Intraoperative Autologous Donation Research Articles

Acute Normovolemic Hemodilution (ANH) impacts postoperative coagulation profile and bleeding in Adult Cardiac Surgery

Introduction: The coagulation profile of cardiac surgery patients is impacted by pro-inflammatory effects caused by procedures involving cardiopulmonary bypass. In order to counteract these effects, pharmacological therapies and allogeneic blood transfusions are required. The strategy of Acute normovolemic hemodilution also known as “intraoperative autologous donation” is also a viable option to address these negative effects. The theoretical basis for ANH is that the removed blood of a patient’s own self is shielded from the inflammatory response of blood cells to the bypass circuit. ANH is an infrequently practiced strategy at various cardiac surgery institutes within Pakistan to enhance coagulation profile, decrease the need for blood transfusions despite being an established approach abroad. Aims and Objectives: The objective of our study is to compare the effect of ANH on patients undergoing adult cardiac surgery in a sample group versus a control group with the primary endpoint of postoperative drain output as a measure of effectiveness of blood coagulation profile. Blood coagulation profiles were also compared between the two groups as secondary variables. Place and Duration of study: The study was conducted at the Faisalabad Institute of Cardiology from December 21st, 2023 to February 13th, 2024. Material and Methods: A randomized controlled trial involving 60 patients over the age of 12 years who were to undergo adult cardiac surgery was conducted. An online research randomizer software randomly selected them into two equal groups, sample and control (n=30). The ANH volume retrieved from the patient's central vein in the sample group was used to fill the CPD blood transfusion bags after administering anesthesia. After the patients in both groups were weaned off CPB and protamine administered to neutralize heparin, ANH blood was infused back into the patients in the sample group whereas the control group received allogenic blood only. Chi square test was applied to all qualitative variables and Independent Samples t-test for all quantitative variables. The results were analyzed using SPSS version 25, and a p-value ? 0.05 was considered statistically significant. Results: Hemoglobin (12.9±0.90 g/dL in ANH and 11.8±1.00 g/dL in non-ANH) and aPTT levels (34.2±6.06 seconds in ANH and 54.2±10.95 seconds in non-ANH) were statistically significant (p-value <0.01). In the ANH group, the mean value (623.3±86.28 mL) of postoperative drain output significantly decreased by approximately 220mL compared to the non-ANH group (842.3±99.26 mL) (p-value <0.01). Conclusion: ANH positively conserves most of the coagulation profile parameters. It assists in reducing postoperative bleeding and the volume of allogeneic blood required perioperatively in cardiac surgery.

Blood conservation strategies in cardiac valve replacement

We aimed to evaluate whether blood conservation strategies including intraoperative autologous donation (IAD) could reduce perioperative blood transfusion for patients undergoing cardiac valve replacement including mitral valve replacement, aortic valve replacement (AVR), and double valve replacement (DVR).A total of 726 patients were studied over a 3-year period (2011–2013) after the implementation of IAD and were compared with 919 patients during the previous 36-month period (January 2008–December 2010). The method of small-volume retrograde autologous priming, strict blood transfusion standard together with IAD constituted a progressive blood-saving strategy.Baseline characteristics and preoperative information showed no statistically significant difference between IAD group and non-IAD group. Most of the postoperative morbidities are statistically the same in the 2 groups. Chest tube output (415.2 vs 1029.8 mL, P < 0.001) and postoperative respiratory failure (5.9% vs 8.6%, P = 0.039) favored the IAD group, whereas hematocrit levels were more favorable in the non-IAD group (30.3% vs 33.0% at the end of the operation, P < 0.001; 30.4% vs 31.5% at the time of discharge). The use of blood product transfusion was higher in the non-IAD group (22.6% vs 43.3%, P < 0.001). Binary multivariate logistic regression analysis showed that high age, non-IAD, DVR surgery, and absent smoking history are associated with a higher risk of intra-/postoperative blood transfusion.Blood conservation is effective and safe in cardiac valve replacement surgeries. The use of intraoperative autologous donation can lead to improved outcomes including a significantly lower rate of intra-/postoperative blood transfusion and postoperative complications.

