Effects of Fresh Frozen Plasma on Hematologic Parameters in Open Heart Surgery

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1 Original article Effects of Fresh Frozen Plasma on Hematologic Parameters in Open Heart Surgery Mahmut Mustafa ULAŞ 1, Necmettin ÇOLAK 2, Kumral ERGUN 3, Gökhan LAFÇI 1, Hacı Alper UZUN 1, Adnan YALÇINKAYA 1, Ersin KADİROĞULLARI 1, Emre YAŞAR 1, Ömer Faruk ÇİÇEK 1, Kerim ÇAĞLI 1 1 Türkiye Yüksek Ihtisas Hospital Department of Cardiovascular Surgery, ANKARA 2 Fatih University Faculty of Medicine Department of Cardiovascular Surgery, ANKARA 3 Türkiye Yüksek Ihtisas Hospital Department of Cardiology, ANKARA ÖZET Açık kalp cerrahisinde taze donmuş plazmanın hematolojik parametreler üzerine etkisi Açık kalp cerrahisi yapılan hastalarda taze donmuş plazma (TDP) transfüzyonunun doza bağımlı olarak hematolojik parametrelere olan etkilerinin ve klinik bulgularının prospektif olarak belirlenmesi amaçlanmıştır. Hastalar intraoperatif veya postoperatif TDP ihtiyaçlarına göre iki gruba ayrıldı.grup A (n=68),0-2u arası, Grup B (n=32), 3 ve üzeri TDP kullanan hastalardan oluşturuldu. Preoperatif ve postoperative hematolojik parametreler analiz edildi ve karşılaştırıldı. Postoperatif dönemde ateş ve enfeksiyon mevcudiyeti, üre, alanine aminotranferaz (ALT) ve C-reaktif protein (CRP) düzeyleri incelendi ve gruplar arasındaki end-organ hasarı ile inflammatuar yanıtları karşılaştırıldı. Operasyon sonrasında, Hemoglobin (Hb), Hematokrit (Hct) düzeyleri ve platelet sayıları belirgin olarak azalmıştı. Lökosit sayısı ve nötrofil ile monosit oranları postoperative dönemde artarken, lenfosit, eozinofil ve bazofillerde belirgin derecede düşüklük mevcuttu. Gruplar karşılaştırıldığında; total lökosit sayıları ve eozinofil hariç diğer lökosit subtiplerinin sayısı Grup B de Grup A dan belirgin olarak daha azdı. Toplam hastaların %30 da 38ºC nin üzerine çıkabilen ateş tespit edildi, gruplar arasındaki oran benzerdi. Her ne kadar CRP, üre ve ALT seviyelerinde operasyon sonrasında her iki grupta da belirgin artış oluşsa da gruplar arasında parametlerin dikkatle incelenmesi ile anlamlı bir farklılık tespit edilemedi. Bu çalışmada postoperative dönemde 2U nin üzerinde verilen TDP transfüzyonunun postoperative lökositozu belirgin derecede azalttığı gözlenmiştir. Ancak lökositozdaki bu azalma end organ hasarı ile ilişkili inflamasyonun önlenmesinde beklenen klinik düzelmeyi sağlamamıştır. Anahtar Kelimeler: Açık kalp cerrahisi, taze donmuş plazma, lökosit ABSTRACT Fresh frozen plasma on open heart surgery To prospectively determine whether fresh frozen plasma transfusion affects hematologic parameters in a dose dependent manner in patients undergoing open heart surgery and its clinical significance. Patients were divided into two groups according to the total intra-and/or postoperative fresh frozen plasma (FFP) requirement. Patients who need 0 to 2 units were included in Group A (n=68) and 3 units in Group B (n=32). Preoperative and postoperative hematologic parameters were analyzed and compared between groups. Presence of postoperative fever, infection and level of urea, alanine aminotransferase (ALT) and C- reactive protein (CRP) were also evaluated and compared between groups for inflammatory response and end-organ injury. After operation, Hemoglobin (Hb), Hematocrit (Hct) level and mean platelet count were decreased significantly. Whereas white blood cells (WBC) count and numbers of neutrophil and monocyte in formulation were increased postoperatively, other types of WBC (lymphocyte, eosinophil and basophil) were decreased significantly. Comparison of the groups revealed that total count of WBCs and count of subtypes except for eosinophil were significantly smaller in Group B than in Group A. Fever>38ºC was observed in 30% of all patients with a similar rate between groups. Although level of CRP, urea and ALT in both groups increased significantly after operation, no significant difference was observed between groups with regard to these parameters. This study demonstrated that postoperative transfusion of >2 units of FFP can reduce postoperative leukocytosis