Blood management of patients undergoing cardiac surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHU Ren ,  HUANG Huanlei

Guangdong Province Key Laboratory of Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangdong General Hospital, Guangzhou, 510100, P.R.China;

Corresponding author：

HUANG Huanlei, Email: hhuanlei@hotmail.com

Keywords：

Blood management; transfusion; threshold; cardiac surgery

DOI：

10.7507/1007-4848.201608071

Video：

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Abstract Full text Figures/Tables Video References Cited by

Red blood cell (RBC) transfusions are frequently used in cardiac surgery. A minority of patients assume most of the blood products transfusion during and after cardiac operations. Observational analysis of transfusion in patients undergoing cardiac surgery has uniformly demonstrated that RBC transfusion is associated with a significantly increasing risk of all-cause mortality and other serious adverse outcomes. In addition, it is an established fact that such patients can tolerate relatively low hemoglubin (Hb) levels. Consequently, it becomes widely accepted that appropriate limitation of transfusions could confer a substantial benefit to patients and decrease the use of limited resource. As a result, a restrictive threshold for blood transfusion is likely to be favored under most circumstances. However, an increasing amount of data differing from the observational analysis shows that clinical outcomes in patients who received transfusions with restrictive thresholds for Hb level are not superior to those with liberal thresholds. It has created a new uncertainty regarding the use of a restrictive threshold for transfusion during the perioperative period of cardiac surgery.

Citation： ZHU Ren, HUANG Huanlei. Blood management of patients undergoing cardiac surgery. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2017, 24(11): 890-895. doi: 10.7507/1007-4848.201608071 Copy

