Ann Thorac Surg 1995;59:184-186
© 1995 The Society of Thoracic Surgeons
Shed Whole Blood Autotransfusion During Aortic Aneurysm Operation With a Modified Collection Infusion System
Rene J. Dekkers, CCP,
Robert J. Rizzo, MD,
Simon C. Body, MB, ChB,
Daniel J. Fitzgerald, CCP,
Lawrence H. Cohn, MD
Departments of Surgery, Cardiac Perfusion, and Anesthesia, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
Accepted for publication August 22, 1994.
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Abstract
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We describe a modified shed whole blood collection and autotransfusion system that allows several options for the processing and autotransfusion of shed blood: use of the Cell Saver (Haemonetics, Braintree, MA) or the ultrafiltration of collected blood, and the autotransfusion of unprocessed shed whole blood. The system has proved useful for transfusion in the setting of thoracic aortic operations, and we describe here our experience in 5 patients undergoing resection of a descending thoracic aortic aneurysm in whom this system was used.
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Introduction
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Patients undergoing resection of a thoracic aortic aneurysm can suffer considerable blood loss. In one study on the use of blood products during thoracoabdominal aortic procedures, the median number of blood products cited was as follows: packed red blood cells, 7 units (range, 1 to 46 units); fresh frozen plasma, 16 units (range, 0 to 132 units); platelets, 20 units (range, 0 to 110 units); cryoprecipitate, 0 units (range, 0 to 100 units), and Cell Saver (Haemonetics, Braintree, MA) salvage, 8 units (range, 0 to 68 units) [1]. The quantity and quality of shed blood during aortic operations differ from those of shed blood observed for most other kinds of operations, in that blood shed during thoracic aortic procedures is usually minimally contaminated by other body or operative fluids, whereas considerable contamination can occur during other procedures [2]. When Cell Savers are used, transfusion is delayed because of the collection and processing that must take place, during which the plasma protein and platelet fractions of the collected blood are discarded; this may result in a dilutional coagulopathy that can only be rectified by component therapy [3]. There is a need for a shed blood management system that is capable of collecting shed whole blood, while preserving the plasma proteins and platelets, and permitting retranfusion in a rapid normothermic fashion [4, 5].
A rapid infusion system (RIS) (Haemonetics) has been developed that is capable of providing rapid normothermic volume replacement during massive transfusion. Because of the design of the RIS, however, it has been limited to serving only as a transfusion device and has not been able to act as a collection device. We needed a device that could collect and anticoagulate shed whole blood; rapidly warm, filter, and reinfuse this shed blood, thus decreasing the risk of homologous blood transfusion; and spare the plasma proteins and platelets otherwise lost during the cell-saving process. Although the present experience has focused on the use of this system during thoracic procedures, the modified RIS may also be useful for other types of major vascular procedures, for hepatic transplantation, or for surgical interventions in patients who have suffered major trauma free of blood contamination.
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Material and Methods
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We reviewed the records of the first 5 patients who underwent thoracic aortic procedures that included autotransfusion using a modified RIS. All 5 underwent repair of descending thoracic aortic aneurysms. The patients' demographic data are given in Table 1
. A 2,600-mL, 150-µm filtered cardiotomy reservoir (Haemonetics) was mounted to the RIS, and a regulated wall suction tube (<150 mm Hg) was connected to the vacuum port on this cardiotomy. A Cell Saver was placed alongside the RIS. The Cell Saver suction tubing was passed onto the surgical field and connected to one of the four filtered ports on top of the Cell Saver cardiotomy reservoir. Either low-dose heparin (30,000 units • L-1 in saline solution) or sodium citrate (10 g/250 mL) was set at a drip rate of about 5 mL • min-1 through the suction tubing. The Cell Saver cardiotomy reservoir was connected to the infusion cardiotomy reservoir by means of a Y connector, allowing the contents of the Cell Saver cardiotomy reservoir to be drained either into the infusion cardiotomy reservoir or into the Cell Saver machine (see Fig 1).
The RIS can deliver infusate at a rate of up to 1,500 mL • min-1 in the normothermic range. The infusion rate can be controlled manually, or the infusate can be delivered in 100-mL or 500-mL boluses. Built-in safety features prevent infusion when the reservoir contains less than 200 mL of fluid, when air is sensed by an in-line bubble detector, when the temperature of the infusate is less than 34°C, or when the in-line pressure exceeds the preset limit. The transfusate is passed through a 40-µm filter before infusion. The large-bore infusion catheters are connected to a 7F or 8F intravenous catheter placed into a large vein. Homologous blood products, autologous blood, and colloid or crystalloid fluids are added to the cardiotomy reservoir, then recirculated, rewarmed, and eventually transfused to the patient, as warranted.
