Ayşegül ÖZGÖK, Demet BÖLÜKBAŞI, Dilek KAZANCI, Büşra TEZCAN, Sema TURAN, Sultan Sevim YAKIN, Alev ŞAYLAN, Hija YAZICIOĞLU

Effect of dilutional anemia that can be treated with only one unit of red blood cell transfusion on tissue oxygenation in cardiac surgery patients

Background/aim: Cardiac surgery, especially in the presence of cardiopulmonary bypass (CPB), is associated with an inflammatoryreaction that may promote microcirculatory alterations, in addition to the general impact on system hemodynamics. Anemia andtransfusion make patients more susceptible to the deleterious effects of CPB. In this study, it was aimed to evaluate the effect of dilutionalanemia, which is caused by CPB and can be treated with 1–2 units of red blood cell (RBC) transfusion, on global tissue oxygenationparameters in cardiac surgery patients.Materials and methods: This prospective observational study comprised 127 patients who had a relatively stable operation periodwithout any major anesthetic or surgical complications (e.g., operation duration >5 h, bleeding or hemodilution requiring more than1–2 units of RBCs, or unstable hemodynamics, requiring inotropic support of more than 5 µg/kg/min dopamine). Patients wereobservationally divided into two groups: minimally transfused (Group Tr) and nontransfused (Group NTr). Global tissue oxygenationparameters were evaluated after anesthesia induction (T1) and at the end of the operation (T3) and compared between the groups.Results: Group Tr consisted of patients who had significantly lower preoperative hemoglobin values than Group NTr patients. Thedilutional anemia of all Group Tr patients could be corrected with 1 unit of RBCs. The lactate levels at T3, increment rates of lactate,and venoarterial carbon dioxide pressure difference (ΔpCO2) levels [(T3 – T1) : T1] in Group Tr were significantly higher than those inGroup NTr.Conclusion: Dilutional anemia as a result of CPB mostly occurs in patients with borderline preoperative hemoglobin concentrationsand its correction with RBC transfusion does not normalize the degree of microcirculatory and oxygenation problems, which thepatients are already prone to because of the nature of CPB. Preventing dilutional anemia and transfusion, especially in patients withpreoperative borderline hemoglobin levels, may therefore reduce the burden of impaired microcirculation-associated organ failure inon-pump cardiac surgery

