Effect Of Retrograde Autologous Priming Research Articles

Effect of Retrograde Autologous Priming on Coagulation Assessed by Rotation Thromboelastometry in Patients Undergoing Valvular Cardiac Surgery

ObjectivesTo investigate the effect of retrograde autologous priming (RAP) on coagulation function using rotation thromboelastometry (ROTEM) in patients undergoing valvular heart surgery. DesignProspective, randomized, patient- and outcome assessor-blinded study. SettingSingle-center university hospital. ParticipantsPatients aged 20 years or more undergoing valvular heart surgery. Interventions104 patients were allocated to the RAP or control group (1:1 ratio). In the RAP group, the prime was displaced into the collection bag before bypass initiation. ROTEM was performed at the induction of anesthesia, at the beginning of rewarming, and after the reversal of heparinization. Allogeneic plasma products and platelet concentrates were transfused according to ROTEM-based algorithms. Measurements and Main ResultsAn average volume of 635 ± 114 mL was removed using RAP (from the 1,600 mL initial prime volume). The hematocrit 10 min after CPB was 24.7 ± 3.5% in the control group and 26.1 ± 4.1% in the RAP group (P=0.330). ROTEM including EXTEM, INTEM, and FIBTEM showed prolonged clotting time and decreased maximal clot firmness after CPB in both groups, without intergroup differences. The number of patients who received intraoperative erythrocyte (27% vs. 25%, control vs. RAP, P=0.823), fresh frozen plasma (14% vs. 8%, control vs. RAP, P=0.339), cryoprecipitate (21% vs. 12%, control vs. RAP, P=0.185), or platelet concentrate transfusion (19% vs. 12%, control vs. RAP, P=0.277) did not differ between the groups. ConclusionsCPB induced impaired coagulation function on ROTEM. However, RAP did not improve coagulation function when compared with conventional priming in patients undergoing valvular heart surgery.

Effect of retrograde autologous priming on lactate and hemoglobin levels of adult patients undergoing coronary artery bypass grafting

Background: Reduced hemoglobin, excessive transfusions and raised lactate levels are important determinants of patient outcome after cardiopulmonary bypass. Many strategies have been studied for optimum management of these parameters. In this study, we evaluated the impact of retrograde autologous priming (RAP) method on hemoglobin and lactate levels in patients undergoing coronary artery bypass grafting (CABG) on cardiopulmonary bypass.
 Methodology: This prospective randomized controlled trial was conducted at Army Cardiac Centre, CMH, Lahore, from January 01, 2021 to June 30, 2021. After approval of institutional ethical committee and taking informed consent from patients, 272 patients undergoing CABG were enrolled. Patients with ages less than 18 y, LVEF ≤ 20%, emergency operations, repeat operations, valvular or combined procedures, recent myocardial infarction, with preoperative lactate levels of more than 2 mmol/L and Hb of less than 9 gm/dL and other preoperative systemic diseases or infection were excluded. Patients were divided into two groups. Group A received conventional priming of bypass circuit with ringer lactate, and Group B received RAP with patient’s own blood. Hb and lactate levels were measured in arterial blood gases before induction and upon weaning from bypass.
 Results: The demographic features of both groups were identical, Group A patients had significantly high levels of lactate (3.76 ± 0.81 vs. 2.64 ± 0.47 mmol/L, P < 0.01). Hb levels of patients in RAP (RAP) (Group B) were significantly better (9 ± 0.31 vs. 7.9 ± 0.39 gm/dL, P < 0.01) than Group A.
 Conclusion: Our study concludes that when compared with crystalloid priming, retrograde autologous priming technique is associated with reduced lactate levels and better hemoglobin levels after cardiopulmonary bypass in patients undergoing coronary artery bypass grafting.
 Abbreviations: CABG - Coronary artery bypass grafting; CPB - cardiopulmonary bypass; LVEF – Left ventricular ejection fraction; Hb – Hemoglobin; RAP – Retrograde autologous priming; FFP - Fresh frozen plasma;
 Key words: cardiopulmonary bypass; coronary artery bypass grafting; lactate levels, retrograde autologous priming.
 Citation: Naseer M, Feroze R, Akram MA, Fakhar-e-Fayaz. Effect of retrograde autologous priming on lactate and hemoglobin levels of adult patients undergoing coronary artery bypass grafting. Anaesth. pain intensive care 2022;26(1):20–24 
 DOI: 10.35975/apic.v26i1.1761
 Received: October 4, 2021, Reviewed: November 14, 2021,, Accepted: January 19, 2022

To RAP or Not to RAP: A Retrospective Comparison of the Effects of Retrograde Autologous Priming

