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Article

Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit

by
Hani Karameh
1,*,
Sharon Bruoha
2,
Louay Taha
1,
Meir Tabi
1,
Rivka Farkash
1,
Mohammad Karmi
1,
Kamal Hamayel
1,
Nimrod Perel
1,
Yoed Steinmetz
1,
David Marmor
1,
Mohammed Manassra
1,
Tomer Maller
1,
Rafael Hitter
1,
Itshak Amsalem
1,
Michael Glikson
1 and
Elad Asher
1 on behalf of the Jerusalem Platelets Thrombosis and Intervention in Cardiology (JUPITER-4) Study Group
1
Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9103102, Israel
2
Department of Cardiology, Barzilai Medical Center, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2023, 12(4), 1304; https://doi.org/10.3390/jcm12041304
Submission received: 20 December 2022 / Revised: 21 January 2023 / Accepted: 3 February 2023 / Published: 7 February 2023
(This article belongs to the Section Cardiology)
Browse Figures
Review Reports Versions Notes

Abstract

:
Background: Acutely ill patients treated with blood transfusion (BT) have unfavorable prognoses. Nevertheless, data regarding outcomes in patients treated with BT admitted into a contemporary tertiary care medical center intensive cardiac care unit (ICCU) are limited. The current study aimed to assess the mortality rate and outcomes of patients treated with BT in a modern ICCU. Methods: Prospective single center study where we evaluated mortality, in the short and long term, of patients treated with BT between the period of January 2020 and December 2021 in an ICCU. Outcomes: A total of 2132 consecutive patients were admitted to the ICCU during the study period and were followed-up for up to 2 years. In total, 108 (5%) patients were treated with BT (BT-group) during their admission, with 305 packed cell units. The mean age was 73.8 ± 14 years in the BT-group vs. 66.6 ± 16 years in the non-BT (NBT) group, p < 0.0001. Females were more likely to receive BT as compared with males (48.1% vs. 29.5%, respectively, p < 0.0001). The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001. Multivariate Cox analysis found that even one unit of BT was independently associated with more than two-fold the mortality rate [HR = 2.19 95% CI (1.47–3.62)] as compared with the NBT-group, p < 0.0001]. Receiver operating characteristic (ROC) curve was plotted for multivariable analysis and showed area under curve (AUC) of 0.8 [95% CI (0.760–0.852)]. Conclusions: BT continues to be a potent and independent predictor for both short- and long-term mortality even in a contemporary ICCU, despite the advanced technology, equipment and delivery of care. Further considerations for refining the strategy of BT administration in ICCU patients and guidelines for different subsets of high-risk patients may be warranted.

1. Introduction

With advanced interventions and delivery of care, modern intensive cardiac care units (ICCUs) have changed from units primarily dedicated to managing patients with acute coronary syndromes (ACS) into units dealing with heterogeneous patients with different acute and chronic cardiovascular conditions [1,2]. Consequently, the prevalence of ischemic heart disease patients has decreased, whereas the proportion of patients with other cardiac comorbidity conditions such as valvular heart disease, heart failure (HF), malignant arrythmias and venous thromboembolism [3] increased. Moreover, not uncommonly, patients with chronic cardiovascular comorbidities presenting with acute noncardiac conditions, such as sepsis and kidney injury, are also managed in the ICCU [2,4].
Anemia commonly affects critically ill patients and is associated with increased morbidity and mortality [5]. The management of low hemoglobin levels frequently includes blood transfusions (BT), one of the most common treatments in the intensive care setting [6]. However, the benefits of liberal BT in hemodynamically stable trauma patients and critically ill patients with anemia are debatable [7,8,9,10,11]. Conversely, patients with pre-existing coronary lesions and limited flow reserve may experience a higher rate of adverse events due to the additional risk of myocardial ischemia and infarction as a result of anemia [12]. In the recently published REALITY trial, evaluating patients with acute myocardial infarction (MI) and anemia, a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiac events (MACE) after 30 days [13]. Despite being a potentially lifesaving therapy, BT may be associated with fatal adverse events including transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury, which are associated with non-neglectable mortality, apart from other infectious and non-infectious transfusion reactions including transfusion-associated immunosuppression and allosensitization, which is known as transfusion-related immune modulation (TRIM) [12,14,15,16,17,18]. Despite several clinical practice guidelines for transfusion, none fully addresses the relevant subgroups of ICCU patients [18,19,20]. Available evidence supports a restrictive BT approach for non-bleeding, critically ill, general ICU patients with hemoglobin (Hb) level <7 g/dL. In patients with coexisting cardiovascular disease and planned cardiac surgery, the cut-off is higher at Hb level of <8 g/dL [15,18,21,22,23,24,25]. Hence, the aim of the current study was to examine mortality rates and outcomes in patients treated with BT in a contemporary tertiary ICCU.

