Institutional variability in red blood cell conservation practices for coronary artery bypass graft surgery. Institutions of the MultiCenter Study of Perioperative Ischemia Research Group

OBJECTIVE: To assess whether substantial institutional variability exists in red blood cell conservation practices associated with coronary artery bypass graft (CABG) surgery. DESIGN: Prospective, randomized patient enrollment and data collection. SETTING: Twenty-four U.S. academic institutions participating in the Multicenter Study of Perioperative Ischemia. PARTICIPANTS: A well-defined subset of primary CABG surgery patients (n = 713) expected to be at low risk for bleeding and exposure to allogeneic transfusion. INTERVENTIONS: None (observational study). MEASUREMENTS AND MAIN RESULTS: Frequency of use of red blood cell conservation techniques was determined among institutions. Correlation was determined between use of each technique and transfusion of allogeneic red blood cells and between use of each technique and median institutional blood loss. Significant variability (p < 0.01) was detected in institutional transfusion practice with respect to the use of predonated autologous whole blood, normovolemic hemodilution, red cell salvage, and reinfusion of shed mediastinal blood. The frequency of institutional use of these techniques was not associated with allogeneic transfusion (r2 < 0.15) or blood loss (r2 < 0.10) in the low-risk population of patients examined. CONCLUSIONS: Institutions vary significantly in perioperative blood conservation practices for CABG surgery. Further study to determine the appropriate use of these techniques is warranted.     

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.     

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.     

Infectious complications after cardiac surgery: lack of association with fresh frozen plasma or platelet transfusions

OBJECTIVE: The purpose of this study was to examine the effect of perioperative transfusion of platelets and fresh frozen plasma (FFP) on infection rates after cardiac surgery. DESIGN: Retrospective study comparing infection rates after cardiac surgery among patients receiving combinations of packed red blood cells (PRBCs), platelets, and FFP. SETTING: Tertiary care university teaching hospital. PARTICIPANTS: All elective primary coronary artery bypass (CABG) surgery patients from July 1995 to January 1998 before introduction of leukocyte-reduced blood products. INTERVENTIONS: Multivariate logistic and linear regression models were applied to identify clinical risk factors for postoperative infection and to determine the relationship between perioperative administration of PRBCs, platelets, and FFP with postoperative infection. MEASUREMENTS AND MAIN RESULTS: Transfusion of PRBCs, diabetes, age, preoperative hematocrit, and the duration of cardiopulmonary bypass were significantly associated with postoperative infection; platelet or FFP transfusion added no additional risk to PRBC transfusion alone. CONCLUSIONS: Infectious complications in a population of adult primary CABG surgery patients were not increased by transfusion of platelets or FFP. It is PRBC transfusion that confers an increased risk of postoperative infection in this population.     

The role of acute blood transfusion in the development of acute respiratory distress syndrome in patients with severe trauma

BACKGROUND: Patients with major trauma necessitating the transfusion of packed red blood cells (PRBCs) are at increased risk for the acute respiratory distress syndrome (ARDS). However, it is presently unknown whether the amount of transfused blood is independently associated with development of ARDS in patients with severe trauma. METHODS: This is a prospective cohort study of 102 consecutive patients with severe trauma from an intensive care unit in a Level I trauma center. RESULTS: Patients were divided into three predetermined groups on the basis of the total number of units of PRBCs received in the initial 24 hours. A significant association was identified between an acute exposure to transfused blood and the development of ARDS. Twenty-one percent of patients who received 0 to 5 units of PRBCs developed ARDS, compared with 31% of those patients who received 6 to 10 units of PRBCs and 57% of those who received greater than 10 units of PRBCs (p = 0.007). The association between the amount of transfused blood and the development of ARDS remained significant in a multivariable logistic regression model accounting for differences in severity of illness, type of trauma, race, gender, and base deficit (p = 0.002; odds ratio, 14.4; 95% confidence interval, 3.2-78.7). Patients who received more units of PRBCs during the first 24 hours also had a higher hospital mortality rate (p = 0.03). CONCLUSION: In severely injured trauma patients who require administration of packed red blood cells, the amount of transfused blood is independently associated with both the development of ARDS and hospital mortality.     

