Intraoperatively taken and used autologous blood transfusion: a cost-effective and beneficial way of blood transfusion in cardiac surgery: a retrospective clinical trial

Authors

Abstract

AimIn recent years autologous blood transfusion (ABT) seems to be more beneficial than allograft blood transfusion in coronary artery bypass, major vascular surgery and other surgeries that have increased elective blood transfusion risk. This current retrospective controlled study aimed to show that the intraoperatively taken and transfused ABT (iABT) is practical, beneficial and cost-effective.
MethodsCardiac surgery patients were investigated from January 2017 to November 2018. Fifty-eight patients’ clinical data were investigated. During the process; the cross-clamp time and the extracorporeal perfusion time, volume of blood loss, blood transfusions needed were investigated. During the intensive care unit hospitalization extubation, ICU hospitalization time, the volume of blood loss, blood transfusions needed were examined. Also, total hospitalization time, the total volume of blood loss, total blood transfusions required, 30 days of mortality and
one year of mortality were investigated.
ResultsFifty-eight patients’ (23 female and 35 male) clinical data were investigated. ICU time was significantly shorter than the patients who were not transfused with iABT (p<0.05). Intraoperative, ICU stay, and total blood loss were significantly lower than who were not transfused with the iABT(p<0.05).
ConclusionThis current study showed that the iABT is more beneficial than allograft blood and blood products transfusions. The iABT is related to less blood loss in operation and during the ICU stay, causing decreased risk of complications. According to less blood loss, fewer blood products transfusion is also a cost effective benefit.

Keywords

Introduction

Cardiovascular operations appear to have a high risk of mortality and morbidity due to intraoperative bleeding problems, hemodilutional anemia, and the need for transfusion of blood and blood products. Reducing mortality and morbidity in cardiac surgery, especially intraoperative and post-operative transfusion-related ones is still our concern. Patients who underwent allograft packed red blood cell transfusion (PRBC) have been associated with morbidity, acute lung injury, acute kidney injury, stroke, myocardial infarction (MI), sepsis, surgical site infections, hemolytic transfusion reactions, prolonged ICU stay and hospitalization, and increased short- and long-term mortality.^1,2,3,4,5 Therefore, several indications have been established for the decision of blood transfusion primarily for patients who are intended to undergo cardiac surgical operations.⁶ The guidelines recommend blood transfusion in the cardiac surgery patient group if the intraoperative anemia value diminishes to Hb 60-70 g/L.^7,8 In recent years, various studies have been performed about two different thresholds to determine the indication limits for blood transfusion; liberal (Hct>30%) and restrictive (Hct>24%). Restrictive transfusion (Hct>24%) protocol managed to reduce the PRBC use.^9,10 During cardiac surgery, the minimum Htc level is 21%. Hct <21% is associated with renal failure and neurocognitive dysfunction.¹¹ Autologous blood can be prepared as preoperative autologous blood donation (PABD) together with acute normovolemic hemodilution (PABD-ANH) or intraoperative autologous blood donation (iABD) together with ANH. There is still no certainty about the usage of PABD or iABD in cardiac surgery patients. Some studies suggest that patients eligible for PABD-ANH should be those with Hb >110g/L, Hct>33%, plt> 100x10^9 /L, normal coagulation results and normal cardio-pulmonary function. Each of PABD and iABD usage in patients with lung cancer and the positive data of the studies about non-affecting liver and blood coagulation factors make them both suitable for the use in cardiac surgery patients.^12,13,14 Intraoperative autologous blood transfusion (iABT) performed by iABD-ANH is more ideal for cardiac surgery patients; it has been widely used in clinical practice since 1946 because it is prepared by the perioperative anesthesiologist and it is performed using crystalloid or colloid replacement while monitoring vital functions with appropriate monitorization methods in the operating theatre.¹⁵ This current retrospective controlled study aimed to show that the intraoperatively taken and transfused ABT (iABT) is practical, beneficial and cost-effective. The hypothesis is that the usage of iABT in cardiac surgery will reduce intraoperative bleeding and post-operative total blood loss and decrease allograft blood and blood product transfusion and related morbidity and mortality while reducing ICU and hospital stay, and thus it is beneficial and cost-effective.

