Impact of blood transfusions on inflammatory mediator release in patients undergoing cardiac surgery

Blood Transfusions in Acute Myocardial Infarctions: A Review

Anemia in acute myocardial infarctions has been an area of curiosity, with studies looking into clinical outcomes of blood transfusions in this patient population for decades without consistent evidence in the literature pointing in the direction of liberal or conservative transfusion use. With the recent publication of the MINT (Restrictive or Liberal Transfusion Strategy in Myocardial Infarction) trial showing that the liberal transfusion strategy did not reduce the recurrent risk of myocardial infarction but that harm in restrictive strategies cannot be excluded, we look to other literature and trials with different endpoints, which indicate that the liberal transfusion strategies may cause more harm. In this review, we will discuss new evidence as compared to the old for the conservative use of blood transfusions in the setting of myocardial infarctions.

Perioperative Transfusion and Mortality for Cardiovascular Surgery: A Cohort Study Based on Population in Republic of Korea

Objective:This study aimed to evaluate the rate of transfusion for cardiovascular surgeries between 2010 and 2019 in Republic of Korea and the association between blood transfusion and postoperative mortality. Methods: Data were extracted from the National Health Insurance Service database in Republic of Korea. This study includes adult patients who underwent cardiovascular surgery between 1 January 2010 and 31 December 2019. The endpoints were in-hospital mortality and the 1-year all-cause mortality. Results: The analysis included 62,794 cases, with transfusions used in 88.8% of cases. Multivariable logistic regression revealed that older age, comorbidities, hospital admission through the emergency room, aortic procedures (versus coronary artery bypass grafting), cardiopulmonary bypass, repeat procedures, and supportive therapies during the intensive care (extracorporeal membrane oxygenation and mechanical ventilation) were risk factors for blood transfusion. Female sex was associated with a lower risk of transfusion. Perioperative blood transfusion was associated with a 6.87-fold increased risk of in-hospital mortality (odds ratio [OR]: 6.87, 95% confidence interval [CI]: 3.95, 11.93; p < 0.001) and a 3.20-fold increased risk of 1-year all-cause mortality (OR: 3.35, 95% CI: 2.75, 3.93; p < 0.001). Conclusions: Blood transfusion is used at a high rate in cardiovascular surgeries, and it was associated with increases in the risk of in-hospital and 1-year all-cause mortality. However, these correlations should be viewed with caution as emergent phenomena rather than causative. Understanding factors associated with the need for blood transfusion can assist surgeons in predicting the outcomes of cardiovascular surgery and in tailoring procedures as needed to optimize outcomes.

Incidence of Intraoperative Vasoplegic Syndrome in Lung Transplantation

OBJECTIVES

Severe hypotension and low systemic vascular resistance in the setting of adequate cardiac output, known as "vasoplegic syndrome" (VS), is a physiologic disturbance reported in 9% to 44% of cardiac surgery patients. Although this phenomenon is well-documented in cardiac surgery, there are few studies on its occurrence in lung transplantation. The goal of this study was to characterize the incidence of VS in lung transplantation, as well as identify associated risk factors and outcomes.

DESIGN

Retrospective study of single and bilateral lung transplants from April 2013 to September 2021.

SETTING

The study was conducted at an academic hospital.

PARTICIPANTS

Patients ≥18 years of age who underwent lung transplantation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The authors defined VS as mean arterial pressure <65 mmHg, cardiac index ≥2.2 L/min/m2, and ≥30 minutes of vasopressor administration after organ reperfusion. The association between VS and risk factors or outcomes was assessed using t tests, Mann-Whitney U, and chi-square tests. The authors ran multivariate logistic regression models to determine factors independently associated with VS. The incidence of VS was 13.9% (CI 10.4%-18.4%). In the multivariate model, male sex (odds ratio 2.85, CI 1.07-7.58, p = 0.04) and cystic fibrosis (odds ratio 5.76, CI 1.43-23.09, p = 0.01) were associated with VS.

CONCLUSIONS

The incidence of VS in lung transplantation is comparable to that of cardiac surgery. Interestingly, male sex and cystic fibrosis are strong risk factors. Identifying lung transplant recipients at increased risk of VS may be crucial to anticipating intraoperative complications.

Impact of perfusion method on perioperative red blood cell transfusions and new-onset postoperative atrial fibrillation in mitral valve surgery patients

INTRODUCTION

Red blood cell (RBC) transfusions are common in cardiac surgery and reportedly associated with increased mortality and morbidity, including increased risk of postoperative new-onset atrial fibrillation (NOAF). The aim of this study was to compare minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) in terms of RBC transfusions and the incidence of NOAF in mitral valve surgery.

METHODS

The study population consisted of 89 MiECC and 169 CECC patients undergoing mitral valve surgery as an isolated procedure (80.6% of the patients) or in combination with coronary artery bypass grafting (19.4% of patients). 79.4% of the patients were male and the mean age was 62.1 years.

RESULTS

30.0% of patients aged < 65 years and 48.1% of patients aged ≥ 65 years needed RBC transfusion. The overall need for RBC transfusions did not differ between the treatment groups. Among patients < 65 years of age transfusions of ≥ 3 units were less frequent in MiECC than in CECC patients (OR 0.31, 95% CI 0.10-0.98, p = 0.045). The overall incidence of NOAF was 41.8% with no significant difference between MiECC and CECC groups. Red blood cell transfusions were associated with an increased risk of NOAF in an unadjusted analysis but not after adjustment for age and sex (OR 1.25, 95% CI 0.64-2.43, p = 0.515).

CONCLUSIONS

In mitral valve surgery MiECC compared to CECC was associated with less need of RBC units and platelets, particularly in patients aged < 65 years. Use of RBC transfusions was associated with increased risk of NOAF significantly only in unadjusted analysis.

Dexmedetomidine as an anesthetic adjunct is associated with reduced complications and cardiac intensive care unit length of stay after heart valve surgery

BACKGROUND

We sought to explore the relationship between dexmedetomidine as an anesthetic adjuvant in cardiac surgery and postoperative complications and length of stay (LOS) in the cardiac intensive care unit (CICU).

METHODS

We conducted a retrospective study of patients aged 18 years and older who underwent heart valve surgery between October 2020 and June 2022. The primary endpoint of the study was major postoperative complications (cardiac arrest, atrial fibrillation, myocardial injury/infarction, heart failure) and the secondary endpoint was prolonged CICU LOS (defined as LOS > 90th percentile). Multivariate logistic regression analysis was performed for variables that were significant in the univariate analysis.

RESULTS

A total of 856 patients entered our study. The 283 patients who experienced the primary and secondary endpoints were included in the adverse outcomes group, and the remaining 573 were included in the prognostic control group. Multivariate logistic regression analysis revealed that age > 60 years (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.23-2.31; p < 0.01), cardiopulmonary bypass (CPB) > 180 min (OR, 1.62; 95% CI, 1.03-2.55; p = 0.04) and postoperative mechanical ventilation time > 10 h (OR, 1.84; 95% CI, 1.35-2.52; p < 0.01) were independent risk factors for major postoperative complications; Age > 60 years (OR, 3.20; 95% CI, 1.65-6.20; p < 0.01), preoperative NYHA class 4 (OR, 4.03; 95% CI, 1.74-9.33; p < 0.01), diabetes mellitus (OR, 2.57; 95% CI, 1.22-5.41; p = 0.01), Intraoperative red blood cell (RBC) transfusion > 650 ml (OR, 2.04; 95% CI, 1.13-3.66; p = 0.02), Intraoperative bleeding > 1200 ml (OR, 2.69; 95% CI, 1.42-5.12; p < 0.01) were independent risk factors for prolonged CICU length of stay. Intraoperative use of dexmedetomidine as an anesthetic adjunct was a protective factor for major complications (odds ratio, 0.51; 95% confidence interval, 0.35-0.74; p < 0.01) and prolonged CICU stay. (odds ratio, 0.37; 95% confidence interval, 0.19-0.73; p < 0.01).

