Pump blood processing, salvage and re-transfusion improves hemoglobin levels after coronary artery bypass grafting, but affects coagulative and fibrinolytic systems

Abstract

Cell saving systems are commonly used during cardiac operations to improve hemoglobin levels and to reduce blood product requirements. We analyzed the effects of residual pump blood salvage through a cell saver on coagulation and fibrinolysis activation and on postoperative hemoglobin levels. Thirty-four elective coronary artery bypass graft (CABG) patients were randomized. In 17 patients, residual cardiopulmonary bypass (CPB) circuit blood was transfused after the cell saving procedure (cell salvage group). In the other 17 patients, residual CPB circuit blood was discarded (control group). Activation of the coagulative, fibrinolytic and inflammatory systems was evaluated pre-operatively (Pre), 2 hours after the termination of CPB (T0) and 24 hours postoperatively (T1), measuring prothrombin fragment 1.2 (PF 1.2), plasmin-anti-plasmin (PAP), plasminogen activator inhibitor-1 (PAI-1) and interleukin-6 (IL-6). The cell salvage group of patients had a significant improvement in hemoglobin levels after processed blood infusion (2.7 ± 1.7 g/dL vs 1.2 ± 1.1 g/dL; p=0.003). PF1.2 levels were significantly higher after infusion (T0: 1175 ± 770 pmol/L vs 730 ± 237 pmol/L; p=0.037; T1: 331 ± 235 pmol/L vs 174 ± 134 pmol/L; p=0.026). Also, PAP levels were higher in the cell salvage group, although not significantly (T0: 253 ± 251 ng/mL vs 168 ± 96 ng/mL; p: NS; T1: 95 ± 60 ng/mL vs 53 ± 32 ng/mL; p: NS). No differences were found for PAI-1, IL-6, heparin levels or for red blood cell (RBC) transfusions. The cell salvage group of patients had increased chest tube drainage (749 ± 320 vs 592 ± 264; p: NS) and fresh frozen plasma transfusion rate (5 (29%) pts vs 0 pts; p<0.04). Pump blood salvage with a cell saving system improved postoperative hemoglobin levels, but induced a strong thrombin generation, fibrinolysis activation and lower fibrinolysis inhibition. These conditions could generate a consumption coagulopathy.

Efficacy of intraoperative cell salvage in decreasing perioperative blood transfusion rates in first-time cardiac surgery patients: a retrospective study

“…The decreased risk of perioperative pRBC transfusions found in patients who received ICS in our study compared favourably to findings from certain previously published studies 8,12,[14][15][16]19,22 but differed from others where either no change 7,9,13,18 or an increase in perioperative pRBC transfusion rates 17 was noted with the use of ICS. With respect to coagulation product transfusion, to our knowledge, the present study is the first to have shown a decrease in coagulation product transfusion with the use of ICS.…”

“…Despite these theoretical benefits, evidence as to whether ICS is safe and effective has been conflicting. [6][7][8][9][10][11][12][13][14][15][16][17][18][19] Several studies have shown ICS to reduce exposure to allogeneic blood products with no changes in clinical outcomes or cost, [14][15][16][19][20][21][22] while others have suggested that reinfusion with washed cell salvaged blood results in increased postoperative bleeding and heightened transfusion. 17 The purpose of this study was to determine the effect of ICS on outcomes following cardiac surgery.…”

Residual blood processing by centrifugation, cell salvage or ultrafiltration in cardiac surgery

“…In contrast, a recent study in CABG patients showed that reinfusion of cell saver blood is associated with increased systemic prothrombin fragment levels when compared to control patients. However, as this study revealed a larger intraoperative decrease in hemoglobin in the cell saver group, and did not report perioperative blood loss and coagulation test results, it is difficult to interpret these findings [24]. There are no clinical studies available evaluating the effects of ultrafiltration or centrifugation on prothrombin fragment or TAT levels in residual blood volumes.…”

Long Period and High Level of D-Dimer after Coronary Artery Bypass Grafting Surgery

“…4) Previous research has shown that compared with extracorporeal circulation, patients usually suffered from delayed hyper-coagulation after OPCAB; the concentration of D-dimer starts increasing on the first day, and is considerably high on day 4 after the operation. 5) However, most studies have reported D-dimer levels in the first two weeks after surgery, while longer-term clinical observations have rarely been reported. Our results demonstrated that within one month after OPCAB, Ddimer level showed a continuous increase till it reached a peak, after which it reduced to baseline until the third month after OPCAB.…”

“…[1][2][3] However, shortly after the operation, patients are in a relatively hyper-coagulative state, which contributes to a high incidence of thrombotic events. 4,5) According to previous studies, hyper-coagulation and hyperfibrinolysis after OPCAB usually peak on the fourth day after the operation. 6,7) However, few studies have reported the range of variation and long-term abnormal coagulation status in patients after OPCAB.…”