1.	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 clinical practice guideline. Ann Thorac Surg, 2007, 83(5 Suppl): S27-S86.
2.	Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, Despotis GJ, 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(3): 944-982.
3.	LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg, 2013, 145(3): 796-803.
4.	中国医学科学院阜外心血管病医院输血科. 提高医疗质量减少手术用血. 中国医学论坛报, 2011, 4(14): A11.
5.	Likosky DS, Fitzgerald DC, Groom RC, et al. Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices. Anesth Analg, 2010, 111(2): 316-323.
6.	Jin R, Zelinka ES, McDonald J, et al. Effect of hospital culture on blood transfusion in cardiac procedures. Ann Thorac Surg, 2013, 95(4): 1269-1274.
7.	Karkouti K, Wijeysyndera D, Beattie W. Risk associated with preoperative anemia in cardiac surgery. A multicenter Cohort Study. Circulation, 2008, 117(4): 478-484.
8.	Hung M, Besser M, Sharples S, et al. The prevalence and association with transfusion, intensive care unit stay and mortality of preoperative anaemia in a cohort of cardiac surgery patients. Anaesthesia, 2011, 66: 812-818.
9.	van Straten AH, Hamad MA, van Zundert AJ, et al. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: a comparison with the matched general population. Circulation, 2009, 120(2): 118-125.
10.	Gupta PK, Sundaram A, Mactaggart JN, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg, 2013, 258(6): 1096-1102.
11.	Kim CJ, Connell H, McGeorge AD, et al. Prevalence of preoperative anemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study. Perfusion, 2015, 30(4): 277-283.
12.	Padmanabhan H, Aktuerk D, Brookes MJ, et al. Anemia in cardiac surgery: next target for mortality and morbidity improvement? Asian Cardiovasc Thorac Ann, 2016, 24(1): 12-17.
13.	Habib RH, Zacharias A, Schufan TA, et al. Adverse effects of low hematocrit during cardiopulmomonary bypass in the adult: Should the current practice be changed? J Thorac Cardiovasc Surg, 2003, 125(6): 1438-1450.
14.	Habib RH, Zacharias A, Schwann TA. Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med, 2005, 33(8): 1749-1756.
15.	Scott DA, Tung HM, Slater R, et al. Perioperative hemoglobin trajectory in adult cardiac surgical patients. J Extra Corpor Technol, 2015, 47(3): 167-173.
16.	Westenbrink BD, Kleijn L, de Boer RA, et al. Sustained postoperative anemia is associated with an impaired outcome after coronary artery bypass graft surgery: insights from the IMAGINE trial. Heart, 2011, 97(19): 1590-1596.
17.	Department of Health and Human Services. The 2011 National Blood Collection and Utilization Report. DHHS; Washington, DC: 2013.
18.	Benson AB, Moss M, Silliman CC, et al. Transfusion-related acute lung injury (TRALI): A clinical review with emphasis on the critically ill. Br J Haematol, 2009, 147(4): 431-443.
19.	Scott BH, Seifert FC, Grimson R, et al. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth, 2008, 11(1): 15-19.
20.	Murphy GJ, Reeves BC, Rogers CA, et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation, 2007, 116(22): 2544-2552.
21.	Koch CG, Li L, Duncan AI. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg, 2006, 81(5): 1650-1657.
22.	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(1): 15-19.
23.	Scott DA, Tung HM, Slater R. et al. Perioperative hemoglobin trajectory in adult cardiac surgical patients. J Extra Corpor Technol, 2015, 47(3): 167-173.
24.	Paone G, Herbert MA, Theurer PF, et al. Red blood cells and mortality after coronary artery bypass graft surgery: an analysis of 672 operative deaths. Ann Thorac Surg, 2015, 99(5): 1583-1589.
25.	Dani C, Pratesi S, Fontanelli G, et al. Blood transfusions increase cerebral, splanchnic, and renal oxygenation in anemic preterm infants. Transfusion, 2010, 50(6): 1220-1226.
26.	Arellano-Orden V, Leal-Noval SR, Cayuela A, et al. Gender influences cerebral oxygenation after red blood cell transfusion in patients with severe traumatic brain injury. Neurocrit Care, 2011, 14(1): 18-23.
27.	Creteur J, Neves AP, Vincent JL. Near-infrared spectroscopy technique to evaluate the effects of red blood cell transfusion on tissue oxygenation. Crit Care, 2009, 13(suppl 5): S11.
28.	Kiraly LN, Underwood S, Differding JA, et al. Transfusion of aged packed red blood cells results in decreased tissue oxygenation in critically injured trauma patients. J Trauma, 2009, 67(1): 29-32.
29.	Schlager O, Gschwandtner ME, Willfort-Ehringer A, et al. Transcutaneous oxygen tension monitoring in critically ill patients receiving packed red blood cells. J Crit Care, 2014, 29(6): 1057-1062.
30.	Cabrales P, Ortiz D, Friedman JM. NO supplementation for transfusion medicine and cardiovascular applications. Future Sci OA, 2015, 1(1): pii51.
31.	Hébert PC, Wells G, Martin C, et al. Variation in red cell transfusion practice in the intensive care unit: A multicentre cohort study. Crit Care, 1999, 3(2): 57-63.
32.	Kirkeby-Garstad I, Sellevold OF, Stenseth R, et al. Mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery. Acta Anaesthesiol Scand, 2005, 49(6): 827-834.
33.	Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA, 1998, 279(3): 217-221.
34.	Valeri CR, Dennis RC, Ragno G, et al. Limitations of the hematocrit level to assess the need for red blood cell transfusion in hypovolemic anemic patients. Transfusion, 2006, 46(3): 365-371.
35.	George TJ, Beaty CA, Kilic A, et al. Hemoglobin drift after cardiac surgery. Ann Thorac Surg, 2012, 94(3): 703-709.
36.	Johnson RG, Thurer RL, Kruskall MS, et al. Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg, 1992, 104(2): 307-314.
37.	Kim TS, Lee JH, An H, et al. Transfusion risk and clinical knowledge (TRACK) score and cardiac surgery in patients refusing transfusion. J Cardiothorac Vasc Anesth, 2016, 30(2): 373-378.
38.	Plumb JO, Otto JM, Grocott MP. Grocott. ‘Blood doping’ from Armstrong to prehabilitation: manipulation of blood to improve performance in athletes and physiological reserve in patients. Extrem Physiol Med, 2016, 5: 5.
39.	Murphy MF, Murphy GJ, Gill R, et al. 2011 Audit of Blood Transfusion in Adult Cardiac Surgery. Birmingham: National Comparative Audit of Blood Transfusion; 2013.
40.	Bennett-Guerrero E, Zhao Y, O’Brien SM, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA, 2010, 304(14): 1568-1575.
41.	Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA, 2010, 304(14): 1559-1567.
42.	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, 150(5): 1314-1320.
43.	Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med, 2001, 29(2): 227-234.
44.	Shehata N, Burns LA, Nathan H, et al. A randomized controlled pilot study of adherence to transfusion strategies in cardiac surgery. Transfusion, 2012, 52(1): 91-99.
45.	Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med, 2015, 372(11): 997-1008.
46.	Mirski MA, Frank SM, Kor DJ, et al. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. Crit Care, 2015, 19: 202.

