Autotransfusion Following Open-Heart Surgery Frederick B. Parker, Jr., M.D., a n d Howard West, C.C.P.
Material In the past 2 years autotransfusion was used in 9 patients following discontinuation of cardiopulmonary bypass and administration of protamine. In each instance, hemorrhage was considered a distinct possibility. Therefore, preparation for autotransfusion was made before commencing bypass or immediately upon its discontinuation. An operative procedure on the thoracic aorta or a reoperation for congenital or acquired disease was involved in each instance. There were 3 DeBakey type I and 1 type Autotransfusion is a useful adjunct during I1 acute dissections, a luetic aneurysm of the major hemorrhage. Introduced in the latter part ascending aorta, a traumatic aneurysm, a reopof the nineteenth century [4, 51, it has only re- eration for both a mitral and an aortic valve recently gained acceptance in modern therapy. placement, and 1 repair of a pseudotruncus Operative procedures can require massive with closure of a Waterston anastomosis and blood usage. Autotransfusion provides a placement of a Hancock prosthesis to the method of increased blood salvage in these in- right ventricular outflow tract. All patients had stances. It has been used most advantageously major hemorrhage immediately following cesin the hemorrhage of acute trauma and in elec- sation of bypass (Table). tive procedures in which major blood loss is a real possibility. In cardiac operations, intra- Method operative autotransfusion has been used in- Autotransfusion and the Extracorporeal Circuit frequently. Improved hemostatic measures The extracorporeal circuit includes a Bentley have greatly decreased the need for major trans- Q l O O oxygenator, a Sarns 5000 cardiopulmofusion in most cardiac procedures. There is, nary bypass pump, a Pall inline filter on both however, a select group of patients with the po- the arterial line and cardiotomy return, and a tential for severe hemorrhage during operation. Bentley Q120 cardiotomy reservoir. The system The operations include procedures involving is modified to provide autotransfusion by placthe ascending aorta, especially acute dissec- ing an equal Y-connector in the arterial line betions and aneurysms, reoperations for both ac- tween the arterial port of the oxygenator and quired and congenital heart disease, and situa- the arterial roller pump. A similar Y-connector tions when unstable suture lines create the is placed in the cardiotomy drain line to the need for massive transfusion. We have had a oxygenator. A 30 cm line connects the carrecent experience with autotransfusion follow- diotomy drain line to the arterial line by way of ing discontinuation of bypass in such a group the Y-connectors (Figure). This line is filled beof patients. Here we review our experience and fore commencing bypass. During cardiopulmonary bypass the line connecting the cardescribe our technique. diotomy drain line to the arterial line is From the Division of Thoracic Surgery, Upstate Medical clamped at both ends. At the conclusion of Center, Syracuse, NY. bypass all the fluid remaining in the oxygenator Accepted for publication Jan 6, 1978. is slowly transfused to the patient. Protamine is Address reprint requests to Dr. Parker, Division of Thoracic administered and preparation for autotransSurgery, Upstate Medical Center, 750 E Adams St, Syracuse, fusion begins by clamping the cardiotomy NY 13210. ABSTRACT Autotransfusion following cardiopulmonary bypass has been used infrequently. Certain patients are noted for the potential of serious hemorrhage following conclusion of bypass. A new autotransfusion technique for use in such patients is described. The method involves a simple modification of the basic cardiopulmonary bypass setup and requires no separate autotransfusion unit. It can be utilized for several minutes after the administration of protamine. Blood salvage can be considerable and at times lifesaving.
559 0003-4975/78/0026-0609$01.25 @ 1978 by Frederick B. Parker, Jr.
560 The Annals of Thoracic Surgery Vol 26
No 6 December 1978
Data on Patients with Major Hemorrhage Controlled with Autotransfusion
Age
Volume of Autotransfusion (ml)
Patient No.
(Y4
Procedure
1 2 3 4 5 6 7
55 35 35 56 19 58 5
8 9
64 64
AVR MVR (reoperation) Acute aortic dissection (type I) Acute aortic dissection (type 111) Traumatic aortic aneurysm Acute aortic dissection (type I) Repair of pseudotruncus, closure of Waterston anastomosis, and graft from RV to PA Ascending aortic aneurysm Acute aortic dissection (type I)
Time after Protamine Administration (min)
1,125 900 4,000 1,700 3,000 1,600 1,300
5 10 17 5" 8:I 5
700 7,000
9 14"
9
;'Died at operation. AVR
=
aortic valve replacement; MVR = mitral valve replacement; RV = right ventricle; PA = pulmonary artery
Hard Shell CARDIOTOMY RESERVOIR
VENOUS RETURN
ARTERIAL
-
ARTERIAL FILTER
OXYGENATOR
/ / I
Cardiotomv
A
The mod1 jied e.utrncorp~renl ciicr~ita n d t h e rnethod f o r converting to the autotransfusion unit. During autotransfusion the oxygenator is taken out of the extracorporeal circuit by clamping a t points A and B .
