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Original Articles: Adult Cardiac

Transfusion and Pulmonary Morbidity After Cardiac Surgery

^a Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio
^b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
^c Department of Laboratory Medicine and Clinical Pathology, Cleveland Clinic, Cleveland, Ohio
^d Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio

Accepted for publication July 10, 2009.

^_* Address correspondence to Dr Koch, Department of Cardiothoracic Anesthesia, J4-245, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195 (Email: kochc{at}ccf.org).

Background: True lung injury is among the leading causes of transfusion-related mortality. Pulmonary morbidity after cardiac surgery has been related to damaging effects of cardiopulmonary bypass and transfusion, but is confounded by cardiac-related events that may not reflect true lung injury. Thus, cardiac surgery poses unique challenges to criteria-specific diagnosis of transfusion-related acute lung injury (TRALI). Our objective was to determine the prevalence of pulmonary morbidity related to transfusion and whether TRALI consensus-criteria are applicable to cardiac surgery.

Methods: A total of 16,847 patients underwent on-pump, coronary artery bypass grafting (CABG), valve, or CABG-valve surgery from September 1998 to February 1, 2006. We performed four propensity-score-matching analyses with logistic regression on probability of receiving a transfusion: total hospital red blood cell (RBC) and fresh frozen plasma (FFP) transfusion and intraoperative RBC and FFP transfusion. Outcomes included traditional cardiac-surgery-defined pulmonary morbidity and ratio of arterial partial pressure of oxygen to fractional inspired oxygen concentration (PaO ₂/FiO ₂), a criterion for TRALI.

Results: Patients receiving RBC transfusion had more risk-adjusted pulmonary complications: respiratory distress 4.8% vs 1.5%, p < 0.001; respiratory failure 2.2% vs 0.39%, p < 0.0001; longer intubation times, 9.9 hours vs 7.5 hours, p < 0.0001; acute respiratory distress syndrome, 0.64% vs 0.21%, p = 0.015; and reintubation, 5.6% vs 1.3%, p < 0.0001. The FFP was similarly related to more pulmonary complications after surgery. By TRALI criteria, the majority manifested "lung injury" (PaO ₂/FiO ₂ ratio < 300) but unrelated to transfusion (65% vs 64%).

Conclusions: Transfusion is associated with many measures of postoperative pulmonary morbidity. Yet the PaO ₂/FiO ₂ ratio as important criterion of TRALI is unrelated to transfusion. Thus, due to the nature of cardiac surgery, application of consensus guided diagnosis of TRALI is problematic.