CONCLUSIONS

In patients undergoing heart valve surgery, age, duration of cardiopulmonary bypass, and duration of mechanical ventilation are associated with major postoperative complication. Age, preoperative NYHA classification 4, diabetes mellitus, intraoperative bleeding, and RBC transfusion are associated with increased CICU length of stay. Intraoperative use of dexmedetomidine may improve such clinical outcomes.

Perioperative Anemia and Transfusions and Late Mortality in Coronary Artery Bypass Patients

BACKGROUND

Perioperative anemia and transfusions are associated with adverse operative outcomes after coronary artery bypass graft surgery (CABG). Their individual association with long-term outcomes is unclear.

METHODS

Patients aged 65 years and older who had undergone CABG and were in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (n = 504,596) from 2011 to 2018 were linked to Centers for Medicare and Medicaid Service data to assess long-term survival. The association of intraoperative anemia defined by intraoperative nadir hematocrit (nHct) and red blood cell (RBC) transfusions, and their interactions, on long-term mortality were assessed with Kaplan-Meier estimates and multivariable Cox regression. Restricted cubic splines were used to explore the association between nHct as a continuous variable and long-term mortality.

RESULTS

258,398 on-pump CABG STS Adult Cardiac Surgery Database patients surviving the perioperative period were linked to Centers for Medicare and Medicaid Service claims files. Per World Health Organization criteria, 41% had preoperative anemia. Mean intraoperative nHct was 24%; RBC transfusion rate was 43.7%. Univariable analysis associated both RBC transfusion and lower nHct with worse survival. Lower nHct was only marginally associated with risk-adjusted mortality: adjusted hazard ratio (AHR) 1.04 (95% CI, 1.01-1.06) and 1.07 (95% CI, 1.00-1.14) at nHct 20% and at nHct 14%, respectively. RBC transfusion was associated with significantly higher adjusted mortality irrespective of timing of transfusion: AHR intraoperative 1.21 (95% CI, 1.18-1.27); AHR postoperative 1.26 (95% CI, 1.22-1.30); AHR both 1.46 (95% CI, 1.40-1.52) and across all levels of nHct. RBC transfusion was not associated with improved survival at any level of nHct.

CONCLUSIONS

Among Medicare CABG patients, RBC transfusions were associated with increased risk-adjusted late mortality across all levels of nHct whereas intraoperative anemia was only marginally so. Tolerance of lower intraoperative nHct than currently accepted may be preferable to transfusions.

TRansfusion strategies in Acute brain INjured patients (TRAIN): a prospective multicenter randomized interventional trial protocol

BACKGROUND

Although blood transfusions can be lifesaving in severe hemorrhage, they can also have potential complications. As anemia has also been associated with poor outcomes in critically ill patients, determining an optimal transfusion trigger is a real challenge for clinicians. This is even more important in patients with acute brain injury who were not specifically evaluated in previous large randomized clinical trials. Neurological patients may be particularly sensitive to anemic brain hypoxia because of the exhausted cerebrovascular reserve, which adjusts cerebral blood flow to tissue oxygen demand.

METHODS

We described herein the methodology of a prospective, multicenter, randomized, pragmatic trial comparing two different strategies for red blood cell transfusion in patients with acute brain injury: a "liberal" strategy in which the aim is to maintain hemoglobin (Hb) concentrations greater than 9 g/dL and a "restrictive" approach in which the aim is to maintain Hb concentrations greater than 7 g/dL. The target population is patients suffering from traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), or intracerebral hemorrhage (ICH). The primary outcome is the unfavorable neurological outcome, evaluated using the extended Glasgow Outcome Scale (eGOS) of 1-5 at 180 days after the initial injury. Secondary outcomes include, among others, 28-day survival, intensive care unit (ICU) and hospital lengths of stay, the occurrence of extra-cerebral organ dysfunction/failure, and the development of any infection or thromboembolic events. The estimated sample size is 794 patients to demonstrate a reduction in the primary outcome from 50 to 39% between groups (397 patients in each arm). The study was initiated in 2016 in several ICUs and will be completed in December 2022.

DISCUSSION

This trial will assess the impact of a liberal versus conservative strategy of blood transfusion in a large cohort of critically ill patients with a primary acute brain injury. The results of this trial will help to improve blood product and transfusion use in this specific patient population and will provide additional data in some subgroups of patients at high risk of brain ischemia, such as those with intracranial hypertension or cerebral vasospasm.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02968654.

Review of Postoperative Care for Heart Transplant Recipients

The early postoperative management strategies after heart transplantation include optimizing the function of the denervated heart, correcting the causes of hemodynamic instability, and initiating and maintaining immunosuppressive therapy, allograft rejection surveillance, and prophylaxis against infections caused by immunosuppression. The course of postoperative support is influenced by the quality of allograft myocardial protection prior to implantation and reperfusion, donor-recipient heart size matching, surgical technique of orthotopic heart transplantation, and patient factors (eg, preoperative condition, immunologic compatibility, postoperative vasomotor tone, severity and reversibility of pulmonary vascular hypertension, pulmonary function, mediastinal blood loss, and end-organ perfusion). This review provides an overview of the early postoperative care of recipients and includes a brief description of the surgical techniques for orthotopic heart transplantation.

Systematic review and meta-analysis of outcome-relevant anemia in patients with subarachnoid hemorrhage

Anemia is a common, treatable condition in patients with aneurysmal subarachnoid hemorrhage (SAH) and has been associated with poor outcome. As there are still no guidelines for anemia management after aneurysm rupture, we aimed to identify outcome-relevant severity of anemia in SAH. We systematically searched PubMed, Embase, Scopus, Web of Science, and Cochrane Library for publications before Oct 23rd, 2022, reporting on anemia in SAH patients. The presence and severity of anemia were assessed according to the reported hemoglobin values and/or institutional thresholds for red blood cells transfusion (RBCT). Out of 1863 original records, 40 full-text articles with a total of 14,701 patients treated between 1996 and 2020 were included in the final analysis (mean 445.48 patients per study). A substantial portion of patients developed anemia during SAH (mean pooled prevalence 40.76%, range 28.3-82.6%). RBCT was administered in a third of the cases (mean 32.07%, range 7.8-88.6%), with institutional threshold varying from 7.00 to 10.00 g/dL (mean 8.5 g/dL). Anemia at the onset of SAH showed no impact on SAH outcome. In contrast, even slight anemia (nadir hemoglobin < 11.0-11.5 g/dL) occurring during SAH was associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. The strongest association with SAH outcome was observed for nadir hemoglobin values ranging between 9.0 and 10.0 g/dL. The effect of anemia on SAH mortality was marginal. The development of anemia during SAH is associated with the risk of cerebral infarction and poor outcome at discharge and follow-up. Outcome-relevant severity of post-SAH anemia begins at hemoglobin levels clearly above the thresholds commonly set for RBCT. Our findings underline the need for further studies to define the optimal management of anemia in SAH patients.

Transfusion in Older Anemic Patients: Should the Troponin Value Be Taken into Account?

BACKGROUND

Anemia is common in older individuals, but it is not known whether the prognostic impact of transfusion differs according to cardiac troponin concentration.