Materials and Methods

Ethical approval was obtained from Yeditepe University Clinical Trials Ethical Committee (No:929, 09/01/2019). Cardiac surgery patients were investigated from January 2017 to November 2018. According to the exclusion criteria of the study, 349 patients operated from peripheral vascular diseases, seven operated from emergent cardiac surgery, three managed from multiple cardiac operations and nine using anticoagulant treatment were excluded from 426 patients who had cardiovascular surgery. Fifty-eight patients were enrolled in the trial according to the following inclusion criteria: 18 years and over, planned elective cardiac surgery, no different surgical approaches during the same operation (e.g., no AVR+CABG), thoracic surgery not planned, no pulmonary hypertension (PAP>60mmHg), no post MI VSD, and none of the comorbidities such as anemia (hct<30%), low cardiac output (EF<30%), diabetes, renal failure, dialysis, cerebrovascular event, and no disease that could increase coagulopathy (hepatic failure, factor 5-8-9-10 deficiency, Vit K deficiency). All clinical perioperative and postoperative data until discharge were investigated from the patients’ records retrospectively. During the operation, the cross-clamp time and the extracorporeal perfusion time, the volume of blood loss, the volume of blood and blood products transfused intraoperatively were investigated as perioperative data. ICU length of stay, extubation time in ICU and the volume of blood loss, the volume of blood and blood products transfused postoperatively were investigated. Also, total hospitalization time, the total volume of blood loss, the total volume of blood and blood products transfused, 30 days of mortality and one year of mortality were investigated.
Statistics AnalysisMinimum-maximum, mean and standard deviation values were included in descriptive statistics. The independent samples t-test to compare volumes of blood loss and transfused blood volumes according to intraoperatively taken ABT usage and the Chi-Square test for comparing complications related to the operation and bleeding according to iABT usage were used. SPSS 22.0 programme was used for analysis. A p-value of less than 0.05 was considered to be statistically significant.

Results

Fifty-eight patients’ (23 female and 35 male) clinical data were investigated. Demographic data of the patients are shown in Table 1. The iABT usage of the patients and the complications occurred in the cardiac surgery operations are shown in Table 2. Complications were significantly decreased according to the iABT usage (p=0.029). Only one complication occurred in CABG in 20 of 35 males who were taken iABT in the surgery. Four of the 15 male patients not taken iABT in CABG had several complications. Seven of 23 women had no complications associated with iABT during surgery. Four of the 16 female patients not taken iABT in ASD, MVR, and AVR operations had several complications. There was no significance between iABT and cross-clamp time, extubation time and hospital stay (p>0.05) but significance was detected on the decreased pump time, and ICU stay related to iABT (p= 0.021 and p= 0.007, respectively). The volumes of perioperative blood loss, ICU blood loss, and the total blood loss were significantly lower than those who were not transfused with iABT (p=0.005, p=0.026, p=0.002, respectively) (Table 3).
The intraoperative volume of blood transfused as whole blood (WB), and PRBC transfusion was significantly lower in the patients who were transfused with iABT (p=0.002, p=0.034 respectively). The volume of blood transfused intraoperatively as fresh frozen plasma (FFP), suspension of blood platelets (sBP) and cryoprecipitate was not significant (p>0.05).
During the ICU stay the volume of blood transfused as WB, and PRBC, FFP transfusion were significantly lower (p=0.012, p= 0.024, p= 0.016 respectively). The volume of blood transfused intraoperatively as sBP and cryoprecipitate was not significant (p>0.05) (Table 4). The total volume of the blood transfused as WB, and PRBC and FFP transfusion was significantly lower in the patients who used iABT (p=0.000, p=0.003, p=0.038 respectively). The volume of blood transfused as sBP and cryoprecipitate was not significant (p=0.054, p>0.05) (Table 4). There was not any occurrence of in-hospital, 30-days or long-term mortality.

Discussion

The most important finding of this study is that the iABT administered to the patient reduces intraoperative and ICU blood loss and thus total blood loss. Furthermore, it is true that iABT administration significantly reduces the total WB, total PRBC and total FFP volume given to the patient and consequently leads to a decrease in complications. Although a review on autologous blood transfusion provides evidence that preoperative autologous blood donation reduces the incidence of postoperative complications in cardiac surgery, hemodynamic and vital function monitoring should be conducted appropriately during donation due to the specific nature of cardiac surgery patients. This is especially important considering studies suggesting that preoperative autologous blood donation, particularly in patients under 18 years of age, increases the emergence of vasovagal reactions three times more than adult patients.^16,17 Also, preoperative autologous blood donation cannot be performed to the patients who will have cardiac surgery emergently. Not all patients planned to undergo cardiac surgery under elective conditions are eligible for the operation, and operation can be delayed in some cases. Therefore, preoperative autologous blood donation can turn into a disadvantage instead of an advantage in these patients due to the blood being held for a long time and a large number of active components and their activities being disrupted.¹² The iABT method in autologous blood donation for cardiac surgery patients has been considered and appropriated in our clinic because it is taken from a patient along with invasive monitorization applied after anesthesia induction in the operating theatre; it ensures hemodynamic control. Crystalloid and/or colloid replacement is performed under the supervision of anesthesiologist if necessary; the blood is not held for a long time and it is an easy method. Although there are studies stating that intraoperative autologous blood donation and hemodilution of the patient require maintaining a Hct level between 15% and 19% and it is safe and feasible with proper cooling and anesthetic management, our clinic adopted the restrictive blood transfusion protocol as a Hct <21% is associated with renal failure and neurocognitive dysfunction.^11,18 There are many recent studies on autologous blood transfusion, and the results vary. Studies like that of Helm et al. claim that autologous blood transfusion does not make a difference concerning postoperative blood loss in cardiac surgery patients.¹⁹ However, other studies recommend autologous fresh whole blood transfusion as an alternative treatment method to reduce in-hospital and 30-day mortality rates, as it reduces extubation time, ICU stay, hospital stay, as well as blood loss and allograft blood transfusion.^20,21,22,23 This current study has parallel positive findings with those studies discussed above.

