 years (75% vs 65%), and 10 years (56% vs 42%) was significantly different as well with a log rank p = 0.002. CONCLUSIONS: These findings suggest that increased donor age is an independent predictor of long-term survival. However, the shortage of organs makes it difficult to follow strict guidelines when placing hearts; therefore, decisions need to be made on a relative basis.     

Age, blood transfusion, and survival after trauma

Blood transfusion affects outcomes after trauma, but whether elderly patients are disproportionately affected remains unknown. To determine the possible interaction between age, packed cell transfusion volume (PCTV), and mortality after injury, we designed a 6-year retrospective review (January 1995 through December 2000) of patients > or = 16 years of age who received blood transfusion within the first 24 hours after injury. One thousand three hundred twelve patients > or = 16 years of age admitted to our trauma center received packed red blood cells in the initial 24 hours after admission. Of the 1312 patients, 1028 (78%) were < or = 55 years and 284 (22%) were > 55 years of age, and overall mortality was 21.2 per cent. Age, Injury Severity Score (ISS) Glasbow Coma Scale (GCS), and PCTV emerged as independent predictors of mortality. PCTV for elderly survivors (4.6 units) was significantly less than that of younger survivors (6.7 units). Furthermore, mean PCTV for all survivors decreased progressively with advancing age. No patient >75 years with a PCTV > 12 units survived. Age and PCTV act independently, yet synergistically to increase mortality following injury.     

Effect of blood transfusion on survival after radiotherapy as treatment for carcinoma of the prostate.

Over a 14-year period, 71 patients underwent transurethral resection of the prostate with high dose radiotherapy. Eighteen patients required perioperative transfusion. The 5-year survival in the non-transfused group was 66% and in the transfused group 17% (P less than 0.001; chi 2 = 11.57). Recurrence of tumour in the transfused group was 72% compared with 21% in the non-transfused group (P less than 0.01; chi 2 = 9.1). When Cox's models and regression analysis were used, the disease state being controlled for grade and stage, only blood transfusion was seen to influence outcome. We conclude that careful thought should be given before transfusing patients undergoing transurethral surgery for prostatic carcinoma.     

Intraoperative blood transfusion contributes to decreased long-term survival of patients with esophageal cancer

Background  

Several prognostic factors for patients who have undergone esophagectomy owing to esophageal squamous cell carcinoma have been suggested, including intraoperative blood loss. There are few data, however, suggesting such an association with the prognosis following radical esophagectomy.     

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.     

Effect of prior malignancy on survival after cardiac surgery

BACKGROUND: The number of patients with a previously treated tumor, needing cardiac surgery is increasing. Whether this operation in these patients is justified is determined by the long-term outcome. METHODS: Of 8620 patients referred for cardiac surgery, 205 had a documented malignant tumor. The time interval between the occurrence of the tumor and the cardiac surgery was recorded. These patients were matched with 205 patients without a tumor according to age, gender, comorbidity and type of cardiac surgery. The patients were followed retrospectively. A chi(2) Kaplan Meier and Cox' regression analysis were performed. RESULTS: During follow-up, 95.8% of the patients were traced (2794 patient years). Univariate analysis showed that 5- and 10-year survival was better in patients without a malignant tumor in the history (0.91 +/- 0.02 versus 0.72 +/- 0.03 and 0.73 +/- 0.04 versus 0.40 +/- 0.05; p < 0.0001). For shorter time intervals, mortality for all causes and mortality due to the tumor increase significantly (p < 0.0001). Multivariate analysis identified 4 independent variables: a malignant tumor in the history (p < 0.001), chronic obstructive pulmonary disease (p = 0.003), age (p = 0.001), and impaired left ventricular function (p = 0.035) CONCLUSIONS: A malignant tumor in the history is the most prognostic factor after cardiac surgery, but the operation is still rewarding. Fatal progression of the tumor is seen if the time interval between the occurrence of the malignant tumor and cardiac surgery is short. Other unfavorable factors are decreased left ventricular function, chronic obstructive pulmonary disease and high age.     

术前输注供者脾细胞联合应用西罗莫司延长小鼠移植心存活时间的机理

目的探讨移植术前输注供者脾细胞(DST)联合应用西罗莫司(SRL)延长小鼠移植心存活时间的机理。方法单向混合淋巴细胞培养中的刺激细胞及静脉输注的脾细胞均采用经丝裂霉素C处理后失去增殖活性的Balb/c(H-2~d)小鼠脾细胞(包括体外实验和体内实验)。(1)体外实验:分为3组,空白对照组:取正常C57BL/6(H-2~b)小鼠(B6小鼠)的脾细胞作为反应细胞;SRL组:取用SRL(1.5μl·g~(-1)·d~(-1))灌胃7 d后的B6小鼠脾细胞作为反应细胞;DST SRL组:取行脾细胞静脉输注8 d、次日予SRL(1.5μl·g~(-1)·d~(-1))灌胃7 d后的B6小鼠的脾细胞作为反应细胞。观察各组在单向混合培养中的脾细胞增殖能力。(2)体内实验:Balb/c小鼠为供者,B6小鼠为受者,建立颈部异位心脏移植模型。实验分为3组,空白对照组:单纯行心脏移植;DST组:受者移植前8 d给予供者脾细胞静脉输注;DST SRL组:受者移植前8 d给予供者脾细胞静脉输注,次日予以SRL灌胃7d(1.5μl·g~(-1)·d~(-1))。术后观察各组移植心的存活时间、病理表现、受者淋巴细胞中CD4~ CD25~ 调节性T细胞(Tr细胞)和凋亡细胞比例的改变及同种抗原刺激后增殖活性变化。结果体外实验中,DST SRL组反应细胞增殖活性平均为(13.76±2.81)%,明显低于空白对照组(28.14%±5.53%,P<0.05)。体内实验中,空白对照组、DST SRL组以及DST组移植心平均存活时间分别为(8.6±0.48)d、(35±14.4)d和(4.83±0.52)d,DST SRL组存活时间显著延长(P<0.05);流式细胞术(FACS)分析显示DST SRL组脾细胞中CD4~ CD25~ Tr细胞比例平均为(3.39±0.21)%,明显高于空白对照组(1.57%±0.3%,P<0.05)。结论移植术前输注供者脾细胞联合应用西罗莫司可通过清除同种反应性T细胞克隆,增加受者体内CD4~ CD25~ Tr细胞的比例,减低对同种抗原的应答能力,从而延长同种小鼠移植心存活时间。     