METHODS

During this 2-year retrospective study in an acute geriatric unit, 514 patients with hemoglobin <10 g/dL and troponin sampling were included. Thirty-day and 1-year mortality were compared according to transfusion status and troponin and hemoglobin levels.

RESULTS

Of the 514 anemic patients included (median age 88 years), 157 (31%) had elevated troponin concentrations. These patients were more likely to die at 30 days (49% vs 27%, P < .001) and 1 year (65% vs 51%, P = .004) than patients with normal values. Among patients with elevated troponin concentrations, 30-day mortality tended to be lower in transfused than in not-transfused patients (hazard ratio 0.48; 95% confidence interval, 0.21-1.08; P = .07). This association was not found in patients without troponin elevation (hazard ratio 1.09; 95% CI, 0.61-1.93; P = .8). Transfusion was associated with 30-day survival in patients with hemoglobin ≤8 g/dL. It was also associated with excess 1-year mortality in patients with hemoglobin >8 g/dL.

CONCLUSIONS

This pilot study suggests that transfusion could be associated with better 30-day outcomes in older anemic patients with anemia-related myocardial injury. Thus, troponin levels could be involved in decision-making relative to transfusion in anemic older patients. Clinical trials are needed to establish the benefit of transfusion in patients with elevated troponins.

Impact of allogeneic red blood cell transfusion on prognosis in soft tissue sarcoma patients. A single-centre study

BACKGROUND

Perioperatively administered (leukocyte reduced) allogeneic red blood cell transfusions (lrRBCTs) may lead to transfusion-related immunomodulation and reduced overall survival (OS) in cancer patients. Herein, the effect of lrRBCT on local recurrence (LR), distant metastasis (DM), and OS in soft tissue sarcoma (STS) patients was analysed.

METHODS

Retrospective study on 432 STS patients (mean age: 60.0 ± 17.8 years; 46.1% female), surgically treated at a tertiary tumour centre. Uni- and multivariate survival models were calculated to analyse impact of perioperative lrRBCTs on LR, DM, OS.

RESULTS

Perioperatively, 75 patients (17.4%) had received lrRBCTs. Older patients, deep, large, lower limb STS rather required lrRBCTs (all p < 0.05). No significant association between lrRBCT administration and LR- (p = 0.582) or DM-risk (p = 0.084) was observed. LrRBCT was associated with worse OS in univariate analysis (HR: 2.222; p < 0.001), with statistical significance lost upon multivariate analysis (HR: 1.658; p = 0.059; including age, histology, size, grading, amputation, depth). Adding preoperative haemoglobin in subgroup of 220 patients with laboratory parameters revealed significant negative impact of low haemoglobin on OS (p = 0.014), whilst effect of lrRBCT was further diminished (p = 0.167).

CONCLUSION

Unfavourable prognostic factors prevail in STS patients requiring lrRBCTs. Low haemoglobin levels rather than lrRBCT seem to reduce OS.

Blood Transfusion Predicts Prolonged Mechanical Ventilation in Acute Stanford Type A Aortic Dissection Undergoing Total Aortic Arch Replacement

Background

This research aimed to evaluate the impacts of transfusing packed red blood cells (pRBCs), fresh frozen plasma (FFP), or platelet concentrate (PC) on postoperative mechanical ventilation time (MVT) in patients with acute Stanford type A aortic dissection (ATAAD) undergoing after total arch replacement (TAR).

Methods

The clinical data of 384 patients with ATAAD after TAR were retrospectively collected from December 2015 to October 2017 to verify whether pRBCs, FFP, or PC transfusion volumes were associated with postoperative MVT. The logistic regression was used to assess whether blood products were risk factors for prolonged mechanical ventilation (PMV) in all three endpoints (PMV ≥24 h, ≥48 h, and ≥72 h).

Results

The mean age of 384 patients was 47.6 ± 10.689 years, and 301 (78.39%) patients were men. Median MVT was 29.5 (4–574) h (h), and 213 (55.47%), 136 (35.42%), and 96 (25.00%) patients had PMV ≥24 h, ≥48 h, and ≥72 h, respectively. A total of 36 (9.38%) patients did not have any blood product transfusion, the number of patients with transfusion of pRBCs, FFP, and PC were 334 (86.98%), 286 (74.48%), and 189 (49.22%), respectively. According to the multivariate logistic regression of three PMV time-endpoints, age was a risk factor [PMV ≥ 24 h odds ratio (ORPMV≥24) = 1.045, p = 0.005; ORPMV≥48 = 1.060, p = 0.002; ORPMV≥72 = 1.051, p = 0.011]. pRBC transfusion (ORPMV≥24 = 1.156, p = 0.001; ORPMV≥48 = 1.156, p &lt; 0.001; ORPMV≥72 = 1.135, p ≤ 0.001) and PC transfusion (ORPMV≥24 = 1.366, p = 0.029; ORPMV≥48 = 1.226, p = 0.030; ORPMV≥72 = 1.229, p = 0.011) were independent risk factors for PMV. FFP had no noticeable effect on PMV [ORPMV≥48 = 0.999, 95% confidence interval (CI) 0.998–1.000, p = 0.039; ORPMV≥72 = 0.999, 95% CI: 0.998–1.000, p = 0.025].

Conclusions

In patients with ATAAD after TAR, the incidence of PMV was very high. Blood products transfusion was closely related to postoperative mechanical ventilation time. pRBC and PC transfusions and age increased the incidence of PMV at all three endpoints.

Cell saver blood transfusions may be associated with a decrease in inflammation and improved outcome measures in pediatric cardiac surgery patients

OBJECTIVE

Cardiopulmonary bypass (CPB) is a requisite for correction of congenital heart disease by open-heart surgery and induces a systemic inflammatory response that can lead to complications such as acute lung injury and acute kidney injury. In addition, blood transfusions are commonly required for this type of surgery, and they may further exacerbate this inflammatory response and increase morbidity and mortality. We hypothesized that, in contrast to red blood cells, intraoperative cell saver (CS) blood transfusions attenuate the post-CPB proinflammatory cytokine response.

METHODS

Serum cytokine concentrations of IL-10, IL-1RA, IL-6, IL-8, and TNF-α were measured at four time points (preoperatively and postoperatively on postoperative days 0, 1, and 2).

RESULTS

Anti-inflammatory IL-10 levels were significantly lower in the CS group on POD 0 than in the control group (mean 1083.2 pg/mL vs 2080.2 pg/mL, 95%CI 357.4-1636.6, p = .0026). Of the clinical parameters measured, mean BUN and creatinine levels on POD 2 were significantly lower in the CS group (13.79 vs 21.88, p = .004 and 0.45 vs 0.55, p = .055, respectively). In addition, the duration of milrinone use decreased by 80% in the CS group (0.20, 95%CI 0.04, 0.94; p = .048), the median time to extubation in hours was significantly lower in the CS group (3.5 vs 6.5; 95%CI -38.00, -0.50; p = .026), and hospital length of stay was decreased by 60% in the CS group (p = .003).

CONCLUSIONS

CS transfusions in children may lower postoperative anti-inflammatory IL-10 levels, possibly due to an overall decrease in proinflammatory state, and may be associated with improvements in renal and pulmonary functions.

Risk factors for mortality in patients undergoing continuous renal replacement therapy after cardiac surgery

BACKGROUND

To investigate the risk factors for mortality in patients with acute kidney injury requiring continuous renal replacement therapy (AKI-CRRT) after cardiac surgery.

METHODS

In this retrospective study, patients who underwent AKI-CRRT after cardiac surgery in our centre from January 2015 to January 2020 were included. Univariable and multivariable analyses were performed to identify the risk factors for in-hospital mortality.

