J Med Allied Sci 2017; 7(1):48-54 DOI: 10.5455/jmas.246306

Original article

Autologous blood transfusion in open heart surgeries under cardiopulmonary bypass - Clinical appraisal

B. Sartaj  Hussain1, S. Vengal Reddy2, L. N. Prasad3, G. Madhavi4

Affiliation(s):

1Department of Cardiothoracic Surgery, Government General & Chest Hospital, Osmania Medical College, Erragadda, Hyderabad-500038, Telangana, India.

2Prime Hospital, Kukatpally, Hyderabad-500072, Telangana, India.

3Department of Cardiothoracic Surgery, Pratima Institute of Medical Sciences, Nagunur, Karimnagar-505417, Telangana, India.

4Department of Anesthesiology, Government General & Chest Hospital, Osmania Medical College, Erragadda, Hyderabad-500038, Telangana, India.

Corresponding author: Dr. B. Sartaj Hussain, Assistant Professor, Department of Cardiothoracic Surgery, Flat no. 22, Roshan Vihar, Maruthi Nagar, Saroor Nagar, Hyderabad-500035, Telangana, India.

Phone: +91-9440230964 Email: dr_sartaj@yahoo.com

Abstract

Autologous blood withdrawal before instituting cardiopulmonary bypass (CPB) protects the platelets, preserve red cell mass and reduce allogeneic transfusion requirements. Ideal condition for autologous blood donation is elective cardiac surgery where there is a high probability of blood transfusion. The purpose of this study was to assess the role of preoperative autologous blood donation in cardiac surgeries. Out of 150 patients registered, 50 cases were excluded on the basis of hemoglobin content (<11 gm/dl) and age group (pediatric group); therefore, the study was conducted on 100 cardiac surgery patients. We collected 13% to 15% of patient’s estimated blood volume in bags containing either heparin or citrate phosphate dextrose (CPD) and stored at room temperature. This was later returned to the patient through a peripheral vein after the bypass. In most of the cases 1-2 units (1 unit=450 ml) were withdrawn and re-administered to the patients. This study showed that there was 10% decrease in banked blood requirements. We conclude that autologous pre-donation is a promising alternative in reducing the harmful effects of allogeneic blood transfusion in elective cardiac surgery. It improves the recovery profile and decreases the transfusion related morbidity.

Keywords: Acute normovolemic hemodilution (ANH), allogeneic transfusion, cardiothoracic surgery, preoperative autologous donation (PAD)

Running title:  Evaluation of autologous blood transfusion

Introduction

Blood and their components suffer diffuse damage during cardiopulmonary bypass. This damage increases all the more when the pump time crosses beyond an hour. The red blood cells (RBCs), white blood cells (WBCs), platelets and various clotting factors get damaged and hence there is increased risk of bleeding in the post bypass period. In addition to these factors, systemic heparinization adds fuel to fire during cardiopulmonary bypass. In banked blood beyond 24 hours, RBC and clotting factors though claimed as freshly collected but is depleted in platelets. This stored blood in refrigerators is also deprived of the requisite amount of 2-3 diphospoglycerate (DPG) which can shift the oxygen dissociation curve to the left and there by hinder the release of oxygen to various tissues in the human body.

Autologous blood transfusion is collection of subject’s own blood before surgery and transfusing the same to the patient during or after major surgery. There are three types of autologous blood transfusion1:

(1)   Preoperative autologous blood donation (PAD)

(2)   Acute normovolemic hemodilution (ANH)

(3)   Intraoperative and postoperative blood salvage

Autologous blood transfusion is a simple concept which enables preserving the integrity of RBCs, platelets and clotting factors so that a quality blood without the problem of the incompatibility is administered to the patient. This can avoid the phase of cross matching thereby saving time and provide the advantage of immediate availability of blood in the operation theatre. As the clotting factors are preserved, hemostatis is best achieved in the post bypass period.

With autotransfusion the risk of infection or alloimmunization is completely eliminated1,2. In addition this blood carries a higher level of oxygen because it has a higher density of clean red blood cells3. There are few disadvantages of autologous blood transfusion namely the risk of ABO incompatibility error is not reduced and also the risk of bacterial contamination is not reduced. It proves more costly than allogeneic blood in peripheral units and can also result in wastage of blood if it is not transfused after bypass surgery. PAD may subject patients to perioperative anemia and increased likelihood of transfusion1.

According to American Association of Blood Banks (AABB) guidelines, patients may donate 10.5 ml/kg.  In addition to testing samples, donations may be scheduled more than once a week, but the last should occur no less than 72 hours before surgery to allow time for restoration of intravascular volume and for transport and testing of the donated blood1.

