Therapeutic options to minimize allogeneic blood transfusions and their adverse effects in cardiac surgery: a systematic review

Antônio Alceu Santos;Silva JP; Silva LF; Sousa AG; Piotto RF; Baumgratz JF.
Rev Bras Cir Cardiovasc 2014;29(4):606-621

http://www.rbccv.org.br/article/2321/Therapeutic-options-to-minimize-allogeneic-blood-transfusions-and-their-adverse-effects-in-cardiac-surgery–a-systematic-review

 Inglês

 Português

COMMENTS: Authors describe several strategies, including medications, techniques, technology and other measures for minimizing blood
transfusions. 


Drug, Devices, Technologies, and Techniques for Blood Management in Minimally Invasive and Conventional Cardiothoracic Surgery

Menkis AH, Martin J, Cheng DCH, Fitzgerald DC, Freedman JJ.
Innovations 2012;7: 229-241.

COMMENTS: This article gathers the main therapeutic options and/or strategies for avoiding or minimizing allogeneic blood transfusions. It also
describes the most important DRUGS and its respective DOSAGES for treating ANEMIA and/or THROMBOCYTOPENIA.

http://journals.lww.com/innovjournal/Abstract/2012/07000/Drug,_Devices,_Technologies,_and_Techniques_for.1.aspx

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What to do if no blood is available but the patient is bleeding?

Mackenzie CF and Shander A.
South Afr J Anaesth Analg: 2008;14(1)39-43.

http://www.sajaa.co.za/index.php/sajaa/article/view/270

http://cogentoa.tandfonline.com/doi/pdf/10.1080/22201173.2008.10872520

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COMMENTS: This article also cites a number of strategies for avoiding allogeneic blood transfusions. The title of the article calls attention for a
situation that is getting nearer to the reality at our days. What to do in an emergency or major catastrophe where we see patients bleeding, but NO blood is available? How to treat? Therefore, the importance of knowing the therapeutics options for avoiding or minimizing the use of blood.


Alternatives to blood transfusion

Spahn DR and Goodnough LT.
Lancet 2013; 381: 1855–65.

http://www.ncbi.nlm.nih.gov/pubmed/23706802

COMMENTS: Authors increasingly stimulate the use of alternatives to allogeneic blood transfusions, mainly because of the associated transfusion risks.


2013: The “Seville” document on Consensus on the Alternatives to Allogenic Blood Transfusion

Leal-Noval SR, Muñoz M, Asuero M, Contreras E et al.
Farm Hosp. 2013;37(3):209-235

http://www.grupoaulamedica.com/fh/pdf/133.pdf

COMMENTS: Several authors have prepared a document with a number of recommendations on the use of alternatives to allogeneic blood transfusions. 

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Efficacy of red blood cell transfusion in the critically ill: A systematic review of the literature

Marik PE and Corwin HL.
Crit Care Med 2008; 36:2667–2674

http://www.ncbi.nlm.nih.gov/pubmed/18679112

COMMENTS: This systematic review shows that in at least 42 of the 45 reviewed clinical trials, involving 272.596 patients, the risk associated to
blood transfusion does not overcome the benefit proposed by the physicians. In two studies the result was neutral. The article has demonstrated that blood transfusions are associated with increased mortality and morbidity risk, and therefore, current transfusional practice should be reevaluated. Authors conclude that the risks and benefits of transfusion should be assessed in every patient before transfusion.


Effect of blood transfusion on long-term survival after cardiac operation

Engoren MC, Habib RH, Zacharias A et al.
Ann Thorac Surg. 2002;74:1180-6.

http://www.annalsthoracicsurgery.org/article/S0003-4975(02)03766-9/pdf

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COMMENTS: This clinical trial has demonstrated that allogeneic blood transfusion (donated blood) is associated with an increase of up to 70%
on mortality, even after correction for comorbidities and other risk factors. According to authors, the blood transfusion by itself can cause death in patients.


Impact on early and late mortality after blood transfusion in coronary artery bypass graft surgery

Antonio Alceu dos Santos, Sousa AG, Thomé HOS, Machado RL and Piotto RF.
Rev Bras Cir Cardiovasc 2013;28(1):1-9.

http://www.scielo.br/pdf/rbccv/v28n1/v28n1a03.pdf

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COMMENTS: Authors demonstrated that red blood cells transfusion was an independent predictor factor of death after Coronary Artery Bypass
Grafting in a population of 1,888 patients. Even in a subgroup of low-risk patients (age <60 years and EuroSCORE ≤ 2%), there were significantly more deaths in the group that received allogeneic blood (someone else's blood). Authors finalize the article saying that “new therapeutic options and autologous blood management and conservation strategies should be encouraged for reducing blood transfusions..


