The use of blood products after cardiac surgical interventions

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1 Identifying Patients at Risk of Intraoperative and Postoperative Transfusion in Isolated CABG: Toward Selective Conservation Strategies Rakesh C. Arora, MD, PhD, Jean-Francois Légaré, MD, Karen J. Buth, MS, John A. Sullivan, MD, and Gregory M. Hirsch, MD Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada CARDIOVASCULAR Background. Allogeneic blood product use during cardiac operation is often reported to exceed 40% despite published guidelines and costly blood conservation strategies. We developed a predictive model, based on eight preoperative risk factors, of allogeneic blood product transfusion rates in patients undergoing a cardiac procedure. Methods. All 3,046 consecutive, isolated coronary artery bypass graft (CABG) procedures at a university hospital from 1995 to 1998 were included. A logistic regression model was created to identify independent predictors of allogeneic blood product transfusion. This model was validated using a prospective patient sample. Results. Overall use of allogeneic blood products was 23% with a crude operative mortality of 2.1%. In isolated, elective, first-time CABG cases, 16.9% received allogeneic blood products. Independent predictors of blood product usage in CABG patients were preoperative hemoglobin 12.0 or less, emergent operation, renal failure, female sex, age 70 years or older, left ventricular ejection fraction 0.40 or less, redo procedure, and low body surface area. Prospective validation of this model on 2,117 consecutive isolated CABG patients demonstrated an observed-toexpected allogeneic blood product transfusion rate ratio of Conclusions. This internally validated logistic regression risk model is a sensitive and specific predictor of allogeneic blood product use in patients undergoing isolated CABG. Utilization of this model allows for preoperative risk stratification and may allow for more rational resource allocation of costly blood conservation strategies and blood bank resources. (Ann Thorac Surg 2004;78: ) 2004 by The Society of Thoracic Surgeons Accepted for publication April 27, Address reprint requests to Dr Hirsch, New Halifax Infirmary, QEII HSC, Division of Cardiac Surgery, 1796 Summer Room 2006, Halifax, Nova Scotia, B3H 3A7, Canada; ghirsch@dal.ca. The use of blood products after cardiac surgical interventions varies from 10% to 100% despite published transfusion guidelines [1 7]. Many factors have been proposed to explain this broad range of transfusion rates, including variation in individual physician practices, institutional policy, and patient comorbidities that will inform physicians about tolerable levels of anemia [6 8]. The substantial rate of allogeneic blood product utilization in cardiac operations, accounting for 10% of all blood products collected in the United States, raises concerns of associated morbidity such as hemolytic or allergic reactions, infections (human immunodeficiency virus, cytomegalovirus, hepatitis) [9], graft-versus-host disease [10] and an increased incidence of postoperative infections [3, 11] Taken together, these complications represent substantial human and financial costs [12 14]. In efforts to reduce perioperative blood product use, several effective blood conservation techniques have been developed. These include the use of nonhemic prime for the cardiopulmonary bypass (CPB) machine [15], salvage of blood from the surgical field with cardiotomy suction [16], hemodilution during CPB, retransfusion of all contents of the oxygenator at the end of CPB, acceptance of perioperative normovolemic anemia [17 19], and the routine use of antifibrinolytic medications. Additional techniques such as supplemental mechanical devices (ie, cell-saving systems), autotransfusion of shed mediastinal chest tube drainage, use of modified ultrafiltration, and autologous blood donation programs have also been demonstrated to reduce allogeneic blood product transfusion [2, 16, 20 22]. However, the cost effectiveness of the indiscriminate application of these expensive strategies for patients undergoing isolated coronary artery bypass grafting (CABG) procedures has been questioned [7, 16, 23]. To allow for appropriate allocation of blood bank resources, a preoperative determination of which patients are at high risk of transfusion is desirable, and by inference would merit the expense associated with these conservation strategies. In the present study, we have retrospectively reviewed the perioperative use of blood products in all patients undergoing an isolated CABG procedure from 1995 through 1998 in a single academic institution. On analysis of this retrospective data, we sought to develop a preoperative risk model capable of predicting the perioperative use of allogeneic blood products and subsequently validate this model on a separate group of patients to guide strategies of blood conservation by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /j.athoracsur