2. Methods

All patients admitted to the ICCU at a tertiary care medical center between January 2020 and December 2021 were included in the study and were followed-up for up to 2 years. Restrictive transfusion strategy was adopted at out center, where BT was indicated if Hb level was ≤7–8 g/dL or if there was evidence of active bleeding with signs of hemodynamic instability [13,26,27]. Hemodynamic instability was defined as persisting hypotension requiring vasopressors to maintain mean arterial pressure ≥65 and serum lactate level greater than 2 mmol/L in the absence of hypovolemia at the time of transfusion [28].

2.1. Data Collection

Data were anonymously submitted and prospectively documented into an electronic case report form and then were checked for accurateness and out-of-range values by a local coordinator. Demographic data, comorbidity conditions and clinical diagnoses were systematically recorded as well as laboratory and imaging data. Overall mortality rates were determined from the Israeli Ministry of Internal Affairs data.
The study was approved by the SZMC Institutional Review Board (approval number 0233-19-SZMC) with the exemption from informed consent.

2.2. Study Outcomes

The primary outcome was overall mortality rates, assessed at 1 year from time of index hospitalization. The study secondary outcomes were in-hospital complications during the index hospitalization and length of stay.

2.3. Statistical Analyses

For categorical variables, characteristics were expressed as numbers and percentages, and for continuous variables, as means, standard deviations or medians with interquartile ranges. Chi-square and Fisher’s exact tests were used to analyze relationships between categorical variables. Through the use of Student’s t- and Mann–Whitney tests, the impact of categorical variables on continuous measurements was examined. The distribution of the continuous variable determined whether a parametric or nonparametric test should be used. By using a stepwise backward Cox proportional hazards model adjusted for blood transfusion groups for age, sex, prior cardiac intervention and different cardiac risk factors, the mortality rate was examined. All tests were two-sided, and statistical significance was set at p < 0.05. Version 25.0 of SPSS Statistics for Windows was used to conduct the analyses (IBM Corp, Armonk, NY, USA).

3. Results

3.1. Patient Characteristics

Two thousand one hundred and thirty-two patients were admitted to the ICCU during the study period. The mean age was 66.9  ±  16 years old and 650 (30.5%) were female. One hundred and eight (5%) patients were treated with BT (BT-group) during their hospitalization, with a total of 305 packed cells (PCs) transfusions. Of them, 31.4% of patients received a single PC, 29.6% received two PCs and 39% received ≥ three PCs, as shown in Figure 1. Patients who received BT were more likely to be elderly, female, have lower body mass index (BMI) and suffer more from hypertension, coronary artery disease (CAD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pulmonary hypertension, anemia and chronic kidney disease (CKD), compared with the non-BT group. Of note, ninety-five percent of PC transfusions were of standard unmodified packed red blood cells, whereas leukocyte reduced or irradiated and leuko-reduced packed red blood cells were documented in 5% of the PC transfusions. (Table 1).

3.2. Diagnosis on Admission and Blood Transfusion

The most common diagnosis for admission was ACS; almost all ACS patients underwent coronary angiography, and the majority also underwent percutaneous coronary intervention (PCI). Nevertheless, there was no increased rate of BT in this subgroup (Table 2). Patients presenting with shock, whether cardiogenic or septic, CHF exacerbation and post trans-catheter aortic implantation (TAVI) were all more likely to receive BT during their admission, as presented in Table 3 and Table 4. Interestingly, patients admitted due to other cardiac interventions, such as mitral clip, electrophysiologic study and implantation of a pacemaker, intracardiac defibrillator (ICD) or cardiac resynchronization therapy (CRT), were less likely to receive BT during their admission.

3.3. Length of Stay (LOS) and In-Hospital Complications

Median LOS [IQR] was 5 [2,3,4,5,6] days in the BT-group versus 3 [2,3,4] days in the NBT-group, p < 0.001. In-hospital complications were also significantly higher in the BT group and included acute kidney injury (AKI), shock and sepsis, as shown in Table 4.

3.4. Mortality Rate

The crude mortality rate was 29.6% in the BT-group and 9.2% in the NBT-group, p < 0.0001, as shown in Figure 2. Multivariate Cox analysis for female gender, previous TAVI, cardiac intervention, pacemaker implantation, CHF, sepsis, pulmonary hypertension and low hemoglobin levels found that BT as compared with NBT was independently associated with more than two-fold the mortality rate [HR = 2.19, 95% CI (1.47–3.62), p < 0.001] as shown in Table 5. Multivariate analysis ROC curve was plotted and showed an AUC of 0.8, [95%CI (0.760–0.852)] (Figure 3). Multivariate Cox regression model for the number of PCs units received per patient was also independently associated with mortality, with HR of 2.4, 1.5 and 2.5 for 1, 2 and ≥3 PCs units, respectively.

