Banked and fresh autologous blood in cardiopulmonary bypass surgery

Short-Term Effects and Safety Analysis of Retrograde Autologous Blood Priming for Cardiopulmonary Bypass in Patients with Cardiac Valve Replacement Surgery

This randomized, double-blind study evaluated the short-term effects and safety of perioperative retrograde autologous priming (RAP) for cardiopulmonary bypass (CPB) in patients with cardiac replacement surgery to determine if this approach is a better substitute for crystal liquids priming in patients with valvular heart disease. We observed that RAP significantly decreased the actual priming volume, preserved the hematocrit and hemoglobin level during CPB to a certain degree, and decreased lactate accumulation in CPB period. Moreover, RAP lowered the volume of transfusion and dosage blood products. Thus, our results showed that RAP approach effectively improved tissue perfusion and lowered intraoperative Lac levels, by reducing the hemodilution, which safely and reliably improve the microcirculation perfusion.

A guideline nomogram to control intraoperative haemodilution in cardiac surgery

Intraoperative blood collection prior to cardiopulmonary bypass (CPB) is a common procedure in cardiac surgery. Its aims are to obtain fresh whole blood to be infused after CPB, to use autologous blood in the prime or to avoid too high levels of haematocrit (HCT) during CPB. Calculations to determine the amount of blood to be collected are generally based on theoretical assumptions. In this paper we have set up and controlled, on a clinical basis, a nomogram to be used in order to obtain a standard pre-CPB HCT equal to 38%, using a moderately hypervolaemic haemodilution based on blood collection simultaneous with fluid replacement. Thirty adult patients were evaluated in order to settle the nomogram; subsequently, the nomogram validity was checked on 100 adult patients. Statistical analysis revealed the good clinical usefulness of this instrument.

Conventional blood conservation techniques in 500 consecutive coronary artery bypass operations

With use of a nonpharmacological, simple, and inexpensive program for blood conservation, 500 consecutive patients underwent elective coronary artery bypass grafting without need of homologous red cell transfusions in 493 (98.6%). At least one internal mammary artery was grafted in all but 1 patient, with supplemental saphenous vein grafts. Intraoperatively, autologous heparinized blood was removed before bypass and retransfused at the conclusion of extracorporeal circulation. The volume remaining in the oxygenator and tubing set was returned without cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart-lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 hours after operation. The mean postoperative mediastinal blood loss was 643 +/- 354 mL, whereas 624 +/- 296 mL was autotransfused. Thirteen patients (2.6%) needed reexploration for bleeding, of whom 7 (7/500, 1.4%) received homologous blood. No other patients required red cell transfusions. In addition, 9 patients were given a mean of 2.6 units of fresh frozen plasma because of suspected coagulopathy. No platelets were transfused, and no cryoprecipitate therapy was undertaken. Thus, in total, 484 patients (96.8%) were not exposed to any homologous blood products during the hospital stay. At discharge, the mean hemoglobin concentration was 121 +/- 14 g/L (12.1 +/- 1.4 g/dL) and the hematocrit, 0.36 +/- 0.04. Postoperative complications were few. There was one in-hospital death (0.2%).

Elective coronary artery bypass surgery without homologous blood transfusion. Early results with an inexpensive blood conservation program

Restriction of donor blood transfusions in cardiac surgery should reduce risks of infective contamination and antigenicity. We report a systemic, simple and inexpensive blood conservation program used for 121 consecutive patients who underwent elective coronary artery bypass surgery without need for homologous blood transfusion. The left internal mammary artery was grafted in all cases, in addition to saphenous vein grafts. Autologous, heparinized blood was removed intraoperatively, pre-bypass, and returned to the patient at conclusion of the extracorporeal circulation. The volume remaining in the oxygenator and the tubing set was returned without cell processing or hemofiltration. Using the hard-shell cardiotomy reservoir from the heart-lung machine, autotransfusion of the shed mediastinal blood was continued hourly up to 18 hours after surgery. The mean postoperative mediastinal bleeding was 551 +/- 206 ml, of which 505 +/- 218 ml was autotransfused. No re-exploration for bleeding was required and no homologous red-cell transfusions were given. Five patients each received 1-2 units of fresh frozen plasma because of prolonged bleeding time. Morbidity was low and mortality nil. At discharge the mean hemoglobin was 12.0 +/- 1.4 g/dl and the hematocrit 36.0 +/- 4.2%.