2 CARDIOVASCULAR 1548 ARORA ET AL Ann Thorac Surg RISK OF TRANSFUSION IN ISOLATED CABG 2004;78: Abbreviations and Acronyms AFL anti-fibrinolytic medication BSA body surface area CABG coronary artery bypass grafting CI confidence interval CMV cytomegalovirus CPB cardiopulmonary bypass DM diabetes mellitus EF left ventricular ejection fraction Hb hemoglobin Hct hematocrit HIV human immunodeficiency virus HTN hypertension IABP intraaortic balloon pump NYHA New York Heart Association O:E observed to expected ratio OPCAB off-pump coronary artery bypass grafting prbc packed red blood cells redo reoperative procedure ROC receiver operator curve SD standard deviation Material and Methods Data Source The Maritime Heart Center Database is a prospectively collected database containing relevant patient demographic data, comorbidities, intraoperative variables, and postoperative outcomes at a large Canadian Centre. These data are captured for all cases undergoing a cardiac procedure at the QEII Health Sciences Centre and undergoes an internal audit annually. The data of 3,046 consecutive patients undergoing isolated CABG between March 1995 and December 1998 were analyzed retrospectively. Comorbid variables (diabetes mellitus, hypertension, hypercholesterolemia, preexisting renal failure), New York Heart Association (NYHA) class, ejection fraction (EF), redo operations, preoperative intravenous nitrate usage, and procedure urgency status were evaluated, and intraoperative and postoperative variables were collected for this study. The use of off-pump CABG (OPCAB) procedures was first initiated in October Subsequently, all OPCAB cases, from October 1997 to January 1999, were included in the analysis. The need for ethics approval was waived as only encrypted, anonymous patient identifiers were used in the data collection process. Urgency status was determined using the Maritime Heart Centre Cardiac Surgery database definitions. An elective case was defined as any patient who remained clinically stable for more than 24 hours before the procedure. The term in-house elective referred to inpatients receiving medical treatment for more than 48 hours, pending surgery. Many of these patients were receiving intravenous heparin or nitrates until the time of operation. An urgent classification denoted patients who required a procedure to be performed within 24 hours to prevent further clinical deterioration, and an emergent/ emergent salvage patient required an immediate operation. Body surface area (BSA) was calculated for each patient. Groupings for BSA were divided into approximate quartiles as follows: 2.04, 1.98 to 2.08, 1.86 to 1.90, and 1.80, as described previously [24]. All procedures were performed at a single tertiary care institution with university affiliation. Blood Conservation Strategies The techniques used at the study center included the use of nonhemic prime for the CPB machine [15], salvage of blood from the surgical field with cardiotomy suction [16], hemodilution during CPB, retransfusion of all contents of the oxygenator at the end of CPB, and acceptance of perioperative normovolemic anemia [17 19]. The use of antifibrinolytic medications, either epsilon aminocaproic acid or tranexamic acid, was routine in all cases except for patients with a known sensitivity to the agent. Aprotinin was used in less than 1% of cases, typically reserved for Jehovah Witness patients and/or selected cases considered at an increased risk of perioperative bleeding (e.g., complicated redo procedures and/or known coagulopathy not including patients on warfarin). The decision to use aprotinin was usually a joint determination between the individual surgeon and cardiac anesthetist. Before the discontinuation of epsilon aminocaproic acid we infused an initial 100 to 150 mg/kg bolus followed by continuous infusion of 10 mg/kg per hour until the termination of the case. For tranexamic acid, our usual dose was a bolus of 10 mg/kg and then an infusion of 1 mg/kg per hour. Aprotinin was given as a full Hammersmith dose with 2 million units