4. Discussion

The optimal strategy of BT in ICCU remains controversial, with an increasing number of studies supporting a more restrictive transfusion strategy. Although several studies have tried to address BT in specific situations, such as ACS [13], CHF or post CABG [29], very few have specifically addressed BT in ICCU patients. The present study evaluated the impact of BT on outcomes in a tertiary care center ICCU all-comers population. Our main findings were: (1) Patients treated with BT were older with a higher proportion of females, concurrent comorbidities and in-hospital complications; (2) Patients diagnosed with shock, CHF exacerbation and post TAVI were more likely to receive BT during their admission. Conversely, patients admitted for other cardiac interventions were less likely to receive BT; (3) Even one unit of BT was independently associated with more than two-fold the risk of death; (4) BT was associated with longer length of hospital stay.
Our findings are in accordance with previous studies that found an increased likelihood of BT in elderly patients [26] and females [27]. In a study including patients with non-ST elevation myocardial infarction (NSTEMI) [26], patients of 75 years of age or more had a three-fold increased likelihood of BT than patients <55 years old. Another study evaluating patients with acute coronary syndrome reported that transfused patients were more likely to be elderly and females [27]. Patients undergoing TAVI do not uncommonly require peri-procedural blood transfusion [30]. The multicenter Transfusion Requirements in Transcatheter Aortic Valve Implantation (TRITAVI) registry reported an RBC transfusion rate of 16% in a transfemoral TAVI population [31]. The relative high transfusion rate in our cohort may be attributed to more complex and elderly patients admitted in the ICCU, a sizeable number of procedures performed via alternative vascular access site and thus associated with higher bleeding rates and treating high-risk patients prone to vascular complications.
The independent increased risk of mortality associated with BT has been documented across multiple “real world” cohorts and randomized trials [32,33,34], including ICU [35] and ICCU [36] populations, as in our study. Although considered generally safe and effective, BT can potentially carry considerable risks due to adverse events such as electrolyte disturbances, volume overload and transfusion reactions [37,38,39,40]. However, in high-risk populations, several factors, such as impaired oxygenation, reduced deformability of stored red blood cells, prothrombotic effects due to increased release of procoagulant factors, and transfusion-associated immunosuppression and allosensitization which is known as transfusion related immune modulation(TRIM), have been proposed to explain the association between blood transfusions and poor prognosis [17,34]. Furthermore, BTs are often administered in response to bleeding events, which themselves confer additional risk [26]. Our findings further support the available data, including the evidence of the detrimental effects of BT seen from the very first administered RBC unit.
The potentially harmful effects of BT have led to the adoption of a more cautious transfusion approach, with current guidelines recommending a restrictive BT strategy [i.e., limiting the transfusion of packed red blood cells to hemodynamically stable patients with a Hb value <7 g/dL] in non-bleeding, critically ill patients [22,41]. The restrictive transfusion strategy was found to be non-inferior to a liberal blood administration approach, also in patients with acute MI and Hb level < 8 g/dL [13]. However, proper implementation of recommendations onto specific subsets of high-risk populations is still rather challenging and often requires a personalized approach [42].
Finally, despite all precautionary measures including fluoroscopy- and US-guided vascular punctures, smaller gauge needles used for vascular access, activated clotting time (ACT) monitoring and experienced interventional cardiologists and ICCU intensivists, iatrogenic vascular complications leading to bleeding and anemia are not uncommon. Unfortunately, a recent study reported no benefit of US-guided arterial access used for cardiac interventions in reducing bleeding or vascular complications [43]. Consequently, additional strategies to make vascular access safer are needed.
Limitations: Our study had several limitations; first, we did not stratify patients according to the BT indication. Hence, the mortality rate recorded in our cohort may underestimate the true fatality rate in patients receiving BT following acute bleeding compared with BT administered following other indications. Second, it is a single-center study with its inherent biases; nevertheless, our study consists of a large number of consecutive patients in a real life setting of a tertiary care center ICCU. Third, the causes of death have not been systematically collected. Lastly, we investigated only RBC transfusions. The administration of other blood products has not been studied.
Conclusion: In a contemporary tertiary ICCU delivering guidelines-oriented care, even a single BT remains an independent strong predictor for poor outcomes. Thus, guidelines for further refining the strategy of BT administration in the ICCU setting, including different subsets of high-risk patients, may be warranted.

Author Contributions

Conceptualization, H.K.; Methodology, R.F.; Validation, R.F.; Formal analysis, M.T. and R.F.; Investigation, R.H. and I.A.; Data curation, L.T., R.F., M.K., K.H., N.P., Y.S., T.M., D.M. and M.M.; Writing—original draft, H.K. and E.A.; Writing—review & editing, H.K., S.B., M.G. and E.A.; Supervision, H.K. and E.A.; Project administration, H.K. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

SZMC Institutional Review Board (approval number 0233-19-SZMC) with the exemption from informed consent.