Blood conservation in cardiac surgery

We reviewed current blood conservation techniques and their use in cardiac surgery. Avoidance of aspirin preoperatively is an important blood conservation measure. Patients scheduled for an elective operation should participate in autologous predonation programs. With careful monitoring, patients with major coronary artery disease can safely donate blood preoperatively. Intraoperative processing of blood withdrawn before cardiopulmonary bypass provides autologous platelet-rich plasma for infusion after reversal of heparin sodium. Blood collected from the field during operation and blood remaining in the oxygenator after bypass can also be processed to yield washed and concentrated red blood cells for reinfusion. Randomized, prospective studies document that postoperative autotransfusion is both safe and effective in reducing homologous blood use. Aprotinin reduces plasma protein activation and platelet damage during bypass. The integration of available blood conservation techniques into a comprehensive program combined with careful consideration of the indications for transfusion may allow more patients to avoid transfusion entirely.

Autologous blood transfusion for combined plastic surgeries

Autologous blood transfusion is indicated and helpful for any patient who is entering surgery in whom the surgeon anticipates a large blood loss because of the multiple or combined plastic operations being planned for one surgical sitting. The advantages of autologous over homologous transfusions include avoidance of incompatibility reactions, better volume expansion, and no risk of acquiring diseases.

Blood conservation techniques

Increasing numbers of operations requiring cardiopulmonary bypass have been accompanied by greater demands for blood resources. Improved techniques of blood conservation have diminished the average blood requirements per operation and have increased the percent of operations that can be done without homologous blood. The conservation of blood can be planned according to each patient's requirements. The techniques include preoperative blood donation, intraoperative withdrawal of blood, reinfusion of oxygenator blood, autotransfusion of blood after heparin neutralization, autotransfusion after wound closure, and hemodilution. The availability of techniques for filtration, centrifugation, and washing of blood have improved the safety of autotransfusion. The techniques that gives the best cost/benefit ratio appear to be preoperative withdrawal of blood, reinfusion of centrifuged oxygenator contents, and reinfusion of filtered blood from chest drainage.

Heparin removal in an autotransfusor device

In order to determine the residual heparin in the supernatant fluid recovered from blood washed with increasing amounts of solution in the Haemonetics Cell Saver, various modifications of Grann's polybrene neutralization test applied. It is suggested that each 450 to 500 ml of recovered heparinized blood be washed with a minimum of 500 ml of saline, although 700 ml is advisable. The red color from hemolyzed erythrocytes may clear while unacceptably high levels of heparin remain.

Blood conservation during myocardial revascularization

A prospective study of blood utilization in 50 consecutive patients undergoing elective coronary artery bypass was undertaken. Blood was removed from all patients during induction of anesthesia and reinfused after bypass (mean, 675 ml). Intraoperatively, all discard suction was routed through a regionally heparinized collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was retained for transfusion. After operation, shed mediastinal blood was collected in a sterile, filtered collection system and transfused. Normovolemic anemia was accepted in hemodynamically stable patients. The mean amount of patients' blood salvaged by the intraoperative system was 259 ml (range, 0 to 724 ml) and by the postoperative system, 194 ml (range, 0 to 564 ml). Ninety-four percent (47/50) of the patients received no bank blood or blood products during their hospital stay. No patients received bank blood intraoperatively or during the first 24 hours following operation. There were no complications attributable to blood salvage techniques.