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Ann Thorac Surg 1995;59:901-907
© 1995 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery and Cardiothoracic Surgery Research Division, University Hospital Groningen, Groningen, the Netherlands
Accepted for publication December 15, 1994.
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Abstract |
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Introduction |
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An interesting phase during CPB in this regard concerns the period after release of the aortic cross-clamp, which is associated with a high level of blood activation. This blood activation is characterized by the circulation of increased concentrations of bioactive products originating from clotting, fibrinolysis, and blood cell damage [4]. Possible explanations include the effect of reperfusion of heart and lungs, rewarming of the patient [5], and the retransfusion of suctioned blood [6]. This suctioned blood originates from the oozing wound sites in the thorax, collects in pleural and pericardial spaces, and is retransfused by suction via the cardiotomy reservoir of the heart-lung machine. Because all these processes coincide, separate contribution of these processes to the blood activation and postoperative hemostasis could not be distinguished.
In a controlled clinical study we altered the technique of retransfusion of suctioned blood and assessed the effect on hemostasis by determination of postoperative blood loss and total consumption of blood products such as red blood cell concentrates (RBC) and single-donor plasma (SDP). Two groups of patients submitted for elective coronary artery bypass grafting were compared: one group in which the suctioned blood was retransfused immediately after release of the aortic cross-clamp and the other group in which the suctioned blood was retained. During the study, 12 consecutive patients, randomized to 6 in each group, were analyzed for plasma components indicating clotting, fibrinolysis, and red blood cell damage, by collecting samples from the circulation and suctioned blood.
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Material and Methods |
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The patients were assigned to one of two study groups: retransfusion of suctioned blood (retransfusion; n = 19) or retainment of suctioned blood (retainment; n = 21). During the ongoing study 12 consecutive patients were randomized prospectively to one of the two groups and sampled for further biochemical analysis.
Operative and Anesthetic Techniques
After premedication with diazepam (10 to 15 mg), anesthesia was induced with sulfentanyl (1 to 3 µg/kg) and midazolam (1 to 2 mg/kg), and muscle relaxation was induced with pancuronium bromide (0.1 mg/kg). Ventilation was controlled by a volume-controlled respirator with an oxygen/air mixture. Anesthesia was sustained with sulfentanyl and midazolam infusion. Cefamandol (2 g) and dexamethasone (1 mg/kg) were administered preoperatively. Before cannulation, bovine heparin (300 IU/kg; Leo, Emmen, the Netherlands) was injected. The activated coagulation time was determined in every patient 5 minutes before the start of CPB and at regular intervals during CPB (International Technidyne Co, Edison, NJ). The activated coagulation time was confirmed to be greater than 400 seconds throughout CPB in every patient. Whenever an activated coagulation time was less than 400 seconds additional heparin (100 IU/kg) was given. The ECC consisted of a flat membrane oxygenator with an integrated cardiotomy reservoir including a 40-µm filter (Cobe Excell; COBE Laboratories Inc, Arvada, CO), and polyvinyl chloride tubing. The circuit was primed with 2,000 mL of oxypolygelatin (Gelifundol; Biotest Pharma GmbH, Dreiech, Germany) and 1,500 IU of bovine heparin (Leo). Cardiopulmonary bypass was performed with moderate hypothermia (27°C nasopharyngeal temperature) with a pump flow of 2.4 L • m-2 • min-1, maintaining a mean arterial pressure of 50 to 60 mm Hg. Myocardial preservation during aortic clamping was implemented with 1 L of St. Thomas' Hospital cardioplegic solution (4°C) injected into the aortic root. After CPB, heparin was neutralized by protamine chloride (3 mg/kg; Hoffman-Laroche bv, Mijdrecht, the Netherlands).
During aortic cross-clamping, the aortic root was vented by a shunt between the aortic root and the venous return line of the heart-lung machine. Topical cooling of the myocardium was achieved with a cold (4°C) saline solution. The blood that gradually oozed from the surgical field into the pericardial and pleural cavities was aspirated by a sucker and collected in a separate plastic polyvinyl chloride blood transfer bag connected to the suction roller pump.
In the retransfusion group, the contents of the blood transfer bag were retransfused gradually via the cardiotomy reservoir. In the retainment group the suctioned blood was not retransfused during the operation. In case of immediate blood transfusion requirement during the operation, the collecting bag could be discharged immediately to the cardiotomy reservoir for rapid transfusion.
