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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

Published:January 22, 2016DOI:https://doi.org/10.1053/j.jvca.2015.10.021

      Objectives

      Increasing evidence suggests benefits from restrictive red blood cell transfusion (RBC) thresholds in major surgery and critically ill patients. However, these benefits are not obvious in cardiac surgery patients with intraoperative anemia. The authors examined the association between uncorrected hemoglobin (Hb) levels and selected postoperative outcomes as well as the effects of RBCs.

      Design

      Cohort study with prospectively collected data from a cardiac surgery registry.

      Setting

      A major cardiac surgical hospital within the Netherlands, which is also a referral center for Jehovah’s Witnesses.

      Participants

      Patients (23,860) undergoing cardiac surgery between 1997 and 2013.

      Interventions

      Comparisons were done in patients with intraoperative nadir Hb<8 g/dL and/or an Hb decrease≥50%. Comparison (A) between Jehovah’s Witnesses (Witnesses) and matched non-Jehovah’s Witnesses (non-Witnesses) transfused with 1 unit of RBC, and comparison (B) between patients given 1 unit of RBC intraoperatively versus matched non-transfused patients.

      Measurements and Main Results

      Postoperative outcomes were myocardial infarction, renal replacement therapy, stroke, and death. With propensity matching, the authors optimized exchangeability of the compared groups. Adverse outcomes increased with a decreasing Hb both among Witnesses and among non-Witnesses. The incidence of postoperative complications did not differ between Witnesses and matched non-Witnesses who received RBC (adjusted odds ratio 1.44, 95% confidence interval 0.63-3.29). Similarly, postoperative complications did not differ between patients who received a red cell transfusion and matched patients who did not (adjusted odds ratio 0.94, confidence interval 0.72-1.23).

      Conclusion

      Intraoperative anemia is associated with adverse outcomes after cardiac surgery, and a single RBC transfusion does not seem to influence these outcomes.

