Predictors of massive transfusion with thoracic aortic procedures involving deep hypothermic circulatory arrest

Abstract

Background Massive perioperative blood product transfusion may be required with thoracic aortic operations and is associated with poor outcomes. Our objective was to determine the independent predictors of massive transfusion in thoracic aortic surgery patients undergoing deep hypothermic circulatory arrest (DHCA). Methods The study consisted of 168 consecutive patients undergoing open thoracic aortic procedure utilizing DHCA between July 2005 and August 2008. We identified 26 preoperative and procedural variables as being potentially related to blood product usage. We tested the variables for association with total blood products transfused using a multivariate linear regression model and then constructed a logistic regression model for massive transfusion, defined as requiring 5 or more units of transfused packed red blood cells between incision and 48 hours postoperatively. Results Multivariate linear regression determined six significant variables as accounting for 42% of the variation in total blood products transfused: age (P=0.008), preoperative hemoglobin (P=0.04), weight (P=0.02), cardiopulmonary bypass time (P<0.0001), emergent status (P<0.0001), and re-do median sternotomy (P<0.0001). A final predictive logistic regression model associated every 1 g/dL increase in preoperative hemoglobin OR=0.54 [0.43, 0.69], P<0.0001; every 10 minute increase in CPB time, OR=1.15 [1.05, 1.26], P=0.0026; and emergent status OR=4.02 [1.53, 10.55], P=0.0047 with massive transfusion. Conclusions Our model described CPB time, emergent status, and preoperative hemoglobin as independent predictors of massive transfusion. These variables, along with weight, age, and re-do median sternotomy are associated with total blood product usage in thoracic aortic operations involving DHCA.

Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery

“…Consistent with our definition, others have used C 5 units in a four-hour period. 24,25 Our surgical time frame also fits the definition since most of the operations in the NSQIP dataset lasted around four hours. Currently, our study could not make an inference about the effect of blood transfusion on mortality by using only massive transfusion patients; however, when we look at the independent association and the association between mortality and the complications and risk factors, we treated the number of * Estimated odds ratio (99.87% CI) of 30-day mortality in those with vs without the specified major complication, and P values from the multivariable logistic regression adjusted for sex (P = 0.01), age (P \ 0.001), ASA classification (P = 0.005), race (P = 0.039), emergency case (P \ 0.001), surgical type (P \ 0.001), functional health status prior to current illness (P = 0.007), previous cardiac surgery (P = 0.048), coma [ 24 hr (P = \ 0.001), steroid use for chronic condition (P \ 0.001), preoperative systemic sepsis (P \ 0.001), abnormal preoperative international normalized ratio of PT (P \ 0.001), number of intraoperative RBC transfusions (P \ 0.001) ** Significant if P \ 0.0013 in the multivariable logistic regression using Bonferroni correction (i.e., 0.05/39 tests) CI = confidence interval; ASA = American Society of Anesthesiologists; PT = prothrombin time; RBC = red blood cells blood transfusions as an important confounding factor.…”

Duration of deep hypothermia during aortic surgery and the risk of perioperative blood transfusion

“…These were: age, preoperative hemoglobin, body weight, CPB time, emergency status, and resternotomy. [14] To our knowledge the relationship between deep hypothermia duration and perioperative bleeding in cardiac surgery remains poorly understood. Numerous in vitro and animal studies have described mechanisms by which deep hypothermia can lead to coagulopathy.…”

Prothrombin Complex Concentrates for Bleeding in the Perioperative Setting

“…53 Thoracic aortic operations requiring hypothermic circulatory arrest are a category of cardiothoracic surgery, which often require multiple transfusions of blood products, procoagulants, and factor concentrates after separation from CPB. 87 The use of ROTEM in a single-center, prospective, randomized trial (n = 56) was noted to reduce the transfusion of allogeneic blood (9 vs 16 units; P = 0.02) when compared with standard management of coagulopathy in patients undergoing thoracic aortic surgery with hypothermic circulatory arrest. 88 Improved outcomes and reduced transfusion of allogeneic blood products were found in another study using 20 to 30 IU/kg 4F-PCCs (PPSB®; CAF-DCF, Brussels, Belgium) as a part of another ROTEM-directed transfusion algorithm.…”