Effects of intraoperative plasmapheresis on blood loss in cardiac surgery. The effect of coagulation protection with combination of epsilon aminocaproic acid and plasma saver in open-heart surgery. Efficacy of autologous fresh whole blood or platelet-rich plasma in adult cardiac surgery. Preoperative plateletpheresis does not reduce blood loss during cardiac surgery. The role of the protein C-thrombomodulin system and fibrinolysis during cardiovascular surgery: influence of acute preoperative plasmapheresis. The influence of acute preoperative plasmapheresis on coagulation tests, fibrinolysis, blood loss and transfusion requirements in cardiac surgery. The haemostatic effectiveness of autologous platelet rich plasma sequestered after heparin administration and institution of cardiopulmonary bypass. [Effects of platelet-rich plasma on hemostasis and transfusion requirement in vascular surgery]. Plateletpheresis before redo CABG diminishes excessive blood transfusion. Autologous platelet sequestration in patients undergoing coronary artery bypass grafting. Intraoperative use of platelet-plasmapheresis in vascular surgery. Platelet-rich plasma sequestration, with therapeutic platelet yields, reduces allogeneic transfusion in complex cardiac surgery. Autologous platelet-rich plasma does not reduce transfusion of homologous blood products in patients undergoing repeat valvular surgery. Comparison of blood reinfusion techniques used during coronary artery bypass grafting. Platelet pheresis is not a useful adjunct to blood-sparing strategies in cardiac surgery. Hematological assessment of patients undergoing plasmapheresis during cardiac surgery. Autologous platelet-rich plasmapheresis: risk versus benefit in repeat cardiac operations. Coagulation tests, blood loss, and transfusion requirements in platelet-rich plasmapheresed versus nonpheresed cardiac surgery patients. Platelet-rich plasma reduces postoperative blood loss after cardiopulmonary bypass. Intraoperative plasmapheresis in cardiac surgery. Influence of acute preoperative plasmapheresis on platelet function in cardiac surgery. Preoperative plasmapheresis in patients undergoing cardiac surgery procedures. Intraoperative plateletpheresis and autologous platelet gel do not reduce chest tube drainage or allogeneic blood transfusion after reoperative coronary artery bypass graft.
Intraoperative platelet-rich plasmapheresis allows autotransfusion of fresh, undamaged platelets and clotting factors at the completion of the operation. To evaluate this technology, we randomly assigned 100 consecutive patients who were to undergo an elective coronary bypass procedure and had normal clotting studies into the experimental (plasmapheresis) or the control group. Characteristics of both groups were similar, including average age (61.4 years versus 61.3 years [experimental versus control group]), sex (78% male versus 74% male), preoperative weight (80.9 kg versus 80.2 kg), preoperative red cell mass (1,989 mL versus 1,890 mL), perfusion time (102 minutes versus 106 minutes), and coagulation studies. Both internal mammary arteries were used in 68% of the patients. All patients had preoperative and postoperative blood volume determinations and complete clotting studies. Sixty-two variables related to bleeding were analyzed. Strict indications for transfusion were a hemoglobin level less than 7 g/100 mL in patients younger than 70 years and a hemoglobin level less than 8 g/100 mL in patients older than 70 years. The group receiving intraoperative plasmapheresis had a significant reduction in operative red cell mass loss (1,050 +/- 43 mL versus 1,226 +/- 61 mL; p = 0.021), a reduction in the average homologous transfusion (0.67 +/- 0.15 unit versus 1.8 +/- 0.25 units; p = 0.0002), and an increase in the percentage of patients not requiring blood transfusions (66% versus 32%; p = 0.001). This technique is useful in reducing postoperative blood loss and homologous transfusions. Bleeding remains a major complication and a major determinant in the prognosis of open-heart surgery. Coagulopathy related to cardiopulmonary bypass (CPB) seems to be the culprit. Since homologous blood transfusion in many occasions is not only responsible for mobidity and mortality but also increases medical costs. Therefore, the application of autologous blood transfusion including components such as PRBC, FFP and platelets concentrate is inevitable and comes in its stead. To reduce the use of homologous plasma and platelets transfusion in open-heart surgery, we designed a study to utilize the combination of autologous platelet rich plasma (PRP) and epsilon aminocaproic acid (EACA) to evaluate its effects on blood loss and blood component transfusion in open-heart patients.
                Sixty patients who received elective cardiac surgery were randomly divided into 3 groups: 1. Control group; 2. EACA group (150 mg/kg, i.v. before CPB); 3. PRP-EACA group (PRP 10 ml/kg harvested with a plasma saver followed by i.v. EACA 150 mg/kg). Anesthesia was uniform in all patients. Coagulation profile was evaluated by thromboelastography (TEG) during the operation. Blood loss during operation and the amount of drainage from the chest tubes in the postoperative period were recorded and compared between groups.
                Patients who were given EACA injection before CPB saw less blood loss perioperatively and received less transfusion of blood components. TEG analysis showed that patients who received EACA injection had a better coagulation profile and the platelet function was also better after CPB. However, no additive effect can be attained from combination of autologous PRP transfusion and EACA injection.