Retrograde autologous priming (RAP) is a process used to reduce hemodilution associated with the initiation of cardiopulmonary bypass (CPB). Previous studies have reported potential benefits to RAP; however, many of these studies do not evaluate the benefits of RAP with limited preoperative fluid administration combined with a condensed CPB circuit. We examined clinical metrics of patients who underwent RAP versus those who did not undergo RAP prior to the initiation of CPB. This was a retrospective data review of 1,303 patients who underwent CPB in the setting of open-heart surgery for a 2-year period. RAP was used on all patients between June 1, 2017 and June 30, 2018 (n = 519) and not used on patients between July 1, 2018 and June 30, 2019 (n = 784). Both groups were subjected to a low-prime CPB circuit volume of 800–900 mL. We compared the clinical metrics for packed red blood cell (PRBC) transfusion, oxygen delivery, postoperative acute kidney injury (AKI), Albumin utilization, ventilator time, Intensive Care Unit length of stay (ICU LOS), and 30-day mortality between the two groups. Our data analysis showed there were no statistically significantly differences between the two groups on the incidence of postoperative AKI, PRBC administration, ventilator time, ICU LOS or 30-day mortality. In the RAP group, there was a statistically significant lower oxygen delivery and a statistically significant increased volume of Albumin administered postoperatively, although those differences were so small, they were potentially not clinically significant. Our analysis revealed no significant benefit to performing RAP with limited preoperative fluid administration and minimized CPB circuit prime volume. We formalized a process that included limiting preoperative fluid administration and minimizing the CPB circuit volume so that we were not required to RAP and did not simultaneously sacrifice patient outcomes in other areas.

To RAP or Not to RAP: A Retrospective Comparison of the Effects of Retrograde Autologous Priming.

Retrograde autologous priming (RAP) is a process used to reduce hemodilution associated with the initiation of cardiopulmonary bypass (CPB). Previous studies have reported potential benefits to RAP; however, many of these studies do not evaluate the benefits of RAP with limited preoperative fluid administration combined with a condensed CPB circuit. We examined clinical metrics of patients who underwent RAP versus those who did not undergo RAP prior to the initiation of CPB. This was a retrospective data review of 1,303 patients who underwent CPB in the setting of open-heart surgery for a 2-year period. RAP was used on all patients between June 1, 2017 and June 30, 2018 (n = 519) and not used on patients between July 1, 2018 and June 30, 2019 (n = 784). Both groups were subjected to a low-prime CPB circuit volume of 800-900 mL. We compared the clinical metrics for packed red blood cell (PRBC) transfusion, oxygen delivery, postoperative acute kidney injury (AKI), Albumin utilization, ventilator time, Intensive Care Unit length of stay (ICU LOS), and 30-day mortality between the two groups. Our data analysis showed there were no statistically significantly differences between the two groups on the incidence of postoperative AKI, PRBC administration, ventilator time, ICU LOS or 30-day mortality. In the RAP group, there was a statistically significant lower oxygen delivery and a statistically significant increased volume of Albumin administered postoperatively, although those differences were so small, they were potentially not clinically significant. Our analysis revealed no significant benefit to performing RAP with limited preoperative fluid administration and minimized CPB circuit prime volume. We formalized a process that included limiting preoperative fluid administration and minimizing the CPB circuit volume so that we were not required to RAP and did not simultaneously sacrifice patient outcomes in other areas.

Effect of retrograde autologous priming based on miniaturized cardiopulmonary bypass in children undergoing open heart surgery

To evaluate the effectiveness of retrograde autologous priming (RAP) based on miniaturized cardiopulmonary bypass (CPB) circuit in children undergoing open heart surgery.We performed a retrospective analysis of all patients (≤15 kg) who underwent open heart surgery with CPB in our center from January 1, 2017, to July 31, 2019. Propensity score matching was used to adjust for significant covariates, and multivariable stratified analysis was used to assess the association of the RAP technique with clinical outcomes.A total of 1111 patients were analyzed. There were 355 (32.0%) children who underwent RAP, and 756 (68.0%) were in the non-RAP group. After propensity score matching, there were a total of 638 patients, with 319 patients in each group. The bloodless priming rate was significantly higher (P = .013), and the ultrafiltration rate was significantly lower (P = .003) in the RAP group than in the non-RAP group. Compared with patients in the non-RAP group, patients in the RAP group had a shorter postoperative mechanical ventilation time (P < .001) and shorter lengths of stay in the intensive care unit (ICU) (P < .001) and the hospital (P < .001). No differences were noted in postoperative hematocrit (P = .920), postoperative 24-hour blood loss (P = .435), and hospital mortality (P = .563). In the stratified analysis, the difference remained statistically significant (P < .05) when the patient weight was >4 kg or the Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery (STAT) category was <3. However, when the patient weight was ≤4 kg or the STAT category was ≥3, there was no significant difference between the 2 groups in terms of bloodless priming, ultrafiltration, postoperative mechanical ventilation time, or length of stay in the ICU or the hospital (P > .05).The RAP technique based on miniaturized CPB system was safe and effective for children who underwent congenital heart surgery. The RAP technique can significantly reduce the priming volume, improve the rate of bloodless priming, and reduce blood product application. It was also associated with a shorter postoperative mechanical ventilation time and shorter lengths of stay in the ICU and the hospital.