Data Availability Statement

Data provided upon request.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Katz, J.N.; Minder, M.; Olenchock, B.; Price, S.; Goldfarb, M.; Washam, J.B.; Barnett, C.F.; Newby, L.K.; van Diepen, S. The Genesis, Maturation, and Future of Critical Care Cardiology. J. Am. Coll. Cardiol. 2016, 68, 67–79. [Google Scholar] [CrossRef]
  2. Katz, J.N.; Shah, B.R.; Volz, E.M.; Horton, J.R.; Shaw, L.K.; Newby, L.K.; Granger, C.B.; Mark, D.B.; Califf, R.M.; Becker, R.C. Evolution of the coronary care unit: Clinical characteristics and temporal trends in healthcare delivery and outcomes. Crit. Care Med. 2010, 38, 375–381. [Google Scholar] [CrossRef]
  3. Sinha, S.S.; Sjoding, M.W.; Sukul, D.; Prescott, H.C.; Iwashyna, T.J.; Gurm, H.S.; Cooke, C.R.; Nallamothu, B.K. Changes in Primary Noncardiac Diagnoses Over Time Among Elderly Cardiac Intensive Care Unit Patients in the United States. Circ. Cardiovasc. Qual. Outcomes 2017, 10, e003616. [Google Scholar] [CrossRef]
  4. Ratcliffe, J.A.; Wilson, E.; Islam, S.; Platsman, Z.; Leou, K.; Williams, G.; Lucido, D.; Moustakakis, E.; Rachko, M.; Bergmann, S.R. Mortality in the coronary care unit. Coron. Artery Dis. 2014, 25, 60–65. [Google Scholar] [CrossRef]
  5. Rodriguez, R.M.; Corwin, H.L.; Gettinger, A.; Corwin, M.J.; Gubler, D.; Pearl, R.G. Nutritional deficiencies and blunted erythropoietin response as causes of the anemia of critical illness. J. Crit. Care 2001, 16, 36–41. [Google Scholar] [CrossRef]
  6. Napolitano, L.M. Scope of the problem: Epidemiology of anemia and use of blood transfusions in critical care. Crit. Care 2004, 8 (Suppl. 2), S1. [Google Scholar] [CrossRef]
  7. Napolitano, L.M.; Kurek, S.; Luchette, F.A.; Corwin, H.L.; Barie, P.S.; Tisherman, S.A.; Hebert, P.C.; Anderson, G.L.; Bard, M.R.; Bromberg, W.; et al. Clinical practice guideline: Red blood cell transfusion in adult trauma and critical care. Crit. Care Med. 2009, 37, 3124–3157. [Google Scholar] [CrossRef]
  8. Shaw, R.E.; Johnson, C.K.; Ferrari, G.; Brizzio, M.E.; Sayles, K.; Rioux, N.; Zapolanski, A.; Grau, J.B. Blood transfusion in cardiac surgery does increase the risk of 5-year mortality: Results from a contemporary series of 1714 propensity-matched patients. Transfusion 2014, 54, 1106–1113. [Google Scholar] [CrossRef]
  9. Turan, A.; Yang, D.; Bonilla, A.; Shiba, A.; Sessler, D.I.; Saager, L.; Kurz, A. Morbidity and mortality after massive transfusion in patients undergoing non-cardiac surgery. Can J. Anaesth 2013, 60, 761–770. [Google Scholar] [CrossRef]
  10. Bernard, A.C.; Davenport, D.L.; Chang, P.K.; Vaughan, T.B.; Zwischenberger, J.B. Intraoperative transfusion of 1 U to 2 U packed red blood cells is associated with increased 30-day mortality, surgical-site infection, pneumonia, and sepsis in general surgery patients. J. Am. Coll. Surg. 2009, 208, 931–937.e2. [Google Scholar] [CrossRef]
  11. Corwin, H.L.; Gettinger, A.; Pearl, R.G.; Fink, M.P.; Levy, M.M.; Abraham, E.; MacIntyre, N.R.; Shabot, M.M.; Duh, M.S.; Shapiro, M.J. The CRIT Study: Anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit. Care Med. 2004, 32, 39–52. [Google Scholar] [CrossRef]
  12. Carson, J.L.; Duff, A.; Poses, R.M.; Berlin, J.A.; Spence, R.K.; Trout, R.; Noveck, H.; Strom, B.L. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996, 348, 1055–1060. [Google Scholar] [CrossRef]
  13. Ducrocq, G.; Gonzalez-Juanatey, J.R.; Puymirat, E.; Lemesle, G.; Cachanado, M.; Durand-Zaleski, I.; Arnaiz, J.A.; Martínez-Sellés, M.; Silvain, J.; Ariza-Solé, A.; et al. Effect of a Restrictive vs Liberal Blood Transfusion Strategy on Major Cardiovascular Events Among Patients With Acute Myocardial Infarction and Anemia: The REALITY Randomized Clinical Trial. JAMA 2021, 325, 552–560. [Google Scholar] [CrossRef]
