Cell Saver Blood Research Articles

S100β in off-pump coronary artery bypass grafting (CABG): a comparison with conventional CABG

Introduction. Recently, it was reported that cardiotomy suction blood contains high levels of S100β. Therefore, the reinfusion of suction blood may be responsible for the low predictive value of S100β for cognitive decline after cardiac surgery with cardiopulmonary bypass. Consequently, it is expected that off-pump cardiac surgery will result in a lower release of S100β. Methods. S100β was measured after induction of anesthesia, at closure of the chest, and 8 hours and 20 hours after admittance at the intensive care unit in 187 patients randomly assigned to off-pump or on-pump coronary artery bypass grafting. In addition, arterio-jugular S100β differences were estimated in a subset of 61 patients. In a minority of the off-pump procedures, cell-saver blood was returned to the patients. Results. Tabled 1Table 1.Off-PumpOn-PumpMean Difference (95% CI)Start0.06 (0.05)0.06 (0.04)0.01–0.005(0.02)Closure0.44 (0.31)1.52 (1.13)−1.08–1.33(−0.83)8 hours0.20 (0.11)0.21 (0.13)−0.01–0.05(0.03)20 hours0.19 (0.11)0.21 (0.12)−0.02–0.06(0.02) Open table in a new tab Tabled 1Table 2.Arterio-jugular Difference95% CIOff-pump:Start−0.01−0.02; 0.01Closure−0.02−0.04; −0.003On-pump:Start−0.004−0.01; 0.003Closure−0.05−0.09; −0.01Data are presented as mean (SD) (μg/L). Open table in a new tab Data are presented as mean (SD) (μg/L). Conclusions. Although these data support the hypothesis that return of cardiotomy suction blood may increase early S100 release, off-pump, surgery without return of suction blood does not result in lower S100 levels 8 and 20 hours after surgery. The insignificant arterio-jugular difference at the start of the procedure and the small but significant negative arterio-jugular difference at the end of surgery indicate release from the brain.

Acid-base, electrolyte and metabolite concentrations in packed red blood cells for major transfusion in infants.

Acid-base, electrolyte and metabolite concentrations were determined in 100 U of packed red blood cells (RBC) preserved in extended-storage media to be used for major transfusion in paediatric and cardiac surgery. In fresh RBC, low pH, bicarbonate (cHCO3-), base excess (BE) and high glucose values were observed all outside the physiological range. With lengthening storage duration, values of pH, cHCO3-, BE, sodium and glucose decreased and carbon dioxide, potassium and lactic acid concentrations increased [mean +/- SD (range): storage duration 6.7 +/- 3.8 (1-17) days, pH 6.79 +/- 0.1 (6.53-6.99); mmol.l-1: cHCO3- 11.1 +/- 1.5 (6.2-14.5), BE - 29.2 +/- 4.1 ([-39.4] - [-20.9]), potassium 20.5 +/- 7.8 (4.2-43.6), glucose 24.1 +/- 6.1 (16.7-29.2), lactic acid 9.4 +/- 4 (4.3-21.4)]. Massive and rapid transfusion of RBC may lead to a severe burden of hydrogen ions, carbon dioxide, potassium, glucose and lactic acid and this can be avoided by cell saver blood processing, when autologous erythrocytes from the operative field are saved and substrate load and storage lesions from packed red blood cells are minimized in one step by washing.

Does Cell-Saver Blood Administration and Free Hemoglobin Load Cause Renal Dysfunction?