Gender is an essential determinant of blood transfusion in patients undergoing coronary artery bypass graft procedure

STUDY OBJECTIVE: To determine factors that account for gender difference in the need for blood transfusion in coronary artery bypass graft (CABG) patients. DESIGN: Retrospective study of consecutive patients. SETTING: Anesthesiology department of a teaching hospital. PATIENTS: 253 CABG patients (163 males and 90 females). INTERVENTIONS: Packed red blood cells (PRBCs), platelets, and fresh frozen plasma (FFP) were transfused depending on the need of each patient. MEASUREMENTS AND MAIN RESULTS: For each patient, we recorded the gender, age, weight, height, body surface area (BSA), and duration of surgery. Hematocrit (Hct) levels prior to surgery, end of surgery, and at discharge from the hospital were recorded. PRBC administration and use of FFP and platelets were noted. Differences between the data for female and male patients were evaluated using Student's t-test, Chi-square test, and regression analysis. Approximately 60% female and only 20% male patients received PRBCs intraoperatively, whereas 78% females and only 43% males received PRBCs during their entire hospital stay. On average, females received 1.20 units of PRBCs intraoperatively and 2.38 units during the entire hospital stay, while the males received 0.31 units and 1.36 units for similar periods. Gender differences in PRBC transfusion persisted even when females and males were compared within the same subgroups for age, weight, duration of surgery, and preoperative Hct. PRBC units given intraoperatively had a significant correlation with age and preoperative Hct in females, but they had a significant correlation with age, preoperative Hct, and duration of surgery in males. PRBCs given during the entire hospital stay, however, had significant correlation with age, preoperative Hct, and duration of surgery in both females and males. Multiple logistic regression analysis showed that the probability of a patient receiving or not receiving PRBC transfusion is significantly influenced by age, preoperative PRBC mass, duration of surgery, and gender. CONCLUSION: Gender is an independent essential determinant of blood transfusion in CABG patients, and it may interact with age, weight, preoperative Hct, duration of surgery, and other factors in determining the probability of transfusion.     

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: There is a dose-dependent correlation between blood product transfusion and adverse outcome (increased mortality and infection) in trauma patients.     

Use of intravenous tranexamic acid to reduce allogeneic blood transfusion in total hip and knee arthroplasty: a meta-analysis

Total hip or knee arthroplasty is associated with significant blood loss. Techniques such as the use of antifibrinolytics or desmopressin, or normovolaemic haemodilution have been used to reduce the need for allogeneic blood transfusion. Tranexamic acid has been used to reduce blood loss and transfusion requirement for total hip and knee arthroplasty, with variable results. This meta-analysis aims to evaluate whether intravenous tranexamic acid, when compared with placebo, reduces blood loss and transfusion requirement in total hip and knee joint replacement surgery and whether it might increase the risk of thromboembolic complications. The literature search was based on MEDLINE, EMBASE, Cochrane Controlled Trials Register, and information from the pharmaceutical company that produces tranexamic acid (Pharmacia-Upjohn). We identified 15 clinical trials and 12 were considered suitable for detailed data extraction. Tranexamic acid reduces the proportion of patients requiring allogeneic blood transfusion (OR 0.16, 95% CI: 0.09-0.26), total amount of blood loss (WMD 460 ml, 95% CI: 274-626 ml), and the total number of units of allogeneic blood transfused (WMD 0.85 unit, 95% CI: 0.36-1.33). Tranexamic acid does not increase the risk of thromboembolic complications such as deep vein thrombosis, pulmonary embolism, thrombotic cerebral vascular accident, or myocardial infarction (OR 0.98, 95% CI: 0.45-2.12). Intravenous tranexamic acid appears effective and safe in reducing allogeneic blood transfusion and blood loss in total hip and knee arthroplasty.     

