Intraoperative Plateletpheresis and Autologous Platelet Gel Do Not Reduce Chest Tube Drainage or Allogeneic Blood Transfusion After Reoperative Coronary Artery Bypass Graft

Abstract

Platelet-rich plasma (PRP) is postulated to decrease postoperative mediastinal chest tube drainage (MCTD) and allogeneic blood transfusions (ABT) after surgery with cardiopulmonary bypass. However, recent metaanalysis of the literature reveals that few good quality (therapeutic yield) trials that show a benefit have been published. The potential hemodynamic instability caused by plateletpheresis has not been emphasized. We studied the effect of plateletpheresis on MCTD, ABT, and hemodynamic stability in reoperative coronary artery bypass graft patients, a group perceived to be at high risk for ABT. Ninety patients were randomly assigned to Pheresis or Control groups. epsilon-Aminocaproic acid was given to all patients. Hemodynamic instability was assessed by degree of volume and inotrope resuscitation required. Part of the sequestered platelet volume was used to make autologous platelet gel, which was applied as a wound sealant. Mean pheresis yield was 30% +/- 7% of the circulating platelet mass or 6.4 +/- 2.2 allogeneic platelet unit equivalents. Total MCTD did not differ between the groups. There were no differences in mean packed red blood cell, platelet, and plasma transfusion rates. Overall, 52% of the Pheresis group received ABT, versus 55% of the Control group. Fifty-three percent of the Pheresis group patients exhibited significant hemodynamic instability, versus 27% of the Control group (P < 0.05). This study was unable to show any reduction in MCTD or ABT, although the plateletpheresis technique may offset platelet dysfunction caused by aspirin or increased blood exposure to nonbiologic surfaces, or it may compensate for lack of antifibrinolytic use. The significantly increased incidence of hemodynamic instability in the Pheresis group means that the risk/benefit ratio must be determined for individual cardiac surgical units.

Platelet-rich-plasmapheresis for minimising peri-operative allogeneic blood transfusion

“…Three trials (Liu 1998, Stover 2000, Wajon 2001) reported the use of the anti-fibrinolytic agent, epsilon aminocaproic acid (EACA). Liu et al (Liu 1998) administered EACA as a bolus dose of 150mg/kg prior to CPB.…”

“…Stover et al (Stover 2000) administered 150mg/kg of EACA as a loading dose over 30 minutes, added 75mg/kg to the CPB circuit priming volume, and maintained a 20mg/kg/hr infusion of EACA throughout the operation. Wajon et al (Wajon 2001) administered 10g of EACA as a bolus dose prior to the commencement of CPB. The use of aprotinin was reported by one trial (Armellin 1995).…”

“…Two trials (Stover 2000, Wajon 2001) reported a mean platelet count of the PRP between 550-600 × 10 3 /uL. These trials included a total of 139 patients of whom 66 were randomised to PRP.…”

Practice Guidelines for Perioperative Blood Management

“…[165][166][167][168][169][170][171][172][173][174][175][176][177][178] Additional metaanalyses of RCTs indicate that ANH combined with intraoperative red blood cell recovery compared with intraoperative red blood cell recovery alone is effective in reducing the volume of allogeneic blood transfused (Category A1-B evidence) and is equivocal regarding the number of patients transfused with allogeneic blood (Category A1-E evidence). [165][166][167][168][169][170][171][172][173][174][175][176][177][178] Additional metaanalyses of RCTs indicate that ANH combined with intraoperative red blood cell recovery compared with intraoperative red blood cell recovery alone is effective in reducing the volume of allogeneic blood transfused (Category A1-B evidence) and is equivocal regarding the number of patients transfused with allogeneic blood (Category A1-E evidence).…”

Η Επίδραση Της Στρατηγικής Περιορισμού Των Ενδοφλεβίως Χορηγούμενων Υγρών Στον Αριθμό Των Μεταγγιζόμενων Μονάδων Συμπυκνωμένων Ερυθρών Στις Καρδιοχειρουργικές Επεμβάσεις Με Εξωσωματική Κυκλοφορία

“…Αυτή η τεχνική έχει το θεωρητικό πλεονέκτηµα, ότι η βελτίωση του αριθµού και της λειτουργίας των αιµοπεταλίων µπορεί να περιορίσει τη µετεγχειρητική αιµορραγία χωρίς µείωση της ικανότητας µεταφοράς οξυγόνου. Με παραλλαγή αυτής της φυγόκεντρης τεχνικής, είναι πιθανό να αποκτηθούν κλάσµατα που είναι είτε πλούσια είτε πτωχά σε αιµοπετάλια [601,602].Τουλάχιστον 18 µελέτες [602][603][604][605][606][607][608][609][610][611][612][613][614][615][616][617][618][619] και µια µεταανάλυση [620] εκτίµησαν την αποτελεσµατικότητα της πλούσιας σε αιµοπετάλια πλασµαφαίρεσης στον περιορισµό της αιµορραγίας και της µετάγγισης αίµατος µετά από καρδιοχειρουργικές επεµβάσεις. Οι υψηλότερης ποιότητας µελέτες που περιλαµβάνουν τυφλές και τυχαιοποιηµένες µελέτες δεν έδειξαν κανένα όφελος από αυτή την παρέµβαση [611][612][613]618], ενώ άλλες δηµοσιευµένες αναφορές έδειξαν κάποιο όφελος από την πλασµαφαίρεση πλούσια σε αιµοπετάλια.…”