INTRAOPERATIVE PREDONATION CONTRIBUTES TO BLOOD SAVING

The merits of reinfusing prebypass-removed autologous blood (intraoperative predonation) to salvage blood and improve postoperative hemostasis are still debated, specifically for patients at a higher risk for bleeding. To evaluate the effect of intraoperative predonation on the platelet count, blood hemoglobin content, and blood saving postoperatively, we retrospectively studied 100 matching patients. All patients underwent internal mammary artery, bypass surgery resulting in a considerable blood loss postoperatively. Intraoperative predonation (800 ml), reinfusion of the residual volume of the extracorporeal circuit, autotransfusion of shed blood, and acceptance of normovolemic anemia postoperatively was the approach adopted in 50 patients (group 1). A similar blood salvage program, excluding intraoperative predonation, was carried out in the other 50 patients (group 2), and these served as the control group. The platelet counts and blood hemoglobin content were significantly higher postoperatively (p <0.01) in the predonated patients than in the control patients. However, the net blood loss, the amount of retransfused shed blood, and the blood requirements postoperatively were significantly less (p <0.01) in the predonated patients than in' the control patients, whereas 65% of the predonated patients versus 10% of the control patients did not need any donor blood products. In conclusion, predonation reduces the postoperative blood loss and thereby importantly ameliorates the blood-saving effect of a blood salvage program after IMA procedures

SYSTEMIC BLOOD ACTIVATION DURING AND AFTER AUTOTRANSFUSION

To evaluate the extent of shed blood activation in two autotransfusion systems and the effect of circulating blood activation upon autotransfusion, we performed a prospective study in 18 patients undergoing internal mammary artery bypass operation and a control group of 10 patients. The autotransfusion systems were from Sorin (n = 9) consisting of a hard shell reservoir with a filter having a small contact area (0.32 m(2)), and from Dideco (n = 9) consisting of a hard shell reservoir with a filter having a larger contact area (4.64 m(2)). We found high concentrations of thromboxane, fibrinogen degradation products, complement split product C3a, and elastase in the shed blood and, with the exception of C3a, in the circulating blood of autotransfused patients. There was no such activation in control patients. The degree of the systemic inflammatory reaction was determined by the type of autotransfusion system and by the amount of infused shed blood. The Dideco system provoked more inflammatory response than did the Sorin. This was reflected by the larger shed blood loss during autotransfusion in the Dideco patients than in Sorin patients, resulting in infusion of more shed blood (means, 737 mL versus 566 mL; not significant). After autotransfusion, Dideco patients shed significantly more blood than did Sorin or control patients (p <0.05). Dideco patients also needed more colloid/crystalloid solution per 24 hours than Sorin patients (p <0.05). This became clinically relevant only after infusion of more than 800 mL of shed blood (p <0.001): hemodilution indicated the need for packed cells in 4 Dideco patients and in 1 Sorin patient. Dideco patients required a similar amount of blood products (0.8 +/- 0.4 unit) to the control patients. In contrast, Sorin patients required a mean of 0.2 +/- 0.2 unit, whereas blood products were avoided in 89% of them, versus 42% of the Dideco and control patients (not significant). In summary, we recommend autotransfusion of a limited amount (less than 800 mL) of shed blood with a reservoir that has the smallest possible contact area. Infusion of more than 800 mL of shed blood provokes derangement of hemostasis and hemodynamics by deleterious systemic blood activation, nullifying blood saving by autotransfusion

LOW-DOSE APROTININ IN INTERNAL MAMMARY ARTERY BYPASS OPERATIONS CONTRIBUTES TO IMPORTANT BLOOD SAVING

The effect on postoperative blood loss and blood use of blood-saving treatment with or without 280 mg of low-dose aprotinin (2 million kallikrein inactivator units) was studied in 200 consecutive patients undergoing either unilateral or bilateral internal mammary artery bypass grafting. Postoperative blood loss and total units of homologous blood products were similar in patients having either bypass procedure without aprotinin treatment. In patients given aprotinin, postoperative blood loss and use of homologous blood products were significantly lower (p <0.05). The use of any donor blood product was prevented in 78% of the patients given aprotinin versus only 45% of patients treated without aprotinin. None of the aprotinin-treated patients underwent repeat thoracotomy for excessive bleeding; repeat thoracotomy was indicated in 8% of the patients having bilateral internal mammary artery grafting without aprotinin treatment. These results demonstrate that low-dose aprotinin reduces blood loss and blood use significantly and prevents excessive bleeding

Preoperative hemoglobin level as a predictor of survival after coronary artery bypass grafting A comparison with the matched general population

Abstract Background—: The predictive value of the preoperative hemoglobin value after coronary artery bypass grafting (CABG) has not been well established. We studied how the preoperative hemoglobin level affects the survival of patients after CABG. Late mortality was compared with that of a general population. Methods and Results—: Early and late mortality of all consecutive patients undergoing isolated CABG between January 1998 and December 2007 were determined. Patients were classified into 4 groups stratified by preoperative hemoglobin level. The cutoff point for anemia was 13 g/dL for men and 12 g/dL for women. Expected survival of a matched general Dutch population cohort was obtained from the database of the Dutch Central Bureau for Statistics. After the exclusion of 122 patients who were lost to follow-up and 481 patients with missing preoperative hemoglobin levels, complete data were obtained in 10 025 patients. Multivariate logistic regression analyses revealed anemia to be an independent risk factor for higher early mortality. Cox regression analyses revealed low hemoglobin level, both as a continuous variable and as a dichotomous variable (anemia), to be a predictor of higher late mortality. Compared with expected survival, patients with the lowest preoperative hemoglobin levels had a worse outcome, whereas patients with the highest hemoglobin levels had a better outcome