Complement split products and proinflammatory cytokines in intraoperatively salvaged unwashed blood during hip replacement: comparison between heparin-coated and non-heparin-coated autotransfusion systems

[Thromboelastometric profile of unwashed shed blood after primary knee arthroplasty]

INTRODUCTION

Knee arthroplasty causes significant blood loss. Different blood-saving measures exist like retransfusion of unwashed salvaged blood. Some studies question the quality of this blood and in particular its ability to clot. These studies use "static" coagulation tests reflecting only partially the reality, unlike viscoelastic methods. The main objective of this study was to evaluate the salvaged blood thromboelastometric profile using ROTEM® system and to compare these results with patient venous blood.

MATERIALS AND METHODS

We performed an observational, prospective, single-center study conducted over 3 months in 2013. Agreement of local ethical committee and patient consent were obtained beforehand. All adult patients who underwent a primary total knee arthroplasty were included. A thromboelastometric profile and standard laboratory tests (hemoglobin, platelets count, PT, aPTT, fibrinogen) were performed in the same time on patient venous blood and on unwashed salvaged blood in the PACU.

RESULTS

Twenty patients were included. The median duration of surgery was 93 minutes. Thirteen patients (65%) received tranexamic acid during procedure. The median volume of shed blood was 225 mL. Two patients (10%) received a reinfusion. Analysis of shed blood showed a major deficiency of clotting factor in standard biology (PT<10%) and an absence of clot formation in thromboelastometric test (In-tem®, Ex-tem®, Fib-tem® or Ap-tem®). Compared to venous blood, shed blood had significantly lower hemoglobin levels: 8.8 vs 13.5 g/dL (P<0.0001). Allogenic transfusion concerned 5% of patients.

DISCUSSION

In this work, we confirmed that shed blood was naturally uncoagulable probably due to a multifactorial mechanism involving a major clot factor deficiency and an activation of fibrinolysis.

Limit allogeneic blood use with routine re-use of patient's own blood: a prospective, randomized, controlled trial in total hip surgery

BACKGROUND

There are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results.

METHODOLOGY/PRINCIPAL FINDINGS

Two hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI -0.05-0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31-346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life.

CONCLUSIONS/SIGNIFICANCE

General low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is under-powered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00822588.

Proinflammatory cytokines and complement activation in salvaged blood from abdominal aortic aneurism surgery and total hip replacement surgery

BACKGROUND

Levels of proinflammatory mediators in unwashed salvaged blood from abdominal aortic aneurism (AAA) surgery are unknown. We hypothesized that there are higher levels of these mediators in unwashed blood salvaged in AAA surgery compared to hip replacement surgery.

STUDY DESIGN AND METHODS

Ten patients scheduled for AAA surgery (Group A) and 10 patients for total hip replacement surgery (Group H) were included. Blood samples from the autotransfusion set were obtained during surgery and arterial samples before, during, and 6 hours after surgery. Determination of interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α, activated complement 3 (C3a), and high-sensitivity C-reactive protein (CRP) were performed. Salvaged blood was not retransfused.

RESULTS

Levels (median [range]) of IL-8 in blood in the salvage system were higher in Group A versus Group H (215.3 [22.5-697.2] vs. 35.3 [16.7-66.6] pg/mL; p = 0.002). Higher levels of IL-6 were also seen in Group A versus Group H (60.0 [52.6-62.2] vs. 42.34 [19.4-62.2] pg/mL; p = 0.049). Levels of IL-6 in blood sampled during surgery were approximately fivefold higher in Group A versus Group H (p = 0.023), whereas approximately 70% higher levels of C3a were observed in Group H versus Group A (p = 0.021). Postoperative concentrations of IL-1β (p = 0.002), IL-6 (p = 0.001), and IL-8 (0.005) were higher in Group A versus Group H.

CONCLUSION

Salvaged blood in AAA surgery contains substantially higher levels of proinflammatory mediators compared to blood in total hip replacement surgery.

Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation

BACKGROUND AND OBJECTIVES

Transfusion of autologous whole blood is one available method to reduce the need for allogenic blood transfusion. The objective of this study was to investigate the safety of transfusion of intra-operative autologous whole blood by monitoring plasma concentration of laboratory variables and adverse events after transfusion with the Sangvia(®) system.

MATERIALS AND METHODS

The clinical trial was designed as an open, prospective, multi-centre study, and a total of 20 patients undergoing primary hip arthroplasty were included. Systemic blood samples were taken and analysed preoperatively, at transfusion start and end and at 3, 6, 24 and 48 h after the transfusion.

RESULTS

Elevated values of complement activation and pro-inflammatory cytokines were seen in the intra-operatively collected blood but the impact on systemic levels were limited with low peak levels, systemic elevations before transfusion and normalization during the study period. Elevated levels of free haemoglobin and potassium were also detected in the intra-operatively collected blood, but systemic values were within reference values after the transfusion. No clinically relevant adverse event occurred during the study.

CONCLUSION

Inflammatory mediators and plasma haemoglobin were increased in intra-operatively salvaged and filtered blood compared to circulatory levels. Intra-operative retransfusion of autologous whole blood caused a transient systemic increase that normalized in the early postoperative period. There were no significant adverse events reported in the study. These data suggest that the Sangvia(®) system can be used for intra-operative collection and retransfusion of salvaged blood.