During the initial surgical dissection and after the administration of protamine, shed blood was diverted to the Cell Saver for processing before being reinfused through the RIS. After systemic anticoagulation was achieved with 5,000 units of heparin, the aorta was cross-clamped, opened, and repaired. During this time when larger volumes of shed whole blood were collected in the Cell Saver cardiotomy reservoir, the regulated suction was interrupted and this shed blood was passively drained into the infusion cardiotomy reservoir. When shed blood enters the infusion cardiotomy reservoir, it is rewarmed, filtered, and if necessary, recirculated through a hemoconcentration filter (Amicon pre-rinsed filter; Limerick, Ireland) placed in the recirculation line, and then rapidly autotransfused. This technique ensures that the shed blood to be reinfused is warmed to 37°C and is devoid of excessive crystalloid fluid scavenged in the operative field.
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Results
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All 5 patients underwent autotransfusion and volume resuscitation with the modified RIS. Ultrafiltration was performed in 2 patients in conjunction with the RIS. The aneurysms ranged from 4.5 to 7.0 cm in diameter. All patients survived the operation and no patient was returned to the operating room for the management of bleeding. There was no significant postoperative morbidity. The total autotransfusion volumes ranged from 1.4 to 7.8 L. A breakdown of the blood products administered during operation is given in Table 2. Because of concern regarding the potential for excessive systemic anticoagulation stemming from the autotransfusion of unwashed shed blood anticoagulated with heparin, we changed to sodium citrate as the shed blood anticoagulant after the second patient. Large volumes of citrate will cause the systemic ionized calcium levels to be depressed, and thus we now routinely measure the baseline ionized calcium level in the patient, as well as the level at hourly intervals during the procedure, or more frequently depending on the quantity of blood reinfused.
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Comment
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Thoracic aortic aneurysm repair represents a challenge for both the surgeon and anesthesiologist. The patient population is primarily elderly, and usually there is considerable comorbidity involved. Operations for the repair of a thoracic aortic aneurysm can lead to massive and sometimes uncontrollable blood loss and considerable coagulopathy. The shed whole blood collection and reinfusion system described here is beneficial in maintaining both hemostasis and hemodynamics during the repair of a thoracic aortic aneurysm, and thus bringing about a decrease in serious postoperative morbidity. The system is versatile, in that the mode of processing the shed blood that has been collected can be selected, so that the clinician can use a Cell Saver to wash the blood, a hemoconcentrator to ultrafiltrate crystalloid fluid–contaminated blood if it is too dilute, or the modified RIS to rapidly autotransfuse warm shed whole blood. With these latter techniques that avoid washing away plasma and platelets, the patient may be less likely to require homologous blood products.
As already noted, to allow the collected shed blood to enter the infusion cardiotomy reservoir from the collection cardiotomy reservoir, the aspiration suction must be temporarily interrupted. A desirable modification that avoids this limitation would be to add an additional roller pump between the collection and infusion cardiotomy reservoirs capable of flows of up to 2 L • min-1. This is a controlled technique for transporting shed blood from the collection cardiotomy reservoir to the infusion cardiotomy reservoir without the need to interrupt aspiration suction. We have now begun to use this modification in subsequent patients. Insertion of a hemoconcentrator in the recirculation line of the Haemonetics RIS provides another option for altering the quality of shed blood. Ultrafiltration is carried out only when there is a suspicion that shed blood is being hemodiluted at the surgical field.
In summary, we describe a simple modified collection and reinfusion system that includes the Haemonetics RIS and Cell Saver and that enables the clinician to quickly transfuse shed whole blood and to process poor-quality shed blood, which may decrease the need for homologous blood products.
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Footnotes
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Address reprint requests to Dr Cohn, Division of Cardiac Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115.
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References
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- Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357–68.[Medline]
- Hartz RS, Smith JA, Green D. Autotransfusion after cardiac operation assessment of hemostatic factors. J Thorac Cardiovasc Surg 1988;96:178–82.[Abstract]
- Wooten MJ. Use and analysis of saline washed red blood cells. Transfusion 1976;16:464–8.[Medline]
- Long GW, Glover JL, Bendick PJ, et al. Cell washing versus immediate reinfusion of intra-operatively shed blood during abdominal aortic aneurysm repair. Am J Surg 1993;166:97–102.[Medline]
- Ouriel K, Shortell CK, Green RM, DeWeese JA. Intraoperative autotransfusion in aortic surgery. J Vasc Surg 1993;18: 16–22.[Medline]
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Abstract
Introduction
