Dr.

Nidhi Mehta
Consultant, Transfusion Medicine
Kokilaben Dhirubhai Ambani Hospital,
Mumbai

ROLE OF TRANSFUSION IN CARDIAC

SURGERY

Any medical or surgical intervention has both systematic

and random effects, some of which are beneficial and
some of which are not .
Allogeneic blood transfusions play a crucial role in
performing many of the more complicated surgical
procedures.
Until the discovery of the AB0- bloodgroups in the early
1900s allogeneic blood transfusions were a high-risk
procedure. Despite the high safety of allogeneic blood
transfusions nowadays, there are still risks leading to
higher morbidity and mortality associated with
allogeneic blood transfusions.

Cardiac surgery has the highest consumption of blood

products of any field in medicine, with half of patients
undergoing cardiac surgery receiving blood products,
estimated approximately 20% of the total blood supply
Most transfusion indications occur in the first 72hours
after surgery, starting in the operating room, where
usually the transfusion indication is due to hemodilution
and based on triggers

Coronary artery bypass graft (CABG) surgery is

frequently performed for re-vascularization of the
myocardium. Worldwide approximately 1,000,000
patients are undergoing cardiac surgery annually.
The transfusion rates for CABG show great variability
between hospitals with a mean number of transfused
units varying between 0.4 to 6.3 units per patient

Effects of blood transfusion in Cardiac

surgery

Anemia and Blood Transfusions in

Cardiac Surgery
Pre-operative Anemia

Reasons - iron deficiency or gastrointestinal bleeding.

Incidence - between 25-32%
Associated with increased neurological and renal complications

Post-operative Anaemia

Reasons hemostatic abnormalites result in intra- and postoperative bleeding

Goal of transfusion during cardiac surgery

In cardiac surgery, blood transfusions increase oxygen delivery to
tissues and stabilises the oxygen utilization by cells. This is due to
improvement in blood physiology i.e viscosit, perfusion and
hemodynamic functions.

Deletrious effects of transfusion

A common problem for many surgeons, and thereby the
patient, is how to balance the risk of surgery-induced
anemia with the increased risk of infection when using
red blood cell transfusion to correct the anemia
Transfusion of RBCs was dose-dependently associated
with postoperative infections and higher mortality
In a prospective study in cardiac surgery, 4.8% of
patients who did not receive RBCs suffered from
postoperative infections, contrasting with 29% in
patients who received 6 or more RBC units.

For decades a Hb-level of 10 g/dL was considered as an

appropriate trigger for red blood cell (RBC)
transfusions. According to the RCT performed in
1990s, patients can be transfused to maintain Hb
either in the range of 7-9 g/dl (restrictive) or above
10 g/dl (liberal). Restrictive group receives an average
of 2.6 units whereas the liberal group receives 5.6
units.

Complications of Blood Transfusion in

Cardiac Surgery

Transfusion-Related Acute Lung Injury

(TRALI)
Incidence of TRALI in general population is 1:1,000 to 5,000
blood transfusions and has an estimated mortality rate of 510%
Incidence of TRALI in cardiac surgery is higher than in any
other clinical setting (2.4%) with a mortality rate of 13%.
Pathophysiology:
Passively transfused anti-leukocyte antibodies in the donors plasma
bind to antigens on patients neutrophils and initiate priming and
activation with release of cytokines, proteases and free oxygen
radicals. Neutrophil sequestration in the lungs can finally leading to
endothelial damage and capillary leakage.

TRALI occur more often in patients in whom leukocytes are already

primed, such as blood transfusions in the past and immunization by
pregnancy
In patients with TRALI who underwent cardiac surgery it has been
found that these patients had an already systemic inflammation
and activation of neutrophils before blood transfusion, which
suggests that blood transfusions act as a second hit in the
development of TRALI

Transfusion-Associated Cardiac
Overload (TACO)

Refers to pulmonary edema after transfusion of blood

products.

Recipients with renal or cardiac diseases and older patients

are more susceptible for TACO MOST UNDERREPORTED

COMPLICATION!!!
Incidence of 2% after red blood cell transfusions and this
could be up to 8% dependening on co-morbidity and age, with a
fatality rate varying between 5 to 20%
High incidence in Cardiac surgeries due to the cardiac status and
more blood transfusions and fluid.
Patients with TACO have usually more cardiac failure then
patients with TRALI
The treatment - volume reduction with eventually ventilatory
and/or circulatory support.
Prevention - by a restrictive transfusion strategy or the use of
diuretics in patients with underlying cardiac and/or renal disease
or in elderly patients.