Limitations

Limitations and StrengthsThe limitations of our study are as follows: not being prospective, being single-center, and our inability to evaluate 30-day and long-term mortality because there was no mortality in our study group, as well as the small number in the study group due to limited inclusion criteria. The strengths of our study include the calculation of blood losses and transfused blood as volumes, making our study statistically robust. Further studies, especially multi-center studies, are needed mostly for morbidity and long term mortality and the minimization of allograft blood transfusion related complications in large study groups.

Conclusion

This current study showed that the iABT is more beneficial than allograft blood and blood products transfusions. The iABT is related to a decreased volume of total blood loss including both in operation and during the ICU stay, and also reduced allograft blood and blood products transfusion (mainly red blood cell transfusion) that provides a reduced risk of complication occurrence, achieving shortened ICU stay. According to all of the positive effects mentioned above, the iABT is also seems to be costeffective

Declarations

References

1. Koch CG, Li L, Duncan AI, Mihaljevic T, Cosgrove DM, Loop FD, 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(6):1608-1616. doi:10.1097/01.ccm.0000217920.48559.d8
   Article PubMed Google Scholar
2. Taylor R, Manganaro L, O’Brien J, Trottier S, Parkar N, Veremakis C. Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient. Crit Care Med. 2002;30(10):2249-2254. doi:10.1097/00003246-200210000-00012
   Article PubMed Google Scholar
3. Michalopoulos A, Tzelepis G, Dafni U, Geroulanos S. Determinants of hospital mortality after coronary artery bypass grafting. Chest. 1999;115(6):1598-1603. doi:10.1378/chest.115.6.1598
   Article PubMed Google Scholar
4. Malone D, Dunne J, Tracy J, Putnam A, Scalea T, Napolitano L. Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma. 2003;54(5):898-907. doi:10.1097/01.ta.0000060261.10597.5c
   Article PubMed Google Scholar
5. Engoren M, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg. 2002;74(4):1180-1186. doi:10.1016/s0003-4975(02)03766-9
   Article PubMed Google Scholar
6. Patel N, Avlonitis VS, Jones HE, Reeves BC, Sterne JAC, Murphy GJ. Indications for red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis. Lancet Haematol. 2015;2(12):e543-e553. doi:10.1016/s2352-3026(15)00198-2
   Article PubMed Google Scholar
7. Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Chan CT, Wong PY, et al. Advance targeted transfusion in anemic cardiac surgical patients for kidney protection. Surv Anesthesiol. 2012;56(5):208-209. doi:10.1097/aln.0b013e3182475e39
   Article PubMed Google Scholar
8. Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, 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. doi:10.1016/j.athoracsur.2010.11.078
   Article PubMed Google Scholar
9. Hajjar LA, Vincent JL, Galas FR, Nakamura RE, Silva CM, Santos MH, et al. Transfusion requirements after cardiac surgery. JAMA. 2010;304(14):1559-1567. doi:10.1001/jama.2010.1446
   Article PubMed Google Scholar
10. Mazer CD, Whitlock RP, Fergusson DA, Hall J, Belley-Cote E, Connolly K. Restrictive versus liberal transfusion for cardiac surgery. N Engl J Med. 2018;379(26):2575-2577. doi:10.1056/nejmc1814414
    Article PubMed Google Scholar
11. Karkouti K, Beattie WS, Wijeysundera DN, Rao V, Chan CT, Dattilo KM, et al. Hemodilution during cardiopulmonary bypass is an independent risk factor for acute renal failure in adult cardiac surgery. J Thorac Cardiovasc Surg. 2005;129(2):391-400. doi:10.1016/j.jtcvs.2004.06.028
    Article PubMed Google Scholar
12. Hill J, James V. Survey of autologous blood transfusion activity in England (2001). Transfus Med. 2003;13(1):9-16. doi:10.1046/j.1365-3148.2003.00418.x
    Article PubMed Google Scholar
13. Dong L, Liu SW, Guan JY. The effect of acute normovolemic hemodilution autologous transfusion on lung cancer. J Clin Hematol. 2014;7:112.