RESULTS

A total of 412 patients were included in our study. Of these, 174 died after AKI-CRRT, and the remaining 238 were included in the survival control group. Multivariable logistic regression analysis revealed that EuroSCORE > 7 (odds ratio [OR], 3.72; 95% confidence interval [CI], 1.92-7.24; p < 0.01), intraoperative bleeding > 1 L (OR, 2.14; 95% CI, 1.19-3.86; p = 0.01) and mechanical ventilation time > 70 h (OR, 5.03; 95% CI, 2.40-10.54; p < 0.01) were independent risk factors for in-hospital mortality in patients who had undergone AKI-CRRT. Our study also found that the use of furosemide after surgery was a protective factor for such patients (odds ratio, 0.48; 95% confidence interval, 0.25-0.92; p = 0.03).

CONCLUSIONS

In summary, the mortality of patients with AKI-CRRT after cardiac surgery remains high. The EuroSCORE, intraoperative bleeding and mechanical ventilation time were independent risk factors for in-hospital mortality. Continuous application of furosemide may be associated with a better outcome.

Higher neutrophil-to-lymphocyte ratio, mean platelet volume, and platelet distribution width are associated with postoperative delirium in patients undergoing esophagectomy: a retrospective observational study

PURPOSE

We investigated whether preoperative inflammatory markers, i.e., the neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), mean platelet volume (MPV), and platelet distribution width (PDW) can predict the development of postoperative delirium (POD) after esophagectomy.

PATIENTS AND METHODS

This single-center, retrospective, observational study included 110 patients who underwent an esophagectomy. We assigned the patients with the Intensive Care Delirium Screening Checklist score ≥ 4 to the POD group. We performed multivariable logistic regression analyses to determine whether the NLR, PLR, MPV, and PDW can be used to predict the development of POD.

RESULTS

The POD group had 20 patients; the non-POD group included the other 90 patients. Although only the preoperative NLR in the POD group was significantly higher than in the non-POD group (3.20 [2.52-4.30] vs. 2.05 [1.45-3.02], p = 0.001), multivariable logistic regression analyses showed that the following three parameters were independent predictors of POD: preoperative NLR ≥ 2.45 (adjusted odds ratio [aOR]: 8.68, 95%CI 2.33-32.4, p = 0.001), MPV ≥ 10.4 (aOR: 3.93, 95%CI: 1.37-11.2, p = 0.011), and PDW ≥ 11.8 (aOR: 3.58, 95%CI: 1.22-10.5, p = 0.020).

CONCLUSION

Our analysis results demonstrated that preoperative NLR ≥ 2.45, MPV ≥ 10.4, and PDW ≥ 11.8 were significantly associated with a higher risk of POD after adjustment for possible confounding factors. However, as the AUCs of the preoperative MPV and PDW for the prediction of the development of POD in univariable ROC analyses were low, large prospective studies are needed to confirm this result.

Fever and breast cancer: A critical review of the literature and possible underlying mechanisms

Fever is a common feature in various pathological conditions that manifests a series of molecular events in the internal milieu. Much less attention has been paid to the clinical importance and the management of fever in breast cancer patients. However, several studies have reported an association between postoperative fever and poor treatment outcomes in breast cancer patients. The fever is a side effect of chemotherapy and a manifestation of cancer recurrence. The postmenopausal breast cancer patients experience another body temperature disturbance that is known as a hot flashes. Here, we reviewed the literature regarding postoperative fever and the possible underlying molecular and cellular mechanisms. Then the efficacy of non-steroidal anti-inflammatory drugs was discussed as a therapeutic option to control postoperative fever. Finally, we reviewed the chemotherapy-induced neutropenic fever and cancer vaccination-induced fever.

Recipient and surgical factors trigger severe primary graft dysfunction after heart transplant

BACKGROUND

Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD.

METHODS

We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression.

RESULTS

PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD.

CONCLUSIONS

Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed.

Impact of age on the incidence of complications after liver transplantation: A single-center retrospective study

Background and objective

Advances in surgical technique, postoperative management, and immunosuppressive therapy have led to a steady increase in the number of patients undergoing organ transplantation. This study aimed to compare the incidence of postoperative complications between young and elderly patients undergoing liver transplantation (LT) at a single university hospital.

Method

The medical records of 253 patients who underwent LT between January 2010 and July 2017 were retrospectively reviewed. The patients were divided into two groups: those younger than 65 years (group Y, n = 231) and those older than 65 years (group O, n = 22). Data on patient demographics, perioperative management, and postoperative complications were collected.

Results

The patients’ baseline characteristics, including underlying diseases and the Model for End-Stage Liver Disease scores, were not different between groups. Preoperative laboratory findings were not significantly different between the two groups, except for hemoglobin level. The total amounts of infused fluid and packed red blood cells were higher in group O than in group Y. The postoperative plasma creatinine level was higher in group O than in group Y; however, the incidence of postoperative complications was not considerably different between the two groups. In addition, there was no difference in the survival rate after LT depending on age.

Conclusion

With the development of medical technology, LT in elderly patients is not an operation to be avoided, and the prognosis is expected to improve. Therefore, continuous efforts to understand the disease characteristics and physical differences in elderly patients who require LT are essential.

Prognostic Value of Preoperative Hemoglobin Levels for Long-Term Outcomes of Acute Type B Aortic Dissection Post-thoracic Endovascular Aortic Repair

Background and Aims: There is scant information available about the prognostic value of preoperative hemoglobin (Hb) levels on the long-term outcomes of acute type B aortic dissection (ABAD) following thoracic endovascular aortic repair (TEVAR).

Methods: A retrospective analysis of consecutive patients from 2010 to 2018 regarding the relationship between Hb level and long-term outcomes was conducted. The primary endpoint was all-cause mortality. Major adverse cardiovascular events (MACEs) included all-cause death, recurrent ruptures, and secondary procedures.

Results: In total, 391 subjects treated by TEVAR were enrolled, with a mean age of 57.1 ± 12.0 years; 79.5% of them were male. Cox multivariate analysis showed that the preoperative Hb level was independently associated with all-cause death [adjusted hazard ratio (HR) 0.797 (per 1 g/dl), 95% confidence interval (CI) 0.693–0.918, p = 0.002] and MACEs (adjusted HR 0.795, 95% CI 0.672–0.871, p = 0.000). The area under the receiver operating characteristic curve of Hb for all-cause death and MACEs were 0.617 (95% CI 0.548–0.687, p = 0.008) and 0.617 (95% CI 0.551–0.684, p = 0.005), respectively. In the linear trend test, Hb concentration was significantly related to all-cause mortality (p for trend = 0.001) and MACEs (p for trend = 0.000). Moreover, in Kaplan–Meier analysis, lower Hb levels (< 12 g/dl) were significantly different from higher Hb (≥12 g/dl) levels for both all-cause death (log-rank p = 0.001) and MACEs (log-rank p = 0.001). Similar results were found when assessing the prognostic value of red blood cell count and anemia.

Conclusions: Preoperative Hb may serve as a prognostic marker for long-range adverse outcomes for ABAD patients post-TEVAR.

Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options

Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.

Elucidation of the novel role of ethnicity and diabetes in poorer outcomes after cardiac surgery in a multiethnic Southeast Asian cohort

BACKGROUND

Although diabetes is associated with ethnicity and worse cardiac surgery outcomes, no research has been done to study the effect of both diabetes and ethnicity on cardiac surgery outcomes in a multiethnic Southeast Asian cohort. Hence, this study aimed to delineate the association of ethnicity on outcomes after cardiac surgery among diabetics in a multiethnic Southeast Asian population.

