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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 Aryeh Shander, MD, FCCM, FCCP
Risks of bleeding, subsequent hypovolemia, and acute anemia
Morbidity & mortality
Risks of transfusions
Surgical Bleeding Vessel interruption Surgical repair Bleeding contained No need for further action Delay in repair Bleeding stops Surgical repair Clotting Factor consumption Impaired clotting Transfusion of blood products SIRS Transfusion related complications
Persistence of donor WBCs in trauma patients for up to 1.5 years after an allogeneic blood transfusion
‘ Survival of donor leukocyte subpopulations in immunocompetent transfusion recipients: frequent long-term microchimerism in severe trauma patients ’
2 x 10 9 WBCs in one unit of packed red blood cells
1 x 10 8 WBCs – c entrifuged, buffy coat depleted
1–5 x 10 6 WBCs – l eukocyte filter, leukocyte-depleted
Lee TH et al, Blood 1999;93:3127 – 3139
Mortality Rates Are Lower When Leukocyte - Reduced Blood Is Used Leukocyte reduction results in a significant reduction of mortality in patients undergoing cardiac surgery van de Watering LMG et al, Circulation 1998;97:562 – 568 Mortality Rate (%) 7.8% 3.3% n=914 Bc=306 Ff=305 Sc=303
A prospective, randomized clinical trial of universal WBC reduction
Men = 704 (49.4%)
Age = 69.4 (39.8, 84.3)
Surgical pts. (62%)
Non-surg. pts. 542 (38%)
Men = 675 (49.8%)
Age = 69.6 (42.0, 84)
Surgical pts. (60.5%)
Non-surg. pts. 535 (39.5%)
Control Leukoreduced No demographic differences between groups N=2780 Dzik WH et al, Transfusion 2002;42:1114-22.
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:
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.
Nosocomial Infection Rates in Critically Ill Patients N = 1,717 n = 416 n = 1,301 P < .05 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
Mortality Rates in Critically Ill Patients N = 1,717 n = 416 n = 1,301 P < .05 Taylor RW et al, Crit Care Med 2002;30:2249-54.
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 with platelet transfusion Patients (%) STROKE DEATH Spiess BD et al, Transfusion 2004;44:1143-1148 N=1720/248 from 6 RCT for Aprotinin FDA approval