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Ann Thorac Surg 1999;68:58-62
© 1999 The Society of Thoracic Surgeons

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Original Articles

Influence of different autotransfusion devices on the quality of salvaged blood

^a Department of Cardiothoracic Surgery, University Hospital, Würzburg, Germany
^b Department of Microbiology, University Hospital, Würzburg, Germany

Address reprint requests to Dr Reents, Klinik und Poliklinik für Herz- und Thoraxchirurgie, Josef-Schneider-Str 6, D-97080 Würzburg, Germany

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Cardiopulmonary bypass causes a systemic inflammatory response and impaired hemostasis. We investigated whether intraoperative blood salvage with the cardiotomy suction contributes to these alterations. Furthermore, an alternative autotransfusion device (Haemonetics cell-saving device) was examined.

Methods. In 10 patients, interleukin-6, interleukin-8, tumor necrosis factor-, thrombin-antithrombin complex, plasmin-antiplasmin complex, free hemoglobin, and the percentage of CD62⁺ thrombocytes were determined in the systemic circulation during cardiopulmonary bypass, in the cardiotomy suction tube, and in the blood from the cell-saving device. Additionaly, bacterial contamination was examined.

Results. Median levels of interleukin-6 (52 versus 10 µg/L; p = 0.005), interleukin-8 (26 versus 20 µg/L; p = 0.017), tumor necrosis factor- (24 versus 1 µg/L; p = 0.005), thrombin-antithrombin complex (113 versus 43 µg/L; p = 0.005), plasmin-antiplasmin complex (566 versus 489 µg/L; p = 0.022), and free hemoglobin (61 versus 30 mg/dL; p = 0.005) were higher in the cardiotomy suction tube compared with the systemic circulation. After processing the blood from the cell-saving device, interleukin-8, thrombin-antithrombin complex, and free hemoglobin remained above reference range, and in 90% of the cases bacterial contamination was observed.

Conclusions. Cardiotomy suction additionally contributes to the release of proinflammatory cytokines, activation of coagulation, and hemolysis. Because blood salvage with a Haemonetics cell-saving device led to normalization of some, but not all, parameters and bacterial contamination was common, the alternative use seems at least questionable.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Heart operations performed with cardiopulmonary bypass (CPB) cause a systemic inflammatory response and lead to profound alterations of hemostasis (eg, coagulation, fibrinolysis, and platelet function) [1, 2]. Clinically, this might result in the so-called postpump syndrome with impaired myocardial, cerebral, pulmonary, and renal function [3] and increased postoperative bleeding [4]. Different components of the extracorporal circuit (eg, type of oxygenator, pump, surface material) as well as the surgical procedure itself may influence the systemic inflammatory response and the impaired coagulation seen after cardiac operations with CPB [5].

To minimize transfusion requirements during operations performed with CPB, the anticoagulated extravascular blood can be salvaged with the cardiotomy suction, returning this blood to the venous reservoir of the heart-lung machine. It has been claimed that intraoperative autotransfusion of blood suctioned with the cardiotomy suction during CPB might further compromise hemostasis [6]. The exposure of blood to tissue and air and the subsequent mechanical stress caused by the cardiotomy suction may alter corpuscular and plasmatic blood elements. This can lead to an activation of leukocytes and cytokine release as well as to an activation of platelets and coagulation. It thus seems possible that salvaging blood with the cardiotomy suction might increase the deleterious effects of CPB. An alternative method for intraoperative blood salvage is the use of a separate suction device with the possibility of processing the collected blood, thereby clearing the blood from plasmatic components.

