-
1.
Intraoperative use of platelet-plasmapheresis in vascular surgery
Safwat AM, Bush R, Prevec W, Reitan JA
Journal of Clinical Anesthesia. 2002;14((1):):10-4.
Abstract
STUDY OBJECTIVE To determine, in a pilot study, whether pheresis of plasma and platelets before surgical blood loss, with reinfusion of the autologous plasma and platelets after completion of the aortic reconstruction, will result in decreased bleeding and decreased transfusion of allogenic blood components in patients undergoing elective aortic reconstruction. DESIGN Randomized study. SETTING University medical center. INTERVENTIONS Patients were randomized to perioperative (acute) platelet plasmapheresis (APP group) versus conventional blood component therapy (control group). In the APP group, blood was withdrawn after induction of anesthesia, to sequester approximately 300 mL of platelet rich plasma (PRP); platelet poor plasma (PPP) and red blood cells (RBC) were sequestered as well. An autotransfusion device was used to collect and re-infuse autologous RBC during the course of the operation in both groups. After completion of the aortic reconstruction, autologous PRP and PPP were re-infused in the APP group. Blood loss, volume of blood component transfusions, and preoperative and postoperative hemoglobin (Hb), hematocrit (Hct), platelet, international normalized ratio (INR), and activated partial thromboplastin time (aPTT) were recorded. MEASUREMENTS AND MAIN RESULTS There was no difference between groups in demographics, preoperative laboratory values, or surgical procedures, although more patients were treated for aneurysms (73% vs. 60%) and fewer for occlusive disease (20% vs. 40%) in the control versus APP group. Also, there were no differences between the control and APP groups in duration of operation, blood loss, volume of colloid infused, or volume of allogenic RBC and plasma transfused. Patients in the APP group received a greater volume of crystalloid solution (9.1 +/- 3.4 L vs. 6.8 +/- 3.0 L; p = 0.002), but fewer units of allogenic platelets than the control group (0.7 +/- 1.0 units vs. 0.2 +/- 0.4 units; p < 0.04). There were no differences in postoperative Hb, Hct, INR, aPTT, or fibrinogen. The platelet count was lower in the APP group than in the control group (123 +/- 40 x 10(3)/mm(3) vs. 182 +/- 51 x 10(3)/mm(3); p = 0.004). CONCLUSIONS Perioperative platelet plasmapheresis led to fewer allogenic platelet transfusions in patients undergoing elective aortic reconstruction. However, there was no decrease in blood loss and no reduction in transfusion of allogenic RBC or plasma. Perioperative platelet plasmapheresis is not recommended for routine use in elective aortic reconstruction.
-
2.
Intraoperative plasmapheresis in cardiac surgery
Armellin G, Sorbara C, Bonato R, Pittarello D, Dal Cero P, Giron G
Journal of Cardiothoracic & Vascular Anesthesia. 1997;11((1):):13-7.
Abstract
OBJECTIVE To determine the effects of intraoperative plasmapheresis on total transfusion requirements, mediastinal drainage, and coagulation. DESIGN The trial was prospective, randomized, and controlled. SETTING Inpatient cardiac surgery at a university medical center. PARTICIPANTS Two hundred ninety-three consecutive patients undergoing cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS Intraoperative plasmapheresis (IP) was performed in 147 patients before heparinization; platelet-rich plasma was reinfused immediately after heparin reversal. MEASUREMENTS AND MAIN RESULTS Mediastinal chest tube drainage during the first 12 postoperative hours was significantly less in the IP group (p = 0.022), but no difference was noted in total postoperative blood loss between the two groups. The amount of packed red cells and fresh frozen plasma transfused to the IP group in the intensive care unit was significantly lower (p = 0.02, p = 0.002, respectively); 51.4% of patients required no transfusion compared with the control group (34.5%) (p = 0.006). No differences were noted for data collected in the intensive care unit in terms of the mean duration of chest tube drainage, ventilator time, or any hematologic variables at baseline or at any subsequent time in the study. CONCLUSIONS After cardiac surgery, intraoperative plasma-pheresis reduces early postoperative bleeding and decreases the need for homologous transfusions.
-
3.
The influence of acute preoperative plasmapheresis on coagulation tests, fibrinolysis, blood loss and transfusion requirements in cardiac surgery
Menges T, Welters I, Wagner RM, Boldt J, Dapper F, Hempelmann G
European Journal of Cardio-Thoracic Surgery. 1997;11((3):):557-63.
