Management of Intraoperative Fluid Balance and Blood Conservation Techniques in Adult Cardiac Surgery
Blood transfusions are associated with adverse physiologic effects and increased cost, and therefore reduction of blood product use during surgery is a desirable goal for all patients. Cardiac surgery is a major consumer of donor blood products, especially when cardiopulmonary bypass (CPB) is used, because hematocrit drops precipitously during CPB due to blood loss and blood cell dilution. Advanced age, low preoperative red blood cell volume (preoperative anemia or small body size), preoperative antiplatelet or antithrombotic drugs, complex or re-operative procedures or emergency operations, and patient comorbidities were identified as important transfusion risk indicators in a report recently published by the Society of Cardiovascular Anesthesiologists. This report also identified several pre- and intraoperative interventions that may help reduce blood transfusions, including off-pump procedures, preoperative autologous blood donation, normovolemic hemodilution, and routine cell saver use.
A multimodal approach to blood conservation, with highrisk patients receiving all available interventions, may help preserve vital organ perfusion and reduce blood product utilization. In addition, because positive intravenous fluid balance is a significant factor affecting hemodilution during cardiac surgery, especially when CPB is used, strategies aimed at limiting intraoperative fluid balance positiveness may also lead to reduced blood product utilization.
This review discusses currently available techniques that can be used intraoperatively in an attempt to avoid or minimize fluid balance positiveness, to preserve the patient's own red blood cells, and to decrease blood product utilization during cardiac surgery.
Abdel-Rahman U, Ozaslan F, Risteski PS, et al. 2005. Initial experience with a minimized extracorporeal bypass system: is there a clinical benefit? Ann Thorac Surg 80:238-43.nAbdel-Rahman U, Martens S, Risteski P, et al. 2006. The use of minimized extracorporeal circulation system has a beneficial effect on hemostasis—a randomized clinical study. Heart Surg Forum 9:E543-8.nAmand T, Pincemail J, Blaffart F, Larbuisson R, Limet R, Defraigne JO. 2002. Levels of inflammatory markers in the blood processed by auto-transfusion devices during cardiac surgery associated with cardiopulmonary bypass circuit. Perfusion 17:117-23.nArnestad JP, Bengtsson A, Bengtson JP, Tylman M, Redl H, Schlag G. 1994. Formation of cytokines by retransfusion of shed whole blood. Br J Anaesth 72:422-5.nArora RC, Légaré JF, Buth KJ, Sullivan JA, Hirsch GM. 2004. Identifying patients at risk of intraoperative and postoperative transfusion in isolated CABG: toward selective conservation strategies. Ann Thorac Surg 78:1547-54.nAmerican Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. 2006. Practice guidelines for perioperative blood transfusion and adjuvant therapies: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Transfusion and Adjuvant Therapies. Anesthesiology 105:198-208.nBabka RM, Petress J, Briggs R, Helsal R, Mack J. 1997. Conventional haemofiltration during routine coronary bypass surgery. Perfusion 12:187-92.nBalachandran S, Cross MH, Karthikeyan S, Mulpur A, Hansbro SD, Hobson P. 2002. Retrograde autologous priming of the cardiopulmonary bypass circuit reduces blood transfusion after coronary artery surgery. Ann Thorac Surg 73:1912-8.nBoettcher W, Merkle F, Huebler M, et al. 2005. Transfusion-free cardiopulmonary bypass in Jehovah's Witness patients weighing less than 5 kg. J Extra Corpor Technol 37:282-5.nBoldt J, von Bormann B, Kling D, Scheld HH, Hempelmann G. 1986. The influence of extracorporeal circulation on extravascular lung water in coronary surgery patients. Thorac Cardiovasc Surg 34:110-5.nBoldt J. 1999. Volume therapy in cardiac surgery: does the kind of fluid