Randomized clinical trial of intraoperative autotransfusion in surgery for abdominal aortic aneurysm

BACKGROUND: Perioperative homologous blood transfusion (HBT) is associated with adverse reactions and risks transmission of infection. It has also been implicated as an immunosuppressive agent. Intraoperative autotransfusion (IAT) is a potential method of autologous transfusion. METHODS: This was a single-centre randomized clinical trial of IAT in surgery for abdominal aortic aneurysm. Forty patients were randomized to IAT and 41 underwent surgery with HBT only. Patients in both groups received HBT to maintain haemoglobin levels above 8 g/dl. Transfusion requirements, and incidence of systemic inflammatory response syndrome (SIRS) and infection, were compared. RESULTS: Significantly fewer patients in the IAT group required HBT (21 versus 31; P = 0.038) and the median blood requirement per patient was 2 units lower (P = 0.012). There was a higher incidence of chest infection (12 versus four patients; P = 0.049) and SIRS (20 versus nine patients; P = 0.020) in the HBT group. Risk of SIRS was related to aortic cross-clamp time in the IAT group only. CONCLUSION: Use of autotransfusion effectively reduced the need for HBT and was associated with a reduced incidence of postoperative SIRS and infective complications.     

A simple method for intraoperative autotransfusion in cardiac surgery

Authors present a simple, safe and inexpensive method of intraoperative autotransfusion (ATF) for open-heart surgery. A brief comparison is given with other techniques already in use.     

The results of intraoperative autotransfusion in orthopaedic surgery

Perioperative hemorrhage associated with major orthopaedic surgery can become life threatening. Homologous bank blood transfusion can replace the volume of blood lost but it has serious disadvantages such as the transmission of viral agents, it has an insufficient platelet count, and transfusion reactions are possible. Hypotensive anesthesia, predeposited autologous blood transfusion and intraoperative autotransfusion are used to reduce these disadvantages. This study evaluates the results of 700 patients who underwent major orthopaedic intervention in our clinic between June 1991 and April 1998. Ninety-nine patients had hip surgery while 601 patients had spinal surgery. The autotransfusion unit saved an average of 858.9 +/- 136.8 cc of blood and an average of 1.9 +/- 1.2 units of saved blood was transfused. None of these patients needed homologous blood transfusion. One hundred patients who had spinal surgery during the same period were used as a control group. The control group required an average of 3.2 +/- 2.1 units of bank blood. Preoperative and postoperative hematocrit values revealed a statistically significant difference between the autotransfusion group and the homologous transfusion group (p < 0.05). The results of this study suggest that intraoperative autotransfusion prevents the decrease in hematocrit values while reducing the need for bank blood transfusion and hence avoiding the risk of transmission of viral infections.     

The effect of intraoperative autotransfusion on antibiotic pharmacokinetics during elective abdominal aortic aneurysm repair

AIM: Blood loss during aortic surgery has been reduced by the use of cell-salvage techniques (CS). Antibiotics are used routinely to prevent prosthetic graft infection. The influence of CS on antibiotic levels is unknown. This study measured antibiotic levels in serum and cell-salvage fluid during aortic reconstruction. METHODS: Teicoplanin, a glycopeptide with activity against gram positive bacteria was the antibiotic studied. Serial blood levels were measured after a single intravenous dose (400 mg) in five patients undergoing elective aortic aneurysm repair. Patient ages ranged from 67 to 82 yr. Cell-salvage (Dideco compact A75171) fluid was also assayed. SETTING: District General Hospital RESULTS: Serum teicoplanin levels peaked at mean 67.8 mg/l (SD 8.9 mg/l) 5 min after administration, and fell to mean 2.88 mg/l (SD 0.4 mg/l) at 720 min. This is less than levels in healthy volunteers but above the MIC90 for most Gram positive bacterial pathogens encountered in aortic surgery. Teicoplanin levels in discarded CS fluid at the end of the procedure were 0.56 mg/l (SD 0.71 mg/l). CONCLUSIONS: Teicoplanin blood levels are reduced during aortic surgery. Levels remain adequate for antibacterial prophylaxis for 12 h postoperatively other than for methicillin-resistant staphylococcus epidermidis (MRSE). Compared with patients undergoing arterial reconstruction without the use of a cell-salvage device there is no significant loss due to CS use.     

Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery.

BACKGROUND: Improvement in patient outcome and reduced use of medical resources may result from using epidural anesthesia and analgesia as compared with general anesthesia and intravenous opioids, although the relative importance of intraoperative versus postoperative technique has not been studied. This prospective, double-masked, randomized clinical trial was designed to compare alternate combinations of intraoperative anesthesia and postoperative analgesia with respect to postoperative outcomes in patients undergoing surgery of the abdominal aorta. METHODS: One hundred sixty-eight patients undergoing surgery of the abdominal aorta were randomly assigned to receive either thoracic epidural anesthesia combined with a light general anesthesia or general anesthesia alone intraoperatively and either intravenous or epidural patient-controlled analgesia postoperatively (four treatment groups). Patient-controlled analgesia was continued for at least 72 h. Protocols were used to standardize perioperative medical management and to preserve masking intraoperatively and postoperatively. A uniform surveillance strategy was used for the identification of prospectively defined postoperative complications. Outcome evaluation included postoperative hospital length of stay, direct medical costs, selected postoperative morbidities, and postoperative recovery milestones. RESULTS: Length of stay and direct medical costs for patients surviving to discharge were similar among the four treatment groups. Postoperative outcomes were similar among the four treatment groups with respect to death, myocardial infarction, myocardial ischemia, reoperation, pneumonia, and renal failure. Epidural patient-controlled analgesia was associated with a significantly shorter time to extubation (P = 0.002). Times to intensive care unit discharge, ward admission, first bowel sounds, first flatus, tolerating clear liquids, tolerating regular diet, and independent ambulation were similar among the four treatment groups. Postoperative pain scores were also similar among the four treatment groups. CONCLUSIONS: In patients undergoing surgery of the abdominal aorta, thoracic epidural anesthesia combined with a light general anesthesia and followed by either intravenous or epidural patient-controlled analgesia, offers no major advantage or disadvantage when compared with general anesthesia alone followed by either intravenous or epidural patient-controlled analgesia.     

Improved intraoperative management of anastomotic bleeding during aortic reconstruction: results of a randomized controlled trial

In a randomized controlled trial, the effectiveness of a polymeric surgical sealant (CoSeal) was compared to Gelfoam/thrombin for managing anastomotic bleeding after implantation of Dacron grafts during aortic reconstruction for nonruptured aneurysms. Each treatment was directly applied to the suture line after confirmation of anastomotic bleeding. The proportion of suture line sites that achieved immediate sealing and the proportion sealed within 5 minutes were determined among 37 experimental (59 sites) and 17 control subjects (27 sites). A significantly greater proportion of bleeding suture line sites treated with the polymeric sealant achieved immediate sealing following reestablishment of blood flow compared with control-treated sites [48 of 59 (81%) vs 10 of 27 (37%); P = 0.002]. The difference between treatment groups was maintained after 5 minutes with approximately 85 per cent (50 of 59) of CoSeal sites compared to just over one-half (14 of 27) of control sites demonstrating ultimate sealing (P = 0.01). There were no adverse events related to the use of the polymeric sealant in this study. These results support the use of this novel sealant for the intraoperative management of anastomotic bleeding during aortic reconstruction procedures.     

No benefit of intraoperative whole blood sequestration and autotransfusion during coronary artery bypass grafting: results of a randomized clinical trial

