Outcome of Patients Who Refuse Transfusion After Cardiac Surgery

Pattakos, Gregory; Koch, Colleen G.; Brizzio, Mariano E.; Batizy, Lillian H.; Sabik, Joseph F.; Blackstone, Eugene H.; Lauer, Michael S.

doi:10.1001/archinternmed.2012.2449

Cited by 118 publications

(159 citation statements)

References 20 publications

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“…Unfortunately, this study was not powered to detect changes in the incidence of AKI. A propensity-matched analysis of 322 patients who were Jehovah's Witnesses and refused blood transfusions during cardiac surgery (compared with 48,986 patients who received transfusions) was notable for an improvement in 1-year survival, a reduction in both complications and length of stay, and no difference in renal failure (as defined by the Society of Thoracic Surgeons database) or the need for dialysis in the Jehovah's Witness group (149). Also of interest, Koch et al (150) recently proposed that the age of packed red blood cells may be related to the probability of causing AKI after cardiac surgery.…”

Section: Perioperative Transfusion Of Packed Red Blood Cellsmentioning

confidence: 99%

AKI Associated with Cardiac Surgery

Thiele¹,

Isbell²,

Rosner

2015

Clinical Journal of the American Society of Nephrology

240

185

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Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short-and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.

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Section: Perioperative Transfusion Of Packed Red Blood Cellsmentioning

confidence: 99%

AKI Associated with Cardiac Surgery

Thiele¹,

Isbell²,

Rosner

2015

Clinical Journal of the American Society of Nephrology

240

185

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“…The total volume of RBC units given in the operating room and ICU was lower in the restrictive than in the liberal group (186 ± 70 vs. 259 ± 90 ml/patient, p \ 0.001). Duration of mechanical ventilation, length of ICU stay and incidence of adverse events were similar in both groups, but length of hospital stay was shorter in the restrictive group [median: 8 (IQR: 7-11) vs. 9 (7)(8)(9)(10)(11)(12)(13)(14) in the liberal group, p = 0.047]. Costs of RBC and plasma were 229 vs. 328 euros per patient.…”

mentioning

confidence: 93%

“…However, there is no such thing as a perfectly safe RBC transfusion: both transfusion-transmitted infections and non-infectious serious hazards of transfusion (NISHOT) can occur [4]. RBC transfusions are associated with a higher mortality rate in cardiac adults [5] and with more morbidity in cardiac children [6][7][8][9]. An association between RBC transfusions and worse outcomes does not mean that there is a cause-effect relationship; it means only that such a cause-effect relationship is possible, and it questions the assertion that RBC transfusions are actually more useful than harmful in patients with cardiovascular disease.…”

mentioning

confidence: 99%

Do cardiac children need more red blood cell transfusions than other critically ill children?

Pont‐Thibodeau

Lacroix

2013

Intensive Care Med

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Anaemia is associated with a higher risk of mortality in cardiac adults [1,2] and children [3]. Only a red blood cell (RBC) transfusion can rapidly increase a low haemoglobin (Hb) concentration. However, there is no such thing as a perfectly safe RBC transfusion: both transfusion-transmitted infections and non-infectious serious hazards of transfusion (NISHOT) can occur [4]. RBC transfusions are associated with a higher mortality rate in cardiac adults [5] and with more morbidity in cardiac children [6][7][8][9]. An association between RBC transfusions and worse outcomes does not mean that there is a cause-effect relationship; it means only that such a cause-effect relationship is possible, and it questions the assertion that RBC transfusions are actually more useful than harmful in patients with cardiovascular disease.In clinical practice, cardiac patients receive more RBC transfusions than other critically ill children [9][10][11]. The question is what prompts physicians to prescribe an RBC transfusion. According to a self-administered survey, determinants in cardiac children include Hb level, patient's stability, active bleeding, inadequate O 2 delivery (low ScvO 2 , high lactate level, low SaO 2 /FiO 2 ratio) and low blood pressure [10]. However, the Hb level remains the most important determinant of RBC transfusion [10,11]. Therefore, it makes sense to ask ourselves the following questions: in cardiac children, how much anaemia can we tolerate and when do the benefits of RBC transfusions overcome their harms?RBC transfusions are given during the perioperative care of paediatric cardiac surgery in the operating room and in the intensive care unit (ICU). While cardiac surgery accounts for only 5 % of anaesthesia episodes, it represents 58 % of perioperative RBC use and 24 % of total hospital RBC use [12]. The lowest Hb level below which an RBC transfusion must be given during a cardiopulmonary bypass (CPB) is not well characterised. Jonas et al. [13] reported that infants randomised at CPB onset to an haematocrit of 20 % (Hb level: about 7 g/dl) had worse 1-year Bayley psychomotor development scores than those allocated to 30 % (10 g/dl); this suggests that the Hb level should be maintained over 7 during a CPB, but it does not tell us what is the best and safest threshold Hb level for transfusion over 7 g/dl.The uncertainty about the threshold Hb level with the best risk/benefits ratio also arises in the ICU after surgery. Most cardiac children (range: 46-79 %) receive at least one RBC transfusion during their ICU stay after a cardiac surgery [15,16]. However, recent data suggest that a restrictive transfusion strategy might be as safe, if not safer than a liberal transfusion strategy. A subgroup analysis that focussed on 125 cardiac children enrolled in the Transfusion Requirements in Pediatric ICU (TRIPI-CU) randomised clinical trial reported that a threshold Hb level of 7 was as safe as 9.5 g/dl in stable non-cyanotic cardiac infants [14].In this issue, de Gast-Bakker et al.[15] published a randomised clin...