matter? J Cardiothorac Vasc Anesth 13:752-63.nBoodhwani M, Hamilton A, de Varennes B, et al. 2010. A multicenter randomized controlled trial to asses the feasibility of testing modified ultrafiltration as a blood conservation technology in cardiac surgery. J Thorac Cardiovasc Surg 139:701-6.nBoonstra PW, van Imhoff GW, Eysman L, et al. 1985. Reduced platelet activation and improved hemostasis after controlled cardiotomy suction during clinical membrane oxygenator perfusions. J Thorac Cardiovasc Surg 89:900-6.nCordell AR, Lavender SW. 1981. An appraisal of blood salvage techniques in vascular and cardiac operations. Ann Thorac Surg 31:421-5.nCosgrove DM, Loop FD, Lytle BW, et al. 1985. Determinants of blood utilization during myocardial revascularization. Ann Thorac Surg 40:380-4.nDaane CR, Golab HD, Meeder JH, Wijers MJ, Bogers AJ. 2003. Processing and transfusion of residual cardiopulmonary bypass volume: effects on haemostasis, complement activation, postoperative blood loss and transfusion volume. Perfusion 18:115-21.nDalrymple-Hay MJ, Dawkins S, Pack L, et al. 2001. Autotransfusion decreases blood usage following cardiac surgery—a prospective randomized trial. Cardiovasc Surg 9:184-7.nDeFoe GR, Ross CS, Olmstead EM, et al. 2001. Lowest hematocrit on bypass and adverse outcomes associated with coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group. Ann Thorac Surg 71:769-76.nDespotis GJ, Filos KS, Zoys TN, Hogue CW Jr, Spitznagel E, Lappas DG. 1996. Factors associated with excessive postoperative blood loss and hemostatic transfusion requirements: a multivariate analysis in cardiac surgical patients. Anesth Analg 82:13-21.nDial S, Delabays E, Albert M, et al. 2005. Hemodilution and surgical hemostasis contribute significantly to transfusion requirements in patients undergoing coronary artery bypass. J Thorac Cardiovasc Surg 130:654-61.nDietrich W, Barankay A, Dilthey G, Mitto HP, Richter JA. 1989. Reduction of blood utilization during myocardial revascularization. J Thorac Cardiovasc Surg 97:213-9.nEising GP, Niemeyer M, Günther T, et al. 2001. Does a hyperoncotic cardiopulmonary bypass prime affect extravascular lung water and cardiopulmonary function in patients undergoing coronary artery bypass surgery? Eur J Cardiothorac Surg 20:282-9.nEising GP, Pfauder M, Niemeyer M, et al. 2003. Retrograde autologous priming: is it useful in elective on-pump coronary artery bypass surgery? Ann Thorac Surg 75:23-7.nEngoren MC, Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ. 2002. Effect of blood transfusion on long-term survival after cardiac operation. Ann Thorac Surg 74:1180-6.nFerraris VA, Ferraris SP, Saha SP, et al. 2007. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 83:S27-86.nFromes Y, Gaillard D, Ponzio O, et al. 2002. Reduction of the inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation. Eur J Cardiothorac Surg 22:527-33.nGoodnough LT, Monk TG, Andriole GL. 1997. Erythropoietin therapy. N Engl J Med 336:933-8.nGoodnough LT, Shander A. 2003. Evolution in alternatives to blood transfusion. Hematol J 4:87-91.nGoto R, Tearle H, Steward DJ, Ashmore PG. 1991. Myocardial oedema and ventricular function after cardioplegia with added mannitol. Can J Anaesth 38:7-14.nGray CL, Amling CL, Polston GR, Powell CR, Kane CJ. 2001. Intraoperative cell salvage in radical retropubic prostatectomy. Urology 58:740-5.nGrünenfelder J, Zünd G, Schoeberlein A, et al. 2000. Modified ultrafiltration lowers adhesion molecule and cytokine levels after cardiopulmonary bypass without clinical relevance in adults. Eur J Cardiothorac Surg 17:77-83.nHabib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A. 2003. Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 125:1438-50.nHabib RH, Zacharias A, Schwann TA, et al. 2005. Role of hemodilutional anemia and transfusion during cardiopulmonary bypass in renal injury after coronary revascularization: implications on operative outcome. Crit Care Med 33:1749-56.nHall RI, Schweiger IM, Finlayson DC. 1990. The benefit of the Hemonetics cell saver apparatus during cardiac surgery. Can J Anaesth 37:618-23.nHansen E, Knuechel R, Altmeppen J, Taeger K. 1999. Blood irradiation for intraoperative autotransfusion in cancer surgery: demonstration of efficient elimination of contaminating tumor cells. Transfusion 39:608-15.nHébert PC, Fergusson DA. 2004. Do transfusions get to the heart of the matter? JAMA 292:1610-2.nHutchinson AB, Fergusson D, Graham ID, Laupacis A, Herrin J, Hillyer CD. 2001. Utilization of technologies to reduce allogeneic blood transfusion in the United States. Transfus Med 11:79-85.nJansen PG, te Velthuis H, Bulder ER, et al. 1995. Reduction in prime volume attenuates the hyperdynamic response after cardiopulmonary bypass. Ann Thorac Surg 60:544-9.nJansen PG, te Velthuis H, Wildevuur WR, et al. 1996. Cardiopulmonary bypass with modified fluid gelatin and heparin-coated circuits. Br J Anaesth 76:13-9.nJewell AE, Akowuah EF, Suvarna SK, Braidley P, Hopkinson D, Cooper G. 2003. A prospective randomised comparison of cardiotomy suction and cell saver for recycling shed blood during cardiac surgery. Eur J Cardiothorac Surg 23:633-6.nKarkouti K, Cohen MM, McCluskey SA, Sher GD. 2001. A multivariable model for predicting the need for blood transfusion in patients undergoing first-time elective coronary bypass graft surgery. Transfusion 41:1193-203.nKeeling MM, Gray LA Jr, Brink MA, Hillerich VK, Bland KI. 1983. Intraoperative autotransfusion. Experience in 725 consecutive cases. Ann Surg 197:536-41.nLaffey JG, Boylan JF, Cheng DC. 2002. The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist. Anesthesiology 97:215-52.nLee J, Ikeda S, Johnston MF. 1997. Efficacy of intraoperative blood salvage during coronary artery bypass grafting. Minerva Cardioangiol 45:395-400.nLindberg H, Svennevig JL, Vatne K, Lilleaasen P, Abdelnor M. 1985. Early postoperative changes with different priming solutions in openheart surgery. Scand J Thorac Cardiovasc Surg 19:39-44.nLowenstein E. 1981. Blood conservation in open heart surgery. Cleve Clin Q 48:112-25.nMayer ED, Welsch M, Tanzeem A, et al. 1985. Reduction of postoperative donor blood requirement by use of the cell separator. Scand J Thorac Cardiovasc Surg 19:165-71.nMerville C, Charlet P, Zerr C, Bricard H. 1991. Effectiveness of the Cell Saver and salvage from ultrafiltered extracorporeal circulation in heart surgery [in French]. Ann Fr Anesth Reanim 10:548-53.nMoran JM, Babka R, Silberman S, et al. 1978. Immediate centrifugation of oxygenator contents after cardiopulmonary bypass. Role in maximum blood conservation. J Thorac Cardiovasc Surg 76:510-7.nMurphy GS, Szokol JW, Nitsun M, et al. 2004. The failure of retrograde autologous priming of the cardiopulmonary bypass circuit to reduce blood use after cardiac surgical procedures. Anesth Analg 98:1201-7.nMurphy GJ, Allen SM, Unsworth-White J, Lewis CT, Dalrymple-Hay MJ. 2004. Safety and efficacy of perioperative cell salvage and autotransfusion after coronary artery bypass grafting: a randomized trial. Ann Thorac Surg 77:1553-9.nMurphy GS, Szokol JW, Nitsun M, et al. 2006. Retrograde autologous priming of the cardiopulmonary bypass circuit: safety and impact on postoperative outcomes. J Cardiothorac Vasc Anesth 20:156-61.nNollert G, Schwabenland I, Maktav D, et al. 2005. Miniaturized cardiopulmonary bypass in coronary artery bypass surgery: marginal impact on inflammation and coagulation but loss of safety margins. Ann Thorac Surg 80:2326-32.nPanico FG, Neptune WB. 1960. A mechanism to eliminate the donor blood prime from the pump-oxygenator. Surg Forum 10:605-9.nPaone G, Spencer T, Silverman NA. 1994. Blood conservation in coronary artery surgery. Surgery 116:672-7.nParrot D, Lançon JP, Merle JP, et al. 1991. Blood salvage in cardiac surgery. J Cardiothorac Vasc Anesth 5:454-6.nPerttilä