Year : 2008 | Volume
: 11 | Issue : 1 | Page : 15--19
Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery
Bharathi H Scott, Frank C Seifert, Roger Grimson
Departments of Anesthesiology and Surgery, SUNY at Stony Brook, New York, USA
Bharathi H Scott
Department of Anesthesiology, SUNY at Stony Brook Health Sciences Center, L4-060 Stony Brook, NY 11794-8480
The purpose of the present investigation was to examine the impact of blood transfusion on resource utilisation, morbidity and mortality in patients undergoing coronary artery bypass graft (CABG) surgery at a major university hospital. The resources we examined are time to extubation, intensive care unit length of stay (ICULOS) and postoperative length of stay (PLOS). We further examined the impact of number of units of packed red blood cells (PRBCs) transfused during PLOS.
This is a retrospective observational study and includes 1746 consecutive male and female patients undergoing primary CABG (on- and off-pump) at our institution. Of these, 1067 patients received blood transfusions, while 677 did not. The data regarding the demography, blood transfusion, resource utilisation, morbidity and mortality were collected from the records of patients undergoing CABG over a period of three years. The mean time to extubation following surgery was 8.0 h for the transfused group and 4.3 h for the nontransfused group ( P ≤ 0.001). The mean ICULOS for the transfused group was 1.6 d and 1.2 d for the nontransfused group ( P < 0.001). The PLOS was 7.2 d for the transfused group and 4.3 d for no-transfused cohorts ( P ≤ 0.001). In all patients and in patients with no preoperative morbidity, partial correlation coefficients were used to examine the effects of transfusion on mortality, time to extubation, ICULOS and PLOS. Linear regression model was used to assess the effect of number of PRBC units transfused on PLOS. We noted that PLOS increased with the number of PRBCs units transfused. Transfusion is significantly correlated with the increased time to extubation, ICULOS, PLOS and mortality. The transfused patients had significantly more postoperative complications than their nontransfused counterparts ( P ≤ 0.001). The 30-day hospital mortality was 3.1% for the transfused group with no deaths in the nontransfused group ( P ≤ 0.001).
We conclude that the CABG patients receiving blood transfusion have significantly longer time for tracheal extubation, ICULOS, PLOS and higher morbidity and 30-day hospital mortality. Blood transfusion was an independent predictor of increased resource utilisation, postoperative morbidity and mortality.
|How to cite this article:|
Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery.Ann Card Anaesth 2008;11:15-19
|How to cite this URL:|
Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth [serial online] 2008 [cited 2014 Nov 20 ];11:15-19
Available from: http://www.annals.in/text.asp?2008/11/1/15/38444
Blood transfusion is common in patients undergoing coronary artery bypass graft (CABG) surgery. Approximately 20% of the available blood supply in the United States is consumed by patients undergoing cardiac surgery.  It is expected that with the increase in age and comorbidities among patients presenting for surgery, blood transfusion will further increase.  Despite this, there is a relatively scant information with regard to the impact of transfusion on resource utilisation and postoperative morbidity and mortality. The goal of our investigation was to examine the impact of transfusion on the duration of intubation, intensive care unit length of stay (ICULOS), postoperative length of stay (PLOS), morbidity and mortality in patients undergoing CABG surgery. We also examined the relation between the number of units of packed red blood cells (PRBCs) transfused and PLOS in this group of patients.
Materials and Methods
This study was approved by the institutional review board for collecting data from the patient's medical records. This is a retrospective observational study. The study population included all patients undergoing primary CABG at a tertiary care heart centre over a period of three years. There were a total of 1746 patients. All patients underwent CABG surgery through a median sternotomy incision. Aspirin was discontinued 7 d prior to elective surgery.