Intraoperative autologous based blood conservation strategies in mitral valve replacement

To evaluate whether intraoperative autologous donation (IAD) can reduce perioperative blood transfusion for patients underwent mitral valve replacement (MVR). A total of 318 patients received implementation of IAD from January 2011 to December 2013 were analyzed retrospectively, and compared with 517 patients of the previous 36-month period (from January 2008 to December 2012). The method of small-volume retrograde autologous priming, strict blood transfusion standard along with IAD together constituted a progressive blood-saving strategy. Statistical methods including Students' t-test, Pearson's χ(2) test, Kruskal-Wallis analysis and multivariate Logistic regression model were used for comparisons of the data. There were no significant difference between IAD group and non-IAD group considering preoperative patient demographics, characteristics and preoperative comorbidities. However, IAD group significantly reduced number of patients transfused with intra/post-operative packed red-blood cell (PRBC) (55(17.0%) vs. 215 (42.1%), χ(2)=53.0, P=0.000), and had significantly reduced postoperative chest tube output (150(380) ml vs. 700(660) ml, H=195.648, P=0.000), length of stay ((16±6) d vs. (20±8)d, t=9.60, P=0.000). But hematocrit were lower in IAD group (30%±5% vs.33%±4% at end of operation, t=7.76, P=0.000; 30%±4% vs. 32%±5% at discharge, P=0.000, t=3.86). Multivariate logistic aggression analysis revealed that age, IAD and smoking history were factors influencing the probability of intra or postoperative blood transfusion. Implementation of blood conservation strategies based on intraoperative autologous donation in mitral valve replacement surgery can significantly reduce intra/postoperative blood transfusion as well as postoperative complications.

Morbidity and mortality after autotransfusion following open heart surgery

BackgroundThe technique of ‘blood pooling’ before the onset of cardiopulmonary bypass (CPB) has been shown to be beneficial as a single technique in patients having elective open heart surgery. We sought to more clearly evaluate the role of intra-operative autologous donation also known as acute normovolemic haemodilution in open heart surgery.MethodsThe study was conducted in the Department of Cardiothoracic and Vascular Surgery, King George’s Medical University, Lucknow, India, in patients who underwent open heart surgery under cardiopulmonary bypass. Autologous blood transfusion was used in all the patients who underwent surgery on CPB since August 2009. Patients were divided into two groups: group I (study group)—patients operated between August 2009 and December 2011 and who received autologous blood and group II (control)—those operated before August 2009 and who did not receive autologous blood transfusion.ResultsThe post-operative haemoglobin and coagulation profile measured on the first post-operative day differed significantly between the two groups. Intensive care unit (ICU) stay, hospital stay, inotropic support and ventilatory support were significantly less in group 1. Mediastinal drainage was found to be significantly higher in the control group compared to the study group. The mean volume of packed red blood cell, fresh frozen plasma and platelet units transfused per patient in the study group were significantly less than the control group.ConclusionThe use of intra-operative autologous blood donation and transfusion improves haemostasis, decreases the post-operative blood loss and improves the post-operative outcome in terms of intensive care unit stay, hospital stay, morbidity and mortality.

Blood conservation strategies in cardiac surgery: more is better

Recent data show that up to 50% of heart procedures require blood transfusion, which can have adverse long- and short-term outcomes for the patient. This led to the updated 2011 Society of Thoracic Surgery (STS)/Society of Cardiovascular Anesthesiologists (SCA) guidelines in an attempt to adopt more effective blood conservation techniques. We present our results after the implementation of a more aggressive strategy for intraoperative blood conservation in cardiac surgery. Our cardiac surgery database was reviewed retrospectively, comparing outcomes from two different time periods, after the implementation of a more effective two-way blood conservation strategy beginning in March 2012: more aggressive intraoperative autologous donation (IAD) based on a newly constructed nomogram, and the use of a shorter length circuit of the cardiopulmonary bypass (CPB) which allowed for lower fluid volume as a prime. The method of retrograde autologous priming (RAP) was the same for both time periods. A total of 1126 patients (Group 1) were studied in a 12-month period (March 2012-February 2013) after the implementation of the new strategy, and compared with 3758 patients (Group 2) of the previous 36-month period (March 2009-February 2012). There was a significant reduction in the percent change of the intraoperative haematocrit between Groups 1 and 2 (14 vs 28%, P = 0.01), with an increase in the mean IAD volume (655 vs 390 ml, P = 0.02) and a reduction in the CPB priming volume (1000 vs 1600 ml, P = 0.03). Group 1 required significantly less blood transfusions in the perioperative period (29 vs 49%, P = 0.02) and had significantly reduced postoperative rates of respiratory failure (3 vs 7%, P = 0.03), pneumonia (1 vs 3.1%, P = 0.01), chest tube output (350 vs 730 ml, P = 0.01), reoperation for bleeding (1.2 vs 2.5%, P = 0.04) and length of stay (6.1 vs 8.2 days, P = 0.05). Blood conservation is safe and effective in reducing transfusions in cardiac surgery, minimizing perioperative morbidity and mortality. Aggressive IAD and low CPB prime, along with effective RAP, is the three-way blood conservation strategy that leads to improved outcomes in cardiac surgery.

