Revista de trastornos sanguíneos y transfusiones

Abstracto

Blood-Sparing Heart Surgery in Critically Anaemic Patients Refusing Red Blood Cell Transfusions

Luca Weltert

Objective: The need for allogenic blood, plasma and platelets is an unresolved dilemma in contemporary surgical practice. There is increasing evidence that transfusions worsen the prognosis and should be avoided as far as possible. Patients refusing transfusion for personal reasons but requiring urgent surgery represent a challenge to maximize blood-sparing strategies.

Methods: As the referral hospital for heart surgery in Jehova’s Witnesses in Central Italy, the European Hospital of Rome has developed a multimodal strategy for blood-sparing heart surgery. This strategy has been in use since January 2006 and from early 2010 the protocol has consisted of four points: high-dose preoperative erythropoietin administration; screening and optimization of platelet aggregation and serum coagulation; intraoperative and early postoperative reinfusion of blood loss; and strict control of fluid administration.

Results: Since January 2006, 202 patients who refused any kind of transfusion have been operated on at our hospital, which represents around 4% of all people undergoing cardiac surgery at our hospital. All types of heart surgery were undertaken, with a prevalence of Coronary Artery Bypass Grafting (CABG), ascending aorta replacement and aortic valve replacement. Not a single unit of blood was transfused to these patients, whereas in a comparison group consisting of 4700 patients with an average of 1.1 units of blood per patient were used. The expected mortality as calculated by EURO score was 8.1%. The overall observed mortality was 3.1%, with mortality directly related to anaemia accounting for 1.6%.

Conclusion: A multimodal approach to the problem of anaemia, involving optimization of preoperative haemoglobin level as far as possible in an emergency setting, optimization of coagulation and aggregation, reinfusion of lost blood intra- and perioperatively and minimizing haemodilution, allows heart surgery to be performed with a minimally increased risk in this subset of patients, casting new light on reducing the use of allogenic transfusion in the general population.