on induction with an additional 2 million units in the CPB prime, followed by 500,000 U per hour until the administration of protamine. An intraoperative cell-saving device was used only occasionally, again, in complicated reoperative and in OPCAB procedures. Postoperatively nonhemic volume expanders were used routinely (ie, crystalloid and pentastarch solutions). Transfusion Triggers The need for perioperative blood product transfusion was determined on an individual, patient-by-patient basis by 1 of the 7 attending cardiovascular surgeons or supporting resident house staff. Overall transfusion rates of allogeneic blood products were captured for blood products given during and after the operation. The principal blood product used was packed red blood cells (prbcs). The decision to use blood products other than prbcs (ie, platelets, fresh frozen plasma, and cryoprecipitate) was made on a case-by-case basis for patients with evidence of ongoing blood loss or a demonstrable coagulopathy. Preoperative transfusions were not included in this analysis. Although no rigid criterion or single absolute hemoglobin (Hb) value was used as a trigger for transfusion, in general, allogeneic blood product transfusion was not considered until the serum Hb was less than 7 g/dl, unless evidence suggested ongoing blood loss or the patient was clinically considered at risk for inadequate

3 Ann Thorac Surg ARORA ET AL 2004;78: RISK OF TRANSFUSION IN ISOLATED CABG Table 1. Patient Demographics Variable Derivation Group (n 3,046) Validation Group (n 2,117) Age, mean SD (years) Age 70, n (%) 1,054 (35%) 703 (33%) Sex (male/female), n (%) 2,225/821 (73%/27%) 1,601/516 (76%/24%) Comorbidities, n (%) DM 888 (29%) 758 (36%) a Preop. renal failure 185 (6%) 104 (5%) HTN 1,680 (55%) 1,355 (64%) a Hypercholesterolmia 1,533 (50%) 1,672 (79%) a EF, mean SD EF 0.40, n (%) 347 (12%) 252 (12%) NYHA class III to IV, n (%) 2,821 (93%) 1,899 (90%) Preoperative hemoglobin, mean SD (g/dl) Antiplatelet therapy, n (%) 2,559 (84%) 1,836 (87%) Nitrate therapy, n (%) 565 (19%) 359 (17%) 1549 CARDIOVASCULAR a Significant difference between the derivation and validation group, p The comorbidities listed are expressed in absolute numbers of patients with the percentage of the overall cohort in parentheses. Renal failure was defined as serum creatinine 2 mg/dl. DM diabetes mellitus; EF left ventricular ejection fraction; HTN hypertension; NYHA New York Heart Association classification. oxygen delivery. This determination included patients with signs of insufficient tissue perfusion (lactate levels 2, mixed venous oxygen saturation 65%, urine output 0.5 ml kg 1 h 1 ), significant hemodynamic instability, the need for two or more inotropic agents, utilization of a intraaortic balloon pump (IABP), or organ dysfunction in two or more systems. The addition of prbcs to the CPB machine prime was considered (although not routinely given) if the calculated dilutional hematocrit was less than The decision to add prbcs to the prime was made in collaboration among the surgeon, anesthetist, and perfusionist at the time of the surgical procedure. Statistics The primary outcome was the transfusion of any allogeneic blood product (prbcs, plasma, platelets, or cryoprecipitate) during the intraoperative or postoperative period. Statistical analysis was performed using SAS 8.2 (SAS Institute Inc, Cary, NC). Continuous and discrete variables underwent univariate analysis by t test, 2,or Fisher exact test, as appropriate. Independent preoperative predictors of blood transfusion were identified by logistic regression, and variables were retained if their associated p A C-statistic was calculated as a measure of the sensitivity and specificity of the logistic regression model. The C-statistic is equivalent to the area under the receiver operating characteristic curve in which a C-value of 0.5 indicates no discriminatory power and a C-value of 1.0 indicates a perfect discrimination between patients requiring blood transfusion. Validation of this stepwise logistic model was performed using a bootstrapping procedure. C-statistic values were calculated for each of 200 bootstrap samples, and the 95% confidence interval (CI) was obtained from the 2.5 and 97.5 percentiles of the bootstrap distribution. In a second validation step, the original model (derivation group) was applied to a subsequent group of 2,117 isolated CABG cases (validation group) performed from January 1999 through September Results Patient Population Preoperative patient demographics are listed