BLOOD TRANSFUSION IN CARDIAC SURGERY- NEED TO FOLLOW BASICS!

More and more data is coming in recent times about hazards of blood transfusion. In a landmark TRICC1 trial Euvolemic patients in the intensive care unit (ICU) with Hb<9 g/dl were randomized to a restrictive transfusion strategy for transfusion of PRBCs (transfused if Hb<7 g/dl to maintain Hb between 7 and 9 g/dl) or a liberal strategy (transfused if Hb<10 g/dl to maintain Hb 10-12 g/dl). Mortality was similar in both groups, indicating that liberal transfusions were not beneficial. An Updated Report by the American Society of AnaesthesiologistsTask Force on Perioperative Blood Management tells us restrictive red blood cell transfusion strategy may be safely used to reduce transfusion administration. It further states that The determination of whether hemoglobin concentrations between 6 and 10 g/dl justify or require red blood cell transfusion should be based on potential or actual on going bleeding (rate and magnitude), intravascular volume status, signs of organ ischemia, and adequacy of cardiopulmonary reserve. Should we extrapolate these guidelines in Cardiac surgery? TRACS2 trial concluded that among patients undergoing cardiac surgery, the use of a restrictive perioperative transfusion strategy compared with a more liberal strategy resulted in noninferior rates of the combined outcome of 30-day all-cause mortality and severe morbidity.They advocated use of restrictive strategy, but 5 years later, the authors 3concluded that A restrictive transfusion threshold after cardiac surgery was not superior to a liberal threshold with respect to morbidity or health care costs. With this conflicting evidence, by which way anaesthesiologist to go?

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Intraoperative Anemia and Single Red Blood Cell Transfusion During Cardiac Surgery: An Assessment of Postoperative Outcome Including Patients Refusing Blood Transfusion

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2015.10.021 ◽

2016 ◽

Vol 30 (2) ◽

pp. 363-372 ◽

Cited By ~ 9

Author(s):

Esther K. Hogervorst ◽

Peter M.J. Rosseel ◽

Leo M.G. van de Watering ◽

Anneke Brand ◽

M. Bentala ◽

...

Keyword(s):

Cardiac Surgery ◽

Blood Transfusion ◽

Blood Cell ◽

Red Blood Cell ◽

Postoperative Outcome ◽

Red Blood Cell Transfusion

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RED BLOOD CELL TRANSFUSION CAN WORSE ORGAN DIS-FUNCTION AND MORTALITY IN PATIENTS SUBMITTED TO RESTRICTIVE TRANSFUSION STRATEGY.

Critical Care Medicine ◽

10.1097/00003246-200612002-00438 ◽

2006 ◽

Vol 34 ◽

pp. A127

Author(s):

Rafael B Tomita ◽

Daniele M Torres ◽

Maria Tereza M Ferrari ◽

João M Silva ◽

Paulo Sérgio D Urtado ◽

...

Keyword(s):

Blood Cell ◽

Red Blood Cell ◽

Red Blood Cell Transfusion ◽

Transfusion Strategy ◽

Restrictive Transfusion ◽

Restrictive Transfusion Strategy

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Restrictive vs. Liberal Red Blood Cell Transfusion Strategy in Patients With Acute Myocardial Infarction and Anemia: A Systematic Review and Meta-Analysis

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.736163 ◽

2021 ◽

Vol 8 ◽

Author(s):

