Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial

George Vretzakis, Athina Kleitsaki, Konstantinos Stamoulis, Metaxia Bareka, Stavroula Georgopoulou, Menelaos Karanikolas, Athanasios Giannoukas, George Vretzakis, Athina Kleitsaki, Konstantinos Stamoulis, Metaxia Bareka, Stavroula Georgopoulou, Menelaos Karanikolas, Athanasios Giannoukas

Abstract

Background: Cardiac surgery is a major consumer of blood products, and hemodilution increases transfusion requirements during cardiac surgery under CPB. As intraoperative parenteral fluids contribute to hemodilution, we evaluated the hypothesis that intraoperative fluid restriction reduces packed red-cell (PRC) use, especially in transfusion-prone adults undergoing elective cardiac surgery.

Methods: 192 patients were randomly assigned to restrictive (group A, 100 pts), or liberal (group B, 92 pts) intraoperative intravenous fluid administration. All operations were conducted by the same team (same surgeon and perfusionist). After anesthesia induction, intravenous fluids were turned off in Group A (fluid restriction) patients, who only received fluids if directed by protocol. In contrast, intravenous fluid administration was unrestricted in group B. Transfusion decisions were made by the attending anesthesiologist, based on identical transfusion guidelines for both groups.

Results: 137 of 192 patients received 289 PRC units in total. Age, sex, weight, height, BMI, BSA, LVEF, CPB duration and surgery duration did not differ between groups. Fluid balance was less positive in Group A. Fewer group A patients (62/100) required transfusion compared to group B (75/92, p < 0.04). Group A patients received fewer PRC units (113) compared to group B (176; p < 0.0001). Intraoperatively, the number of transfused units and transfused patients was lower in group A (31 u in 19 pts vs. 111 u in 62 pts; p < 0.001). Transfusions in ICU did not differ significantly between groups. Transfused patients had higher age, lower weight, height, BSA and preoperative hematocrit, but no difference in BMI or discharge hematocrit. Group B (p < 0.005) and female gender (p < 0.001) were associated with higher transfusion probability. Logistic regression identified group and preoperative hematocrit as significant predictors of transfusion.

Conclusions: Our data suggest that fluid restriction reduces intraoperative PRC transfusions without significantly increasing postoperative transfusions in cardiac surgery; this effect is more pronounced in transfusion-prone patients.

Trial registration: NCT00600704, at the United States National Institutes of Health.

Figures

Figure 1
Figure 1
Number of transfused PRC units/patient. Significantly more Group A patients received 0 or 1 PRC unit, whereas significantly more Group B patients received 3, 4, or more PRC units (p < 0.0007).

References

    1. Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth. 2008;11:15–19. doi: 10.4103/0971-9784.38444.
    1. Oliver E, Carrio ML, Rodriguez-Castro D, Javierre C, Farrero E, Torrado H, Castells E, Ventura JL. Relationships among haemoglobin level, packed red cell transfusion and clinical outcomes in patients after cardiac surgery. Intensive Care Med. 2009;35:1548–1555. doi: 10.1007/s00134-009-1526-0.
    1. Weightman WM, Gibbs NM, Sheminant MR, Newman MA, Grey DE. Moderate exposure to allogeneic blood products is not associated with reduced long-term survival after surgery for coronary artery disease. Anesthesiology. 2009;111:327–333. doi: 10.1097/ALN.0b013e3181ab6743.
    1. Whitson BA, Huddleston SJ, Savik K, Shumway SJ. Risk of Adverse Outcomes Associated With Blood Transfusion After Cardiac Surgery Depends on the Amount of Transfusion. J Surg Res. 2010;158:20–7. doi: 10.1016/j.jss.2008.10.015.
    1. Arora RC, Legare JF, Buth KJ, Sullivan JA, Hirsch GM. Identifying patients at risk of intraoperative and postoperative transfusion in isolated CABG: toward selective conservation strategies. Ann Thorac Surg. 2004;78:1547–1554. doi: 10.1016/j.athoracsur.2004.04.083.
    1. Dial S, Delabays E, Albert M, Gonzalez A, Camarda J, Law A, Menzies D. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg. 2005;130:654–661. doi: 10.1016/j.jtcvs.2005.02.025.
    1. Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Ferraris VA, Ferraris SP, Saha SP, Hessel EA, Haan CK, Royston BD, Bridges CR, Higgins RS, Despotis G, Brown JR. Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion. Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg. 2007;83:S27–S86. doi: 10.1016/j.athoracsur.2007.02.099.
    1. Karkouti K, Cohen MM, McCluskey SA, Sher GD. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion. 2001;41:1193–1203. doi: 10.1046/j.1537-2995.2001.41101193.x.
    1. Vretzakis G, Kleitsaki A, Stamoulis K, Dragoumanis Ch, Tasoudis V, Kyriakaki K, Microulis D, Giannoukas A, Tsilimingas N. The impact of fluid restriction policy in reducing the use of red blood cells in cardiac surgery. Acta Anaesth Belg. in press .
    1. Rogers MA, Blumberg N, Saint S, Langa KM, Nallamothu BK. Hospital variation in transfusion and infection after cardiac surgery: a cohort study. BMC Med. 2009;7:37. doi: 10.1186/1741-7015-7-37.
    1. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology. 2006;105:198–208. doi: 10.1097/00000542-200607000-00030.
    1. Stover EP, Siegel LC, Parks R, Levin J, Body SC, Maddi R, D'Ambra MN, Mangano DT, Spiess BD. Variability in transfusion practice for coronary artery bypass surgery persists despite national consensus guidelines: a 24-institution study. Institutions of the Multicenter Study of Perioperative Ischemia Research Group. Anesthesiology. 1998;88:327–333. doi: 10.1097/00000542-199802000-00009.
    1. Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg. 2003;125:1438–1450. doi: 10.1016/S0022-5223(02)73291-1.
    1. Karkouti K, Djaiani G, Borger MA, Beattie WS, Fedorko L, Wijeysundera D, Ivanov J, Karski J. Low hematocrit during cardiopulmonary bypass is associated with increased risk of perioperative stroke in cardiac surgery. Ann Thorac Surg. 2005;80:1381–1387. doi: 10.1016/j.athoracsur.2005.03.137.
    1. Vretzakis G, Ferdi E, Argiriadou H, Papaziogas B, Mikroulis D, Lazarides M, Bitzikas G, Bougioukas G. Influence of bispectral index monitoring on decision making during cardiac anesthesia. J Clin Anesth. 2005;17:509–516. doi: 10.1016/j.jclinane.2004.12.018.

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