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The Effect of Cell Salvage on Bleeding and Transfusion Needs in Cardiac Surgery
Tachias F, Samara E, Petrou A, Karakosta A, Siminelakis S, Apostolakis E, Tzimas P
Anesthesiology research and practice. 2022;2022:3993452
Abstract
INTRODUCTION Cell salvaging is well established in the blood management of cardiac patients, but there remain some concerns about its effects on perioperative bleeding and transfusion variables. This randomized controlled study investigated the potential effects of the centrifuged end-product on bleeding, transfusion rates, and other transfusion-related variables in adult cardiac surgery patients submitted to extracorporeal circulation. MATERIALS AND METHODS Patients were randomly chosen to receive (cell-salvage group, 99 patients) or not to receive (control group, 110 patients) the centrifuged product of a cell salvage apparatus. Bleeding and transfusion rates according to the universal definition of perioperative bleeding (UDPB) classification, postoperative hemoglobin, coagulation, and oxygenation indices were recorded and compared between the groups. RESULTS Both groups had almost identical bleeding and transfusion rates (median value: 2 units of red blood cells (RBC) and no units of fresh frozen plasma (FFP) and platelets (PLT) for both groups, p > 0.05). Patients in the cell-salvage group presented slightly higher hemoglobin concentrations (10.6 ± 1.1 vs. 10.1 ± 1.7 g/dL, p < 0.05, respectively) and a tendency towards better oxygenation indices (P(a)O(2)/F(i)O(2): 241 ± 94 vs. 207 ± 84, p=0.013) in the postoperative period albeit with a tendency for prolongation of prothrombin time (INR: 1.31 ± 0.18 vs. 1.26 ± 0.12, p=0.008). CONCLUSION Within the study's constraints, the perioperative use of the cell salvage concentrate does not seem to affect bleeding or transfusion variables, although it could probably ameliorate postoperative oxygenation in adult cardiac surgery patients. A tendency to promote coagulation disturbances was detected.
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The neurocognitive outcomes of hemodilution in adult patients undergoing coronary artery bypass grafting using cardiopulmonary bypass
Soliman R, Saad D, Abukhudair W, Abdeldayem S
Annals of cardiac anaesthesia. 2022;25(2):133-140
Abstract
OBJECTIVE The study aimed to evaluate the effect of mild and moderate hemodilution during CPB on the neurocognitive dysfunction in patients undergoing coronary artery bypass grafting. DESIGN A randomized clinical study. SETTING Cardiac center. PATIENTS 186 patients scheduled for cardiac surgery with cardiopulmonary bypass. INTERVENTION The patients were classified into 2 groups (each = 93), Mild hemodilution group: The hematocrit value was maintained >25% by transfusion of packed-red blood cells plus hemofiltration during CPB. Moderate hemodilution group: the hematocrit value was maintained within the range of 21-25%. MEASUREMENTS The monitors included the hemofiltrated volume, number of transfused packed red blood cells, and the incidence of postoperative cognitive dysfunction. MAIN RESULTS The hemofiltrated volume during CPB was too much higher with mild hemodilution compared to the moderate hemodilution (p = 0.001). The number of the transfused packed red blood cells during CPB was higher with mild hemodilution compared to the moderate hemodilution (p = 0.001), but after CPB, the number of the transfused packed red blood cells was lower with the mild hemodilution group than the moderate hemodilution (p = 0.001). The incidence of total postoperative neurological complications was significantly lower with the mild hemodilution group than moderate hemodilution (p = 0.033). The incidence of neurocognitive dysfunction was significantly lower with mild hemodilution group than moderate hemodilution (p = 0.042). CONCLUSIONS The mild hemodilution was associated with a significant decrease in the incidence of neurocognitive dysfunction compared to moderate hemodilution in patients undergoing coronary artery bypass grafting. Also, the transfused packed red blood cells increased during CPB and decreased after CPB with the mild hemodilution than moderate hemodilution.