                With Pre-CPB EACA as protection, reduction of both blood loss and blood transfusion could be realized in open-heart surgery. Transfusing fresh autologous blood during cardiac surgery may improve hemostasis and decrease the need for transfusion.
                A prospective randomized study was performed with fresh whole blood (WB) obtained by intraoperative hemodilution (IH) and with platelet-rich plasma (PRP) obtained by perioperative apheresis from adult cardiac surgery patients.
                Seventy patients were randomly assigned to three arms: 24 to the PRP arm, 18 to the IH arm, and 28 to serve as controls. A mean of 924 +/- 130 mL of WB was collected from the IH group, and a mean of 650 +/- 124 mL of PRP was collected from the PRP group (mean, 1.42 +/- 0.74 x 10(11) platelets); these components were transfused after bypass. Preoperative measures were similar among groups. Intraoperatively, the groups did not differ in bypass time, estimated blood loss, number of transfusions, or proportion receiving transfusion(s). Postoperatively, control patients had more mediastinal drainage (736 mL vs. 476 mL [IH] and 463 mL [PRP]; p = 0.014), but there was no difference in the proportion of patients requiring red cell transfusion (p = 0.87), the hemoglobin at discharge (p = 0.20), or the length of hospitalization (p = 0.57).
                Although a hemostatic benefit manifested as reduced postoperative bleeding was observed, this study does not support the use of fresh blood components obtained by IH or PRP collection during low-risk cardiac surgery. Additional studies are needed to assess whether more aggressive component collection or the use of these techniques in high-risk cases may have a greater impact on clinical outcome variables, including transfusion. Acute preoperative plateletpheresis has been reported to be effective in reducing blood loss and blood component transfusion while improving haematological profiles in patients undergoing open-heart surgery. However, in these studies, the concomitant use of cell saver techniques may have been responsible for the beneficial effects because they remove free haemoglobin and activated procoagulants and, therefore, could mask the deleterious effects of combined plateletpheresis and cardiopulmonary bypass (CPB). In the present study, 40 patients undergoing primary myocardial revascularization were randomly divided into two groups: a control group without plateletpheresis performed, and a second group in which preoperative platelet-rich plasma 10 ml.kg-1 (PRP group) was collected and later reinfused after reversal of heparin. Standardized surgery, anaesthesia and CPB without concomitant cell saver techniques were employed. In the PRP group, blood transfusion was reduced (1.5 +/- 1.3 vs 2.4 +/- 1.3 units, P < 0.05) but this was accompanied by lower postoperative haemoglobin concentrations. There were no differences in blood loss (992.6 +/- 327.4 vs 889.6 +/- 343.7 ml), fresh frozen plasma (2/19 vs 3/20 patients) or platelet requirements (1/19 vs 1/20 patients). Reinfusion of autologous PRP did not improve platelet count and function, nor tests of coagulation. Fibrinogen concentrations were lower in the PRP group on the operative day (P < 0.05), suggesting increased fibrinogen consumption; and more patients in the PRP group had low haptoglobin levels during CPB (8/19 vs 0/20 patients, P < 0.005), which indicated greater haemolysis in this group. We conclude that acute preoperative plateletpheresis offers no advantage in haemostasis during elective primary myocardial revascularization surgery. To assess the benefits of withdrawn autologous plasma, the objective of this study was to investigate whether withdrawal of acutely performed platelet-rich or platelet-poor plasmapheresis allays changes in the protein C-thrombomodulin and fibrinolytic systems after retransfusion secondary to cardiopulmonary bypass (CPB). In addition, the study attempted to determine the influence of acute plasmapheresis (APP) on the protein C-thrombomodulin and fibrinolytic systems as well as on homologous blood consumption and perioperative blood loss in elective aortocoronary bypass patients.
                The investigation was scheduled as a prospective, randomized, unblinded study.
                This single investigation was conducted in the Department of Anesthesiology and Intensive Care Medicine at a university in Germany. The study protocol was approved by the Ethics Committee of the hospital, and informed consent was obtained.
                Sixty male patients scheduled for elective coronary artery bypass grafting with extracorporeal circulation were included in the study.
                APP was performed between induction of anesthesia and incision, collecting either 10 mL/kg of autologous platelet-poor plasma (PPP patients, group 1; n = 20) or the same amount of platelet-rich plasma (PRP patients, group 2; n = 20). Patients of group 3 (n = 20) had no APP (control group). All patients were maintained on their usual regimen of cardiac drugs until the morning of surgery. To preserve hemodynamic stability and restore the intravascular oncotic pressure, the separated plasma was replaced by infusion of an equal amount of hydroxyethyl starch solution (HES) (6% HES, molecular weight 2 x 10(5), substitution rate 0.5%). In all operations, the same surgical procedure was chosen. For all patients, induction and maintenance of anesthesia were similar, consisting of weight-related doses of fentanyl (35 micrograms/kg), midazolam (0.65 mg/kg), and pancuronium bromide (0.15 mg/kg). The lungs of all patients were mechanically ventilated during the first 5 hours after the end of the operation.