Transfusion of 1 and 2 Units of Red Blood Cells Is Associated With Increased Morbidity and Mortality

Paone G, Likosky DS, Brewer R, Theurer PF, Bell GF et all.
Ann Thorac Surg 2014;97:87–94.

http://www.annalsthoracicsurgery.org/article/S0003-4975(13)01629-9/pdf

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COMMENTS: This article makes it clear that transfusion of as little as 1 or 2 units of RBCs, which is very common in surgeries, is significantly associated with increased patients mortality and morbidity (post-surgery complications). The authors conclude by suggesting aggressive practices of patient’s own blood conservation. They also state that even small amounts should be avoided in Coronary Artery Bypass Grafting.


Mortality risk is dose-dependent on the number of packed red blood cell transfused after coronary artery bypass graft

Antonio Alceu Santos, Sousa AG, Piotto RF, Pedroso JCM.
Rev Bras Cir Cardiovasc 2013;28(4):509-17.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4389431/pdf/rbccv-28-04-0509.pdf

 PDF Português

 PDF Inglês

COMMENTS: The authors investigated the effect of transfusion of 1, 2, 3, 4, 5 and ≥6 allogeneic blood bags (donated blood) in the risk of death in a population of nearly 2,000 patients. They demonstrated that increasing transfusions of packed red blood cell units result in increased risk of mortality, thereby showing a dose-response relationship. The conclusion was that the greater the amount of allogeneic blood transfused the greater the risk of mortality for the patients. They finalize the article by suggesting that the current transfusion practice needs to be reevaluated.


Outcome of Patients Who Refuse Transfusion After Cardiac Surgery: A Natural Experiment With Severe Blood Conservation

Pattakos G, Koch CG, Brizzio ME, Batizy LH et al.
Arch Intern Med. 2012;172(15):1154-1160

http://archinte.jamanetwork.com/article.aspx?articleid=1211993

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COMMENTS: Authors have found that out of a sample of 87,453 cardiac surgeries, the group of 322 patients who refused blood transfusion had fewer myocardial infarctions and higher one-year survival compared to patients who received donated blood.


Morbidity and mortality risk associated with red blood cell and blood-component transfusion in isolated coronary artery bypass grafting

Koch CG, Li L, Duncan AI et al.
Crit Care Med. 2006;34:1608-16.

http://www.ncbi.nlm.nih.gov/pubmed/16607235

Comentários: This study enrolled 11,963 patients undergoing cardiac surgery. It was found in the group of 5,814 patients who received transfusions of red blood cells a significant increase in cardiac, renal, and neurological complications, severe infections, and even higher risk of death.


Harms associated with single unit perioperative transfusion: retrospective population based analysis

Whitlock EL,Kim H, Auerbach AD.
BMJ 2015;350:h3037

http://www.bmj.com/content/350/bmj.h3037

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COMMENTS: Study with the participation of 346 hospitals in the United States and enrolled 1,583,819 patients undergoing several surgeries, except cardiac, intracranial and vascular. Authors found that in the group of 41,421 patients who received at least one allogeneic blood bag there were significantly more myocardial infarctions and strokes.


Blood transfusion. An independent risk factor for postinjury multiple organ failure

Moore FA, Moore EE, Sauaia A
Arch Surg 1997;132(6):620-4.

http://www.ncbi.nlm.nih.gov/pubmed/9197854

COMMENTS: This article demonstrates that the blood transfusion in 513 post-traumatic patients was identified as an independent risk factor for multiple organ failure.


Intraoperative Red Blood Cell Transfusion During Coronary Artery Bypass Graft Surgery Increases the Risk of Postoperative Low-Output Heart Failure

Surgenor SD, DeFoe GR, Fillinger MP, Likosky DS, Groom RC et al.
Circulation. 2006; 114[suppl I]:I-43–I-48.

http://circ.ahajournals.org/content/114/1_suppl/I-43.full.pdf+html

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COMMENTS: This study was conducted in England and enrolled 8,004 patients undergoing cardiac surgery. Authors concluded that the risk of heart failure is greater among patients who received to intraoperative red blood cells transfusions compared to the risks of the anemia alone.

 


The blood donation experience: self-reported motives and obstacles for donating blood

Sojka EN, Sojka P.
Vox Sanguinis. 2008; 94, 56 – 63.

http://www.ncbi.nlm.nih.gov/pubmed/18171329

COMMENTS: Authors demonstrate that there are many difficulties and obstacles to get people to donate blood, which makes this resource increasingly scarce in blood banks around the world..