METHODS

Perioperative data from 3008 adult patients undergoing elective cardiac surgery from 2008 to 2011 at the two main heart centers in Singapore was analyzed prospectively, and confirmatory analysis was conducted with the generalized structural equation model.

RESULTS

Diabetes was significantly associated with postoperative acute kidney injury (AKI) and postoperative hyperglycemia. Postoperative AKI, Malay ethnicity, and blood transfusion were associated with postoperative dialysis. Postoperative AKI and blood transfusion were also associated with postoperative arrhythmias. In turn, postoperative dialysis and arrhythmias increased the odds of 30-day mortality by 7.7- and 18-fold, respectively.

CONCLUSIONS

This study identified that diabetes is directly associated with postoperative hyperglycemia and AKI, and indirectly associated with arrhythmias and 30-day mortality. Further, we showed that ethnicity not only affects the prevalence of diabetes, but also postoperative diabetes-related outcomes.

Predicting peripartum blood transfusion: focusing on pre-pregnancy characteristics

Background

Obstetric hemorrhage is one of the most common causes of obstetrical morbidity and mortality, and transfusion is the most important management for hemorrhage. The aim of our study was to investigate the pre-pregnancy and pregnancy risk factors for peripartum transfusion.

Methods

Women who delivered a baby from 2010 to 2014 in Korea and participated in the Korean National Health Screening Program for Infants and Children were included. To analyze pre-pregnant risk factors for peripartum transfusion, an additional analysis was done for women who underwent a National Health Screening Examination within 1 year before pregnancy, including maternal waist circumference, body mass index, blood pressure, laboratory tests and history of smoking. Multivariable logistic regression analysis was used to estimate the risk factors for peripartum transfusion.

Results

Of the total 1,980,126 women who met the inclusion criteria, 36,868 (1.86%) were transfused at peripartum. In a multivariable regression model, the pregnancy risk factors for peripartum transfusion included maternal age above 35 years [odds ratio (OR): 1.41; 95% confidence interval (CI): 1.32–1.50], preterm birth (OR: 2.39; 95% CI: 2.15–2.65), and maternal hypertension (OR: 2.49; 95% CI: 2.24–2.77). Pre-pregnancy risk factors including fasting glucose level of more than 126 mg/dL (OR: 1.11; 95% CI: 1.02–1.20), current-smoker status (OR: 1.20; 95% CI: 1.06–1.37), and waist-circumference less than 80 cm (OR: 1.18; 95% CI: 1.06–1.30) were independently associated with peripartum blood transfusion.

Conclusions

Several pre-pregnancy and pregnancy risk factors were associated with peripartum blood transfusion. Some identified factors are modifiable before conception, and our study validated peripartum blood transfusion as a form of triage.

Packed red blood cell transfusion associates with acute kidney injury after transcatheter aortic valve replacement

Background

Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors.

Methods

This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters).

Results

Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13–2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m², 95% CI 0.94–1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61–1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19–3.67, P = 0.01).

Conclusion

Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations.

Risk factors and impact of postoperative hyperglycemia in nondiabetic patients after cardiac surgery: A prospective study

Cardiac surgery induces a significant inflammatory hypermetabolic stress response, resulting in postoperative hyperglycemia in both preoperatively diabetic and nondiabetic patients. Such postoperative hyperglycemia has been associated with adverse outcomes in surgery and postsurgical recovery. Yet, while diabetes is a known risk factor for postoperative hyperglycemia, predictors of postoperative hyperglycemia among nondiabetics in the local Southeast Asian population remain unknown.We aim to investigate the predictors and outcomes associated with hyperglycemia after cardiac surgery among nondiabetics in the local Southeast Asian population. We analyzed data from 1602 nondiabetic adult patients undergoing elective cardiac surgery, from 2008 to 2010 at the 2 main heart centers in Singapore.Nondiabetic patients who developed postoperative hyperglycemia tended to be women, older, more obese, and hypertensive. Higher body mass index (BMI), age, aortic cross-clamp time, and blood transfusion were identified as independent risk factors of postoperative hyperglycemia. Postoperative hyperglycemia was also significantly associated with postoperative cardiac arrhythmias (26.9% vs 15.0%, P < .001), acute kidney injury (30.0% vs 20.1%, P < .001), longer intensive care unit (ICU) stay (46.7 ± 104.1 vs 37.2 ± 76.6 hours, P = .044) and longer hospitalization (11.5 ± 12.2 vs 9.6 ± 8.0 days, P < .001).Our study identified aortic cross-clamp time and blood transfusion as independent risk factors of postoperative hyperglycemia after cardiac surgery in nondiabetics. Similar to other studies, higher BMI and age were independent risk factors for postoperative hyperglycemia. Postoperative hyperglycemia was also associated with adverse perioperative outcomes and should thereby be avoided by treating modifiable risk factors identified in this study including reducing blood transfusion and aortic cross-clamp time. Our findings contribute to early risk stratification of nondiabetic patients who are at increased risk of postoperative hyperglycemia.

Routine practice in mechanical ventilation in cardiac surgery in Italy

BACKGROUND

Management of mechanical ventilation is a key issue in the prevention of postoperative pulmonary complications (PPCs) and the improvement of surgical outcome. This is especially true in cardiac surgery where the use of the cardiopulmonary bypass (CPB) increases the risk of lung injury. In the last years a growing number of studies have shown that protective ventilation has led to excellent results. However, the literature in this regard is lacking in cardiac surgery and there are no univocal guidelines in this sense. The aim of this survey was to investigate the actual clinical practice about ventilation techniques used in the Italian cardiac surgery centers.

METHODS

A questionnaire of 32-item was sent to 69 Italian cardiac surgery centers, 56 of which return a completed form (81.2%). The questionnaire was assembled by three independent researchers and the final version was e-mailed to all members of the SIAARTI (Italian society of anesthesia resuscitation and intensive care medicine) Study Group on Cardiothoracic and Vascular Anesthesia. The answers were collected using a Google Forms sheet. In case of multiple questionnaires returned from the same center (i.e., different physicians from the same center responded) the head of department was asked to give a definite answer. Furthermore, for the 17 centers who reported multiple questionnaires, no large differences were found between the responses of different doctors belonging to the same center (12.3%±4.2% of discordant answers).

RESULTS

Intraoperatively, patients were ventilated with a tidal volume (TV) of 6-8 mL/kg (91.1% of centers), a positive end-expiration pressure of 3-5 cmH2O (76.8% of centers) and a fraction of inspired oxygen (FiO2) of 50-80% (60.7% of centers). During the CPB, the "stop ventilation" technique was frequently adopted (73.2%). Before the discharge from the intensive care unit (ICU) non-invasive ventilation (NIV) was never applied in 32.1% of the centers, but it was used in 46.4% of patients with postoperative complications.

CONCLUSIONS

This study shows a significant heterogeneity in ventilatory techniques among the Italian centers during CPB, whereas in the other surgical time the majority of the responding centers adopted a protective mechanical ventilation strategy.

Altered Expression Levels of CD59, but Not CD55, on Red Blood Cells in Stored Blood

OBJECTIVE

Red blood cells (RBCs) in storage undergo structural and biochemical changes that may cause functional effects. Studies exploring structural changes affecting the expression levels of CD55 and CD59 on RBCs are limited. The aim of this study was to investigate the pattern of CD55 and CD59 expression on RBCs in stored blood from Arab donors.

MATERIALS AND METHODS

Flow-cytometric analysis was performed on RBCs from 92 packed RBC (PRBC) units, stored for varying times, and from 56 nonstored RBC from healthy controls using the commercial REDQUANT kit.