                All patients had serial coagulation studies including antithrombin (AT) III-activity, prekallikrein, factor XII, and immunologic tests such as thrombin-antithrombin III (TAT), fibrinopeptide A (FPA), protein C and S (PC and PS), thrombomodulin (TM), tissue-plasminogen-activator (t-PA), plasminogen-activator-inhibitor (PAI 1), fibrinopeptide B beta 15-42 (FPB beta 15-42), D-dimers, and hemoglobin and platelet counts determined intraoperatively and postoperatively. Chest tube drainage and transfusion requirements were recorded. APP had no negative effects on the quality of PPP and PRP plasma. The platelet count of the withdrawn plasma was 28 +/- 12 x 10(9)/L (PPP group) and 245 +/- 36 x 10(9)/L (PRP group). At the end of the operation (after retransfusion of autologous plasma) and on the morning of the first postoperative day, platelet counts were significantly higher (p > 0.05) in the PRP than in the PPP and control groups. Plasma concentrations of TAT and FPA increased (ranging from +185% to +340% from baseline values) and AT III-activity, PC, PS, and TM antigen decreased (ranging from -8% to -55% from baseline values) to a different extent for all three groups throughout CPB. t-PA-activity increased with a maximum at the end of CPB (PPP group, 6.9 +/- 1.5 IU/mL: PRP group, 3.8 +/- 0.8 IU/mL; control group, 10.9 +/- 2.8 IU/mL). Fibrin and fibrinogen degradation markers such as D-dimers and FPB beta 15 to 42 occurred in peak concentrations after neutralization of heparin by protamine. Only PRP patients showed baseline concentrations of coagulation parameters the next morning (p < 0.05). Total postoperative blood loss within the first 24 hours reached 482 +/- 273 mL (PRP group), 775 +/- 256 mL (PPP group), and 948 +/- 342 mL in the control group (p < 0.05).(ABSTRACT TRUNCATED) Withdrawal of autologous plasma and reinfusion after cardiopulmonary bypass (CPB) offers the opportunity of improving patients' haemostasis and reducing homologous blood consumption in cardiac surgery. The influence of acute, preoperative plasmapheresis (APP) on coagulation tests, fibrinolysis, blood loss and transfusion requirements was investigated in elective aortocoronary bypass patients.
                Forty patients were randomized to a control or pheresis group. The pheresis group had platelet-rich plasmapheresis (PRP-group, n = 20) performed before incision and the platelet-rich plasma (PRP) was returned after CPB. The control group (n = 20) was managed without pheresis. All patients had serial coagulation studies, including prothrombin split products (F1/F2), fibrinopeptide A (FPA), protein C (PC), thrombomodulin (TM), tissue-plasminogen-activator (t-PA), plasminogen-activator-inhibitor (PAI 1), fibrinopeptide B beta 15-42 (FPB beta 15-42), haemoglobin and platelet counts determined intra- and postoperatively. Chest tube drainage and transfusion requirements were recorded.
                APP had no negative effects on the quality of PRP. The platelet count of the withdrawn autologous plasma was 239 +/- 33 x 10(9)/l. From the end of the operation (after retransfusion of autologous plasma) until the first postoperative day platelet counts were significant higher in the PRP-group (P > 0.05). Plasma concentrations of modified antithrombin III (ATM), F1/F2 and FPA increased (166-290% from baseline) and PC- and TM-antigen decreased (11-49% from baseline) to a different extent for both groups throughout CPB. t-PA-activity increased intraoperatively peaking at the end of CPB (PRP-group: 4.8 +/- 0.8 IU/ml, control-group: 8.1 +/- 2.3 IU/ml)(P > 0.05). With onset of CPB PAI-1 levels decreased and were further reduced after CPB in control patients in comparison to PRP-patients (P < 0.05). FPB beta 15-42 occurred in peak concentrations after neutralisation of heparin by protamine. Only PRP-patients showed baseline values of coagulation and fibrinolytic parameters on the next morning (P < 0.05). Total postoperative blood loss during the first 24 h was 503 +/- 251 ml (PRP-group) and 937 +/- 349 ml in the control-group (P < 0.05). None of the PRP-patients received allogeneic blood, whereas five control-patients received 11 units of packed red cells (P < 0.05).