in Table 1 (derivation group). For the 3,046 isolated CABG patients, the mean age was years (range 26 to 93 years) and 35% (n 1,054) were older than 70 years of age. In this group of patients approximately 73% were male and 93% were NYHA class III or IV. The most common form of anticoagulant used before operation was antiplatelet therapy (84% of patients); 19% (n 565) were given intravenous nitrates. Reoperative procedures comprised 8% of all cases in the derivation group (Table 2). In the derivation group, the operation was classified as in-house elective for 33% (n 1,011). In our current surgical practice, OPCAB is undertaken for approximately 10% to 15% of our isolated CABG patients; however, when the derivation group data were collected, OPCAB procedures comprised a smaller percentage (n 83; 3% of derivation group). Therefore, we were unable to derive meaningful statistical analysis of the data as a group separate from the on-pump CABG cases in the derivation group. It is interesting to note, however, as displayed in Figure 1, that OPCAB patients had the lowest rates of transfusion among all groups of isolated CABG patients. Use of Blood Products The overall allogeneic transfusion rate for all patients undergoing an isolated CABG procedure (irrespective of urgency) was 23%. This included 83 OPCAB cases, with a rate of blood product utilization of 3.6% (Fig 1). With

4 CARDIOVASCULAR 1550 ARORA ET AL Ann Thorac Surg RISK OF TRANSFUSION IN ISOLATED CABG 2004;78: Table 2. Operative Variables Variable Derivation Group Validation Group All CABG cases 3,046 2,117 On-pump 2,963 (97%) 1,972 (93%) OPCAB 83 (3%) 145 (7%) a Operative mortality Isolated CABG 63 (2.1%) 60 (2.8%) OPCAB 0 (0%) 1 (0.7%) Redo operation 235 (8%) 107 (5%) a Urgency True elective 1,431 (47%) 1,075 (51%) In-house elective 1,011 (33%) 761 (36%) Urgent 467 (15%) 196 (9%) a Emergent/emergent salvage 137 (5%) 85 (4%) Overall transfusion rate 704 (23.1%) 500 (23.6%) a Significant difference between the derivation and validation group, p On-pump refers to isolated CABG requiring CPB. Preoperative urgency was based on the preoperative status of the patient (see Methods for descriptions). Emergent/emergent salvage patients needing an immediate operation or undergoing cardiopulmonary resuscitation en route to the operating theater. CABG coronary artery bypass grafting; CPB cardiopulmonary bypass; OPCAB off-pump coronary artery bypass grafting. respect to the frequency of the type of blood product used, 96.2% of all the patients transfused received packed red blood cells (prbcs), while 15.3% received fresh frozen plasma, 10.2% received platelets, and 1% received cryoprecipitate. Some patients received more than one type of product. Of the patients transfused in the original derivation group, 3.8% received blood products that did not include prbcs. Fig 1. Rate of allogeneic blood product transfusion in CABG procedures. (CABG coronary artery bypass grafting; OPCAB offpump CABG; redo reoperative CABG procedure [includes patients who underwent a previous sternotomy for a non-cabg procedure]; 1st time patient undergoing their first CABG procedure [no previous sternotomy]; urgent transfusion rate for all patients needing a CABG procedure within 24 hours; emergent/ emergent salvage patients needing an immediate operation or undergoing cardiopulmonary resuscitation en route to the operating theater.) Table 3. Univariate Risk Factors for Isolated CABG Cases Variable OR 95% CI p Preoperative hemoglobin to g/dl Renal failure to Emergent/emergent to salvage Female sex to Age 70 years to BSA to EF to Redo procedure to HTN to DM to Renal failure defined as serum creatinine 2 mg/dl; Emergent/ emergent salvage patients needing an immediate operation or undergoing cardiopulmonary resuscitation en route to the operating theatre. BSA body surface area; CABG coronary artery bypass grafting; DM diabetes mellitus; EF left ventricular ejection fraction; HTN hypertension. The in-hospital mortality for the derivation group was 2.1% (n 63). Of these 63 patients, 85.7% received at least one allogeneic blood product transfusion versus 21.8% in the remaining patients (p 0.001). Twenty-three patients (0.76%) required reexploration for postoperative bleeding, and 100% of these patients received a blood product. Procedure Urgency, Redo Operations, and Intraaortic Balloon Pump Use Procedure urgency was associated with increased rates of transfusion. Isolated elective ( true elective and inhouse elective) CABG procedures were associated with a transfusion rate of 