Koch Colleen, Li Liang, Figueroa Priscilla, Mihaljevic Tomislav, Svensson Lars, Blackstone Eugene H
Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio 44195, USA.
Ann Thorac Surg. 2009 Nov;88(5):1410-8. doi: 10.1016/j.athoracsur.2009.07.020.
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.
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 (PaO(2)/FiO(2)), a criterion for TRALI.
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" (PaO(2)/FiO(2) ratio < 300) but unrelated to transfusion (65% vs 64%).
Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the PaO(2)/FiO(2) 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.
真性肺损伤是输血相关死亡的主要原因之一。心脏手术后的肺部并发症与体外循环和输血的损害作用有关，但被可能无法反映真性肺损伤的心脏相关事件所混淆。因此，心脏手术对输血相关急性肺损伤（TRALI）的标准特异性诊断提出了独特的挑战。我们的目的是确定与输血相关的肺部并发症的发生率，以及TRALI共识标准是否适用于心脏手术。
1998年9月至2006年2月1日，共有16847例患者接受了体外循环冠状动脉旁路移植术（CABG）、瓣膜手术或CABG-瓣膜联合手术。我们进行了四项倾向评分匹配分析，采用逻辑回归分析输血概率：全院红细胞（RBC）和新鲜冰冻血浆（FFP）输血以及术中RBC和FFP输血。结果包括传统心脏手术定义的肺部并发症以及动脉血氧分压与吸入氧分数浓度之比（PaO₂/FiO₂），这是TRALI的一个标准。
接受RBC输血的患者有更多经风险调整的肺部并发症：呼吸窘迫4.8%对1.5%，p<0.001；呼吸衰竭2.2%对0.39%，p<0.0001；插管时间更长，9.9小时对7.5小时，p<0.0001；急性呼吸窘迫综合征，0.64%对0.21%，p = 0.015；再次插管，5.6%对1.3%，p<0.0001。FFP与术后更多的肺部并发症同样相关。根据TRALI标准，大多数表现为“肺损伤”（PaO₂/FiO₂比值<300）但与输血无关（65%对64%）。
输血与多种术后肺部并发症指标相关。然而，作为TRALI重要标准的PaO₂/FiO₂比值与输血无关。因此，由于心脏手术的性质，应用共识指导的TRALI诊断存在问题。