Effect of Retrograde Autologous Priming on Clinical Outcome of Cardiopulmonary Bypassing on Patients Undergoing Coronary Artery bypass Grafting

Introduction: Cardiopulmonary bypass is a standard and low mortality-associated method used across the world. This method allows cardiac surgery to be performed in a bloodless environment. The study aimed to compare Conventional priming and Retrograde autologous prime (RAP) on patients undergoing coronary artery bypass grafting (CABG).Methods: The study population was patients undergoing CABG using cardiopulmonary bypass in Rajaei Hospital, of whom 80 patients were selected by simple random sampling convenience sampling and then were randomly assigned to two groups: Conventional priming and RAP. Demographic information, blood components transfused in the operating room and the intensive care unit, ejection fraction (EF) of left ventricle and changes in blood gases were collect.Results: The mean requirement for red blood cell transfusion bags to the patient during surgery was lower in the RAP group than the conventional priming group (P = 0.002). But the difference after surgery in both groups was not significant statistically (P = 0.2). The difference amount of platelet transfusion during operation the difference was not statistically significant (P = 0.4). The difference postoperative platelet transfusion was not statistically significant (P = 0.7). The fresh frozen plasma transfusion during surgery in the RAP group lower than the usual prime group, but the difference was not statistically significant (P = 0.406). The Fresh frozen plasma (FFP) transfusion after surgery in the two groups was not statistically significant (P = 0.217).Conclusion: RAP is compared with conventional priming a safe and low-cost technique in reducing the priming volume of the CPB system, causes less hemodilution, and reduces the need for intra- and postoperative blood transfusion. Therefore, it is recommended to consider RAP as an effective and low-cost technique of priming Cardiopulmonary bypass circuits.

Effects of retrograde autologous priming in adult patients undergoing cardiac surgery

Effects of retrograde autologous priming in adult patients undergoing cardiac surgery

Effects of retrograde autologous priming in adult patients undergoing cardiac surgery

Background Adult cardiac surgery with extracorporeal circulation (ECC) is known to be associated with increased risk of blood transfusion and systemic inflammatory response leading to adverse outcomes. Modern procedures like retrograde autologous priming (RAP) may reduce these negative side effects of ECC. This randomized prospective study was initiated to assess whether RAP using specifically designed RAP bag (Terumo) has immediate effects on patient outcome.

The effect of retrograde autologous priming on intraoperative blood product transfusion in coronary artery bypass grafting

Retrograde autologous priming (RAP) of the cardiopulmonary bypass (CPB) circuit could reduce the degree of haemodilution associated with priming with acellular solutions. However, there is no strong evidence to prove that the practice of RAP reduced intraoperative packed red cell (PRC) or blood product transfusion. To evaluate the effect of RAP on intraoperative PRC usage in coronary artery bypass grafting (CABG). This study is a prospective, observational study on patients who underwent first-time, isolated CABG using CPB between April 2012 and July 2012. Two groups of patients were identified: 1. Non-RAP group (n=128) and 2. RAP group (n=73). The primary outcome for the study was the amount of PRC and blood product usage between the induction of anaesthesia and the cessation of CPB. Use of PRC and blood products in the operating room was comparable in both groups. Univariate logistic regression showed that RAP was not an independent predictor of PRC or blood product transfusion (p=0.43). Multivariate logistic regression showed that CPB time, preoperative haemoglobin (Hb) levels and creatinine clearance were independent predictors of blood product transfusion. Practising RAP with mean volumes of 300 ml does not necessarily reduce PRC and other blood product transfusion requirements during CABG. In our practice, RAP was performed, aiming at displacing CPB circuit prime volume with which the perfusionist felt comfortable and dictated by haemodynamic parameters prior to commencing CPB. We presume this is the case in many units around the world. This practice, in our opinion, is not enough to achieve the benefits of RAP, if any, in the form of a reduction of packed red cell transfusion requirements. The true advantages of RAP in cardiac surgery need to be studied in a prospective, randomized, controlled trial.

EReply. Is retrograde autologous priming effective on cerebral functions and haematocrit levels?