18% versus 40% and 56% for urgent and emergent/emergent salvage procedures, respectively (p 0.001) (Fig 1). Redo operations accounted for 7.7% of all isolated CABG cases, and elective redo operations (n 162) had a higher transfusion rate (34%) than elective first-time CABG (17%) (p 0.001). Approximately 10% of OPCAB procedures (n 8) were done on an urgent basis, and 6% (n 5) of OPCAB cases were redo operations. Only 6.3% (n 191) of patients required perioperative IABP assistance. Of these patients, 60.2% (n 115) received an allogeneic transfusion compared with 20.6% transfusion rate in all other patients not requiring IABP use (p 0.001). The timing of insertion of an IABP also appeared to be related to the risk of transfusion. Patients who required an IABP preoperatively (n 153) had a transfusion rate of 54.2%, those receiving an IABP intraoperatively (n 19) required a blood transfusion 73.7% of the time, and nearly all patients (94.7%) requiring a postoperative IABP (n 19) received a blood transfusion. Univariate Predictors Several univariate risk factors were associated significantly with increased rate of blood transfusion; the strongest risk factor was the presence of a low preoperative Hb ( 12.0 g/dl) with a univariate odds ratio of 13.1 (Table 3).

5 Ann Thorac Surg ARORA ET AL 2004;78: RISK OF TRANSFUSION IN ISOLATED CABG Table 4. Multivariable Risk Factors for Isolated CABG Variable OR CI (95%) p Preoperative hemoglobin to g/dl Emergent/emergent to salvage Renal failure to EF to Redo procedure to Female sex to Age 70 years to BSA to CARDIOVASCULAR Renal failure was defined as serum creatinine 2 mg/dl. BSA body surface area; CABG coronary artery bypass grafting; EF left ventricular ejection fraction; Emergent/emergent salvage patients needing an immediate operation or undergoing cardiopulmonary resuscitation en route to the operating theatre. The mean SD preoperative Hb level of patients receiving blood transfusions was g/dl, compared with g/dl for patients not requiring blood transfusions (p 0.001). In addition, low BSA ( 1.80), female sex, and renal failure were also associated with an increased rate of allogeneic transfusion. However, preoperative Hb was significantly lower in patients with preoperative renal failure ( g/dl versus g/dl with normal renal function, p 0.001) and between sexes ( g/dl and g/dl in female versus male, p 0.001). Additionally, a greater proportion of women had a preoperative Hb less than 12.0 g/dl (36.3% versus 12.9%, female versus male, p 0.001). Furthermore, more women were in the lowest quartile of BSA ( 1.80) than men (71.5 versus 15.7 respectively; p 0.001). Multivariable Analysis The independent risk factors for increased rates of allogeneic blood product utilization are listed in Table 4. These risk factors are similar to predictors reported in previous studies of outcome after CABG operation [1, 2, 7, 25, 26]. Predicted probability of blood transfusion was calculated using coefficients from the logistic regression model (Fig 2). The lowest risk factor, BSA 1.80, carried a risk of 9.1% of transfusion whereas the strongest risk factor, preoperative Hb ( 12.0 g/dl), conferred a risk of 28.1%. The addition of further risk factors had an incremental risk of receiving allogeneic blood products, ultimately reaching 99.5% if all eight risk factors were present in a single patient. Model Validation For the logistic regression model, the Hosmer-Lemeshow goodness of fit p value was 0.83 and the C-statistic was The 95% CI of the C-statistic was calculated as 0.82 to 0.86 by bootstrap procedure. In the derivation group, the predicted allogeneic blood product transfusion rate was 22.8% while the actual observed transfusion rate was 23.1%, with an observed to expected (O:E) ratio of Fig 2. Predictive model of risk of allogeneic blood transfusion. The predicted probability of transfusion was directly related to the number of preoperative risk factors. Curve shown indicates body surface area as a single risk factor with the cumulative probability of allogeneic transfusion with additional preoperative risk factors. As a second validation step, the model was subsequently applied to a separate validation group of 2,117 consecutive patients (validation group) (January 1999 through September 2001). The validation group was similar to the derivation group except for a higher proportion of patients with diabetes mellitus, hypertension, and hypercholesterolemia (Table 1) and a lower proportion of patients undergoing a redo procedure or urgent status (Table 2). The