Blood transfusion during cardiac surgery: massive transfusion coagulopathy

Background

Massive transfusion is usually defined as transfusion of more than 10 units of packed RBCs within 24h. Trigger for red cell transfusion in cardiac surgical patients is HGB 100 g/L or HCT 0.30 L/L. We implemented control resuscitation with preemptive use of platelets and plasma in transfusion (1:1:1).

Methods

Total of 406 patients (f/m N=103/303) were studied in the ICU in 2011; 21 (5.17%) males were observed,. HGB in OR prior to surgery was: 127.43 g/L(SD±19.4; range 85-165; median 129g/L). Patients were divided into two groups, according to the quantity of RBCs received. Group 1 (N=15) received 5-9 units RBCs; group 2 (N=6) received ≥10 units RBCs. EuroSCORE II was used for operation risk calculation. Patients abode 6.9 days (±7.97) in ICU. LVEF was 61.1±11.06%. The consumption of RBCs, platelet concentrates (PCs), and fresh frozen plasma (FFP) within 24 h was calculated. In all these cases CBC, PT, aPTT and INR were used to evaluate perioperative bleeding. Patients were monitored prior to surgery and for the first 24 h of transfusion of blood components for creatinine, pH, Ca++, troponin I. Data are presented as median and IQR; mean and standard deviation, P < 0.05 was considered statistically significant.

Results

GROUP 1: (before/after) blood transfusion: PLT 171.47x109/L (±56.69) / PLT 139.53x109/L (±44.86); P=0.02. PV 0.85(0.62-0.97) / 0.94(0.31-1.113); aPTT 30 (26-36) / 30 (26-120); aPTT R 1.04(0,91-1.18) / 1.05 (0.91-1.27). GROUP 2:PLT 156.67x109 L (±76.26) / PLT 119.67x109 (±62.44);P=0.04. PV 0.78(53-1.09) / 0.94(0.34-1.00); aPTT 32(25-49) / 35.5 (27-50); aPTT R 1.10 (0.86-1.70) / 1.23(0.93-1.71). Patients who were massively transfused received: RBC 10.5(SD±3.93; r:10-20) units, FFP 11(SD±5.42; r:5-21) units, PCs 10 (SD±5.11; r:7-20) units.

Conclusion

With this protocol we prevent bleeding following massive transfusion that can occure due to hypothermia, dilutional coagulopathy, platelet dysfunction, fibrinolysis, and hypofibrinogenemia.