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Eur J Cardiothorac Surg 2002;21:160-161
© 2002 Elsevier Science NL
Letter to the Editor |
Division of Cardiac Anesthesia and Intensive Care, Policlinico di Monza, via Amati 111, 20052 Monza, Milano, Italy
Received 25 June 2001; accepted 16 October 2001.
* Tel.: +39-39-281-0259; fax: +39-39-281-0322
e-mail: valter.casati{at}tin.it
Key Words: Bleeding • Cardiac surgery • Fresh frozen plasma • Prophylactic allogeneic transfusion
The article by Wilhelmi and coworkers [1] poses the important question regarding the prophylactic transfusion of fresh frozen plasma (FFP) in patients undergoing cardiac surgery, and imposes some evaluations.
The principal conclusion of the Consensus Conference on the good use of FFP published in 1985 [2] was as following: "...Attempts to alter FFP use frequently have been ineffective. The most successful attempts can be attributed to a strong local proponent of modern transfusion practice". The same conclusions derive by a more recent paper [3], which underlines the inappropriate transfusion practice in coronary surgery.
A foreseen conclusion of Wilhelmi’s paper is that prophylactic use of FFP not only does not reduce postoperative bleeding, but also increases transfusions of packed red cells, if compared with patients who received plasma expander, because of the different hemodilutional effect and colloid-osmotic properties of the two fluids.
Another major criticism concerning Wilhelmi’s study is that the authors did not consider laboratory coagulation variables among the criteria for postoperative plasma transfusion, basing their decision exclusively on a generic excessive postoperative bleeding. On the contrary, international guidelines suggest precise criteria for FFP transfusion [3]: microvascular bleeding or hemorrhage in patients who are massively transfused, and with a PT/PTT value exceeding 1.5 times the laboratory normal values.
In previously published study evaluating the hemostatic properties of drugs such as aprotinin and tranexamic acid in patients undergoing cardiac surgery [4,5], our group followed the criteria for FFP transfusions indicated above: we obtained that about the 5% of elective patients required FFP transfusion [4], and in a subgroup of high-risk patients for bleeding about the 9% of patients needed FFP [5]. Then, a small percentage of the cardiosurgical patients, considering also those with increased risk for bleeding (cardiosurgical reintervention, combined procedure) really benefited from FFP transfusion.
The conclusions of Wilhelmi’s study are different. The authors stated that the prophylactic use of FFP has no benefit, but they also stated that: "...This approach should be considered for routine use in patients undergoing CABG without previous thoracic surgical intervention or coagulation disorders". This signifies that the authors carry out the prophylactic transfusion of FFP in patients undergoing reinterventions, or with a non-specified coagulopathy.
In 1991, Mhyre, writing on transfusion medicine, significantly entitled an editorial: "To treat the patient or to treat the surgeon" (J Am Med Assoc 1991;265:97), and he concluded his considerations with the following sentence: "...The institutional effect implies treating a laboratory report instead of the patient, or even worse, treatment with a protocol based on no contact with the patient and little contact with the modern effect of blood transfusion. The patients know this is not acceptable; we must realize it too. Blood and blood products should be given only when there are clear indications".
My opinion is that the application of the international guidelines clearly limit excessive and erroneous allogeneic transfusion and, at present, there is no basis to continue using unnecessary prophylactic transfusion medicine in cardiac surgery.
References
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