561
Parker and West: Autotransfusion after Open-Heart Surgery
drain line distal to the Y-connector and the arterial line between the oxygenator and the Y-connector. If the autotransfusion modification is made at the conclusion of bypass instead of before bypass, the transfusion line must be de-aired by allowing blood to displace air from the cardiotomy line. Transfusion can be continued for a period of time following protamine administration. The cardiotomy filter will remove emboli 200 p or larger from the suctioned blood and arterial line filter will remove emboli 36 p in size. When clots appear in the cardiotomy reservoir, the autotransfusion is discontinued. Initially, we transfused through the arterial cannula. However, to further decrease the chance of injurious emboli, the arterial line is divided and transfusion is now performed through the divided arterial line attached to one of the venous cannulas in the right atrium.
Neurologically, the surviving patients were intact, although the patient with a luetic aneurysm had a severe postoperative psychosis three days after operation. It cleared without sequelae.
Comment Several techniques of autotransfusion have been developed over the past several years, and autotransfusion is now a recognized technique in transfusion therapy. Most of these methods deal with blood salvage in massive hemorrhage after trauma or during elective noncardiac procedures. Units with built-in filters and a collecting reservoir are available commercially and allow a more facile setup. Both massive autotransfusion and massive homologous blood transfusion create coagulation defects. Rakower and associates [7] reported thrombocytopenia and hypofibrinoResults genemia following an experience with highThree patients died in the operating room. Two volume autotransfusion (2 to 30 liters per pawith acute dissection died of massive hemor- tient) in a series of ll patients, but Brener and rhage secondary to rupture in the area of the co-workers [2] in a series of 10 patients with suture line, and the other with traumatic rup- lower autotransfused volumes (1.5 liters per pature of the aorta following graft replacement tient) showed little effect on the coagulation and hemorrhage control died of irreversible mechanism. Coagulation defects appear to be ventricular fibrillation secondary to a severe directly proportional to volume transfused. Milmyocardial and pulmonary contusion, both ler and co-workers [6] studied the effect of maspresent before the operation. The remaining sive (20 to 25 units per patient) homologous patients all had major hemorrhage. With the aid blood transfusion with blood eight to twenty of autotransfusion, it was eventually controlled, days old. In most patients, they also reported a and the condition of each patient was sta- bleeding diathesis after 15 units of blood. The bilized. The mean volume of autotransfusion or major cause of continued bleeding appeared blood salvage in this group of patients was secondary to thrombocytopenia. Our own ex2,369 ml per patient (highest, 7,000 ml; lowest, perience has demonstrated the presence of 700 ml). Following the administration of pro- thrombocytopenia with prolonged bypass and tamine, autotransfusion was continued for an multiple transfusions [31. average of 8.9 minutes (longest interval, 17 Because of the threat of emboli, filters must minutes; shortest interval, 5 minutes) (see the be an integral part of any autotransfusion unit. Table). Unless there is total body heparinization, the Postoperative coagulation studies in surviv- formation of a fibrin membrane across the filter ing patients revealed no abnormality inconsis- may well serve as a means for platelet trapping tent with prolonged cardiopulmonary bypass and destruction. Blood rich in clotting factors or or directly attributable to the autotransfusion platelet transfusions should be considered to mechanism. Two patients had platelet counts correct this defect if it is present after massive below 100,000: the patient with pseudotruncus transfusion. Autotransfusion following open-heart operahad a platelet count of 64,000 and the patient with luetic aneurysm, 78,000. The other clotting tion has received little attention. It is the responsibility of the cardiac surgeon to be asfactors were within normal limits.