One day before surgery, the patients in the hospital were premedicated with morphine and scopolamine prior to their arrival in the operating room. Patients arriving on the day of surgery were premedicated with midazolam as deemed appropriate by the anaesthesiologist. Intraoperative monitors included the standard American Society of Anesthesiologists monitors along with 5-lead electrocardiogram with continuous automated ST segment analysis, continuous arterial pressure determination using a radial artery catheter and a pulmonary artery catheter. All patients received standard fast-track anaesthetic induction using a combination of 5-10 µg/kg fentanyl and 0.05-0.1 mg/kg midazolam. We used 0.1 mg/kg vecuronium or 1 mg/kg rocuronium for neuromuscular blockade. Anaesthesia was maintained with supplements of propofol, isoflurane or sevoflurane as deemed appropriate by the anaesthesiologist. Patients undergoing CABG under CPB received 300 units/kg of heparin, and the activated clotting time (ACT) was maintained above 400 s prior to institution of cardiopulmonary bypass. Patients undergoing off-pump coronary artery bypass (OPCAB) received 100 to 200 units/kg of heparin to maintain the ACT above 350 s. Both groups received additional heparin as deemed necessary to maintain the ACT at the desired levels. The left internal mammary artery was harvested as surgically indicated and the saphenous vein was used for additional conduits. Patients undergoing CABG under cardiopulmonary bypass (CPB) were cannulated with an aortic cannula and a two-stage venous cannula prior to institution of cardiopulmonary bypass. Membrane oxygenators were used in all patients. Both retrograde and antegrade intermittent cold (6 °C) blood cardioplegia solution was administered for myocardial protection. Systemic temperature was permitted to maintain at 30-32 °C during cardiopulmonary bypass. All distal and proximal anastomoses were constructed using a single cross-clamp technique. In patients undergoing OPCAB, special off-pump coronary retractors and stabilisers were utilised during distal coronary anastomosis (Guidant, Indianapolis, IN). Proximal anastomoses were constructed using multiple cross-clamp technique. All patients were actively rewarmed to 37 °C prior to weaning from CPB. All patients undergoing CABG under CPB received epsilon aminocaproic acid during surgery. No antifibrinolytics were used in the OPCAB patients. The guidelines we followed for blood transfusion was triggered by the hematocrit values, ventricular function and other associated comorbidities. The end points of blood transfusion were to maintain a hematocrit value over 25% in patients with normal haemodynamics and ventricular function and over 30% in patients with compromised haemodynamics and ventricular function. These guidelines applied to all patients.
All demographic and clinical data were collected on the standardized data collection forms as required by the New York State cardiac surgical reporting system for predicting the risk-adjusted mortality rate according to the New York State department of health. This included age, gender, weight, body surface area (BSA), use of intraaortic balloon pump, left ventricular ejection fraction, use of cardiopulmonary bypass pump, number of distal coronary grafts, comorbid conditions such as diabetes, hypertension, congestive heart failure (CHF), renal failure, chronic obstructive pulmonary disease (COPD), previous myocardial infarction and postoperative bleeding requiring reoperation. The data pertaining to pre- and post-operative hematocrit values, the time to postoperative tracheal extubation, PRBC transfusion, ICULOS, PLOS and mortality and morbidity were obtained from the medical records of the patients. Extubation time is defined as the time from leaving the operating room to the removal of the endotracheal tube. ICULOS is defined as the time of admission to the ICU until the time of discharge to the intermediate care or step down unit. PLOS is defined as the time from the day of surgery until the day of discharge from the hospital. All patients were assessed for extubation within the first hour of arrival in the ICU and placed on our standard extubation protocol. The data pertaining to postoperative complications such as stroke, renal failure and 30-day mortality were also collected.
Data are summarized and described using means, standard deviations and proportions. The demographic, clinical and outcome variables were compared between the transfused and nontransfused patients using the Wilcoxon rank sum test. The P values for these comparisons are reported. A P value of P 72 h of mechanical ventilation ( P P P P values for partial correlation coefficients between transfusion and time to extubation, ICULOS, PLOS and mortality were P values to be , Our data also showed that 3.6% of the transfused patients remained intubated for longer than 72 h; however, in the nontransfused group, no patient remained intubated for longer than 72 h. This is an important utilisation factor because early tracheal extubation has been shown to decrease the cost of surgery.  We examined ICULOS as the subsequent resource. We believe that this resource generally follows a trend similar to the time to extubation. Our data shows that the transfused patients had significantly longer ICULOS similar to that in extubation. This fact is in agreement with those from previous reports. ,,,, With regard to PLOS, the transfused patients had significantly longer PLOS as compared to their nontransfused cohorts. Our results are in agreement with those of previous reports. ,, Our study shows that the incidence of postoperative complications was significantly higher in the transfused group. They had a significantly higher incidence of postoperative renal failure, stroke, infection and GI complications ,, and were reexplored for postoperative bleeding more often. This data is in agreement with previously reported studies. , We examined the 30-day mortality and found that patients who received blood transfusion had significantly higher incidence of 30-day mortality. No deaths occurred in the nontransfused group. Previous studies have examined mortality in the transfused CABG patients and a majority of these reports have documented the deleterious effects of transfusion on long-term mortality. Our results are in agreement with those of previous studies. ,,,, We further examined the relationship between the number of units of PRBCs transfused and PLOS. We found that PLOS increased as the number of units of blood administered increased in a linear fashion. The length of stay increased by approximately 0.82 d for every unit of blood transfused. This is in agreement with a previously published report examining the relation between PLOS and number of units of PRBCs transfused. 
