Blood transfusion in cardiac surgery: Does the choice of anesthesia or type of surgery matter?

Abstract

Background/Aim. In spite of the evidence suggesting a significant morbidity associated with blood transfusions, the use of blood and blood products remain high in cardiac surgery. To successfully minimize the need for blood transfusion, a systematic approach is needed. The aim of this study was to investigate the influence of different anesthetic techniques, general vs combine epidural and general anesthesia, as well as different surgery strategies, on-pump vs off-pump, on postoperative bleeding complications and the need for blood transfusions during perioperative period. Methods. Eighty-two consecutive patients scheduled for coronary artery bypass surgery were randomized according to surgical and anesthetic techniques into 4 different groups: group 1 (patients operated on off-pump, under general anesthesia); group 2 (patients operated on off-pump, with combined general and high thoracic epidural anesthesia); group 3 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, under general anesthesia), and group 4 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, with combined general and high thoracic epidural anesthesia). Indications for transfusion were based on clinical judgment, but a restrictive policy was encouraged. Bleeding was considered significant if it required transfusion of blood or blood products, or reopening of the chest. The quantity of transfused blood or blood products was specifically noted. Results. None of the patients was transfused blood or blood products during the surgery, and as many as 70/81 (86.4%) patients were not transfused at all during hospital stay. No difference in postoperative bleeding or blood transfusion was noted in relation to the type of surgery and anesthetic technique applied. If red blood cells were transfused, postoperative bleeding was the most influential parameter for making clinical decision. Conclusion. No influence of off-pump surgery or epidural anesthesia on blood transfusion requirements during a perioperative period was confirmed by this study. It seems, however, that encouraging lower hemoglobin triggers in clinical decision-making could result in less transfusions during surgery or hospital stay.Uvod/Cilj. Uprkos postojecim dokazima u literaturi o stetnim efektima i povecanom morbiditetu bolesnika posle transfuzija krvi, primena krvi i krvnih derivata u kardiohirurgiji je cesta. Neophodan je sistematski pristup da bi se postigli rezultati u snizavanju potrosnje krvi tokom perioperativnog perioda. Cilj ove studije bio je da se ispita uticaj razlicitih vrsta anestezije, opste i kombinovane opste i epiduralne anestezije, kao i razlicitih hirurskih tehnika, on-pump i off-pump (sa ili bez primene ekstrakorporalne cirkulacije) na ucestalost postoperativnog krvarenja i potrosnju krvi. Metode. Ispitivanjem su bila obuhvacena 82 konsekutivna bolesnika planirana za hirursku revaskularizaciju miokarda i kompjuterski randomizovana u cetiri grupe prema hirurskoj i anestezioloskoj tehnici koja je koriscena: grupa 1 (bolesnici koji se operisu na kucajucem srcu (off-pump), bez primene visoke torakalne epiduralne anestezije (TEA); grupa 2 (bolesnici koji se operisu off-pump, uz primenu TEA); grupa 3 [bolesnici koji se operisu standardnom tehnikom uz primenu ekstrakorporalne cirkulacije (EKC), bez primene TEA]; grupa 4 (bolesnici koji se operisu standardnom tehnikom uz primenu EKC i primenu TEA). Da li ce bolesnici primiti transfuziju krvi ili ne zavisilo je od klinicke procene lekara koji su bili ohrabrivani da primene restriktivne indikacije. Znacajno krvarenje je definisano kao potreba da bolesnici prime krv ili krvne derivate, odnosno da budu reintervenisani zbog revizije hemostaze. Posebno je evidentirana sva primenjena kolicina krvi i krvnih derivata. Rezultati. Nijedan bolesnik u ispitivanoj grupi nije dobio krv tokom hirurske intervencije, a cak 70/81 (86,4) bolesnika nije primalo transfuzije krvi tokom citave hospitalizacije. Nije utvrdjena razlika u postoperativnom krvarenju ili transfuziji u odnosu na primenjenu hirursku tehniku i vrstu anestezije. Postoperativna drenaza najvise je uticala na donosenje klinicke odluke o transfuziji. Zakljucak. Rezultati ove studije ne ukazuju na uticaj off-pump hirurgije ili epiduralne anestezije na kolicinu primenjene krvi tokom perioperativnog perioda. Izgleda da ohrabrivanje lekara da primene i usvoje restriktivni stav i odluce se za transfuziju kod nizih vrednosti hemoglobina moze dati rezultate pri stednji krvi tokom operacije i hospitalizacije.