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Ann Thorac Surg 1998;66:987
© 1998 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, The New York Hospital-Cornell Medical Center, 525 E 68th St, F-2103, New York, NY 10021, USA
To the Editor
Shapira and associates have described in their recent report [1] a method by which homologous blood transfusion can be reduced by decreasing the cardiopulmonary bypass (CPB) prime volume. Their technique, part of an integrated blood conservation program, involved retrograde drainage of the patient’s blood volume into the bypass circuit, whereby a majority of the crystalloid bypass prime volume was eliminated. This resulted in a lower level of hemodilution and increased CPB hematocrit. We are pleased that this study further validates our group’s work on the importance of avoiding excessive hemodilution during CPB. We agree with Shapira and associates that in addition to pharmacologic intervention, minimal hemodilution is paramount in a multidisciplinary blood conservation program. Helm and associates [2] have recently made a similar argument.
Our retrograde autologous priming [3] is somewhat different than that described by Shapira and associates. They used heparin-coated circuitry with minimal heparinization (activated coagulation time >280 seconds), warm bypass, and venous before arterial side drainage. During draining the mean arterial blood pressure was allowed to drop to 55 mm Hg before discontinuation of this process. Vasoconstrictors were strictly avoided. Shapira and associates report good results with this technique; however, they do not fully describe the steps taken in this process. We have found that rapid exsanguination immediately before CPB leads to episodic hypotension and severe hypovolemia.
In contrast, we use non–heparin-coated circuitry, standard anticoagulation (3 mg/kg of heparin), and maximal intraoperative autologous donation (up to four units of blood) [4]. Our retrograde autologous priming technique is a three-step process occurring over 4 to 5 minutes just before bypass. Initially the arterial line is drained, followed by autologous priming of the venous reservoir and oxygenator. As bypass is initiated, the venous line is drained into the same collection bag. Up to 1,200 mL of crystalloid is removed from the bypass circuit. This reduces the effective prime volume to 200 to 400 mL. Throughout the entire process systolic arterial blood pressure is maintained at greater than 100 mm Hg. Although phenylephrine is administered to maintain blood pressure, the total amount of vasopressor has been equivalent to that used in our control groups.
As discussed in the report by Shapira and associates, hemodynamic instability may ensue, possibly because of the rapidity of venous blood withdrawal or the avoidance of vasopressor. Our retrograde autologous priming technique appears to be associated with improved hemodynamic stability. We congratulate Shapira and associates on their work and highly recommend this simple yet effective technique, which we have now employed in more than 4,000 patients undergoing CPB since 1995.
References
This article has been cited by other articles:
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  M. A Sobieski II, M. S Slaughter, D. E Hart, P. S Pappas, and A. J Tatooles Prospective study on cardiopulmonary bypass prime reduction and its effect on intraoperative blood product and hemoconcentrator use Perfusion, January 1, 2005; 20(1): 31 - 37. [Abstract] [PDF]
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