In the present study we investigated the influence of the cardiotomy suction on proinflammatory cytokines, activation of platelets, and coagulation, fibrinolysis, and hemolysis factors. Therefore, blood samples were drawn from the systemic circulation and simultaneously from the cardiotomy suction tube. Furthermore, the same parameters were determined in blood collected with a Haemonetics cell-saving device. Both autotransfusion devices were used during aortic valve replacement, a procedure with substantial intraoperative blood extravasation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
The present study included 10 patients undergoing aortic valve replacement for aortic stenosis (8 patients) or aortic insufficiency (2 patients). Mean age was 70 years (range, 43 to 76 years), mean bypass time was 108 minutes (range, 82 to 133 minutes), and mean aortic cross-clamping time was 73 minutes (range, 56 to 105 minutes). Individuals with renal or liver insufficiency or coagulation disorders were excluded from this study. All patients gave written consent. Anesthesia was standardized in all patients and consisted of weight-related doses of flunitrazepam, fentanyl, and vecuronium bromide. Perioperative antibiotic prophylaxis with cefuroxime was started with induction of anesthesia. Cardiopulmonary bypass was performed at moderate hypothermia (rectal temperature, 30 to 32°C). A centrifugal pump (Bio-Medicus BP 80, Medtronic, Düsseldorf, Germany), a Bard HF 5000 membrane oxygenator (Bard/Angiomed AG, Karlsruhe, Germany), and a 40-µm arterial filter (Dideco D734, Sorin Biomedica, Puchheim, Germany) were used together with a venous reservoir (Venocard D 774, Sorin Biomedica). Anticoagulation was achieved by administration of heparin 450 IU/kg before the onset of CPB and was checked by means of the activated clotting time, which had to be in excess of 450 seconds during CPB. All patients received aprotinin (Trasylol, Bayer AG, Leverkusen, Germany), 2 x 10⁶ IU at the beginning and 0.5 x 10⁶ IU/h during CPB. At the end of CPB anticoagulation was reversed by protamine. Both autotransfusion devices, the cardiotomy suction and the cell-saving device (Haemonetics CS4, Munich, Germany) were used during the operation, whereas during CPB only the cardiotomy suction was applied.

Sample collection and laboratory analysis
Blood samples were drawn from the radial arterial catheter at induction of anesthesia (preoperatively), after unclamping the aorta (intraoperatively), and after termination of CPB and reversal of anticoagulation with protamine (postoperatively). With unclamping of the aorta (intraoperatively), blood samples were taken simultaneously from the cardiotomy suction tube before entering the venous reservoir. Blood samples from the Haemonetics cell-saving device were drawn before (Haem 1) and after (Haem 2) blood processing.

The following parameters were measured: white blood cell count, interleukin (IL)-6, IL-8, and tumor necrosis factor-[] (TNF-) as indicators of an inflammatory response; thrombin-antithrombin complex (TAT) and plasmin-antiplasmin complex (PAP) as indicators of the activation of coagulation and fibrinolysis, respectively; free hemoglobin as an indicator of hemolysis; and thrombocyte count and the percentage of CD62⁺ thrombocytes as indicators of the activation of thrombocytes.

White blood cell count and thrombocyte count were determined in whole blood specimens, anticoagulated with potassium-EDTA, with a Technikon H1 automatic cell counter (Bayer Diagnostics, Munich, Germany). The percentage of CD62⁺ thrombocytes was assessed by flow cytometry according to the method described previously [7]. Values of IL-6, IL-8, TNF-, TAT, and PAP were measured in citrate-plasma using enzyme-linked immunosorbent assay kits according to the instruction of the manufacturer (IL-6: reference range, ~8 µg/L; IL-8: reference range, ~8 µg/L; TNF-: reference range, < 5 µg/L; all by Coulter-Immunotech Diagnostics, Hamburg, Germany; TAT: reference range, 1.0 to 4.1 µg/L; and PAP: reference range, 99 to 368 µg/L; Behring Diagnostica, Marburg, Germany). Free hemoglobin (reference range, 0 to 40 mg/dL) was assessed by spectrophotometric measurement with an automatic clinical analyzer (ACA SX, Behring Diagnostica).

