|Year : 2019 | Volume
| Issue : 2 | Page : 180-185
Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study
Basudev Pokhrel1, Abhishekh Basavarajegowda1, Sai Chandran2, Debdatta Basu3, Tanveer Rehman4
1 Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Cardiovascular Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
4 Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||07-Aug-2019|
|Date of Acceptance||31-Aug-2019|
|Date of Web Publication||17-Oct-2019|
Dr. Abhishekh Basavarajegowda
epartment of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Introduction: The clinical use of blood with regard to cardiac surgeries should be justifiable as it is associated with significant transfusion requirements, and tends to put a great burden on the blood inventory. Storage of red blood cell (RBC) induces various biochemical, biomechanical, and immunological changes that affect red cell viability, deformability, oxygen-carrying capacity, microcirculatory flow, and hence cause various adverse outcomes related to transfusion. Aim of Study: We made an effort to investigate the patterns of usage of allogenic blood products and the effect of volume and storage age of transfused RBCs with morbidity and mortality after cardiac surgery. Methodology: This was a cross-sectional analytical study conducted from January 2016 to June 2017, including all patients undergoing elective open-heart cardiac surgery at a tertiary care hospital. Records were reviewed for the details of blood components issued such as date of collection, date of transfusion, date of expiry and number of units of blood components transfused, details of the surgery, demographic details, postoperative length of stay (PLOS), and complications. Results: A total of 75 patients were included in this study. The majority of the surgeries (60%) were done for rheumatic heart disease. The difference in the transfusion patterns of various blood products with respect to the types of surgery, age or gender was statistically not significant. There was an association between increased PLOS (considered to be >11 days which is the mean) and mean unit age of the transfused packed RBCs (pRBCs) and the difference was statistically significant using the Chi-square test. Conclusion: There is a wide variation in transfusion practices in patients undergoing cardiac surgery. There is no significant association between the number of pRBCs transfusions and postoperative neurological, pulmonary, and other complications when number of pRBCs units ≤4.
Keywords: Blood requirements, postoperative cardiac surgery, storage age of blood
|How to cite this article:|
Pokhrel B, Basavarajegowda A, Chandran S, Basu D, Rehman T. Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study. Glob J Transfus Med 2019;4:180-5
|How to cite this URL:|
Pokhrel B, Basavarajegowda A, Chandran S, Basu D, Rehman T. Allogenic blood transfusion requirements and effects of storage age of blood units on postoperative period in cardiac surgeries: An analytical study. Glob J Transfus Med [serial online] 2019 [cited 2019 Nov 20];4:180-5. Available from: http://www.gjtmonline.com/text.asp?2019/4/2/180/269392
| Introduction|| |
Cardiac surgery is associated with significant transfusion requirements and tends to put a great burden on the blood inventory. Hence, their clinical use should be justifiable in terms of patient's benefit. Hazards associated with transfusions are transfusion-transmitted infections and noninfectious complications which include allergic, hemolytic, hypotensive, febrile reactions, transfusion-related acute lung injury, transfusion-associated circulatory overload, etc.,
The cardiac surgery is associated with sizeable morbidity and mortality due to the nature of the surgery itself, comorbidities in the patient, blood loss, use of cardiopulmonary bypass (CPB), etc. The amount of blood transfused during the surgery is known to add to the adverse outcome. Postulated pathophysiology is that the soluble mediators in the packed red blood cells (pRBCs) unit causing a second inflammatory insult for the priming of neutrophils, adding on to the first inflammatory insult being caused by the CPB circuit tubing and pumps. This cumulative effect can lead to enhanced activation of adherent leukocytes leading to increased release of inflammatory markers and its consequent ill effects on the patient's physiological state, and enhancing transfusion-related immunomodulation. This is generally noticed objectively by the aggravation of lung injury in the patient already on ventilator, more incidences of infections in the transfused patients, more time taken for recovering from the surgical stress and worse postoperative outcomes.
Storage of red blood cells (RBCs) induces progressive biochemical, biomechanical, and immunological changes that affect red cell viability, deformability, oxygen-carrying capacity, microcirculatory flow, and recipient response, etc., which are described as “RBC storage lesions.” It also includes decrease in adenosine triphosphate, decrease in 2,3-diphosphoglycerate, ammonia accumulation and increase potassium in supernatant, increased adhesion of red cells to endothelial cells, etc.
