Research Proposal: Bloodless Surgery

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Bloodless Surgery

Blood transfusion is a life saving intervention for many seriously injured patients, patients undergoing complex invasive surgeries, people with hemophilia and other blood related diseases. More recently though, the focus has shifted on the potential side effects of blood transfusion including allogenic transfusion associated with sepsis, immunosupression, and other complications including multiple organ dysfunction syndrome, respiratory distress syndrome, etc. The growing literature in the field of blood transfusion has contributed to an increase in our understanding of the negative consequences of blood transfusion. Some recent studies have also ascribed a possible role of blood transfusion in the onset of atrial fibrillation post cardiac surgery. In particular, the role of blood transfusion in increasing the inflammatory response post surgery as a contributory mechanism in the development of new onset atrial fibrillation is now studied more seriously. Some studies have also indicated a high risk for developing septic complications in trauma patients receiving blood transfusion that is independent of the injury severity. Overall, these studies have recommended a restrictive strategy of red blood cells transfusion to minimize the side effects. A brief review of some recent research studies pertaining to the blood transfusion, discussion of the methods and clinical significance of the results would help provide better insight into this important medical topic.

Red Blood Cell Transfusion (Review of studies)

Blood transfusion is a life saving intervention for many but it also has some serious side effects. One recent study by Hassan (2009) focused on the possible effects of red blood transfusion on the onset of atrial fibrillation (AF) post cardiac surgery. Statistics suggest that new onset atrial fibrillation occurs in 10 to 43% of all patients who underwent cardiac surgery. Though atrial fibrillation is well recognized as a postoperative complication in some patients who underwent Coronary Artery Bypass Graft (CABG), the causative mechanisms have not been clearly understood. The study researchers hypothesized that the increase in plasma concentrations of the inflammatory mediators due to red blood cells transfusion may be implicated in the new onset AF. To prove this hypothesis, the researchers included a total of 1692 patients who had undergone CABG at the Imam Khomeini Medical Center, at the Tehran University of medical sciences between Jan 2005 and July 2007. All the patients were regularly monitored for their heart rhythm in the ICU and the postoperative ward and long lead 11 was recorded upon identification of any irregular pattern. Based on this, patients were segregated into two groups -- those with new onset AF and those without AF irrespective of the use of blood transfusion. Also for those patients who had blood transfusion, the amount of transfusion products used was also noted down from hospital records.

Of the 487 patients who had received blood transfusion, 223 (45.9%) developed AF. AF was also manifest in 571 (37.9%) of the 1508 patients who did not receive blood transfusion. After adjusting the study results for age and previous history of AF, it transpires that blood transfusion in the ICU had a direct impact on developing AF. (odds ratio unit transfused, 1.16; 95% confidence limits, 1.14, 1.24; P<.001). Though the authors of this study were not able to pinpoint the increase in atrial fibrillation to inflammatory changes, the results do suggest an association between onset of AF and blood transfusion. Other pathways maybe involved in the manifestation of AF but the study clearly suggests a strong association between transfusion and onset of AF among post surgery cardiac patients. [Hassan (2009)]

The researchers also quoted earlier studies that reported similar results. For instance Koch (2005) was an extensive study at the Cleveland clinic between Feb 2002 and Jan 2005 involving 5841 patients who had undergone CABG. Logistic regression was used to identify the association between the different patient related clinical variables and the onset of AF. It was found that ICU and blood transfusion increased the risk for developing AF (odds ratio per unit transfused, 1.18; 95% confidence limits, 1.14, 1.23; P<.0001). Hassan also quote Fransen, a previous study that links transfusion with increase in pro-inflammatory mediators. Fransen is a Dutch study that observed 140 cardiac surgery patients to find out if intra-operative blood transfusion could affect the levels of pro-inflammatory mediators. The levels of Bactericidal permeability increasing protein (BPI) was measured as an indicator of neutrophil activation. IL -- 6 and lipopolysaccharide-binding protein (LBP) and C-reactive protein (CRP) levels were also measured. Further, the researchers also measured these protein levels in the packed red cell units (PC) that were administered to the patients. In all, 36 patients received the packed red cell units. It was observed that BPI levels measured at 0.5 hours and 4 hours after aortic unclamping were much higher among these patients compared to those who did not (P<.05). Similarly, the levels of IL (6) measured at 0.5, 4 hours and 8 hours were considerably higher compared with those who did not have any transfusion . (P<.01). This study concluded that intra-operative blood transfusion was clearly associated with increased levels of pro-inflammatory mediators and poor postoperative prognosis. [Hassan (2009)]