predicted allogeneic blood product transfusion rate in the validation group was 22.2% while the actual observed transfusion rate was 23.6%, with an observed-to-expected ratio of Using the coefficients from the original model, the C-statistic for the validation group was 0.79, with a 95% CI of 0.77 to 0.81 obtained by bootstrap procedure. Risk Stratification In using the generated risk model, we were able to subdivide the original cohort (derivation group) of patients into four groups based on the predicted risk of allogeneic transfusion: very low ( 10% risk), low ( 10% to 20% risk), intermediate ( 20% to 50% risk), and high ( 50% risk) (Fig 3). When using these cut-off points, most patients in our original series of patients were allocated to the very low risk (39%) or low-risk group (29%), followed by an equal distribution in both the intermediate and high-risk groups (16% in each group). A small percentage of allogeneic transfusion occurred in the very low and low-risk groups, whereas substantially larger percentages of patients were transfused in both the remaining two groups (p ). Comment Nearly 10% of all collected prbcs are used in patients undergoing cardiac procedures [23, 27, 28]. This relatively high rate of transfusion is costly, and exposes patients undergoing cardiac operation to significant risk of com-

6 CARDIOVASCULAR 1552 ARORA ET AL Ann Thorac Surg RISK OF TRANSFUSION IN ISOLATED CABG 2004;78: Fig 3. Risk stratification of patients based on preoperative risk factors and the rates of transfusion for each group. Very low, low, intermediate, and high-risk ( ) groups refer to the percentage of patients in the original cohort who had a 10%, 10% to 20%, 20% to 50%, and 50% preoperative risk of transfusion. The black bars ( ) refer to distribution of patients who received an allogeneic transfusion. (y-axis percentage of patients in derivation group.) plications related to allogeneic blood products [10, 29, 30]. Many centers continue to report allogeneic blood transfusion rates of more than 50% despite pressures to minimize use of blood products [9, 27, 31]. In our patient population, which is representative of most large cardiac surgical centers in Canada [32, 33], the overall observed transfusion rate of 23% in the derivation group of patients (n 3046) with an overall mortality of 2.0% compares favorably with other reports in the literature [2, 7, 26, 31, 34, 35]. A significant proportion of these patients were older than 70 years (34.6%), 7.7% were reoperative procedures, and 92.6% were in NYHA functional class III or IV. The lowest transfusion rates were achieved for elective, first-time isolated CABG procedures, with a rate of 17.3% when using CPB and 2.7% for OPCAB cases (Fig 1) Costly supplemental methods of blood conservation, such as the use of preoperative donation of autologous blood and postoperative autotransfusion of shed mediastinal blood [21], were not used at our institution and therefore not included in this study. These data suggest that indiscriminate implementation of these conservation techniques is not necessary to achieve relatively low overall transfusion rates. A risk model generated from a retrospective analysis of 3,046 consecutive, isolated CABG patients reliably predicted allogeneic blood product transfusion rates based on eight, easily identifiable, preoperative risk factors. Independent risk factors identified for blood transfusion in isolated CABG patients in this study included preoperative Hb less than g/dl, emergent operation, renal failure, female sex, age older than 70 years, EF less than 0.40, redo procedure, and low BSA, are similar to those reported by others [1]. Validation of this model in a separate group of 2,117 CABG patients confirmed its predictive value. Practical Implementation of the Predictive Model The safety and cost efficacy of autologous blood donation programs remain controversial [36]. Data derived from a prospective study examining a preoperative autologous donation program for CABG patients demonstrated significant associated cost implications in the order of $508,000 to $909,000 (US dollars) per quality-adjusted year of life saved [31]. Similarly, whereas autotransfusion of shed mediastinal blood may reduce the risk of infection and administrative errors associated with stored blood, several studies, including two prospective, randomized trials, failed to show any significant reduction in the amount of allogeneic transfusion requirements in postoperative cardiac patients [22, 37, 38]. One conclusion to be drawn from