Cardiac anesthesia risk management. Hemorrhage, coagulation, and transfusion: a risk-benefit analysis

Transfusion risks include the possibility of ABO/Rh incompatibility, sepsis, febrile reactions, immunosuppression, and viral transmission; incidences and consequences of these complications are reviewed. Predonation of autologous blood generally reduces the need for homologous blood by about 30% to 40%, but relatively few coronary artery bypass surgery (CABG) patients predonate blood. Drug products to decrease blood use include 1-deamino-8-D-arginine vasopressin (DDAVP), tranexamic acid, epsilon-aminocaproic acid, and aprotinin. A recent study suggests that a subgroup of patients with abnormal platelet function may benefit from a platelet therapy such as DDAVP. The prophylactic use of tranexamic acid reduces cardiac surgery postoperative blood loss, as measured by chest-tube output, by about 30%; unfortunately, data demonstrating a reduction in transfusion requirements are not available. Aprotinin use is associated with major reductions in blood transfusion requirements. Aprotinin provides platelet protection during cardiopulmonary bypass. Duration of stay in the intensive care unit was not increased by use of aprotinin, thus alleviating some concerns that aprotinin might promote coronary thrombosis. A recent report cites early graft closure as a major concern with aprotinin therapy, but data from other studies show no significant differences in rates of graft closure between patients receiving and those not receiving aprotinin. Routine use of a thromboelastogram with all cardiopulmonary bypass surgery at the University of Washington Hospital has reduced use of blood products by 30%.