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SPECIAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 10  |  Issue : 2  |  Page : 108-112
Blood transfusion in cardiac surgery: Is it appropriate?


Department of Anesthesiology, SUNY at Stony Brook Helath Sciences Center, Stony Brook, New York, USA

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How to cite this article:
Scott BH. Blood transfusion in cardiac surgery: Is it appropriate?. Ann Card Anaesth 2007;10:108-12

How to cite this URL:
Scott BH. Blood transfusion in cardiac surgery: Is it appropriate?. Ann Card Anaesth [serial online] 2007 [cited 2019 Oct 14];10:108-12. Available from: http://www.annals.in/text.asp?2007/10/2/108/37935


Blood transfusion is commonly used in cardiac surgical patients and accounts for about 10-20% of blood transfused. Inspite of published guidelines there are tremendous variations in transfusion practices among physicians and institutions. The incidence of blood transfusion among patients undergoing cardiac surgery has been reported to vary between 27% and 92%. [1] More recently it has been reported to be 29.4%. [2] It is noted that approximately 10-20% of patients consume 80% of total blood transfused among cardiac surgery patients. [3] The observed variability in transfusion practices may be reduced by altering blood use in this high usage group. Although there are concerns about blood shortage and risks of allogenic blood transfusion, present rate of blood utilization is expected to continue because the transfusion guidelines are not applied appropriately and consistently. It is important to note that blood transfusion is safer than ever today in the United States. This is attributed to the new testing guidelines and donor policies. On the other hand these new guidelines are also responsible for donor shortage. Needless to say transfusion trigger in patients undergoing cardiac surgery and cardiopulmonary bypass (CPB) remains contentious. The aim of this review is to provide clinically useful guidelines, based on available evidence.


   Factors influencing blood transfusion Top


The factors influencing blood utilization are well documented. They include, older age, female gender, comorbidities, small body size, low preoperative haematocrit, preoperative anti­platelet or anti-thrombotic medication, redo and complex procedures, emergency operations, and on-pump surgery. [4]


   Blood Transfusion. Why we do it? Top


Clinicians transfuse blood to increase haemoglobin (Hb) levels with the intention of increasing oxygen carrying capacity, blood volume, especially in acute blood loss and in the process improve outcomes. [5] Studies examining impact of blood transfusion on clinical outcomes often have shown conflicting and confusing results. It is hard to define the benefits of blood transfusion, since randomized trials to support the use of blood products do not exist. However, clinical reports of survival benefit support transfusion in certain clinical situations. [6],[7],[8] So what are the risks of anaemia? Most of the information on the risks of anaemia is from our experience with patients who refuse blood transfusion on religious grounds. One of the earlier studies showed that patients with lower haematocrits had higher mortality especially in patients with cardiovascular disease. [9] The next question to ask is how low can the Hb go without adverse consequences?

Weiskopf et al showed that Hb lowered to 5-6 g/dL produced subtle decreases in cognitive function in humans, which was reversed with transfusion of blood to a Hb >7g/dL. [5] Jehovah witness patients with ischaemic heart disease had increased mortality, if preoperative Hb was <10 g/ dL. [9] Increased incidence of myocardial ischaemia was noted in patients with haematocrit <28% undergoing radical prostatectomies and vascular surgery. [10],[11]

So from these studies it is reasonable to conclude that in patients with coronary artery disease, anaemia increases mortality and morbidity. What should the transfusion trigger be? Lowest haematocrit that can be tolerated in patients with coronary artery disease is not known. At the present time there is a lot of uncertainty as to the level of haematocrit at which blood transfusion should be triggered in the perioperative setting and during CPB.