Teixeira (2008) is an exhaustive retrospective study that analyzed 25, 599 patients in a trauma care center over a period of 6 years (jan 200 to dec 2005) at the University of Southern California medical center. The trauma registry was consulted to obtain information such as patient's age, gender, admission vital signs, 'Glasgow coma scale' (GCS), 'injurity severity scale' (ISS) and the volume of blood transfusion used. Blood bank database was also cross-linked with the trauma registry to accurately verify patient specific transfusion information. Using statistical linear regression for trend analysis the researchers also discerned changes in the blood transfusion rate over the six-year period. Logistic regression analysis allowed the researchers to identify the factors that directly affected mortality.

It was found that of the 25, 599 patients (over the six-year period) 4,241 (16.6%) had received blood transfusion. The study results indicated that patients who received transfusion had a much higher mortality rate at 20%, which was consistent over the entire study period. Discounting for age and other patient characteristics, the adjusted odd ratio for mortality among the transfusion patients was 6.7 (95% CI: 6.1-7.5; P < 0.001) clearly suggesting the increased risk for mortality among transfused patients. The study also indicated a reported decrease in the average number of packed red blood cells (PRBC) usage over the years (8.1 + 10.4 units in 2000 to 6.2 ± 8.4 in 2005). The increase in the usage of fresh frozen plasma (FFP) may account for this reduction in PRBC usage. In the absence of a clinical directive regarding transfusion strategies, the authors of this study feel that evidence-based practice might have influenced this reduction in transfusion amounts over the last few years. The authors also quote another study by Malone (2003) that also reported higher mortality rate among trauma patients who had blood transfusion. [Teixeira (2008)]

Stone (2008) is a recent study that focused on red blood cell transfusion in a pediatric trauma care center and its association with mortality within the first 24 hours of admission. This study, which extended over 8 years, analyzed 1639 pediatric patients of which 106 (6.5%) had received PRBC transfusion within the first 24 hours of admission. The study reported that pediatric patients who had received blood transfusion had a greater length of stay at the ICU and also had a significantly increased mortality rate (29.2% vs. 2.7%, p < 0.001) compared the non-transfused group. This study also quotes other previous studies such as Claridge (2002), Moore (1997) and Zallen (1999) that have reported blood transfusion as an independent predictor of post injury infection and multiple system organ failure. Though the authors of this study do not implicate blood transfusion as an independent predictor of pediatric mortality in the trauma care setting, they do suggest a positive correlation. [Stone, 2008]

Tinmouth (2008) is an extensive review of blood conservation strategies with a view to limit the use of blood transfusion for the critically ill people. This review focused on alternative approaches including the use of Antifibrinolytic agents to minimize blood loss in critical care patients, use of hemoglobin substitutes, oxygen carriers including erythropoietin-receptor agonists to improve oxygen circulation and the use of restrictive blood transfusion triggers in order to avoid mortality associated with free blood transfusion practices. The reviewers quote several studies such as Hebert (1999), Lacroix (2007), Kirpalani (2006) etc., which discuss the practice of restrictive blood transfusion triggers in the adult, pediatric and neonatal settings respectively. All the above-mentioned studies reported in favor of restrictive transfusion strategies. Lacroix, in particular, showed that a lower hemoglobin threshold of 70 g/L reduced the transfusion requirement by 44% (0.9 [SD 2.6] v. 1.7 [SD 2.2] units per patient, p < 0.001) compared with a higher threshold of 95 g/L. This review concluded that lower hemoglobin thresholds and restrictive transfusion strategies is not associated with increased mortality among… [END OF PREVIEW]

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Bloodless Surgery.  (2009, December 3).  Retrieved September 15, 2019, from

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"Bloodless Surgery."  3 December 2009.  Web.  15 September 2019. <>.

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"Bloodless Surgery."  December 3, 2009.  Accessed September 15, 2019.