心脏外科术后大量输血并发症的治疗

目的:总结心脏外科术后大量输血并发症的治疗经验方法:本组23例,男17例,女6例.年龄27～71岁;输血量2000～8700 ml.监测输血后凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(FIB),计算APTT比率,同时监测血小板计数(Plt)及全血生化.结果:全组治愈20例,死亡3例;患者术前凝血功能正常,输血后PT、APTT、TT时间明显延长(p<0.01),APTT比率增高,同时FIB、PIt、下降明显(p<0.01),血Na+变化不明显(p>0.05),血K+、Ca2+、白蛋白与输血前相比明显降低(p<0.05).结论:接受大量输血后由于可能出现的代谢问题,应综合分析,才能对病情作出正确的判断,指导进一步的治疗.     

Predictors of allogenic blood transfusion in elective cardiac surgery after preoperative autologous blood donation

Purpose  Preoperative autologous blood donation (PAD) is important for reducing exposure to allogenic blood in cardiac surgery. Unfortunately, even after PAD, allogenic blood transfusion is not always avoided. We investigated the predictors of blood component usage during elective cardiac surgery in patients prepared with PAD. Methods  Clinical data were collected for 143 consecutive patients (103 men and 40 women; mean age, 62 ± 9 years) who underwent elective cardiac surgery after PAD (959 ± 240 ml), often using iron supplement and recombinant human erythropoietin. Results  Allogenic blood transfusion was avoided during and after surgery in 107 patients (75%), whereas 36 patients required an allogenic transfusion (4.1 ± 3.8 U of packed red cells, 3.4 ± 4.1 U of fresh frozen plasma, and 5.8 ± 11.0 U of platelet concentrate). The independent factors for perioperative allogenic blood transfusion in these patients included the pre-donation hemoglobin value, the preoperative platelet count, and the lowest hemoglobin value during cardiopulmonary bypass. Conclusion  Even with PAD for elective cardiac surgery, patients whose pre-donation hemoglobin value and preoperative platelet count are low may require allogenic blood transfusion.     

Effect of substituting allogenic blood transfusion with autologous blood transfusion on outcomes after radical oesophagectomy for cancer.

BACKGROUND: The oncologic benefit of avoiding allogenic blood transfusion in oesophageal cancer resection has not been studied. METHODS: The medical records of 68 patients (Auto group) who underwent a potentially curative oesophageal cancer resection without allogenic blood transfusion from 1996 to 1999 receiving 800 g of autologous blood donated preoperatively, and 97 patients (Allo group) who underwent the same operation with allogenic blood transfusion from 1990 to 1995 were compared. RESULTS: There were no differences in age, gender, stage of disease, number of retrieved nodes, or perioperative hemoglobin concentration between the two groups. The survival of the 45 patients with nodal involvement in the Auto group was better than that of the 59 patients in the Allo group (p=0.0435), and the survival of the 35 patients with T3 or T4 lesions in the Auto group was better than that of the 61 patients in the Allo group (p=0.0408). According to logistic regression analysis, allogenic blood transfusion correlated with tumour recurrence in patients with either nodal involvement or a T3-4 lesion. The natural killer cell activity remained higher in the Auto group than in the Allo group (p<0.05). CONCLUSION: Avoidance of allogenic blood transfusion favorably effected the survival of patients with oesophageal cancer at risk for recurrence.     

Effect of prior cardiac surgery on survival after heart transplantation

We conducted a retrospective analysis of 182 adult orthotopic heart transplant patients who underwent operations at our institution between July 1982 and October 1987 to determine whether prior cardiac operation affects survival. Group I included the 72 patients (39.6%) who had undergone a previous cardiac operation or operations and group II, the 110 (60.4%) who had not. The mean age of the patients in group I was 52.1 +/- 8.1 years and in group II, 46.1 +/- 10.2 years (p less than 0.01). The incidence of ischemic heart disease was 86.1% in group I and 29.1% in group II (p less than 0.01). All patients received cyclosporine-based immunosuppression. More patients in group I than in group II required reoperation for bleeding after transplantation: 18 (25.0%) versus 9 (8.2%) (p less than 0.01). The actuarial 1-year and 3-year survival rates were 77.6% and 66.5%, respectively, for group I and 77.1% and 66.3%, respectively, for group II. Because both groups had similar survival rates, we believe that prior cardiac operation in heart transplant recipients does not compromise long-term survival.