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“…[1][2][3] In fact, several academic health centers are establishing "Bloodless Medicine & Surgery Programs" that specialize in treating patients who do not accept allogeneic blood transfusions (ABTs). [4][5][6][7][8][9][10][11][12][13][14][15][16] A multidisciplinary approach is frequently required to optimize clinical outcomes for these patients, particularly in the setting of multiple comorbidities or high-risk surgical procedures.…”

Section: Introductionmentioning

confidence: 99%

“…[4][5][6][7][8][9][10][11][12][13][14][15][16] Based on religious beliefs, these individuals do not accept blood products considered to be "primary components," which includes RBCs, WBCs, platelets, or plasma. 4 In addition, JW patients do not typically accept autologous blood donated preoperatively, although most will accept autologous blood that is considered to be physically contiguous with one's body.…”

Section: Introductionmentioning

confidence: 99%

Bloodless medicine: what to do when you can't transfuse

Resar¹,

Frank

2014

Hematology

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A better understanding of risks associated with allogeneic blood transfusions (ABTs), along with a growing population of patients who do not accept transfusions, have led to the emergence of new treatment paradigms with "bloodless medicine." In this chapter, we review prior studies describing management and outcomes in patients who refuse transfusion (referred to as "bloodless patients" herein) and summarize the approaches used at our institution. Bloodless management for surgical patients includes treatment of preoperative anemia, use of autologous blood salvage, and minimizing blood loss with procedures. Other adjuncts for both medical and surgical patients include minimizing blood loss from laboratory testing using pediatric phlebotomy tubes and conservative testing. Anemia can be treated with erythropoiesis-stimulating agents, as well as iron, folate, and B12 when indicated. Although there are limited retrospective studies and no prospective studies to guide management, prior reports suggest that outcomes for surgical patients managed without ABTs are comparable to historic controls. A recent risk-adjusted, propensitymatched, case-control study of outcomes of all hospitalized patients who refused ABT at a large academic health center showed that bloodless management was not an independent predictor of adverse outcomes. Surprisingly, there was a lower overall mortality in the bloodless group and discharge hemoglobin levels were similar for both bloodless and control groups. Further research is now needed to optimize therapy and identify novel interventions to manage bloodless patients. Lessons learned from bloodless patients are likely to benefit all patients given recent evidence suggesting that patients who avoid ABTs do as well, if not better, than those who accept transfusions. Learning Objectives• To describe patient populations for whom transfusions are not an option • To discuss prior studies with outcomes and "bloodless medicine" • To outline currently available approaches to manage anemia or bleeding in "bloodless patients" • To discuss areas in need of further research to advance bloodless medicine

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Outcome of Patients Who Refuse Transfusion After Cardiac Surgery

Abstract: Witnesses do not appear to be at increased risk for surgical complications or long-term mortality when comparisons are properly made by transfusion status. Thus, current extreme blood management strategies do not appear to place patients at heightened risk for reduced long-term survival.

Cited by 118 publications

References 20 publications

AKI Associated with Cardiac Surgery

AKI Associated with Cardiac Surgery

Do cardiac children need more red blood cell transfusions than other critically ill children?

Bloodless medicine: what to do when you can't transfuse

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