Does the Use of Erythropoietin Reduce the Risk of Exposure to Allogeneic Blood Transfusion in Cardiac Surgery? A Systematic Review and Meta‐Analysis

BACKGROUND: The use of blood conservation techniques is important in cardiac surgery as postoperative bleeding is common and allogeneic blood transfusion carries the risk of transfusion reactions and infection transmission. Erythropoietin with and without preoperative autologous blood donation is one of the modalities to avoid allogeneic blood transfusion. The objective of this review was to assess the effectiveness of erythropoietin in reducing the risk of exposure to allogeneic blood transfusion during or after cardiac surgery. METHODS: A meta-analysis of 11 identified randomized controlled trials, reporting comparisons between erythropoietin and control, was undertaken. The primary outcome was the number of patients exposed to allogeneic blood transfusion during or after cardiac surgery. RESULTS: Eleven studies, involving 708 patients, met the inclusion criteria for this review. In total, 471 patients were given erythropoietin, and 237 patients formed the control group. The administration of erythropoietin with and without preoperative autologous blood transfusion prior to cardiac surgery is associated with a significant risk reduction: RR = 0.28 (95% CI 0.18-0.44, P < 0.001) and RR = 0.53 (95% CI 0.32-0.88, P < 0.01), respectively. CONCLUSION: The administration of erythropoietin before cardiac surgery is associated with a significant reduction in the risk of exposure to allogeneic blood transfusion. Further studies are warranted to define the patients' subgroups that may benefit the most from EPO administration.     

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.     

Perflubron emulsion (AF0144) augments harvesting of autologous blood: a phase II study in cardiac surgery

OBJECTIVE: To assess tolerance and preliminary efficacy of a perfluorocarbon emulsion (AF0144) used with acute normovolemic hemodilution to reduce allogeneic blood transfusion for patients undergoing coronary artery bypass graft (CABG) surgery with cardiopulmonary bypass (CPB). DESIGN: Controlled, single-blind, parallel-group phase II dose escalation trial. SETTING: Single-institution university medical center. PARTICIPANTS: Adult patients undergoing elective CABG surgery (n = 36). INTERVENTIONS: A calculated volume of autologous whole blood was harvested for each patient with a target on-bypass hematocrit of 20% to 22%. Placebo, low-dose (1.8 g/kg) AF0144, or high-dose (2.7 g/kg) AF0144 was infused. During CPB, blood was transfused at protocol-defined triggers (hematocrit <15%, PvO(2) <30 mmHg, SvO(2) <60%). After CPB, all autologous whole blood was reinfused. Allogeneic red blood cells were transfused if a trigger was reached. MEASUREMENTS AND MAIN RESULTS: Safety assessments (vital signs, hematology, blood chemistry, coagulation, and adverse events) were monitored through postoperative day 21. Efficacy endpoints included percentage of patients reaching a transfusion trigger and number of allogeneic units of red blood cells transfused. During CPB, <25% of subjects reached a transfusion trigger. During hospitalization, significantly fewer (p < 0.01) high-dose subjects (33%) reached a trigger than did control patients (91%). Allogeneic red blood cell transfusion did not differ significantly among groups. Safety assessments indicated AF0144 was well tolerated. CONCLUSION: The data suggest that AF0144 when used with acute normovolemic hemodilution is well tolerated and may be effective when used to enhance oxygen delivery for patients undergoing CABG surgery. Confirmation of safety and efficacy in a larger phase III clinical trial is warranted.     

Perioperative blood transfusions and delayed wound healing after hip replacement surgery: effects on duration of hospitalization

Patients who receive allogeneic blood transfusions after orthopedic surgery have a longer duration of hospitalization, and this cannot be explained by a more frequent incidence of infections in transfused patients. To determine whether transfusion of allogeneic blood interferes with wound healing and therefore increases the duration of hospitalization, we performed an observational study in 444 consecutive patients scheduled for elective primary hip surgery. Transfusion, wound, and infection variables were collected at five time points during treatment. Of the 444 consecutive patients studied, 92 received blood transfusions during their perioperative course. Thirty-one percent of transfused patients developed wound-healing disturbances versus 18% of the nontransfused group (P < 0.05); allogeneic blood transfusion was the only significant predictor for development of minor wound-healing disturbances. Duration of hospitalization was prolonged in transfused patients (12.3 versus 9.8 days) and could be predicted by 4 significant variables: requirement for blood transfusion (adds 2.7 +/- 0.5 days), presence of wound-healing disturbances (adds 1.3 +/- 0.5 days), duration of surgery (adds 0.2 +/- 0.1 days/10 min), and patient's age (adds 0.9 +/- 0.2 days/10 yr). These data suggest that allogeneic blood transfusion is associated with an increased incidence of wound-healing disturbances and that prevention of allogeneic blood transfusion may be relevant in limiting the duration of admission after elective orthopedic surgery.     