The American Society of Anesthesiologists published transfusion guidelines in 1996 and an amended report was published in 2005. This task force developed a consensus statement based mostly on best available evidence that concluded that "red blood cell transfusions should not be dictated by a single Hb transfusion trigger but instead should be based on the patient's risk of developing complications of inadequate oxygenation". These guidelines do not specifically address the transfusion needs of the cardiac surgery patient. Based on the American Society of Anesthesiologists and Society of Thoracic Surgeons guidelines, it is reasonable to advocate blood transfusion when Hb is <6g/dL. Blood transfusion is probably not indicated in patients with Hb >10g/ dL. [12],[ 13] There is also a general consensus that patients with cardiovascular disease should be transfused at higher haematocrit levels when compared to their healthy counterparts. Because of lack of randomized trials to define the optimum transfusion trigger in cardiac surgery, this issue will continue to remain controversial. [12]

The author believes that it is important to examine at what level of haematocrit the benefits of transfusion outweigh the risks. Wu et al demonstrated that in patients with acute myocardial infarction, haematocrit <33% was associated with increased 30 day and one year mortality. Those who received transfusion for haematocrits less than 33% had lower mortality rates than patients who did not receive a transfusion for similar haematocrit levels. [14] Cardiac anaesthesiologists deal with similar patients in their practice and the author believes this supports the belief that patients with cardiovascular disease have better outcomes with higher haematocrit levels. Routine use of blood transfusion to maintain an arbitrary haematocrit is questioned as there is conflicting data as to whether blood transfusion really improves patient outcome. Bracy et al in a randomized control trial examined the impact of transfusion at two different triggers. One group received transfusion with a Hb level <9.0g/dL as threshold for transfusion and the second group received transfusion for Hb level <8.0 g/dL.This study demonstrated that there were no differences in the outcome between the two groups. [15] In this study functional recovery issue was not addressed. There is limited data in this area, but it is suggested that patients with Hb levels <10g/dl improve their exercise tolerance and functional recovery with transfusion. The author believes this is an important consideration, as cardiac surgery patients are routinely fast tracked and discharged early from hospitals.


   Transfusion during cardiopulmonary bypass Top


This is another controversial area. The Society of Thoracic Surgeons guidelines suggests that in patients with severe anaemia on CPB (Hb£ 6.0 g/ dL or £8 g/dL in elderly patients) or acute blood loss (³30% of blood volume), receive red blood cell transfusion to support cardiac output and sustain oxygen carrying capacity with the expectation that operative mortality will be improved. Certain patients with critical non-cardiac end-organ ischaemia (e.g. central nervous system, gastrointestinal system) may also benefit from Hb levels as high as 10 g/dL, but more evidence to support this recommendation is required. [13] In the setting of Hb values exceeding 6 g/dL while on CPB, the patient's clinical situation should be considered as the most important component of the decision making process. Indications for transfusion of red blood cells in this setting are multifactorial and should be guided by patient­related factors such as age, acuity of illness, end­organ ischaemia, cardiac function, the clinical setting of active blood loss and laboratory or clinical data. Fang et al demonstrated that haematocrit less than 17% during CPB in high risk patients was an independent predictor of increased mortality. [16] Again, the decision to transfuse should be based on the risk for organ ischaemia and potential for or presence of active bleeding.

In a comprehensive database study from the Northern New England Cardiovascular Disease Study Group, DeFoe et al reported that of 6,980 consecutive patients who underwent coronary artery bypass at six medical centres between 1996 and 1998, the lowest haematocrit during CPB was associated with increased mortality, return to bypass after separation and increased incidence of intra-aortic balloon placement. They also noted that patients with low preoperative haematocrit and smaller body size, as expected had low haematocrits during CPB leading to higher mortality risk. This was attributed to greater haemodilution and anaemia during CPB. [17]