  14. Ferraris, V.A.; Brown, J.R.; Despotis, G.J.; Hammon, J.W.; Reece, T.B.; Saha, S.P.; Song, H.K.; Clough, E.R.; Shore-Lesserson, L.J.; Goodnough, L.T.; et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann. Thorac. Surg. 2011, 91, 944–982. [Google Scholar] [CrossRef]
  15. Semple, J.W.; Rebetz, J.; Kapur, R. Transfusion-associated circulatory overload and transfusion-related acute lung injury. Blood 2019, 133, 1840–1853. [Google Scholar] [CrossRef]
  16. Ackfeld, T.; Schmutz, T.; Guechi, Y.; Le Terrier, C. Blood Transfusion Reactions—A Comprehensive Review of the Literature including a Swiss Perspective. J. Clin. Med. 2022, 11, 2859. [Google Scholar] [CrossRef]
  17. Nelson, K.A.; Aldea, G.S.; Warner, P.; Latchman, Y.; Gunasekera, D.; Tamir, A.; Gernsheimer, T.; Bolgiano, D.; Slichter, S.J. Transfusion-related immunomodulation: Gamma irradiation alters the effects of leukoreduction on alloimmunization. Transfusion 2019, 59, 3396–3404. [Google Scholar] [CrossRef]
  18. Padhi, S.; Kemmis-Betty, S.; Rajesh, S.; Hill, J.; Murphy, M.F.; Group, G.D. Blood transfusion: Summary of NICE guidance. BMJ 2015, 351, h5832. [Google Scholar] [CrossRef]
  19. Mueller, M.M.; Van Remoortel, H.; Meybohm, P.; Aranko, K.; Aubron, C.; Burger, R.; Carson, J.L.; Cichutek, K.; De Buck, E.; Devine, D.; et al. Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference. JAMA 2019, 321, 983–997. [Google Scholar] [CrossRef]
  20. Carson, J.L.; Guyatt, G.; Heddle, N.M.; Grossman, B.J.; Cohn, C.S.; Fung, M.K.; Gernsheimer, T.; Holcomb, J.B.; Kaplan, L.J.; Katz, L.M.; et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA 2016, 316, 2025–2035. [Google Scholar] [CrossRef]
  21. Hébert, P.C.; Wells, G.; Blajchman, M.A.; Marshall, J.; Martin, C.; Pagliarello, G.; Tweeddale, M.; Schweitzer, I.; Yetisir, E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N. Engl. J. Med. 1999, 340, 409–417. [Google Scholar] [CrossRef] [PubMed]
  22. Holst, L.B.; Haase, N.; Wetterslev, J.; Wernerman, J.; Guttormsen, A.B.; Karlsson, S.; Johansson, P.I.; Aneman, A.; Vang, M.L.; Winding, R.; et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N. Engl. J. Med. 2014, 371, 1381–1391. [Google Scholar] [CrossRef]
  23. Cooper, H.A.; Rao, S.V.; Greenberg, M.D.; Rumsey, M.P.; McKenzie, M.; Alcorn, K.W.; Panza, J.A. Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). Am. J. Cardiol. 2011, 108, 1108–1111. [Google Scholar] [CrossRef] [PubMed]
  24. Carson, J.L.; Brooks, M.M.; Abbott, J.D.; Chaitman, B.; Kelsey, S.F.; Triulzi, D.J.; Srinivas, V.; Menegus, M.A.; Marroquin, O.C.; Rao, S.V.; et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am. Heart J. 2013, 165, 964–971.e961. [Google Scholar] [CrossRef]
  25. Sadana, D.; Pratzer, A.; Scher, L.J.; Saag, H.S.; Adler, N.; Volpicelli, F.M.; Auron, M.; Frank, S.M. Promoting High-Value Practice by Reducing Unnecessary Transfusions With a Patient Blood Management Program. JAMA Intern. Med. 2018, 178, 116–122. [Google Scholar] [CrossRef] [PubMed]
  26. Yang, X.; Alexander, K.P.; Chen, A.Y.; Roe, M.T.; Brindis, R.G.; Rao, S.V.; Gibler, W.B.; Ohman, E.M.; Peterson, E.D.; Investigators, C. The implications of blood transfusions for patients with non-ST-segment elevation acute coronary syndromes: Results from the CRUSADE National Quality Improvement Initiative. J. Am. Coll. Cardiol. 2005, 46, 1490–1495. [Google Scholar] [CrossRef]