Abstract
OBJECTIVE Withdrawal of autologous plasma and reinfusion after cardiopulmonary bypass (CPB) offers the opportunity of improving patients' haemostasis and reducing homologous blood consumption in cardiac surgery. The influence of acute, preoperative plasmapheresis (APP) on coagulation tests, fibrinolysis, blood loss and transfusion requirements was investigated in elective aortocoronary bypass patients. METHODS Forty patients were randomized to a control or pheresis group. The pheresis group had platelet-rich plasmapheresis (PRP-group, n = 20) performed before incision and the platelet-rich plasma (PRP) was returned after CPB. The control group (n = 20) was managed without pheresis. All patients had serial coagulation studies, including prothrombin split products (F1/F2), fibrinopeptide A (FPA), protein C (PC), thrombomodulin (TM), tissue-plasminogen-activator (t-PA), plasminogen-activator-inhibitor (PAI 1), fibrinopeptide B beta 15-42 (FPB beta 15-42), haemoglobin and platelet counts determined intra- and postoperatively. Chest tube drainage and transfusion requirements were recorded. RESULTS APP had no negative effects on the quality of PRP. The platelet count of the withdrawn autologous plasma was 239 +/- 33 x 10(9)/l. From the end of the operation (after retransfusion of autologous plasma) until the first postoperative day platelet counts were significant higher in the PRP-group (P > 0.05). Plasma concentrations of modified antithrombin III (ATM), F1/F2 and FPA increased (166-290% from baseline) and PC- and TM-antigen decreased (11-49% from baseline) to a different extent for both groups throughout CPB. t-PA-activity increased intraoperatively peaking at the end of CPB (PRP-group: 4.8 +/- 0.8 IU/ml, control-group: 8.1 +/- 2.3 IU/ml)(P > 0.05). With onset of CPB PAI-1 levels decreased and were further reduced after CPB in control patients in comparison to PRP-patients (P < 0.05). FPB beta 15-42 occurred in peak concentrations after neutralisation of heparin by protamine. Only PRP-patients showed baseline values of coagulation and fibrinolytic parameters on the next morning (P < 0.05). Total postoperative blood loss during the first 24 h was 503 +/- 251 ml (PRP-group) and 937 +/- 349 ml in the control-group (P < 0.05). None of the PRP-patients received allogeneic blood, whereas five control-patients received 11 units of packed red cells (P < 0.05). CONCLUSIONS The findings suggest that in elective cardiac surgery heparin cannot prevent generation of both thrombin and fibrin, born throughout CPB and postoperatively. The use of PRP withdrawn immediately preoperatively is an attractive technique to reduce allogeneic blood usage and preoperative blood loss, especially in patients in whom withdrawal of autologous whole blood cannot be performed.
-
4.
Autologous platelet-rich plasmapheresis: risk versus benefit in repeat cardiac operations
Shore-Lesserson L, Reich DL, DePerio M, Silvay G
Anesthesia & Analgesia. 1995;81((2):):229-35.
Abstract
Preoperative platelet-rich plasmapheresis has been suggested as a means of reducing homologous blood transfusions in cardiac surgical patients. The current study evaluated this technique in patients undergoing repeat cardiac operations. Fifty-two patients undergoing repeat myocardial revascularization and/or valve replacement were evaluated in a prospective randomized controlled study design. Autologous platelet-rich plasma (PRP) was harvested after the induction of anesthesia in the experimental group. After reversal of heparin, each patient received his or her autologous plasma. Patients in the control group did not have plasmapheresis and received standard transfusion therapy if coagulation variables were abnormal and a coagulopathy was clinically evident. Routine coagulation tests, thromboelastography (TEG), perioperative bleeding, and transfusion requirements were compared in the two groups. Forty-four patients completed the study. A significantly larger volume of packed red blood cells (PRBCs) was transfused in the PRP group than in the control group (P = 0.03). Platelet and fresh frozen plasma (FFP) transfusions did not differ between the two groups. Mediastinal tube drainage did not differ between the two groups. During PRP infusion, 60% of the patients required treatment for moderate hypotension (mean arterial pressure [MAP] < 60 mm Hg). Only 16% of control patients required treatment for hypotension during the comparable time period (P < 0.05). No patient who completed the study returned to the operating room for postoperative bleeding. These data suggest that PRP did not reduce postbypass bleeding or transfusion requirements in repeat cardiac surgical patients. Moreover, the incidence of hypotension during PRP reinfusion introduces a potential risk to the procedure in the absence of any obvious benefit.
-
5.
Plasmapheresis and intraoperative hemodilution. Comparison of 2 methods Italian
Sonzogni V, Bellavita P, Aceti M, Cossolini M, Lorini L
Minerva Anestesiologica. 1995;61((7-8):):293-7.
