title: Increased red blood cell transfusions are associated with worsening outcomes in pediatric heart transplant patients.
abstract: BACKGROUND
  Red blood cell (RBC) transfusions are associated with increased morbidity. Children receiving heart transplants constitute a unique group of patients due to their risk factors. Although previous studies in nontransplant patients have focused primarily on the effects of postoperative blood transfusions, a significant exposure to blood occurs during the intraoperative period, and a larger percentage of heart transplant patients require intraoperative blood transfusions when compared with general cardiac surgery patients. We investigated the relationship between clinical outcomes and the amount of blood transfused both during and after heart transplantation. We hypothesized that larger amounts of RBC transfusions are associated with worsening clinical outcomes in pediatric heart transplant patients.
  
  
  METHODS
  A database comprising 108 pediatric patients undergoing heart transplantation from 2004 to 2010 was queried. Preoperative and postoperative clinical risk factors, including the amount of blood transfused intraoperatively and 48 hours postoperatively, were analyzed. The outcome measures were length of hospital stay, duration of tracheal intubation, inotrope score, and major adverse events. Bivariate and multivariate analyses were performed to control for simultaneous risk factors and determine outcomes in which the amount of blood transfused was an independent risk factor.
  
  
  RESULTS
  Ninety-four patients with complete datasets were included in the final analysis. Eighty-eight percent received RBC transfusions, with a median transfusion amount of 38.7 mL/kg. A multivariate analysis correcting for 8 covariate risk factors, including the Index for Mortality Prediction After Cardiac Transplantation, age, weight, United Network for Organ Sharing status, warm and cold ischemia time, repeat sternotomy, and pretransplant hematocrit, showed RBC transfusions were independently associated with increased length of intensive care unit stay (means ratio = 1.34; 95% confidence interval, 1.03-1.76; P = 0.03), and increased inotrope score in the first postoperative 24 hour (mean ratio = 1.26; 95% confidence interval, 1.04-1.52; P = 0.04). Patients suffering major adverse events received significantly larger median amounts of blood RBC transfusions (P = 0.002). Transfusions >60 mL/kg were also associated with increased risk of major adverse events (accuracy 76%) including postoperative sepsis, extracorporeal membrane oxygenation, open chest, dialysis, and graft failure.
  
  
  CONCLUSIONS
  The majority of pediatric patients undergoing orthotropic heart transplantation receive RBC transfusions, with the largest amount transfused in the operating room. Escalating amounts of RBC transfusions are independently associated with increased length of intensive care unit stay, inotrope scores, and major adverse events. Since heart allografts are a limited resource, improvement in the blood transfusion and conservation practices can enhance clinical outcomes in pediatric heart transplant patients.
authors.affiliation: Department of Anesthesiology, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Los Angeles, CA 90095, USA.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Howard-Quijano
authors.forename: Johanna C
authors.initials: JC
authors.lastname: Schwarzenberger
authors.forename: Jennifer C
authors.initials: JC
authors.lastname: Scovotti
authors.forename: Alexandra
authors.initials: A
authors.lastname: Alejos
authors.forename: Jason
authors.initials: J
authors.lastname: Ngo
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Gornbein
authors.forename: Aman
authors.initials: A
authors.lastname: Mahajan
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D017707:Erythrocyte Transfusion / Q000009:adverse effects*; D005260:Female; D016027:Heart Transplantation / Q000009:adverse effects* / Q000401:mortality; D006801:Humans; D007223:Infant; D007362:Intensive Care Units; D007902:Length of Stay; D008297:Male; D017063:Outcome Assessment, Health Care