Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center

doi:10.1016/S0003-4975(03)01345-6

The Annals of Thoracic Surgery

Volume 77, Issue 2, February 2004, Pages 626-634

https://doi.org/10.1016/S0003-4975(03)01345-6 Get rights and content

Abstract

Background

Previous studies defining perioperative risk factors for allogeneic transfusion requirements in cardiac surgery were limited to highly selected cardiac surgery populations or were associated with high transfusion rates. The purpose of this study was to determine perioperative risk factors and create a formula to predict transfusion requirements for major cardiac surgical procedures in a center that practices a multimodality approach to blood conservation.

Methods

We performed an observational study on 307 consecutive patients undergoing coronary artery bypass grafting, valve, and combined (coronary artery bypass grafting and valve) procedures. An equation was derived to estimate the risk of transfusion based on preoperative risk factors using multivariate analysis. In patients with a calculated probability of transfusion of at least 5%, intraoperative predictors of transfusion were identified by multivariate analysis.

Results

Thirty-five patients (11%) required intraoperative or postoperative allogeneic transfusions. Preoperative factors as independent predictors for transfusions included red blood cell mass, type of operation, urgency of operation, number of diseased vessels, serum creatinine of at least 1.3 mg/dL, and preoperative prothrombin time. Intraoperative factors included cardiopulmonary bypass time, three or fewer bypass grafts, lesser volume of acute normovolemic hemodilution removed, and total crystalloid infusion of at least 2,500 mL. The derived formula was applied to a validation cohort of 246 patients, and the observed transfusion rates conformed well to the predicted risks.

Conclusions

A multimodality approach to blood conservation in cardiac surgery resulted in a low transfusion rate. Identifying patients' risks for transfusion should alter patient management perioperatively to decrease their transfusion rate and make more efficient use of blood resources.

Section snippets

Patients and methods

At Englewood Hospital and Medical Center, a broad-based blood conservation program is practiced in all patients. This program includes (1) preoperative optimization of hemoglobin, (2) intraoperative acute normovolemic hemodilution (ANH), (3) autotransfusion, (4) tolerance of anemia, (5) meticulous surgical technique, (6) endovascular vein harvesting, (7) on-site coagulation monitoring (thromboelastography and heparin concentration determination), and (8) targeted pharmacotherapy

Results

The study population consisted of 307 consecutive patients, including 199 patients who underwent CABG, 58 valve, and 50 combined CABG and valve procedures. The demographic and clinical characteristics of these patients are shown in (Table 1). Eleven patients died in the hospital for an overall mortality of 3.5% (11 of 307). Two patients (<1%) required reoperation for bleeding. Two patients (<1%) had perioperative myocardial infarction, 4 patients (1%) experienced permanent stroke, and 1 patient

Comment

Cardiac surgery, above all other major surgical procedures, continues to place the largest demand on the available blood supply. Despite major advances in perioperative blood conservation, transfusion rates in cardiac surgery remain high with large variations among individual centers. Reported average transfusion rates even for isolated coronary revascularization procedures vary between 10% and 70% 1, 2. This study reports a remarkably low overall transfusion rate of 13% reflecting the spectrum

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Routine analyses, clinical data, and the number of blood transfusions were recorded during the hospital stay. Among the 272 patients included, 31% had preoperative iron deficiency and 13% were anemic. Patients with iron deficiency had significantly lower hemoglobin levels throughout the hospital stay and received blood transfusions more frequently during surgical procedures (31% v 19%, p = 0.0361). Detailed analysis showed that patients with iron deficiency received more red blood cell units. There were no differences in postoperative bleeding, morbidity, or mortality.
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Citation Excerpt :
Anemia is a marker of RBC transfusion in a variety of surgery populations, and RBC transfusion guidelines suggest using hemoglobin levels or hematocrit as the major determinant in transfusion decisions.11–17 Similarly, other studies have found that thrombocytopenia and elevations in INR and PTT were associated with increased transfusion.18,19 The present finding that the Model for End-stage Liver Disease (MELD) score was not independently associated with transfusion differed from a previous study from the authors’ institution, which found that each 5-unit MELD score increase was associated with 15.1±3.8 units of total perioperative blood products transfused.6
The identification of transfusion risk factors in patients receiving left ventricular assist devices to allow for targeted use of blood conservation strategies and improved blood utilization.
This is a retrospective analysis of prospectively collected data between April 2009 and June 2012. Linear regression was used to determine factors associated with increased transfusion. Logistic regression was used to determine factors that were associated with more than the median number of units transfused.
Single center, university hospital.
Patients (n = 144) who underwent left ventricular assist device implantation.
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Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are among the most common surgical procedures that necessitate blood transfusion. The purpose of this study was to examine the trends in the utilization of blood transfusions in THA and TKA in the US from 2000 to 2009 by analyzing the Nationwide Inpatient Sample (NIS). During the last decade, the allogeneic blood transfusion (ALBT) rate increased (THA: 11.2% to 19.1%, TKA: 7.7% to 12.4%), whereas the predonated autologous blood transfusion (PR-ABT) rate decreased (THA: 7.7% to 3.9%, TKA: 6.1% to 2.4%) in primary unilateral THA and TKA patients in US hospitals. Overall blood transfusion rates remained stable over time in primary unilateral THA and TKA patients.
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There are limited data in the literature concerning the effect of a blood conservation strategy (BCS) on aortic valve replacement (AVR) patients.
From 2007 to 2011, 778 patients underwent AVR at a single institution. During this period, a multidisciplinary BCS was initiated with emphasis on limiting intraoperative hemodilution, tolerance of perioperative anemia, and blood management education for the cardiac surgery care providers.
Mortality was 3.0% (23 of 778) overall and 1.7% (9 of 522) for isolated first-time AVR. There was no difference in rates of mortality (p = 0.5) or major complications (p = 0.4) between the pre-BCS and post-BCS groups; however, the BCS was associated with a lower risk of major complications (odds ratio, 1.7; p = 0.046) by multivariable analysis. The incidence of red blood cell (RBC) transfusion decreased from 82.9% (324 of 391) to 68.0% (263 of 387; p < 0.01). Of those patients who did not receive any day-of-operation RBC transfusions, 64.5% (191 of 296) did not receive any postoperative RBC transfusions. Lower risk of RBC transfusion was associated with isolated AVR (p < 0.01), a minimally invasive approach (p < 0.01), and BCS (p < 0.01), whereas a greater risk of RBC transfusion was associated with older age (p < 0.01), prior cardiac operation (p = 0.01), female sex (p < 0.01), and smaller body surface area (p < 0.01). Day-of-operation RBC transfusion of 2 units or more was associated with increased deaths (p = 0.01), prolonged intubation (p < 0.01), postoperative renal failure (p = 0.01), and increased incidence of any complication (p < 0.01).
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Original article: cardiovascularPredictors of transfusion requirements for cardiac surgical procedures at a blood conservation center

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and methods

Results

Comment

J Cardiothorac Vasc Anesth

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Cardiothorac Vasc Anesth

J Thorac Cardiovasc Surg

Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelinesa 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group

Anesthesiology

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

JAMA

Factors influencing haemostasis and blood transfusion in cardiac surgery

Perfusion

The stratification of cardiac surgical procedures according to use of blood productsa retrospective analysis of 1480 cases

Can J Anaesth

Original article: cardiovascular
Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center