019 * BLOOD CONSERVATION STRATEGIES IN CARDIAC SURGERY: MORE IS BETTER

Objectives: Recent data show that up to 50% of heart procedures require blood transfusion, which can have adverse long- and short-term outcomes for the patient. This led to the updated 2011 STS/SCA guidelines in an attempt to adopt more effective blood conservation techniques. We present our results after the implementation of a more aggressive strategy for intraoperative blood conservation in cardiac surgery. Methods: Our cardiac surgery database was reviewed retrospectively, comparing outcomes from two different time periods, after the implementation of a more effective two-fold blood conservation strategy beginning in March 2012: more aggressive intraoperative autologous donation (IAD) based on a newly constructed nomogram, and the use of a shorter length circuit of the cardiopulmonary bypass (CPB) which allowed for lower fluid volume as a prime. The method of retrograde autologous priming (RAP) was the same for both time periods. Results: A total of 1126 patients (group 1) were studied in a 12-month period (March 2012-February 2013) after the implementation of the new strategy, and compared to 2758 patients (group 2) from the previous 36-month period (March 2009-February 2012). There was a significant reduction in the percentage change of the intraoperative haematocrit between groups 1 and 2 (14% vs 28%, P = 0.01), with an increase in the mean IAD volume (655 ml vs 390 ml, P = 0.02) and a reduction in the CPB prime volume (1000 ml vs 1600 ml, P = 0.03). Group 1 required significantly fewer blood transfusions in the perioperative period (29% vs 49%, P = 0.02) and had significantly reduced postoperative rates of respiratory failure (3% vs 7%, P = 0.03), pneumonia (1% vs 3.1%, P = 0.01), chest tube output (350 ml vs 730 ml, P = 0.01), reoperation for bleeding (1.2% vs 2.5%, P = 0.04), and length of stay (6.1 days vs 8.2 days, P = 0.05). Conclusions: Aggressive IAD and low CPB prime, along with effective RAP, is the three-fold blood conservation strategy that leads to improved outcomes in cardiac surgery.

Perfluorocarbon-based Oxygen Delivery

The basic properties of perfluorocarbons (PFCs) and PFC emulsions relevant to their use as oxygen delivery systems are briefly reviewed. The key issues related to the selection of an appropriate, readily excretable PFC and the engineering of a stable injectable PFC emulsion are discussed. Oxygent, a terminally heat-sterilized, injectable 60% w/v PFC emulsion made primarily of F-octyl bromide and a few percent of F-decyl bromide, with egg phospholipids as an emulsifier, has been developed. Its efficacy in avoiding and reducing red cell transfusion during surgery has been established during a Phase III clinical evaluation. Another Phase III clinical trial in cardiopulmonary bypass surgery, with a protocol that included both augmented-acute normovolemic hemodilution and intraoperative autologous donation, has, however, been interrupted following the observation of adverse events. Data analysis assigned these events to an inappropriate study protocol. A search for possible interactions between Oxygent and fluids present during cardiopulmonary bypass surgery detected no effect of the emulsion on hemostasis, hemolysis and blood rheology.

A phase II dose-response study of hemoglobin raffimer (Hemolink) in elective coronary artery bypass surgery