Our aim was to evaluate the impact of cell-saver volume and free hemoglobin load on renal dysfunction. Intraoperative blood salvage was conducted in standard fashion, and in each case a sample of the blood was removed for testing. Outcome data on individual patients were collected during a 6-year period (1992-1998). The total amount of free hemoglobin each patient received was calculated. Renal dysfunction was defined as a rise in creatinine level of 1.0 mg/dL above baseline. There were a total of 125 patients who received salvaged blood. The free hemoglobin concentration ranged from 19 to 304 mg/dL (mean, 87.5 mg/dL). Patients were stratified into groups on the basis of the total free hemoglobin received, and the Kruskal-Wallis test demonstrated a difference between groups in the prevalence of renal dysfunction (P < 0.001). A total of 15 patients (12%) had significant postoperative renal dysfunction. There was an association between the amount of free hemoglobin load and subsequent renal dysfunction. This may warrant further study toward establishing policies and limits regarding maximal free hemoglobin blood.

Blood loss in orthotopic liver transplantation: a retrospective analysis of transfusion requirements and the effects of autotransfusion of cell saver blood in 164 consecutive patients.

Liver transplantation is associated with excessive blood loss. In order to identify factors influencing blood loss and to provide a basis for a pilot study to evaluate recombinant activated factor VII as a haemostatic agent, a retrospective study was performed in 164 consecutive patients with cholestatic or noncholestatic liver disease, who underwent orthotopic liver transplantation at a single centre between 1989 and 1996. Transfusion of allogeneic and autologous (cell saver) blood was used as a measurement of blood loss. Transfusion requirements were associated with age, gender, primary disease, Child-Pugh classification, serum levels of activated partial thromboplastin time, antithrombin III, urea and creatinine, platelet number, year of transplantation, length of cold ischaemia time and autologous blood transfusion. Of these variables, Child-Pugh classification (P = 0.001), urea (P = 0.0007), year of transplantation (P = 0.002), cold ischaemia time (P = 0.01) and autologous blood transfusion (P < 0.0001) were independent predictors of transfusion requirements by multivariate analysis. Thus, blood loss and transfusion requirements depend primarily on the severity of liver disease, quality of the donor liver, experience of the transplantation team and use of autologous (cell saver) blood transfusion. These findings emphasize the need for appropriate drug therapy and a critical reappraisal of current transfusion policy.

Living liver donor surgery: report of initial anesthesia experience

The charts and anesthetic records of 12 patients who donated the left lateral segment of their liver to a related infant or child to treat liver failure were retrospectively reviewed. Blood loss, need for transfusion, fluids administered, surgical length, and perioperative complications were investigated. The records also were examined to determine the hemodynamic stability of patients undergoing donor hepatectomy to assess their need for invasive monitoring. There were no episodes of hypotension or hemodynamic instability. The average operating time was 9.6 ± 1.1 hours. The blood loss was 562 ± 244 mL (range 300 to 1100 mL). Four patients received their own cell saver blood (200 mL, 220 mL, 300 mL, 475 mL), and one patient received 1 U (350 mL) of predonated autologous blood. The average hemoglobin decreased significantly (p = 0.001) from a preoperative value of 14.1 ± 1.2 to 12.3 ± 1.8 g/dL in the recovery room. All patients were extubated in the operating room or recovery room. Patients were discharged home in 6.9 ± 1.3 days (range 5 to 9 days). Living-related liver resection can be performed with noninvasive monitoring and without the need for heterologous blood products.

Cytokines as immunological indicators in retransfusion of cell saver blood

Cytokines as immunological indicators in retransfusion of cell saver blood

The Effects of Perioperative Blood Salvage and Autologous Blood Donation on Transfusion Requirements in Scoliosis Surgery