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Autologous red blood cell transfusion does not result in a more profound increase in pulmonary capillary wedge pressure compared to saline in critically ill patients: A randomized crossover trial
Bosboom JJ, Klanderman RB, Terwindt LE, Bulle EB, Wijnberge M, Eberl S, Driessen AH, Winkelman TA, Geerts BF, Veelo DP, et al
Vox sanguinis. 2022
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Abstract
BACKGROUND AND OBJECTIVES Transfusion-associated circulatory overload (TACO) is a major cause of severe transfusion-related morbidity. Transfusion of red blood cells (RBCs) has been shown to induce hydrostatic pressure overload. It is unclear which product-specific factors contribute. We set out to determine the effect of autologous RBC transfusion versus saline on pulmonary capillary wedge pressure (PCWP) change. MATERIALS AND METHODS In a randomized crossover trial, patients who had undergone coronary bypass surgery were allocated to treatment post-operatively in the intensive care unit with either an initial 300 ml autologous RBC transfusion (salvaged during surgery) or 300 ml saline infusion first, followed by the other. Primary outcome was the difference in PCWP change. Secondary outcome measures were the difference in extra-vascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). RESULTS Change in PCWP was not higher after autologous RBC transfusion compared to saline (ΔPCWP 0.3 ± 0.4 vs. 0.1 ± 0.4 mmHg). ΔEVLWI and ΔPVPI were significantly decreased after autologous RBC transfusion compared to saline (ΔEVLWI -1.6 ± 0.6 vs. 0.2 ± 0.4, p = 0.02; ΔPVPI -0.3 ± 0.1 vs. 0.0 ± 0.1, p = 0.01). Haemodynamic variables and colloid osmotic pressure were not different for autologous RBC transfusion versus saline. CONCLUSION Transfusion of autologous RBCs did not result in a more profound increase in PCWP compared to saline. RBC transfusion resulted in a decrease of EVLWI and PVPI compared to saline. Our data suggest that transfusing autologous RBCs may lead to less pulmonary oedema compared to saline. Future studies with allogeneic RBCs are needed to investigate other factors that may mediate the increase of PCWP, resulting in TACO.
PICO Summary
Population
Patients undergoing coronary bypass surgery (n= 16).
Intervention
Autologous red blood cells (RBCs) transfusion, with a subsequent infusion of saline (RBCs: Saline, n= 8).
Comparison
Saline infusion with a subsequent transfusion of RBCs (Saline: RBCs, n= 8).
Outcome
The primary outcome was the difference in pulmonary capillary wedge pressure (PCWP) before and after transfusion (ΔPCWP). Secondary outcome measures were the difference in extra-vascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI). Change in PCWP was not higher after autologous RBCs transfusion compared to saline (ΔPCWP 0.3 ± 0.4 vs. 0.1 ± 0.4 mmHg). ΔEVLWI and ΔPVPI were significantly decreased after autologous RBCs transfusion compared to saline (ΔEVLWI -1.6 ± 0.6 vs. 0.2 ± 0.4; ΔPVPI -0.3 ± 0.1 vs. 0.0 ± 0.1). Haemodynamic variables and colloid osmotic pressure were not different for autologous RBCs transfusion versus saline.