Habib et al reported a retrospective analysis of operative results and resource utilization in consecutive cardiac operations with CPB. [18] Myocardial infarction, renal failure, stroke, prolonged ventilation, sepsis and multiorgan failure were significantly increased as lowest haematocrit value decreased below 22%. They noted that hospital length of stay, and mortality were significantly greater as a function of haemodilution severity. Long-term survival is improved in patients with higher haematocrits during CPB, suggesting that increased haemodilution severity is associated with worse perioperative outcomes. [18] Karkouti et al prospectively evaluated 10,949 consecutive patients who underwent coronary bypass with extracorporeal circulation from 1999 to 2004, and reported that nadir haematocrit of 21% during cardiopulmonary bypass was an independent predictor of perioperative stroke. After controlling for confounding variables, each percent decrease in haematocrit was associated with a ten percent increase in the odds of suffering perioperative stroke. [19] Hardy et al demonstrated that Hb <6 gm/dL in the first 24 hours after CPB was associated with increased incidence of renal and gastrointestinal complications. The low Hb group also had longer length of stay and haemodynamic instability. [20] Karkouti et al in yet another observational study showed that the nadir haematocrit <21% during CPB was associated with acute renal failure. [21]


   Blood transfusion in the postoperative cardiac surgery patient Top


Blood transfusion in this group of patients after surgery requires careful consideration of patient factors such as cardiac, pulmonary and neurological status, surgical factors such as potential for ongoing bleeding and haemodynamic and physiological parameters. Again, there is a paucity of data in support of transfusion. Society of Thoracic surgeons guidelines strongly recommends blood transfusion, when Hb level is < 6g/dL, especially when anaemia is acute and it is reasonable to transfuse, if Hb is <7g/dL. Transfusion is not recommended, if Hb is >10g/ dL. [13] Hebert et al found that patients with cardiac disease admitted to the critical care unit had a significantly higher risk of death with lower Hb value. [22] But in a subsequent prospective, randomized, controlled trial the same authors reported that there was no difference in mortality between restrictive and liberal transfusion groups. They claimed that the restrictive protocol was at least as effective and possibly superior to the liberal transfusion protocol. [23] Spiess et al examined the impact of transfusion in patients undergoing coronary artery bypass grafts. They divided their patients into three groups based on the admission haematocrit in the intensive care unit. They found that patients classified into the high haematocrit group (34%) had higher incidence of myocardial infarction than the patients in the low group (<24%). [24]


   Complications of Blood transfusion Top


Complications associated with blood transfusion include, ABO incompatibility, alloimmunization, immunosuppression, febrile reactions, infections, pneumonia, sepsis, and viral transmission. Bradykinin, cytokines and complement in stored blood are thought to cause acute lung injury and add to inflammatory response after cardiopulmonary bypass. [25] Blood transfusion in coronary operations has been associated with increased risk of mortality during a one year follow­up period with the majority of deaths occurring within the first thirty days. [26] Because of the possible association of blood transfusion on CPB with worse outcomes, several investigators evaluated this possibility with observational studies. Engoren and co-workers studied 1,915 patients who underwent first-time isolated coronary artery bypass operations between 1994 and 1997 and found that 649 of the study patients (34%) received a transfusion during their hospitalization. Transfused patients were older, smaller, more likely to be female, and had more co-morbidity. The transfused patients also had twice the five-year mortality (15% vs. 7%) of non-transfused patients. After correction for co-morbidities and other factors, transfusion was still associated with an increase in mortality. The authors concluded that blood transfusions during or after coronary bypass operations are associated with increased long term morbidity and mortality. [27] In a review of over 15,000 patients undergoing CPB procedures at the Cleveland Clinic a strong association was demonstrated between the use of transfusions and postoperative infections. [28] Examining the data over a period of three years at the author's institution, it was found that transfused patients had significantly higher mortality, morbidity and length of stay. It should be pointed out that transfused patients had significantly more preoperative comorbidities. [29] All of the data reviewed above are derived from observational studies and therefore only document associations but not cause and effect. Anaemia may well drive a number of physiological responses as well as physician behaviours such as inclination towards transfusion. It is therefore unclear at this time how important any level of anaemia is, in creating organ failure or long term adverse outcomes. Then to add to all this conflicting information, it has been shown that 28 days or longer stored red blood cells are depleted of 2,3 diphosphoglycerate leading to leftward shift of the oxyhaemoglobin dissociation curve. This leads to question the basic premise of blood transfusion as a vehicle to increase oxygen carrying capacity. [30] The storage duration of red blood cells is shown to be associated with increased intensive care and hospital length of stay and mortality. [31]


