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Ann Thorac Surg 2000;70:1296-1300
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Processing scavenged blood with a cell saver reduces cerebral lipid microembolization

^a Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
^b Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
^c Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA

Address reprint requests to Dr Hammon, Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157
e-mail: jhammon{at}wfubmc.edu

Presented at the Forty-sixth Annual Meeting of the Southern Thoracic Surgical Association, San Juan, Puerto Rico, Nov 4–6, 1999.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Microembolization during cardiopulmonary bypass (CPB) can be detected in the brain as lipid deposits that create small capillary and arteriolar dilations (SCADs) with ischemic injury and neuronal dysfunction. SCAD density is increased with the use of cardiotomy suction to scavenge shed blood. Our purpose was to determine whether various methods of processing shed blood during CPB decrease cerebral lipid microembolic burden.

Methods. After hypothermic CPB (70 minutes), brain tissue from two groups of mongrel dogs (28 to 35 kg) was examined for the presence of SCADs. In the arterial filter (AF) group (n = 12), shed blood was collected in a cardiotomy suction reservoir and reinfused through the arterial circuit. Three different arterial line filters (Pall LeukoGuard, Pall StatPrime, Bentley Duraflo) were used alone and in various combinations. In the cell saver (CS) group (n = 12), shed blood was collected in a cell saver with intermittent preocessing (Medtronic autoLog model) or a continuous-action cell saver (Fresenius Continuous Auto Transfusion System) and reinfused with and without leukocyte filtration through the CPB circuit.

Results. Mean SCAD density (SCAD/cm²) in the CS group was less than the AF group (11 ± 3 vs 24 ± 5, p = 0.02). There were no significant differences in SCAD density with leukocyte filtration or with the various arterial line filters. Mean SCAD density for the continuous-action cell saver was 8 ± 2 versus 13 ± 5 for the intermittent-action device.

Conclusions. Use of a cell saver to scavenge shed blood during CPB decreases cerebral lipid microembolization.

	Introduction

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Despite continued improvements in overall outcome, neurologic complications after heart surgery with the use of cardiopulmonary bypass (CPB) remain relatively common. The incidence of major and minor deficits may be as high as 60% to 80% [1, 2]. The etiology of many of these deficits, which range from overt stroke to subtle neuropsychological changes, such as behavioral, intellectual, and fine motor disturbances, is at least partly caused by arterial embolization. Furthermore, in a manner similar to the overt stroke being caused by gross atherosclerotic material, the less severe neurologic deficit appears to be related to embolization of microscopic debris [3]. Autopsy studies in patients who have undergone CPB have detected microscopic emboli, composed primarily of lipid, dispersed within the cerebral microvasculature [4]. The histopathological lesion caused by these microemboli, after processing and staining, takes the form of a small capillary and arteriolar dilatation (SCAD) that is associated with ischemic injury and neuronal dysfunction [5]. SCADs are detected in the brain after CPB and after arterial manipulation proximal to the organ examined, range in size from 10 to 70 µm, and can number in the millions in the affected end-organ [6].

While the exact source of these lipid microemboli is unknown, studies from as early as 1974 demonstrate a direct relationship between the use of cardiotomy suction and the production of microemboli [7]. More recently in a canine model, cerebral SCADs were demonstrated after use of left heart CPB with cardiotomy suction, but not with right heart cardiac bypass, or without cardiotomy suction [8].

With this background, the purpose of the present study is to improve the quality of shed blood before its autotransfusion during CPB. This paper examines two potential strategies, including arterial line lipid filtration and processing blood with a washing and centrifugation device (cell saver), as a means to reduce cerebral microembolization.

	Material and methods

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This study was approved by the Animal Care and Use Committee at the Wake Forest University School of Medicine. All animals have received humane care in compliance with the "Guide for the Care and Use of Laboratory Animals" published by the National Institutes of Health (NIH publication 85-23, revised, 1985).

