Blood utilization in revision versus first‐time cardiac surgery: an update in the era of patient blood management

Abstract

BACKGROUND Relative to first‐time (primary) cardiac surgery, revision cardiac surgery is associated with increased transfusion requirements, but studies comparing these cohorts were performed before patient blood management (PBM) and blood conservation measures were commonplace. The current study was performed as an update to determine if this finding is still evident in the PBM era. STUDY DESIGN AND METHODS Primary and revision cardiac surgery cases were compared in a retrospective database analysis at a single tertiary care referral center. Two groups of patients were assessed: 1) those having isolated coronary artery bypass (CAB) or valve surgery and 2) all other cardiac surgeries. Intraoperative and whole hospital transfusion requirements were assessed for the four major blood components. RESULTS Compared to the primary cardiac surgery patients, the revision surgery patients required approximately twofold more transfused units intraoperatively (p < 0.0001) and approximately two‐ to threefold more transfused units for the whole hospital stay (p < 0.0001). Intraoperative massive transfusion (>10 red blood cell [RBC] units) was substantially more frequent with revision versus primary cardiac surgery (2.6% vs. 0.1% [p < 0.0001] for isolated CAB or valve and 6.1% vs. 1.9% [p < 0.0001] for all other cardiac surgeries). Revision surgery was an independent risk factor for both moderate (6‐10 RBC units) and massive intraoperative transfusion. CONCLUSIONS In the era of PBM, with restrictive transfusion strategies and a variety of methods for blood conservation, revision cardiac surgery patients continue to have substantially greater transfusion requirements relative to primary cardiac surgery patients. This difference in transfusion requirement was greater than what has been previously reported in the pre‐PBM era.

Perioperative Plasma in Addition to Red Blood Cell Transfusions Are Associated With Increased Venous Thromboembolism Risk Postoperatively

“…Due to the nature of surgery, 10% 15% of the US blood supply is allocated for cardiac surgical patients with approximately 40% to 60% of patients receiving an allogeneic transfusion during hospitalization. 22,23 Blood conservation practices in cardiac and other surgeries include (1) preoperative anemia management, (2) retrograde autologous priming, 24 (3) acute normovolemic hemodilution, (4) antifibrinolytics, (5) restrictive hemoglobin transfusion triggers, (6) viscoelastic testing transfusion algorithms, (7) modified ultrafiltration on bypass, 25 (8) cell salvage, and (9) hemostatic sealants. These strategies aim to prevent unnecessary transfusions and prevent coagulopathy.…”

The Effect of Standardizing Autologous Prime Techniques in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

“…We decided to evaluate the effect in adults undergoing cardiac surgery for diverse procedures, excluding emergencies and patients presenting with a preoperative anemia. Such a diverse patient population may have influenced outcomes because cardiac valvular surgeries and resternotomy procedures are known to result in an increased risk for transfusion (31).…”

How do I audit intraoperative blood component utilization in cardiac surgery?

“…Efforts to address risk adjustment for the more “difficult” cases prone to higher blood use included a similar bar graph for the anesthesia attendings showing the percentage of their cases that were “redo” cases (with a revision sternotomy). Repeat sternotomy is a well‐recognized variable that has been associated with a two‐ to threefold increase in transfusion requirements …”