Background We performed this study to determine the dose-response of hemoglobin raffimer administered in conjunction with intraoperative autologous donation in patients undergoing coronary artery bypass grafting surgery. A secondary objective was to evaluate hemoglobin raffimer for reducing the incidence of allogeneic red blood cell transfusions. Methods This was a phase II, single-blind, multicenter, placebo-controlled, open-label study. Patients undergoing coronary artery bypass grafting with cardiopulmonary bypass and intraoperative autologous donation were randomized to receive a single dose of hemoglobin raffimer or control (10% pentastarch). Patients were sequentially enrolled in a dose block of 250, 500, 750, and 1000 mL. Results Sixty patients received hemoglobin raffimer (n = 30) or control (n = 30). Hemoglobin raffimer was well tolerated. Most (98%) adverse events were mild or moderate in severity. There was an expected dose-dependent increase in the incidence of blood pressure increases and jaundice in hemoglobin raffimer–treated patients. In a dose-pooled analysis of hemoglobin raffimer versus control, increased blood pressure (43% vs 17%), nausea (37% vs 33%), and atrial fibrillation (37% vs 17%) were the most frequently reported adverse events. All serious adverse events were considered unrelated or unlikely to be related to study drug. No hemoglobin raffimer–treated patient required an intraoperative allogeneic red blood cell transfusion, compared with 5 (17%) pentastarch-treated patients ( P = .052). This advantage of hemoglobin raffimer was maintained at 24 hours after surgery (7% vs 37%; P = .010) and up to 5 days after surgery (10% vs 47%; P = .0034). Conclusions Hemoglobin raffimer was not associated with any serious adverse events in patients undergoing primary coronary artery bypass grafting with cardiopulmonary bypass and intraoperative autologous donation in a dose-response study up to 1000 mL. Hemoglobin raffimer was effective in facilitating decreased exposure or avoidance of allogeneic red blood cell transfusions when used in conjunction with intraoperative autologous donation.

Hemoglobin-based oxygen carriers

Transfusable fluids that may be used as alternatives to red blood cell transfusion offer the promise of preserving tissue perfusion and minimizing hypoxic cellular damage, and this promise may soon be fulfilled. Clinical testing of hemoglobin-based oxygen carriers has faced and met challenges involving molecular design, safety, efficacy, and regulatory requirements. Three leading candidates have emerged: two human (PolyHeme® and HemoLink™) and one bovine-based hemoglobin solution (Hemopure®). Because a survival benefit has been difficult to demonstrate, avoidance of allogeneic transfusion has been adopted as the standard efficacy end-point for these agents. An update on clinical trial status is provided, and the potential utility of hemoglobin-based oxygen carriers in surgery combined with intraoperative autologous donation is discussed.

Intraoperative autologous blood donation and retrograde autologous priming for cardiopulmonary bypass : a safe and effective technique for blood conservation.

Haemodilution resulting from crystalloid priming of the cardiopulmonary bypass (CPB) circuit is one of the important reasons for blood transfusion in cardiac surgery, especially in patients with low body surface area (BSA). A prospective study was performed to investigate the technique of intraoperative blood donation (IAD) and retrograde autologous priming (RAP) to limit haemodilution and transfusion requirements. Forty patients with low BSA (<1.7 m2) undergoing primary valvular cardiac surgery were assigned to either RAP group or a control group (C). The RAP group (n=20) was subjected to IAD by collecting a calculated volume of blood (272+/-44.3 mL) after induction of anaesthesia. Prior to initiation of CPB the prime volume was reduced by discarding some of it and the CPB reservoir was filled retrogradely through the aortic cannula draining 482+/-78.4 mL of blood. In group C (n=20) only IAD was carried out collecting 295.0+/-62.6 mL of blood. Anaesthetic technique was similar in both groups. Strict transfusion thresholds were observed. There were no significant difference between the groups with respect to baseline characteristics, BSA, type of procedure, perfusion technique and haematologic profile. The haematocrit on CPB was significantly higher in the RAP group as compared with group C (24.2+/-1.3% and 22.1+/-2.5% respectively, p=0.009). Transfusion of allogenic blood during and after surgery was significantly lower in the RAP group (143.6+/-117 mL) versus 405.2+/-358.1 mL in group C (p=0.02). Postoperative chest tube drainage was 218+/-67.4 mL in the RAP group and 300+/-191 mL in group C which was not significantly different (p=0.18). The technique of intraoperative autologous donation and retrograde priming is simple, safe and cost effective procedure for blood conservation in patients with small BSA undergoing primary valvular surgery.