Leucocyte-Depleted Blood Transfusion is an Independent Predictor of Surgical Morbidity in Patients Undergoing Elective Colon Cancer Surgery—A Single-Center Analysis of 531 Patients

Background

Leukocyte-depleted packed red blood cells (PRBC) were introduced to reduce potential immunomodulatory effects and transfusion-associated morbidity. It has, however, remained unclear, if leucocyte depletion prevents negative side effects of blood transfusion. The aim of this analysis was to examine the effects of leukocyte-depleted PRBC on surgical morbidity after elective colon cancer surgery.

Methods

Data were prospectively collected from 531 consecutive patients undergoing elective colon cancer surgery at a single high-volume center (University Hospital) from 2002 to 2008. Potentially predictive factors for surgical morbidity were tested on univariate and multivariate analysis.

Results

A total of 531 patients with colon cancer were included. A curative (R0) resection was performed in 497 patients (94%). The mortality rate, overall morbidity rate, and surgical morbidity rate were 1.1, 33, and 21%, respectively. Some 135 patients (25%) received perioperative transfusion of PRBCs. On multivariate analysis age (odds ratio [OR] 1.04, 95% confidence interval [95% CI] 1.02–1.06; P = 0.001), BMI (OR 1.08, 95% CI 1.03–1.13; P = 0.003), and PRBC transfusion (2.4, 1.41–4.11; P = 0.001) were revealed as independent predictors of surgical morbidity. The risk of surgical complications increased continuously with the amount of transfused PRBCs. The adverse impact of PRBC transfusion was neither restricted to the timepoint of transfusion (intraoperative or postoperative), nor to the kind of complication (infectious vs noninfectious complication).

Conclusion

Perioperative transfusion of leukocyte-depleted PRBCs has a significantly negative effect on surgical morbidity of patients undergoing elective colon cancer surgery. The use of perioperative blood transfusions in these patients should be avoided, whenever possible.     

A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators.

Concern about risks of allogeneic transfusion has led to an interest in methods for decreasing perioperative transfusion. To determine whether cell salvage reduces patient exposure to allogeneic blood, we performed meta-analyses of randomized trials, evaluating the effectiveness and safety of cell salvage in cardiac or orthopedic elective surgery. The primary outcome was the proportion of patients who received at least one perioperative allogeneic red cell transfusion. Twenty-seven studies were included in the meta-analyses. Cell salvage devices that do not wash salvaged blood were marginally effective in cardiac surgery patients when used postoperatively (relative risk [RR] = 0.85, 95% confidence interval [CI] = 0.79-0.92). Devices that wash or do not wash salvaged blood considerably decreased the proportion of orthopedic surgery patients who received allogeneic transfusion (RR = 0.39, 95% CI = 0.30-0.51 and RR = 0.35, 95% CI 0.26-0.46, respectively). No studies of cell savers that wash salvaged blood during cardiac surgery were included. Cell salvage did not appear to increase the frequency of adverse events. We conclude that cell salvage in orthopedic surgery decreases the risk of patients' exposure to allogeneic blood transfusion perioperatively. Postoperative cell salvage in cardiac surgery, with devices that do not wash the salvaged blood, is only marginally effective. IMPLICATIONS: This meta-analysis of all published randomized trials provides the best current estimate of the effectiveness of cell salvage and is useful in guiding clinical practice. We conclude that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion perioperatively, but postoperative cell salvage is only marginally effective in cardiac surgery.     

