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Ann Thorac Surg 1996;61:900-903
© 1996 The Society of Thoracic Surgeons
Regional Department of Cardiac Surgery, Los Angeles Kaiser Permanente Medical Center, Los Angeles, California
Accepted for publication November 20, 1995.
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. One hundred patients undergoing coronary artery bypass graft operations were randomized to an autotransfusion group (group A) or control group (group C). Group A patients had 10 mL/kg of whole blood removed before cardiopulmonary bypass; they had retransfusion at the termination of cardiopulmonary bypass and heparin reversal. Both groups had intraoperative cell saving and autotransfusion of shed mediastinal blood postoperatively. The indications for blood transfusion were standardized, and the physicians ordering blood products were blinded to the study.
Results. Compared with the control group, patients in the autotransfusion group had a 28% reduction of chest tube drainage at 8 hours and a 45% reduction in the total homologous blood units transfused.
Conclusions. Autotransfusion during cardiopulmonary bypass provides benefit in addition to other techniques in reducing blood loss and the need for blood products in the postoperative period.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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In contrast, an increasing proportion of our operations are performed urgently, and patients are receiving heparin and aspirin preoperatively. Our standard blood conservation protocol includes the intraoperative use of a cell-saving device, postoperative retransfusion of shed mediastinal blood, and a strict protocol for blood product transfusion. The present study was conducted to determine whether intraoperative whole blood autotransfusion provides any benefit in addition to these techniques in our current practices.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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All operations were done by the same team of surgeons using the same operative technique, membrane oxygenators, and cardioplegia technique. Cardiopulmonary bypass was performed using a membrane oxygenator (Bentley Univox; Baxter Healthcare Corp, Irvine, CA) primed with 1,000 mL of Isolyte S, 300 mL of 25% albumin, and 50 mL of sodium bicarbonate. The patients received anticoagulation therapy with 3 mg/kg heparin to maintain the activated clotting time greater than 480 seconds. An additional 1 mg/kg heparin was used to treat an activated clotting time less than 450 seconds. The pump flow was 2.2 to 2.4 L•min-1•m-2, and moderate hypothermia was used to lower the patient's blood temperature to 32°C. Rewarming was continued to 37°C before discontinuation of cardiopulmonary bypass. The anesthetic management of these patients included premedication with 2 mg lorazepam. Induction was performed with a loading dose of fentanyl 20 mg/kg and pancuronium 0.1 mg/kg; anesthesia was maintained by a continuous infusion of fentanyl at 15 to 20 mg•kg-1• h-1. At the termination of cardiopulmonary bypass, protamine was used to reverse the circulating heparin by titrating to the activated clotting time.
Patients received a transfusion during cardiopulmonary bypass only if their hematocrit was less than 18%. Patients in the autotransfusion group were transfused autologous blood first if their hematocrit fell to less than 18%. Our blood conservation protocol for both groups included the use of a cell-saving device intraoperatively and retransfusion of all oxygenator and tubing blood contents after cardiopulmonary bypass. Postoperatively, the chest tube drainage was autotransfused for both groups of patients at 3 hours if 300 mL or more was present in the chest tube containers, and this was repeated at 6 hours.
The operating surgeons used an algorithm approach for hemostatic therapy, as proposed by Goodnough [9]. The physicians ordering the blood component therapy were blinded to the study groups. The trigger for transfusion therapy was as follows. If the chest tube blood loss was greater than 300 mL/h for the first 2 hours postoperatively, the patients were transfused 10 U of platelets and 2 U of fresh frozen plasma and were treated with Amicar, 10 g intravenously and 2 g/h for 5 hours. If the chest tube blood loss exceeded 150 mL/h, specific replacement therapy was used to treat coagulation abnormalities. For example, if the platelet count was less than 100 x 109/L the patients were given platelet transfusions. Similarly, if the coagulation profile was abnormal (prothrombin time and partial thromboplastin time greater than 1.8), the patients were treated with fresh frozen plasma. If fibrinolysis was demonstrated by D-dimer test, the patients were treated with 
-aminocaproic acid therapy. Patients were given packed red blood cell transfusions when the hematocrit level fell to less than 25%.
Baseline patient variables and operative variables were compared between the groups using the 
2 test, Student's t test, or Wilcoxon rank sum test. The Wilcoxon rank sum test was also used to evaluate the difference in the postoperative chest tube drainage and homologous blood products transfused to the two groups of patients during their hospital stay.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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) shows that the sex was predominantly male in both groups. The average age was 59 years and the weight was 87 kg; the body surface area was 2.04 m2 in both groups. These differences were not statistically significant. A similar number of patients took aspirin up until the time of operation. Slightly more patients in the autotransfusion group underwent urgent operations and were receiving intravenous heparin therapy before operation. These differences also were not significant.
