Elsevier

The Annals of Thoracic Surgery

Volume 88, Issue 5, November 2009, Pages 1410-1418
The Annals of Thoracic Surgery

Original article
Adult cardiac
Transfusion and Pulmonary Morbidity After Cardiac Surgery

https://doi.org/10.1016/j.athoracsur.2009.07.020Get rights and content

Background

True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery.

Methods

A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (Pao2/Fio2), a criterion for TRALI.

Results

Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p < 0.001; respiratory failure 2.2% vs 0.39%, p < 0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p < 0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p < 0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested “lung injury” (Pao2/Fio2 ratio < 300) but unrelated to transfusion (65% vs 64%).

Conclusions

Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the Pao2/Fio2 ratio as important criterion of TRALI is unrelated to transfusion. Thus, due to the nature of cardiac surgery, application of consensus guided diagnosis of TRALI is problematic.

Section snippets

Patients

Between September 1998 and February 2006, 16,847 patients underwent coronary artery bypass grafting (CABG), a valve procedure, or combination of CABG and valve surgery at Cleveland Clinic. Baseline demographics and perioperative variables were obtained from the Department of Cardiothoracic Anesthesia Registry. Registry information was prospectively collected concurrent with patient care by trained database personnel. The Cardiovascular Information Registry, a similar prospective registry, was

Pulmonary Morbidity and Transfusion

A total of 79,530 red blood cell and component blood product units were transfused. Among propensity-matched patients, those who received RBC transfusion had more pulmonary morbidity postoperatively (Table 1). They had longer intubation time, higher prevalence of respiratory distress and failure, and more frequently required reintubation for pulmonary-related reasons. Prevalence of ARDS was higher. They also had more readmissions to the ICU, and longer overall ICU length of stay.

Among matched

Comment

We report that transfusion was associated with a higher risk-adjusted prevalence of respiratory distress and failure, ARDS, reintubation for pulmonary-related reasons, longer total intubation time, more readmissions to the ICU for pulmonary-related reasons, and longer ICU length of stay. Similarly, FFP transfusion was associated with significantly more pulmonary complications in the postoperative period. Surprisingly, a substantial proportion of patients manifested (Pao2/Fio2 < 300) for both

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