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
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.
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
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.
Effect of Retrograde Autologous Blood Priming of Cardiopulmonary Bypass on Hemodynamic Parameters and Pulmonary Mechanics in Pediatric Cardiac Surgery: A Randomized Clinical Study
Singab H, Gamal MA, Refaey R, Al-Taher W
Seminars in thoracic and cardiovascular surgery. 2020
The present study aimed to assess the impact of retrograde autologous priming (RAP) on hemodynamics and pulmonary mechanics in children subjected to cardiothoracic surgery. This prospective randomized study analyzed the clinical records of 124 children with Rachs-1 left to right lesions subjected to cardiac surgery. They comprised 64 patients in RAP group and 60 patients in the conventional priming group. The preoperative, intraoperative and postoperative data of the studied patients were reported. The outcome measures included hematocrit value, blood gases, lung mechanics parameters, transfusion needs, ICU stay, postoperative complications and mortality. Preoperatively, there were no significant differences between the studied groups regarding the demographic data, underlying lesions, laboratory data, blood gases and pulmonary mechanics parameters. Intraoperatively, RAP group patients had significantly lower amount of blood loss, less frequent need to packed RBCs transfusion and better hematocrit values when compared with the control group. Postoperatively, RAP group patients had significantly higher Hct % at ICU arrival, significantly better pulmonary mechanics parameters and significantly shorter duration on mechanical ventilation. Retrograde autologous priming in children older than 12 months subjected to cardiac surgery for Rachs-1 left to right lesions is associated with less transfusion needs and better pulmonary mechanics.
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
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.
Additional filtering of blood from a cell salvage device is not likely to show important additional benefits in outcome in cardiac surgery
de Vries AJ, Vermeijden WJ, van Pelt LJ, van den Heuvel ER, van Oeveren W
BACKGROUND Several authors and manufacturers of cell salvage devices recommend additional filtering of processed blood before transfusion. There is no evidence to support this practice. Therefore, we compared the clinical outcome and biochemical effects of cell salvage with or without additional filtering. STUDY DESIGN AND METHODS The patients, scheduled for coronary artery bypass grafting, valve replacement, or combined procedures were part of our randomized multicenter factorial study of cell salvage and filter use on transfusion requirements (ISRCTN 58333401). They were randomized to intraoperative cell salvage or cell salvage plus additional WBC depletion filter. We compared the occurrence of major adverse events (combined death/stroke/myocardial infarction) as primary outcome and minor adverse events (renal function disturbances, infections, delirium), ventilation time, and length of stay in the intensive care unit and hospital. We also measured biochemical markers of organ injury and inflammation. RESULTS One hundred eighty-nine patients had cell salvage, and 175 patients had cell salvage plus filter and completed the study. Demographic data, surgical procedures, and amount of salvaged blood were not different between the groups. There was no difference in the primary outcome with a risk of 6.3% (95% confidence interval [CI], 3.34-11.25) in the cell salvage plus filter group versus 5.8% (95% CI, 3.09-10.45) in the cell salvage group, a relative risk of 1.08 (95% CI, 0.48- 2.43]. There were no differences in minor adverse events and biochemical markers between the groups. CONCLUSION The routine use of an additional filter for transfusion of salvaged blood is unlikely to show important additional benefits.
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
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.
A comparison of haemostatic biomarkers during low-risk patients undergoing cardiopulmonary bypass using either conventional centrifugal cell salvage or the HemoSep device
Boyle G, Kuffel A, Parmar K, Gibson K, Smith M, Grehan A, Hunt BJ, Chambers DJ
BACKGROUND Cardiac surgery using cardiopulmonary bypass (CPB) is associated with a coagulopathy due to haemodilution, thrombocytopenia and platelet dysfunction and the activation of coagulation and fibrinolysis, despite the use of large doses of unfractionated heparin. Conventional red cell salvage may exacerbate post-operative bleeding as plasma containing haemostatic factors is discarded. We hypothesized that a novel cell salvage device (HemoSep) may attenuate haemostatic changes associated with red cell salvage. We studied haemostatic markers following autologous transfusion from conventional cell salvage or the HemoSep device. METHODS This randomised, controlled trial compared haemostatic markers in patients undergoing coronary artery bypass grafting or aortic valve replacement who received autologous blood returned from cell salvage (control) or HemoSep (study). Blood samples were taken pre-operatively, end of CPB, post-transfusion of salvaged blood and 3 hours post-operatively and analysed for full blood count (FBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer and endogenous thrombin potential (ETP). RESULTS Fifty-four patients were recruited (n=28 control, n=26 study). Processed blood volume for transfusion was significantly (p<0.001) higher in the HemoSep group. In the HemoSep group, the PT was shorter (18.7+/-0.3 vs 19.9+/-0.3 sec; p<0.05) post-operatively and the aPTT was longer (48.6+/-3.8 vs 37.3+/-1.0 sec; p<0.01) following autologous transfusion. In the control group, D-dimer and ETP levels were higher (1903+/-424 vs.1088+/-151; p<0.05 and 739+/-46 vs. 394+/-60; p<0.001, respectively) following autologous transfusion. CONCLUSIONS Although centrifuged cell salvage is known to adequately haemoconcentrate and remove unwanted substrates and bacteriological contamination, the process can exacerbate coagulopathy. The HemoSep device demonstrated some increase in haemostatic markers when used in low-risk cardiac surgery patients.