  27. Jani, S.M.; Smith, D.E.; Share, D.; Kline-Rogers, E.; Khanal, S.; O’Donnell, M.J.; Gardin, J.; Moscucci, M. Blood transfusion and in-hospital outcomes in anemic patients with myocardial infarction undergoing percutaneous coronary intervention. Clin. Cardiol. 2007, 30, II49–II56. [Google Scholar] [CrossRef]
  28. Singer, M.; Deutschman, C.S.; Seymour, C.W.; Shankar-Hari, M.; Annane, D.; Bauer, M.; Bellomo, R.; Bernard, G.R.; Chiche, J.D.; Coopersmith, C.M.; et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016, 315, 801–810. [Google Scholar] [CrossRef]
  29. Paone, G.; Likosky, D.S.; Brewer, R.; Theurer, P.F.; Bell, G.F.; Cogan, C.M.; Prager, R.L.; Membership of the Michigan Society of Thoracic and Cardiovascular Surgeons. Transfusion of 1 and 2 units of red blood cells is associated with increased morbidity and mortality. Ann. Thorac. Surg. 2014, 97, 87–93; discussion 84–93. [Google Scholar] [CrossRef]
  30. Kolte, D.; Beale, C.; Aronow, H.D.; Kennedy, K.F.; Apostolidou, E.; Sellke, F.W.; Sharaf, B.L.; Gordon, P.C.; Abbott, J.D.; Ehsan, A. Trends and outcomes of red blood cell transfusion in patients undergoing transcatheter aortic valve replacement in the United States. J. Thorac. Cardiovasc. Surg. 2019, 159, 104–110. [Google Scholar] [CrossRef] [Green Version]
  31. Zimarino, M.; Barbanti, M.; Dangas, G.D.; Testa, L.; Capodanno, D.; Stefanini, G.G.; Radico, F.; Marchioni, M.; Amat-Santos, I.; Piva, T.; et al. Early Adverse Impact of Transfusion After Transcatheter Aortic Valve Replacement: A Propensity-Matched Comparison From the TRITAVI Registry. Circ. Cardiovasc. Interv. 2020, 13, e009026. [Google Scholar] [CrossRef] [PubMed]
  32. Apostolidou, E.; Aronow, H.D.; Beale, C.E.; Kolte, D.; Kennedy, K.F.; Sellke, F.W.; Gordon, P.C.; Sharaf, B.; Ehsan, A. Association Between Red Blood Cell Transfusion and Clinical Outcomes Among Patients Undergoing Transcatheter Aortic Valve Replacement. Ann. Thorac. Surg. 2019, 107, 1791–1798. [Google Scholar] [CrossRef]
  33. Sherwood, M.W.; Wang, Y.; Curtis, J.P.; Peterson, E.D.; Rao, S.V. Patterns and outcomes of red blood cell transfusion in patients undergoing percutaneous coronary intervention. JAMA 2014, 311, 836–843. [Google Scholar] [CrossRef] [PubMed]
  34. Doyle, B.J.; Rihal, C.S.; Gastineau, D.A.; Holmes, D.R. Bleeding, blood transfusion, and increased mortality after percutaneous coronary intervention: Implications for contemporary practice. J. Am. Coll. Cardiol. 2009, 53, 2019–2027. [Google Scholar] [CrossRef]
  35. Blet, A.; McNeil, J.B.; Josse, J.; Cholley, B.; Cinotti, R.; Cotter, G.; Dauvergne, A.; Davison, B.; Duarte, K.; Duranteau, J.; et al. Association between in-ICU red blood cells transfusion and 1-year mortality in ICU survivors. Crit. Care 2022, 26, 307. [Google Scholar] [CrossRef] [PubMed]
  36. Jentzer, J.C.; Lawler, P.R.; Katz, J.N.; Wiley, B.M.; Murphree, D.H.; Bell, M.R.; Barsness, G.W.; Kor, D.J. Red blood cell transfusion threshold and mortality in cardiac intensive care unit patients. Am. Heart J. 2021, 235, 24–35. [Google Scholar] [CrossRef] [PubMed]
  37. Hendrickson, J.E.; Roubinian, N.H.; Chowdhury, D.; Brambilla, D.; Murphy, E.L.; Wu, Y.; Ness, P.M.; Gehrie, E.A.; Snyder, E.L.; George Hauser, R.; et al. Incidence of transfusion reactions: A multicenter study utilizing systematic active surveillance and expert adjudication. Transfusion 2016, 56, 2587–2596. [Google Scholar] [CrossRef]
  38. Panch, S.R.; Montemayor-Garcia, C.; Klein, H.G. Hemolytic Transfusion Reactions. N. Engl. J. Med. 2019, 381, 150–162. [Google Scholar] [CrossRef]
  39. Dodd, R.Y.; Crowder, L.A.; Haynes, J.M.; Notari, E.P.; Stramer, S.L.; Steele, W.R. Screening Blood Donors for HIV, HCV, and HBV at the American Red Cross: 10-Year Trends in Prevalence, Incidence, and Residual Risk, 2007 to 2016. Transfus. Med. Rev. 2020, 34, 81–93. [Google Scholar] [CrossRef]
