Anemia During the Late Postoperative Period Following Cardiopulmonary Bypass Surgery

  • David J. Wolf


Owing to a variety of causes, most patients who undergo cardiopulmonary bypass (CPB) surgery develop anemia. Blood-loss anemia is related to the actual procedure: often delayed anemia follows. Causes range from common conditions such as poor nutrition and inadequate iron store due to prior blood loss, and less common cause such as delayed hemolytic transfusion reaction (DHTR). This chapter discusses causation and treatment of delayed post-CPB anemia. Treatment of delayed anemia includes iron supplementation, subcutaneous (sc) recombinant human erythropoietin (rhEPO) injections, packed red cell transfusion (PRCT), folic acid, and diet. Less often, others types of anemia, such as hemolytic anemia, may need to be addressed from a specific perspective. The impact of perioperative blood product administration, the actual surgical procedure, and the individual patient’s need for anticoagulation and/or antiplatelet drugs constitute additional consideration. Lastly, infectious complication of CPB surgery will be discussed with regard to the anemia such infections may engender. For the sake of clarity, the late post-CPB period will be considered to commence approximately 5 days after surgery.1


Hemolytic Anemia Oral Iron Recombinant Human Erythropoietin Prosthetic Heart Valve Cold Agglutinin 
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  1. 1.
    Mora CT. Cardiopulmonary Bypass—Principles and Techniques of Extracorporeal Circulation. New York: Springer-Verlag, 1995.Google Scholar
  2. 2.
    Williams W. Approach to the patient. In: Beutler E, Lichtman M, Coller B, Kipps T, eds.Williams’ Hematology. 5th ed. New York: McGraw-Hill, 1995;5.Google Scholar
  3. 3.
    Kleinman S, Nelson R, Smith L, Goldfinger D. Positive direct antiglobulin tests and immune hemolytic anemia in patients receiving procainamide. N Engl J Med 1984;311:809.PubMedCrossRefGoogle Scholar
  4. 4.
    Means RT. Pathogenesis of the anemia of chronic disease: a cytokine-mediated anemia. Stem Cells 1995;13:32–37.PubMedCrossRefGoogle Scholar
  5. 5.
    Ferguson BJ, Skikine BS, Simpson KM, et al. Serum transferrin receptor distinguishes the anemia of chronic disease from iron deficiency anemia. J Lab Clin Med 1992;19:385–390.Google Scholar
  6. 6.
    Cosgrove MD, Loop FD, Lytle BW, et al. Determinants of blood utilization during myocardial revascularization. Ann Thorac Cardiovasc Surg 1976;72:714–726.Google Scholar
  7. 7.
    Ray MJ, Hawson GAT, Just SJE, McLachlan G, O’Brien M. Relationship of platelet aggregation to bleeding after cardiopulmonary bypass. Ann Thorac Surg 1994;57:981–986.PubMedCrossRefGoogle Scholar
  8. 8.
    Kestin AS, Valeri CR, Khuri SF, Loscalzo J, et al. The platelet function defect of cardiopulmonary bypass. Blood 1993;82:107–117.PubMedGoogle Scholar
  9. 9.
    Salmerpera MT, Levy JH, Harker LA. Hemostasis and cardiopulmonary bypass. In: Mora CT, ed. Cardiopulmonary Bypass—Principles and Techniques of Extracorporeal Circulation. New York: Springer-Verlag, 1995;88–113.Google Scholar
  10. 10.
    Sane CD, Califf RM, Topel EJ, et al. Bleeding during thrombolytic therapy for acute myocardial infarction: mechanisms and management. Ann Intern Med 1989;111:1010–1022.PubMedGoogle Scholar
  11. 11.
    Cosgrove DM III, Heric B, Lytle BW, et al. Aprotinin therapy for reoperative myocardial revascularization: a placebo-controlled study. Ann Thorac Surg 1992;54:1031–1038.PubMedCrossRefGoogle Scholar
  12. 12.
    Gillon J, Greenburg AG. Transfusion: infectious complications. Blood 1992;81:19–28.Google Scholar
  13. 13.
    Waymack JP. Sequelae of blood transfusions. Infect Surg 1990;22:41–47.Google Scholar
  14. 14.
    Dodd RY. The risk of transfusion-transmitted infection (editorial). N Engl J Med 1992;327:419–421.PubMedCrossRefGoogle Scholar
  15. 15.