Fifty consecutive cases of surgical instrumentation and fusion for adolescent idiopathic scoliosis were prospectively studied to test the hypothesis that the use of predonated autologous blood combined with judicious perioperative blood salvage could decrease the amount of homologous blood needed. All cases had posterior instrumentation and fusion. Nineteen patients had their rib prominence resected with an average of 4.8 ribs per patient. Our protocol called for perioperative blood salvage with the cell saver and reinfusion of postoperative drained blood if more than 300 ml were drained in 4 hours. Two units of predonated autologous blood was made available. Hypotensive anesthesia and meticulous hemostasis kept the blood loss to a minimum. The average total blood loss was 1,055 ml. Blood loss per segment was 91 ml with an average of 11 segments fused per patient. Patients with rib resection had a blood loss of 1,105 ml, while those without had a blood loss of 955 ml. The cell saver blood returned per case was 391 ml with the hematocrit of the product averaging 46%. Twelve patients were reinfused an average of 300 ml of the postoperative drained blood. The predonated autologous blood was used as part of the intraoperative fluid management. In no patient was homologous blood needed. The average starting hematocrit was 35.6%, with the hematocrit at discharge (seventh day) being 32.4%. There were no complications or blood transfusion reactions. Our results suggest that judicious perioperative blood management may decrease the need for homologous blood transfusion in selected posterior idiopathic scoliosis surgery.

Pulmonary Hypertension and Major Surgery

Pulmonary Hypertension and Major Surgery

P-4-475 - Lumbar drains in instrumented spinal fusion surgery: Analysis of results

To evaluate intraoperative autologous blood collection with autotransfusion (Cell Saver) with respect to patient acceptance, risk of tumor cell co-transfusion, and risk of recurrence in patients undergoing radical hysterectomy for cervical cancer.All patients explored for radical hysterectomy between August 1991 and July 1994 were offered the use of intraoperative autotransfusion. Clinical-pathologic and transfusion-related characteristics were compared for a group of historic controls surgically treated for similar disease. The risk of tumor cell co-transfusion was assessed intraoperatively with peritoneal cytology before blood collection, and postoperatively with Cell Saver blood cytology.Ninety-eight patients were offered enrollment; four declined Cell Saver use, and 71 were acceptable for analysis. Thirty-one women (mean estimated blood loss 1338 mL) were reinfused with their own blood collected in the Cell Saver, whereas 40 patients (mean estimated blood loss 631 mL) were not autotransfused. There was no significant difference in preoperative hemoglobin concentration between groups. Cell Saver use significantly reduced the need for homologous transfusions, intraoperatively (P < .001) and postoperatively (P = .02). Historic controls (mean operative blood loss 1743 mL) were nearly four times more likely to have been transfused and three times more likely to have been transfused postoperatively than was the autotransfused Cell Saver group. The mean hemoglobin concentration at discharge was lower in the autotransfused group, 9.3 g/dL, than in the historic controls, 10.8 g/dL. Nontransfused Cell Saver blood and all peritoneal cytologies were negative for tumor cells. Three pelvic recurrences, but no disseminated disease, have been noted over a mean follow-up of 24 months: one in the autotransfused group and two in the group in which the collected blood was discarded.Cell Saver use is well accepted by patients, decreases the need for homologous transfusions, and does not appear to co-transfuse tumor cells.

Carbon Monoxide Levels in Cell Saver Salvaged Blood Exposed to Electrocautery During Lumbar Spine Surgery

Carboxyhemoglobin levels were measured in patients undergoing posterior lumbar spine surgery with use of intraoperative cell saver blood salvage. Increased carboxyhemoglobin levels were demonstrated in cell saver salvaged blood. Systemic blood carboxyhemoglobin levels increased with cell saver blood transfusion. No patient demonstrated clinical effects of carbon monoxide toxicity.

Prone Position

Prone Position

Intraoperative autologous blood collection and autotransfusion in the surgical management of early cancers of the uterine cervix