  40. Abdallah, R.; Rai, H.; Panch, S.R. Transfusion Reactions and Adverse Events. Clin. Lab. Med. 2021, 41, 669–696. [Google Scholar] [CrossRef]
  41. Villanueva, C.; Colomo, A.; Bosch, A.; Concepción, M.; Hernandez-Gea, V.; Aracil, C.; Graupera, I.; Poca, M.; Alvarez-Urturi, C.; Gordillo, J.; et al. Transfusion strategies for acute upper gastrointestinal bleeding. N. Engl. J. Med. 2013, 368, 11–21. [Google Scholar] [CrossRef] [PubMed]
  42. Vlaar, A.P.; Oczkowski, S.; de Bruin, S.; Wijnberge, M.; Antonelli, M.; Aubron, C.; Aries, P.; Duranteau, J.; Juffermans, N.P.; Meier, J.; et al. Transfusion strategies in non-bleeding critically ill adults: A clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med. 2020, 46, 673–696. [Google Scholar] [CrossRef]
  43. Jolly, S.S.; AlRashidi, S.; d’Entremont, M.A.; Alansari, O.; Brochu, B.; Heenan, L.; Skuriat, E.; Tyrwhitt, J.; Raco, M.; Tsang, M.; et al. Routine Ultrasonography Guidance for Femoral Vascular Access for Cardiac Procedures: The UNIVERSAL Randomized Clinical Trial. JAMA Cardiol. 2022, 7, 1110–1118. [Google Scholar] [CrossRef] [PubMed]
Jcm 12 01304 g001 550
Figure 1. Number of BT units per patient during their admission. RBC = red blood cells.
Figure 1. Number of BT units per patient during their admission. RBC = red blood cells.
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Jcm 12 01304 g002 550
Figure 2. Multivariate Cox Proportional Hazards Analysis. HR = 2.19, 95% CI [1.47–3.62]; p < 0.0001.
Figure 2. Multivariate Cox Proportional Hazards Analysis. HR = 2.19, 95% CI [1.47–3.62]; p < 0.0001.
Jcm 12 01304 g002
Jcm 12 01304 g003 550
Figure 3. Receiver operating characteristic curve, AUC = 0.806–95% CI [0.760–0.852].
Figure 3. Receiver operating characteristic curve, AUC = 0.806–95% CI [0.760–0.852].
Jcm 12 01304 g003
Table
Table 1. Patients’ characteristics according to blood transfusion vs. non-blood transfusion.
Table 1. Patients’ characteristics according to blood transfusion vs. non-blood transfusion.
Clinical VariablesAll Patients
(n = 2132) 		Blood Transfusion Group
(n = 108) (5%)		Non-Blood Transfusion Group (n = 2024) (95%)p-Value
Age in years (mean)66.9 ± 1673.8 ± 1466.6 ± 16<0.0001
Female sex—no. (%)650 (30.5%)52 (48.1%)598 (29.5%)<0.0001
BMI—Median [IQR]27.4 [24.3–31.1]25.9 [22.5–30.9]27.5 [24.4–31.2]0.026
Hypertension1283 (60.2%)75 (69.4%)1208 (59.7%)0.043
DM757 (35.5%)47(43.5%)710 (35.1%)0.074
Hyperlipidemia1097 (51.5%)58 (53.7%)1039 (51.3%)0.631
Smoking597 (28%)22 (20.4%)575 (28.4%)0.07
Prior CAD602 (28.2%)40 (37%)562 (27.8%)0.037
Prior CABG132 (6.2%)13 (12%)119 (5.9%)0.01
CVA150 (7%)11 (10.2%)139 (6.9%)0.189
PAD90 (4.2%)9 (8.3%)81 (4%)0.029
CHF300 (14.1%)38 (35.2%)262 (12.9%)0.0001
COPD168 (7.9%)17 (15.7%)151 (7.5%)0.002
Pulmonary HTN103 (4.8%)19 (17.6%)84 (4.2%)<0.0001
PE25 (1.2%)2 (1.9%)23 (1.1%)0.501
Atrial fibrillation284 (13.3%)26 (24.1%)258 (12.7%)0.001
Anemia95 (4.5%)28 (25.9)67 (3.3%)<0.0001
CKD256 (12%)32 (29.6%)224 (11.1%)<0.0001
Cognitive decline70 (3.3%)7 (6.5%)63 (3.1%)0.056
BMI = body mass index; DM = diabetes mellitus; CAD = coronary artery disease; CABG = coronary artery bypass graft; CVA = cerebrovascular accident; PAD = peripheral artery disease; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; PE = pulmonary embolism; CKD = chronic kidney disease; HTN = hypertension.
Table
Table 2. Blood transfusion vs. non-blood transfusion according to diagnosis on admission.
Table 2. Blood transfusion vs. non-blood transfusion according to diagnosis on admission.