562 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
sured of proper hemostasis before discontinuing bypass and administering protamine. Failing in this responsibility and hoping “protamine will take care of it” constitutes a dangerous assumption leading to massive transfusion of homologous blood with its attendant dangers, including possible death from hemorrhage. In spite of meticulous attention to hemostasis, there continues to remain a small group of patients in whom bleeding may persist following discontinuation of bypass. Autotransfusion should be considered in this group to not only salvage blood, but also to decrease the risks attendant on transfusion of large amounts of homologous blood. Bregman and co-workers [l] reported utilization of a commercially available autotransfusion system (Bentley ATS-100) with a 20 p nylon filter to salvage shed blood following bypass. Autotransfusion was continued until clotting occurred within the unit. They performed this procedure in 3 patients undergoing cardiac operation. To our knowledge, this is the only report of autotransfusion in an open-heart procedure. In our system, the same end is gained by a simple modification of the bypass setup. The risk of consequential emboli appears minimal with the filters present in the system. A further safeguard is discontinuation of the transfusion when clots appear in the cardiotomy reservoir.
In spite of this limitation, our small series reveals that blood recovery can be considerable. Autotransfusion following cardiopulmonary bypass has been infrequently used. Massive homologous blood transfusion with its attendant risks (transfusion reaction or hepatitis) must be controlled if blood banks are to remain solvent. The addition of a simple autotransfusion technique decreases the need for homologous blood and may prove lifesaving.
References 1. Bregman D, Parodi EN, Hutchinson JE 111, et al: Intraoperative autotransfusion during emergency thoracic and elective open-heart surgery. Ann Thorac Surg 18:590, 1974 2. Brener BJ, Raines JK, Darling RC: Intraoperative autotransfusion in abdominal aortic resections. Arch Surg 107:78, 1973 3. Davey FR, Parker FB Jr: Delayed hemostatic changes following cardiopulmonary bypass. Am J Med Sci 271:171, 1976 4. Duncan J: O n reinfusion of blood in primary and other amputations. Br Med J 1:192, 1886 5. Miller AG: Case of amputation of the hip joint in which reinjection of blood was performed and rapid recovery took place. Edinburgh Med J 31:721, 1885 6. Miller RD, Robbins TO, Tong MJ, et al: Coagulation defects associated with massive blood transfusions. Ann Surg 174:794, 1971 7. Rakower SR, Worth MH Jr, Lackner H: Massive intraoperative autotransfusion of blood. Surg Gynecol Obstet 137:633, 1973
Material In the past 2 years autotransfusion was used in 9 patients following discontinuation of cardiopulmonary bypass and administration of protamine. In each instance, hemorrhage was considered a distinct possibility. Therefore, preparation for autotransfusion was made before commencing bypass or immediately upon its discontinuation. An operative procedure on the thoracic aorta or a reoperation for congenital or acquired disease was involved in each instance. There were 3 DeBakey type I and 1 type Autotransfusion is a useful adjunct during I1 acute dissections, a luetic aneurysm of the major hemorrhage. Introduced in the latter part ascending aorta, a traumatic aneurysm, a reopof the nineteenth century [4, 51, it has only re- eration for both a mitral and an aortic valve recently gained acceptance in modern therapy. placement, and 1 repair of a pseudotruncus Operative procedures can require massive with closure of a Waterston anastomosis and blood usage. Autotransfusion provides a placement of a Hancock prosthesis to the method of increased blood salvage in these in- right ventricular outflow tract. All patients had stances. It has been used most advantageously major hemorrhage immediately following cesin the hemorrhage of acute trauma and in elec- sation of bypass (Table). tive procedures in which major blood loss is a real possibility. In cardiac operations, intra- Method operative autotransfusion has been used in- Autotransfusion and the Extracorporeal Circuit frequently. Improved hemostatic measures The extracorporeal circuit includes a Bentley have greatly decreased the need for major trans- Q l O O oxygenator, a Sarns 5000 cardiopulmofusion in most cardiac procedures. There is, nary bypass pump, a Pall inline filter on both however, a select group of patients with the po- the arterial line and cardiotomy return, and a tential for severe hemorrhage during operation. Bentley Q120 cardiotomy reservoir. The system The operations include procedures involving is modified to provide autotransfusion by placthe ascending aorta, especially acute dissec- ing an equal Y-connector in the arterial line betions and aneurysms, reoperations for both ac- tween the arterial port of the oxygenator and quired and congenital heart disease, and situa- the arterial roller pump. A similar Y-connector tions when unstable suture lines create the is placed in the cardiotomy drain line to the need for massive transfusion. We have had a oxygenator. A 30 cm line connects the carrecent experience with autotransfusion follow- diotomy drain line to the arterial line by way of ing discontinuation of bypass in such a group the Y-connectors (Figure). This line is filled beof patients. Here we review our experience and fore commencing bypass. During cardiopulmonary bypass the line connecting the cardescribe our technique. diotomy drain line to the arterial line is From the Division of Thoracic Surgery, Upstate Medical clamped at both ends. At the conclusion of Center, Syracuse, NY. bypass all the fluid remaining in the oxygenator Accepted for publication Jan 6, 1978. is slowly transfused to the patient. Protamine is Address reprint requests to Dr. Parker, Division of Thoracic administered and preparation for autotransSurgery, Upstate Medical Center, 750 E Adams St, Syracuse, fusion begins by clamping the cardiotomy NY 13210. ABSTRACT Autotransfusion following cardiopulmonary bypass has been used infrequently. Certain patients are noted for the potential of serious hemorrhage following conclusion of bypass. A new autotransfusion technique for use in such patients is described. The method involves a simple modification of the basic cardiopulmonary bypass setup and requires no separate autotransfusion unit. It can be utilized for several minutes after the administration of protamine. Blood salvage can be considerable and at times lifesaving.