                The findings suggest that in elective cardiac surgery heparin cannot prevent generation of both thrombin and fibrin, born throughout CPB and postoperatively. The use of PRP withdrawn immediately preoperatively is an attractive technique to reduce allogeneic blood usage and preoperative blood loss, especially in patients in whom withdrawal of autologous whole blood cannot be performed. Preoperative harvesting and postoperative reinfusion of autologous platelet rich plasma (PRP) has been reported to decrease blood loss as well as the requirement for homologous blood transfusion following cardiopulmonary bypass (CPB). We have developed a technique of intraoperative PRP sequestration which occurs during the initial period of CPB after the patient's circulation is supported and heparin has been given (PRP+). This process does not require any additional hardware, personnel or expense and it is performed without difficulty or complication. To evaluate the effect of PRP+ sequestration and reinfusion on blood loss and homologous blood requirement after CPB, we randomly assigned 126 consecutive patients undergoing elective open heart surgery into the experimental group 1 (PRP+) (n = 64) or the control (no platelet pheresis) group 2 (n = 52). A third group (n = 10) were not included in the randomization. Patients in group 3 had PRP prepared by conventional techniques (PRPc) prior to heparin administration and given to the patient after protamine infusion. Aggregation and activation studies were performed on the PRP+, PRPc, and blood bank platelets (BBP). Per cent aggregation of PRP in response to ADP was superior to that of BBP. There were no significant differences in ADP induced aggregation between PRP+ and PEPc. There was no significant difference in platelet activation (CD62) or number between the three groups. Patients infused with PRP+ showed significantly increased aggregation to ADP when compared with untreated patients 120 minutes after return to the ICW. Furthermore, more homologous haemostatic components (platelets/fresh frozen plasma) were required in the control group. We have demonstrated that collection of autologous PRP+ after administration of heparin does not interfere with its haemostatic effectiveness compared with PRPc prepared before the initiation of bypass. Moreover, this can be performed universally in haemodynamically unstable patients without any additional costs. To assess the effect of intraoperative autologous platelet-rich plasma (PRP) transfusion on haemostasis, blood loss and blood requirements during vascular surgery.
                Randomized clinical trial.
                Twenty patients undergoing elective abdominal infrarenal aortic aneurysmectomy, using autologous transfusion techniques (predonation programme and/or preoperative normovolaemic haemodilution and/or intraoperative use of a cell-saver), were randomly allocated either into the PRP group (n = 10) or the Control group (n = 10).
                In patients of PRP group, 10 mL.kg-1 of PRP were obtained over 40 to 50 min, prior to induction of anaesthesia, and compensated simultaneously with an equivalent amount of hydroxyethyl starch. Each PRP unit was transfused to its donor after aortic declamping. Blood samples were obtained before induction, before incision, at wound closing and at the end of PRP unit transfusion for determination of biological variables.
                The PRP units transfused in the patients of PRP group contained 755 +/- 117 mL of plasma with a platelet count of 62 +/- 31 G.L-1. The intra and postoperative blood losses were similar in both groups (1622 +/- 758 and 233 +/- 322 mL respectively in PRP group vs 1890 +/- 1331 and 291 +/- 303 mL respectively in Control group). In both groups, three patients required an additional transfusion of homologous blood. The results of biological tests (haematocrit, platelet and white cell counts, prothrombin time, aPTT, thrombin time, fibrinogen, D-dimers, proteins, calcium) were also similar between groups at the various times of sampling. The reinfusion of the PRP unit did not increase the platelet count.
                This study demonstrates that intraoperative infusion of autologous PRP does not decrease blood loss and homologous transfusion requirements in patients undergoing elective abdominal infrarenal aortic aneurysmectomy. This result can be related to the relatively moderate enrichment in platelets obtained with the centrifugation speed used in this study. Blood conservation remains an important element for patients undergoing cardiac operations with cardiopulmonary bypass. Preoperative platelet-rich plasma (PRP) harvest is an autologous blood conservation method. The efficacy of preoperative PRP harvest and post-cardiopulmonary bypass reinfusion on postoperative bleeding and need for postoperative blood transfusion was evaluated in patients undergoing redo coronary artery bypass grafting in a prospective, randomized manner.
                All adult patients admitted for redo coronary artery bypass grafting entered into the study. The PRP harvest aim was 20% or more of the total estimated circulating platelets. Immediately preoperatively three sequestration cycles were performed. The PRP was reinfused after weaning from cardiopulmonary bypass. One hundred seven parameters/patient were recorded. There were 20 patients in the RPR group and 20 controls (without PRP harvest).
                Patient characteristics, operative data, and preoperative hematologic parameters did not differ between the groups. In the PRP group, the mean platelet count in the PRP was 864 +/- 139 x 10(3)/microL, and the platelet yield was 27% +/- 5% (range, 20% to 37%). The average total chest tube blood loss was 423 mL (PRP) compared with 1,462 mL (controls; p < 0.001). Fourteen patients in the control group required blood transfusions postoperatively compared with only 1 patient in the PRP group (p < 0.001). Postoperative fluid requirements were also significantly greater in the control group (p < 0.001). Postextubation gas exchange was significantly better in the PRP group compared with controls (p < 0.01). Postoperative ventilation time and intensive care stay were significantly shorter in patients in the PRP group.
                A preoperative PRP harvest of 20% or more of the total platelets and reinfusion of the PRP after cardiopulmonary bypass resulted in significantly less postoperative blood loss and decreased fluid and blood transfusion requirements compared with controls. Postextubation gas exchange, ventilation time, and time required in the intensive care unit were also better, and the method was found cost-effective. Blood conservation remains an important issue for patients undergoing cardiac surgery with cardiopulmonary bypass. Platelet sequestration (PSQ) is an aggressive autologous blood conservation method, whose effectiveness is still debated. The main objective of the present study was to evaluate whether PSQ reduces postoperative blood transfusion requirements in patients undergoing coronary artery bypass grafting (CABG) and to determine if PSQ is a cost-effective blood conservation method.