      Key Words

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      References

        • Munoz M.
        • Ariza D.
        • Gomez-Ramirez S.
        • et al.
        Preoperative anemia in elective cardiac surgery: Prevalence, risk factors, and influence on postoperative outcome.
        Transfusion Alternatives in Transfusion Medicine. 2010; 11: 47-56
        • Ranucci M.
        • Baryshnikova E.
        • Castelvecchio S.
        • et al.
        Major bleeding, transfusions, and anemia: The deadly triad of cardiac surgery.
        Ann Thorac Surg. 2013; 96: 478-485
        • Karkouti K.
        • Wijeysundera D.N.
        • Yau T.M.
        • et al.
        The influence of baseline hemoglobin concentration on tolerance of anemia in cardiac surgery.
        Transfusion. 2008; 48: 666-672
        • Carson J.L.
        • Noveck H.
        • Berlin J.A.
        • et al.
        Mortality and morbidity in patients with very low postoperative Hb levels who decline blood transfusion.
        Transfusion. 2002; 42: 812-818
        • Carson J.L.
        • Carless P.A.
        • Hebert P.C.
        Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion.
        Cochrane Database Syst Rev. 2012; 4: CD002042
        • Hebert P.C.
        • Yetisir E.
        • Martin C.
        • et al.
        Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?.
        Crit Care Med. 2001; 29: 227-234
        • Curley G.F.
        • Shehata N.
        • Mazer C.D.
        • et al.
        Transfusion triggers for guiding RBC transfusion for cardiovascular surgery: A systematic review and meta-analysis.
        Crit Care Med. 2014; 42: 2611-2624
        • Vonk A.B.
        • Meesters M.I.
        • van Dijk W.B.
        • et al.
        Ten-year patterns in blood product utilization during cardiothoracic surgery with cardiopulmonary bypass in a tertiary hospital.
        Transfusion. 2014; 54: 2608-2616
        • Hebert P.C.
        • Wells G.
        • Martin C.
        • et al.
        A Canadian survey of transfusion practices in critically ill patients. Transfusion Requirements in Critical Care Investigators and the Canadian Critical Care Trials Group.
        Crit Care Med. 1998; 26: 482-487
        • Vincent J.L.
        • Baron J.F.
        • Reinhart K.
        • et al.
        Anemia and blood transfusion in critically ill patients.
        JAMA. 2002; 288: 1499-1507
        • Shehata N.
        • Burns L.A.
        • Nathan H.
        • et al.
        A randomized controlled pilot study of adherence to transfusion strategies in cardiac surgery.
        Transfusion. 2012; 52: 91-99
        • Murphy G.J.
        • Pike K.
        • Rogers C.A.
        • et al.
        Liberal or restrictive transfusion after cardiac surgery.
        N Engl J Med. 2015; 372: 997-1008
        • Hogervorst E.
        • Rosseel P.
        • van der Bom J.
        • et al.
        Tolerance of intraoperative hemoglobin decrease during cardiac surgery.
        Transfusion. 2014; 54: 2696-2704
        • Shander A.
        • Javidroozi M.
        • Naqvi S.
        • et al.
        An update on mortality and morbidity in patients with very low postoperative hemoglobin levels who decline blood transfusion (CME).
        Transfusion. 2014; 54: 2688-2695
        • Pattakos G.
        • Koch C.G.
        • Brizzio M.E.
        • et al.
        Outcome of patients who refuse transfusion after cardiac surgery: A natural experiment with severe blood conservation.
        Arch Intern Med. 2012; 172: 1154-1160
        • Vaislic C.D.
        • Dalibon N.
        • Ponzio O.
        • et al.
        Outcomes in cardiac surgery in 500 consecutive Jehovah’s Witness patients: 21 year experience.
        J Cardiothorac Surg. 2012; 7: 95-102
        • Jassar A.S.
        • Ford P.A.
        • Haber H.L.
        • et al.
        Cardiac surgery in Jehovah’s Witness patients: Ten-year experience.
        Ann Thorac Surg. 2012; 93: 19-25
        • Koetsier A.
        • Peek N.
        • de K.N.
        Identifying types and causes of errors in mortality data in a clinical registry using multiple information systems.
        Stud. Health Technol Inform. 2012; 180: 771-775
      1. ASA Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Practice guidelines for perioperative blood transfusion and adjuvant therapies: An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies.
        Anesthesiology. 2006; 105: 198-208
        • Ferraris V.A.
        • Brown J.R.
        • Despotis G.J.
        • et al.
        2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines.
        Ann Thorac Surg. 2011; 91: 944-982
        • de Vries R.
        • Haas F.
        English translation of the Dutch Blood Transfusion guideline 2011.
        Vox Sang. 2012; 103: 363
        • Stamou S.C.
        • White T.
        • Barnett S.
        • et al.
        Comparisons of cardiac surgery outcomes in Jehovah’s versus Non-Jehovah’s Witnesses.
        Am J Cardiol. 2006; 98: 1223-1225
        • Bhaskar B.
        • Jack R.K.
        • Mullany D.
        • et al.
        Comparison of outcome in Jehovah’s Witness patients in cardiac surgery: An Australian experience.
        Heart Lung Circ. 2010; 19: 655-659
        • Emmert M.Y.
        • Salzberg S.P.
        • Theusinger O.M.
        • et al.
        How good patient blood management leads to excellent outcomes in Jehovah’s witness patients undergoing cardiac surgery.
        Interact Cardiovasc Thorac Surg. 2011; 12: 183-188
        • Middelburg R.A.
        • van de Watering L.M.
        • van der Bom J.G.
        Blood transfusions: Good or bad? Confounding by indication, an underestimated problem in clinical transfusion research.
        Transfusion. 2010; 50: 1181-1183
        • Zalpuri S.
        • Middelburg R.A.
        • van de Watering L.
        • et al.
        Association vs. causality in transfusion medicine: Understanding multivariable analysis in prediction vs. etiologic research.
        Transfus Med Rev. 2013; 27: 74-81
        • Bilgin Y.M.
        • van de Watering L.M.
        • Versteegh M.I.
        • et al.
        Postoperative complications associated with transfusion of platelets and plasma in cardiac surgery.
        Transfusion. 2011; 51: 2603-2610
        • Gajic O.
        • Dzik W.H.
        • Toy P.
        Fresh frozen plasma and platelet transfusion for nonbleeding patients in the intensive care unit: Benefit or harm?.
        Crit Care Med. 2006; 34: S170-S173
        • Carson J.L.
        Risk of anemia and transfusion triggers: implications for bloodless care.
        Surg Infect. 2005; 6: S17-S21
        • Wu W.C.
        • Rathore S.S.
        • Wang Y.
        • et al.
        Blood transfusion in elderly patients with acute myocardial infarction.
        N Engl J Med. 2001; 345: 1230-1236
        • Banbury M.K.
        • Brizzio M.E.
        • Rajeswaran J.
        • et al.
        Transfusion increases the risk of postoperative infection after cardiovascular surgery.
        J Am Coll Surg. 2006; 202: 131-138
        • Shimmer C.
        • Hamouda K.
        • Ozkur M.
        • et al.
        Influence of storage time and amount of red blood cell transfusion on postoperative renal function: An observational cohort study.
        Heart Lung Vessel. 2013; 5: 148-157
        • Rao S.V.
        • Jollis J.G.
        • Harrington R.A.
        • et al.
        Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes.
        JAMA. 2004; 292: 1555-1562
        • Murphy G.J.
        • Reeves B.C.
        • Rogers C.A.
        • et al.
        Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.
        Circulation. 2007; 116: 2544-2552
        • Koch C.G.
        • Li L.
        • Duncan A.I.
        • et al.
        Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting.
        Crit Care Med. 2006; 34: 1608-1616
        • Surgenor S.D.
        • Kramer R.S.
        • Olmstead E.M.
        • et al.
        The association of perioperative red blood cell transfusions and decreased long-term survival after cardiac surgery.
        Anesth Analg. 2009; 108: 1741-1746
        • Jakobsen C.J.
        • Ryhammer P.K.
        • Tang M.
        • et al.
        Transfusion of blood during cardiac surgery is associated with higher long-term mortality in low-risk patients.
        Eur J Cardiothorac Surg. 2012; 42: 114-120
        • Yun J.J.
        • Helm R.E.
        • Kramer R.S.
        • et al.
        Limited blood transfusion does not impact survival in octogenarians undergoing cardiac operations.
        Ann Thorac Surg. 2012; 94: 2038-2045
      2. Nakamura RE, Vincent JL, Fukushima JT, et al: A liberal strategy of red blood cell transfusion reduces cardiogenic shock in elderly patients undergoing cardiac surgery. J Thorac Cardiovasc Surg: 2015 July 26, [epub ahead of print]

        • Fowler A.J.
        • Ahmad T.
        • Phull M.K.
        • et al.
        Meta-analysis of the association between preoperative anemia and mortality after surgery.
        Br J Surg. 2015; 102: 1314-1324