Surgical protocol
A total of 24 mongrel dogs (28 to 35 kg) were studied using the following protocol. After overnight fasting, general anesthesia was induced using intravenous thiopental sodium (20 mg/kg) and subsequently maintained using a continuous fentanyl (0.5 to 0.8 µg/kg/min) and midazolam (1.0 µg/kg/min) intravenous infusion. The animal was placed supine on the operating table, endotracheally intubated, and mechanically ventilated with 30% oxygen and 70% room air to maintain an arterial oxygen tension of 150 to 200 mm Hg and carbon dioxide tension of 35 to 40 mm Hg. Catheters were inserted in the left common femoral artery for monitoring of blood pressure and arterial blood gases, and left external jugular vein for monitoring of core temperature. A median sternotomy was performed, and the periosteum was cauterized. No bone wax was used in any case. Heparin sodium, 300 units/kg, was administered and supplemented as needed to achieve an activated clotting time of greater than 400 seconds. A 20F inflow cannula was inserted in the left subclavian artery, and venous cannulas, 26F and 28F, were placed into the superior and inferior vena cavae. CPB, using lactated Ringer’s prime, supplemented with mannitol, albumin, sodium bicarbonate, and heparin, was instituted through standard bypass tubing (Bentley, Irvine, CA), heparin-coated venous reservoir (BMR-1900; Bentley), and cardiotomy suction reservoir (William Harvey H3700; Bard, Haber Hill, MA). A roller pump (5000; Sarns, Ann Arbor, MI) and membrane oxygenator (Turbo 440; Sarns) were used, Three different arterial line filters were used as discussed below. A minimum mean arterial pressure of 60 mm Hg was maintained by adjusting pump flows and by a phenylephrine infusion (60 µg/mL) as needed. No exologous blood transfusions or fluids, other than the prime and medications, were administered. After initiating CPB, the dog was immediately cooled to a core temperature of 28°C. The internal mammary arteries were then dissected from the chest wall intact, and an intercostal artery on each side of the chest was lacerated. During the dissection, there was extensive use of the electrocautery. Pooled mediastinal blood was collected in the cardiotomy suction reservoir or a cell saver until a total of 700 mL of blood was obtained, after which time hemostasis was achieved.

After 40 minutes of hypothermic CPB, rewarming to 36°C was instituted using external source and arterial inflow heating to a maximum of 39°C. During rewarming, the cardiotomy suction reservoir blood, or processed cell saver blood, was added to the arterial circuit. After 30 minutes of recirculation of shed blood, dogs were euthanized with intravenous potassium chloride, and the brains were immediately harvested.

Histologic methods
Brain tissue was fixed in 70% ethanol, embedded in celloidin, sectioned at a thickness of 100 µm, and stained for alkaline phosphatase, according to a previously reported method [9]. SCADs were counted using light microscopy in coronal sections taken through the middle of the brain. Each count was performed within a standard area of 0.45 cm². Four separate counts were obtained in different areas within the centrum semiovale and adjacent cortex. The counts for each animal were then averaged to yield SCAD density, expressed as SCADs/cm². A representative photomicrograph is shown in Figure 1.

View larger version (126K): [in this window] [in a new window]   Fig 1. Representative photomicrograph of canine brain tissue with SCADs, indicating by arrows, after CPB and return of scavenged blood (alkaline phosphatase-stained, 100 µm thick).

In the other 12 dogs (cell saver group), shed blood was collected with one of two different cell saver devices, either the Medtronic autoLog (Medtronic, Minneapolis, MN) or the Fresenius Continuous Auto Transfusion System (Fresenius, Concord, CA), a device that has been shown to remove fat in vitro [10]. The Bentley Duraflo arterial line filter was used during the entire CPB run. In each experiment, a total of 700 mL of shed blood was collected, processed, and then returned through the arterial circuit. In 6 animals, additional processing of the cell saver product was performed by infusing the washed, concentrated red blood cells into the CPB circuit through a Pall RCXL 1 leukocyte removal filter. The number of animals receiving the various filter and cell saver techniques is shown in Table 1.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
There were no study protocol variances, and all dogs survived to completion of the experiments. SCAD densities for individual dogs are displayed in Table 1. The mean SCAD densities by filter and cell saver type are shown in Figure 2. Mean SCAD density for the cell saver group was significantly less than for the arterial filtration group (11 ± 3 vs 24 ± 5, p = 0.02). There were no significant differences within each group.

View larger version (13K): [in this window] [in a new window]   Fig 2. Mean SCAD density ± standard error by filter or cell saver group. Closed bars represent arterial filter group; open bars represent cell saver group. p < 0.05 for cell saver versus arterial filter groups; p > 0.05 for all other intergroup comparisons. (B = Bentley Duraflo II AF-1025D; PL = Pall LeukoGuard AL; PS = Pall StatPrime; M = Medtronic autoLog cell saver, LF = Pall RCXL 1 leukocyte removal filter; F = Fresenius Continuous autotransfusion System.)

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Over the relatively recent history of cardiac surgery, innumerable innovations have decreased the morbidity and mortality of elective heart surgery to strikingly low numbers, estimated recently to be less than 36% and 3%, respectively [11]. The inclusion of neurologic complications within these statistics, however, may not entirely represent the spectrum of major and minor neurologic events suffered by patients undergoing cardiac procedures, especially those assisted by CPB. While the incidence of stroke is low at 2% to 3% [11], some estimate the incidence of less severe neurological complications, such as cognitive and fine motor deficits, to be 60% to 80% [1, 2]. These clinically subtle neurologic deficits are associated with higher mortality, longer hospitalizations, and a higher rate of discharge to long-term care facilities [12].