these studies is that the cost of implementing these techniques is not justified. An alternate conclusion may be that widespread utilization of these strategies may not be rational; however, selected use in patients most likely to benefit may demonstrate a cost-effective savings. For efficacious delivery, patients who are most likely to benefit from these interventions would need to be identified preoperatively. Our findings suggest that, based on easily identifiable preoperative patient characteristics, subgroups of patients have a very low, low, intermediate, or high risk of receiving allogeneic blood products (Figs 2, 3). Utilizing the predictive model in this manner, the efficacy of costly blood conservation strategies could be evaluated in a subset of patients, and cost-effectiveness determined. An example, proposed by others in both limited cardiac and noncardiac patient populations, are potential cost savings by eliminating the need for an obligatory preoperative allogeneic blood cross-match (at an additional cost of Canadian $72.00/patient at our center) in patients identified as low risk for transfusion. If we set the criteria for a low-risk patient at a predicted risk of transfusion of 20% or less (as suggested by others in noncardiac operation patients [39] (n 2,058 or 68% of isolated CABG cases in our center), the cost saving per annum of performing a group and screen only (ABO typing and basic antibodies) versus a full cross-match is approximately $148,000 ($Cdn) at our institution. We have, since the close of this study, initiated a no cross-match policy in a limited manner for elective low risk patients at our institution. At 6 months (n 300 patients), we have experienced no morbidity or mortality related to this procedural change. This model, in contrast to previous studies [1, 34, 35], examined the transfusion rates of all postoperative blood products for a large group of consecutive patients and included both on-pump and off-pump cases, first-time and redo CABG, as well as elective, urgent, and emergent cases. In addition, this robust predictive model was further validated on a separate large group of consecutive patients. Others [25] have suggested that, due to baseline differences, ubiquitously applying a predictive model to all isolated CABG patients may not be appropriate and use of the model should therefore be limited to elective, first-time CABG cases. In contrast, our model included 1,011 patients (33% of the derivation group) who

7 Ann Thorac Surg ARORA ET AL 2004;78: RISK OF TRANSFUSION IN ISOLATED CABG Fig 4. Sample score card for predicting the risk of receiving allogeneic blood products to determine if a patient receives a group and screen versus full cross-match and type blood analysis. (BSA body surface area [m 2 ]; EF left ventricular ejection fraction; renal failure serum creatinine 2 mg/dl.) were, as stated in-house elective receiving medical treatment (including intravenous nitrates) for more than 48 hours before operation. Inclusion of these patients and subsequent application of our model to a large validation group, using only basic blood conservation strategies, demonstrated its generalizability to a more diverse group than purely elective, first-time isolated CABG cases. These results broaden the application of such data to a more representative group of patients in most surgeons practices. An example of an easy-to-use preoperative risk-score card based on our model that could be used to predict the risk of transfusion is illustrated in Figure 4. Limitations This study, while an assessment of transfusion rates at a single center, provided important information on transfusion practices. We showed that despite having many levels of decision makers (house staff, cardiac surgeons, anesthetists) and a lack of rigid transfusion criterion, the overall transfusion rate was maintained at less than 25% with low mortality in a population with a high premorbid risk [32, 33]. Additionally, the model was validated internally on a large group of consecutive, isolated CABG patients to ensure generalizability to a diverse (both elective and nonelective) group of patients. Validation of our model in another center with similar transfusion and perioperative blood conservation strategies would add further strength to the predictive power of this model as site specificity may also play a role in allogeneic transfusion rates. Although utilizing the predictive model allows for stratification of risk based on preoperative risk factors, an overlap exists in groups of