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Ann Thorac Surg 2003;76:748
© 2003 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer 52621, Israel
e-mail: jaylavee{at}netvision.net.il
Intraoperative autologous blood predonation is one of the oldest techniques of blood conservation after cardiopulmonary bypass (CPB). First reported by Dodrill et al in 1957 [1], the technique gained popularity and was studied and adopted by several groups in the late 60’s and early 70’s. In this issue, Flom-Halvorsen et al [2] report their results of the quality of intraoperative donated autologous blood units, a report which calls for reevaluation of this old technique.
Reinfusion of prebypass donated autologous blood has been shown to reduce postoperative blood loss and allogeneic transfusion requirements and improve platelet count; improve platelet adhesiveness; improve the aggregation response to ristocetin, and improve the ability to form platelet aggregrates on extracellular matrix [3]. These studies complement the results of other studies showing the superiority of transfusing one unit of homologous fresh whole blood (FWB) over 8–10 units of homologous platelet concentrates after CPB [3]. The improved hemostasis observed after FWB administration is related to the large, potent platelets that remained in the packed red blood cells and were not separated to the platelet-rich plasma during standard platelet concentrate preparation [3].
The improved hemostasis observed after transfusion of FWB may also be related to the presence of some labile plasmatic factors in FWB, like factor VIII-von Willebrand or factor V which have been shown to be deficient in bleeders after CPB.
The isovolumic hemodilution associated with the technique of intraoperative donation of fresh autologous blood is generally considered to be safe as it combines decreased viscosity and sludging with acceptable oxygen-carrying capacity. However, acute hemodilution cannot be tolerated by and is even dangerous in patients with unstable angina, severe left ventricular dysfunction, and aortic stenosis. It is interesting to note that in spite of the fact that Flom-Halvorsen et al [2] claim to have used this method safely in more than 6500 consecutive CABG patients, they have excluded from their study patients with unstable angina. Patients with preoperative anemia or with preoperative anticoagulant therapy are not candidates for this procedure either.
The vast majority of patients referred nowadays for CABG operations are treated with aspirin, which effects platelets between 7 to 10 days; and many patients require urgent or emergent operations while still on aspirin. Hence, utilizing intraoperative autologous blood predonation in these patients may prove nonbeneficial as there are currently no preoperative screening tests to identify aspirin-induced bleeders from nonbleeders. Again, these patients were excluded from Flom-Halvorsen’s study.
In summary, while intraoperative autologous blood predonation has been proved as a safe and very efficacious technique for blood conservation after CPB, the current mix in cardiac surgery prevents widespread use because of contra-indications. Nevertheless, the benefits of autologous blood should encourage more widespread use. Such an approach may expose post CBP patients to fewer blood donors than current practice of transfusion, only fractionated blood products.
References
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