Commentary

Using a protocol of preoperative autologous blood donation, Masuda and associates have achieved what is expected of contemporary pediatric cardiac programs, namely, the near complete avoidance of homologous blood transfusion in children weighing more than about 12 kg undergoing operations for simple cardiac defects. Their method, however, must be time consuming and anxiety provoking for the child and family, could be an organizational nightmare for higher volume programs, and is not without its own inherent risks. These disadvantages were not analyzed by the authors nor compared with those of other methods of blood conservation. Similar results with transfusion-free cardiac surgery in this weight range have been achieved in other programs for years by use of lower pump primes (350 mL for infants in our institution), modified ultrafiltration, and intraoperative autologous donation and by minimizing blood loss while avoiding wastage of shed blood during the operation. These maneuvers are straightforward and ought to be achievable at the authors' institution. Even for higher risk operations, we are generally able to avoid additional, expensive agents such as aprotinin and commercially made fibrin “glue” while minimizing homologous transfusion. Children who are preoperatively anemic may avoid transfusion by receiving recombinant human erythropoietin and iron. Their application to increase red cell mass before elective operations was approved in the United States in 1996. The safety and efficacy of this approach in children undergoing orthopedic surgery, in children with chronic renal failure, in premature infants with anemia, and in children with cancer have been demonstrated. The availability of an oral form of human erythropoietin strengthens the rationale for using it in children facing cardiac surgery. A prospective study to demonstrate the advantage of human erythropoietin in children undergoing cardiac surgery is sorely needed. When patients do require a transfusion, a component that satisfies multiple needs, including repletion of red cell mass, serum proteins, and functional platelets, should be used. At our institution, we believe these needs are met by using “fresh whole blood” (obtained less than 72 hours before transfusion), especially in infants. With this strategy, infants undergoing an operation who do require a transfusion at our institution are exposed to an average of only 1.7 donors. All cardiac surgeons have the responsibility of applying all reasonable strategies to minimize homologous transfusion. This must be placed in perspective, however, by knowing the actual risks of transfusion in the current era. In fact, the Centers for Disease Control and Prevention have registered only two children in the United States in whom acquired immunodeficiency syndrome has developed as a result of transfusion (for all reasons) in the past 15 years and no cases of transfusion-associated hepatitis C viral infection since 1994. These results are attributable to a national policy of viral screening of blood and to the education of donors. On the other hand, more than two thirds of the world's nations do not have policies to ensure a safe blood supply. Unfortunately, many of these countries have higher prevalence rates of transmittable viruses and yet lack the economic resources to afford expensive pharmacologic means to minimize blood loss during pediatric cardiac surgery. Cardiac programs in these countries may stand to benefit from the policy of multiple autologous donation demonstrated nicely by the authors.

Room B, 10/17/2000 2: 00 PM - 4: 00 PM (PS) Hemoglobin Replacement Therapy with Hemolink™ in Patients Undergoing CABG in Conjunction with Intraoperative Autologous Donation (IAD)

<b>Room B, 10/17/2000 2: 00 PM - 4: 00 PM (PS) Hemoglobin Replacement Therapy with Hemolink™ in Patients Undergoing CABG in Conjunction with Intraoperative Autologous Donation (IAD)</b>

Intraoperative autologous blood donation preserves red cell mass but does not decrease postoperative bleeding

Postoperative bleeding and transfusion remain a source of morbidity and cost after open heart operations. The benefit of the acute removal and reinfusion of fresh autologous blood around the time of cardiopulmonary bypass-a technique known as intraoperative autologous donation (IAD)-has not been universally accepted. We sought to more clearly evaluate the effects of IAD on allogeneic transfusion and postoperative bleeding by removing, preserving, and reinfusing a calculated maximum volume of fresh autologous whole blood. Ninety patients undergoing coronary artery bypass grafting or valvular operations were prospectively randomized to either have (IAD group) or not have (control group) calculated maximum volume IAD performed. Treatment was otherwise identical. Transfusion guidelines were uniformly applied to all patients. An average volume of 1,540 +/- 302 mL of fresh autologous blood was removed and reinfused in the IAD group. Postoperative hematocrits were significantly greater at 12 and 24 hours postoperatively in the IAD group versus the control group despite a significant decrease in both the percentage of patients in whom allogeneic red blood cells were transfused (17% versus 52%; p < 0.01) and the number of red blood cell units transfused per patient per group (0.28 +/- 0.66 and 1.14 +/- 1.19 units; p < 0.01). Conversely, chest tube output, incidence of excessive postoperative bleeding, postoperative prothrombin time, and platelet and coagulation factor transfusion requirement did not differ between groups. These results indicate that intraoperative autologous donation serves to preserve red blood cell mass. Its routine use in eligible patients is therefore justified. However, the removal and reinfusion of an individually calculated maximum volume of fresh autologous blood had no effect on postoperative bleeding or platelet and coagulation factor transfusion requirement. This lack of hemostatic effect belies the beliefs of many about the primary action of IAD, helps to delineate the optimal way in which to perform IAD, and carries implications regarding the use of allogeneic platelet and coagulation factors for the treatment of early postoperative bleeding.