   Conclusion Top


The author believes that it is important to recognize that despite a large body of literature, the precise haematocrit, at which benefits of blood transfusion outweigh the risks is not known. Most cardiac anaesthesiologists would agree that it is reasonable to administer blood when Hb is <7 g/dL especially to treat symptoms and signs of inadequate tissue oxygen delivery, and transfusion is not needed when Hb is >10g/dL. The practice of blood transfusion in the setting of Hb between 7.1 and 9.92g/dL is variable and perhaps, determined by the patient's condition. In the clinical setting, the anaesthesiologist will continue to make transfusion decisions based on clinical assessment of the situation weighing risks versus benefits of blood transfusion. Guidelines presently available may not apply to every patient, especially in high risk cardiac surgical patients. Practitioners and institutions should develop their own multidisciplinary blood transfusion and conservation guidelines to maintain appropriate blood transfusion practices.

 
   References Top

1.Stover EP, Siegel LC, Parks R, et al. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24­institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology 1998; 88: 327-333.  Back to cited text no. 1    
2.Karkouti K, Cohen MM, McCluskey SA, Sher GD. A multivariate model for predicting the need for blood transfusion in patients undergoing first time elective coronary artery bypass graft surgery. Transfusion 2001; 41: 1193-203.  Back to cited text no. 2    
3.Ferraris V, Ferraris S. Limiting excessive postoperative blood transfusion after cardiac procedures: A review. Tex Heart Inst J. 1995; 22: 216-230.  Back to cited text no. 3    
4.Scott BH, Seifert FC, Glass PSA, et al. Blood use in patients undergoing coronary artery bypass surgery: Impact of cardiopulmonary bypass pump, hematocrit, gender, age and body weight. Anesth Analg 2003; 97: 958-63.  Back to cited text no. 4    
5.Weiskopf RB, Viele MK, Feiner J, Kelley S, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA 1998; 279: 217-221.  Back to cited text no. 5    
6.Goodnough LT, Despotis GJ. Transfusion medicine: support of patients undergoing cardiac surgery. Am J Cardiovasc Drugs 2001; 1: 337-351.  Back to cited text no. 6    
7.Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion. Transfusion 2002; 42: 812-818.  Back to cited text no. 7    
8.Carson JL, Duff A, Poses RM, Berlin JA, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996; 348: 1055-1060.  Back to cited text no. 8    
9.Viele MK, Weiskopf RB. What can we learn about the need for transfusion from patients who refuse blood? The experience with Jehovah's Witnesses. Transfusion 1994; 34: 396-401.  Back to cited text no. 9    
10.Nelson AH, Fleisher LA, Rosenbaum SH. Relationship between postoperative anemia and cardiac morbidity in high risk vascular patients in the intensive care unit. Crit Care Med 1993; 21: 860-866.  Back to cited text no. 10    
11.Hogue CW, Goodnough LT, Monk TG. Perioperative myocardial ischemic episodes are related to hematocrit level in patients undergoing radical prostatectomy. Transfusion 1998; 38: 924-931.  Back to cited text no. 11    
12.Guidelines. Practice Guidelines for blood component therapy: A report by the American Society of Anesthesiologists Task Force on Blood Component Therapy. Anesthesiology 1996; 84: 732-747 (amended in 2005 available at publicationsAndServices/BCTGuidesFinal.pdf.)  Back to cited text no. 12    
13.Ferraris VA, Ferraris SP, Saha SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery. The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists practice guidelines. Ann Thorac Surgery 2007; 83: S 27-S 86.  Back to cited text no. 13    
14.Wu Wc, Rathore SS, Wang Y, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Eng J Med 2001; 345: 1230-1236.  Back to cited text no. 14    