559 0003-4975/78/0026-0609$01.25 @ 1978 by Frederick B. Parker, Jr.
560 The Annals of Thoracic Surgery Vol 26
No 6 December 1978
Data on Patients with Major Hemorrhage Controlled with Autotransfusion
Age
Volume of Autotransfusion (ml)
Patient No.
(Y4
Procedure
1 2 3 4 5 6 7
55 35 35 56 19 58 5
8 9
64 64
AVR MVR (reoperation) Acute aortic dissection (type I) Acute aortic dissection (type 111) Traumatic aortic aneurysm Acute aortic dissection (type I) Repair of pseudotruncus, closure of Waterston anastomosis, and graft from RV to PA Ascending aortic aneurysm Acute aortic dissection (type I)
Time after Protamine Administration (min)
1,125 900 4,000 1,700 3,000 1,600 1,300
5 10 17 5" 8:I 5
700 7,000
9 14"
9
;'Died at operation. AVR
=
aortic valve replacement; MVR = mitral valve replacement; RV = right ventricle; PA = pulmonary artery
Hard Shell CARDIOTOMY RESERVOIR
VENOUS RETURN
ARTERIAL
-
ARTERIAL FILTER
OXYGENATOR
/ / I
Cardiotomv
A
The mod1 jied e.utrncorp~renl ciicr~ita n d t h e rnethod f o r converting to the autotransfusion unit. During autotransfusion the oxygenator is taken out of the extracorporeal circuit by clamping a t points A and B .
561
Parker and West: Autotransfusion after Open-Heart Surgery
drain line distal to the Y-connector and the arterial line between the oxygenator and the Y-connector. If the autotransfusion modification is made at the conclusion of bypass instead of before bypass, the transfusion line must be de-aired by allowing blood to displace air from the cardiotomy line. Transfusion can be continued for a period of time following protamine administration. The cardiotomy filter will remove emboli 200 p or larger from the suctioned blood and arterial line filter will remove emboli 36 p in size. When clots appear in the cardiotomy reservoir, the autotransfusion is discontinued. Initially, we transfused through the arterial cannula. However, to further decrease the chance of injurious emboli, the arterial line is divided and transfusion is now performed through the divided arterial line attached to one of the venous cannulas in the right atrium.
Neurologically, the surviving patients were intact, although the patient with a luetic aneurysm had a severe postoperative psychosis three days after operation. It cleared without sequelae.