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Retrograde autologous priming method reduces plasma free hemoglobin level in aortic surgery
Balci E, Aykut A, Demir A, Vardar K, Karduz G, Aksu U
Annals of cardiac anaesthesia. 2021;24(4):427-433
Abstract
BACKGROUND Although conventional cardiopulmonary bypass (cCPB) is still the most widely used method in open heart surgery, methods such as retrograde autologous priming (RAP) are increasingly popular in terms of limiting hemodilution. Our hypothesis is that the use of the RAP method in aortic surgery may result in a limitation of hemodilution and a decrease in fHb levels. For this purpose, plasma free hemoglobin (fHb) levels were investigated in adult open aortic arch repair with axillary artery cannulation patients using cCPB and rRAP methods. MATERIALS AND METHODS In this study, a total of 36 patients undergoing aortic surgery using rRAP and standard cCPB were investigated. Measurements were performed at five time points: After induction of anesthesia, 5(th) minute of CPB, 10(th) minute of antegrade cerebral perfusion, 30(th) minute after declamping of aorta, and at sternum closure. Besides hemodynamic variables, arterial blood gas analysis and postoperative variables, patients were assessed for fHb levels. RESULTS The rRAP group had a significantly lower increase in fHb levels in T3, T4, and T5 time points, when compared to the cCPB group (p = 0.002, 0.047, 0.009, respectively). There was no significant difference between the rRAP and cCPB groups in other intraoperative, and postoperative variables. Also, it was observed that rRAP did not make a difference in terms of blood and blood product transfusion. CONCLUSION In this study, in patients undergoing aortic surgery, a reduction in the increase of fHb was observed with the rRAP method which is a simple procedure that does not require high cost or advanced technology.
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Novel, digital, chest drainage system in cardiac surgery
Barozzi L, Biagio LS, Meneguzzi M, Courvoisier DS, Walpoth BH, Faggian G
J Card Surg. 2020
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Abstract
BACKGROUND A new, self-contained, digital, continuous pump-driven chest drainage system is compared in a randomized control trial to a traditional wall-suction system in cardiac surgery. METHODS One hundred and twenty adult elective cardiac patients undergoing coronary artery bypass graft and/or valve surgery were randomized to the study or control group. Both groups had similar pre/intra-operative demographics: age 67.8 vs 67.0 years, Euroscore 2.3 vs 2.2, and body surface area 1.92 vs 1.91 m(2) . Additionally, a satisfaction assessment score (0-10) was performed by 52 staff members. RESULTS Given homogenous intra-operative variables, total chest-tube drainage was comparable among groups (566 vs 640 mL; ns), but the study group showed more efficient fluid collection during the early postoperative phase due to continuous suction (P = .01). Blood, cell saver transfusions and postoperative hemoglobin values were similar in both groups. The study group experienced drain removal after 29.8 vs 38.4 hours in the control group (ns). Seven crossovers from the Study to the Control group were registered but no patient had drain-related complications. The Personnel Satisfaction Assessment scored above 5 for all questions asked. CONCLUSIONS The new, digital, chest drainage system showed better early drainage of the chest cavity and was as reliable as conventional systems. Quicker drain removal might impact on intensive care unit (ICU) stay and reduce costs. Additional advantages are portable size, battery operation, patient mobility, noiseless function, digital indications and alarms. The satisfaction assessment of the new system by the staff revealed a higher score when compared to the traditional wall suction chest drainage system.
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Does Intraoperative Cell Salvage Reduce Postoperative Infection Rates in Cardiac Surgery?
van Klarenbosch J, van den Heuvel ER, van Oeveren W, de Vries AJ
Journal of cardiothoracic and vascular anesthesia. 2020
Abstract
OBJECTIVE Primary outcome was the risk for infections after cell salvage in cardiac surgery. DESIGN Data of a randomized controlled trial on cell salvage and filter use (ISRCTN58333401). SETTING Six cardiac surgery centers in the Netherlands. PARTICIPANTS All 716 patients undergoing elective coronary artery bypass grafting, valve surgery, or combined procedures over a 4-year period who completed the trial. INTERVENTIONS Postoperative infection data were assessed according to Centre of Disease Control and Prevention/National Healthcare Safety Network surveillance definitions. MEASUREMENTS AND MAIN RESULTS Fifty-eight (15.9%) patients with cell salvage had infections, compared with 46 (13.1%) control patients. Mediation analysis was performed to estimate the direct effect of cell salvage on infections (OR 2.291 [1.177;4.460], p=0.015) and the indirect effects of allogeneic transfusion and processed cell salvage blood on infections. Correction for confounders, including age, seks and body mass index was performed. Allogeneic transfusion had a direct effect on infections (OR=2.082 [1.133;3.828], p=0.018), but processed cell salvage blood did not (OR=0.999 [0.999; 1.001], p=0.089). There was a positive direct effect of cell salvage on allogeneic transfusion (OR=0.275 [0.176;0.432], p < 0.001), but a negative direct effect of processed cell salvage blood (1.001 [1.001;1.002], p < 0.001) on allogeneic transfusion. Finally, there was a positive direct effect of cell salvage on the amount of processed blood. CONCLUSIONS Cell salvage was directly associated with higher infection rates, but this direct effect was almost completely eliminated by its indirect protective effect through reduced allogeneic blood transfusion.