OBJECTIVES: In a randomized clinical trial of patients undergoing elective coronary artery bypass grafting, we evaluated the effect of intraoperative whole blood sequestration and autotransfusion on postoperative blood loss and the use of allogeneic blood products. METHODS: Male patients were included if it was possible to obtain at least 500 mL of autologous blood. For patients in group H (heparin autotransfusion, 50 patients; mean age 59 +/- 8 years), an average of 670 +/- 160 mL heparinized blood was drawn before bypass and reinfused after the period of the extracorporeal circulation. For patients in group C (citrate autotransfusion, 48 patients; mean age 60 +/- 10 years), 450 +/- 109 mL of citrate blood, drawn before administration of heparin, was used. Controls (N-group) consisted of 46 patients aged 62 +/- 8 years. Strict transfusion criteria were used, and blood loss and use of allogeneic blood products during the hospital stays of all patients were recorded. Mean differences with their 95% confidence intervals adjusted for potential confounders were obtained by multiple linear regression. RESULTS: The mean difference (95% confidence interval) of blood loss of group H minus N was -93 mL (-307 to 139) and for C minus N was -66 mL (-186 to 179). The mean number of allogeneic blood transfusions for group H was 0.85 +/- 1.74. Group C and group N used 0.94 +/- 1.56 and 0.84 +/- 1.24. CONCLUSION: In coronary artery bypass grafting there is no effect of heparin or citrate intraoperative whole blood sequestration with regard to blood loss or use of allogeneic blood.     

自体血液回输在胸腰椎前路手术中的应用

目的　探讨术中血液回输技术安全性和效果 ,评价其在胸腰椎前路手术中的应用价值。方法　 45例胸腰椎骨折行前路手术的病人分为自体血液回输组和非自体血液回输组。对两组病人术中出血量、输血量及手术前后血常规进行观测。结果　两组术中出血量无显著差异 (P>0 .0 5 ) ,自体血回输组所需异体血较对照组明显减少 (P <0 .0 1)。两组术后血常规的变化规律一致。分别比较术前、术后第 1天、第 7天两组间血常规 ,均无显著性差异。但是 ,两组内WBC、中性粒细胞含量在术后有一过性显著增高 ,术后第 7天两组均恢复正常 (P >0 .0 5 )。RBC、HGB、HCT均较术前有显著降低 (P <0 .0 5 )。未发现应用自体血液回输出现的并发症。结论　①术中自体血液回输能有效地减少自体血的丢失和异体血的输入量 ,安全有效 ;②胸腰椎骨折前路手术出血量大 ,术中血液回输在此手术中具有很高的应用价值。     

Safety, efficacy, and cost of intraoperative cell salvage and autotransfusion after off-pump coronary artery bypass surgery: a randomized trial

OBJECTIVE: We evaluated, in a randomized controlled trial, the safety and effectiveness of intraoperative cell salvage and autotransfusion of washed salvaged red blood cells after first-time coronary artery bypass grafting performed on the beating heart. METHODS: Sixty-one patients undergoing off-pump coronary artery bypass grafting surgery were prospectively randomized to autotransfusion (n = 30; receiving autotransfused washed blood from intraoperative cell salvage) or control (n = 31; receiving homologous blood only as blood-replacement therapy). Homologous blood was given according to unit protocols. RESULTS: The groups were well matched with respect to demographic and comorbid characteristics. Patients in the autotransfusion group had a significantly higher 24-hour postoperative hemoglobin concentration (11.9 g/dL; SD, 1.41 g/dL) than those in the control group (10.5 g/dL; SD, 1.37 g/dL) (mean difference, 1.02 g/dL; 95% confidence interval, 1.60-0.44 g/dL; P = .0007), as well as a 20% reduction in the frequency of homologous blood product use (11/31 vs 5/30; P = .095). Autotransfusion of washed red blood cells was not associated with any derangement of thromboelastograph values or laboratory measures of clotting pathway function (prothrombin time, activated partial thromboplastin time, and fibrinogen levels), increased postoperative bleeding, fluid requirements, or adverse clinical events. There was no statistical difference between groups in the total operation, hospitalization, and management costs per patient (median difference, USD 1015.90; 95% confidence interval, -USD 2260 to USD 206; P = .11). Conclusions Intraoperative cell salvage and autotransfusion was associated with higher postoperative hemoglobin concentrations, a modest reduction in transfusion requirements, no adverse clinical or coagulopathic effects, and no significant increase in cost compared with controls. This study supports its routine use in off-pump coronary artery bypass grafting surgery.     