Comment Several techniques of autotransfusion have been developed over the past several years, and autotransfusion is now a recognized technique in transfusion therapy. Most of these methods deal with blood salvage in massive hemorrhage after trauma or during elective noncardiac procedures. Units with built-in filters and a collecting reservoir are available commercially and allow a more facile setup. Both massive autotransfusion and massive homologous blood transfusion create coagulation defects. Rakower and associates [7] reported thrombocytopenia and hypofibrinoResults genemia following an experience with highThree patients died in the operating room. Two volume autotransfusion (2 to 30 liters per pawith acute dissection died of massive hemor- tient) in a series of ll patients, but Brener and rhage secondary to rupture in the area of the co-workers [2] in a series of 10 patients with suture line, and the other with traumatic rup- lower autotransfused volumes (1.5 liters per pature of the aorta following graft replacement tient) showed little effect on the coagulation and hemorrhage control died of irreversible mechanism. Coagulation defects appear to be ventricular fibrillation secondary to a severe directly proportional to volume transfused. Milmyocardial and pulmonary contusion, both ler and co-workers [6] studied the effect of maspresent before the operation. The remaining sive (20 to 25 units per patient) homologous patients all had major hemorrhage. With the aid blood transfusion with blood eight to twenty of autotransfusion, it was eventually controlled, days old. In most patients, they also reported a and the condition of each patient was sta- bleeding diathesis after 15 units of blood. The bilized. The mean volume of autotransfusion or major cause of continued bleeding appeared blood salvage in this group of patients was secondary to thrombocytopenia. Our own ex2,369 ml per patient (highest, 7,000 ml; lowest, perience has demonstrated the presence of 700 ml). Following the administration of pro- thrombocytopenia with prolonged bypass and tamine, autotransfusion was continued for an multiple transfusions [31. average of 8.9 minutes (longest interval, 17 Because of the threat of emboli, filters must minutes; shortest interval, 5 minutes) (see the be an integral part of any autotransfusion unit. Table). Unless there is total body heparinization, the Postoperative coagulation studies in surviv- formation of a fibrin membrane across the filter ing patients revealed no abnormality inconsis- may well serve as a means for platelet trapping tent with prolonged cardiopulmonary bypass and destruction. Blood rich in clotting factors or or directly attributable to the autotransfusion platelet transfusions should be considered to mechanism. Two patients had platelet counts correct this defect if it is present after massive below 100,000: the patient with pseudotruncus transfusion. Autotransfusion following open-heart operahad a platelet count of 64,000 and the patient with luetic aneurysm, 78,000. The other clotting tion has received little attention. It is the responsibility of the cardiac surgeon to be asfactors were within normal limits.
562 The Annals of Thoracic Surgery Vol 26 No 6 December 1978
sured of proper hemostasis before discontinuing bypass and administering protamine. Failing in this responsibility and hoping “protamine will take care of it” constitutes a dangerous assumption leading to massive transfusion of homologous blood with its attendant dangers, including possible death from hemorrhage. In spite of meticulous attention to hemostasis, there continues to remain a small group of patients in whom bleeding may persist following discontinuation of bypass. Autotransfusion should be considered in this group to not only salvage blood, but also to decrease the risks attendant on transfusion of large amounts of homologous blood. Bregman and co-workers [l] reported utilization of a commercially available autotransfusion system (Bentley ATS-100) with a 20 p nylon filter to salvage shed blood following bypass. Autotransfusion was continued until clotting occurred within the unit. They performed this procedure in 3 patients undergoing cardiac operation. To our knowledge, this is the only report of autotransfusion in an open-heart procedure. In our system, the same end is gained by a simple modification of the bypass setup. The risk of consequential emboli appears minimal with the filters present in the system. A further safeguard is discontinuation of the transfusion when clots appear in the cardiotomy reservoir.
In spite of this limitation, our small series reveals that blood recovery can be considerable. Autotransfusion following cardiopulmonary bypass has been infrequently used. Massive homologous blood transfusion with its attendant risks (transfusion reaction or hepatitis) must be controlled if blood banks are to remain solvent. The addition of a simple autotransfusion technique decreases the need for homologous blood and may prove lifesaving.
References 1. Bregman D, Parodi EN, Hutchinson JE 111, et al: Intraoperative autotransfusion during emergency thoracic and elective open-heart surgery. Ann Thorac Surg 18:590, 1974 2. Brener BJ, Raines JK, Darling RC: Intraoperative autotransfusion in abdominal aortic resections. Arch Surg 107:78, 1973 3. Davey FR, Parker FB Jr: Delayed hemostatic changes following cardiopulmonary bypass. Am J Med Sci 271:171, 1976 4. Duncan J: O n reinfusion of blood in primary and other amputations. Br Med J 1:192, 1886 5. Miller AG: Case of amputation of the hip joint in which reinjection of blood was performed and rapid recovery took place. Edinburgh Med J 31:721, 1885 6. Miller RD, Robbins TO, Tong MJ, et al: Coagulation defects associated with massive blood transfusions. Ann Surg 174:794, 1971 7. Rakower SR, Worth MH Jr, Lackner H: Massive intraoperative autotransfusion of blood. Surg Gynecol Obstet 137:633, 1973