    Selik RM, Ward JW, Buehler JW. Trends in transfusion-associated acquired immune deficiency syndrome in the United States, 1982 through 1991. Transfusion 1993;33:890–893.PubMedCrossRefGoogle Scholar
  16. 16.
    Lostumbo MM, Holland PV, Schmidt PJ. Isoimmunization after multiple transfusions. N Engl J Med 1966;275:141–144.PubMedCrossRefGoogle Scholar
  17. 17.
    Brunson ME, Alexander JW. Mechanisms of transfusion-induced immunosuppression. Transfusion 1990;30:651–658.PubMedCrossRefGoogle Scholar
  18. 18.
    Anderson KC, Weinstein HJ. Transfusion-associated graft-versus-host disease. N Engl J Med 1990;323:315–321.PubMedCrossRefGoogle Scholar
  19. 19.
    Vamvakas E, Moore SB. Preoperative blood transfusion and colorectal cancer recurrence: a qualitative statistical overview and meta-analysis. Transfusion 1993;33:754–765.PubMedCrossRefGoogle Scholar
  20. 20.
    Erslev AJ, Beutler E. Production and destruction of erythrocytes. In: Beutler E, Lichtman M, Coller B, Kipps T, eds. Williams’ Hematology. 5th ed. New York: McGraw-Hill, 1995;425.Google Scholar
  21. 21.
    Flaharty KK, Caro J, Erslev AJ, et al. Pharmacokinetics and erythropoietic response to human recombinant erythropoietin in healthy men. Clin Pharmacol Ther 1990;47:557.PubMedCrossRefGoogle Scholar
  22. 22.
    Levine EA, Rosen AL, Sehgal LR, et al. Erythropoietin deficiency after coronary artery bypass procedures. Ann Thorac Surg 1991;51:759–763.CrossRefGoogle Scholar
  23. 23.
    Rosengart TK, Helm RE, Klemperer J, et al. Combined aprotinin and erythropoietin use for blood conservation: results with Jehovah’s Witnesses. Ann Thorac Surg 1994;58:1397–1403.PubMedCrossRefGoogle Scholar
  24. 24.
    Dacie JV. Secondary or symptomatic hemolytic anemias. In: Dacie JV, ed. The Haemolytic Anaemias. New York: Grune & Stratton, 1967;908.Google Scholar
  25. 25.
    Robboy SJ, Salisbury K, Ragsdale B, et al. Mechanism of aspergillus-induced microangiopathic hemolytic anemia. Arch Intern Med 1971;128:790.PubMedCrossRefGoogle Scholar
  26. 26.
    Suzuki A, Yamada A, Maruyama H. A case of acute haemolytic anemia due toClostridium perfrigenssepticemia. Jpn J Clin Hematol 1972;13:850.Google Scholar
  27. 27.
    Petz LD, Fudenberg HH. Coombs-positive hemolytic anemia caused by penicillin administration. N Engl J Med 1966;274:171.PubMedCrossRefGoogle Scholar
  28. 28.
    Chamber LA, Donovan BA, Kruskall MS. Ceftazidime-induced hemolysis patient with drug-dependent antibodies reactive by immune complex and drug adsorption mechanisms. Am J Clin Pathol 1991;95:393.Google Scholar
  29. 29.
    Tishler M. Phenazopyridine-induced hemolytic anemia in a patient with G-6-PD deficiency. Acta Haematol (Basel) 1983;70:208.CrossRefGoogle Scholar
  30. 30.
    Williamson D. The unstable haemoglobins. Blood Rev 1993;7:146.PubMedCrossRefGoogle Scholar
  31. 31.
    Hines R, Barash PG. Infusions of sodium nitroprusside induces platelet dysfunction in vitro. Anesthesia 1989;70:611.CrossRefGoogle Scholar
  32. 32.
    Schafer Al, Alexander RW, Handin RI. Inhibition of platelet function by organic nitrate vasodilators. Blood 1980;55:649.PubMedGoogle Scholar
  33. 33.
    Weksler B, Gillick M, Pink J. Effect of propranolol on platelet function. Blood 1977;49:185.PubMedGoogle Scholar
  34. 34.
    Barnathan E, Addonizio VP, Shattil SJ. Interaction of verapamil with human platelet alpha-adrenergic receptors (abstract). Am J Physiol 1982;242:H19.PubMedGoogle Scholar
  35. 35.
