Massive Transfusion in Cardiac Surgery: The Impact of Blood Component Ratios on Clinical Outcomes and Survival

Abstract

Background Cardiac surgery is the most common setting for massive transfusion in medically advanced countries. Studies of massive transfusion following injury suggest that the ratios of administered plasma and platelets (PLT) to red blood cells (RBCs) affect mortality. The Red Cell Storage Duration Study (RECESS) was a large randomized trial of the effect of RBC storage duration in patients undergoing complex cardiac surgery. Data from that study was analyzed retrospectively to investigate the association between blood components ratios used in massively transfused patients and subsequent clinical outcomes. Methods Massive transfusion in subjects enrolled in RECESS was defined as those who had ≥6 RBC units or ≥8 total blood components. For plasma, high ratio was defined as ≥1 plasma unit:1 RBC unit. For PLT transfusion, high ratio was defined as ≥0.2 PLT doses:1 RBC unit; PLT dose was defined as one apheresis PLT or 5 whole blood PLT equivalents. The clinical outcomes analyzed were mortality and the change in the Multiple Organ Dysfunction Score (Δ MODS) comparing the pre-operative score to the highest composite score through the earliest of death, discharge or day 7. These outcomes were compared between patients transfused with high and low ratios of plasma to RBCs, and also PLT to RBCs. Linear and Cox regression were used to explore relationships between predictors and continuous outcomes (ICU length of stay, 7-day ΔMODS, 28-day ΔMODS, hemoglobin, creatinine and total bilirubin) and time to event outcomes (all-cause mortality at postoperative day 2, 7, and 28), respectively. Results 324 out of 1098 RECESS subjects met the definition of massive transfusion. In those receiving high plasma:RBC ratio, the mean (SE) 7-and 28-day ΔMODS was 1.24 (0.45) and 1.26 (0.56) points lower, (p=0.007 and p=0.024), respectively, than in patients receiving lower ratios. In patients receiving high PLT:RBC ratio, the mean (SE) 7- and 28-day ΔMODS were 1.55 (0.53) and 1.49 (0.65) points lower (p=0.004 and p=0.022) respectively. Subjects who received low ratio plasma:RBC transfusion had excess 7-day mortality compared to those who received high ratio (7.2% vs 1.7%, respectively, p=0.0318), which remained significant at 28 days (p=0.035). The ratio of PLT:RBCs was not associated with differences in mortality. The mean (SE) hemoglobin level on day 2 was 0.36 (0.15) g/L lower in the high plasma group for the entire cohort (p=0.016). It was also 0.62 (0.24) g/L lower in the high platelet group for those in the long blood storage group (p=0.009). However, these changes are unlikely to be clinically significant. Conclusion This analysis found that in complex cardiac surgery patients who received massive transfusion, there was an association between the composition of blood products used and clinical outcomes. Specifically, there was less organ dysfunction in those who received high ratio transfusions (plasma:RBC and PLT:RBCs), and lower mortality in those who received high ratio plasma:RBC transfusions.

Risk of massive blood product requirement in cardiac surgery

“…In the present study, MRT was defined as receiving at least 4 units of RBCs during hospitalization. The minimum number of RBCs in MRT has been variously set at 4, [3] 5, [17] 6, [9] or 8, [28] and we opted for 4 as our cut-off because morbidity sharply increases beyond this level, [8] and postoperative complications even increase 19.4% ( P < .01) when the patients receive ≥4 units of RBCs. [29]…”

Cardiopulmonary bypass strategy without donor blood components as a method for preventing brain damage in children

“…Между группами с использованием крови и отказом от нее выявлены значимые различия в уровне гемоглобина и гематокрита, однако с учетом анализа интраоперационного периода (уровня лактата крови, сатурации венозной крови, пульсоксиметрии и церебральной оксиметрии) гемической гипоксии и нарушения доставки кислорода к головному мозгу не обнаружено. Вместе с тем уровень маркеров СВО оказался ниже в группе больных без трансфузии, что согласуется с теорией о компонентах донорской крови как одном из источников развития СВО [4]. Логичным продолжением данного предположения должен быть более низкий уровень повреждения нейроваскулярной единицы в контрольной группе, что и подтвердилось с помощью маркеров.…”

“…Причина данной проблемы в повышенной кровопотере в интра-и послеоперационном периоде кардиохирургических операций и специфической для детей особенности -добавлении компонентов донорской крови в объем первичного заполнения аппарата ИК как метода профилактики критической гемодилюции. Однако в литературе представлены исследования, доказывающие роль интраоперационной трансфузии в развитии СВО [4]. В свою очередь, в головном мозге СВО реализуется с вовлечением нейроваскулярной единицы, последующим нейровоспалением и нарушением функции и структуры нейронов и гематоэнцефалического барьера [5].…”

Clinical presentation and in-hospital outcomes of intraoperative red blood cell transfusion in non-anemic patients undergoing elective valve replacement

“…Of note, it has been shown that massive hemorrhage is likely to be associated with huge trauma, abnormal anatomy, or operation techniques, which will lead to poor prognosis of cardiac surgery ( 15 , 16 ). Therefore, these kinds of patients were excluded from our research to offset bias.…”