Blood Loss and Transfusion of Blood Products
Operative blood loss was assessed by measuring the weight of the separate collection bag before and after collection of the suctioned blood. Postoperative blood loss was assessed by measuring the blood volume collected from mediastinal and chest tubes during the first 24 postoperative hours. During the period in the operating room and the first 24 postoperative hours, the transfusion of RBC and SDP also was monitored. Assessment of blood products consumption during intensive care was validated by blinding the intensive care unit staff in their policy to use such products. Transfusion of RBC was indicated by hematocrit values lower than 25%; SDP transfusion was used for volume replacement in case the postoperative infusion volume of colloid plasma expander exceeded 1.5 L. The chest tubes were removed from all patients at about 48 hours after the operation.
Blood Samples
Before starting CPB but after heparinization, one blood sample was taken from the radial arterial line for determination of baseline values. Just before the end of aortic occlusion a blood sample was taken from the arterial line of the oxygenator. At 5 minutes after the end of aortic occlusion, blood samples were taken simultaneously from the arterial line of the oxygenator and from the collected suctioned blood. At 5 minutes after all suctioned blood was either retransfused to the circulation of the patient (retransfusion group 1) or retained (retainment group), blood samples were taken from the arterial line of the oxygenator. Finally, a blood sample was taken after the protamine infusion immediately before leaving the operating room. Blood samples were collected in the appropriate collecting medium, stored on ice, and, after determination of cell counts and hematocrit, centrifuged at 1,000 g for 10 minutes to obtain platelet-poor plasma (PPP). The PPP samples were stored at -80°C until further processing.
Laboratory Assays
In PPP from blood samples collected in 3.06% sodium citrate containing 1,000 KIU/mL aprotinin and 0.05 U/mL hirudin, we determined the concentration of tissue-type plasminogen activator (t-PA) antigen (enzyme-linked immunosorbent assay [ELISA]; Kabi Diagnostica, Stockholm, Sweden), thrombin-antithrombin III complexes (TAT) (ELISA; Behring, Marburg, Germany), and fibrin degradation products (FbDP) (ELISA; Organon Teknika, Turnhout, Belgium). Heparin concentration was determined by its capacity to inhibit factor Xa activity. In the presence of excess antithrombin III and factor Xa the conversion rate of factor Xa specific substrate was determined (S2222; Kabi Diagnostica). Red blood cell damage was assessed by measuring free hemoglobin concentrations in the plasma samples by a spectrophotometric determination [7].
The concentration of fibrin fragments was determined in 6 separate patients from the retainment group, additionally sampled immediately after start of bypass. In PPP from blood samples, collected in 3.06% sodium citrate and 10 mmol/L EDTA, from circulation and the pericardial cavity fibrin fragments concentrations were determined according to the method of Wiman and Rånby [8]. Briefly, to excess t-PA, plasminogen, and a specific plasmin substrate (S2403; Chromogenix, Stockholm, Sweden) a small amount of PPP was added. Because of the t-PA--stimulating character of fibrin fragments, the turnover of plasmin substrate is indicative of fibrin fragment concentrations in the PPP samples. Concentrations of metabolites in the blood circulation also are influenced by hemodilution caused by factors such as the pump-prime solution at the start of bypass, infusion of cardioplegia, and topical cooling solution in the pericardial cavity. All data presented in the figures are not ``corrected'' for any such dilution effects. Finally, amounts of free plasma hemoglobin and FbDP in the circulating and suctioned blood were calculated from their concentrations in the blood times the blood volumes. The obtained data were processed to create the correlation diagrams of Figure 8
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), allowing comparison of clinical and biochemical data.
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).
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). After this retransfusion phase, TAT concentrations rose significantly in both study groups: tenfold in the retransfusion group and fourfold in the retainment group (p < 0.01 for both). The ensuing difference between the two groups also was significant (p < 0.01). In both groups, TAT concentration in the suctioned blood was significantly greater than in the circulating blood at the same time (p < 0.001 for both groups).
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). The observed increase also resulted in a significantly higher t-PA concentration in the retransfusion group compared with the retainment group (p < 0.05). After protamine administration, however, circulating levels of t-PA again were similar in both groups. Concentrations of t-PA antigen in the suctioned blood were similar to concentrations in the circulating blood at the same time.
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). After this retransfusion phase, FbDP concentrations rose significantly in both study groups: fourfold in the retransfusion group and twofold in the retainment group (p < 0.01 for both). The ensuing differences between the two groups after the retransfusion phase and after protamine administration also were significant, associated with p values of less than 0.01 and less than 0.05. The concentrations of FbDP in the suctioned blood were significantly higher than in the circulating blood at the same time (p < 0.01 for both groups).