1. 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 clinical practice guideline. Ann Thorac Surg, 2007, 83(5 Suppl): S27-S86.
2. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, Despotis GJ, 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(3): 944-982.
3. LaPar DJ, Crosby IK, Ailawadi G, et al. Blood product conservation is associated with improved outcomes and reduced costs after cardiac surgery. J Thorac Cardiovasc Surg, 2013, 145(3): 796-803.
4. 中国医学科学院阜外心血管病医院输血科. 提高医疗质量减少手术用血. 中国医学论坛报, 2011, 4(14): A11.
5. Likosky DS, Fitzgerald DC, Groom RC, et al. Effect of the perioperative blood transfusion and blood conservation in cardiac surgery clinical practice guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon clinical practices. Anesth Analg, 2010, 111(2): 316-323.
6. Jin R, Zelinka ES, McDonald J, et al. Effect of hospital culture on blood transfusion in cardiac procedures. Ann Thorac Surg, 2013, 95(4): 1269-1274.
7. Karkouti K, Wijeysyndera D, Beattie W. Risk associated with preoperative anemia in cardiac surgery. A multicenter Cohort Study. Circulation, 2008, 117(4): 478-484.
8. Hung M, Besser M, Sharples S, et al. The prevalence and association with transfusion, intensive care unit stay and mortality of preoperative anaemia in a cohort of cardiac surgery patients. Anaesthesia, 2011, 66: 812-818.
9. van Straten AH, Hamad MA, van Zundert AJ, et al. Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting: a comparison with the matched general population. Circulation, 2009, 120(2): 118-125.
10. Gupta PK, Sundaram A, Mactaggart JN, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg, 2013, 258(6): 1096-1102.
11. Kim CJ, Connell H, McGeorge AD, et al. Prevalence of preoperative anemia in patients having first-time cardiac surgery and its impact on clinical outcome. A retrospective observational study. Perfusion, 2015, 30(4): 277-283.
12. Padmanabhan H, Aktuerk D, Brookes MJ, et al. Anemia in cardiac surgery: next target for mortality and morbidity improvement? Asian Cardiovasc Thorac Ann, 2016, 24(1): 12-17.
13. Habib RH, Zacharias A, Schufan TA, et al. Adverse effects of low hematocrit during cardiopulmomonary bypass in the adult: Should the current practice be changed? J Thorac Cardiovasc Surg, 2003, 125(6): 1438-1450.
14. Habib RH, Zacharias A, Schwann TA. Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med, 2005, 33(8): 1749-1756.
15. Scott DA, Tung HM, Slater R, et al. Perioperative hemoglobin trajectory in adult cardiac surgical patients. J Extra Corpor Technol, 2015, 47(3): 167-173.
16. Westenbrink BD, Kleijn L, de Boer RA, et al. Sustained postoperative anemia is associated with an impaired outcome after coronary artery bypass graft surgery: insights from the IMAGINE trial. Heart, 2011, 97(19): 1590-1596.
17. Department of Health and Human Services. The 2011 National Blood Collection and Utilization Report. DHHS; Washington, DC: 2013.
18. Benson AB, Moss M, Silliman CC, et al. Transfusion-related acute lung injury (TRALI): A clinical review with emphasis on the critically ill. Br J Haematol, 2009, 147(4): 431-443.
19. Scott BH, Seifert FC, Grimson R, et al. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth, 2008, 11(1): 15-19.
20. Murphy GJ, Reeves BC, Rogers CA, et al. Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation, 2007, 116(22): 2544-2552.
21. Koch CG, Li L, Duncan AI. Transfusion in coronary artery bypass grafting is associated with reduced long-term survival. Ann Thorac Surg, 2006, 81(5): 1650-1657.
22. 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(1): 15-19.
23. Scott DA, Tung HM, Slater R. et al. Perioperative hemoglobin trajectory in adult cardiac surgical patients. J Extra Corpor Technol, 2015, 47(3): 167-173.