Additionally, the blood collected with the Haemonetics cell-saving device and the blood from the heart-lung machine were tested for bacterial contamination. Therefore, different agar plates (nutrition agar, blood agar, and anaerobic media) and blood culture bottles were inoculated with blood samples from the venous reservoir at the end of CPB and with samples from the blood collected with the Haemonetics cell-saving device before (Haem 1) and after (Haem 2) washing. The presence of antibiotics was tested using Bacillus subtilis as an indicator. Thus, a known B. subtilis concentration (10⁴/mL) was mixed with Mueller-Hinton agar; the plates were inoculated with 10 µL of blood, and inhibition of bacterial growth was assessed according to standard microbiologic protocols.

Statistical analysis
Data are presented as medians with lower and upper quartiles unless indicated otherwise. Statistical analysis was performed by applying the Wilcoxon signed rank test (SPSS; SPSS Inc, Chicago, IL). A probability value less than or equal to 0.05 was considered to be significant.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Levels of investigated factors in patients during operation
The concentration of the proinflammatory cytokines IL-6 and IL-8 increased in the course of the operation, whereas TNF- remained within the reference range (Table 1). Amounts of TAT and PAP showed a continuous increase, as did the percentage of CD62⁺ thrombocytes (Table 1). The decrease in the number of thrombocytes (Table 1) was caused by hemodilution; hematocrit-corrected values (value_corr = value x hematocrit (preoperatively/hematocrit) remained constant. There was a modest rise of free hemoglobin. However, median values remained within the reference range. The number of leukocytes increased about twofold (Table 1).

Effect of the haemonetics cell-saving device
In the native, unprocessed blood (Haem 1), the concentrations of IL-6, IL-8, and TNF-, as well as of TAT, PAP, and free hemoglobin (Table 1) were markedly higher than the corresponding reference range. Washing and centrifugation of the blood (Haem 2) led to a profound decrease of IL-6, TNF-, and PAP (> 20-fold) and to a moderate decrease of TAT and free hemoglobin (more than fivefold). The concentration of IL-8 was halved (Table 1). Nevertheless, even after processing the blood, the concentrations of IL-8, TAT, and free hemoglobin remained above the reference range. Processing of the blood nearly doubled the hematocrit, retained the leukocytes, and further reduced the number of thrombocytes.

Bacterial contamination
In samples from the venous reservoir and in unprocessed blood collected with the Haemonetics cell-saving device, bacterial growth in blood culture bottles was detectable in 2 of 10 (venous reservoir) and 4 of 10 (Haem 1) cases. The presence of antibiotics could be demonstrated in 6 of 10 (venous reservoir) and 9 of 10 (Haem 1) samples. After processing the Haemonetics blood (Haem 2), positive blood cultures were seen in 9 of 10 cases, whereas antibiotics were not found in any of these samples.

After inoculating plates with the positive blood cultures, Staphylococcus epidermidis, Propionibacteria species, corynebacterium species, and Peptococcus species could be isolated. In general, bacterial growth could only be demonstrated after enrichment in blood culture bottles. Direct cultures from all samples remained negative, indicating a low germ load (< 10/mL).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The primary aim of the present study was to investigate whether salvaging blood with the cardiotomy suction would contribute to the inflammatory response and impaired hemostasis seen after operations performed with CPB. There were significantly higher concentrations of IL-6, IL-8, TNF-, TAT, PAP, and free hemoglobin in blood samples from the cardiotomy suction tube compared with the values measured in samples from the systemic circulation at the same time. We conclude that blood salvage with the cardiotomy suction causes an additional release of proinflammatory cytokines, additional activation of coagulation and fibrinolysis, and additional hemolysis.