To evaluate intraoperative autologous blood collection with autotransfusion (Cell Saver) with respect to patient acceptance, risk of tumor cell co-transfusion, and risk of recurrence in patients undergoing radical hysterectomy for cervical cancer. All patients explored for radical hysterectomy between August 1991 and July 1994 were offered the use of intraoperative autotransfusion. Clinical-pathologic and transfusion-related characteristics were compared for a group of historic controls surgically treated for similar disease. The risk of tumor cell co-transfusion was assessed intraoperatively with peritoneal cytology before blood collection, and postoperatively with Cell Saver blood cytology. Ninety-eight patients were offered enrollment; four declined Cell Saver use, and 71 were acceptable for analysis. Thirty-one women (mean estimated blood loss 1338 mL) were reinfused with their own blood collected in the Cell Saver, whereas 40 patients (mean estimated blood loss 631 mL) were not autotransfused. There was no significant difference in preoperative hemoglobin concentration between groups. Cell Saver use significantly reduced the need for homologous transfusions, intraoperatively (P < .001) and postoperatively (P = .02). Historic controls (mean operative blood loss 1743 mL) were nearly four times more likely to have been transfused and three times more likely to have been transfused postoperatively than was the auto-transfused Cell Saver group. The mean hemoglobin concentration at discharge was lower in the autotransfused group, 9.3 g/dL, than in the historic controls, 10.8 g/dL. Nontransfused Cell Saver blood and all peritoneal cytologies were negative for tumor cells. Three pelvic recurrences, but no disseminated disease, have been noted over a mean follow-up of 24 months: one in the autotransfused group and two in the group in which the collected blood was discarded. Cell Saver use is well accepted by patients, decreases the need for homologous transfusions, and does not appear to co-transfuse tumor cells.

Titanium contamination of recycled cell saver blood in revision hip arthroplasty

The use of Cell Saver blood during revision hip arthroplasty has many benefits, both medical and economic. After a review of the current literature, to our knowledge, no case of metallic debris has been reported in the blood after complete treatment with the Haemonetics Cell Saver (Braintree, MA) and appropriate filter system. A case of total hip revision of a loose, cemented acetabular component with a commercially pure titanium metal backing and a titanium alloy plasma-spray textured surface was undertaken. The titanium alloy femoral component was not visibly loose and was not revised. The joint lining tissues were black. Throughout the procedure, the operative site was suctioned with a double-lumen heparinized catheter that delivered blood and other materials to a Haemonetics Cell Saver 3 Plus. The reservoir and filter unit used were the compatible Bentley BCR-3500 (Baxter, Irvine, CA), a system capable of filtering particulates down to 20 μm. Prior to infusion of the salvaged blood, many large black clumps of material were observed mixed in the blood. Some measured 10 × 5 × 5 mm and could easily be seen macroscopically. Light microscopy demonstrated red blood cells with intermixed neutrophils, and black foreign material scattered as separate particles and within the cytoplasm of the scattered histiocytes. Energy dispersive analysis of the black material confirmed the composition as primarily titanium with minute quantities of copper, iron, phosphorous, and sulfer. A scanning electron photomicrograph of one of the specimens demonstrated a large conglomerate, approximately 2,000 μm in diameter, composed primarily of titanium and organic material. No malfunction in the Cell Saver machine, defects in the Cell Saver disposable components, or defects in the Bentley reservoir and filter were identified. In this case, if the individual titanium fragments did not aggregate into grossly visible particles, the contaminant likely would not have been discovered. Use of the Cell Saver in tissues with gross metallosis is not a reported contraindication. The authors suggest careful observation of the Cell Saver during the portion of revision surgery dealing with grossly blackened tissues in order to avoid aggregates of titanium as encountered in this case. Further, the authors now use a second suction not attached to the Cell Saver when grossly blackened tissues are encountered.

