Cell saver efficacy for routine coronary artery bypass surgery

Cell salvage during coronary artery bypass surgery and allogenic blood exposure

AIM

Our primary aim was to assess the impact of intraoperative cell saver usage on patient exposure to allogenic blood transfusion during elective coronary artery bypass. The secondary endpoint was the impact of cell savage on the units of blood and blood products transfused perioperatively.

METHODS

A prospective observational cohort study with a historical cohort as a control group was performed in a single tertiary care center. One hundred and twenty-four patients undergoing primary on-pump coronary artery bypass grafting were included. Intraoperative cell salvage was performed in 60 patients (study group) but not in the control group (n = 64). Transfusion data, intensive care unit stay, hospital stay, and postoperative complications were evaluated in the cell saver and control groups.

RESULTS

The number of patients exposed to allogenic red blood cell transfusion was significantly less in the study group (55% vs. 82.8%; p = 0.001) and the units per patient was also less in the study group (1.10 ± 1.7 vs. 2.25 ± 2.289 units; p = 0.002). However, there was no significant difference in terms of units of purified plasma fraction, platelets, or cryoprecipitate transfused. Intensive care unit stay, total hospital stay, number of reexplorations, complications, readmissions, and 28-day mortality were similar in both groups.

CONCLUSIONS

Intraoperative cell salvage with a cell saver in patients undergoing primary elective coronary artery bypass decreases the proportion of patients exposed to allogenic red cell transfusions and the number of units of red blood cells transfused.

Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline

BACKGROUND

A minority of patients having cardiac procedures (15% to 20%) consume more than 80% of the blood products transfused at operation. Blood must be viewed as a scarce resource that carries risks and benefits. A careful review of available evidence can provide guidelines to allocate this valuable resource and improve patient outcomes.

METHODS

We reviewed all available published evidence related to blood conservation during cardiac operations, including randomized controlled trials, published observational information, and case reports. Conventional methods identified the level of evidence available for each of the blood conservation interventions. After considering the level of evidence, recommendations were made regarding each intervention using the American Heart Association/American College of Cardiology classification scheme.

RESULTS

Review of published reports identified a high-risk profile associated with increased postoperative blood transfusion. Six variables stand out as important indicators of risk: (1) advanced age, (2) low preoperative red blood cell volume (preoperative anemia or small body size), (3) preoperative antiplatelet or antithrombotic drugs, (4) reoperative or complex procedures, (5) emergency operations, and (6) noncardiac patient comorbidities. Careful review revealed preoperative and perioperative interventions that are likely to reduce bleeding and postoperative blood transfusion. Preoperative interventions that are likely to reduce blood transfusion include identification of high-risk patients who should receive all available preoperative and perioperative blood conservation interventions and limitation of antithrombotic drugs. Perioperative blood conservation interventions include use of antifibrinolytic drugs, selective use of off-pump coronary artery bypass graft surgery, routine use of a cell-saving device, and implementation of appropriate transfusion indications. An important intervention is application of a multimodality blood conservation program that is institution based, accepted by all health care providers, and that involves well thought out transfusion algorithms to guide transfusion decisions.

CONCLUSIONS

Based on available evidence, institution-specific protocols should screen for high-risk patients, as blood conservation interventions are likely to be most productive for this high-risk subset. Available evidence-based blood conservation techniques include (1) drugs that increase preoperative blood volume (eg, erythropoietin) or decrease postoperative bleeding (eg, antifibrinolytics), (2) devices that conserve blood (eg, intraoperative blood salvage and blood sparing interventions), (3) interventions that protect the patient's own blood from the stress of operation (eg, autologous predonation and normovolemic hemodilution), (4) consensus, institution-specific blood transfusion algorithms supplemented with point-of-care testing, and most importantly, (5) a multimodality approach to blood conservation combining all of the above.

A minimal priming technique that allows for a higher circulating hemoglobin on cardiopulmonary bypass

Reduction in circuit prime during cardiopulmonary bypass has benefits for the patient with a low body surface area, anemia, patient refusal to receive blood products, and aids the practitioner's goal to minimize exposure to blood products. Described here is a simple, low-cost technique that has been shown to decrease priming volume in any bypass circuit and allow a significant increase in 'on bypass hemoglobin'.