The systemic increase of proinflammatory cytokines and the activation of coagulation and fibrinolysis caused by CPB has been described previously [2, 8] and has been linked to organ dysfunction [9] and increased postoperative bleeding [4]. The mechanisms by which the cardiotomy suction contributes to these alterations may include the exposure of extravascular blood to tissue and air and the mechanical stress caused by the suction device. With the present study design only a qualitative statement is possible, ie, that the cardiotomy suction additionally contributes to the release of cytokines, hemolysis, and activation of coagulation and fibrinolysis already seen during and after CPB. The question as to which extent the cardiotomy suction contributes to cytokine release and impaired hemostasis may require further studies. However, considering a blood volume of 1,000 to 1,500 mL that is salvaged with the cardiotomy suction during aortic valve replacement, renunciation of the cardiotomy suction and the salvaged blood with the price of higher transfusion requirements seems not to be justified. It is presumable that renunciation might be advantageous with an operative procedure causing less blood extravasation (eg, coronary artery bypass grafting). However, this issue needs further investigation. Nevertheless, it is obvious that in cases of massive intraoperative hemorrhage, blood replacement without delay must be the primary goal. Under these circumstances, blood salvage with the cardiotomy suction is an effective and valuable tool.

Cardiopulmonary bypass is known to cause an activation of platelets [10], which could lead to thrombocytopenia because of consumption of activated platelets as well as platelet dysfunction. The CD62 antigen is involved in the binding of platelets to vascular endothelium and to neutrophils and monocytes [11, 12], and the amount of CD62 expression is correlated to the viability of platelets [13]. An increase of the CD62 expression on platelets during CPB has been demonstrated [14, 15]. In the present study, the percentage of CD62⁺ thrombocytes showed a 10-fold increase during operation. However, in blood salvaged with the cardiotomy suction, no increase of CD62⁺ platelets was seen.

The second aim of the study was to investigate the quality of blood collected with a Haemonetics cell-saving device. Processing of the blood led to an approximately 20-fold reduction of IL-6, TNF-, and PAP, an approximately fivefold reduction of TAT and free hemoglobin, and an approximately twofold reduction of IL-8. However, the concentrations of IL-8, TAT, and free hemoglobin still remained above the reference range. This different degree of clearage might be because of different affinities of the measured variables to retained cells or incompletely washed-out proteins. Alternatively, the washing procedure itself might have caused further release of IL-8, TAT, and free hemoglobin. It should also be pointed out that leukocytes, a major source of cytokines, were retained in the processed blood.

Another aspect concerning the use of the Haemonetics cell-saving device was bacterial contamination; 90% of the blood cultures taken from the processed blood were positive for bacteria. Before processing the blood, the rate of positive blood cultures was 40%. We cannot exclude that the washing procedure itself caused this increased rate of bacterial contamination. However, because washing of the blood only needed one additional connection of saline solution to an otherwise closed system, processing of the blood as a source of bacterial contamination seems unlikely. In contrast, the absence of antibiotics, probably being washed out, could have allowed a higher rate of culturable bacteria. The majority of the isolated microorganisms were common skin commensals. The presence of people in the operating room leads to an inevitable germ load of the air and environmental surfaces [16]. Bacterial contamination may be caused by germs being pulled into the operative field by the air current created by the suction tube. In contrast to the cardiotomy suction, the Haemonetics cell-saving device was used with a permanent suction pressure, which also might contribute to the higher rate of bacterial contamination. Despite the bacterial contamination, none of the patients showed signs of sepsis or other adverse effects after transfusion of the blood collected with the Haemonetics cell-saving device. Other reports investigating the bacterial contamination of blood processed with a Haemonetics cell-saving device showed a rate between 20% and 97% [17–19]. Although bacterial contamination was frequent, no major adverse effects were observed after transfusion of the blood, probably because of the low germ load (< 10/mL in the present study).