Acute normovolemic hemodilution (ANH) is the removal of whole blood from a patient, while restoring the circulating blood volume with an acellular fluid shortly before an anticipated significant surgical blood loss. In this procedure, blood is collected in standard blood bags containing anticoagulant on a tilt-rocker with automatic cut off via volume sensors which is then stored at room temperature and reinfused during surgery4. Simultaneous infusions of crystalloids (approximately 3 ml crystalloid for each 1 ml of blood withdrawn) and colloids – dextrans, albumins, starch, gelatin (approximately 1 ml for each 1 ml of blood withdrawn) have been recommended. Blood units collected are infused in reverse order of collection since the first unit, as the last unit transfused, has the highest hematocrit and concentration of coagulation factors and platelets5.

In contrast to autologous blood donation under standard conditions, studies of aggressive autologous blood phlebotomy twice weekly for 3 weeks beginning 25-35 days before surgery have demonstrated that endogenous erythropoietin levels do increase, along with enhanced erythropoiesis representing RBC volume expansion of 19-26%. Presurgical erythropoietin therapy is approved worldwide for anemic [Packed Cell Volume<30%] patients scheduled for non-cardiac non-vascular surgeries5.

The use of autologous blood transfusion to decrease blood bank requirements and improve coagulation parameters during cardiac surgery is still controversial6. This study was undertaken to evaluate the benefits of autologous blood transfusion in cardiac surgeries in teaching hospitals of a medical college situated in Hyderabad.      

Materials and methods

The study was conducted at teaching hospitals of Osmania Medical College, Hyderabad between 2006 and 2009 after approval from Institutional Ethics Committee. Consecutive patient undergoing various elective open heart surgeries [coronary artery bypass grafting (CABG), CABG with aortic or mitral valve replacement, aortic valve replacement (AVR), mitral valve repair/replacement (MVR), double valve replacement (DVR) or miscellaneous types of operations], aged between 18 and 60 years belonging to both the sexes were enrolled for the study. All patients were evaluated for preoperative autologous blood donation. Following were the exclusion criteria: preoperative hemoglobin concentration < 11 g/dL1, evidence of infection and risk of bacteremia5, uncontrolled hypertension, history of syncope, unstable angina7, severe aortic stenosis7 with mean systolic pressure gradient > 100 mm Hg, active seizure disorder1, myocardial infarction1 or cerebrovascular accidents (CVA) within 6 months, cyanotic heart disease and significant pulmonary diseases.

A total of 150 patients were registered (Table 1) but 50 cases were excluded on the basis of hemoglobin content (<11 gm/dl and/or hematocrit <33%). Among remaining 100 cases, 50 were selected for autologous blood transfusion, while the other 50 cases acted as control group who did not receive autologous blood transfusion.

Patients were operated under high risk consent. While obtaining informed written consent from patient and their attendants, consent for autologous transfution was also taken. After inducing the anesthesia and after securing all the necessary invasive monitoring, a decision to collect autologous blood from the femoral vein was taken after sternotomy and before going on bypass.

If the hemodynamic parameters are maintained in stable way, an amount of 5 ml per kg body weight (13 to 15 percent of the patient's estimated blood volume) of blood was collected from the patient’s femoral vein in bags containing citrate phosphate dextrose (CPD) solution or heparin6. The femoral vein was selected because of a superior quality of blood which drains into inferior venacava in comparison to superior venacaval blood collected from arm. Simultaneously a colloid or crystalloid of necessary volume was transfused in other intravenous line to compensate for the hypovolemia produced by blood letting. After collection, blood was kept in the operation theatre (OT) itself at room temperature and used for retransfusion in the post bypass period after reversal of systemic heparinization with portamine and after achieving and ensuring that activated clotting time (ACT) value is <150 seconds. Autologus blood was given as the first blood transfusion (one or two units) after protamine and only later the banked blood was administered if required. The patients were observed for bleeding in the postoperative period from the mediastinal and the pleural drains for the first 48 hours. They were also monitored for the need of subsequent blood product transfusion, hemodynamics, further bleeding and the clotting parameters.

Volume of blood to be withdrawn was calculated by the given formula:

These patients were compared with controlled group where no autologous blood was collected and observed for above parameters in the both the groups. The anesthesia technique and the drugs used during the pre bypass period were the same to avoid any discrepancy in the results.

Statistical analysis: Data obtained was subjected to Chi-square test. Significance was fixed at p<0.05.

Results

The quantum of patients that visited our hospital belonged to lower socio-economic group and in moribund condition. Most of them were with sick hearts or lungs or both.  Rheumatic valvular disease and tuberculosis were the commonest causes.