patients with two or more risk factors (Fig 2). Nevertheless, patients at either extreme of the model have predictable rates of transfusion and therefore are amenable to both further study and costsaving strategies. In summary, we evaluated blood transfusion practices after CABG operation. The patient population was representative of a tertiary referral center and the findings are likely applicable to other similar populations found in North American centers [32, 33]. A stable predictive model was generated from a large CABG population in which we could predict preoperatively, on an individual basis, the risk of receiving any blood products after operation. The strategy of introducing a no-cross-match policy is one example of the utility of the model presented in this study. The model provides the framework for a rational approach of appropriately targeting more costly strategies such as autologous blood donation, cell-saving systems, and the use of more expensive fibrinolytics (ie, aprotinin). By eliminating unnecessary expense among low-risk patients and identifying highrisk patients in whom more costly blood conservation strategies could be effective, this predictive model could have a substantial effect on both quality and cost of care. References Cosgrove DM, Loop FD, Lytle BW, et al. Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg 1985;40: Breyer RH, Engleman RM, Rousou JA, Lemeshow S. Blood conservation for myocardial revascularization. J Thorac Cardiovasc Surg 1987;93: LoCicero J, Massad M, Gandy K, et al. Aggressive blood conservation in coronary artery surgery: impact on patient care. J Cardiovasc Surg 1990;31: Giordano GF, Rivers SL, Chung GKT, et al. Autologous platelet-rich plasma in cardiac surgery: effect on intraoperative and postoperative transfusion requirements. Ann Thorac Surg 1988;46: Hasley PB, Lave JR, Hanusa BH, et al. Variation in the use of red blood cell transfusions. A study of four common medical and surgical conditions. Med Care 1995;33: Welch HG, Meehan KR, Goodnough LT. Prudent strategies for elective red blood cell transfusion. Ann Intern Med 1992;116: Goodnough LT, Despotis GJ, Hogue CW, Ferguson TB. On the need for improved transfusion indicators in cardiac surgery. Ann Thorac Surg 1995;60: Goodnough LT, Marilyn FM, Shah T, Chernosky A. A two-institution study of transfusion practice in 78 consecutive adult elective open-heart procedures. Am J Clin Pathol 1989;91: Goodnough LT, Brecher ME, Kanter MH, AuBuchon JP. CARDIOVASCULAR

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Autotransfusion of unwashed mediastinal shed blood fails to decrease banked blood requirements in patients undergoing aortocoronary surgery. Am J Surg 1991;162: van Klei WA, Moons KG, Leyssius AT, Knape JT, Rutten CL, Grobbee DE. A reduction in type and screen: preoperative prediction of RBC transfusions in surgery procedures with intermediate transfusion risks. Br J Anaesth 2001;87: INVITED COMMENTARY Being able to identify patients undergoing open-heart surgery who are likely to receive transfusion now extends back over nearly 20 years [1]. Subsequent single center analyses [2, 3], including that by Arora and colleagues in this issue [4], have confirmed or extended our knowledge of predictors. Yet there remains an underutilization of algorithms or strategies that base patient management on these predictors, as evidenced by the continued variability of both blood transfusion outcomes and blood conservation utilization across institutions. The resulting transfusion rates of 23% [4] to 61% [2] in programs without aggressive utilization of blood conservation versus those as low as 10% [1] to 13% [3] at institutions with more aggressive blood conservation [5] illustrates the dilemma. Comprehensive use of all blood conservation modalities with appropriately restrictive use of transfusion thresholds may result in a tighter definition of predictors, as illustrated by other authors [6]. Age, gender, and other variables that are accepted predictors of blood product transfusion may lose their value as more data becomes available on conservation techniques in elective cardiac surgery [3]. What efforts are needed to more effectively use blood in this population, particularly for elective, uncomplicated cardiac surgery? Emerging data suggest that use of rigorous protocols, especially in the detection and treatment of preoperative anemia and intraoperative realtime coagulation monitoring can reduce the need for 2004 by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /j.athoracsur