Intraoperative autotransfusion during abdominal aortic reconstruction

Intraoperative autotransfusion by a continuous-flow centrifuge system was used during more than 300 abdominal aortic reconstructions at the Cleveland Clinic since May 1979. Fifty consecutive patients undergoing such operations were studied prospectively. Volumes of blood lost, salvaged, and transfused during each operation were tabulated. Autologous autotransfused blood was compared with homologous bank blood with respect to oxygen-carrying capacity, coagulation factors, microaggregate levels, red cell mass, pH, and free hemoglobin concentration. Chromium-51 red cell survival studies were performed in autotransfused blood in random patients and in control subjects. Renal, hepatic, and coagulation functions were determined during the first postoperative week. Each patient received a mean volume of 1,203 ml of autotransfused blood and 1,682 ml of bank blood to replace a mean operative blood loss of 2,386 ml. Red blood cell survival of both salvaged autologous and unshed autologous blood in the control group was nearly identical. Salvaged blood had superior oxygen-carrying capacity, a lower microaggregate level, and better buffering capacity than bank blood. Although transient elevations in liver function values and free hemoglobin levels were noted, no clinically important aberration of coagulation, hepatic, or renal function was demonstrated.     

A new method for intraoperative autotransfusion

In the surgical department of the University of Cologne a new system for autotransfusion (Solcotrans) was used 74 times in 18 patients. This system consists of a plastic case connected with a vacuum pump by an air tube. After filling the plastic case with 50 ml of sodium citrate, 500 ml blood can be aspirated by the surgeon and reinfused by the anaesthetist. The system was used in venous thrombectomy, in aneurysms of the abdominal aorta and in shunt surgery due to portal hypertension. Thus stored blood was not necessary in 13 operations.     

Effectiveness of pulmonary artery catheters in aortic surgery: A randomized trial

Purpose: To evaluate the routine use of pulmonary artery catheters (PAC) in patients who undergo aortic surgery. Methods: One hundred twenty patients were randomized to placement of PACs for perioperative monitoring and hemodynamic optimization (tune up) in the intensive care unit on the night before aortic operation, or to intravenous hydration in the ward and perioperative monitoring without PACs. Before randomization, all patients underwent routine adenosine thallium-201 scintigraphy. Results: To meet predetermined endpoints, 30 PAC patients (50%) received nitrates, inotropic agents, or both. PAC patients received more fluid in the preoperative period (p < 0.001) and in the first 24 hours after operation (p = 0.002) than control subjects. Eleven PAC patients (18%) and three control subjects (5%) had adverse intraoperative events (p = 0.02). There were 20 adverse postoperative events in 15 PAC patients (25%; nine cardiac, seven pulmonary, four acute tubular necrosis), which was not different compared with 11 postoperative events in 10 control subjects (17%; five cardiac, five pulmonary, one acute tubular necrosis). There were also no differences in duration of mechanical ventilation, intensive care unit stay, or hospital stay between groups. Postoperative cardiac complications were more common among patients who had a history of congestive heart failure (p = 0.02; odds ratio, 3.75; confidence interval, 1.3 to 11) or reperfusion defects on adenosine thallium scintigraphy (p = 0.01; odds ratio, 3.4; confidence interval, 1.2 to 9.4), regardless of group. Conclusions: Routine use of PACs for perioperative monitoring with the above protocol during aortic surgery is not beneficial and may be associated with a higher rate of intraoperative complications. Preoperative tune up does not prevent postoperative cardiac, renal, and other complications. Variables such as cardiac risk factors and adenosine thallium scintigraphy may be more important predictors of cardiac events in patients who undergo aortic operations. (J Vasc Surg 1998;27:203-12.)     

Limited effectiveness of intraoperative autotransfusion in major back surgery.

BACKGROUND AND OBJECTIVE: The efficiency of intraoperative autotransfusion in scoliosis surgery is poorly known but needs to be evaluated, not least because of the large blood losses in these patients. This is a retrospective analysis of transfusion requirements of 43 such patients. METHODS: Records from 43 patients were studied. During surgery, the shed blood was salvaged and washed in an autotransfusion device (AT1000 Autotransfusion Unit) and a suspension of red cells was reinfused. RESULTS: Fifty-eight per cent of the intraoperative blood loss was salvaged. The total blood loss during the patients' hospital stay was calculated from the haemoglobin balance; 24% of this loss was salvaged by the device. Moreover, 36 of the patients needed allogeneic blood transfusion. CONCLUSION: The efficiency of the autotransfusion device was relatively low in relation to the total extravasation, mainly because the postoperative blood loss is substantial.     

