1Département dAnesthésie-Réanimation, Groupe hospitalier Necker-Enfants Malades, 149, rue de Sèvres, F-75743 Paris cedex 15, France. 2Service de Neurochirurgie Pédiatrique, Groupe hospitalier Necker-Enfants Malades, 149, rue de Sèvres, F-75743 Paris cedex 15, France
Accepted for publication: May 17, 2000
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Abstract |
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Br J Anaesth 2000; 85: 5505
Keywords: surgery, paediatric; blood, loss; transfusion, autotransfusion
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Introduction |
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The risks associated with homologous blood transfusion (HBT) are well known.8 They are particularly relevant in haemorrhagic surgery and have lead to the development of methods for reducing HBT,9 including perioperative autotransfusion and blood salvaging. Perioperative autotransfusion of washed red blood cells is an established method to reduce perioperative transfusion requirements.10 The technique was limited until recently to adults because the processing of less than 300 ml of salvaged blood was considered a contraindication to intraoperative autotransfusion;11 the centrifugation bowls used by such devices were too large compared with the small blood volume of children. This has led to the introduction of new autotransfusion devices1214 with smaller bowls that can support a smaller blood volume. A new generation of autotransfusion devices (CATS, Fresenius AG, Bad Homburg, Germany), based on the technology of cell separators is also available. The CATS, introduced recently in our hospital, has a washing chamber in the shape of a double spiral, with a capacity of 30 ml, which processes shed blood continuously.15 16
We performed a retrospective, case-controlled study to ascertain the efficiency of perioperative autotransfusion using the CATS in infants scheduled for surgical correction of craniosynostosis. The hypothesis of this study was that the use of the CATS was associated with a reduction in the amount of homologous blood transfused.
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Patients and methods |
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Intraoperative management
All the procedures were performed by the same paediatric neurosurgeon under general anaesthesia without induced hypotension, after skull infiltration with epinephrine 1:200 000 in normal saline. After premedication with oral potassium clorazepate 0.5 mg kg1, general anaesthesia was induced with 8% sevoflurane and 50% nitrous oxide in oxygen, followed by sufentanil 0.5 µg kg1 i.v. Neuromuscular block was achieved with vecuronium 0.1 mg kg1. After orotracheal intubation, general anaesthesia was maintained using a continuous infusion of sufentanil (0.5 µg kg1 h1) and controlled ventilation with 11.5 MAC sevoflurane and 50% nitrous oxide in oxygen. Monitoring included continuous ECG, invasive arterial and central venous pressures (CVP), core temperature, pulse oximetry, end-tidal carbon dioxide concentration and urine output (vesical catheter) measurements. Intraoperative management was as previously described.4 6 7 Briefly, isovolaemic compensation of blood loss was strictly observed, with fluid replacement based upon haemodynamic variables (to maintain mean arterial pressure in the range 4555 mm Hg and CVP above 2 mm Hg) using colloid and blood transfusion. Transfusion of packed red blood cells, or of salvaged blood when available, was used to maintain an haematocrit (Hct) in the range 0.280.35. Fresh frozen plasma was used only in patients requiring transfusion of more than 70% of estimated blood volume.
Postoperative management
At the end of the surgical procedure, all the patients were admitted to the post-anaesthesia care unit (PACU) for 20 h. The CATS blood saver device was used to salvage the blood during the surgical procedure and for the first 6 h in the PACU.
Measurements
Preoperative blood samples were drawn for measurement of red blood cell and platelet count (PC), haemoglobin concentration (Hb), Hct, and coagulation screening, including prothrombin time (PT) and activated partial thrombin time (aPTT). Serial blood samples were obtained for measurement of bloodgas tensions and Hct at the beginning of the surgical procedure, at least every 30 min during the operation and as frequently as clinically indicated during the perioperative stay in PACU.
For the two groups the following data were collected: the type of craniosynostosis (Table 1); physical characteristics of the patients (age and body weight at the time of surgery); preoperative clotting status (PT, aPTT, PC); and preoperative Hct (pre Hct), Hct at admission and Hct at discharge from the PACU. In addition, blood loss, the volumes of colloid and crystalloid infused, the volume of homologous and autologous blood transfused, and the number of packed red cell units used were recorded for the intraoperative period, the postoperative period and for the total duration of the study (intra- and postoperative periods).
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Statistical analysis
The primary endpoint for assessing the efficiency of the CATS was the comparison of intraoperative, postoperative and perioperative volumes of homologous blood transfusion and the number of homologous packed red blood cell units transfused. The other variables used to ensure a comparability between the two groups were the physical characteristics and factors influencing perioperative bleeding and transfusion.
Data are expressed as mean (SD) in case of normal distribution, or as median (95% confidence interval) in case of non-normal distribution, or as number of cases (%). Statistical analysis used the unpaired Students t-test in cases of normal distribution and the MannWhitney U-test in cases of non-normal distribution for continuous variables, while the Fishers exact test was used for discrete variables. All P values were two-tailed, and a P value of less than 0.05 was required to reject the null hypothesis. Statistical analysis was performed using NCSS 6.0 software (BMDP Company, Los Angeles, CA, USA).
