Risk Factors Of Red Blood Cell Transfusion In Adult Patients Receiving Cardiac Surgery With Cardiopulmonary Bypass And The Influence Of Circuit Albumin Coating On Platelet Functions And Inflammatory Response For Patients Underwent Aortic Arch Replacement

Part I Risk factors of red blood cell transfusion in adult patients receiving cardiac surgery with cardiopulmonary bypassObjective Perioperative allogeneic blood transfusions are recognized to increase morbidity and mortality. The aim of the study was to identify the risk factors of patient characteristics for red blood cell transfusion during cardiopulmonary bypass (CPB) and disclose the impacts of CPB parameters on red blood cell (RBC) consumption after extracorporeal circulation.Methods This retrospective study consisted of 700 consecutive adult patients receiving cardiac procedures with CPB from January 2014 to March 2014. Emergent procedures were excluded. Baseline demographic and clinical variables were retrieved from electronic medical record (EMR) database. Baseline demographic and clinical variables were retrieved from electronic medical record (EMR) database. These included gender, age, weight, height, body mass index (BMI), hematocrit (HCT), hemoglobin (HB), platelet count (PLT), activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (FIB), alanine transferase (ALT), aspartate aminotransferase (AST), creatinine (Cre), ejection fraction (EF), history of hypertension (HTN), diabetes mellitus (DM), hyperlipidemia (HLP), cerebrovascular disease (CVD), peripheral vascular diseases (PVD), smoker (including currently active smokers and those who recently quit), category of cardiac surgery procedure [coronary artery bypass grafting (CABG), cardiac valve replacement (CVR), CABG and CVR, total aortic arch replacement with deep hypothermic circulatory arrest (DHCA), repair of atrial septal defect (ASD), repair of ventricular septal defect (VSD)]. CPB information included the lactate level before CPB, cardiopulmonary bypass time, aortic cross clamping time, cardioplegia, the apex of activated clotting time (ACT), the lowest nasopharyngeal temperature, the lowest rectal temperature, nadir hemoglobin (nHb) levels, amount of heparin administered during CPB, conventional ultrafiltration (CUF), zero-balanced ultrafiltration (ZBUF) during CPB and the incidence of automatic heart resuscitation. Thirty-four perioperative variables were recorded and analyzed with logistic regression as potential risk factors related to red blood product use.Results The multivariable logistic regression analysis determined that age (P< 0.001), female (P=0.006), low body weight (P<0.001), non-smoker (P=0.002), hyperlipidemia (P=0.004), low preoperative hemoglobin(P< 0.001) and total aortic arch replacement [P=0.039, compare with coronary artery bypass grafting (CABG)] were risk factors of RBC transfusion during CPB. The following factors were independently associated with an increased risk of RBC transfusion after CPB:age (P=0.010), diabetes mellitus(P=0.048), low preoperative hemoglobin (P< 0.001), prolonged activated partial thromboplastin time (APTT) (P=0.015) and cardiopulmonary bypass time (P=0.016).Conclusion Preoperative patient characteristics, such as female, low body weight, non-smoker, hyperlipidemia, were risk factors of RBC transfusion during CPB. Compare with CABG, the total aortic arch replacement with DHCA increased the risk of exposure to red blood cell transfusion. The risk factors of RBC transfusion after CPB contained diabetes mellitus, prolonged APTT and CPB time. The level of perioperative HB and age were both risk factors of RBC transfusion not only during but also after CPB.Part IIThe influence of circuit albumin coating on platelet functions and inflammatory response for patients underwent aortic arch replacementObjective There is not a standard albumin prime protocol for total aortic arch replacement patients with deep hypothermic circulatory arrest (DHCA). The administration of platelet and plasma transfusion after protamine infusion is mainly based on empirical foundations by the anesthetists. The aim of the current study was 1) to observe the changes of blood routine examination, platelet and coagulation functions, inflammatory mediators and blood transfusions after protamine reversal for patients receiving aortic arch replacement with DHCA; 2) to evaluate the effects of human serum albumin coating before cardiopulmonary bypass (CPB) on these variables.Methods Our study was a randomized controlled trial with a 1:1 allocation ratio. Consecutive patients in aortic dissection or thoracic aortic aneurysms, from Apr.2014 to Mar.2015, were enrolled. The exclusion criteria included:re-operation, anti-platelet drugs treatment within 7 days before operation, infectious diseases and chronic renal or hepatic dysfunction. The patients was randomized into two groups:the Control Group (CG, administering 40g human serum albumin 5 minutes after initiation of CPB) and the Study Group (SG, circulating the prime with 40g albumin for 5 minutes before CPB). Preoperative demographic data was recorded. Rapid-thromboelastography, complete blood count, coagulation tests and cytokines were measured at two intervals, namely after anesthesia induction (T1),10 minutes after protamine neutralization (T2). Repeated measurement analysis of variance (ANOVA) was used to compare the variables between the two groups at different time points.Results Sixty patients underwent thoracic aortic procedures with DHCA were enrolled in the study. These patients were randomly assigned to the Control Group (n=29) or the Study Group (n=31). The levels of MA and FIB significantly reduced after protamine administration in two groups(P<0.01, P<0.01) and fell in normal range for most patients. But there were no statistically differences between the two groups in the decrease of the MA and FIB at T2 in repeated measurement ANOVA analysis (P=0.405, P=0.247); Compare with T1, there were significant differences in the levels of HB, PLT, FX of the two group at T2. The platelet count reduction (△PLT) in the Study Group was significantly less than that in the Control Group (P=0.031). All the cytokine levels of the two groups increased after CPB. However, no differences were found between the two groups。Fewer red blood cells were given in the Study Group, however this was not significant (p=0.050).Conclusion The levels of HB, PLT, MA, FIB and FX in patients receiving aortic arch replacement with DHCA significantly reduced after heparin reversal. Most have normal platelet function and fibrinogen level after protamine neutralization. Albumin coating before CPB may mitigate the platelet count reduction but not the platelet dysfunction. There is a trend that patients treated with albumin coating received less red blood cells transfusion.