In our hospital the elective cardiac surgeries performed during 2006-2009 are as follows:

Table 1: Diseases and cardiac surgeries profile of registered patients (N=150)

Category of disease

Name of disease and surgery

Number (%)

Congenital heart disease

OS atrial septal defect (ASD)

44 (29.3)

 

Patent ductus arteriosus (PDA)

15 (10.0)

 

Lutembacher

3 (2.0)

 

Ventricular septal defect (VSD)

3 (2.0)

 

OP atrial septal defect (ASD)

1 (0.6)

 

Tetralogy of Fallot (TOF)

1 (0.6)

Valvular heart disease

Rheumatic heart disease (RHD) – Mitral stenosis / Regurgitation – Mitral valve repair (MVR)

33 (22)

 

Rheumatic heart disease (RHD) – Mitral + Tricuspid annuloplasty

5 (3.3)

 

Aortic valve replacement (AVR)

5 (3.3)

 

Double valve replacement (DVR)

5 (3.3)

 

Ruptured sinus of valsalva repair (RSOV)

3 (2.0)

Ischemic heart disease

Coronary artery bypass graft (CABG)

8 (5.3)

Tumors

Myxoma

4 (2.6)

Pericardial disease

Constrictive pericarditis and others

20 (13.3)

 

Table 2: Mortality (n=19)

Disease

Number (%)

Constrictive pericarditis

4 (21.0)

OS ASD

6 (31.5)

DVR

3 (15.7)

MVR

3 (15.7)

TOF

1 (5.2)

CABG

1 (5.2)

Myxoma

1 (5.2)

 

Many patients were on drug like oral anticoagulants and anti platelet agents like aspirin/clopidgrel, amiodrone, etc. which can alter the hemostatic mechanism in the patient.

In most of the cases we withdrew 1-2 units of blood and re-infused at the end of surgical procedure except in children and anemic patients and other patients excluded based on the exclusion criteria.

This study was done in 100 cases and autologous transfusion found to be helpful in fast recovery and also aided in shortening the duration of operation in cardiac surgeries. However, the quantum of post operative blood transfusions in a given patient has not come down though there was saving of 10 percent in banked blood requirements. There was no significant decrease in total blood bank requirements in ‘autologous blood’ group than for controls. The transfusion related morbidity was less in ‘autologous blood’ group than for controls. The overall mortality between the groups was also not significant (Chi square=0.065, p=0.79).

Table 3: Distribution of patients who received or did not received autologous blood transfusion and mortality proportion

Surgery

No predonation

Predonation

Total Mortality

Excluded

Total

N

Mortality

N

Mortality

MVR

9

2

13

1

3

11

33

M + TR Annuloplasty

1

0

4

0

0

0

5

AVR

1

0

2

0

0

2

5

DVR

1

0

4

3

3

0

5

RSOV

3

0

0

0

0

0

3

Myxomas

1

0

3

1

1

0

4

CABG

3

0

4

1

1

1

8

OS ASD

11

4

11

2

6

22

44

OP ASD

0

0

1

0

0

0

1

VSD

3

0

0

0

0

0

3

TOF

1

1

0

0

1

0

1

PDA

6

0

3

0

0

6

15

Constrictive pericarditis

7

3

5

1

4

8

20

Lutembacher

3

0

0

0

0

0

3

Total

50

10

50

9

19

50

150

 

Discussion

Bleeding is a major problem during and after open heart surgery. Reasons for this being systemic heparinization, the turbulence phase of blood during its transport through the heart-lung machine and the disturbances in the hemostatic mechanism of the patient due to other factors like stasis of blood, sludging of blood, chronic passive congestion of the liver and lung, nutritional deficiencies and diseases like rheumatic heart disease which makes the tissue friable and hyperemic.

Autologous transfusion is a simple, cost effective and non phase mode of collecting blood from the patient in a safe environment and reusing it in the post bypass period for improving hemostatic mechanism of the patients. The blood is rich in its resources and oxygen content when compared to the blood collected from the superior vena caval (SVC) distribution. The reason for high quality of blood collected from the inferior vena cava (IVC) through the femoral vein lies in the fact that the blood is rich in oxygen and nutrients since majority of IVC blood is contributed by the renal veins, right and left; and as 25% of a cardiac output goes to both the kidneys through the renal arteries which is used for the purpose of glomerular filtration and urine formation. This blood also satisfies the metabolic needs of the kidneys, but the renal arteries return almost the same quantity of the blood into the renal veins after negligible extraction by the kidney for the metabolic needs. The renal vein empty approximately 1-3 liters of blood into the IVC every minute (cardiac output is 5 liters) with rich oxygen and reasonable nutrients. Within 1-4 hours after collection, this blood collected from IVC is again transfused to the same patient without any deterioration in RBC, platelet quality and hemostatic function.

Bell et al demonstrated that predonation of autologous blood is an effective method to reduce allogeneic blood transfusion. They showed a decrease in allogeneic transfusion from 57% to 16% which was similar or even superior to that seen when compared with other blood conservation strategies8.

