Does Art Imitate Life or Does Life Imitate Art?
Fundamental Message
The ideal methods to tease out the contributions of anemia and transfusion to adverse events after cardiac surgery from observational information are however beyond our grasp.
The investigators from this report take harvested data from a large registry comprising patients from Virginia and North Carolina. They have focused on a clinical dilemma that cardiac surgery teams confront on a daily ground. Notably, none of united states of america are comfortable with the inevitable iatrogenic anemia that accompanies cardiac surgery, but neither are we entirely sure that transfusion is risk costless, and is the cure worse than the disease?
I don't underestimate the chore that the researchers have undertaken to employ convincing analytic techniques to tease out this respond from observational data. Information technology is undoubtedly hard to split the ii factors of anemia and transfusion, because they are intimately intertwined. In the end, LaPar and colleagues
have come to the conclusion that transfusions are more closely associated with negative outcomes than the absolute hematocrit. The resulting tale of the danger of transfusions has been a theme of other investigators who have analyzed large observational trials, and so their bulletin adds to the strong phone call of caution to all of united states of america to refrain from unnecessary red blood cell transfusions.
Regardless of the size of the registry sample and the rigor of their assay, unfortunately I remain unconvinced that the authors have answered the question they set out to address. Probably the most important gene that leads me to hedge my bet relates to the information from cardiac surgery randomized controlled trials that back up that there really are not a lot of differences in the incidence of complications between those who practice and do not receive transfusions. "Life imitates art" comes to mind in this situation because registry data are close to "life" and well-designed clinical trials are constructed "art" of medical behavior. In my mind, I have to reconcile the findings of LaPar and colleagues
with those of Mazer and colleagues,
2
- Mazer C.D.
- Whitlock R.P.
- Fergusson D.A.
- Hall J.
- Belley-Cote E.
- Connolly K.
- et al.
TRICS Investigators and Perioperative Anesthesia Clinical Trials Group
Restrictive or liberal scarlet-cell transfusion for cardiac surgery.
- Crossref
- PubMed
- Scopus (321)
- Google Scholar
and information technology is not an easy path. In the randomized controlled trials, transfusion does not seem to be associated with more issues than doing nothing. On the other hand, at that place are compelling data that anemia is convincingly associated with complications and that this relationship grows stronger as the level of anemia increases.
3
- Karkouti K.
- Wijeysundera D.N.
- Beattie Westward.Southward.
Reducing bleeding in cardiac surgery I. Take a chance associated with preoperative anemia in cardiac surgery: a multicenter accomplice report.
- Crossref
- PubMed
- Scopus (339)
- Google Scholar
Statistical machinations of observational data are challenging, but what nigh this detail analysis gives me pause? First of all, I am not clear that the models are detailed plenty with only three covariates (twelvemonth, logit of the predicted risk of mortality/renal failure/stroke, and hematocrit or packed red cell use). Comparing the models is hard because they are not nested, and thus it is non entirely articulate that De Long's exam is appropriate to say one is better than the other.
The investigators are to exist commended for having recognized the importance of fixed and random effects on the upshot variables. In item, they accept indicated that the institution was included in the analysis as a random effect. We are enlightened that there is remarkable heterogeneity in transfusion practices beyond jurisdictions.
four
- Karkouti K.
- Wijeysundera D.Northward.
- Beattie Westward.Due south.
- Callum J.Fifty.
- Cheng D.
- Dupuis J.Y.
- et al.
Reducing haemorrhage in cardiac surgery research group. Variability and predictability of large-volume red blood prison cell transfusion in cardiac surgery: a multicenter written report.
- Crossref
- PubMed
- Scopus (fourscore)
- Google Scholar
On the other hand, having washed the statistical legwork, it would have been interesting had the authors indicated whether taking into account this variability had improved the sensitivity of the models, as I expect it must have.
The Grateful Expressionless guitarist and vocalist Jerry Garcia said, "constantly choosing the lesser of ii evils is still choosing evil."
No 1 volition argue that massive unnecessary transfusion will create a health burden, but I do believe that in the larger population of cardiac surgery patients (who are not bloodless preoperatively) if they receive a transfusion that amounts to an advisable proportionate response, they are not likely harmed. They may not be helped as much as we wish, just I'one thousand not sure information technology (transfusion) is evil.
References
-
Preoperative anemia versus blood transfusion: which is the culprit for worse outcomes in cardiac surgery?.
J Thorac Cardiovasc Surg. 2018; 156 : 66-74 -
Restrictive or liberal scarlet-cell transfusion for cardiac surgery.
N Engl J Med. 2017; 377 : 2133-2144 -
Reducing bleeding in cardiac surgery I. Risk associated with preoperative anemia in cardiac surgery: a multicenter accomplice study.
Circulation. 2008; 117 : 478-484 -
Reducing bleeding in cardiac surgery enquiry grouping. Variability and predictability of large-volume crimson blood cell transfusion in cardiac surgery: a multicenter study.
Transfusion. 2007; 47 : 2081-2088 -
Goodman F. Jerry Garcia: The Rolling Rock interview. Rolling Stone. Nov 30, 1989. Available at: https://world wide web.rollingstone.com/music/features/the-rolling-stone-interview-jerry-garcia-19891130. Accessed April 16, 2018.
Article Info
Publication History
Published online: March 29, 2018
Accepted: March 15, 2018
Received: March 10, 2018
Footnotes
Disclosures: Author has nix to disclose with regard to commercial support.
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DOI: https://doi.org/10.1016/j.jtcvs.2018.03.082
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© 2018 past The American Association for Thoracic Surgery
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- Preoperative anemia versus blood transfusion: Which is the culprit for worse outcomes in cardiac surgery?
The Periodical of Thoracic and Cardiovascular Surgery Vol. 156 Issue 1
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Reducing blood production utilization after cardiac surgery has go a focus of perioperative care as studies have suggested improved outcomes. The relative bear upon of preoperative anemia versus packed red blood cells (PRBC) transfusion on outcomes remains poorly understood, however. In this report, nosotros investigated the relative association between preoperative hematocrit (Hct) level and PRBC transfusion on postoperative outcomes after coronary artery featherbed grafting (CABG) surgery.
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