In conclusion, the present study demonstrated an additional release of proinflammatory cytokines as well as an additional activation of coagulation and increased hemolysis caused by the cardiotomy suction during CPB. Blood salvage and processing of the blood with a Haemonetics cell-saving device led to normalization of some, but not all, factors and spared the probably activated leukocytes. Furthermore, bacterial contamination was common. Thus, the alternative use of the Haemonetics cell-saving device seems at least questionable. To minimize the deleterious effects of the cardiotomy suction, intraoperative suctioning should be done with the lowest feasible suction pump pressure and avoided whenever possible.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Butler J., Rocker G.M., Westaby S. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg 1993;55:552-559.[Abstract]
2. Grossmann R., Babin-Ebell J., Misoph M., et al. Changes in coagulation and fibrinolytic parameters caused by extracorporeal circulation. Heart Vessels 1996;11:310-317.[Medline]
3. Kirklin J.K., Westaby S., Blackstone E.H., Kirklin J.W., Chenoweth D.E., Pacifico A.D. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86:845-857.[Abstract]
4. Woodman R.C., Harker L.A. Bleeding complications associated with cardiopulmonary bypass. Blood 1990;76:1680-1697.[Abstract/Free Full Text]
5. Janvier G., Baquey C., Roth C., Benillan N., Belisle S., Hardy J.F. Extracorporeal circulation, hemocompatibility and biomaterials. Ann Thorac Surg 1996;62:1926-1934.[Abstract/Free Full Text]
6. De Haan J., Boonstra P.W., Monnink S.H.J., Ebels T., van Oeveren W. Retransfusion of suctioned blood during cardiopulmonary bypass impairs hemostasis. Ann Thorac Surg 1995;59:901-907.[Abstract/Free Full Text]
7. Misoph M., Babin-Ebell J., Schwender S. A comparative evaluation of the effect of pump-type and heparin-coated surfaces on platelets during cardiopulmonary bypass. Thorac Cardiovasc Surg 1997;45:302-308.[Medline]
8. Misoph M., Babin-Ebell J. Interindividual variations of cytokine levels following cardiopulmonary bypass. Heart Vessels 1997;12:119-127.[Medline]
9. Casey L.C. Role of cytokines in the pathogenesis of cardiopulmonary bypass-induced multisystem organ failure. Ann Thorac Surg 1993;56:92-96.[Abstract]
10. Wahba A., Black G., Koksch M., et al. Cardiopulmonary bypass leads to a preferential loss of activated platelets. A flow cytometric assay of platelet surface antigens. Eur J Cardiothorac Surg 1996;10:768-773.[Abstract]
11. Diacovo T.G., Puri K.D., Warnock R.A., Springer T.A., von Adrian U.H. Platelet-mediated lymphocyte delivery to high endothelial venules. Science 1996;273:252-255.[Abstract]
12. Hamburger S.A., McEver R.P. GMP-140 mediates adhesion of stimulated platelets to neutrophils. Blood 1990;75:550-554.[Abstract/Free Full Text]
13. Holme S., Sweeney J.D., Sawyer S., Elfath M.D. The expression of P-selectin during collection, processing and storage of platelet concentrates. Transfusion 1997;37:12-17.[Medline]
14. Rinder C.S., Mathew J., Rinder H.M., Bonan J., Ault K.A., Smith B.R. Modulation of platelet surface adhesion receptors during cardiopulmonary bypass. Anesthesiology 1991;75:563-570.[Medline]
15. Metzelaar M.J., Korteweg J., Sixma J.J., Niewenhuis H.K. Comparison of platelet membrane markers for the detection of platelet activation in vitro and during platelet storage and cardiopulmonary bypass. J Lab Clin Med 1993;121:579-587.[Medline]
16. Kluge R.M., Calia F.M., McLaughlin J.S. Sources of contamination in open heart surgery. JAMA 1974;230:1415-1418.[Medline]
17. Bennet J.G. Autotransfusion of drained mediastinal blood. Thorac Cardiovasc Surg 1982;30:28-30.[Medline]
18. Schwieger I.M., Gallagher C.J., Finlayson D.C., Daly W.L., Maher K.L. Incidence of cell saver contamination during cardiopulmonary bypass. Ann Thorac Surg 1989;48:51-53.[Abstract]
19. Bland M.A., Villarino M.E., Arduino M.J., et al. Bacteriologic and endotoxin analysis of salvaged blood used in autologous transfusions during cardiac surgery. J Thorac Cardiovasc Surg 1992;103:582-588.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Olaf Elert Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Reents, W. Articles by Elert, O. Search for Related Content PubMed PubMed Citation Articles by Reents, W. Articles by Elert, O.