                All adult patients admitted for CABG entered the study. Exclusion criteria were: recent blood transfusion (<7 days), a platelet count of 150x10(3)/microl or less, hematocrit less than 35% and body weight 50 kg or less. The sequestration was aim 20% or more of the total platelet plasma volume. The sequestration protocol was three sequestration cycles performed just prior to surgery. The concentrated platelet portion was reinfused after weaning from the cardiopulmonary bypass. Hundred seven parameters/patients were recorded. Sixty patients entered the study; 30 in the PSQ group and 30 controls (CTR).
                Patient characteristics, operation data, preoperative hematology and coagulation parameters did not differ between the groups. In the PSQ group a mean of 433+/-34 ml concentrated platelet portion was collected. The mean platelet count in the concentrated platelet portion was 749+/-157x10(3)/microl, resulting in a platelet yield of 28+/-6% (2040%). The average total chest tube blood loss was 423 ml (PSQ) compared to 858 ml (CTR), p<0.001. A greater number of CTR patients required blood transfusion postoperatively (23) compared to PSQ (3), P<0.001, and fluid requirements were also significantly increased in the control group, P<0.001. No statistical differences in hematology and coagulation parameters between the groups were observed. The hospital mortality was low and the incidence of postoperative complications was few and without group differences. Post-extubation gas exchange was better in PSQ patients compared to CTR.
                A preoperative PSQ of a minimum 20% of the total platelet plasma volume resulted in significantly lower postoperative blood loss and fluid and blood transfusion requirements compared to controls. Post-extubation gas exchange was also better after PSQ. Only one patient did not tolerate the sequestration. No other adverse effects of the procedure were observed. To determine, in a pilot study, whether pheresis of plasma and platelets before surgical blood loss, with reinfusion of the autologous plasma and platelets after completion of the aortic reconstruction, will result in decreased bleeding and decreased transfusion of allogenic blood components in patients undergoing elective aortic reconstruction.
                Randomized study.
                University medical center.
                Patients were randomized to perioperative (acute) platelet plasmapheresis (APP group) versus conventional blood component therapy (control group). In the APP group, blood was withdrawn after induction of anesthesia, to sequester approximately 300 mL of platelet rich plasma (PRP); platelet poor plasma (PPP) and red blood cells (RBC) were sequestered as well. An autotransfusion device was used to collect and re-infuse autologous RBC during the course of the operation in both groups. After completion of the aortic reconstruction, autologous PRP and PPP were re-infused in the APP group. Blood loss, volume of blood component transfusions, and preoperative and postoperative hemoglobin (Hb), hematocrit (Hct), platelet, international normalized ratio (INR), and activated partial thromboplastin time (aPTT) were recorded.
                There was no difference between groups in demographics, preoperative laboratory values, or surgical procedures, although more patients were treated for aneurysms (73% vs. 60%) and fewer for occlusive disease (20% vs. 40%) in the control versus APP group. Also, there were no differences between the control and APP groups in duration of operation, blood loss, volume of colloid infused, or volume of allogenic RBC and plasma transfused. Patients in the APP group received a greater volume of crystalloid solution (9.1 +/- 3.4 L vs. 6.8 +/- 3.0 L; p = 0.002), but fewer units of allogenic platelets than the control group (0.7 +/- 1.0 units vs. 0.2 +/- 0.4 units; p < 0.04). There were no differences in postoperative Hb, Hct, INR, aPTT, or fibrinogen. The platelet count was lower in the APP group than in the control group (123 +/- 40 x 10(3)/mm(3) vs. 182 +/- 51 x 10(3)/mm(3); p = 0.004).
                Perioperative platelet plasmapheresis led to fewer allogenic platelet transfusions in patients undergoing elective aortic reconstruction. However, there was no decrease in blood loss and no reduction in transfusion of allogenic RBC or plasma. Perioperative platelet plasmapheresis is not recommended for routine use in elective aortic reconstruction. Platelet dysfunction is the most common cause of nonsurgical bleeding after cardiopulmonary bypass (CPB). We hypothesized that reinfusion of a therapeutic quantity of platelets sequestered before CPB would decrease the need for allogeneic platelet transfusion, as well as decrease bleeding and total allogeneic transfusion, in cardiac surgery patients at moderately high risk for bleeding. Fifty-five patients undergoing either reoperative coronary artery bypass (CABG) or combined CABG and valve replacement were randomized to control or platelet-rich plasma sequestration (pheresis) groups. All patients received intraoperative epsilon-aminocaproic acid infusions. There was no significant difference between groups with respect to preoperative characteristics, duration of CPB, or target postoperative hematocrit. Mean platelet yields were 6.2 +/- 2.1 units (3.1 x 10(11) platelets). Mean pheresis time was 44 min. Allogeneic platelets (range = 6-12 units) were transfused to 28% of control patients, compared with 0% of pheresis patients (P < 0.01). Allogeneic packed red blood cells were transfused to 45% of control patients (1.2 units per patient) versus 31% of pheresis patients (0. 7 unit per patient) (P = 0.35). Total allogeneic units transfused were significantly reduced in the pheresis group (P < 0.02). Mediastinal chest tube drainage was not significantly decreased in the pheresis group. In this prospective, randomized study, therapeutic platelet yields were obtained before CPB. In contrast with recent studies with low platelet yields, these data support the conclusion that platelet-rich plasma sequestration is effective in reducing allogeneic platelet transfusions and total allogeneic units transfused in cardiac surgery patients at moderately high risk for post-CPB coagulopathy and bleeding.
