title: Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial.
abstract: BACKGROUND
  Blood transfusions are common in cardiac surgery, but have been associated with increased morbidity and long-term mortality. Efforts to reduce blood product use during cardiac surgery include fluid restriction to minimize hemodilution, and protocols to guide transfusion decisions. INVOS is a modality that monitors brain tissue oxygen saturation, and could be useful in guiding decisions to transfuse. However, the role of INVOS (brain tissue oxygen saturation) as part of an algorithm to direct blood transfusions during cardiac surgery has not been evaluated. This study was conducted to investigate the value of INVOS as part of a protocol for blood transfusions during cardiac surgery.
  
  
  METHODS
  Prospective, randomized, blinded clinical trial, on 150 (75 per group) elective cardiac surgery patients. The study was approved by the Institution Ethics committee and all patients gave written informed consent. Data were initially analyzed based on "intention to treat", but subsequently were also analyzed "per protocol".
  
  
  RESULTS
  When protocol was strictly followed ("per protocol analysis"), compared to the control group, significantly fewer patients monitored with INVOS received any blood transfusions (46 of 70 patients in INVOS group vs. 55 of 67 patients in the control group, p = 0.029). Similarly, patients monitored with INVOS received significantly fewer units of red blood cell transfusions intraoperatively (0.20 ± 0.50 vs. 0.52 ± 0.88, p = 0.008) and overall during hospital stay (1.31 ± 1.20 vs. 1.82 ± 1.46, p = 0.024). When data from all patients (including patient with protocol violation) were analyzed together ("intention to treat analysis"), the observed reduction of blood transfusions in the INVOS group was still significant (51 of 75 patients transfused in the INVOS group vs. 63 of 75 patients transfused in the control group, p = 0.021), but the overall number of units transfused per patient did not differ significantly between the groups (1.55 ± 1.97 vs. 1.84 ± 1.41, p = 0.288).
  
  
  CONCLUSIONS
  Our data suggest that INVOS could be a useful tool as part of an algorithm to guide decisions for blood transfusion in cardiac surgery. Additional data from rigorous, well designed studies are needed to further evaluate the role of INVOS in guiding blood transfusions in cardiac surgery, and circumvent the limitations of this study.
authors.affiliation: Cardiac Anesthesia Unit, Anesthesiology Clinic, University of Thessaly, Biopolis, Larissa, Greece.
authors.forename: George
authors.initials: G
authors.lastname: Vretzakis
authors.forename: Stavroula
authors.initials: S
authors.lastname: Georgopoulou
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Stamoulis
authors.forename: Vassilios
authors.initials: V
authors.lastname: Tassoudis
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Mikroulis
authors.forename: Athanasios
authors.initials: A
authors.lastname: Giannoukas
authors.forename: Nikolaos
authors.initials: N
authors.lastname: Tsilimingas
authors.forename: Menelaos
authors.initials: M
authors.lastname: Karanikolas
mesh_terms: D000368:Aged; D001803:Blood Transfusion / Q000706:statistics & numerical data*; D001921:Brain / Q000378:metabolism*; D006348:Cardiac Surgical Procedures; D016009:Chi-Square Distribution; D002985:Clinical Protocols; D005260:Female; D005440:Fluid Therapy; D006400:Hematocrit; D006801:Humans; D008297:Male; D008991:Monitoring, Physiologic; D010100:Oxygen / Q000378:metabolism*; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D016896:Treatment Outcome
chemical_list: D010100:Oxygen