significantly but it could not establish clinical improvement which would be expected as a result of the prevention of inflammation related end-organ injury Key Words: Open heart surgery, fresh frozen plasma and white blood cell INTRODUCTION Although recent advances in surgical techniques and perfusion technology decreased operative mortality of open heart surgery, bleeding disorders, thrombotic complications and the activation of blood components that are collectively known as systemic inflammatory response are still important problems of continuous blood purification (CPB). Exposure of blood to artificial surfaces of extracorporeal circuit and anomalous mechanical and environmental factors, such as high shear stress, turbulance, decreased oncotic pressure and hypothermia cause damage to blood elements, which is manifested by hemolysis, thrombocytopenia along with platelet dysfunction and reactivity of mononuclear cells 1-3. Currently prevention of these adverse effects by the means 169

2 of extracorporeal surface modifications, control of flow dynamics, pharmacological interventions and antinflammatory methods is an interesting subject of investigations. In this study we evaluated whether intra-and/or postoperative transfusion of fresh frozen plasma (FFP) in patients undergoing CPB has a hemoprotective role on white blood cells (WBCs) which may result in partial inhibition of inflammatory response and end organ injury. MATERIALS AND METHODS Our study was designed in prospective manner among 100 consecutive patients who underwent open heart surgery with CPB (coronary artery bypass grafting, valve surgery, or corrective surgery or repair for congenital defects). Patients who had transfusion of preoperative FFP or other blood products and postoperative whole blood, preoperative leukocytosis (over /mm 3 ) and angiographic procedures including radiocontrast administration within 15 days were excluded from the study. Study Analysis: Patient characteristics were noted down preoperatively. Intraoperative variables such as aortic cross-clamp period (XCl), total perfusion period (TPP) and degree of hypothermia and intraoperative and/or postoperative requirement of FFP were recorded for each patient. Patients were divided into two groups according to the dose of FFP need. Patients who required 0 to 2 units of FFP were included in Group A (n=68) and 3 units in Group B (n=32). The hematological parameters including hematocrite and hemoglobin level, platelet count and WBC count and formulation and level of C-reactive protein (CRP), urea and alanin amino transferase (ALT) were checked preoperatively and on the second postoperative day for comparison. Presence of postoperative fever (>38ºC) or infection that is confirmed by appropriate cultures were also noted down. Statistical analysis: Data obtained from the current study were evaluated by SPSS (Statistical Package for Social Sciences) 11-5 package program. Values were expressed as (mean) (standard deviation). Student-t (Paired and independent) and chi-square tests were used for statistical analysis. Paired sample t-test was used for analyzing of same groups before and after procedure. Independent samples t-test was used for analyzing of different groups. AP value of <0.05 was considered to indicate statistical significance. All statistical analyses were in the 95 % CI and performed on a personal computer with the statistical package SPSS for Windows. RESULTS Patient characteristics were given in Table 1. Sixty-five of patients were male and 35 were female. The mean age of all population was 54,3 22,3 years. Fifty-five patients had coronary artery bypass surgery, 34 had valve replacement surgery (18 mitral valve replacement, 8 aortic valve replacement, 7 double valve replacement) and 11 had repair or corrective operations for congenital heart disease. Intraoperative variables such as XCl, TPP and hypothermic degrees are given in Table 2. The mean degree of hypothermia was moderate and CPB duration was less than 150 minutes. In Table 3 number of patients according to the their requirement of intraoperative and/or