Evaluation of STAT-CRIT?? Hematocrit Determination in Comparison to Coulter and Centrifuge

The accuracy of the STAT-CRIT hematocrit (hct) was compared to Coulter and centrifuge methods in this study of the interrelationship between non-red cell blood constituents and accuracy of conductivity-based hct measurements. In the first part of the study, blood samples from 31 patients undergoing elective cardiac procedures were analyzed at three times: before induction of anesthesia (Time 1), during the rewarming period of cardiopulmonary bypass (CPB) (Time 2), and after transfusion of all cell-saver blood available after termination of CPB (Time 3). Laboratory evaluation included hct using the Stat-Crit, Coulter, and centrifuge methods, and sodium (Na), potassium (K), chloride (Cl), white blood cell count, total protein (TP), and albumin. In the second part of the study, patients were randomized to receive either 5% albumin (n = 14) or isotonic crystalloid (n = 14) after termination of CPB to determine the effect of protein colloid replacement on conductivity-based hct measurements. Blood samples were obtained before and after fluid volume replacement for multivariate analysis. Correlation of Coulter hct (absolute) with microhematocrit by centrifuge at all times (n = 93) was 0.95 (R2) with a bias and precision of -0.26 +/- 1.7%. Blood variables having the most significant effect on the Coulter-Stat-Crit difference (bias) were protein, Cl, and Na. Single regression analysis indicated that a 1-g/dL decrease in TP resulted in an absolute decrease in the hct reading by 1 hct% units. A 10-mmol/L change in either Cl or Na concentration resulted in a change in Stat-Crit accuracy of 3.5% and 2.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Heparin Washout in the Pediatric Cell Saver® Bowl

The possibility of residual heparin in washed red cells transfused to neonatal or pediatric cardiac patients following bypass prompted a measurement of heparin concentrations. Samples were taken during 10 adult and 10 neonatal and pediatric bypass cases. Sample A was from the bypass circuit, Sample B from the Haemonetics Cell Saver bowl inlet before washing, Sample C from the Cell Saver bowl outlet after washing, and Sample D from the patient ten minutes after protamine. Heparin concentrations were measured by a chromogenic assay using activated Factor X. There was no significant difference between the adult and pediatric groups in the levels of heparin concentration on bypass, pre-washing and post-washing, and in the patients following protamine. In the pediatric group, only .002% of the pre-washed heparin remained after washing. This extremely low level of heparin (.0027 units/ml) is only 0.34 units in a 125 ml pediatric unit of Cell Saver blood. Based on post bypass patient samples, this has no clinical significance. Therefore, the Cell Saver can be used safely with neonates and pediatric patients without concern regarding residual heparin when properly processed.

Laboratory Hemostatic Abnormalities in Massively Transfused Patients Given Red Blood Cells and Crystalloid

Most of the literature on massive transfusion concerns whole blood replacement, whereas clinically, packed red blood cells are commonly given. To determine when hemostatic abnormalities occur in patients resuscitated primarily with packed red blood cells and crystalloid, the cases of 39 consecutive patients who were transfused with 10 or more red blood cell units of any kind within 24 hours were reviewed. After transfusion with 20 or more units of red blood cell products of any kind (packed red blood cells, cell-saver units, or whole blood), 75% (3 of 4) of patients had platelet counts less than 50 x 10(9)/L, compared to 0 of 29 patients given less than 20 units (P less than 0.001). After transfusion of 12 units of relatively plasma-free red blood cell products (packed red blood cells or cell-saver units), 100% (8 of 8) of patients had prothrombin time prolonged by more than 1.5 times mid-range of normal, compared to 36% (5 of 14) of patients given less than 12 units (P = 0.012). These data confirm that patients massively transfused with red blood cells of any kind develop significant thrombocytopenia after 20 units. Importantly, probably clinically significant prothrombin time and partial thromboplastin time prolongations occurred consistently after transfusion of 12 units of relatively plasma-free red blood cells in unselected patients at an urban trauma hospital. These data suggest that coagulation factor replacement is necessary in patients who receive 12 or more units of packed red blood cells or cell-saver blood, and platelet replacement is necessary in patients who receive 20 or more units of any red blood cell product. A prospective study is needed to determine whether the expected abnormal clinical bleeding indeed occurs in patients with such laboratory coagulation abnormalities and to determine when plasma transfusion is indicated in patients massively transfused with red blood cells.

