Blood conservation strategies in cardiac surgery: more is better.
OBJECTIVE
Recent data show that up to 50% of heart procedures require blood transfusion, which can have adverse long- and short-term outcomes for the patient. This led to the updated 2011 Society of Thoracic Surgery (STS)/Society of Cardiovascular Anesthesiologists (SCA) guidelines in an attempt to adopt more effective blood conservation techniques. We present our results after the implementation of a more aggressive strategy for intraoperative blood conservation in cardiac surgery.


METHODS
Our cardiac surgery database was reviewed retrospectively, comparing outcomes from two different time periods, after the implementation of a more effective two-way blood conservation strategy beginning in March 2012: more aggressive intraoperative autologous donation (IAD) based on a newly constructed nomogram, and the use of a shorter length circuit of the cardiopulmonary bypass (CPB) which allowed for lower fluid volume as a prime. The method of retrograde autologous priming (RAP) was the same for both time periods.


RESULTS
A total of 1126 patients (Group 1) were studied in a 12-month period (March 2012-February 2013) after the implementation of the new strategy, and compared with 3758 patients (Group 2) of the previous 36-month period (March 2009-February 2012). There was a significant reduction in the percent change of the intraoperative haematocrit between Groups 1 and 2 (14 vs 28%, P = 0.01), with an increase in the mean IAD volume (655 vs 390 ml, P = 0.02) and a reduction in the CPB priming volume (1000 vs 1600 ml, P = 0.03). Group 1 required significantly less blood transfusions in the perioperative period (29 vs 49%, P = 0.02) and had significantly reduced postoperative rates of respiratory failure (3 vs 7%, P = 0.03), pneumonia (1 vs 3.1%, P = 0.01), chest tube output (350 vs 730 ml, P = 0.01), reoperation for bleeding (1.2 vs 2.5%, P = 0.04) and length of stay (6.1 vs 8.2 days, P = 0.05).


CONCLUSIONS
Blood conservation is safe and effective in reducing transfusions in cardiac surgery, minimizing perioperative morbidity and mortality. Aggressive IAD and low CPB prime, along with effective RAP, is the three-way blood conservation strategy that leads to improved outcomes in cardiac surgery.
Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, USA davgerinos@gmail.com.
Dimitrios V
DV
Avgerinos
Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, USA.
William
W
DeBois
Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medical Center, New York, USA.
Arash
A
Salemi
D000368:Aged; D001804:Blood Transfusion, Autologous; D057668:Bloodless Medical and Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D002315:Cardiopulmonary Bypass / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged
Blood conservation; Cardiopulmonary bypass; Intraoperative autologous priming; Retrograde autologous priming