                Transfusion of allogeneic blood products, including platelets, is common during complex cardiac surgical procedures. In the present prospective, randomized study, a significant reduction in allogeneic platelet transfusion and total allogeneic units transfused was observed after the reinfusion of a therapeutic quantity of autologous platelets sequestered before cardiopulmonary bypass. Patients undergoing cardiac surgery employing cardiopulmonary bypass frequently require transfusion of homologous blood products and, therefore, are exposed to the risk of transfusions. Autologous platelet-rich plasma administration may reduce homologous transfusion and attendant risks.
                In a blinded, randomized fashion, patients undergoing repeat sternotomy and valvular surgery received either a sham product (n = 28) or autologous platelet-rich plasma (n = 28) at the conclusion of cardiopulmonary bypass. Perioperative blood loss, coagulation profiles, and transfusion requirements were compared between the two groups.
                In the first 24 h postoperatively, both the platelet-rich plasma and sham groups received a median of 10.5 units of homologous blood products. Total median perioperative homologous transfusion requirements were 13 and 11.5 units for the platelet-rich plasma and sham groups, respectively. There was no significant difference in intraoperative or postoperative bleeding between the groups.
                Autologous platelet-rich plasma did not reduce perioperative bleeding or transfusion requirements in repeat valvular surgery. A comparison of intraoperative autologous blood conservation techniques was carried out in 100 patients undergoing coronary artery bypass grafting. To facilitate comparisons of similar groups, patients were stratified into high-risk and low-risk groups based on the ratio of preoperative bleeding time to preoperative red blood cell volume. Our previous work suggested that patients with an elevated ratio have increased risk of excessive post-operative blood transfusion. We used this ratio to stratify the 100 patients to either the high-risk (39 patients) or low-risk (61 patients) strata. Within each stratum, patients were randomized to one of three groups: no intraoperative autologous blood conservation (control group), infusion of autologous platelet-rich plasma obtained from intraoperative plasmapheresis (PRP group), and infusion of autologous whole blood harvested immediately before cardiopulmonary bypass (whole blood group). Variables of postoperative blood loss and transfusion requirements were measured in each patient. Analysis of variance showed significant differences in blood product transfusions between groups. Patients in the high-risk stratum required significantly more blood product transfusions than those in the low-risk stratum (5.4 +/- 0.7 versus 2.0 +/- 0.6 units per patient; p < 0.001). In the high-risk stratum, PRP patients required significantly less postoperative blood transfusion compared with patients in the high-risk control group (2.9 +/- 2.1 versus 8.1 +/- 2.2 units per patient; p = 0.05). In the low-risk stratum, no intraoperative blood infusion method resulted in significant improvement in postoperative blood use.(ABSTRACT TRUNCATED AT 250 WORDS) To examine whether specific platelet pheresis (minimal plasma harvested) would contribute toward reduced blood loss and allogenic blood requirements after cardiac surgery.
                A prospective randomized trial.
                A large cardiothoracic surgical center.
                Consenting patients undergoing routine coronary artery or valve surgery (n = 54).
                Patients in the pheresis group underwent platelet pheresis in the anesthetic preparation room before general anesthesia. Pheresed platelets were stored during cardiopulmonary bypass and were returned to the patients after reversal of heparin with protamine toward the end of surgery. Control patients underwent their operations without this intervention.
                Primary endpoints were blood loss and transfusion requirements. There were no differences between the 2 groups (pheresis v control: median loss, 960 mL v 1100 mL, p = 0.15; median blood transfused, 896 mL v 635 mL, p = 0.71). Secondary endpoints included analysis of platelet counts, platelet function, and surface markers. Counts remained the same after retransfusion of platelets up to 2 hours after surgery. Platelet aggregation to ristocetin was well preserved, but adenosine diphosphate caused almost no aggregation of the harvested platelets. Flow cytometry revealed the platelets to have a reduced surface density of the glycoprotein 1b receptor, and 13% of them were irreversibly activated.
                Platelet pheresis activates a proportion of the harvested platelets and impairs the function of the remainder; this may explain its failure to reduce postoperative blood loss and transfusion requirements.
