Aryeh Shander, MD, FCCM, FCCP Surgical Bleeding and Transfusions: The Issues in 2004 Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor, Mount Sinai School of Medicine
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Aryeh Shander, MD,FCCM, FCCP
Surgical Bleeding and Transfusions: The Issues in 2004
Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor,
Mount Sinai School of Medicine
Objectives
Risks of bleeding, subsequent hypovolemia, and acute anemia
– Local (surgery) Vs. Systemic (trauma) Pro and inflammatory response
The role of interleukin-10 in the regulation of the systemic inflammatory response following trauma-hemorrhage Schneider CP et al, Biochim Biophys Acta 2004;1689:22-32.
– Protective role
– Damaging role
Risks of Anemia
Anemia in CVD
Hgb = Mortality in CVDCarson/Gould – 300 Pts with Hgb <8
gm/dL - StratifiedCarson JL et al, Lancet
1996;348:1055-60
Hgb < 9.5 g/dL = high risk with CVD
Hebert PC at al, Am J Respir Crit Care Med 1997;155:1618-23
Hgb < 7.0 g/dL acceptable with normal coronary circulation
Low Hct and Adverse Outcome
Lowest CPB HCT of <14% in low risk patients and <17% in high risk patients associated with doubling of mortality risk (Fang WC, Circulation 1997)
Below 23%, CPB HCT is inversely related to mortality (Defoe GR, Ann Thorac Surg 2001)
In postop cardiac surgical pts, inverse relationship exists between hemoglobin and major morbidity (Hardy JF, Br J Anaesth 1998)
Perioperative vital organ dysfunction, short- and intermediate-term mortality increased with lowest HCT <22% (Habib RH, J Thorac Cardiovasc Surg 2003)
Blood transfusion in Elderly Patients with Acute Myocardial
InfarctionWu WC et al, NEJM 2001;345:1230-36
Cooperative Cardiovascular Project– 234,769 total patients 78,974 (33.6%) included– CMS ICD-9 discharge code for MI and anemia– Anemia – WHO definition Hct of 39% or less– Hct in the first 24 hrs– 30 day mortality
3324 (4.2%) had Hct less than 30%– These patients had more trauma, surgery,
internal bleeding, coexisting diseases, DNR, shock and less treatments (β blockers ASA etc.)
3680 (4.7%) of the cohort received transfusions
Low Hct and Adverse Outcome
Retrospective database reviews
These studies did not assess impact of transfusion or preoperative hematocrit
Lowest HCT groups were transfused at a significantly higher rate
Prospective, randomized trial results supporting these conclusions not available
Risks of Blood Transfusions
Blood Transfusion:The Global Picture
>82,000,000 units donated per annum world wide
In the US, ~12,500,000 units of RBCs transfused
That’s one unit every 25 seconds!
WHO 2003
Risk and Prevention of Bloodborne Diseases
43% of WHO participating countries (191) test their blood for HIV HCV HBV
13,000,000 units per annum are not tested!
20% of the world’s population uses 80% of the safe blood supply
LOS from the first transfusion avg. 10.6 days + 14.5
Total hospital cost avg. $29,800 + $33.2K
median = $19,500) Nonprophylactic
antibiotic use after transfusion (days) 5.1
In-hospital death 122 (9.0%) LOS from the first transfusion avg. 10.3 days + 13.7 Total hospital cost avg. $29,000 + $34K
(median = $19,200) Nonprophylactic antibiotic use after transfusion (days) 4.5
Control Leukoreduced
Dzik WH et al, Transfusion 2002;42:1114-22.
The Impact of PRBCs on Nosocomial Infection Rates
in ICU
Retrospective database study of 1,717 patients using Project IMPACT
NI rates of 3 groups were compared:
– Entire cohort
– Transfusion group
– Nontransfusion group
Patients stratified for age, gender, and probability
of survival using Mortality Prediction Model (MPM-0) scores
Taylor RW et al, Crit Care Med 2002;30:1-6.
5.9
15.4
2.9
0
2
4
6
8
10
12
14
16
18
Per
cen
t o
f P
atie
nts
All Patients
Transfused Patients
Non-transfusedPatients
N = 1,717 n = 416 n = 1,301
P < .05
Nosocomial Infection Rates in Critically Ill Patients
Adjusted for severity of illness using MPM-0 scores, age, gender (Project IMPACT).Taylor RW et al, Crit Care Med 2002;30:2249-54.
For each unit of PRBCs given, the odds of infection is increased by a factor of 1.5
13.6
24
10.2
0
5
10
15
20
25
Pe
rce
nt
of
Pa
tie
nts
All Patients
Transfused Patients
Non-transfusedPatients
N = 1,717 n = 416 n = 1,301
P < .05
Taylor RW et al, Crit Care Med 2002;30:2249-54.
Mortality Rates in Critically Ill Patients
Transfusion and Outcome
• Retrospective, database study of long-term outcome in 1,915 patients after primary CABG
• Excluded for death within 30 days of surgery
• 546 patients transfused during hospitalization were matched by propensity score (age, gender, size, LOS, perfusion time and STS risk) with patients not transfused and 5-year mortality compared
• 5-year mortality twice as high in transfused patients
• After correction for comorbidity, 5-year mortality remained 70%higher in transfused group (p<0.001)
Engoren et al, Ann Thorac Surg 2002;74:1180-6
Univariate association rates of stroke and death in CABG