24. Paone G, Herbert MA, Theurer PF, et al. Red blood cells and mortality after coronary artery bypass graft surgery: an analysis of 672 operative deaths. Ann Thorac Surg, 2015, 99(5): 1583-1589.
25. Dani C, Pratesi S, Fontanelli G, et al. Blood transfusions increase cerebral, splanchnic, and renal oxygenation in anemic preterm infants. Transfusion, 2010, 50(6): 1220-1226.
26. Arellano-Orden V, Leal-Noval SR, Cayuela A, et al. Gender influences cerebral oxygenation after red blood cell transfusion in patients with severe traumatic brain injury. Neurocrit Care, 2011, 14(1): 18-23.
27. Creteur J, Neves AP, Vincent JL. Near-infrared spectroscopy technique to evaluate the effects of red blood cell transfusion on tissue oxygenation. Crit Care, 2009, 13(suppl 5): S11.
28. Kiraly LN, Underwood S, Differding JA, et al. Transfusion of aged packed red blood cells results in decreased tissue oxygenation in critically injured trauma patients. J Trauma, 2009, 67(1): 29-32.
29. Schlager O, Gschwandtner ME, Willfort-Ehringer A, et al. Transcutaneous oxygen tension monitoring in critically ill patients receiving packed red blood cells. J Crit Care, 2014, 29(6): 1057-1062.
30. Cabrales P, Ortiz D, Friedman JM. NO supplementation for transfusion medicine and cardiovascular applications. Future Sci OA, 2015, 1(1): pii51.
31. Hébert PC, Wells G, Martin C, et al. Variation in red cell transfusion practice in the intensive care unit: A multicentre cohort study. Crit Care, 1999, 3(2): 57-63.
32. Kirkeby-Garstad I, Sellevold OF, Stenseth R, et al. Mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery. Acta Anaesthesiol Scand, 2005, 49(6): 827-834.
33. Weiskopf RB, Viele MK, Feiner J, et al. Human cardiovascular and metabolic response to acute, severe isovolemic anemia. JAMA, 1998, 279(3): 217-221.
34. Valeri CR, Dennis RC, Ragno G, et al. Limitations of the hematocrit level to assess the need for red blood cell transfusion in hypovolemic anemic patients. Transfusion, 2006, 46(3): 365-371.
35. George TJ, Beaty CA, Kilic A, et al. Hemoglobin drift after cardiac surgery. Ann Thorac Surg, 2012, 94(3): 703-709.
36. Johnson RG, Thurer RL, Kruskall MS, et al. Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg, 1992, 104(2): 307-314.
37. Kim TS, Lee JH, An H, et al. Transfusion risk and clinical knowledge (TRACK) score and cardiac surgery in patients refusing transfusion. J Cardiothorac Vasc Anesth, 2016, 30(2): 373-378.
38. Plumb JO, Otto JM, Grocott MP. Grocott. ‘Blood doping’ from Armstrong to prehabilitation: manipulation of blood to improve performance in athletes and physiological reserve in patients. Extrem Physiol Med, 2016, 5: 5.
39. Murphy MF, Murphy GJ, Gill R, et al. 2011 Audit of Blood Transfusion in Adult Cardiac Surgery. Birmingham: National Comparative Audit of Blood Transfusion; 2013.
40. Bennett-Guerrero E, Zhao Y, O’Brien SM, et al. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA, 2010, 304(14): 1568-1575.
41. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA, 2010, 304(14): 1559-1567.
42. 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, 150(5): 1314-1320.
43. Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med, 2001, 29(2): 227-234.
44. Shehata N, Burns LA, Nathan H, et al. A randomized controlled pilot study of adherence to transfusion strategies in cardiac surgery. Transfusion, 2012, 52(1): 91-99.
45. Murphy GJ, Pike K, Rogers CA, et al. Liberal or restrictive transfusion after cardiac surgery. N Engl J Med, 2015, 372(11): 997-1008.
46. Mirski MA, Frank SM, Kor DJ, et al. Restrictive and liberal red cell transfusion strategies in adult patients: reconciling clinical data with best practice. Crit Care, 2015, 19: 202.

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