Abstract
Fifty patients undergoing cardiac surgery suffering from coronary artery disease and valvular incompetence or stenosis, were randomly divided into two groups of 25 patients to compare the plasmapheresis effects on bleeding, transfusion requirements, economicity and paramedical staff compliance versus intraoperative autotransfusion. Standardized anesthetics, perfusion, and surgical techniques were used. We used plasmapheresis with cell saver and haemodilution with bypass ultrafiltration. Platelet counts, haemoglobin concentration, haematocrit, fibrinogen, bleeding times were evaluated at fixed times for the patients on plasmapheresis and after surgical homologous transfusion. It was that these parameters did not change significantly in the two groups. Intraoperative plasmapheresis is more expensive and less accepted into an operating room than autotransfusion. Intraoperative plasmapheresis will be a good alternative to haemodilution for selected patients.
-
6.
Influence of acute preoperative plasmapheresis on platelet function in cardiac surgery
Boldt J, Zickmann B, Ballesteros M, Oehmke S, Stertmann F, Hempelmann G
Journal of Cardiothoracic & Vascular Anesthesia. 1993;7((1):):4-9.
Abstract
Withdrawal of autologous plasma offers the possibility of improving patients' hemostasis and of reducing homologous blood consumption in cardiac surgery. The influence of acute, preoperatively performed plasmapheresis (APP) on platelet function was investigated in elective aortocoronary bypass patients subjected to APP producing either platelet-poor plasma (PPP; group 1; n = 12) or platelet-rich plasma (PRP; group 2; n = 12). APP-treated patients were randomly compared to patients without APP (control group; n = 12). Platelet aggregation induced by ADP (concentration 0.25, 0.5, 1.0, and 2.0 mumol/L), collagen (4 microL/mL), and epinephrine (25 mumol/L) was determined by the turbidometric method before and after APP, as well as before and after cardiopulmonary bypass (CPB) until the morning of the 1st postoperative day. APP had no negative effects on the patients' aggregation parameters (maximum aggregation and maximum gradient of aggregation). The platelet counts in the withdrawn plasma were 25 +/- 10 x 10(9)/L (PPP-group) and 250 +/- 30 x 10(9)/L (PRP-group). Platelet counts were highest in the PRP-group at the end of the operation (after retransfusion of autologous plasma). After CPB, maximum aggregation and maximum gradient of aggregation were reduced in all groups (ranging from -6% to -25% from baseline values). Retransfusion of autologous plasma improved platelet aggregability significantly only in the PRP-group. By the first postoperative day, maximum aggregation and maximum gradient of aggregation recovered in all groups (including the control group) or even exceeded baseline values (ranging from +8% to +42% from baseline values.(ABSTRACT TRUNCATED AT 250 WORDS)
-
7.
Hematological assessment of patients undergoing plasmapheresis during cardiac surgery
Stammers AH, Kratz J, Johnson T, Crumbley J, Merrill J
Journal of Extra-Corporeal Technology. 1993;25((1):):6-14.
Abstract
Methods of reducing patient exposure to homologous blood transfusions include the technique of intraoperative plasmapheresis for the production of platelet rich plasma (PRP). The present study was designed to determine the patient benefits of PRP by examining hemostatic changes in coagulation screens and viscoelastic whole blood monitoring (Thrombelastography, [TEG]). One hundred fifteen patients undergoing elective cardiac surgery were prospectively randomized into a blinded study. Sixty-three patients had 20 percent of the circulating plasma volume sequestered prior to heparinization and pheresed into PRP, which was reinfused 10 minutes following heparin reversal with protamine. The control (CTR) group of 52 patients were exposed to no sequestration procedure. Patients were followed to discharge and 112 parameters, including anthropometric, operative, and postoperative factors, were measured. There were no significant differences between patient groups in preoperative, cardiopulmonary bypass (CPB), or surgical parameters. Average PRP volume was 600+/-100 ml with a total platelet yield of 1.1 billion platelets per patient. TEG indices were determined at four distinct times during the surgical procedure. The CTR group had significantly higher pre-CPB TEG indices of 2.3+/-1.2 and 2.1+/-1.2 (mean+/-SD), vs. 1.8+/-1.5 and 1.4+/-1.7 in the PRP group (p less than .04). Following heparin reversal, pre-PRP reinfusion TEG values were similar between groups, although both groups had significantly decreased indices when compared to pre-CPB values. Thirty minutes post-PRP infusion the treatment group had significantly improved TEG recovery when compared to the CTR group, 1.0+/-1.2 vs. 0.3+/-1.7 (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
-
8.
Acute preoperative plasmapheresis and established blood conservation techniques
Boldt J, Kling D, Zickmann B, Jacobi M, Dapper F, Hempelmann G
Annals of Thoracic Surgery. 1990;50((1):):62-8.
