Transfusion requirement prediction score for patients undergoing cardiac surgery: An experience from a tertiary care set-up from South India.

BACKGROUND: Prediction of transfusion requirement is part of preoperative management in a surgical case. We aimed to develop one such tool for patients undergoing cardiac surgery. METHODS: A retrospective study for a period of 3 years was done to develop the scoring tool, Transfusion Requirement Prediction Score for Cardiac Surgery (TRPS), and internal validation was done prospectively. The primary outcome was administration of allogenic red cell units to the patients during perioperative period. The outcome is dichotomized as controls and cases based on the number of Red Blood Cell units received. Independent variables were chosen based on statistical significance and clinical judgement. Receiver operating characteristic curve was used to obtain the cut-off for each independent variable, odds ratio, and regression coefficients were used to assign the score. All patients with a cumulative score below the cut-off value were categorised as 'low risk' and above the cut off as 'high risk' group. RESULTS: During the study period, out of 602 patients, 345 met the inclusion criteria (controls: 175; cases: 170). Six variables such as age (more than 58 years), gender (female), bypass time (more than 148 min), haemoglobin (less than 12.5 g/dL), ejection fraction (less than 57%), and history of warfarin prophylaxis were chosen to develop the score. The total score value of 5 was chosen as the cut-off for the two risk groups. It predicted blood utilisation with a strength of 68% sensitivity and 79% specificity. On internal validation, the score was observed to have an accuracy of 70%. CONCLUSION: The TRPS is a simple reliable and handy tool with high accuracy.

Should we use mechanical valves in patients with end-stage renal disease?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether a mechanical or bioprosthetic valve is superior for immediate and long-term survival in patients with end-stage renal disease (ESRD) undergoing a valve replacement. Altogether more than 150 papers were found using the reported search; of which, eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There were no randomized controlled trials addressing the question. There was one systematic review and meta-analysis. All the other evidence was in the form of retrospective studies. The papers show that there is no significant difference in the results and survival between patients receiving a mechanical and those receiving a bioprosthetic valve. This was seen in the meta-analysis as well as the larger series of patients who underwent valve replacement. Bleeding complications were more common with mechanical valves. We conclude that the choice of valve for patients with ESRD should be determined by age, level of activity and patient choice. Due to the limited life expectancy of these patients, bioprosthetic valves should be considered, especially since there is no evidence of early degeneration of tissue valves in this subgroup of patients.

Are there any good treatments for keloid scarring after sternotomy?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with hypertrophic and keloid scarring of the sternotomy wound, is surgical excision with or without adjuvant treatment of any benefit in reducing the size of the scar? Altogether, more than 15 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One of the studies showed no difference between surgery and adjunctive triamcinolone or colchicine. One study showed that incomplete excision resulted in higher recurrence rates. Postoperative radiation was found to be useful in two of the studies, although one study showed that it was not useful. One randomized control trial showed improvement after laser compared to no treatment. Two other trials showed no difference between laser, silicone gel, intralesional steroid or 5-fluorouracil. One trial showed that perioperative systemic steroid application gave rise to no improvement but in fact worsened scar formation. We conclude that small keloids can be treated radically by surgery with adjuvant therapy (radiation or corticosteroid injections) or by non-surgical therapy (corticosteroid injections, laser and anti-tumour/immunosuppressive agents, such as 5-fluorouracil). Large and multiple keloids are difficult to treat radically and are currently only treatable by multimodal therapies that aim to relieve symptoms.