Yeshen Zhang ◽

Zhengrong Xu ◽

Yuming Huang ◽

Qirao Ye ◽

Nianjin Xie ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Blood Cell ◽

Red Blood Cell ◽

Red Blood Cell Transfusion ◽

Transfusion Strategy ◽

Restrictive Transfusion ◽

Liberal Transfusion ◽

Overall Mortality

Objective: Anemia is frequent in patients with acute myocardial infarction (AMI), and the optimal red blood cell transfusion strategy for AMI patients with anemia is still controversial. We aimed to compare the efficacy of restrictive and liberal red cell transfusion strategies in AMI patients with anemia.Methods: We systematically searched PubMed, EMBASE, Web of Science, Cochrane Library, and Clinicaltrials.gov, from their inception until March 2021. Studies designed to compare the efficacy between restrictive and liberal red blood cell transfusion strategies in patients with AMI were included. The primary outcome was all-cause mortality, including overall mortality, in-hospital or follow-up mortality. Risk ratios (RR) with 95% confidence intervals (CI) were presented and pooled by random-effects models.Results: The search yielded a total of 6,630 participants in six studies. A total of 2,008 patients received restrictive red blood cell transfusion while 4,622 patients were given liberal red blood cell transfusion. No difference was found in overall mortality and follow-up mortality between restrictive and liberal transfusion groups (RR = 1.07, 95% CI = 0.82–1.40, P = 0.62; RR = 0.89, 95% CI = 0.56–1.42, P = 0.62). However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion (RR = 1.22, 95% CI = 1.00–1.50, P = 0.05). No secondary outcomes, including follow-up reinfarction, stroke, and acute heart failure, differed significantly between the two groups. In addition, subgroup analysis showed no differences in overall mortality between the two groups based on sample size and design.Conclusion: Restrictive and liberal red blood cell transfusion have a similar effect on overall mortality and follow-up mortality in AMI patients with anemia. However, restrictive transfusion tended to have a higher risk of in-hospital mortality compared with liberal transfusion. The findings suggest that transfusion strategy should be further evaluated in future studies.

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Safety of a Restrictive versus Liberal Approach to Red Blood Cell Transfusion on the Outcome of AKI in Patients Undergoing Cardiac Surgery: A Randomized Clinical Trial

Journal of the American Society of Nephrology ◽

10.1681/asn.2019010004 ◽

2019 ◽

Vol 30 (7) ◽

pp. 1294-1304 ◽

Cited By ~ 8

Author(s):

Amit X. Garg ◽

Neal Badner ◽

Sean M. Bagshaw ◽

Meaghan S. Cuerden ◽

Dean A. Fergusson ◽

...

Keyword(s):

Cardiac Surgery ◽

Blood Cell ◽

Red Blood Cell ◽

Primary Outcome ◽

Red Blood Cell Transfusion ◽

Restrictive Transfusion ◽

Red Blood Cell Transfusions ◽

Liberal Approach ◽

Care Costs ◽

Care Ward

BackgroundSafely reducing red blood cell transfusions can prevent transfusion-related adverse effects, conserve the blood supply, and reduce health care costs. Both anemia and red blood cell transfusion are independently associated with AKI, but observational data are insufficient to determine whether a restrictive approach to transfusion can be used without increasing AKI risk.MethodsIn a prespecified kidney substudy of a randomized noninferiority trial, we compared a restrictive threshold for red blood cell transfusion (transfuse if hemoglobin<7.5 g/dl, intraoperatively and postoperatively) with a liberal threshold (transfuse if hemoglobin<9.5 g/dl in the operating room or intensive care unit, or if hemoglobin<8.5 g/dl on the nonintensive care ward). We studied 4531 patients undergoing cardiac surgery with cardiopulmonary bypass who had a moderate-to-high risk of perioperative death. The substudy’s primary outcome was AKI, defined as a postoperative increase in serum creatinine of ≥0.3 mg/dl within 48 hours of surgery, or ≥50% within 7 days of surgery.ResultsPatients in the restrictive-threshold group received significantly fewer transfusions than patients in the liberal-threshold group (1.8 versus 2.9 on average, or 38% fewer transfusions in the restricted-threshold group compared with the liberal-threshold group; P<0.001). AKI occurred in 27.7% of patients in the restrictive-threshold group (624 of 2251) and in 27.9% of patients in the liberal-threshold group (636 of 2280). Similarly, among patients with preoperative CKD, AKI occurred in 33.6% of patients in the restrictive-threshold group (258 of 767) and in 32.5% of patients in the liberal-threshold group (252 of 775).ConclusionsAmong patients undergoing cardiac surgery, a restrictive transfusion approach resulted in fewer red blood cell transfusions without increasing the risk of AKI.

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Red blood cell transfusion induces abnormal HIF-1α response to cytokine storm after adult cardiac surgery

Scientific Reports ◽

10.1038/s41598-021-01695-4 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Emma Viikinkoski ◽

Juho Jalkanen ◽

Jarmo Gunn ◽

Tuija Vasankari ◽

Joonas Lehto ◽

...