PDF

___

1. Koning NJ, Atasever B, Vonk AB, Boer C. Changes in microcirculatory perfusion and oxygenation during cardiac surgery with or without cardiopulmonary bypass. Journal of Cardiothoracic and Vascular Anesthesia 2014; 28 (5): 331-340. doi: 10.1053/j.jvca.2013.04.009
2. De Backer D, Dubois MJ, Schmartz D, Koch M, Ducart A et al. Microcirculatory alterations in cardiac surgery: effects of cardiopulmonary bypass and anesthesia. Annals of Thoracic Surgery 2009; 88 (5): 1396-1403. doi: 10.1016/j. athoracsur.2009.07.002
3. Karkouti K. Transfusion and risk of acute kidney injury in cardiac surgery. British Journal of Anaesthesia 2012; 109 (Suppl. 1): i29-i38. doi: 10.1093/bja/aes422
4. Bellomo R, Auriemma S, Fabbri A, D’Onofrio A, Katz N et al. The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI). International Journal of Artificial Organs 2008; 31 (2): 166-178. doi: 10.1038/nrneph.2017.119
5. Bernard AC, Davenport DL, Chang PK, Vaughan TB, Zwischenberger JB. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. Journal of the American College of Surgeons 2009; 208 (5): 931-937. doi: 10.1016/j. jamcollsurg.2008.11.019
6. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y et al. Methodological index for non-randomized studies (minors): development and validation of a new instrument. ANZ Journal of Surgery 2003; 73 (9): 712-716. doi: 10.1046/j.1445- 2197.2003.02748.x
7. Yuruk K, Almac E, Bezemer R, Goedhart P, de Mol B et al. Blood transfusions recruit the microcirculation during cardiac surgery. Transfusion 2011; 51 (5): 961-967. doi: 10.1111/j.1537- 2995.2010.02971.x
8. Raat NJ, Ince C. Oxygenating the microcirculation: the perspective from blood transfusion and blood storage. Vox Sanguinis 2007; 93 (1): 12-18. doi: 10.1111/j.1423- 0410.2007.00909.x
9. Karkouti K, Wijeysundera DN, Yau TM, McCluskey SA, Chan CT et al. Advance targeted transfusion in anemic cardiac surgical patients for kidney protection: an unblinded randomized pilot clinical trial. Anesthesiology 2012; 116 (3): 613-621. doi: 10.1097/ALN.0b013e3182475e39
10. Marik PE, Sibbald WJ. Effect of stored-blood transfusion on oxygen delivery in patients with sepsis. Journal of the American Medical Association 1993; 269 (23): 3024-3029. doi: 10.1001/ jama.269.23.3024
11. Sakr Y, Chierego M, Piagnerelli M, Verdant C, Dubois MJ et al. Microvascular response to red blood cell transfusion in patients with severe sepsis. Critical Care Medicine 2007; 35 (7): 1639-1644. doi: 10.1097/01.CCM.0000269936.73788.32
12. Creteur J, Neves AP, Vincent JL. Near-infrared spectroscopy technique to evaluate the effects of red blood cell transfusion on tissue oxygenation. Critical Care Medicine 2009; 13 (5): S11. doi: 10.1186/cc8009
13. Weinberg JA, MacLennan PA, Vandromme-Cusick MJ, Angotti JM, Magnotti LJ et al. Microvascular response to red blood cell transfusion in trauma patients. Shock 2012; 37 (3): 276-281. doi: 10.1097/SHK.0b013e318241b739
14. Damiani E, Adrario E, Luchetti MM, Scorcella C, Carsetti A, et al. Plasma free hemoglobin and microcirculatory response to fresh or old blood transfusions in sepsis. PLoS One 2015; 10: e0122655. doi: 10.1371/journal.pone.0122655
15. Nielsen ND, Martin-Loeches I, Wentowski C. The effects of red blood cell transfusion on tissue oxygenation and the microcirculation in the intensive care unit: a systematic review. Transfusion Medicine Reviews 2017; 31 (4): 205-222. doi: 10.1016/j.tmrv.2017.07.003
16. Tsui AK, Marsden PA, Mazer CD, Sled JG, Lee KM et al. Differential HIF and NOS responses to acute anemia: defining organ-specific hemoglobin thresholds for tissue hypoxia. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 2014; 307 (1): R13-25. doi: 10.1152/ ajpregu.00411.2013
17. Fergusson D, Khanna MP, Tinmouth A, Hébert PC. Transfusion of leukoreduced red blood cells may decrease postoperative infections: two meta-analyses of randomized controlled trials. Canadian Journal of Anesthesia 2004; 51 (5): 417-424. doi: 10.1007/BF03018302
18. Vamvakas EC. WBC-containing allogeneic blood transfusion and mortality: a meta-analysis of randomized controlled trials. Transfusion 2003; 43 (7): 963-973. doi: 10.1046/j.1537- 2995.2003.00426.x
19. Barshtein G, Arbell D, Yedgar S. Hemodynamic functionality of transfused red blood cells in the microcirculation of blood recipients. Frontiers in Physiology 2018; 30: 9-41. doi: 10.3389/ fphys.2018.00041
20. Karkouti K, Grocott HP, Hall R, Jessen ME, Kruger C et al. Interrelationship of preoperative anemia, intraoperative anemia, and red blood cell transfusion as potentially modifiable risk factors for acute kidney injury in cardiac surgery: a historical multicentre cohort study. Canadian Journal of Anesthesia 2015; 62 (4): 377-384. doi: 10.1007/s12630-014- 0302-y