Although the etiology of these subtle, yet potentially lifestyle-altering neuropsychological changes is not completely understood, substantial evidence suggests that microembolization of air and other material to the brain during CPB may be causative. At least two groups have demonstrated a definite relationship between the number of microemboli detected by Doppler during CPB and postoperative neuropsychological deficits [13, 14].

Attempts at reducing this microembolic burden have been directed at decreasing the intravascular source. For example, Hammon and associates demonstrated that operative techniques designed to minimize cerebral microembolization, such as epiaortic scanning to locate plaques and use of a single aortic cross-clamp, may reduce the incidence of neurobehavioral changes [15]. This reduction is consistent with studies that estimate that approximately 60% of emboli are produced during physical manipulation of the heart and great vessels [16]. In a study designed to examine the remaining microemboli, which likely originate from an extravascular source or within the CPB apparatus, Brooker and associates determined in a canine model that blood shed during surgery leads to more lipid microemboli when collected and returned through cardiotomy suction [8]. Other microdebris, including air, cellular fragments, silicone particles, and other exogenous chemicals, have also been associated with the use of cardiotomy suction [7, 17].

Over two decades ago, Loop and associates demonstrated that microembolic could be decreased with the use of an arterial line filter [18], now a standard component on virtually all CPB circuits. Since then, other changes in apparatus, including reduction or elimination of antifoaming agents, and a conversion to membrane oxygenators from bubble oxygenators, have also led to a decrease in exogenous debris [19]. In this setting, endogenous lipids, disrupted from the chest wall and mediastinal tissues during surgical dissection, have been identified as an important source of microemboli. As a method for removal of this lipid material, standard inert arterial line filters have theoretical limitations because of the deformability of the lipid particle, which allows it to pass through even small filter pores. This theory is supported by the present study that demonstrates the presence of SCADs even with small-pore filtration.

It was hypothesized in this study that an active filtration or separation technique would be required to further reduce cerebral microembolic burden. According to the manufacturer, the Pall LeukoGuard AL filter removes leukocytes, as well as lipid, by electrostatic attraction. Surprisingly, use of this filter resulted in the highest SCAD density of any method tested. This finding, however, is consistent with other studies of leukocyte-depleting filters that have shown variable reductions in circulating leukocyte counts and no definite clinical advantage with respect to cardiac and pulmonary-related outcomes [20, 21]. To our knowledge, the effects of leukocyte-depleting filters on neurologic outcomes have not been examined.

The other active strategy used in this study to decrease cerebral microembolization was to improve the quality of shed blood by collection and processing with a cell saver. The washing of the blood, separation of components by weight, and ultimate hemoconcentration of red cells resulted in a decreased cerebral microembolic burden. Passage of the cell saver product through a transfusion-type leukocyte filter resulted in an insignificant decrease in microemboli, a finding in contrast to the leukocyte depleting arterial line filter. While no definite reason exists for this finding, it may relate to possible "overloading" of the filtering capabilities of the arterial line filter, through which many hundreds of liters of blood pass during a typical procedure versus the relative small quantity of concentrated scavenged blood filtered by the transfusion filter.

Further improvement in cerebral microembolic burden may be possible with the use of the continuous autotranfusion cell saver system, which has been shown in vitro to remove more lipid than a standard cell saver [10]. This finding is thought to be due to the continuous nature of the centrifugation device that prevents lipid and other debris from leaching back into adjacent, stagnant washed cells as can occur with standard, intermittent processing. Another potential advantage of the continuous system is that it may allow for easier integration into the CPB system as a replacement for cardiotomy suction.

Although this study suggests that the cell saver may be a better tool to scavenge shed blood than the cardiotomy suction with respect to microembolic burden, it does not address the potential problems associated with using a cell saver, including fragmentation and deformation of blood cells leading to their early removal from the circulation, or activation of the clotting and other inflammatory cascades. Cell savers also require additional time to process blood, potentially necessitating administration of donor blood products or hemodiluting crystalloids when intravascular volume is urgently needed. Further laboratory and clinical studies are warranted to address these issues.

In conclusion, the present study reaffirms the theory that shed blood scavenged from the mediastinum and subsequently autotransfused is a source for large quantities of cerebral lipid microemboli. Use of a cell saver to retrieve and process this debris-laden blood appears to decrease microembolic burden compared with cardiotomy suction blood passed through various arterial line filters. Based on our data, it is doubtful that a role exists for the use of a leukocyte-depleting arterial line filter for the prevention of this problem.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This work was supported in part by grants from the National Institute of Neurologic Disease and Stroke (NS-28955, NS-20618, and NS-27500) and by a grant from the Fresenius Corporation, Concord, CA.

	References

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