Autologous Versus Allogeneic Transfusion in Aortic Surgery: A Multicenter Randomized Clinical Trial

OBJECTIVE: To evaluate the efficacy of acute normovolemic hemodilution (ANH) and intraoperative cell salvage (ICS) in blood-conservation strategies for infrarenal aortic surgery. SUMMARY BACKGROUND DATA: Recent concerns over the risks of transfusion-related infection have resulted in sharp rises in the cost of blood preparations. Autologous transfusion may be a safe alternative to allogeneic transfusion, which has been associated with immune modulation and postoperative infection. METHODS: This multicenter prospective randomized trial compared standard transfusion practice with autologous transfusion combining ANH with ICS in 145 patients undergoing elective aortic surgery. The primary outcome measures were the proportion of patients requiring allogeneic blood and the volume of allogeneic transfusion. The secondary outcome measures were the frequency of complications, including postoperative infection, and postoperative hospital stay. RESULTS: The combination of ANH and ICS reduced the volume of allogeneic blood transfused from a median of two units to zero units. The proportion of patients transfused was 56% in allogeneic and 43% in autologous. There were no significant differences in complications or length of hospital stay. CONCLUSIONS: Both ANH and ICS were safe and reduced the allogeneic blood requirement in patients undergoing elective infrarenal aortic surgery.     

Solicitud de sangre preoperatoria en cirugía programada de colon: ¿necesidad o rutina?

Background

Preoperative blood ordering is frequently in elective colon surgery, even for procedures that rarely require blood transfusion. Most often this procedure is performed without proper analysis of the real needs. The aim of this study was to evaluate the patients who receive transfusion and determining their associated factors.

Methods

Retrospective study of all consecutive patients scheduled for elective colon surgery was carried out at 2007-2012. Several clinico-pathological and surgical variables were analyzed and predictive blood transfusion indices such as the cross-matched/transfusion ratio (C/T ratio), transfusion index and transfusion probability were calculated. Patients were divided in 2 groups according have received perioperative surgical transfusion or not.

Results

There were 457 surgery patients. A total of 171 blood units, in a 74 patients were perioperative transfused. Overall cross-matched transfused ratio was 5.34, the transfusion probability 162%, and the transfusion index 0.18. Variables that were significantly associated with receiving blood transfusion in a multivariable analysis were a preoperative haemoglobin level less than 10 g/dl (OR: 309.8; 95% CI: 52.7-985.2), chronic pulmonary obstructive disease (OR: 3.7; 95% CI: 1.3-10.7), oral anticoagulant therapy (OR: 5.7; 95% CI: 1.7-19.4) and surgical time over 120 min (OR: 10.7; 95% CI: 4.7-24.1).

Conclusions

Likelihood of receiving perioperative transfusion in elective colon surgery is very low. Among their associated factors, the haemoglobin level less than 10 g/dl is the one with strongest association. Those patients with such low preoperative haemoglobin level should not be scheduled for elective colon surgery until they received specific treatment.     

Transfusion after coronary artery bypass surgery: the impact of heparin-bonded circuits.

OBJECTIVE: To identify the impact of heparin bonded (Carmeda) circuits on the need for transfusion of packed red blood cells (PRBC) after CABG independent of the influence of patient, procedural, and surgical experience variables. METHODS: A prospective, randomized trial examined the impact of heparin-bonded circuits in 210 patients undergoing coronary artery bypass surgery at Medical Center of Delaware (Christiana Care Health Services). Patients were randomized to either non-bonded circuits or heparin-bonded (Carmeda) circuits. There were no significant differences in patient characteristics between the treatment and control group. A multivariate analysis was performed to identify the independent predictors of both the need for transfusion (logistic) and number of units of PRBC transfused (OLS). RESULTS: The only significant (P < 0.05) independent predictors of need for transfusion were gender (odds ratio (OR) = 0.35 for males), use of anticoagulants prior to surgery (OR = 2.09), cross-clamp time (OR = 1.03 for each extra minute), and use of heparin-bonded circuits (OR = 0.50 for patients in the heparin-bonded; Carmeda, circuit group). The only significant independent predictors of number of PRBCs were anticoagulants prior to surgery, cross-clamp time, catheterization procedure on the same day, body surface area, and use of heparin-bonded circuits. Other patient demographic variables, comorbidities, and surgical variables were not significant independent predictors of the need for transfusion or the number of units transfused. CONCLUSIONS: Several factors influence the probability of transfusion that patients face following coronary artery bypass surgery. The probability of transfusion is 50% less and the number of PRBCs transfused are 1.42 units less when heparin-bonded (Carmeda) circuits are used, adjusted for patient demographics, comorbidities, or surgical variables.     

