Department of Anesthesiology, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Los Angeles, CA 90095, USA.
Anesth Analg. 2013 Jun;116(6):1295-308. doi: 10.1213/ANE.0b013e31828d64ac. Epub 2013 Apr 4.
Red blood cell (RBC) transfusions are associated with increased morbidity. Children receiving heart transplants constitute a unique group of patients due to their risk factors. Although previous studies in nontransplant patients have focused primarily on the effects of postoperative blood transfusions, a significant exposure to blood occurs during the intraoperative period, and a larger percentage of heart transplant patients require intraoperative blood transfusions when compared with general cardiac surgery patients. We investigated the relationship between clinical outcomes and the amount of blood transfused both during and after heart transplantation. We hypothesized that larger amounts of RBC transfusions are associated with worsening clinical outcomes in pediatric heart transplant patients.
A database comprising 108 pediatric patients undergoing heart transplantation from 2004 to 2010 was queried. Preoperative and postoperative clinical risk factors, including the amount of blood transfused intraoperatively and 48 hours postoperatively, were analyzed. The outcome measures were length of hospital stay, duration of tracheal intubation, inotrope score, and major adverse events. Bivariate and multivariate analyses were performed to control for simultaneous risk factors and determine outcomes in which the amount of blood transfused was an independent risk factor.
Ninety-four patients with complete datasets were included in the final analysis. Eighty-eight percent received RBC transfusions, with a median transfusion amount of 38.7 mL/kg. A multivariate analysis correcting for 8 covariate risk factors, including the Index for Mortality Prediction After Cardiac Transplantation, age, weight, United Network for Organ Sharing status, warm and cold ischemia time, repeat sternotomy, and pretransplant hematocrit, showed RBC transfusions were independently associated with increased length of intensive care unit stay (means ratio = 1.34; 95% confidence interval, 1.03-1.76; P = 0.03), and increased inotrope score in the first postoperative 24 hour (mean ratio = 1.26; 95% confidence interval, 1.04-1.52; P = 0.04). Patients suffering major adverse events received significantly larger median amounts of blood RBC transfusions (P = 0.002). Transfusions >60 mL/kg were also associated with increased risk of major adverse events (accuracy 76%) including postoperative sepsis, extracorporeal membrane oxygenation, open chest, dialysis, and graft failure.
The majority of pediatric patients undergoing orthotropic heart transplantation receive RBC transfusions, with the largest amount transfused in the operating room. Escalating amounts of RBC transfusions are independently associated with increased length of intensive care unit stay, inotrope scores, and major adverse events. Since heart allografts are a limited resource, improvement in the blood transfusion and conservation practices can enhance clinical outcomes in pediatric heart transplant patients.
红细胞(RBC)输血与发病率增加有关。由于其危险因素,接受心脏移植的儿童构成了一组独特的患者群体。尽管以前的非移植患者研究主要侧重于术后输血的影响,但在手术期间会发生大量血液暴露,并且与一般心脏手术患者相比,更多的心脏移植患者需要术中输血。我们研究了术中及术后输血量与临床结局之间的关系。我们假设,较大剂量的 RBC 输血与儿科心脏移植患者的临床结局恶化有关。
查询了 2004 年至 2010 年间接受心脏移植的 108 例儿科患者的数据库。分析了术前和术后的临床危险因素,包括术中及术后 48 小时内输血的量。主要结局指标为住院时间、气管插管时间、儿茶酚胺评分和主要不良事件。进行了双变量和多变量分析,以控制同时存在的危险因素,并确定输血量是独立危险因素的结果。
在最终分析中,共有 94 例具有完整数据集的患者。88%的患者接受了 RBC 输血,中位输血量为 38.7 毫升/公斤。多变量分析校正了 8 个协变量危险因素,包括心脏移植后死亡率预测指数、年龄、体重、联合器官共享网络状态、热缺血和冷缺血时间、再次开胸和移植前血细胞比容,结果显示 RBC 输血与 ICU 住院时间延长(均数比=1.34;95%置信区间,1.03-1.76;P=0.03)和术后 24 小时儿茶酚胺评分增加(均数比=1.26;95%置信区间,1.04-1.52;P=0.04)有关。发生主要不良事件的患者接受的中位 RBC 输血量明显更大(P=0.002)。输血量>60 毫升/公斤也与主要不良事件(准确性 76%)的风险增加有关,包括术后败血症、体外膜氧合、开胸、透析和移植物衰竭。
大多数接受正交心脏移植的儿科患者接受 RBC 输血,术中输血量最大。RBC 输血量的增加与 ICU 住院时间延长、儿茶酚胺评分增加和主要不良事件独立相关。由于心脏同种异体移植物是一种有限的资源,因此改善输血和保存实践可以提高儿科心脏移植患者的临床结局。