J, Leino L, Pöyhönen M, Salo M. 1995. Leucocyte content in blood processed by autotransfusion devices during open-heart surgery. Acta Anaesthesiol Scand 39:445-8.nRaman JS, Hata M, Bellomo R, Kohchi K, Cheung HL, Buxton BF. 2003. Hemofiltration during cardiopulmonary bypass for high risk adult cardiac surgery. Int J Artif Organs 26:753-7.nRosengart TK, DeBois W, O'Hara M, et al. 1998. Retrograde autologous priming for cardiopulmonary bypass: a safe and effective means of decreasing hemodilution and transfusion requirements. J Thorac Cardiovasc Surg 115:426-38.nRousou JA, Engelman RM, Flack JE 3rd, Deaton DW, Garb JL, Owen SG. 1999. The ‘primeless pump’: a novel technique for intraoperative blood conservation. Cardiovasc Surg 7:228-35.nSade RM, Stroud MR, Crawford FA Jr, Kratz JM, Dearing JP, Bartles DM. 1985. A prospective randomized study of hydroxyethyl starch, albumin, and lactated Ringer's solution as priming fluid for cardiopulmonary bypass. J Thorac Cardiovasc Surg 89:713-22.nShapira OM, Aldea GS, Treanor PR, et al. 1998. Reduction of allogeneic blood transfusions after open heart operations by lowering cardiopulmonary bypass prime volume. Ann Thorac Surg 65:724-30.nShin'oka T, Shum-Tim D, Jonas RA, et al. 1996. Higher hematocrit improves cerebral outcome after deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 112:1610-20.nSpiess BD. 2005. Choose one: damned if you do/damned if you don't! Crit Care Med 33:1871-4.nSvenmarker S, Engström KG. 2003. The inflammatory response to recycled pericardial suction blood and the influence of cell-saving. Scand Cardiovasc J 37:158-64.nSwaminathan M, Phillips-Bute GB, Conlon PG, Smith PK, Newman MF, Stafford-Smith M. 2003. The association of lowest hematocrit during cardiopulmonary bypass with acute renal injury after coronary artery bypass surgery. Ann Thorac Surg 76:784-91.nTempe D, Bajwa R, Cooper A, et al. 1996. Blood conservation in small adults undergoing valve surgery. J Cardiothorac Vasc Anesth 10:502-6.nTempe DK, Banerjee A, Virmani S, et al. 2001. Comparison of the effects of a cell saver and low-dose aprotinin on blood loss and homologous blood usage in patients undergoing valve surgery. J Cardiothorac Vasc Anesth 15:326-30.nTempe DK. 2005. Reducing allogeneic transfusion in cardiac surgery. Br J Anaesth 95:277-8.nThomas MJ. 1999. Infected and malignant fields are an absolute contraindication to intraoperative cell salvage: fact or fiction? Transfus Med 9:269-78.nThurer RL, Lytle BW, Cosgrove DM, Loop FD. 1979. Autotransfusion following cardiac operations: a randomized, prospective study. Ann Thorac Surg 27:500-7.nTinmouth A, Macdougall L, Fergusson D, et al. 2005. Reducing the amount of blood transfused: a systematic review of behavioral interventions to change physicians' transfusion practices. Arch Intern Med 165:845-52.nUtley JR. 1990. Pathophysiology of cardiopulmonary bypass: current issues. J Card Surg 5:177-89.nVretzakis G, Ferdi E, Argiriadou H, et al. 2005. Influence of bispectral index monitoring on decision making during cardiac anesthesia. J Clin Anesth 17:509-16.nVretzakis G, Kleitsaki A, Stamoulis K, et al. 2010. Intra-operative intravenous fluid restriction reduces perioperative red blood cell transfusion in elective cardiac surgery, especially in transfusion-prone patients: a prospective, randomized controlled trial. J Cardiothorac Surg 5:7.nWalpoth BH, Eggensperger N, Hauser SP, et al. 1999. Effects of unprocessed and processed cardiopulmonary bypass blood retransfused into patients after cardiac surgery. Int J Artif Organs 22:210-6.nWiesenack C, Liebold A, Philipp A, et al. 2004. Four years' experience with a miniaturized extracorporeal circulation system and its influence on clinical outcome. Artif Organs 28:1082-8.nWinton TL, Charrette EJ, Salerno TA. 1982. The cell saver during cardiac surgery: does it save? Ann Thorac Surg 33:379-81.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).