关于心脏手术中自体血回收有效性随机试验的荟萃分析

背景在心脏手术中可以通过自体血回收来避免输注同种异体血。另外已有人提出,血液中的碎片可能会增加卒中或神经意识功能障碍的风险,因此,清除回收血中的碎片可改善患者的预后。在此研究中,我们试图通过系统性回顾已发表的随机控制性试验进行荟萃分析,明确在心脏手术中自体血回收的整体安全性和有效性。方法全面检索找出关于所有有关心脏手术中应用自体血回收技术的所有随机试验。截止到2008年11月的MEDLINE、Cochrane图书馆、EMBASE和摘要资料库均被检索完全。将所有心脏手术中应用自体血回收技术与未应用自体血回收技术进行比较,并且报道至少一个明确的临床结果的随机试验均被列为研究对象。随机效应模型被用来依次计算比值比（OR,95％可信区间）、二分法加权平均差（WMD,95％可信区间）和连续变量。结果包括2282例患者在内的31个随机试验最终被作为研究对象进行荟萃分析。在心脏手术中,进行手术中自体血回收减少了接触同种异体异基因血制品（比值比0．63,95％可信区间：0．43—0．94,P=0．02）及红细胞（比值比0．60,95％可信区间：0．39—0．92,P=0．02）的概率,也降低了平均每例患者输注同种异体异基因血制品的总量（加权平均差-256ml,95％可信区间：-416--95ml,P=0．002）。但在以下几个方面进行自体血回收组与未进行自体血回收组之间并无差异,包括：院内死亡率（比值比0．65,95％可信区间：0．25—1．68,P=0．37）、手术后卒中或短暂缺血性发作（比值比0．59,95％可信区间：0．20～1．76,P=0．34）、房颤（比值比0．92,95％可信区间：0．69—1．23,P=0．56）、肾功能衰竭（比值比0．86,95％可信区间：0．41—1．80,P=0．70）、感染（比值比1．25,95％可信区间：0．75—2．10,P=0．39）、接受新鲜冰冻血浆治疗（比值比1．16,95％可信区间：0．82—1．66,P=0．40）以及接受血小板输注治疗（比值比0．90,95％可信区间：0．63—1．28,P=0．55）。结论现有的证据表明应用自体血回收技术可减少心脏手术中患者异体血制品或红细胞的输注。进一步的分析认为,只有在收集失血和（或）剩余机血,或在整个手术过程中应用自体血回收技术才是有利的。如果只在体外循环期间用自体血回收技术作为心内吸引,则对于血液保护没有明显效应且增加新鲜冰冻血浆的输注。     

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.     

Use of off-pump and on-pump CABG strategies in current clinical practice: the Clinical Outcomes Assessment Program of the state of Washington

BACKGROUND: The purpose of this study is to assess clinical outcomes and regional differences in the use of on-pump and off-pump CABG in current clinical practice. METHODS: Between January 1, 1999, and December 31, 2000, there were 10,429 CABG procedures performed in 16 Washington state hospitals, all of which participate in Clinical Outcomes Assessment Program database. This analysis excluded patients with a history of prior CABG as well as those who underwent emergent surgery. After applying these exclusion criteria, 8402 patients (7169 on-pump and 1233 off-pump CABG procedures) were evaluated and presented as both unadjusted and risk-adjusted outcomes. OUTCOMES: Off-pump CABG constituted 14.7% of all surgical revascularization procedures. These varied enormously among individual centers from an incidence of 0% to 68.9%. The use of off-pump CABG was not associated with a decreased risk of risk-adjusted hospital mortality or stroke, but was associated with a reduction in hospital stay > 7 days (OR 0.62, CI 0.51-0.76), ventilator > 24 hours (OR 0.52, CI 0.34-0.81), dialysis (OR 0.34, CI 0.14-0.86), and RBC transfusion (OR 0.5, CI 0.40-0.61). CONCLUSIONS: Despite its highly variable use, off-pump CABG seems to be judiciously used in current clinical practice in the State of Washington and is associated with a decrease in morbidity in appropriately selected patients.