Minimizing blood transfusions during abdominal aortic surgery: recent advances in rapid autotransfusion

The purpose of this study was to determine what percentage of patients could avoid the transfusion of any homologous bank blood products during elective abdominal aortic surgery with a recently developed semicontinuous, rapid autotransfusion device. Fifty patients (26 with abdominal aortic aneurysms and 24 with aortic occlusive disease) prospectively received intraoperative autologous transfusion (group 1) and were matched for comparison with 50 patients receiving homologous blood without use of any autotransfusion equipment (group 2). For the entire perioperative period, 34 group 1 patients (68%) received only their own autotransfused blood and no other homologous blood components compared with group 2 in which 48 patients (96%) required some bank blood (p less than 0.0001). Rapid autotransfusion reduced usage of homologous red cell transfusion by 75%. The mean postoperative hemoglobin was similar in both groups (group 1, 11.91 gm/dl vs. group 2, 11.90 gm/dl, p = 0.73). Rapid autotransfusion was not associated with significant hemolysis, air embolism, or coagulopathy and did not increase morbidity or death. By eliminating the need for any bank blood components in most patients, rapid autotransfusion minimizes the risk of blood-borne diseases and transfusion reactions. New rapid autotransfusion devices offer a distinct advantage over past equipment and allow significant changes in current transfusion practices during elective abdominal aortic reconstructions.     

A modified collection and rapid infusion system for shed whole blood autotransfusion during aortic aneurysm surgery

We describe our experience in 10 patients (5 males) undergoing resection of a descending thoracic aortic aneurysm or a thoracoabdominal aortic aneurysm in which a modified shed whole blood collection and autotransfusion system was used. This modification allows several options for the processing and autotransfusion of shed blood: use of the cell saving device or the ultrafiltration of collected blood, and the autotransfusion of unprocessed shed whole blood. Either low dose heparin or sodium citrate was used for anticoagulation. All 10 patients underwent autotransfusion and volume resuscitation with the modified rapid infusion device. Total autotransfusion ranged from 1400 ml to 7843 ml. Ultrafiltration volumes ranged from 600 ml to 1100 ml. There were no intraoperative deaths and no patient reoperations for bleeding. Arterial blood gases, potassium, and platelet counts were all within the normal laboratory ranges. This modification enables the clinician to process poor quality shed blood and reinfuse whole blood, in an attempt to decrease the need for homologous blood products.     

Intraoperative autotransfusion in aortic surgery: Comparison of whole blood autotransfusion versus cell separation

Objective: Differences concerning alteration of hemostatic, hemolysis, and hematologic parameters after transfusion of blood from a cell-separation (CS) device or whole blood autotransfusion (WBA) were prospectively evaluated during major aortic surgery.Method: Thirty-two patients were randomly selected to receive autologous retransfusion by using either WBA or a CS device. Coagulation and hematologic parameters and levels of hemolytic degradation products (HDP) were assessed in the retransfused blood and in the patients' plasma preoperatively and until 24 hours after autologous retransfusion, respectively.Results: Mean volume of retransfused blood was 1072 + 473 ml in the WBA group and 556 + 504 in the CS group. Level of HDP (bilirubin, free hemoglobin [free HB[, and lactic dehydrogenase [LDH[) and hemostatic disturbances (d-dimer value, fibrin degradation products) were significantly higher in the WBA device compared with the CS blood. Blood samples taken from the WBA group revealed significantly higher levels of HDP (free HB, LDH) and of d-dimer values after autotransfusion compared with the CS group.Conclusion: Levels of HDP and the degree of hemostatic disturbances were significantly higher in retransfused whole blood compared with CS blood. Hemostatic disturbances and levels of HDP were significantly pronounced in the patients' plasma after WBA compared with CS. CS retransfused blood seems to be of superior quality compared with WBA and the degree of hemolysis and hemostatic disturbances is minor after CS retransfusion. (J Vasc Surg 1996;24:102-8.)