    Okita Y, Miki S, Kusukara K, et al. Propranolol for intractable hemolysis after open heart operation. Ann Thorac Surg 1991;52:1154–1157.CrossRefGoogle Scholar
  36. 36.
    Rose JC, Hufnagel CA, Fries ED, et al. The hemodynamic alterations produced by plastic valvular prosthesis for severe aortic insufficiency in man.J Clin Invest 1954;33:8911.CrossRefGoogle Scholar
  37. 37.
    Amidon TM, Chou TM, Rankin JS, Ports TA. Mitral and aortic paravalvular leaks with hemolytic anemia. Am Heart J 1993;125:266.PubMedCrossRefGoogle Scholar
  38. 38.
    American College of Physicians. Practice strategies for elective red blood cell transfusion. Ann Intern Med 1992;116:403–406.Google Scholar
  39. 39.
    Cordts PR, LaMorte WW, Fisher JB, et al. Poor predictive value of hematocrit and hemodynamic parameters for erythrocyte deficits after extensive elective vascular operations.Surg Gynecol Obstet 1992;175:243–248.PubMedGoogle Scholar
  40. 40.
    Goodnough LT, Johnston MFM, Toy PTCY, et al. The variability of transfusion practice in coronary artery bypass surgery. JAMA 1991;265:86–89.PubMedCrossRefGoogle Scholar
  41. 41.
    Johnson RG, Thurer RL, Kruskall MS, et al. Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg 1992;104:307–314.PubMedGoogle Scholar
  42. 42.
    Goodnough LT. Clinical application of recombinant erythropoietin in the perioperative period. Hematol Oncol Clin North Am 1994;8:1011–1020.PubMedGoogle Scholar
  43. 43.
    Rapaport SJ. RBC metabolism: relations to RBC function and hemolytic anemias. In: Rapaport SI, ed.Introduction to Hematology. 2nd ed. Philadelphia: JB Lippincott, 1987;118–129.Google Scholar
  44. 44.
    Jain R. Use of blood transfusion in management of anemia. Med Clin North Am 1992;76:727–744.PubMedGoogle Scholar
  45. 45.
    Triulzi DJ, Gilmor GD, Ness PM, et al. Efficacy of autologous fresh whole blood or platelet-rich plasma in adult cardiac surgery. Transfusion 1995;35:627–634.PubMedCrossRefGoogle Scholar
  46. 46.
    LoCicero J III, Massad M, Gandy K, et al. Aggressive blood conservation in coronary artery surgery: impact on patient care. J Cardiovasc Surg 1990;31:559–563.Google Scholar
  47. 47.
    Bordin JO, Heddle NM, Blajchmann MA. Biologic effects of leukocytes present in transfused cellular blood products. Blood 1994;84:1703–1721.PubMedGoogle Scholar
  48. 48.
    Finch C. Regulators of iron balance in humans. Blood 1994;84:1697–1702.PubMedGoogle Scholar
  49. 49.
    Rapaport SI. Iron deficiency anemia. In: Rapaport SI, ed. Introduction to Hematology. 2nd ed. Philadelphia: JB Lippincott, 1987;39–54.Google Scholar
  50. 50.
    O’Sullivan DJ, Higgins PG, Wilkinson JF. Oral iron compounds: a therapeutic comparison. Lancet 1955;2:482.CrossRefGoogle Scholar
  51. 51.
    Spivak JL. Recombinant human erythropoietin and its role in transfusion medicine (editorial). Transfusion 1994;34:1–4.PubMedCrossRefGoogle Scholar
  52. 52.
    Watanabe Y, Fuse K, Konishi T, et al. Autologous blood transfusion with recombinant human erythropoietin in heart operations. Ann Thorac Surg 1991;51:767–772.PubMedCrossRefGoogle Scholar
  53. 53.
    Zuzza C, Ottino G, DiSumma M, et al. Porcine cardiac bioprostheses: evaluation of long-term results in 990 patients. Ann Thorac Surg 1985;39:243.CrossRefGoogle Scholar
  54. 54.
    Rapaport SL. Transfusion therapy. In: Rapaport SI, ed. Introduction to Hematology. 2nd ed. Philadelphia: JB Lippincott, 1987;578–590.Google Scholar
  55. 55.
    Goodnough LT. Erythropoietin as a pharmacologic alternative to blood transfusion in the surgical patient.Transfusion Med Rev 1990;4:288–296.CrossRefGoogle Scholar
  56. 56.