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Results |
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Discussion |
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The surgical correction of craniosynostosis is usually performed in children under 6 months with a small blood volume. Relatively small blood losses can therefore have significant clinical consequences. A review of the literature shows that blood losses vary from 20% EBV to as high as 500% EBV.1719 The majority of studies report losses between 50 and 100% EBV.5 6 2022 Transfusion rates of homologous blood parallel the amount of blood loss. Thus, the blood losses observed in the present study are comparable to those that we have reported previously and are also in the range reported by the majority of authors.
The introduction of CATS for blood salvage is considered a major advance in HBT reduction. This device can support, through its centrifugation bowl of 30 ml, very small volumes of blood loss. In addition, it can continuously treat blood loss, which minimizes the time required for obtaining autologous packed red cells ready for transfusion. Moreover, this device has been shown, in a recent experimental study comparing three autotransfusion devices (CATS, Haemonetics Cell Saver 5 and DIDECO Compact-A & Advanced), to be the autotransfusion device most adaptable to paediatric use.16 In fact, continuous operation of the CATS guarantees a Hct level >60%, independent of the amount of shed blood to be processed, with a recovery rate near 100% of the processed blood.16
We were not able to show a reduction in HBT during the intraoperative period. This may be related to the low EBV of infants and the sudden intraoperative blood loss that cannot be salvaged by the device, due to an inevitable delay in use. The small volumes of autologous blood transfused in the intraoperative period (Table 4) support this assumption. This finding is in contrast to the results of Jimenez and Barone.23 Surprisingly, these authors showed efficient blood salvage for the majority of their patients during the intraoperative period using the Haemonetics Cell Saver III (centrifugation bowl of 125 ml) with a relatively low blood loss.23 However, the results of this study have been the subject of controversy.24 On the other hand, the results of our study, regarding the efficiency of the blood salvaging technique, are in accordance with the results of others.25 26 It should be noted that except for the study by Jimenez and Barone23 which focused on paediatric neurosurgery, the other studies were orthopaedic, in particular scoliosis surgery.26 In this particular type of surgery the patients are usually older and have a higher blood volume which can be more easily maintained by intraoperative autotransfusion.
The transfusion risks associated with allogenic blood are well known. Transfusion-related morbidity includes haemolysis, transfusion-related acute lung injury, bacterial contamination, post-transfusion hepatitis, graft versus host disease, haemolytic transfusion reactions, allergic reactions, leucocyte-platelet allo-immunization, acquired immunodeficiency syndrome and complications associated with massive transfusion.8 27 28 The residual risk (per million donations) of viral transmission by seroconverting donors has been estimated to range from 1.56 for HTLV to 15.83 for HBV.8 Serious or fatal transfusion-transmitted disease will occur in three out of 10 000 single-unit transfusions given.29 Attempts to decrease these rates have resulted in the development of many techniques, including intraoperative blood salvage.
Our finding leads us to assume that reduction in the volume of homologous blood transfused could reduce the risk of viral transmission. However, more studies are needed to confirm such an hypothesis. There are, however, risks of perioperative blood salvage. Some reports have described complications related to the use of this device, such as transfusion of haemolysed blood,30 acute haemolytic reactions related to inadvertently giving autologous packed red cells to the wrong patients,31 and bacterial contamination.32 The epidemiology of these complications is unknown: more studies on the safety of blood salving methods should be undertaken before confirming their safety.
The economic issues of blood transfusion are also of interest. Autologous blood donation has been proven to be more cost effective than homologous blood transfusion,33 due to the relatively low price of the blood salvage kit and the potential reduction of complications related to homologous blood transfusion. But, some studies have found no cost effectiveness of intraoperative blood salvage,26 although these have considered only the intraoperative period and the costs of long-term complications. Autotransfusion therapy may be more attractive if used both during the intraoperative and postoperative periods. In our study, autotransfusion was associated with a reduction of homologous blood transfused in the postoperative but not the intraoperative period.
Interpretation of the results must take into account the major limitations of this study, namely that it was retrospective and non-randomized. However, there was no significant difference between the two groups regarding the preoperative data (Table 1) or the factors affecting blood loss and transfusion (Tables 3 and 4). Equally, Hct in the preoperative period, on admission to the PACU and at discharge from the PACU, the clotting status, and volumes of colloid and crystalloid infused were not significantly different between the two groups. There was also no difference in blood loss between groups (Table 3). Moreover, the study was performed over a relatively short period of time (20 months) and all the patients were operated on by the same paediatric neurosurgeon, using the same surgical procedures. It is therefore unlikely that there is a methodological bias related to the study design.
In summary, we conclude that there is strong evidence for the efficiency of blood salvage in surgical correction of craniosynostosis when used intraoperatively and for the first 6 h in the PACU.
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Appendix |
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Estimated blood volume (EBV)=80 ml kg1.
Estimated red cell volume (ERCV)=EBV x pre Hct.
Estimated homologous red cell volume transfused (ERCTh)=0.75 x volume of homologous packed red cells.
Estimated autologous red cell volume transfused (ERCTa)=0.65 x volume of autologous salvaged blood.
Estimated red cell transfused (ERCT)=ERCTh + ERCTa.
Estimated red cell deficit (ERCD)=ERCV x difference in Hct.
Estimated red cell lost (ERCL)=ERCD + ERCT.
Percentage of patients ERCV lost=ERCL/ERCV.
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Footnotes |
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References |
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