The clinical consequence of these storage lesions is the reduced survival of RBC after transfusion, and probably a worse patient outcome as found in many clinical studies.
Aims and objectives
Herein, we made an effort to study the patterns of usage of allogenic blood products in patients undergoing cardiac surgery by a single surgeon to avoid bias at our hospital and identify the effect if any of the volume and storage age of transfused RBCs with morbidity and mortality after cardiac surgery.
| Methodology|| |
This was a cross-sectional analytical study conducted from January 2016 to June 2017 including all patients undergoing elective open-heart cardiac surgery at JIPMER. Patients with specific comorbid conditions, namely cirrhosis, malignancy, those who underwent emergency surgeries, age group ≤10 years, cases where adequate data were not available and death during the surgery were excluded from the study. Blood bank records were reviewed for the details of blood components issued such as date of collection, date of transfusion, date of expiry, and number of units of blood components (i.e., pRBCs, fresh frozen plasma (FFP), and random donor platelets [RDPs]) transfused per patient. The pRBCs units issued were categorized based on their dates of the collection (<7 days, 8–14 days, >14 days old). Patients were categorized based on the age of the oldest unit transfused irrespective of the volume or age of the remaining transfused units, as even a single unit of long-stored blood transfused can lead to adverse effects. The case records were reviewed for the details of the surgery, demographic details, postoperative length of stay (PLOS), complications, biochemical and pathological parameters, and deaths.
Postoperative length of stay
It was the number of days the patient stayed in the hospital postoperatively. A cutoff of 11 days was defined as increased PLOS.
Serum creatinine >2mg% or a rise of >0.7mg% from the baseline values within 2 weeks of surgery or a need for dialysis was considered as indicators of renal dysfunction.
Pulmonary complications considered were postoperative pneumonia, pleural effusion, increased dependence on ventilator (>3 days), or persistent chest tube drainage.
Deranged liver function tests were considered as indicators of hepatic complications.
Fresh neurological deficit or central nervous system infections were considered as neurological complications.
The distribution of data on categorical variables such as age, gender, type of surgery, components transfused, and complications profile was expressed as frequency and percentages. The continuous data such as age and PLOS were expressed as mean with standard deviation or median with range. The comparison of the blood transfusion patterns with different categorical variables mentioned above was carried out using the Chi-square test or Fisher's exact test. The comparison of storage age of the blood components in relation to complication status was carried out by using the independent Student's t-test/Mann–Whitney U-test. The independent factors associated with blood transfusion patterns and also the complications were explored by using multiple logistic regression analysis.
All the data were entered in Microsoft Excel, and statistical analysis were carried out at 5% level of statistical significance using IBM SPSS Statistics for Windows, version 21.0., 2013 (IBM Corp., Armonk, New York City, NY, USA).
| Results|| |
A total of 75 patients were included in this study. The biophysical profile, diagnosis, and type of surgery are summarized in [Table 1]. Males were slightly higher than females (44 vs. 33). Mean age of the patients was 43.7 ± 12.9 years. Mean age of male patients was 45.9 ± 12.9 years and that of female patients was 40.9 ± 12.7 years. The proportion of patients transfused with pRBCs and FFPs in relation to type of surgery are summarized in [Table 2]. None of the RBC units were leukoreduced. The median number of pRBCs transfused per patient was 1 (interquartile range [IQR] 0 and 2) unit with the mean age of the unit being 10.5 ± 3 days. Only two patients were transfused with RDP and cryoprecipitate intraoperatively. Sixty-nine patients (92%) received one or more FFP transfusions intraoperatively with a mean of 3.16 ± 1.39 units transfused per patient. The volume of each FFP was approximately 180 mL. Distribution of 194 units of FFP transfusions is shown in [Table 2]. The difference in the transfusion patterns of various blood products with respect to the types of surgery, age or gender was statistically not significant.
|Table 2: Patterns and volume of transfusion in patients who underwent cardiac surgery|
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Thirty-nine (52%) patients developed postoperative complications. There were no deaths during their in-hospital stay. Various complications that occurred, and the number of pRBC units received are summarized in [Table 3]. Only hepatic and renal complications were statistically significant in relation to the number of pRBCs unit transfused.
