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Risks associated with bleeding and transfusion: rationale for the optimal management of bleeding after cardiac surgery

Published online by Cambridge University Press:  01 June 2007

G. Despotis ,
M. Renna  and
C. Eby
G. Despotis*
Affiliation:
Washington University School of Medicine, Department of Pathology, Immunology and Anesthesiology, St. Louis, MO, USA
M. Renna
Affiliation:
Royal Brompton Hospital, Department of Cardiothoracic Anaesthesia, USA
C. Eby
Affiliation:
Washington University School of Medicine, Departments of Immunology, Pathology and Medicine, St. Louis, MO, USA
*
Correspondence to: George Despotis, Department of Pathology and Immunology, Box 8118, Washington University School of Medicine, 660 South Euclid Avenue, St. Louis, MO 63110, USA. E-mail: [email protected]; Tel: +(314) 362 6584; Fax: +(314) 362 1461
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Summary

Background and objectives

The main aim of this review is to summarize the literature with respect to transfusion and bleeding risks and the therapeutic strategies with respect to optimal management of perioperative bleeding.

Methods

This review was generated using peer-reviewed manuscripts pertinent to this topic that were identified using a computer-based Medline search.

Results

Although the pathophysiology of many transfusion-related complications are well-documented, the incidence of these complications is changing. Transfusion Medicine initiatives are being implemented to reduce complications, however, the literature is describing new potential problems related to transfusion in addition to identification of new potential pathogens while blood shortages may limit our ability to adequately manage our anemic and bleeding patients. Excessive bleeding after cardiac surgery can result in increased morbidity and mortality related to transfusion and hypoperfusion related complications as well as injury to critical organ systems. Seven of eight studies have demonstrated that use of point-of-care (POC) tests of hemostatic function can facilitate the optimal management of excessive bleeding and reduce transfusion after cardiac surgery. Two randomized prospective studies have demonstrated that point-of-care tests that assess platelet function can identify patients at risk for acquired, platelet-related bleeding that may be attenuated with pharmacologic agents such as DDAVP. The current literature contains fifty publications with over 400 patients that describe the fairly consistent efficacy of off-label use of recombinant factor VIIa to manage intractable, life-threatening bleeding. Most of these publications involve either case reports or case series that describe the use of this agent and therefore do not adequately address the safety of this agent.

Conclusions

There are substantial risks related to excessive bleeding and transfusion. The literature indicates that use of point-of-care diagnostics with a standardized management algorithm can optimize the management of bleeding and reduce transfusion requirements. Recombinant FVIIa has the potential to reduce transfusion and transfusion-related sequelae and may be life-saving in certain circumstances. However, randomized, controlled trials are warranted to assess both the efficacy and, more importantly, the safety of this intervention (i.e., especially with respect to thrombotic complications) in cardiac surgical patients prior to its use as a first line therapy for bleeding or for bleeding prophylaxis. We must continue to carefully investigate the role of new interventions since the ability to reduce use of blood products, to decrease operative time and/or re-exploration rates has important implications for disease prevention and overall patient safety, blood inventory and associated costs as well as overall health care costs.

Keywords

BleedingTransfusionCardiac surgeryBloodBlood componentsBlood risksPoint-of-care diagnostic testsFactor concentrates
Type
Original Article
Information
European Journal of Anaesthesiology , Volume 24 , Issue S40 , June 2007 , pp. 15 - 36
Copyright
Copyright © European Society of Anaesthesiology 2007

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