15.Bracey AW, Radovancevic R, Riggs SA, et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: Effect on patient outcome. Transfusion 1999; 39: 1070-1077.  Back to cited text no. 15    
16.16 Fang WC, Helm RE, Krieger KH, et al. Impact of minimum hematocrit during cardiopulmonary bypass on mortality in patients undergoing coronary artery surgery. Circulation 1997; 96(Suppl II): 194-199.  Back to cited text no. 16    
17.DeFoe GR, Ross CS, Olmstead EM, et al. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 2001; 71: 769-776.  Back to cited text no. 17    
18.Habib RH, Zacharias A, Schwann TA, et al. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 2003; 125: 1438-1450.  Back to cited text no. 18    
19.Karkouti K, Djaiani G, Borger MA, et al. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg 2005; 80: 1381-1387.  Back to cited text no. 19    
20.Hardy JF, Martineau R, Couturier A, et al. Influence of hemoglobin concentration after extracorporeal circulation on mortality and morbidity in patients undergoing cardiac surgery. Br J Anaesth 1998; 81: 38-45.  Back to cited text no. 20    
21.Karkouti K, Beattie WS, Wijeysundera DN, et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Tharac Cardiovasc Surg 2005; 129: 391­-400.  Back to cited text no. 21    
22.Hebert PC, Wells G, Tweeddale M, et al. Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. Am J Respir Crit Care Med 1997; 155: 1618-1623.  Back to cited text no. 22    
23.Herbert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion requirements in Critical Care Investigators. Canadian Critical care Trials Group. N Eng J Med 1999; 340: 409-417.  Back to cited text no. 23    
24.Spiess BD, Ley C, Body SC, et al. Hematocrit value on intensive care unit entry influences the frequency of Q wave myocardial infarction after coronary artery bypass grafting.The multicenter study of perioperative ischemia (Mc SPI) research group. J Thorac Cardiovasc Surg 1998; 116: 460-467.  Back to cited text no. 24    
25.Murkin JM, Wall MH. Transfusion trigger Hct 25%: Above or below, which is better? Pro: Hct <25% is better and Con : > 25% is better. J Cardiothorac Vasc Anesth 2004; 18: 234-241.  Back to cited text no. 25    
26.Kudavalli M, Oo AY, Newall N, et al. Effect of peri­operative red blood cell transfusion on 30 - day and 1­year mortality following coronary artery bypass surgery. Eur J of Cardiothorac Surg 2005; 27: 592-598.  Back to cited text no. 26    
27.Engoren MC, Habib RH, Zacharias A, et al. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 2002; 74: 1180-1186.  Back to cited text no. 27    
28.Banbury MK, Brizzio ME, Rajeswaran J, et al. Transfusion increases the risk of postoperative infection after cardiovascular surgery. J Am Coll Surg 2006; 202: 131-138.  Back to cited text no. 28    
29.Scott B, Seifert F, Grimson R. Transfusion in cardiac surgery: Impact on hospital length of stay and mortality. Annual meeting of the American Society of Anesthesiologists. Chicago 2006. http:// www.asaabstracts.com A1014.  Back to cited text no. 29    
30.van Bommel J, decorate D, Lind A, et al. The effect of the transfusion of stored RBC's on intestinal microvascular oxygenation in the rat. Transfusion 2001; 41: 1515-1523.  Back to cited text no. 30    
31.Basaran S, Frumento RJ, Cohen A, et al. The association between duration of storage of transfused red blood cells and morbidity and mortality after reoperative cardiac surgery. Anesth Analg 2006; 103: 15-20.  Back to cited text no. 31    

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Correspondence Address:
Bharathi H Scott
Department of Anesthesiology SUNY at Stony Brook, Health Sciences Center, L4-060 Stony Brook, NY 11794-8480.
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.37935

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