We were pleased to receive Dr Gurbuz and colleagues' comments on our study [1]. Yet, we would like to add some comments to their remarks. Firstly, we can state that there were no differences between the study and the control group concerning the surgeons performing the procedure. We agree that the surgeon himself, often directly affects the amount of blood lost intraoperatively. However, in our hospital, the transfusion strategies are the result of a team approach and they are the same for each patient, regardless of the team members present in the operating theatre. Secondly, as the effect of retrograde autologous priming (RAP) on haemodilution and transfusion requirements was the main endpoint of our study, the effect of this technique on neurological complications were not reported. As referred in our article, lower intraoperative haematocrit levels can result in postoperative end-organ dysfunction, as shown by several large observational studies [2], including both transient and permanent stroke. As RAP increases the intraoperative haematocrit, one could suggest that this technique should improve the preservation of multiple organs. However, we did not look into the direct effect of RAP on these outcome variables and we think this should be the subject of further investigation. Finally, we agree with Dr Gurbuz that the phosphorylcholine coating has been proven to protect the platelets [3] during cardiopulmonary bypass (CPB) and affects blood loss and hematocrit levels. We want to emphasize that, besides the cannulas, all CPB circuits used in our study were completely phosphorylcholine-coated. Indeed, there was no difference between the haematocrit of both groups on admission to the ICU, which means that in the RAP group, the same haematocrit was achieved with less transfusion compared to the control group. In conclusion, we would like to thank Dr Gurbuz and his colleagues for their constructive remarks and hopefully, together we can further improve blood management strategies in the future. Conflict of interest: none declared.

Effects of retrograde autologous priming on blood transfusion and clinical outcomes in adults: a meta-analysis

Reducing the priming volume is an effective means of decreasing hemodilution and blood transfusion during cardiopulmonary bypass (CPB). The patient's own blood was used to replace the crystalloid in the CPB circuit by retrograde autologous priming (RAP) in order to decrease the priming volume. Therefore, we performed a meta-analysis to investigate whether RAP could reduce blood transfusion and improve clinical outcomes. A comprehensive search was conducted for randomized, controlled trials (RCTs) exploring RAP in PubMed, Embase, The Cochrane Library, Google Scholar and Chinese literature databases (WanFang, WeiPu and CNKI). Clinical parameters and outcomes were focused on the lowest hematocrit (Hct) during CPB, the number of patients transfused blood intraoperatively, the number of patients transfused blood perioperatively, the number of blood units transfused, 24-hour chest tube drainage, hours to extubation, length of ICU stay, and length of hospital stay. Ten trials, with a total of 1123 patients, were included. The number of patients transfused blood intraoperatively (RR = 0.39, 95% CI = [0.29, 0.53], p<0.00001, I(2) = 40%) and perioperatively (RR = 0.53, 95% CI = [0.43, 0.66], p<0.00001, I(2) = 0%) and the number of blood units transfused (SMD = -0.53, 95% CI = [-0.73, -0.33], p<0.00001, I(2) = 14%) were all significantly reduced in the RAP group. No differences in the hours to extubation (SMD = -0.11, 95% CI = [-0.33, 0.12], p=0.37, I(2) = 0%) and the length of ICU stay (SMD = -0.17, 95% CI = [-0.41, 0.08], p=0.18, I(2) = 0%) were observed between the two groups. Compared to conventional priming, RAP could reduce transfusion in adults significantly, but had no effect on clinical outcomes, comparing to conventional priming. Further studies involving RAP are expected to investigate if this technique is beneficial to the patient.

The Effect of Retrograde Autologous Priming of the Cardiopulmonary Bypass Circuit on Cerebral Oxygenation

The aim of this study was to investigate the effect of retrograde autologous priming (RAP) of the cardiopulmonary bypass (CPB) circuit on cerebral oxygenation. A retrospective cohort study. A university hospital. Ninety-four patients undergoing CPB. CPB was primed with a RAP technique in the RAP group (n = 46) or with a conventional technique in the control group (n = 48). Cerebral oxygenation was monitored by measuring the regional cerebral oxygen saturation (rSO(2)). The rSO(2) and Hct values were compared between the groups during surgery. During the CPB period, the RAP group showed significantly higher values for rSO(2) (%) (immediately after the onset of CPB: 51.3 ± 8.4 and 56.3 ± 8.3; 30 minutes after the onset of CPB: 56.3 ± 5.1 and 59.7 ± 7.0; control group and RAP groups, respectively; p < 0.01 for each) and Hct (%) (immediately after the onset of CPB: 21.1 ± 3.7 and 23.1 ± 3.3; 30 minutes after the onset of CPB: 21.9 ± 3.7 and 23.3 ± 2.3; control group and RAP group, respectively; p < 0.02 for each). However, the 2 groups did not differ in rSO(2) (%) (67.2 ± 6.3 and 67.8 ± 6.4) or Hct (%) (27.8 ± 4.1 and 28.9 ± 3.6, control group and RAP group, respectively) at the end of the surgery. The application of RAP to CPB limits the degree of hemodilution and improves cerebral oxygenation during CPB. The present findings suggest a potential benefit of RAP from a neurologic aspect.