RESULTS

The proportions of CD55- and CD59-deficient RBCs from stored PRBC units did not significantly differ when compared with those from healthy controls; however, the mean fluorescent intensity (MFI) of CD59 expression, but not MFI of CD55 expression, on RBCs from stored PRBC units was significantly reduced when compared to the expression of RBCs from healthy controls (p = 0.02). MFI of CD55 expression on RBCs from PRBC units did not significantly differ among the 3 groups of stored RBC; however, there was a statistically significant time-dependent preferential decline in MFI of CD59 expression on RBCs from stored PRBC units (p < 0.01).

CONCLUSION

There is a preferential time-dependent decline in the expression of CD59, but not of CD55, on stored RBCs, the in vivo significance of which in relation to the response to PRBC transfusion needs further investigation.

Hypothermia does not influence liver damage and function in a porcine polytrauma model

BACKGROUND

Previous studies revealed evidence that induced hypothermia attenuates ischemic organ injuries after severe trauma. In the present study, the effect of hypothermia on liver damage was investigated in a porcine long term model of multi-system injury, consisting of blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shockMETHODS: In 30 pigs, a standardized polytrauma including blunt chest trauma, penetrating abdominal trauma, musculoskeletal injury, and hemorrhagic shock of 45% of total blood volume was induced. Following trauma, hypothermia of 33∘C was induced for 12 h and intensive care treatment was evaluated for 48 h. As outcome parameters, we assessed liver function and serum transaminase levels as well as a histopathological analysis of tissue samples. A further 10 animals served as controls.

RESULTS

Serum transaminase levels were increased at the end of the observation period following hypothermia without reaching statistical significance compared to normothermic groups. Liver function was preserved (p⩽ 0.05) after the rewarming period in hypothermic animals but showed no difference at the end of the observation period. In H&E staining, cell death was slightly increased hypothermic animals and caspase-3 staining displayed tendency towards more apoptosis in hypothermic group as well.

CONCLUSIONS

Induction of hypothermia could not significantly improve hepatic damage during the first 48 h following major trauma. Further studies focusing on multi-organ failure including a longer observation period are required to illuminate the impact of hypothermia on hepatic function in multiple trauma patients.

Association Between Transfusion of RBCs and Subsequent Development of Delirium in Critically Ill Children

OBJECTIVES

To determine the temporal relationship between the transfusion of RBCs and the subsequent development of delirium in a cohort of critically ill children.

DESIGN

Nested retrospective cohort study within prospective cohort study.

SETTING

Urban academic tertiary care PICU.

PATIENTS

All consecutive admissions from September 2014 through August 2015.

INTERVENTIONS

Children were screened twice daily for delirium during their PICU admission.

MEASUREMENTS AND MAIN RESULTS

Among 1,547 independent admissions screened for delirium, 166 (10.7%) were transfused RBCs. Children who were transfused RBCs were more than twice as likely to be delirious during their admission compared with children who were never transfused, after controlling for known predictors of delirium development (adjusted odds ratio, 2.16; 95% CI, 1.38-3.37; p = 0.001). Among transfused children, a temporal relationship was observed between receipt of RBCs and the subsequent development of delirium. For each additional 10 mL/kg of RBCs transfused, the recipients were 90% more likely to develop delirium or coma in the 72 hours following the transfusion, after controlling for confounders (adjusted odds ratio, 1.90; 95% CI, 1.14-3.17; p = 0.01). Anemia (represented by nadir hemoglobin prior to transfusion) was not associated with delirium development.

CONCLUSIONS

In this cohort of critically ill children, there is an independent association between the receipt of an RBC transfusion and the subsequent development of delirium. Further prospective studies are warranted to replicate this finding and investigate possible pathophysiologic mechanisms for this association.

Superior blood-saving effect and postoperative recovery of comprehensive blood-saving strategy in infants undergoing open heart surgery under cardiopulmonary bypass

BACKGROUND

Optimization of blood-saving strategies during open heart surgery in infants is still required. This study aimed to study a comprehensive blood-saving strategy during cardiopulmonary bypass (CPB) on postoperative recovery in low-weight infants undergoing open heart surgery.

METHODS

This was a prospective study of 86 consecutive infants (weighing <5 kg) with acyanotic congenital heart disease treated at the Tianjin Chest Hospital between March and December 2016, and randomized to the control (traditional routine CPB) and comprehensive blood-saving strategy groups. The primary endpoints were blood saving and clinical prognosis. The secondary endpoints were safety and laboratory indicators, prior to CPB (T1), after 30 minutes of CPB (T2), after modified ultrafiltration (T3), and postoperative 12 (T4), 24 (T5), 48 (T6), and 72 h (T7).

RESULTS

The total priming volume and banked red blood cells in the comprehensive strategy group were significantly lower than in the control group (P = .009 and P = .04, respectively). In the comprehensive strategy group, immediately after CPB, the amount of salvaged red blood cells exceeded the priming red blood cells by 40 ± 11 mL. Postoperatively, the comprehensive strategy group showed a significant decrease in the inotrope score (P = .03), ventilation time (P = .03), intensive care unit stay (P = .04), and hospital stay (P = .03) in comparison with the control group.

CONCLUSION

The comprehensive blood-saving strategies for CPB were associated with less blood use and favorable postoperative recovery in low-weight infants with congenital heart disease undergoing open heart surgery.

Blood transfusion and risk of atrial fibrillation after coronary artery bypass graft surgery: A meta-analysis of cohort studies

The aim of this study was to systematically evaluate the effect of blood transfusion (BT) on postoperative atrial fibrillation (AF) in adult patients who had undergone coronary artery bypass grafting (CABG) surgery.PubMed, Embase, and Cochrane Library databases from inception to January 2017 were searched. Cohort studies were searched that evaluated the association between BT and the risk of postoperative AF in adult patients who had undergone CABG surgery. Study quality was assessed by using the Newcastle-Ottawa scale (NOS). A meta-analysis was performed with the random-effect model.Eight cohort studies involving 7401 AF cases and 31,069 participants were identified and included in our data analysis. The pooled odds ratio of postoperative AF in patients with BT was 1.45 (95% confidence interval, 1.26-1.67), with significant heterogeneity (P < .0001, I = 79%). Excluding one study that had an off-pump CABG did not significantly impact this result (odds ratio, 1.36; 95% confidence interval, 1.23-1.50; n = 7). To examine the stability of the primary results, we performed subgroup analyses. The association between BT and the risk of postoperative AF was similar, as determined in the stratified analyses conducted according to study design, type of surgery, and country.The findings of the present meta-analysis demonstrated a statistically significant increase in postoperative AF risk among adult patients with BT. Further prospective large-scale studies are needed to establish causality and to elucidate the underlying mechanisms.

Blood Transfusion and Increased Perioperative Risk in Coronary Artery Bypass Grafts

OBJECTIVE

To correlate blood transfusions and clinical outcomes during hospitalization in coronary artery bypass grafting surgery (CABG).

METHODS

Transfusion, clinical and hematological data were collected for 1,378 patients undergoing isolated or combined CABG between January 2011 and December 2012. The effect of blood transfusions was evaluated through multivariate analysis to predict three co-primary outcomes: composite ischemic events, composite infectious complications and hospital mortality. Because higher risk patients receive more transfusions, the hospital mortality outcome was also tested on a stratum of low-risk patients to isolate the effect of preoperative risk on the results.