Application of autologous blood cell salvage in off-pump coronary artery bypass graft operation
Zhao H, Ma H, Meng L, Zhao Z, Quan X, Cheng Z
The Heart Surgery Forum. 2017;20((3)):E107-E110.
OBJECTIVE To analyze whether application of autologous blood cell salvage can reduce the transfusion volume of allogeneic blood and complications of blood transfusion in off-pump coronary artery bypass operations. Methods: We randomly divided 120 patients into autologous blood cell salvage group (experimental group, n = 60) and non-autologous blood cell salvage group (control group, n = 60). Volume of perioperative allogeneic blood transfusion of each patient was recorded. Moreover, complications and ICU retention times (H) of each patient were also recorded. The data were analyzed using t tests. Results: The volume of allogeneic blood transfusion was significantly less in the experimental group than in the control group. Conclusion: Application of autologous blood cell salvage in off-pump coronary artery bypass graft operation can reduce the volume of allogeneic blood transfusion, alleviate blood shortage, and reduce the incidence of postoperative complications, leading to medical, economic, and social benefits.
Shed-blood-separation and cell-saver: an integral part of MiECC? Shed-blood-separation and its influence on the perioperative inflammatory response during coronary revascularization with minimal invasive extracorporeal circulation systems - a randomized controlled trial
Bauer A, Hausmann H, Schaarschmidt J, Scharpenberg M, Troitzsch D, Johansen P, Nygaard H, Eberle T, Michael Hasenkam J
OBJECTIVE The postoperative systemic inflammatory response after cardiopulmonary bypass (CPB) is still an undesirable side-effect after cardiac surgery. It is most likely caused by blood contact with foreign surfaces and by the surgical trauma itself. However, the recirculation of activated shed mediastinal blood is another main cause of blood cell activation and cytokine release. Minimal invasive extracorporeal circulation (MiECC) comprises a completely closed circuit, coated surfaces and the separation of suction blood. We hypothesized that MiECC, with separated cell saved blood, would induce less of a systemic inflammatory response than MiECC with no cell-saver. The aim of this study was, therefore, to investigate the impact of cell washing shed blood from the operating field versus direct return to the ECC on the biomarkers for systemic inflammation. MATERIAL AND METHODS In the study, patients with MiECC and cell-saver were compared with the control group, patients with MiECC and direct re-transfusion of the drawn blood shed from the surgical field. RESULTS High amounts of TNF-alpha (+ 120% compared to serum blood) were found in the shed blood itself, but a significant reduction was demonstrated with the use of a cell-saver (TNF-alpha ng/l post-ECC 10 min: 9.5+/-3.5 vs. 19.7+/-14.5, p<0.0001). The values for procalcitonin were not significantly increased in the control group (6h: 1.07+/-3.4 vs. 2.15+/-9.55, p=0.19) and lower for C-reactive protein (CRP) (24h: 147.1+/-64.0 vs.134.4+/-52.4 p=0.28). CONCLUSION The use of a cell-saver and the processing of shed blood as an integral part of MiECC significantly reduces the systemic cytokine load. We, therefore, recommend the integration of cell-saving devices in MiECC to reduce the perioperative inflammatory response.
Better platelet function, less fibrinolysis and less hemolysis in re-transfused residual pump blood with the Ringer's chase technique - a randomized pilot study
Olsson A, Alfredsson J, Ramstrom S, Svedjeholm R, Kenny D, Hakansson E, Berglund JS, Berg S
INTRODUCTION Residual pump blood from the cardiopulmonary bypass (CPB) circuit is often collected into an infusion bag (IB) and re-transfused. An alternative is to chase the residual blood into the circulation through the arterial cannula with Ringer's acetate. Our aim was to assess possible differences in hemostatic blood quality between these two techniques. METHODS Forty adult patients undergoing elective coronary artery bypass graft surgery with CPB were randomized to receive the residual pump blood by either an IB or through the Ringer's chase (RC) technique. Platelet activation and function (impedance aggregometry), coagulation and hemolysis variables were assessed in the re-transfused blood and in the patients before, during and after surgery. Results are presented as median (25-75 quartiles). RESULTS Total hemoglobin and platelet levels in the re-transfused blood were comparable with the two methods, as were soluble platelet activation markers P-selectin and soluble glycoprotein VI (GPVI). Platelet aggregation (U) in the IB blood was significantly lower compared to the RC blood, with the agonists adenosine diphosphate (ADP) 24 (10-32) vs 46 (33-65), p<0.01, thrombin receptor activating peptide (TRAP) 50 (29-73) vs 69 (51-92), p=0.04 and collagen 24 (17-28) vs 34 (26-59), p<0.01. The IB blood had higher amounts of free hemoglobin (mg/L) (1086 (891-1717) vs 591(517-646), p<0.01) and D-dimer 0.60 (0.33-0.98) vs 0.3 (0.3-0.48), p<0.01. Other coagulation variables showed no difference between the groups. CONCLUSIONS The handling of blood after CPB increases hemolysis, impairs platelet function and activates coagulation and fibrinolysis. The RC technique preserved the blood better than the commonly used IB technique.