 


Oxygen carriers free of cells in transfusion medicine

Novaretti MCZ.
Rev Bras Hematol Hemoterapia. 2007; 29(4):394 – 405.

http://www.scielo.br/pdf/rbhh/v29n4/a14v29n4.pdf

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COMMENTS: This article draws attention to demand for blood transfusion that is increasingly growing worldwide. It was found that in Brazil while blood demand grows at a rate of 1% per year, the expectations for growing of blood donations vary from 0.5 to 0.7% per year. Consequently, the estimate for the year 2030 will be a deficit of approximately 1,000,000 (one million) of collected blood units, has concluded the researching. 


Increased mortality, postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery.

Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD.
Circulation. 2007; 16:2544 – 52.

http://circ.ahajournals.org/content/116/22/2544.full.pdf+html

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COMMENTS: This study enrolled 8,598 patients. Authors have found that transfusion of red blood cells, in addition of being associated with increased death risk, it also increased significantly patient’s length of stay in the hospital as well as the hospital costs.


Is it the patient or the physician who cannot tolerate anemia? A prospective analysis in 1854 non-transfused coronary artery surgery patients.

Senay S, Toraman F, Karabulut H, Alhan C.
Perfusion. 2009;24(6):373 – 80.

http://www.ncbi.nlm.nih.gov/pubmed/20093331

COMMENTS: This article shows that a hospital in California (USA), by simply remind the doctors the current guidelines regarding the use of allogeneic blood (donated) it reduced by 24% (about one quarter) blood transfusions and thereby saved US $ 1.6 million per year, it also reduced the average of patients’ length of stay in hospital from 10.1 to 6.2 days. But the main achievement of this attitude was to save lives, because mortality among people who received blood transfusions fell from 5.5% to Is it the patient or the physician who cannot tolerate anemia? A prospective analysis in 1854 non-transfused coronary artery surgery patients.


Clinical and surgeries strategies for reducing blood transfusions

Antonio Alceu Santos, Silva JP, Silva LF, Baumgratz JF, Vila JHA, Costa FAA, Lippi Neto E e StelaFAM.
Sociedade Brasileira de Cardiologia • ISSN-0066-782X • Volume 104, Nº 1, Supl. 1, Janeiro 2015 Página 4

http://www.arquivosonline.com.br/2015/10402/pdf/Resumo%20das%20Comunicacoes.pdf

COMMENTS: Authors describe a case of ascending aortic aneurysm repair surgery, aortic valve replacement by bioprosthesis, CABG in a patient with chronic renal failure requiring hemodialysis. Due to various complications in the postoperative period progressed to SEVERE ANEMIA (2.9 g / dL hemoglobin), but the patient survived through the use of clinical and surgical strategies for conservation of his own blood, thus avoiding conventional treatment with homologous blood transfusions (someone else’s blood). It was possible to save the patient’s life with therapeutic options, other than donated blood.


Heart retransplantation in children without the use of blood products

Heart retransplantation in children without the use of blood product
Antonio Alceu dos Santos, Silva JP, Fonseca L, Baumgratz JF
Rev Bras Cir Cardiovasc 2012;27(2):327-30

 http://www.scielo.br/pdf/rbccv/v27n2/v27n2a23.pdf – Portugues

 http://www.scielo.br/pdf/rbccv/v27n2/en_v27n2a23.pdf – Inglês

COMMENTS: Authors report the FIRST case in the WORLD of HEART RETRANSPLANTATION in a 6 year old child without the use of homologous blood (someone else’s blood). The article draws attention the importance of a multidisciplinary planning (surgeon, anesthesiologist, clinic and intensive care doctors) for performing complexes surgeries (like this) without the use of allogeneic blood transfusion (donated blood).


Severe blood loss anemia in a Jehovah’s Witness treated with adjunctive hyperbaric oxygen therapy

Graffeo C and Dishong W.
American Journal of Emergency Medicine 31 (2013) 756.e3–756.e4.

http://www.ncbi.nlm.nih.gov/pubmed/23380087

COMMENTS: This case report has shown that it is possible successfully treat patient with SEVERE ANEMIA (1.9 g/dL hemoglobin), using just the therapeutic options to the blood transfusions.


Postoperative management of severe acute anemia in a Jehovah’s Witness

Araújo Azi LMT, Lopes FM and Garcia LV.
Transfusion. 2014 Apr;54(4):1153-7.