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. The average patient received one internal mammary artery graft, and an average of three bypass grafts were performed per patient. The lowest hematocrit during cardiopulmonary bypass was slightly lower in the autotransfusion group because of the removal of whole blood and the resulting hemodilution. The chest tube blood loss was measured in both groups at 8 and 24 hours, as seen in Figure 1. At 8 hours, group A had a mean (± standard deviation) blood loss of 367 ± 230.6 mL and group C had a mean blood loss of 507 ± 320.8 mL; the difference was statistically significant (p = 0.003). At 24 hours, the autotransfusion group had a mean blood loss of 696 ± 310.9 mL and the control group had blood loss of 916 ± 409.8 mL; this difference also was significant (p < 0.001).
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, the autotransfusion patients required fewer packed red blood cell transfusions, fewer fresh frozen plasma transfusions, and fewer platelet transfusions (p = 0.123, p = 0.003, and p = 0.044, respectively). The total of homologous blood products transfused in the autotransfusion group was 78 U (1.60 ± 2.99 U), and the corresponding value in the control group was 143 U (2.84 ± 3.11 U). This difference was significant at p = 0.006 based on the Wilcoxon rank sum test. Twenty-six patients in the autotransfusion group required no homologous blood product transfusions, compared with 15 patients in the control group. Five patients in the autotransfusion group had a total of 2,320 mL of chest tube drainage autotransfused in the intensive care unit, compared with 11 patients in the control group who had a total of 4,190 mL autotransfused (p = not significant). The amounts of colloid transfusion including hespan and salt-poor albumin were measured in both groups. Group A had 24% less hespan and 37% less salt-poor albumin transfused, although this did not reach statistical significance. The platelet count was reduced postoperatively to a similar degree in both groups (see Table 2
). The hematocrit at discharge was 33% in both groups, indicating that the blood products transfused to the patients were appropriate.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Moreover, previous studies have excluded patients receiving aspirin therapy or heparin therapy, or patients requiring urgent operations [7, 8, 12]. In our study group, 62% of the patients were scheduled for operations on an urgent basis, 52% were receiving heparin therapy before operation, and 42% were taking aspirin up to the time of operation. An elevated activated clotting time and partial thromboplastin time preoperatively confirm that many patients were anticoagulated on arrival to the operating room.
The autotransfusion group had 10 mL/kg whole blood removed before cardiopulmonary bypass, which resulted in modest hemodilution to an average hematocrit of 22%. In 1 patient, the hematocrit fell to less than 18% during cardiopulmonary bypass, and half of the pooled blood was retransfused to that patient. No neurologic event occurred as a result of hemodilution in these patients. Postoperatively, this technique reduced the chest tube drainage by 28% at 8 hours and 26% at 24 hours in the autotransfusion group. This group required less retransfusion of shed mediastinal blood and less colloid transfusion postoperatively. More important, the autotransfusion group had 45% less homologous blood transfused during their hospital stay. In the autotransfusion group, 52% of the patients required no blood products, compared with 31% of the patients in the control group.
The mechanism for the reduced chest tube blood loss does not appear to be a hemodilution effect, because of the absence of any significant difference in the hematocrit or the drop in platelet count postoperatively between the groups. Several authors have suggested that pooled blood retains platelet function and clotting factors by avoiding contact with the foreign surfaces during cardiopulmonary bypass [7, 8], although the routine clotting tests (international normalized ratio, partial thromboplastin time) did not show a difference in our study. The coagulation advantage of pooled blood remained intact in patients exposed to aspirin or heparin preoperatively and contributed to reducing the blood products transfused when combined with cell saving and postoperative autotransfusion of shed mediastinal blood.
Although the safety of the blood supply has increased in recent years, a major fear of patients undergoing cardiac operations is the risk of contracting transmittable viral infections. Other potential risks are the occurrence of major and minor transfusion reactions [1, 2].
The goal of transfusion-free cardiac operations meets patients' expectations and is cost-effective in times of healthcare cost containment. The direct cost for processing a unit of packed red blood cells at our institution is $97. In contrast, the cost of the tubing and blood bag used for intraoperative autotransfusion is less than $10 per patient.
In conclusion, our study demonstrates that intraoperative autotransfusion is effective when combined with other transfusion-saving techniques and should be incorporated into a standardized blood conservation protocol. This simple technique is safe and reduces the patient's exposure to possible complications of homologous blood transfusion.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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References |
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