                Copyright 2002, Elsevier Science (USA). All rights reserved. Methods of reducing patient exposure to homologous blood transfusions include the technique of intraoperative plasmapheresis for the production of platelet rich plasma (PRP). The present study was designed to determine the patient benefits of PRP by examining hemostatic changes in coagulation screens and viscoelastic whole blood monitoring (Thrombelastography, [TEG]). One hundred fifteen patients undergoing elective cardiac surgery were prospectively randomized into a blinded study. Sixty-three patients had 20 percent of the circulating plasma volume sequestered prior to heparinization and pheresed into PRP, which was reinfused 10 minutes following heparin reversal with protamine. The control (CTR) group of 52 patients were exposed to no sequestration procedure. Patients were followed to discharge and 112 parameters, including anthropometric, operative, and postoperative factors, were measured. There were no significant differences between patient groups in preoperative, cardiopulmonary bypass (CPB), or surgical parameters. Average PRP volume was 600+/-100 ml with a total platelet yield of 1.1 billion platelets per patient. TEG indices were determined at four distinct times during the surgical procedure. The CTR group had significantly higher pre-CPB TEG indices of 2.3+/-1.2 and 2.1+/-1.2 (mean+/-SD), vs. 1.8+/-1.5 and 1.4+/-1.7 in the PRP group (p less than .04). Following heparin reversal, pre-PRP reinfusion TEG values were similar between groups, although both groups had significantly decreased indices when compared to pre-CPB values. Thirty minutes post-PRP infusion the treatment group had significantly improved TEG recovery when compared to the CTR group, 1.0+/-1.2 vs. 0.3+/-1.7 (p less than .05).(ABSTRACT TRUNCATED AT 250 WORDS) Preoperative platelet-rich plasmapheresis has been suggested as a means of reducing homologous blood transfusions in cardiac surgical patients. The current study evaluated this technique in patients undergoing repeat cardiac operations. Fifty-two patients undergoing repeat myocardial revascularization and/or valve replacement were evaluated in a prospective randomized controlled study design. Autologous platelet-rich plasma (PRP) was harvested after the induction of anesthesia in the experimental group. After reversal of heparin, each patient received his or her autologous plasma. Patients in the control group did not have plasmapheresis and received standard transfusion therapy if coagulation variables were abnormal and a coagulopathy was clinically evident. Routine coagulation tests, thromboelastography (TEG), perioperative bleeding, and transfusion requirements were compared in the two groups. Forty-four patients completed the study. A significantly larger volume of packed red blood cells (PRBCs) was transfused in the PRP group than in the control group (P = 0.03). Platelet and fresh frozen plasma (FFP) transfusions did not differ between the two groups. Mediastinal tube drainage did not differ between the two groups. During PRP infusion, 60% of the patients required treatment for moderate hypotension (mean arterial pressure [MAP] < 60 mm Hg). Only 16% of control patients required treatment for hypotension during the comparable time period (P < 0.05). No patient who completed the study returned to the operating room for postoperative bleeding. These data suggest that PRP did not reduce postbypass bleeding or transfusion requirements in repeat cardiac surgical patients. Moreover, the incidence of hypotension during PRP reinfusion introduces a potential risk to the procedure in the absence of any obvious benefit. The results of several studies suggest that acute platelet-rich plasmapheresis decreases blood loss and allogeneic blood product transfusion requirements in cardiac surgery patients. We designed a randomized, prospective study to determine whether acute platelet-rich plasmapheresis decreases blood loss and allogeneic transfusion requirements in primary cardiac surgery patients. Forty patients were randomized to a control or pheresis group. The pheresis group had platelet-rich plasmapheresis performed before cardiopulmonary bypass (CPB) and the platelet-rich plasma (PRP) was returned after CPB. The control group was managed in the normal fashion without pheresis. All patients had serial coagulation studies, hemoglobin, and platelet counts determined intra- and postoperatively. Chest tube drainage and transfusion requirements were recorded. There were no differences in the coagulation tests, platelet counts, chest tube drainage, or allogeneic blood product transfusion requirements between the two groups at any time. The authors conclude that the use of acute platelet-rich plasmapheresis in primary cardiac surgery patients does not decrease chest tube drainage or the need for allogeneic blood transfusions. To study the effect of plasma sequestration and reinfusion of platelet-rich plasma on blood loss after cardiopulmonary bypass, 18 patients undergoing heart operations were randomly selected either to have collected or not to have collected approximately 250 ml of platelet-rich plasma before initiating cardiopulmonary bypass with the use of the Haemonetics Plasma Saving System (Haemonetics Corporation, Braintree, Mass.). All patients had standardized anesthesia and cardiopulmonary bypass. After reversal of heparin, autologous platelet-rich plasma was reinfused in nine patients. Thrombocyte counts, hemoglobin, and hematocrit were calculated before, during, and after cardiopulmonary bypass, and 24 and 48 hours postoperatively. Blood loss and total number of transfusions were recorded. Although 9% of the total platelet volume was removed, there were no hemodynamic complications related to the use of the Haemonetics Plasma Saving System. In both groups, significant low levels of thrombocytes, hemoglobin, and hematocrit were seen after cardiopulmonary bypass. Platelet-rich plasma-reinfused patients had a significantly higher number of platelets after heparin reversal. They also had significantly less blood loss after the operation, necessitating 65% less banked blood products (p less than 0.05). We concluded that reinfusion of autologous platelet-rich plasma may serve as an effective and safe way to restore some of the hematologic derangements after cardiopulmonary bypass. To determine the effects of intraoperative plasmapheresis on total transfusion requirements, mediastinal drainage, and coagulation.