Clinical VariablesAll Patients (n = 2132)Blood Transfusion Group (n = 108) (5%)Non-Blood Transfusion Group (n = 2024) (95%)p-Value
ACS967 (45.4%)25 (23.1%)942 (46.5%)<0.0001
NSTEMI/UAP495 (23.2%)16 (14.8%)479 (23.7%)0.033
STEMI472 (22.1%)9 (8.3%)463 (22.9%)<0.0001
CHF209 (9.8%)18 (16.7%)191 (9.4%)0.014
Cardiogenic Shock62 (2.9%)8 (7.4%)54 (2.7%)0.004
Septic Shock22 (1%)4 (3.7%)18 (0.9%)0.005
VT/VF57 (2.7%)5(4.6%)52 (2.6%)0.196
AF/AFL14 (0.7%)0 (0%)14 (0.7%)0.386
Brady-Arrythmia 176 (8.3%)4 (3.7%)172 (8.5%)0.078
Cardiac Tamponade24 (1.1%)0 (0%)24 (1.2%)0.255
ACS = Acute coronary syndrome; NSTEMI = non-ST-elevation myocardial infarction; UAP = unstable angina pectoris; STEMI = ST elevation myocardial infarction; CHF = congestive heart failure; VT = ventricular tachycardia; VF = ventricular fibrillation; AF = atrial fibrillation; AFL = atrial flutter.
Table
Table 3. Blood transfusion rate according to cardiac procedure.
Table 3. Blood transfusion rate according to cardiac procedure.
Clinical VariablesAll Patients (n = 2132)Blood Transfusion Group (n = 108) (5%)Non-Blood Transfusion Group (n = 2024) (95%)p-Value
TAVI284 (13.3%)35 (32.4%)249 (12.3%)<0.0001
Mitral Clip27 (1.3%)2 (1.9%)25 (1.2%)0.577
EPS44 (2.1%)2 (1.9%)42 (2.1%)0.874
Pacemaker/ICD/CRT5 (0.2%)0 (0%)5 (0.2%)0.605
TAVI = transcutaneous aortic valve intervention; EPS = electrophysiological study; ICD = implantable cardioverter-defibrillator; CRT = cardiac resynchronization therapy.
Table
Table 4. Blood transfusion rate according to in-hospital complications.
Table 4. Blood transfusion rate according to in-hospital complications.
Clinical VariablesAll Patients (n = 2132)Blood Transfusion Group (n = 108)Non-Blood Transfusion Group (n = 2024)p-Value
Acute kidney injury85 (4%)21 (19.4%)64 (3.2%)<0.001
Shock, any100 (4.7%)31 (28.7%)69 (3.4%)<0.001
Congestive heart failure76 (3.6%)10 (9.3%)66 (3.3%)<0.001
Sepsis36 (1.7%)11 (10.2%)25 (1.2%)<0.001
Anoxic brain damage7 (0.6%)3 (5.0%)4 (0.4%)0.004
Table
Table 5. Multivariable regression model for blood transfusion during hospitalization.
Table 5. Multivariable regression model for blood transfusion during hospitalization.
Clinical Variablep-ValueOdds Ratio95% CI
Female Sex0.0301.5941.0452.431
Sepsis0.0252.8611.1417.174
History of CHF0.0141.8241.1292.946
History of Pulmonary HTN0.0551.8460.9873.453
History of Pacemaker/ICD 0.0242.1291.1044.106
History of Anemia<0.0016.0693.54810.378
TAVI During Admission0.051.7051.0002.908
Any Intervention 0.0033.6221.5528.452
CHF = congestive heart failure; HTN = hypertension; ICD = Implantable cardioverter-defibrillator; TAVI = transcutaneous aortic valve intervention.
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Karameh, H.; Bruoha, S.; Taha, L.; Tabi, M.; Farkash, R.; Karmi, M.; Hamayel, K.; Perel, N.; Steinmetz, Y.; Marmor, D.; et al. Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit. J. Clin. Med. 2023, 12, 1304. https://doi.org/10.3390/jcm12041304

AMA Style

Karameh H, Bruoha S, Taha L, Tabi M, Farkash R, Karmi M, Hamayel K, Perel N, Steinmetz Y, Marmor D, et al. Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit. Journal of Clinical Medicine. 2023; 12(4):1304. https://doi.org/10.3390/jcm12041304

Chicago/Turabian Style

Karameh, Hani, Sharon Bruoha, Louay Taha, Meir Tabi, Rivka Farkash, Mohammad Karmi, Kamal Hamayel, Nimrod Perel, Yoed Steinmetz, David Marmor, and et al. 2023. "Outcomes of Patients Treated with Blood Transfusion in a Contemporary Tertiary Care Medical Center Intensive Cardiac Care Unit" Journal of Clinical Medicine 12, no. 4: 1304. https://doi.org/10.3390/jcm12041304

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