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Red blood cell transfusion is associated with adverse outcomes. Transfusion practices remain varied in cardiac surgery and are a subject of growing debate. We initiated a data-driven, multidisciplinary effort to decrease allogeneic red blood cell transfusion at our institution. Creative perfusion strategies are an essential component of our program and led to a low transfusion rate. Innovations in treatment protocols were implemented and evaluated to reduce hemodilution associated with the cardiopulmonary bypass machine. Frequent review of outcomes guided our evolving clinical practice. Standardization among the perfusionists was the first step to a successful blood conservation program. Techniques included vacuum assisted venous drainage with dry 3/8″ tubing, a short (10 foot) arterial-venous loop, retrograde autologous prime, and saline prime removal from the primary and cardioplegia circuit. We used a polymer-coated perfusion circuit. Hemoconcentrator and cell saver use was determined on a case-by-case basis. Normothermia was maintained except in cases of circulatory arrest or specific surgeon request. Two thousand nine hundred and seventy-nine consecutive cardiac surgical procedures (2.8% off pump coronary artery bypass) were performed from January 1, 2003 to December 31, 2008. Our overall utilization of red blood cell transfusion decreased from 43.2% to 13.6% for all patients and 38.5% to 8.7% for coronary artery bypass graft only patients. Patient outcomes were not significantly changed through 2007. Cardiopulmonary perfusion can be performed safely with low utilization of allogeneic red blood cell transfusions. Standardization and creative perfusion techniques, in the presence of a multi-faceted approach to blood management, play an important role in blood conservation.

Previous studies have shown that minimizing the amount of hemodilution during open-heart surgery reduces the need for a blood transfusion. Transfusion increases a patient’s medical risks and leads to increased costs. We used a shortened bypass circuit, primed with autologous blood in a retrograde fashion, to decrease red cell transfusion in high-risk patients. One hundred twenty-three patients having first-time, nonemergent coronary artery surgery were chosen for this trial, based on their low prebypass hematocrit and weight. In seventy-two cases, we used a shortened bypass circuit and retrograde autologous prime. A historical control group of Fifty-one patients received a standard bypass circuit and prime method. The prebypass hematocrit was 35 ± 2.62% and 34 ± 2.99% in the control and study groups, respectively. Red blood cell transfusion was necessary in 70% of the control group during their hospital stay, whereas only 51.4% of the study group required transfusion (p = .006). Patients receiving no blood products were significantly higher in the study group, 48.6% vs. 30.0% (p = .005). The postbypass hematocrit was similar at 26.5 ± 1.82% vs. 25.5 ± 2.38%, and the discharge hematocrit was 30.8 ± 3.33% and 31.2 ± 3.04% in the control and study groups. respectively. Minimizing hemodilution by shortening the bypass circuit and performing retrograde autologous prime conserves the use of blood during routine coronary artery bypass surgery. These methods can be used for patients who are at greater risk for transfusion.