Abstract
Plasmapheresis performed weeks before an operation producing autologous plasma has proved to be of benefit in elective operations. First experiences in acute plasmapheresis, which is performed immediately before the operation, have been reported recently. When acute plasmapheresis is used in cardiac operations, however, it must be viewed in connection with other techniques for reducing blood consumption such as the Cell Saver (CS) and ultrafiltration devices. In 60 patients undergoing elective aortocoronary bypass grafting, acute plasmapheresis was performed, producing either platelet-poor plasma or platelet-rich plasma, in combination with either the Cell Saver or hemofiltration. Fluid balance during cardiopulmonary bypass was significantly lower in the hemofiltration patients. Postoperatively, none of these patients received donor blood, whereas 4 patients of the Cell-Saver groups needed packed red blood cells. AT-III, fibrinogen, the number of platelets, albumin, total protein, and colloid osmotic pressure were less compromised when hemofiltration was used in combination with acute plasmapheresis in contrast to combination with the Cell-Saver technique. Plasma hemoglobin was without differences during the investigation period, and polymorphonuclear elastase was less increased when platelet-rich plasma was produced preoperatively. On the first postoperative day, most of the differences between the groups had already disappeared. We conclude that when acute plasmapheresis is used in cardiac operations, discarding of plasma by the Cell Saver should be avoided and ultrafiltration devices should replace centrifugation techniques for blood conservation.
-
9.
Preoperative plasmapheresis in patients undergoing cardiac surgery procedures
Boldt J, von Bormann B, Kling D, Jacobi M, Moosdorf R, Hempelmann G
Anesthesiology. 1990;72((2):):282-8.
Abstract
Donor plasmapheresis that is carried out weeks before the operation has proven to be of benefit in elective orthopedic patients with regard to reducing homologous blood consumption and preserving coagulation. In this study acute preoperatively performed plasmapheresis (APP) was investigated in cardiac surgery patients. Forty-five patients scheduled for elective aortocoronary bypass surgery were randomly divided into three groups of 15 patients each: 1) removal of platelet-poor plasma (PPP), 2) removal of platelet-rich plasma (PRP), and 3) no plasmapheresis (control group). Plasma volume removed was 10 ml/kg in all APP patients, and plasma was replaced by the same amount of low-molecular weight hydroxyethylstarch solution (6% HES 200/0.5). Various laboratory data were investigated before, during, and after extracorporeal circulation (ECC). Blood loss in control patients was more pronounced than in the two APP groups; two of the control patients needed packed red cells. APP itself did not affect coagulation variables, free hemoglobin, or polymorphonuclear (PMN) elastase. At the end of the operation, 5 h after ECC, and at the first postoperative day the number of platelets was significantly lower in the control group; PRP patients showed the highest values. Fibrinogen and AT-III levels were less compromised in APP patients than in the control group. Global coagulation parameters did not differ between the groups within the whole investigation period. PMN elastase increased significantly during ECC in all groups with the greatest increase in the control group (722%) and the smallest increase in PRP patients (280%), possibly due to the removal of cellular elements in this group.(ABSTRACT TRUNCATED AT 250 WORDS)
-
10.
Effects of intraoperative plasmapheresis on blood loss in cardiac surgery
Jones JW, McCoy TA, Rawitscher RE, Lindsley DA
Annals of Thoracic Surgery. 1990;49((4):):585-9; discussion 590.
Abstract
Intraoperative platelet-rich plasmapheresis allows autotransfusion of fresh, undamaged platelets and clotting factors at the completion of the operation. To evaluate this technology, we randomly assigned 100 consecutive patients who were to undergo an elective coronary bypass procedure and had normal clotting studies into the experimental (plasmapheresis) or the control group. Characteristics of both groups were similar, including average age (61.4 years versus 61.3 years [experimental versus control group]), sex (78% male versus 74% male), preoperative weight (80.9 kg versus 80.2 kg), preoperative red cell mass (1,989 mL versus 1,890 mL), perfusion time (102 minutes versus 106 minutes), and coagulation studies. Both internal mammary arteries were used in 68% of the patients. All patients had preoperative and postoperative blood volume determinations and complete clotting studies. Sixty-two variables related to bleeding were analyzed. Strict indications for transfusion were a hemoglobin level less than 7 g/100 mL in patients younger than 70 years and a hemoglobin level less than 8 g/100 mL in patients older than 70 years. The group receiving intraoperative plasmapheresis had a significant reduction in operative red cell mass loss (1,050 +/- 43 mL versus 1,226 +/- 61 mL; p = 0.021), a reduction in the average homologous transfusion (0.67 +/- 0.15 unit versus 1.8 +/- 0.25 units; p = 0.0002), and an increase in the percentage of patients not requiring blood transfusions (66% versus 32%; p = 0.001). This technique is useful in reducing postoperative blood loss and homologous transfusions.