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), especially when hemodilution by pump prime solution was taken into account. Throughout the bypass procedure no significant changes in fibrin fragment levels were observed. Concentrations in the suctioned blood, sampled directly from the thoracic cavity during CPB, exceeded values five times higher than in samples taken from circulation at the same time (p < 0.01).
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). Heparin concentrations in the suctioned blood were significantly lower at about one fifth in both groups compared with the circulating blood at the same time (p < 0.001). Although the heparin concentrations were significantly lower after the retransfusion phase (p < 0.05 for both groups), no significant difference was observed between the two groups.
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). After this retransfusion phase, free plasma hemoglobin concentrations rose significantly in both study groups: 300% in the retransfusion group and 50% in the retainment group (p < 0.01 for both). The ensuing differences between the two groups after the retransfusion phase and after protamine administration also were significant (p < 0.05). Free plasma hemoglobin concentration in the suctioned blood was significantly higher than in the circulating blood at the same time (p < 0.001 for both groups).
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Comment |
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In this study we showed unequivocally that retransfusion of suctioned blood is potentially hazardous for impairing hemostasis. Retainment of this highly activated blood preserved hemostasis, which was demonstrated by the significantly reduced postoperative blood loss. Donor blood requirement was not statistically significantly reduced, but the mere fact that retainment of suctioned blood during the operation did not cause additional demand for blood products indicates the doubtful hematologic benefits of suctioned blood retransfusion.
Furthermore, suctioned blood is highly activated blood, especially with regard to clotting and fibrinolysis. Two key factors in these processes are expressed in the thoracic cavity on or by the damaged pericardial and pleural tissue: tissue factor, a strong stimulus for the extrinsic clotting system [9], and t-PA, a potent activator of the fibrinolytic system [10, 11]. As in an earlier study [4], we demonstrated extremely high concentrations of clotting and fibrinolysis metabolites in the suctioned blood. Compared with concentrations of the metabolites in the systemic circulation at that time, concentrations in the suctioned blood were up to 40 times (TAT and FbDP) greater. Moreover, hemolysis in the suctioned blood also was increased significantly, demonstrating once more the blood damage in the pericardial cavity. Heparin concentrations in the suctioned blood were much lower than in circulation, suggesting either heparin binding to nonplasma components such as platelets or debris [12], or increased heparin consumption by platelet factor 4 activity [13]. After retransfusion of suctioned blood proportionally increased levels of free plasma hemoglobin were observed in the circulating blood, as demonstrated by the correlation between free plasma hemoglobin values in the suctioned blood and free plasma hemoglobin levels in circulation (Fig 8A
). This leaves the conclusion that the retransfusion is not inducing additional hemolysis. However, the increased concentrations of circulating t-PA, TAT, and FbDP after retransfusion are higher than can be explained by the mere infusion of suctioned blood (Fig 8B, FbDP data; data for t-PA and TAT are similar). Hence, an additional mechanism responsible for renewed clotting and fibrinolysis in the blood of retransfused patients must exist.
Because heparin concentration in the suctioned blood is about 20% of that in the systemic circulation, we have to consider the possibility that clotting inhibition is not sufficient, and that thrombin is infused during the retransfusion process. In vitro testing of plasma samples from the suctioned blood confirmed the presence of active thrombin, in contrast to the lack of thrombin activity in samples collected from circulation. We hypothesize that this active thrombin is present on soluble fibrin fragments or fibrin monomers in suctioned blood. It has been shown that thrombin remains irreversibly bound to these fibrin fragments [14] and can be recirculated as an active enzyme. Moreover, thrombin bound to fibrin fragments is poorly accessible to its inhibitor, antithrombin III [15]. In our study we demonstrated high concentrations of fibrin fragments in suctioned blood. The infusion into the circulation of fibrin fragments therefore is likely to induce renewed formation of thrombin, which could account for the observed increase of TAT concentration. Whether the observed TAT increase is related to an active systemic clotting process remains doubtful, although some initial effects immediately after retransfusion cannot be excluded. One of these local effects could be illustrated by the significant increase in circulating t-PA antigen in the retransfused patients, as thrombin is one of the most potent stimulators of t-PA release [16].