Decreasing homologous blood transfusion in spinal surgery by use of the cell saver and predeposited blood.

Blood loss and blood replacement are necessities in spinal surgery. They also have increasing risks. Three blood replacement options and combinations were investigated in patients undergoing major spinal deformity surgery. In Section 1, intraoperative replacement from harvested cell saver blood was investigated in 35 patients. This group averaged 40% (20-60%) return of the red cell mass lost intraoperatively. In Section 2, intraoperative replacement via predeposited autologous blood was investigated in 41 patients. The predeposited blood replaced 64% of the intraoperative red cell mass lost. In Section 3, ten single-stage and ten two-stage spinal surgery cases using both cell saver and autologous predeposited blood were investigated. With this program, 90% of the single-stage patients did not require additional homologous blood, while 80% of the two-stage patients did. In Section 4, 65 patients undergoing six general types of spinal surgery were examined to determine the number of predeposited autologous units needed to avoid homologous blood during hospitalization. Guidelines for determining optimal donation were developed assuming the use of intraoperative cell saver use.

Coronary artery bypass grafting within 24 hours after intracoronary streptokinase thrombolysis

Little specific information currently exists describing the management of patients with an evolving acute myocardial infarction (AMI) treated with direct intracoronary infusion of streptokinase (SK) followed by emergency coronary artery bypass grafting (CABG). A total of 194 patients with an evolving AMI underwent emergency coronary artery angiography with infusion of SK. Thirty-four of these patients with partial restoration of orthograde blood flow in the infarct-related coronary artery (as determined by clinical and objective evidence of myocardial salvage) were referred for emergency CABG. Problems related to the surgical and anesthetic care of these high-risk patients involved: (1) management of resuscitation of patients with AMI, (2) SK-induced coagulopathy and ongoing thrombolysis, and (3) timely CABG to preserve myocardial salvage. To highlight comparisons of SK-CABG management, data regarding 34 consecutive patients having routine non-SK-CABG surgery were collected simultaneously during the study. Data collected retrospectively included: anesthetic drug summaries, time frame of events from admission to the emergency room until commencing bypass, use of invasive monitoring and hemodynamic assist devices, induction complications, operative complications, coagulation derangements, volume replacement, and blood loss. Results revealed no deaths up to 24 hours postoperatively in the 34 emergency SK-CABG patients, even though complications were frequent intraoperatively. Furthermore, there were no statistically significant differences in SK patients v non-SK patients in blood lost, banked blood and cell saver blood administered, or platelet transfusions. However, in comparison to the non-SK-CABG patients, the SK patients received significantly larger amounts of fresh frozen plasma, cryoprecipitate, and aminocaproic acid.

A Comparison of Two Methods of Post-Bypass Hemoconcentration

Post-pump hemoconcentration is currently accomplished by centrifugation and saline washing, the product being packed red cells suspended in saline. This study was designed to compare centrifugation with ultrafiltration by an artificial kidney, the product of this method being whole blood. Sixteen adult patients undergoing cardiopulmonary bypass were assigned to one of two groups. Hemoconcentration was achieved in Group I with the Cell Saver and with an artificial kidney in Group II. Coagulation data, plasma proteins, colloid osmotic pressure, hematocrit, platelet count, plasma free hemoglobin, and fibrinogen levels were collected and compared at various times during each case. The mean total protein concentration of the ultrafiltered blood (8.01 ± 1.31 g/dl) was significantly greater than that of the Cell Saver blood (0.29 ± 0.29 g/dl, p &lt; .01). Also, the mean total protein concentration in the discard was significantly greater in the Cell Saver group (1.69 ± 0.56 g/dl) than the artificial kidney group (0.09 ± 0.14, p &lt; .01). There were no significant differences between the two groups in the other parameters compared. While the artificial kidney was quite effective in conserving the plasma proteins during hemoconcentration, no additional advantages were demonstrated during this study.