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Effect of Autotransfusion Using Intraoperative Predonated Autologous Blood on Coagulopathy during Thoracic Aortic Surgery: A Randomized Controlled Trial
Suzuki R, Mikamo A, Matsuno Y, Fujita A, Kurazumi H, Yamashita A, Hamano K
Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 2019
Abstract
BACKGROUND Intraoperative predonated autologous blood transfusion is thought to replenish platelets and coagulation factors and ameliorate coagulopathy. This study aimed to evaluate whether intraoperative predonated autotransfusion improves coagulopathy during thoracic aortic surgery. METHODS Patients who underwent thoracic aortic surgery were randomized into two groups as follows: those who received intraoperative predonated blood (group A: n = 31) and those who did not receive (group N: n = 22). In group A, autologous blood was retransfused immediately after cessation of cardiopulmonary bypass (c-CPB). RESULTS The mean intraoperative allogenic blood or blood product transfusion requirements were significantly lesser in group A than in group N (packed red blood cells [RBCs]: 6.3 +/- 5.1 vs. 9.1 +/- 4.3 units, p = 0.04; fresh frozen plasma [FFP]: 3.0 +/- 4.1 vs. 6.1 +/- 5.7 units, p = 0.03). After c-CPB, hemoglobin (Hb) level, platelet count, and coagulopathy became significantly worse than those at the start of surgery in both the groups. However, the values significantly improved 30 min after c-CPB only in group A. Renal function was significantly worse in group N. CONCLUSIONS Intraoperative predonated autotransfusion significantly improved coagulopathy, with reduced allogeneic blood transfusion volume during thoracic aortic surgery. Furthermore, reduction of allogeneic blood transfusion may reduce the adverse effects on renal function.
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Reduction of drainage-associated complications in cardiac surgery with a digital drainage system: a randomized controlled trial
Van Linden A, Hecker F, Courvoisier DS, Arsalan M, Kohne J, Brei C, Holubec T, Walther T
Journal of thoracic disease. 2019;11(12):5177-5186
Abstract
Background: Thoracic chest drains are placed after cardiac surgery allowing for the clearance of blood, fluid, and air to prevent post-operative complications. Despite its importance, there is little data on the application of digital chest drainage systems in cardiac surgery. Therefore, the differences between an analog and a digital chest drainage system in cardiac surgery patients were investigated in a randomized controlled trial. Methods: A total of 354 elective cardiac surgery patients were preoperatively randomized 1:1 between September 2016 and September 2017 to either an analog (Ocean) or a digital (Thopaz(+)) chest drainage system aiming to compare drainage-associated postoperative outcome parameters. Results: A total of 340 patients were included in the analysis (analog: 188; digital: 152) with no significant differences in preoperative baseline parameters. Incidence of X-rays to detect air leaks was significantly lower in the digital group (analog: 20.2%; digital: 8.6%; P<0.01). Patients treated with the digital system showed a 3.3% reduction of re-thoracotomies, however, not statistically significant (analog: 5.3%; digital: 2.0%; P=0.19). Median total fluid amount did not significantly differ between study groups [median (P25; P75); analog: 705 (400; 1,333) mL; digital: 686 (404; 1,229) mL; P=0.83]; however, the use of the digital drainage system resulted in a quicker removal with a reduced median drainage duration of 16 hours (analog: 65 hours; digital: 49 hours; P≤0.01). Conclusions: The study provides evidence that digital drainage systems can be safely applied in cardiac surgery patients. The use of the digital management system led to a decreased incidence of drainage-associated complications as well as to shortened chest tube duration. Findings require confirmation by additional studies.