    PubMed Google Scholar
14. Guo J, Jin X, Yu J, Xu F, Zhang Y, Shen H, et al. Acute normovolemic hemodilution effects on perioperative coagulation in elderly patients undergoing hepatic carcinectomy. Asian Pac J Cancer Prev. 2013;14(8):4529-4532. doi:10.7314/apjcp.2013.14.8.4529
    Article PubMed Google Scholar
15. Zhou J. A review of the application of autologous blood transfusion. Braz J Med Biol Res. 2016;49(9). doi:10.1590/1414-431x20165493
    Article PubMed Google Scholar
16. Mangu H, Samantaray A, Anakapalli M. Blood transfusion practices in cardiac anaesthesia. Indian J Anaesth. 2014;58(5):616. doi:10.4103/0019-5049.144669
    Article PubMed Google Scholar
17. Nishimori H, Fujii N, Fujii K, Ikeda T, Asano N, Ogo H, et al. Predictors of vasovagal reactions during preoperative autologous blood donation: a single-institution analysis. Int J Hematol. 2017;105(6):812-818. doi:10.1007/s12185-017-2204-6
    Article PubMed Google Scholar
18. Li J, Huang M. Analysis of cardiopulmonary bypass diluted autologous blood transfusion: a report of 5000 cases. Zhonghua Yi Xue Za Zhi. 2013;93(17):1324-1326.
    PubMed Google Scholar
19. Helm RE, Klemperer JD, Rosengart TK, Gold JP, Peterson P, DeBois W, et al. Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding. Ann Thorac Surg. 1996;62(5):1431-1441. doi:10.1016/0003-4975(96)00755-2
    Article PubMed Google Scholar
20. Huseyin S, Yuksel V, Guclu O, Turan F, Canbaz S, Ege T, et al. Comparison of early period results of blood use in open heart surgery. J Res Med Sci. 2016;21(1):28. doi:10.4103/1735-1995.181988
    Article PubMed Google Scholar
21. Savas Oz B, Arslan G, Kaya E, Gunay C, Cingoz F, Arslan M. Comparison of results of autologous versus homologous blood transfusion in open-heart surgery: cardiovascular topics. Cardiovasc J Afr. 2013;24(4):121-129. doi:10.5830/cvja-2013-020
    Article PubMed Google Scholar
22. Stammers AH, Mongero LB, Tesdahl E, Stasko A, Weinstein S. The effectiveness of acute normovolemic hemodilution and autologous prime on intraoperative blood management during cardiac surgery. Perfusion. 2017;32(6):454-465. doi:10.1177/0267659117706014
    Article PubMed Google Scholar
23. Santos AAD, Sousa AGD, Thomé HODS, Machado RL, Piotto RF. Impact on early and late mortality after blood transfusion in coronary artery bypass graft surgery. Rev Bras Cir Cardiovasc. 2013;28(1):1-9. doi:10.5935/1678-9741.20130003
    Article PubMed Google Scholar

Tables

Table 1. Demographic data of the patients

View Fullscreen

N:number, Min: minimum, Max: maximum, SD: standard deviation, kg:kilogram, m:meter, cm: centimeter,min: minute, hr: hour. ICU: Intensive care unit, BT:Blood transfusion, iABT: intraoperative autologous blood transfusion

Table 2. Cardiac Surgery and iABT related Complications and Mortality

View Fullscreen

ASD: atrial septal defect, AVR: aortic valve replacement, AVR-REV: aortic valve replacement - revision, MVR: mitral valve replacement, MVR-REV: mitral valve replacement-revision , CABG: coronary artery bypass grafting, iABT: intraoperative autologous blood transfusion, BT: blood transfusion , N: number

Table 3. The volume of blood loss during operation, ICU stay and hospital stay

View Fullscreen

Independent t test, Bold: p<0.05, *:p<0.01 ICU: Intensive care unit

Table 4. Volumes and types of blood transfused perioperatively, during ICU stay and total hospital stay

View Fullscreen

Independent t test, Bold: p<0.05, *:p<0.01 ICU: Intensive care unit, WB: whole blood, PRBC: packed red blood cell, FFP: fresh frozen plasma, sBP: suspension of blood platelets

Additional Information

Publisher’s Note
Bayrakol MP remains neutral with regard to jurisdictional and institutional claims.

Rights and Permissions

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0). To view a copy of the license, visit https://creativecommons.org/licenses/by-nc/4.0/

View full license details →

About This Article

Received:

February 26, 2019

Accepted:

March 16, 2019

Published Online:

March 18, 2019

Printed:

May 1, 2019