postoperative FFP use are shown. Patients with transfusion less than 3 units are in Group A and 3 units are in Group B. Table 1. Patient characteristics Group A Group B P values Age(y) ±18.4 NS Sex(M/F) 44/24 20/12 NS Smoking 31(45,58%) 14(43,75%) NS Diabetes Mellitus 19(27,94%) 10(31,25%) NS Hypertension 37(54,41%) 17(53,12%) NS Coronary artery bypass grafting surgery 38(55,88%) 18(56,25%) NS Valvular surgery 23(33,82%) 11(34,37%) NS Congenital surgery 7(10,29%) 3(9,37%) NS NS:Not significant Table 2. Operative variables Group A Group B p values Cross-clamp (XCl) time (min) 38±19,05 42±16,23 NS Cardiopulmonary bypass time (min) 63,11±30,00 66,44±27,76 NS Hypothermia degree (ºC) 31,58±1,52 30,97±1,34 NS NS:Not significant 170

3 Table 3. FFP requirements and number of patients Fresh frozen Number of % plasma unit patient All hematologic parameters were changed significantly after open heart surgery for all patient cohort (Table 4). Mean Hb and Hct level were decreased from 13,4 3,98 g/dl to 8,34 1,95g/dl, p<0.001 and from 40,3 18,3% to 26,3 7,05%, p<0.001 respectively. Mean platelet count were also decreased significantly ( /μl vs /μl, p<0.001). Whereas WBC count and numbers of neutrophil and monocyte in formulation were increased postoperatively ( /μl vs /μl, p<0.001;4500± 613/μl vs 11593±2213/μl, p<0.001, and 400±116/μl vs 689±289/μl, p<0.001 respectively), other types of WBC (lymphocyte, eosinophil and basophil) were decreased significantly. Comparison of after transfusion value of total WBC count and WBC formulation between groups are shown in table 5. It revealed that total count of WBC and count of subtypes except for eosinophil were significantly smaller in Group B than in Group A. Postoperative infection was not observed in any patient but fever>38ºc was noted in 30% of all patient with a similar rate between two groups (24/68 vs 6/32, p>0.05). Level of CRP, urea and ALT in both groups increased significantly after operation (Table 6). Table 4. Hematologic changes with FFP administration in preoperative and postoperative period Preoperative Postoperative Parameters n Mean ± SD n Mean±SD p Hematocrit ± ±7 <0.001 Hemoglobin ± ±1.95 <0.001 Platelet ± ±45820 <0.001 White blood cell ± ±6820 <0.001 Neutrophil ± ±2213 <0.001 Lymphocyte ± ±857.8 <0.001 Monocyte ± ±289 <0.001 Eosinophil ± ±135 <0.001 Basophil ± ±23.5 <0.001 Table 5. Comparison of WBC counts and leucocyte formula after FFP administration Group A Group B Parameters n Mean ± SD n Mean±SD p White blood cell ± ± Neutrophil ± ±871.6 <0.001 Lymphocyte ± ± Monocyte ± ±220.6 <0.001 Eosinophil ± ± Basophil 68 42± ± Group A: 2 Units and lesser Group B: 3 and 4 Units Table 6. Levels of CRP, urea and ALT in both groups FFP Preoperative postoperative Parameter n Mean ± SD N Mean ± SD P (Pre-post-op CRP(mg/l)Total ± ±32.6 <0.001 Group A ± ±32.8 <0.001 Group B ± ±31.6 <0.001 p (Group A-B) Urea(mg/dl)Total <0.001 Group A <0.001 Group B <0.001 P(Group A-B) 0.007* 0.32 ALT(IU/I) Total <0.001 Group A <0.001 AGroup B <0.001 P(Group A-B) 0.024* 0.21 <0.001 Group A: 2 units and lesser CRP: C-reactive protein Group B: 3 and units ALT: Alanine aminotranferase 171

4 CRP level increased from 0.00 mg/l to mg/l in Group A (p<0.001) and from 0.00 mg/l to mg/l in group B (p<0.001). Increment of urea level is from to in Group A (p<0.001) and from to in Group B (p<0.001). ALT level also increased significantly in both Group A and Group B ( IU/l vs IU/l and IU/l vs IU/l, respectively). Although preoperative level of urea was significantly higher in Group A as ALT level in Group B, no significant difference was observed between groups with regard to these parameters after operation. DISCUSSION CPB, especially when prolonged, results in activation of the coagulation cascade, fibrinolytic system, complement system (by way of C3a and C5a), kallikrein-bradykinin system, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production and the synthesis of various cytokines from mononuclear cells (including tumor necrosis factor-alpha, interleukin-1(il-1), IL-6, IL-8 4,5. These activated cascades result in a decrease in the