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Superior blood-saving effect and postoperative recovery of comprehensive blood-saving strategy in infants undergoing open heart surgery under cardiopulmonary bypass
Wu T, Liu J, Wang Q, Li P, Shi G
Medicine. 2018;97((27)):e11248.
Abstract
BACKGROUND Optimization of blood-saving strategies during open heart surgery in infants is still required. This study aimed to study a comprehensive blood-saving strategy during cardiopulmonary bypass (CPB) on postoperative recovery in low-weight infants undergoing open heart surgery. METHODS This was a prospective study of 86 consecutive infants (weighing <5 kg) with acyanotic congenital heart disease treated at the Tianjin Chest Hospital between March and December 2016, and randomized to the control (traditional routine CPB) and comprehensive blood-saving strategy groups. The primary endpoints were blood saving and clinical prognosis. The secondary endpoints were safety and laboratory indicators, prior to CPB (T1), after 30 minutes of CPB (T2), after modified ultrafiltration (T3), and postoperative 12 (T4), 24 (T5), 48 (T6), and 72 h (T7). RESULTS The total priming volume and banked red blood cells in the comprehensive strategy group were significantly lower than in the control group (P = .009 and P = .04, respectively). In the comprehensive strategy group, immediately after CPB, the amount of salvaged red blood cells exceeded the priming red blood cells by 40 +/- 11 mL. Postoperatively, the comprehensive strategy group showed a significant decrease in the inotrope score (P = .03), ventilation time (P = .03), intensive care unit stay (P = .04), and hospital stay (P = .03) in comparison with the control group. CONCLUSION The comprehensive blood-saving strategies for CPB were associated with less blood use and favorable postoperative recovery in low-weight infants with congenital heart disease undergoing open heart surgery.
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Comparative evaluation of blood salvage techniques in patients undergoing cardiac surgery with cardiopulmonary bypass
Gunaydin S, Robertson C, Budak AB, Gourlay T
Perfusion. 2017;:267659117728328.
Abstract
BACKGROUND The primary objective of this study was to test and compare the efficacy of currently available intraoperative blood salvage systems via a demonstration of the level of increase in percentage concentration of red blood cells (RBC), white blood cells 9WBC) and platelets (Plt) in the end product. METHODS In a prospective, randomized study, data of 80 patients undergoing elective cardiac surgery with cardiopulmonary bypass in a 6-month period was collected, of which the volume aspirated from the surgical field was processed by either the HemoSep Novel Collection Bag (Advancis Surgical, Kirkby-in-Ashfield, Notts, UK) (N=40) (Group 1) or a cell- saver (C.A.T.S Plus Autotransfusion System, Fresenius Kabi, Bad Homburg, Germany) (N=40) (Group 2). RESULTS Hematocrit levels increased from 23.05%+/-2.7 to 43.02%+/-12 in Group 1 and from 24.5+/-2 up to 55.2+/-9 in Group 2 (p=0.013). The mean number of platelets rose to 225200+/-47000 from 116400 +/-40000 in the HemoSep and decreased from 125200+/-25000 to 96500+/-30000 in the cell-saver group (p=0.00001). The leukocyte count was concentrated significantly better in Group 1 (from 10100+/-4300 to 18120+/-7000; p=0.001). IL-6 levels (pg/dL) decreased from 223+/-47 to 83+/-21 in Group 1 and from 219+/-40 to 200+/-40 in Group 2 (p=0.001). Fibrinogen was protected significantly better in the HemoSep group (from 185+/-35 to 455+/-45; p=0.004). CONCLUSIONS Intraoperative blood salvage systems functioned properly and the resultant blood product was superior in terms of red blood cell species. The HemoSep group had significantly better platelet and leukocyte concentrations and fibrinogen content.