|Table 3: Complications and patterns of blood transfusion of patients who underwent cardiac surgery|
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PLOS was the number of days the patient stayed in the hospital postoperatively. The PLOS ranged from 4 to 36 days with a mean PLOS of 13 ± 6 days. The association between PLOS and number of pRBCs transfusions was not statistically significant [Table 3]. The association between increased PLOS (considered to be >11 days which is the mean), and mean unit age of the transfused pRBC was carried out using Chi-square test. Chi-square test value was 7.489 and the value of P = 0.024, which is statistically significant. [Table 3] shows the details of PLOS with respect to the number of units of pRBCs transfused.
| Discussion|| |
Cardiac surgery is a prime example, in which one can expect excessive bleeding and need for ample amount of blood transfusions. At many centers, cardiac surgery accounts for a substantial portion of the total institutional use of allogeneic blood components. Due to the differences in perioperative practice patterns as well as possible inappropriate usage, a significant variation in institutional usage of allogeneic blood and blood components has been identified. A multicenter audit of 18 institutions has demonstrated a wide range of RBC transfusion requirements for adult patients undergoing coronary artery bypass grafting from as low as 0.4 ± 0.2 to as high as 6.3 ± 0.6 pRBCs units per procedure. In patients undergoing cardiac surgery, blood transfusion has been associated with an increased postoperative incidence of infection, prolonged ventilatory support, longer stay in the intensive care unit, new atrial fibrillation, new renal failure, cardiac complications, and neurological events.
Studies have suggested that in patients undergoing cardiac surgery, transfusion of red cells that has been stored for >2 weeks is associated with a significantly increased risk of postoperative complications and mortality. The administration of blood derivatives, mainly RBCs, is known to be associated in a dose-dependent manner with the development of severe postoperative infections, primarily nosocomial pneumonia in patients undergoing heart surgery.
Blood transfusion rate in cardiac surgery varies significantly between institutions. This wide variability may be explained by a variety of facts, including differences in the patient population, preoperative medication with antiplatelet agents and anticoagulants and several surgical and procedure-related complications. It is, therefore, essential for individual centers to pay due attention to their current transfusion practices.
With the information on the blood transfusion practices and statistics of transfused blood products and their associated postoperative complications, we can help improve the utilization of transfusion resources.
In this study, the rates of intraoperative transfusion were 69.33% for pRBCs, 91.89% for FFP, and 2.67% for both RDP and cryoprecipitate. Fifty-two patients (69.33%) received one or more allogenic pRBCs transfusions intraoperatively. The median number of pRBCs transfused per patient was 1 (IQR 0 and 2) unit with the mean age of the unit being 10.5 ± 3.06 days. Sixty-nine patients (92%) received one or more FFP transfusions intraoperatively with a mean of 3.16 ± 1.39 units transfused per patient. The differences in the transfusion patterns of both pRBCs and FFP with respect to the types of surgery and sex of the patient were statistically not significant.
We observed no significant difference in the postoperative neurological, pulmonary, and other complications in patients who had received one or more than one unit of pRBCs as compared to those who did not receive any of pRBCs transfusions intraoperatively. This reason might be that in our study none of the patients received >four units of pRBCs transfusion. Preoperative anemia in patients undergoing cardiac surgery is associated not only with a higher risk of allogenic blood transfusion but also with an increased risk for postoperative complications and lower survival rates. In this study, mean hemoglobin was 12.06% ± 1.5% g and this could be the possible reason for less number of intraoperative pRBCs transfusions.
Only postoperative hepatic and renal complications were statistically significant in relation to the number of pRBCs unit transfused (P = 0.001 and <0.001, respectively).
Makroo et al. did a multivariate analysis to assess the effect of pRBCs transfusion on postoperative complications in patients undergoing cardiac surgery and found that the risk of postoperative complications was significant in individuals transfused with more than 4 units of pRBCs. According to Horvath et al., there was a dose-related association between quantity of pRBCs transfused and risk of infection, with crude risk increasing by an average of 29% with each pRBCs unit. Specifically, lower risk of infection was observed when platelets were transfused with more than 4 units of pRBCs.
