CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
AFRICA
123
diseases, or one in every five donors.
In another study by Madrona
et al
.,
8
the main reasons for
donor refusal were listed among 2 070 patients as deficiency
anaemias (3%), major surgery (3.6%), minor surgery (1.9%),
high-risk behaviour (1.0%), drug or alcohol consumption (0.3%),
more than three or four donations in a year (3.5%), pregnancy
or lactation (1.2%), endoscopy, tattoo and piercings (10.5%),
fever, mild infections (15.4%), hypotension (1.3%), malaise,
unwell (11.0%), delivery, miscarriage (2.2%), unreliable answers
(0.5%), tachycardia or bradycardia (3.6%), blood pressure
>
180/
>
110 mmHg (6.4%), and taking medication (7.4%).
Nearly three out of every four donors in this study (72.8%) were
considered unsuitable.
In cardiac surgery patients, postoperative bleeding may be
considerable despite meticulous operative technique. In some
regions it may be difficult to find even two units of blood for
open-heart surgery. Blood-conservation strategies are therefore
very important. Despite a widespread interest in reducing blood
use for cardiac procedures, the practice of homologous blood
transfusion is still widespread.
On average 50 to 60% of patients undergoing cardiac
surgery receive blood transfusions.
9
These patients are prone
to transfusion-related morbidity and complications, such as
allergies, renal disease, pulmonary complications and infection.
3,4
Homologous blood usage also makes surgery more costly. There
is growing evidence of an association between transfusion of
blood products and increased morbidity and mortality, and
reduced long-term survival rates.
9
We therefore started blood-conservation protocols using
autologous blood that was prepared before the bypass procedure
and re-transfused into the patient at the end of surgery. In this
study we compared results from two different surgical eras.
Although autologous blood transfusion has the potential to
decrease bleeding following surgery, Helm
et al.
10
showed no
statistical difference in the auto-transfusion group between the
amount of autologous blood removed before the administration
of heparin (1 532
±
320 ml) compared with the amount
of postoperative bleeding. However in our study, when we
compared the amount of drainage in the two groups, there was a
statistically significant difference in favour of group 1 (
p
<
0.01).
In their study, Paker
et al
.
11
could not demonstrate any
difference in the group with no blood or blood products used
following cardiac surgery with regard to parameters of extubation
time and ICU stay, compared with a group using blood/
blood products. However in our study, there were significant
differences between the two groups in terms of extubation time,
ICU and hospital stay. These parameters were less in group 1.
The number of patients needing inotropic support and patients
with LCOS was also lower in group 1.
David and colleagues
12
reported that in patients undergoing
cardiac surgery, transfusion was found to be associated with an
increased risk of atrial fibrillation, with an odds ratio of 1.18
for each unit of blood transfused. Sood
et al
.
13
also found that
atrial fibrillation was twice as common in transfused patients.
Similarly, in our study, the number of patients with postoperative
atrial fibrillation was higher in group 2.
Gök
ş
in
et al.
14
showed the beneficial effect of autologous
blood transfusion with regard to lung damage following
ischaemia–reperfusion injury. Although not directly related,
in our study when compared to group 2, there were fewer
pulmonary complications in group 1 following cardiac surgery.
This may have been related to the earlier extubation and less time
in ICU observed in group 1 patients. Shorter ICU and hospital
stay in group 1 may also have been due to the lack of early
complications related to homologous blood transfusion.
Using autologous blood transfusion reduces the cost of
surgery. In our hospital, one unit of fresh whole blood costs 60
Turkish Lira (TL) (nearly 25 Euro) and one unit of erythrocyte
suspension costs 90 TL (nearly 38 Euro). In group 1, 328 units
of blood and blood products were used, and in group 2, 517
units. Comparing costs, it was 16 480 TL (nearly 7 012 Euros)
in group 1 and 41 730 TL (nearly 17 757 Euros) in group 2. The
difference was more than 10 000 Euros. It is easy to see the cost
effectiveness of using autologous blood transfusion.
Conclusion
A simple and inexpensive blood-conservation programme,
mainly combining autologous blood removal before bypass and
re-transfusion of the volume remaining in the oxygenator, has
enabled us to avoid homologous transfusions. Autologous blood
transfusion is a safe and effective method in selected patients
undergoing cardiac surgery. It not only prevents transfusion-
related co-morbidities and complications but also allows earlier
extubation time, and shorter ICU and hospital stay. Furthermore,
it reduces the cost of surgery.
References
1.
Moskowitz DM, Klein JJ, Shander A, Cousineau KM, Goldweit RS,
Bodian C,
et al
. Predictors of transfusion requirements for cardiac
surgical procedures at a blood conservation center.
Ann Thorac Surg
2004;
77
(2): 626–634.
2.
Ovrum E, Holen EA, Abdelnoor M, Oystese R. Conventional blood
conservation techniques in 500 consecutive coronary artery bypass
operations.
Ann Thorac Surg
1991;
52
(3): 500–505.
3.
Douglas BC, Terri GM. Extreme normovolemic hemodilution: how
low an you go and other alternative trnasfuisons?
Crit Care Med
2001;
29
: 908–910.
4.
Murphy PJ, Connery C, Hicks GL, Numberg N. Homologous blood
transfuison as a risk factor for postoperative infection after coro-
nary artery bypass opeations.
J Thorac Cardiovasc Surg
1992;
104
:
1092–1099.
5.
Scott WJ, Kessler R, Wernly JA. Blood conservation in cardiac surgery.
Ann Thorac Surg
1990;
50
: 843–851.
TABLE 3. POSTOPERATIVE MORBIDITY
DATA OF THE GROUPS
Variable
Group 1 (
n
=
163) Group 2 (
n
=
160)
p
-value
Re-intubation
0
0
1
Sternal infections
2
6
0.148
Pulmonary complications
5
24
<
0.001
Pneumonia
1
6
0.054
Atrial fibrillation
6
26
<
0.001
Renal disease
4
8
0.231
Inotropic support
2
15
0.001
LCOS
2
9
0.003
30-day mortality
0
0
1
LCOS: low cardiac output syndrome
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