SYMPTOMS

TRALI

TACO

Onset of symptoms

< 6 hours

Mainly < 6 hours

Respiratory symptoms

Dyspnea

Dyspnea

Central venous
pressure
Pulmonary wedge
pressure
Fluid balance

Normal

Increased

Normal

Increased

Positive or negative

Positive

X-ray thorax

Bilateral infiltrates

ECG

Normal ejection
fraction
Low or normal

Bilateral inflitrates
with signs of fluid
overload
Decreased ejection
fraction
High

B-type natriuretic
peptide

After TACO

Resolved TACO

Storage Time of Red Blood Cells

 During storage, red blood cells show a number of structural

and functional alterations, referred to as storage lesions.

Changes in shape, rigidity, depletion of 2,3-diphosphoglycerate

(2,3 DPG) and nitric oxide scavengers are presumed to result in

impaired perfusion and oxygen delivery

Transfusion-Related
Immunomodulation (TRIM)
Immunomodulatory effect of blood transfusions, presumed to
result from allogeneic leukocytes are referred to as
transfusion-related immunomodulation (TRIM).

The mortality rate was increased with 72% in patients who

received leukocyte-containing RBCs

However after the implementation of universal leukodepletion

and utilisation of leukodepleted red cells, reduced hospital
mortality, decreased occurrence of fever and use of
antibiotics

Inflammatory Response and Blood

Transfusions in Cardiac Surgery
Definition of SIRS (SIRS can be diagnosed when two or more
criteria are present):

body temperature less than 36C or more than 380 C,

leukocyte count less than 4x109 /l or more than 12x109 /l.

heart rate more than 90/min,

tachypnea with breaths more than 20/min or pCO2 less than 4.4
kPa (32 mm Hg)

Mechanism:

In addition to the surgical and anesthesiological operative trauma,

per se, it is primarily the pathophysiological conditions of
extracorporeal circulation (ECC), such as hemodilution,
mechanical damage to cellular blood components, and contact of
the blood with air and with artificial surfaces (CPB device), that
leads to the activation of the non-specific immune response and
associated systemic inflammatory cascade.

The foreign surface of the extracorporeal system,

temporary ischemia, and subsequent organ reperfusion,
as well as surgical trauma, cause an activation of the
cascade systems:
Kallikrein-kinin system
Complement system
Coagulation and fibrinolysis system
Blood pressure system

Outline of the inflammatory response generated

by cardio-pulmonary bypass

Clinical:
Myocardial dysfunction, arrhythmia, stroke, acute lung failure, and
neurocognitive dysfunction, disorders of coagulation and kidney
and liver dysfunction.
Depending on the progression, multiple organ failure or death may
occur.
The degree of severity of the SIRS response, as well as the extent
of organ dysfunction or failure, varies greatly from patient to
patient and depends on a multitude of factors (e.g. type of
intervention, machine time, HLM used, comorbidities, genetic
predisposition).

 SIRS is a subset of cytokine storm with an abnormal regulation

of cytokines and is immediately counteracted by a
compensatory anti-inflammatory response syndrome (CARS)

An overwhelming SIRS can dominate CARS resulting in

multiple-organ dysfunction-syndrome (MODS). W

While when CARS dominates, this may lead to more enhanced

susceptibility for postoperative infections

Leukocyte-containing RBC transfusions to patients with an

activated inflammatory response (as after cardiac surgery) could
further imbalances the postoperative SIRS-CARS equilibrium
initially in favour of SIRS; this second-hit response induced by
allogeneic leukocytes in combination with infections, can cause a
more severe MODS

Acute Kidney Injury (AKI)

Pathophysiological

mechanism

RBCs undergo irreversible morphological and biochemical changes

during storage.
As a result, after transfusion, they can promote a proinflammatory state, impair tissue oxygen delivery, and
exacerbate tissue oxidative stress.
This in turn can cause AKI in susceptible patients undergoing
cardiac surgery with CPB, such as those with pre-existing
kidney dysfunction or anaemia.

 The rationale for implementing a restrictive transfusion

strategy is based on analysis of studies reporting a lack of

benefit and, at the same time, substantially increased costs
and adverse effects associated with RBC transfusion.

References:

Complications after Cardiac Surgery due to Allogeneic Blood

Transfusions, YM Bilgin and LMG van de Watering, 2013

Clinical and Experimental Cardiology

://dx.doi.org/10.4172/2155-9880.S7-005

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