Autologous blood withdrawal before instituting bypass protects the platelets from the damaging effects of the CPB. The quality of this blood is excellent, with only slight activation of platelets, and it has been demonstrated to preserve red cell mass and reduce transfusion requirements. It should be considered in patients for whom the calculated hematocrit on the pump will remain adequate after withdrawal of 1-2 units of blood with non-heme fluid replacement. Preoperative autologous blood donation is a feasible option in patients with valvular heart disease or stable angina. However, its limited usage in recent years can be ascribed to several factors9:-

1.     The urgency of surgery in most cases

2.     Concern about precipitating angina in patients with the severe coronary disease

3.     Lessened concern over Hepatitis C and HIV virus

4.     Questions about its cost effectiveness with the availability of the other measures to reduce blood loss (such as antifibrinolytic drugs, cell-saving)

5.     Logistic blood-bank considerations

There is an opinion that intraoperative predonation contributes to red cell saving. However, its efficacy in reducing perioperative bleeding is controversial6. It can be considered when the calculated on-pump hematocrit after withdrawal remains satisfactory (>20-22%). This can be calculated using the following equation9:

where EBV is the estimated blood volume, PV is priming volume ECV is estimated cardioplegia volume and HCT is hematocrit (pre-withdrawal).

According to Hedayatallah and associates, there is no benefit of intraoperative whole blood sequestration and autotransfusion during CABG10. But Bouchard et al believe that preoperative autologous blood donation has a promising role in cardiac surgery11. Dupuis et al showed that patients who predonated blood before elective cardiac surgery were at lower risk of receiving allogeneic transfusions than the nondonors12.

Since the recognition of human immunodeficiency virus (HIV) being transmitted by blood transfusion, there has been increasing demand for autologous blood donations before elective surgery. Autologous blood donation is, however, a more expensive process than the donation of allogeneic blood by volunteers. Of late, improvements in the safety of the donated blood supply enabled administration of allogeneic blood with as minimum complications as compared to that of autologous blood13.

In our study, autologous transfusion did not reduce the post-operative blood requirements but it fulfilled the qualities of fresh blood. It is evident that it helps in neutralizing the effects of heparin working in tandem with protamine and helps in early closure of sternum.

In our hospital, we withdraw 1-2 units of autologous blood into the CPD bags and keep it at room temperature and transfuse them in the reverse order of withdrawal to benefit the patient with more concentrated and platelet rich blood.

Our practice of keeping 4-6 units of homologous fresh blood and 2 units of fresh frozen plasma (FFP) or platelets especially in patients with congestive liver conditions is routine. The rate of postoperative jaundice is around 5% especially in large amounts of transfusion. 1-2 % of post-operative cases needed peritoneal / hemodialysis because of the rise of potassium levels. The incidence of we operating on HIV-infected patients is around 1% and 2% were HBsAg positive.

Conclusions

Autologous transfusion is a simple useful concept to conserve blood and reduce the transfusion requirement in the post operative period in open heart surgeries and CPB. It is not a new concept. It is the collection preoperatively and re-infusion postoperatively of the patient's own blood or blood components. It reduces the need for allogeneic blood products in adult cardiac surgery14,15.

It definitely contributes to the reduction in the bleeding from the drain in the post CBP period and reduces the requirement for use of blood products like fresh frozen plasma (FFP) and platelet rich plasma (PRP).The biggest advantage is the cost effectiveness because no costly gadgets are needed to perform this procedure especially if done on case by case basis.

In carefully selected patients, preoperative autologous donation is a safe and efficient alternative to allogeneic transfusion. Patients with rare blood phenotypes or allogeneic antibodies can benefit from autologous transfusion because compatible allogeneic blood may not be always available. Potential complications of allogeneic transfusion that can be eliminated or minimized when autologous blood is administered include acute and delayed hemolytic reactions, alloimmunization, allergic and febrile reactions and transfusion-transmitted infectious diseases15. 

In our study, we conclude that, total blood bank requirements were not significantly less for the autologous blood group than for controls. There was a saving of 10 percent in banked blood requirements and obviously the transfusion-related morbidity was less in these patients.

Autologous transfusion was found to be helpful in fast recovery and also aided in shortening the duration of operation in cardiac surgeries. However, the quantum of post operative blood transfusions in a given patient has not come down.  

The Society of Cardiovascular Anesthesiologists clinical practice guideline16 gives a comprehensive approach to perioperative blood transfusion. In order to decrease the consumption of blood components, diminish morbidity and mortality and reduce hospital costs, this treatment strategy should be incorporated into medical practice. Further studies with multiple variables may resolve the shortcomings of this strategy and its consequences. This practice can become cost effective when it is applied at a larger scale and where the turnover is high. Adequate infrastructural facilities and requisite staff can make autologous blood transfusion, a feasible option in at least cardiac surgical division.

Acknowledgments: None

Conflict of interest: None

References

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