Khan et al. studied renal complications in 1210 adult patients who underwent cardiac surgery. Patients were divided into three groups on the basis of the number of intraoperative pRBCs units transfusions: No pRBCs (n = 894), 2 or less pRBCs units (n = 206), and more than 2 pRBCs units. They found that postoperative renal complications were more common in those who received more than 2 pRBCs units.
In this study, the association between the number of pRBCs transfusions and PLOS was not statistically significant (P ≥ 0.05), whereas the association between the age of the unit transfused and the increase in PLOS was statistically significant. Galas et al. analyzed data from 502 patients included in Transfusion Requirements After Cardiac Surgery study to assess the relationship between RBC transfusion and PLOS and observed that RBC transfusion is an independent risk factor for increased PLOS in patients undergoing cardiac surgery.
As on one hand efforts are being made to discover novel additive solutions extending the shelf life beyond 42 days, there are researchers who propose a benefit of transfusing fresher blood due to the possible deleterious effects of transfusing older units. Several studies have taken several cutoffs such as 7, 14, 21, 28, and 30 days to delineate fresh blood from old blood.,,,
Most of the studies done were retrospective. Prospective studies are done mostly on a particular group of critical patients, namely, trauma patients receiving transfusion support, cardiac surgery, and septic patients. The study was a prospective design, with the goal of improving the quality of care of cardiac surgical patients through judicious use of blood components. Patients undergoing cardiac surgery are at greater risk due to their altered physiology during CPB, and any harmful effects of transfusing older RBCs may be more evident in these patients.
Till date, the data regarding the benefit of transfusing fresh blood, especially in cardiac surgical, critically ill and trauma patients requiring massive transfusion is inconclusive. The turnaround time for a unit of whole blood to be available for issue after component preparation and screening for transfusion-transmitted infections is around 1–2 days. This reduces the actual available shelf life of blood to 11–12 days if 14-day cutoff is proven to be beneficial. In this study, pRBCs units issued were categorized based on their dates of collection <7 days, 7–14 days, and >14 days old. Patients were categorized based on the age of the oldest unit transfused irrespective of the volume or age of the remaining transfused units, as even a single unit of long-stored blood transfused can lead to adverse effects. We observed that the association between unit age of the pRBCs and postoperative complications was not statistically significant. As turnover rate of units at our blood bank inventory was quicker with the mean age of the pRBCs unit being 10.5 ± 3.06 days, 92% of the transfused patients received pRBCs units of unit age <14 days. This may be one of the reasons why effect of unit age of a pRBCs on postoperative complications is not evident in this study.
Makroo et al. found that transfusion of pRBCs with unit age 21 days was associated with higher postoperative complications, but not with in-hospital mortality. However, in our study, none of the patients received pRBCs with unit age >21 days.
The Age of RBCs in Premature Infants randomized trial studied the effect of fresh pRBCs transfusions on clinical outcomes in premature and very low birthweight infants and found that the use of fresh pRBCs (unit age <7 days) in comparison to standard blood bank practice did not improve outcomes in these group of patients.
The main strength of the study is that all the patients underwent surgery by the same surgeon, thereby reducing the confounding of surgical skills on complications and outcome.
The shortcoming of our study is that sample size was small, and there was a lack of patient follow-up to assess long-term mortality. In the study of this kind where multiple factors (surgical complications, transfusion-related complications, age and gender of the individual, etc.,) play a role in the outcome of the surgery, it is difficult to arrive at a conclusion on the definitive role of a particular factor. Since our inventory was a fast-moving with the mean age of the pRBCs unit being 10.5 ± 3.06 days, we could not study the effect of older age pRBCs on postoperative complications.
| Conclusion|| |
From this study, we conclude that there is a wide variation in transfusion practices in patients undergoing cardiac surgery. There is no significant association between the number of pRBCs transfusions and postoperative neurological, pulmonary, and other complications when number of pRBCs units ≤4. Furthermore, there is no significant association unit age of pRBCs postoperative complications when mean age pRBCs units ≤11 days. More extensive studies with larger sample size and longer followup need to be undertaken so as to get a meaningful outcome with regard to immunomodulatory effects of allogenic blood transfusions.
The authors would like to thank Dr. Soumya Das.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]