    Steinberg SE. Mechanisms of folate homeostasis. Am J Physiol 1984;246:G319.PubMedGoogle Scholar
  57. 57.
    Savage D, Lindenbaum J. Anemia in alcoholics. Medicine (Baltimore) 1986;65:322.Google Scholar
  58. 58.
    Miller DC, Oyer PE, Mitchell RS, et al. Performance characteristics of the Starr-Edwards model 1260 aortic valve prosthesis beyond ten years.J Thorac Cardiovasc Surg 1984;88:193.PubMedGoogle Scholar
  59. 59.
    Cohn LH, Allred EN, DiSesa VJ, et al. Early and late risk of aortic valve replacement. J Thorac Cardiovasc Surg 1984;88:695.PubMedGoogle Scholar
  60. 60.
    Gonzalez-Lavin L, Tandon AP, Chi S, et al. The risk of thromboembolism and hemorrhage following mitral valve replacement.J Thorac Cardiovasc Surg 1984;87:340.PubMedGoogle Scholar
  61. 61.
    Chesebro JH, Fuster V, Elveback LR, et al. Trial of combined warfarin plus dipyrimadole or aspirin therapy in prosthetic heart valve replacement: danger of aspirin compared with dipyrimadole.Am J Cardiol 1983;51:1537.PubMedCrossRefGoogle Scholar
  62. 62.
    Levine MN, Hirsh J, Landefeld S, Raskob G. Hemorrhagic complications of anticoagulant treatment. Chest 1992;102(4):352S.PubMedCrossRefGoogle Scholar
  63. 63.
    Hirsh J, Dalen JE, Deykin D, Poller L. Oral anticoagulants: mechanism of action, clinical effectiveness, and optimal therapeutic range. Chest 1992;102(4):312S.PubMedCrossRefGoogle Scholar
  64. 64.
    Pineda AA, Paswell HF, Brzica SM Jr. Delayed hemolytic transfusion reaction: an immunologic hazard of blood transfusion. Transfusion 1978;18:1.PubMedCrossRefGoogle Scholar
  65. 65.
    Ness PM, Shirey RS, Thoman SK, Buck SA. The differentiation of delayed serologic and delayed hemolytic transfusion reactions: incidence, long-term serologic findings, and clinical significance. Transfusion 1990;30:688–693.PubMedCrossRefGoogle Scholar
  66. 66.
    Pinkerton PH, Coovadia AS, Goldstein J. Frequency of delayed hemolytic transfusion reactions following antibody screening and immediate-spin crossmatching.Transfusion 1992;32:814–817.PubMedCrossRefGoogle Scholar
  67. 67.
    Tonkin AM, Mond HG, Alford FP, Hurley TH. Severe acute haemolytic anaemia complicating infectious mononucleosis. Med J Aust 1973;2:1048.PubMedGoogle Scholar
  68. 68.
    Horwitz CA, Skradski K. Reece E, et al. Haemolytic anaemia in previously healthy adult patients with CMV infections: report of two cases and an evaluation of subclinical haemolysis in CMV mononucleosis. Scand J Haematol 1984;33:35.PubMedCrossRefGoogle Scholar
  69. 69.
    Watson A, Gimerez L, Cotton J, et al. Treatment of anemia of chronic renal failure with subcutaneous rHEpo. Am J Med 1990;89:432.PubMedCrossRefGoogle Scholar
  70. 70.
    Pruzanski W, Shumak KH. Biologic activity of cold-reacting autoantibodies. N Engl J Med 1977;297:583.PubMedCrossRefGoogle Scholar
  71. 71.
    Taft EG, Propp RP, Sullivan SA. Plasma exchange for cold agglutinin hemolytic anemia.Transfusion 1977;17:173.PubMedCrossRefGoogle Scholar
  72. 72.
    Ott DA, Cooley DA. Cardiovascular surgery in Jehovah’s Witnesses.JAMA 1977;238:1256–1258.PubMedCrossRefGoogle Scholar
  73. 73.
    Lee RB, Martin TD. Religious objections to blood transfusion. In: Mora CT, ed. Cardiopulmonary Bypass—Principles and Techniques of Extracorporeal Circulation. New York: Springer-Verlag, 1995;473–480.Google Scholar

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© Springer-Verlag New York, Inc. 1998

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  • David J. Wolf

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