In addition to activation of the clotting system, fibrin fragments also activate t-PA [17] and thus fibrinolysis. This was visualized in the suctioned blood by the high FbDP levels. Also, an enhanced fibrinolysis is to be expected after retransfusion, because fibrinolysis is mainly dependent on plasminogen activation by t-PA in association with fibrin or fibrin monomers [17]. As t-PA concentrations were increased in both groups from the initiation of CPB and because fibrin fragments were retransfused from suctioned blood. A comparable situation was found during retransfusion of postoperative drained blood in which renewed fibrinolysis and a significant correlation between postoperative FDP levels and postoperative blood loss were observed [18]. Likewise, our present data indicate that by retransfusion of suctioned blood the fibrinolytic activity in circulation is enhanced, causing impaired hemostasis.
These findings also indicate that use of aprotinin could have two effects. Because of aprotinin's potential to preserve hemostasis, the amount of suctioned blood most likely will be reduced, allowing one more easily to discard this blood [19]. Moreover, the inhibition of fibrinolysis by aprotinin will reduce the damaging effects of suctioned blood if it is retransfused.
Finally, as a result of the technical set-up of the study, we demonstrated that reperfusion of heart and lungs after release of the aortic cross-clamp does not result in increased circulating concentrations of ischemia-related products such as t-PA.
In conclusion, we demonstrated that retainment of suctioned blood during coronary artery bypass grafting decreases the postoperative blood loss and diminishes the blood activation as observed in the control group with conventional retransfusion of suctioned blood. Therefore we believe that during uncomplicated elective coronary artery bypass grafting amounts of suctioned blood unsuitable for processing in a cell-saving device should be discarded, and amounts that are suitable for such processing should be washed and retransfused. In particular, the increasing use of aspirin and consequently higher blood loss during CPB [20] is an indication that cell-saving during CPB could be appropriate more frequently.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Y. J. Gu, P. W. Boonstra, A. A. Rijnsburger, J. Haan, and W. van Oeveren Cardiopulmonary Bypass Circuit Treated With Surface-Modifying Additives: A Clinical Evaluation of Blood Compatibility Ann. Thorac. Surg., May 1, 1998; 65(5): 1342 - 1347. [Abstract] [Full Text] [PDF]
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K. N. Maquelin, R. J. Berckmans, R. Nieuwland, M. C. L. Schaap, K. ten Have, L. Eijsman, and A. Sturk Disappearance of glycoprotein Ib from the platelet surface in pericardial blood during cardiopulmonary bypass J. Thorac. Cardiovasc. Surg., May 1, 1998; 115(5): 1160 - 1165. [Abstract] [Full Text] [PDF]
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 G. J. Despotis, J. H. Joist, and L. T. Goodnough Monitoring of hemostasis in cardiac surgical patients: impact of point-of-care testing on blood loss and transfusion outcomes Clin. Chem., September 1, 1997; 43(9): 1684 - 1696. [Abstract] [Full Text] [PDF]
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M. Ernofsson, S. Thelin, and A. Siegbahn MONOCYTE TISSUE FACTOR EXPRESSION, CELL ACTIVATION, AND THROMBIN FORMATION DURING CARDIOPULMONARY BYPASS: A CLINICAL STUDY J. Thorac. Cardiovasc. Surg., March 1, 1997; 113(3): 576 - 584. [Abstract] [Full Text]
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Y. J. Gu, J. de Haan, U. P. M. Brenken, W. J. de Boer, Jm. Prop, W. van Oeveren, and G. L. T. Group CLOTTING AND FIBRINOLYTIC DISTURBANCE DURING LUNG TRANSPLANTATION: EFFECT OF LOW-DOSE APROTININ J. Thorac. Cardiovasc. Surg., September 1, 1996; 112(3): 599 - 606. [Abstract] [Full Text]
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D. D. Muehrcke, P. M. McCarthy, K. Kottke-Marchant, H. Harasaki, J. Pierre-Yared, J. A. Borsh, D. A. Ogella, and D. M. Cosgrove BIOCOMPATIBILITY OF HEPARIN-COATED EXTRACORPOREAL BYPASS CIRCUITS: A RANDOMIZED, MASKED CLINICAL TRIAL J. Thorac. Cardiovasc. Surg., August 1, 1996; 112(2): 472 - 483. [Abstract] [Full Text]
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D. Royston Systemic inflammatory responses to surgery with cardiopulmonary bypass Perfusion, May 1, 1996; 11(3): 177 - 189. [PDF]
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S. Daniel Review on the multifactorial aspects of bioincompatibility in CPB Perfusion, May 1, 1996; 11(3): 246 - 255. [Abstract] [PDF]
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C. Bartels, M. Bechtel, C. Winkler, and S. Horsch Quality of retransfused blood: whole blood versus cell separation. Ann. Thorac. Surg., January 1, 1996; 61(1): 279 - 280. [Full Text]
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