The Rationale for Intraoperative Blood Salvage in Cardiac Surgery

The use of therapeutic plasma exchange to reduce serum bilirubin in a dog with kernicterus

OBJECTIVE

To describe the use of a manual method of therapeutic plasma exchange to reduce total serum bilirubin, manage kernicterus, and halt progression of neurological dysfunction in a dog with immune-mediated hemolytic anemia (IMHA).

CASE SUMMARY

A 5-year-old male neutered Lhasa Apso diagnosed with IMHA developed acute onset neurologic signs consistent with kernicterus. Manual therapeutic plasma exchange was performed in an attempt to reduce total serum bilirubin. The initial exchange was performed at a lower plasma exchange volume due to the dog's critical status and the dog's clinical signs progressed. More aggressive plasma exchange was performed that resulted in a reduction in total serum bilirubin and no further progression of neurologic signs. The dog was euthanized due to suspicion of permanent neurologic changes and need for further blood transfusions. Histopathology postmortem confirmed a diagnosis of kernicterus.

NEW OR UNIQUE INFORMATION PROVIDED

Kernicterus secondary to hyperbilirubinemia is well described in people, but has rarely been reported in dogs. Therapeutic plasma exchange has been used for decades in people to rapidly decrease serum bilirubin when hyperbilirubinemia progresses to neurologic signs, but to the authors' knowledge this has not been described in a dog.

Cell salvage as part of a blood conservation strategy in anaesthesia

The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.