Keyword(s):

Cardiac Surgery ◽

Blood Transfusion ◽

Blood Cell ◽

Red Blood Cell ◽

Adverse Outcomes ◽

Red Blood Cell Transfusion ◽

Clinical Trial Registration ◽

Packed Red Blood Cells ◽

The Impact ◽

Adult Cardiac Surgery

AbstractPatients undergoing cardiac surgery develop a marked postoperative systemic inflammatory response. Blood transfusion may contribute to disruption of homeostasis in these patients. We sought to evaluate the impact of blood transfusion on serum interleukin-6 (IL-6), hypoxia induced factor-1 alpha (HIF-1α) levels as well as adverse outcomes in patients undergoing adult cardiac surgery. We prospectively enrolled 282 patients undergoing adult cardiac surgery. Serum IL-6 and HIF-1α levels were measured preoperatively and on the first postoperative day. Packed red blood cells were transfused in 26.3% of patients (mean 2.93 ± 3.05 units) by the time of postoperative sampling. Postoperative IL-6 levels increased over 30-fold and were similar in both groups (p = 0.115), whilst HIF-1α levels (0.377 pg/mL vs. 0.784 pg/mL, p = 0.002) decreased significantly in patients who received red blood cell transfusion. Moreover, greater decrease in HIF-1α levels predicted worse in-hospital and 3mo adverse outcome. Red blood cell transfusion was associated with higher risk of major adverse outcomes (stroke, pneumonia, all-cause mortality) during the index hospitalization. Red blood cell transfusion induces blunting of postoperative HIF-1 α response and is associated with higher risk of adverse thrombotic and pulmonary adverse events after cardiac surgery. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03444259.

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Red blood cell transfusion threshold after pediatric cardiac surgery

Medicine ◽

10.1097/md.0000000000014884 ◽

2019 ◽

Vol 98 (11) ◽

pp. e14884 ◽

Cited By ~ 1

Author(s):

Xicheng Deng ◽

Yefeng Wang ◽

Peng Huang ◽

Jinwen Luo ◽

Yunbin Xiao ◽

...

Keyword(s):

Cardiac Surgery ◽

Blood Cell ◽

Red Blood Cell ◽

Pediatric Cardiac Surgery ◽

Red Blood Cell Transfusion ◽

Transfusion Threshold

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A multicentre randomised controlled trial of Transfusion Indication Threshold Reduction on transfusion rates, morbidity and health-care resource use following cardiac surgery (TITRe2)

Health Technology Assessment ◽

10.3310/hta20600 ◽

2016 ◽

Vol 20 (60) ◽

pp. 1-260 ◽

Cited By ~ 5

Author(s):

Barnaby C Reeves ◽

Katie Pike ◽

Chris A Rogers ◽

Rachel CM Brierley ◽

Elizabeth A Stokes ◽

...

Keyword(s):