number of circulating coagulation factors, hyperfibrinolysis, trombocytopenia, platelet defects, and an acute inflammatory response. In the most extreme form, this inflammation is associated with a generalised whole body postpump syndrome, characterised by increased capillary permeability, pulmonary edema, fever, leucocytosis, renal dysfunction and hemodynamic collapse. The post-cpb inflammatory response is a consequence of exposure of the blood to foreign surfaces during prolonged CPB and depends upon recruitment and activation of inflammatory cells. Leucocyte recruitment is a complex process that involves several protein families, including proinflammatory cytokine, adhesion molecules and chemokines 6. Especially activation of neutrophils with degranulation and protease enzyme release is a crucial step in inflammation and results in neutrophil sequestration within the tissues 7. Generation of the anaphylatoxins C3a and C5a mediates leucocyte chemotaxis, aggregation, and enzyme release 5,8,9. Sequestration of activated leucocytes and platelets in tissues, especially in lungs 10, occurs with attendant damage to the vascular integrity 11 and increase morbidity and mortality. There is a direct relationship between the duration of CPB and the development of post- CPB inflammatory response 12. Duration of CPB, level of proinflammatory cytokines and WBCs count are also longer and higher in patients with long lasting post-cpb inflammatory response 13. Currently recognition of the significance of this inflammatory response led to development of antiinflammatory therapies including aprotinin 14, inhibitors of the complement system 15, antiinflammatory cytokines such as interleukin-10 16, off-pump surgery 17, steroids 18, L-arginine 19 and leucocyte depletion techniques In this study we demonstrated that FFP transfused for hemostatic problems also reduces the postoperative leucocytosis in a dose dependent manner, which could reflect partial inhibition of post-cpb inflammation. All patients who undergo CPB develop a multifactorial derangement of the hemostatic system. These abnormalities are platelet dysfunction caused by exposure of the blood to artificial surfaces, hemodilution related thrombocytopenia 23 and coagulation factor depletion 24 and heparinization itself. Platelet dysfunction is the most significant hemostatic abnormality, although depletion of coagulation factors may have greater significance in patients with preoperative hemostatic deficiency. Although patients undergoing cardiac operations constitute the majority of recipients of FFP, in CPB surgery, FFP is only indicated in the presence of bleeding and disturbed coagulation 25 and routine use is widely advocated to avoid viral infections 26,27. This study demonstrated that intra-and/or postoperative transfusion of >2 units of FFP can reduce postoperative leukocytosis significantly but it could not establish clinical improvement which would be expected as a result of the prevention of inflammation related end-organ injury. Therefore larger studies including wider spectrum of endorgan injury and inflammatory response analysis, and morbidity and early postoperative mortality evaluation are needed before making a conclusion. REFERENCES 1. Hsu LC. Biocompatibility in cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1997;11: Kameneva MV, Undar A, Antaki JF, Watach MJ, Calhoon JH, Borovetz HS. Decrease in red blood cell deformability caused by hypothermia, hemodilution and mechanical stress: factors related to cardiopulmonary bypass. ASAIO J. 1999;45: Hansbro SD, Sharpe DA, Catchpole R. Haemolysis during cardiopulmonary bypass: an in vivo comparison of standard roller pumps, nonocclusive roller pumps and centrifugal pumps. Perfusion 1999;14: Donahue MA, Price PM. Aprotinin : antifibrinolytic and antiinflammatory mechanism of action in cardiac surgery with cardiopulmonary bypass. Dynamics 2002;13: Butler J, Rocker GM, Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1993;55: Ben-Abraham R, Weinbroum AA, Dekel B, Paret G. Chemokines and the inflammatory response following cardiopulmonary bypass- a new target for therapeutic intervention?- A review. Paediatr Anaesth 2003;13:

5 7. Al-Ruzzeh S, Hoare G, Marczin N, Asimakopoulos G, George S, Taylor K, Amrani M. Off-pump coronary artery bypass surgery is associated with reduced neutrophil activation as measured by the expression of CD11b: a prospective randomized study. Heart Surg Forum 2003;6: Svennevig J, Geiran O, Karlsen J. Complement activation during extracorporeal circulation: In vitro comparison of duraflo-ii heparin-coated and uncoated oxygenator circuits. J Thorac Cardiovasc Surg 1993;106: Shafique T, Jhonson R, Dai H. Altered pulmonary microvascular reactivity after total cardiopulmonary bypass. J Thorac Cardiovasc Surg 1993;106: Ito H, Hamano K, Gohra H. Relationship between respiratory distress and cytokine response after cardiopulmonary bypass. Surg Today 1997;27: vom Dahl J, Eitzman D, Al-Aouar z. Relation of regional function, perfusion, and metabolism in patients with advanced coronary artery disease undergoing surgical revascularisation. Circulation 1994;90: Lippmann M, Goldberg S, Walkenstein M. Pulmonary complications of open heart surgery. In Kotler M and Alfieri A (eds): Cardiac and Noncardiac Complications of Open Heart Surgery: prevention, Diagnosis, and Treatment. Mt. Kisco NY, Futura 1992; p Hirai S. Systemic inflammatory response syndrome after cardiac surgery under cardiopulmonary bypass. Ann Thorac Cardiovasc Surg 2003;9: Lei Y, Haider Hkh, Chusnsheng W. Dose dependent effect of aprotinin on aggravated pro-inflammatory cytokines in patients with pulmonary hypertension following cardiopulmonary bypass. Cardiovasc Drugs Ther 2003;17: Pugsley MK, Abramova M, Cole T, Yang X, Ammons WS. Inhibitors of the complement system currently in development for cardiovascular disease. Cardiovasc Toxicol 2003;3: Giomarelli P, Scolletta S, Borrelli E, Biagioli B. Myocardial and lung injury after cardiopulmonary bypass: role of interleukin(il)-10. Ann Thorac Surg 2003;76: Biglioli P, Cannata A, Alamanni F, et al. Biological effects of offpump vs on-pump coronary artery surgery: focus on inflammation, hemostasis and oxidative stress. Eur J Cardiothorac Surg 2003;24: Gormley SM, Armstrong MA, McMurray TJ, McBride WT. The effect of methylprednisolone on cytokine concentration and leucocyte adhesion molecule expression in an isolated cardiopulmonary bypass system. Cytokine 2003;22: Dewanjee MK, Wu SM, De D. Reduction of neutrophil margination by L- arginine during hypothermic cardiopulmonary bypass in a pig model. ASAIO J 1996;42: Olivencia-Yurvati AH, Ferrara CA, Tierney N, Wallace N, Mallet RT. Strategic leukocyte depletion reduces pulmonary microvascular pressure and improves pulmonary status post-cardiopulmonary bypass. Perfusion 2003;18: Samankatiwat P, Samartzis I, Lertsithichai P. Leucocyte depletion in cardiopulmonary bypass: a comparison of four strategies. Perfusion 2003;18: Ichihara T, Yasuura K, Maseki T. The effects of using a leucocyte removal filter during cold cardioplegia. Surg Today 1994;24: Cines DB, Tomaski A, Tannenbaum S. Immune endothelial cell injury in heparin-associated thrombocytopenia. N Engl J Med 1987;316: Kajani M, Waxman H. Hematologic problems after open heart surgery. In Kotler M, Alfieri A(eds.): Cardiac and Noncardiac Complications of Open Heart Surgery: Prevention, Diagnosis, and Treatment. Mt. Kisco NY, Futura 1992, p Contreras M, Ala FA, Greaves M. Guidelines for the use of fresh frozen plasma. British Committee for Standards in Haematology, Working Party of the Blood Transfusion Task Force. Transfus Med 1992;2: Consten EC, Henny CP, Eijsman L, Dongelmans DA, van Oers MH. The routine use of fresh frozen plasma in operations with cardiopulmonary bypass is not justified. J Thorac Cardiovasc Surg 1996;112: Schlayer HJ, Peters T, Preisler S, Berthold H, Gerok W, Rasenack J. Cause and frequency of posttransfusion hepatitis after open heart surgery. Clin Investig 1992;70: Correspondence: Mahmut Mustafa ULAŞ M.D. Yüksek Ihtisas Hospital Department of Cardiovascular Surgery, Ankara Arrival date : Acceptance date :

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