COMMENTS: Authors describe a case of post-operative acute blood loss, resulting in a SEVERE ANEMIA (1.4 g/dL of hemoglobin), but through the use of therapeutic options to the allogeneic blood transfusion (someone else’s blood) it was possible save the patient’s life. They conclude the article calling for attention to resilience of the human body to tolerate circumstances of extreme anemia.. 

http://www.ncbi.nlm.nih.gov/pubmed/24117834


Intraoperative Management of Extreme Hemodilution in a Patient with a Severed Axillary Artery

Daí J, Tu W, Yang Z, Lin R
Anesth Analg 2010;111:1204 –6)

http://www.ncbi.nlm.nih.gov/pubmed/20581160

COMMENTS: Authors describe a case of CRITICAL ANEMIA tolerance in a post-trauma patient (multiple stab wounds). His hemoglobin reached 0.7g/dL and 2.2% hematocrit. There was no evidence of cardiac ischemia and he was discharged in good condition. They conclude by saying that conditions of extreme anemia can be successfully controlled by maintaining a normal blood volume, 100% oxygen supply and the use of plasma substitutes.


The importance of a multi-disciplinary team to reduce allogenic blood transfusions in cardiac surgeries

Antonio Alceu Santos, Silva JP, Silva LF, Baumgratz JF, Vila JHA, Stela FAM, Lippi E, Costa FAA e Araújo JG.

J Thorac Cardiovasc Surg 2013;145:796-804.

http://www.arquivosonline.com.br/2015/10501/pdf/deic_2015.pdf (Resumo das comunicações página 27; Volume 105, Nº 1, Supl. 1, Julho 2015)

COMMENTS: The authors describe the fundamental role of the PRACTITIONER (cardiologist), the ANESTHESIOLOGIST, the SURGEON and the INTENSIVE CARE doctor for the success of two serious surgeries without using allogenic blood (donated). First case: ACUTE DISSECTION OF THE ASCENDENT THORACIC AORTA (69mm diameter) and important
AORTIC VALVAR INSUFICIENCY. Second case: CORONARIAN ARTHERY DISEASE, important AORTIC STENOSIS (average gradient of 55mmHg), important MITRAL STENOSIS (valvar area 1.0 cm²), besides anemia and THROMBOCYTOPENIA (61 thousand/mm³). They conclude by saying that it is possible to perform large surgeries with high risk of bleeding without using donated blood (homologous).


Evidence-based medicine: Save blood, save lives

Transfusions are one of the most overused treatments in modern medicine, at a cost of billions of dollars. Researchers are working out how to cut back.

EMILY ANTHES
Nature Volume: 520, Pages: 24-26 Date published: (02 April 2015) doi:10.1038/520024a

http://www.nature.com/news/evidence-based-medicine-save-blood-save-lives-1.17224

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COMMENTS: This article shows that a hospital in California (USA), by simply remind the doctors the current guidelines regarding the use of allogeneic blood (donated) it reduced by 24% (about one quarter) blood transfusions and thereby saved US $ 1.6 million per year, it also reduced the average of patients’ length of stay in hospital from 10.1 to 6.2 days. But the main achievement of this attitude was to save lives, because mortality among people who received blood transfusions fell from 5.5% to 3.3%.


Reducing the Amount of Blood Transfused: A Systematic Review of Behavioral Interventions to Change Physicians’ Transfusion Practices

Tinmouth A, MacDougall L, Fergusson D, Amin M, Graham ID et al.
Arch Intern Med. 2005;165(8):845-852.

http://archinte.jamanetwork.com/article.aspx?articleid=486525

COMMENTS: Through this systematic review, authors have concluded that is possible to reduce the amount of blood and blood components transfusion in each patient, and thereby change the transfusional practice. The first step for this approach is the simple desire to change a transfusional behavior for a non-transfusional behavior.

 


Activity-based costs of blood transfusions in surgical patients at four hospitals

Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR
Transfusion 2010;50:753–65.

http://www.ncbi.nlm.nih.gov/pubmed/20003061

COMMENTS: Authors have demonstrated that allogeneic blood (donated blood) to be transfused is expensive. It was found that the cost of a single bag of blood in the USA may reach US $ 1,200 (One Thousand and Two Hundred Dollars) when considered all the activities involved in the blood transfusion.

 


THE BLOOD INDUSTRY
What happens to the bags of blood that you donate?

Época Journal

http://revistaepoca.globo.com/Revista/Epoca/0,,EMI242291-15230,00-A+INDUSTRIA+DO+SANGUE.html


WORLD HEALTH ORGANIZATION – WHO
Recommends reducing allogeneic blood transfusions (someone else’s blood)

http://apps.who.int/medicinedocs/documents/s15371p/s15371p.pdf


WORLD HEALTH ORGANIZATION – WHO
Stimulates development of patient blood conservation programs (PATIENT BLOOD MANAGEMENT)

http://www.who.int/bloodsafety/events/gfbs_01_pbm_concept_paper.pdf