Health Care ◽

Cardiac Surgery ◽

Blood Cell ◽

Red Blood Cell ◽

Primary Outcome ◽

Controlled Trial ◽

Red Blood Cell Transfusion ◽

Restrictive Transfusion ◽

Randomised Controlled

BackgroundUncertainty about optimal red blood cell transfusion thresholds in cardiac surgery is reflected in widely varying transfusion rates between surgeons and cardiac centres.ObjectiveTo test the hypothesis that a restrictive compared with a liberal threshold for red blood cell transfusion after cardiac surgery reduces post-operative morbidity and health-care costs.DesignMulticentre, parallel randomised controlled trial and within-trial cost–utility analysis from a UK NHS and Personal Social Services perspective. We could not blind health-care staff but tried to blind participants. Random allocations were generated by computer and minimised by centre and operation.SettingSeventeen specialist cardiac surgery centres in UK NHS hospitals.ParticipantsPatients aged > 16 years undergoing non-emergency cardiac surgery with post-operative haemoglobin < 9 g/dl. Exclusion criteria were: unwilling to have transfusion owing to beliefs; platelet, red blood cell or clotting disorder; ongoing or recurrent sepsis; and critical limb ischaemia.InterventionsParticipants in the liberal group were eligible for transfusion immediately after randomisation (post-operative haemoglobin < 9 g/dl); participants in the restrictive group were eligible for transfusion if their post-operative haemoglobin fell to < 7.5 g/dl during the index hospital stay.Main outcome measuresThe primary outcome was a composite outcome of any serious infectious (sepsis or wound infection) or ischaemic event (permanent stroke, myocardial infarction, gut infarction or acute kidney injury) during the 3 months after randomisation. Events were verified or adjudicated by blinded personnel. Secondary outcomes included blood products transfused; infectious events; ischaemic events; quality of life (European Quality of Life-5 Dimensions); duration of intensive care or high-dependency unit stay; duration of hospital stay; significant pulmonary morbidity; all-cause mortality; resource use, costs and cost-effectiveness.ResultsWe randomised 2007 participants between 15 July 2009 and 18 February 2013; four withdrew, leaving 1000 and 1003 in the restrictive and liberal groups, respectively. Transfusion rates after randomisation were 53.4% (534/1000) and 92.2% (925/1003). The primary outcome occurred in 35.1% (331/944) and 33.0% (317/962) of participants in the restrictive and liberal groups [odds ratio (OR) 1.11, 95% confidence interval (CI) 0.91 to 1.34;p = 0.30], respectively. There were no subgroup effects for the primary outcome, although some sensitivity analyses substantially altered the estimated OR. There were no differences for secondary clinical outcomes except for mortality, with more deaths in the restrictive group (4.2%, 42/1000 vs. 2.6%, 26/1003; hazard ratio 1.64, 95% CI 1.00 to 2.67;p = 0.045). Serious post-operative complications excluding primary outcome events occurred in 35.7% (354/991) and 34.2% (339/991) of participants in the restrictive and liberal groups, respectively. The total cost per participant from surgery to 3 months postoperatively differed little by group, just £182 less (standard error £488) in the restrictive group, largely owing to the difference in red blood cells cost. In the base-case cost-effectiveness results, the point estimate suggested that the restrictive threshold was cost-effective; however, this result was very uncertain partly owing to the negligible difference in quality-adjusted life-years gained.ConclusionsA restrictive transfusion threshold is not superior to a liberal threshold after cardiac surgery. This finding supports restrictive transfusion due to reduced consumption and costs of red blood cells. However, secondary findings create uncertainty about recommending restrictive transfusion and prompt a new hypothesis that liberal transfusion may be superior after cardiac surgery. Reanalyses of existing trial datasets, excluding all participants who did not breach the liberal threshold, followed by a meta-analysis of the reanalysed results are the most obvious research steps to address the new hypothesis about the possible harm of red blood cell transfusion.Trial registrationCurrent Controlled Trials ISRCTN70923932.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 60. See the NIHR Journals Library website for further project information.

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Perioperative Changes in Hemoglobin Levels During Major Hepatopancreatic Surgery in Transfused and Non-Transfused Patients

Scandinavian Journal of Surgery ◽

10.1177/1457496920964362 ◽

2020 ◽

pp. 145749692096436

Author(s):

J.P. Lammi ◽

M. Eskelinen ◽

J. Tuimala ◽

T. Selander ◽

J. Saarnio ◽

...

Keyword(s):

Blood Transfusion ◽

Blood Cell ◽

Partial Hepatectomy ◽

Red Blood Cell ◽

Total Pancreatectomy ◽

Trigger Points ◽

Red Blood Cell Transfusion ◽

Hepatic Surgery ◽

Restrictive Transfusion ◽

Red Blood Cell Transfusions

Background: Several studies have shown that restrictive transfusion policies are safe. However, in clinical practice, transfusion policies seem to be inappropriate. In order to assist in decision-making concerning red blood cell transfusions, we determined perioperative hemoglobin (Hb) levels during major pancreatic and hepatic operations. Methods: Patients who underwent major pancreatic or hepatic resections between 2002 and 2011 were classified into the transfused (TF+) and non-transfused (TF) groups. The perioperative Hb values of these patients were evaluated at six points in time. Results: The study included 1596 patients, of which 785 underwent pancreatodu-odenectomy, 79 total pancreatectomy, and 732 partial hepatectomy. Similar perioperative changes in Hb levels were seen in all patients regardless of whether they received a blood transfusion. In patients undergoing pancreatoduodenectomy and total pancreatectomy, the median of the lowest measured hemoglobin values was 89.2 g/L and in partial hepatectomy patients 92.6 g/L, and these were assumed to be the trigger points for red blood cell transfusion. Conclusion: Despite guidelines on blood transfusion thresholds, restrictive blood transfusion policies were not observed during our study period. After major pancreatic and hepatic surgery, Hb levels recovered without transfusions. This should encourage clinicians to obey the restrictive blood transfusion policies after major hepatopancreatic surgery.

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