It is important to note that our transfused patients were older, smaller and had lower preoperative hematocrit values. The transfused group comprised significantly more females. All these are the known risk factors for transfusion. ,, The transfused group also had significantly more preoperative comorbidities. They had a significantly higher incidence of preoperative diabetes, hypertension, renal failure, CHF, COPD and PVD. They also had a lower preoperative hematocrit value. This is similar to what has been reported in previous studies. , The question is "is it the higher incidence of preoperative comorbidities that is responsible for the increased incidence of postoperative morbidity and mortality or is transfusion a marker for the severity of illness." Our analysis shows that transfusion is an independent predictor of increased resource utilisation because even in patients with no preoperative morbidities, transfusion correlated with increased duration of intubation, ICULOS and PLOS. Among these patients, PLOS increased with the number of units of PRBCs transfused. Some of the previous reports have encountered the same question and have concluded that transfusion is an independent predictor of early and late mortality and increased ICULOS and PLOS. ,, Our results are in agreement with these previous reports.
In conclusion, our data show that patients who received transfusion had significantly longer time to extubation, ICULOS and PLOS. They also had significantly higher incidence of the 30-day mortality. We found that PLOS increased with the number of units of PRBCs transfused.
|1||Spiess BD. Transfusion and outcome in heart surgery. Ann Thorac Surg 2002;74:986-7.|
|2||Scott B, Seifert FC, Glass PS, Grimson R. Blood utilization in patients undergoing coronary artery bypass surgery: Impact of cardiopulmonary bypass pump, Hematocrit, Gender, Age and Body weight. Anesth Analg 2003;97:958-63.|
|3||Leal-Noval SR, Jara-Lopez I, Garcia-Garmendia JL, Marνn-Niebla A, Herruzo-Avilιs A, Camacho-Laraρa P, et al. Influnce of erythrocyte concentrate storage time on post surgical morbidity in cardiac surgery patients. Anesthesiology 2003;98:815-22.|
|4||Habib RH, Zacharias A, Engoren M. Determinants of prolonged mechanical ventilation after coronary artery bypass grafting. Ann Thorac Surg 1996;62:1164-71.|
|5||Cheng DC. Fast track cardiac surgery: Economic implications in postoperative care. J Cardiothorac Vasc Anesth 1998;12:72-9.|
|6||Vamkas EC, Carven JH. RBC transfusion and postoperative length of stay in the hospital or the intensive care unit among patients undergoing coronary artery bypass graft surgery: The effects of confounding factors. Transfusion 2000;40:832-9.|
|7||Basran S, Frumento RJ, Cohen A, Lee S, Du Y, Nishanian E, 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.|
|8||Kuduvalli M, Oo AY, Newall N, Grayson AD, Jackson M, Desmond MJ, et al. Effect of perioperative red blood cell transfusion on 30 day and 1 year mortality following coronary artery bypass surgery. Eur J Cardiothorac Surg 2005;27:592-8.|
|9||Fransen E, Maessen J, Dentener M, Senden N, Buurman W. Impact of blood transfusion on inflammatory mediator release in patients undergoing cardiac surgery. Chest 1999;116:1233-9.|
|10||Engoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long term survival after cardiac operation. Ann Thorac Surg 2002;74:1180-6.|
|11||Koch G, Li L, Duncan AI, Mihaljevic T, Loop FD, Starr NJ, Blackstone EH. Transfusion in coronary artery bypass grafting is associated with reduced long term survival. Ann Thorac Surg 2006;81:1650-7.|
|12||Bracey AW, Radovancevic R, Riggs SA, Houston S, Cozart H, Vaughn WK, et al. Lowering the haemoglobin threshold for transfusion in coronary artery bypass procedures: Effect on patient outcome. Transfusion 1999;39:1070-7.|
|13||Parr KG, Patel MA, Dekker R, Levin R, Glynn R, Avorn J, et al. Multivariate predictors of blood product use in cardiac surgery. J Cardiothorac Vasc Anesth 2003;17:176-81.|
|14||Utley JR, Wilde EF, Leyland SA, Morgan MS, Johnson HD. Intra-operative blood transfusion is a major risk factor for coronary artery bypass grafting. Ann Thorac Surg 1995;60:570-5.|