RESULTS

The transfusion rate was 63.9%. The use of blood products was associated with a higher incidence of the three coprimary outcomes: composite infectious complications (OR 2.67, 95% CI 1.70 to 4.19; P<0.001), composite ischemic events (OR 2.42, 95% CI 1.70 to 3.46; P<0.001) and hospital mortality (OR 3.07, 95% CI 1.53 to 6.13; P<0.001). When only patients with logistic EuroSCORE ≤ 2% were evaluated, i.e., low-risk individuals, the mortality rate and the incidence of ischemic events and infectious complications composites remained higher among the transfused patients [6% vs. 0.4% (P<0.001), 11.7% vs. 24,3% (P<0.001) and 6.5% vs. 12.7% (P=0.002), respectively].

CONCLUSION

The use of blood components in patients undergoing CABG was associated with ischemic events, infectious complications and hospital mortality, even in low-risk patients.

RBC Transfusions Are Associated With Prolonged Mechanical Ventilation in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

Blood products are often transfused in critically ill children, although recent studies have recognized their potential for harm. Translatability to pediatric acute respiratory distress syndrome is unknown given that hypoxemia has excluded pediatric acute respiratory distress syndrome patients from clinical trials. We aimed to determine whether an association exists between blood product transfusion and survival or duration of ventilation in pediatric acute respiratory distress syndrome.

DESIGN

Retrospective analysis of prospectively enrolled cohort.

SETTING

Large, academic PICU.

PATIENTS

Invasively ventilated children meeting Berlin Acute Respiratory Distress Syndrome and Pediatric Acute Lung Injury Consensus Conference Pediatric Acute Respiratory Distress Syndrome criteria from 2011 to 2015.

INTERVENTIONS

We recorded transfusion of RBC, fresh frozen plasma, and platelets within the first 3 days of pediatric acute respiratory distress syndrome onset. Each product was tested for independent association with survival (Cox) and duration of mechanical ventilation (competing risk regression with extubation as primary outcome and death as competing risk). A sensitivity analysis using 1:1 propensity matching was also performed.

MEASUREMENTS AND MAIN RESULTS

Of 357 pediatric acute respiratory distress syndrome patients, 155 (43%) received RBC, 82 (23%) received fresh frozen plasma, and 92 (26%) received platelets. Patients who received RBC, fresh frozen plasma, or platelets had higher severity of illness score, lower PaO2/FIO2, and were more often immunocompromised (all p < 0.05). Patients who received RBC, fresh frozen plasma, or platelets had worse survival and longer duration of ventilation by univariate analysis (all p < 0.05). After multivariate adjustment for above confounders, no blood product was associated with survival. After adjustment for the same confounders, RBC were associated with decreased probability of extubation (subdistribution hazard ratio, 0.65; 95% CI, 0.51-0.83). The association between RBC and prolonged ventilation was confirmed in propensity-matched subgroup analysis.

CONCLUSIONS

RBC transfusion was independently associated with longer duration of mechanical ventilation in pediatric acute respiratory distress syndrome. Hemoglobin transfusion thresholds should be tested specifically within pediatric acute respiratory distress syndrome to establish whether a more restrictive transfusion strategy would improve outcomes.

Point-of-care washing of allogeneic red blood cells for the prevention of transfusion-related respiratory complications (WAR-PRC): a protocol for a multicenter randomised clinical trial in patients undergoing cardiac surgery

INTRODUCTION

The transfusion-related respiratory complications, transfusion-related acute lung injury (TRALI) and transfusion-associated circulatory overload (TACO), are leading causes of transfusion-related morbidity and mortality. At present, there are no effective preventive strategies with red blood cell (RBC) transfusion. Although mechanisms remain incompletely defined, soluble biological response modifiers (BRMs) within the RBC storage solution may play an important role. Point-of-care (POC) washing of allogeneic RBCs may remove these BRMs, thereby mitigating their impact on post-transfusion respiratory complications.

METHODS AND ANALYSIS

This is a multicenter randomised clinical trial of standard allogeneic versus washed allogeneic RBC transfusion for adult patients undergoing cardiac surgery testing the hypothesis that POC RBC washing is feasible, safe, and efficacious and will reduce recipient immune and physiologic responses associated with transfusion-related respiratory complications. Relevant clinical outcomes will also be assessed. This investigation will enrol 170 patients at two hospitals in the USA. Simon's two-stage design will be used to assess the feasibility of POC RBC washing. The primary safety outcomes will be assessed using Wilcoxon Rank-Sum tests for continuous variables and Pearson chi-square test for categorical variables. Standard mixed modelling practices will be employed to test for changes in biomarkers of lung injury following transfusion. Linear regression will assess relationships between randomised group and post-transfusion physiologic measures.

ETHICS AND DISSEMINATION

Safety oversight will be conducted under the direction of an independent Data and Safety Monitoring Board (DSMB). Approval of the protocol was obtained by the DSMB as well as the institutional review boards at each institution prior to enrolling the first study participant. This study aims to provide important information regarding the feasibility of POC washing of allogeneic RBCs and its potential impact on ameliorating post-transfusion respiratory complications. Additionally, it will inform the feasibility and scientific merit of pursuing a more definitive phase II/III clinical trial.

REGISTRATION

ClinicalTrials.gov registration number is NCT02094118 (Pre-results).

Impact of Preoperative Anemia and Postoperative Hemoglobin Drop on the Incidence of Acute Kidney Injury and In-Hospital Mortality in Patients With Type B Acute Aortic Syndromes Undergoing Thoracic Endovascular Aortic Repair

BACKGROUND

The impact of preoperative anemia and postoperative hemoglobin (Hb) drop on the incidence of acute kidney injury (AKI) after thoracic endovascular aortic repair (TEVAR) for type B acute aortic syndromes (AAS) as well as their prognostic value is unknown.

METHODS

This retrospective study included 144 patients with type B AAS undergoing TEVAR at our center. Preoperative anemia was classified as no/mild (Hb ≥ 12.0 g/dL in men; ≥11.3 g/dL in women), moderate (Hb 10.80-11.99 g/dL in men; 10.23-11.29 g/dL in women), and severe (<10.80 g/dL in men; <10.23 g/dL in women). Postoperative Hb drop was classified as mild (<2 g/dL), moderate (2-4 g/dL), and severe (>4 g/dL). End points of the study were postoperative AKI and in-hospital mortality.

RESULTS

Postoperative AKI was higher in the severe and moderate anemia groups than the no/mild anemia group (63.2%, 52.0%, and 31.0%, respectively, P = .01). In-hospital mortality and AKI were higher in patients with severe postoperative Hb drop (40.9% and 86.4%) than patients with moderate (6.9% and 36.2%) and mild (4.7% and 25.0%) postoperative Hb drop (both P < .001). Postoperative Hb drop (odds ratio [OR]:1.67, P = .036), postoperative Hb levels (OR: 0.57, P = .025), and mesenteric ischemia (OR: 4.65, P = .044) were identified as independent predictors of in-hospital mortality. Preoperative Hb (OR: 0.26, P = .001), postoperative Hb drop (OR: 4.34, P < .001), contrast medium (OR: 1.82, P = .004), and diabetes mellitus (OR: 3.79, P = .001) were independent predictors of AKI. At follow-up, anemia and postoperative Hb drop were not associated with increased mortality.

CONCLUSION

Preoperative Hb and postoperative Hb drop were significant risk factors for AKI. Postoperative Hb drop and Hb levels predicted in-hospital mortality.

Red blood cell transfusion in surgical cancer patients: Targets, risks, mechanistic understanding and further therapeutic opportunities

Anemia is present in more than half of cancer patients and appears to be an independent prognostic factor of short- and long-term adverse outcomes. It increases in the advanced period of cancer and perioperatively, in patients with solid tumors who undergo surgery. As a result, allogeneic red blood cell (RBC) transfusion is an indispensable treatment in cancer. However, its safety remains controversial, based on several laboratory and clinical data reporting a linkage with increased risk for cancer recurrence, infection and cancer-related mortality. Immunological, inflammatory and thrombotic reactions mediated by the residual leukocytes and platelets, the stored RBCs per se, the biological response modifiers and the plasticizer of the unit may underlie infection and tumor-promoting effects. Although the causality between transfusion and infection has been established, the effects of transfusion on cancer recurrence remain confusing; this is mainly due to the extreme biological heterogeneity that characterizes RBC donations and cancer context. In fact, the functional interplay between donation-associated factors and recipient characteristics, including tumor biology per se, inflammation, infection, coagulation and immune activation state and competence may synergistically and individually define the clinical impact of each transfusion in any given cancer patient. Our understanding of how the potential risk is mediated is important to make RBC transfusion safer and to pave the way for novel, promising and highly personalized strategies for the treatment of anemia in surgical cancer patients.

Hemotransfusion and mechanical ventilation time are associated with intra-hospital mortality in patients with traumatic brain injury admitted to intensive care unit

OBJECTIVE

To identify the factors associated with the intra-hospital mortality in patients with traumatic brain injury (TBI) admitted to intensive care unit (ICU).

METHODS

The sample included patients with TBI admitted to the ICU consecutively in a period of one year. It was defined as variables the epidemiological characteristics, factors associated with trauma and variables arising from clinical management in the ICU.

RESULTS

The sample included 87 TBI patients with a mean age of 28.93 ± 12.72 years, predominantly male (88.5%). The intra-hospital mortality rate was of 33.33%. The initial univariate analysis showed a significant correlation of intra-hospital death and the following variables: the reported use of alcohol (p = 0.016), hemotransfusion during hospitalization (p = 0.036), and mechanical ventilation time (p = 0.002).

CONCLUSION

After multivariate analysis, the factors associated with intra-hospital mortality in TBI patients admitted to the intensive care unit were the administration of hemocomponents and mechanical ventilation time.

Posterior reversible encephalopathy syndrome in a postpartum hemorrhagic woman without hypertension: A case report

RATIONALE

Posterior reversible encephalopathy syndrome (PRES), which diagnosis is based on clinical symptoms and radiological features, is a neurotoxic disease characterized by a set of clinical manifestations, such as seizure, headache, visual, and/or consciousness disturbance. It is the first case of PRES followed by postpartum hemorrhage (PPH) without underlying disease.

PATIENT CONCERNS

A 37-year-old healthy woman had PPH after caesarean section. Six days after delivery, headache occurred suddenly, followed by episodes of clonus seizure.

DIAGNOSES

Brain computed tomography showed ischemic stroke. However, magnetic resonance imaging revealed characteristics consistent with PRES.

INTERVENTIONS

The patient received phenytoin for seizure control.

OUTCOMES

Seizure was under good control over the following days. Three months later, repeated magnetic resonance imaging showed complete remission.

LESSONS

PRES may be triggered by PPH and is not necessarily secondary to typical predisposing factors such as hypertension or pre/eclampsia. Hormone fluctuation, increased blood pressure variation, and massive blood transfusion may be contributed to the development of PRES in our case. Also, it is necessary to rule out those life-threatening diseases, such as cavernoma hemorrhage, cerebral venous thrombosis, and ischemic stroke before the diagnosis of PRES.

The Effect of Treatment of Anemia with Blood Transfusion on Delirium: A Systematic Review

OBJECTIVES

Treating the precipitating factors of delirium is the mainstay of the prevention and treatment of delirium. We aim to investigate the role of anemia and blood transfusion within the multicomponent prevention and treatment strategy of delirium.

DESIGN

Systematic review.

SETTING

We included cohort studies or Randomized Controlled Trials (RCTs) that considered blood transfusion as treatment for delirium or risk factor, and had delirium as outcome.

PARTICIPANTS

Hospitalized patients above 55 years old.

MEASUREMENTS

We searched MEDLINE from 1946 through November 2014. Quality assessment and data extraction were performed systematically.

RESULTS

We included 23 studies (n = 29,471). The majority of the studies (n = 22) had a limited quality and for one study quality was uncertain. Two studies evaluated the association between transfusion strategy and postoperative delirium and found no association. Twenty-one studies investigated blood transfusion as a risk factor for delirium. In four of the 21 studies it could be assumed that delirium occurred after transfusion. One of these studies stated that transfusion was a significant risk factor for subsequent delirium (odds ratio (OR) = 3.68, 95% confidence interval (CI) = 1.32-10.94). The other three studies found no association between transfusion and delirium. In the remaining 17 studies, it was not clear whether delirium occurred before or after transfusion, so no conclusion could be drawn on the role of transfusion in delirium development.

CONCLUSION

The majority of the included studies was not suited to answer the research question properly as the time course of the beginning of delirium as to transfusion was lacking. Our review shows that there is no good quality evidence available for blood transfusion to be a risk factor for delirium or to be a preventive or treatment option.

Evaluation of a new condensed extra-corporeal circuit for cardiac surgery: a prospective randomized clinical pilot study

This prospective randomized clinical pilot study was conducted to evaluate a recently introduced reduced volume CPB system that is coated with the biopassive Xcoating™. Twenty-two patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB), either with a fully heparin-coated CPB circuit (control, n=11) or with an Xcoating™ coated condensed extra-corporeal circuit (CondECC, n=11), were included.

We examined activation of the complement system (C3bc and C4bc), activation of neutrophils (BPI), the acute phase response (interleukin (IL)-6, and acute phase proteins (LBP, AGP, and CRP)), myocardial tissue injury (troponin T), hemolysis (free hemoglobin (FHb)), and clinical outcome parameters. Preoperative risk profiles were identical for both patient groups. All patients went through the procedure without major complications and were discharged from the hospital. FHb and BPI levels at the end of pump support ( p <0.01) and at 15 min after the administration of protamine ( p <0.05) were significantly higher in the control group. In addition, FHb levels were still significantly elevated upon arrival on the cardiothoracic intensive care unit (CICU) in the control group ( p <0.05). C3bc and C4bc, acute phase proteins, IL-6, and troponin T concentrations, and clinical outcome variables were identical in both patient groups.

In conclusion, the evaluated condensed extracorporeal circuit is a flexible and multifunctional CPB sytem that offers safe procedures. Furthermore, the results indicate improved biocompatibility of this option for extracorporeal circulation.

The use of a mini bypass system (Cobe Synergy) without venous and cardiotomy reservoir in a mitral valve repair: a case report

The use of mini cardiopulmonary bypass circuits is an emerging technology. The venous and cardiotomy reservoir have been excluded from the circuit. This results in a reduction of the blood contact surface area and of the priming volume.

Entrainment of venous air, however, remains a drawback in the widespread acceptance of using these mini circuits.

The technique described resolves this problem by automatic removal of venous air, and explains how this mini cardiopulmonary bypass circuit was utilized on a 64-year-old female presented for a mitral valve repair.

In the absence of a cardiotomy reservoir, an autotrans-fusion cell separator was used to process shed blood and, after CPB, the residual pump blood.

This mini bypass circuit, with the safety feature to remove automatically venous air, provided an additional degree of protection.

In our experience, mini bypass circuits allow us safely to perform cardiopulmonary bypass during valve procedures.

Transfusion-related immunomodulation: review of the literature and implications for pediatric critical illness

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.