                The trial was prospective, randomized, and controlled.
                Inpatient cardiac surgery at a university medical center.
                Two hundred ninety-three consecutive patients undergoing cardiac surgery requiring cardiopulmonary bypass.
                Intraoperative plasmapheresis (IP) was performed in 147 patients before heparinization; platelet-rich plasma was reinfused immediately after heparin reversal.
                Mediastinal chest tube drainage during the first 12 postoperative hours was significantly less in the IP group (p = 0.022), but no difference was noted in total postoperative blood loss between the two groups. The amount of packed red cells and fresh frozen plasma transfused to the IP group in the intensive care unit was significantly lower (p = 0.02, p = 0.002, respectively); 51.4% of patients required no transfusion compared with the control group (34.5%) (p = 0.006). No differences were noted for data collected in the intensive care unit in terms of the mean duration of chest tube drainage, ventilator time, or any hematologic variables at baseline or at any subsequent time in the study.
                After cardiac surgery, intraoperative plasma-pheresis reduces early postoperative bleeding and decreases the need for homologous transfusions. Withdrawal of autologous plasma offers the possibility of improving patients' hemostasis and of reducing homologous blood consumption in cardiac surgery. The influence of acute, preoperatively performed plasmapheresis (APP) on platelet function was investigated in elective aortocoronary bypass patients subjected to APP producing either platelet-poor plasma (PPP; group 1; n = 12) or platelet-rich plasma (PRP; group 2; n = 12). APP-treated patients were randomly compared to patients without APP (control group; n = 12). Platelet aggregation induced by ADP (concentration 0.25, 0.5, 1.0, and 2.0 mumol/L), collagen (4 microL/mL), and epinephrine (25 mumol/L) was determined by the turbidometric method before and after APP, as well as before and after cardiopulmonary bypass (CPB) until the morning of the 1st postoperative day. APP had no negative effects on the patients' aggregation parameters (maximum aggregation and maximum gradient of aggregation). The platelet counts in the withdrawn plasma were 25 +/- 10 x 10(9)/L (PPP-group) and 250 +/- 30 x 10(9)/L (PRP-group). Platelet counts were highest in the PRP-group at the end of the operation (after retransfusion of autologous plasma). After CPB, maximum aggregation and maximum gradient of aggregation were reduced in all groups (ranging from -6% to -25% from baseline values). Retransfusion of autologous plasma improved platelet aggregability significantly only in the PRP-group. By the first postoperative day, maximum aggregation and maximum gradient of aggregation recovered in all groups (including the control group) or even exceeded baseline values (ranging from +8% to +42% from baseline values.(ABSTRACT TRUNCATED AT 250 WORDS) Donor plasmapheresis that is carried out weeks before the operation has proven to be of benefit in elective orthopedic patients with regard to reducing homologous blood consumption and preserving coagulation. In this study acute preoperatively performed plasmapheresis (APP) was investigated in cardiac surgery patients. Forty-five patients scheduled for elective aortocoronary bypass surgery were randomly divided into three groups of 15 patients each: 1) removal of platelet-poor plasma (PPP), 2) removal of platelet-rich plasma (PRP), and 3) no plasmapheresis (control group). Plasma volume removed was 10 ml/kg in all APP patients, and plasma was replaced by the same amount of low-molecular weight hydroxyethylstarch solution (6% HES 200/0.5). Various laboratory data were investigated before, during, and after extracorporeal circulation (ECC). Blood loss in control patients was more pronounced than in the two APP groups; two of the control patients needed packed red cells. APP itself did not affect coagulation variables, free hemoglobin, or polymorphonuclear (PMN) elastase. At the end of the operation, 5 h after ECC, and at the first postoperative day the number of platelets was significantly lower in the control group; PRP patients showed the highest values. Fibrinogen and AT-III levels were less compromised in APP patients than in the control group. Global coagulation parameters did not differ between the groups within the whole investigation period. PMN elastase increased significantly during ECC in all groups with the greatest increase in the control group (722%) and the smallest increase in PRP patients (280%), possibly due to the removal of cellular elements in this group.(ABSTRACT TRUNCATED AT 250 WORDS) Platelet-rich plasma (PRP) is postulated to decrease postoperative mediastinal chest tube drainage (MCTD) and allogeneic blood transfusions (ABT) after surgery with cardiopulmonary bypass. However, recent metaanalysis of the literature reveals that few good quality (therapeutic yield) trials that show a benefit have been published. The potential hemodynamic instability caused by plateletpheresis has not been emphasized. We studied the effect of plateletpheresis on MCTD, ABT, and hemodynamic stability in reoperative coronary artery bypass graft patients, a group perceived to be at high risk for ABT. Ninety patients were randomly assigned to Pheresis or Control groups. epsilon-Aminocaproic acid was given to all patients. Hemodynamic instability was assessed by degree of volume and inotrope resuscitation required. Part of the sequestered platelet volume was used to make autologous platelet gel, which was applied as a wound sealant. Mean pheresis yield was 30% +/- 7% of the circulating platelet mass or 6.4 +/- 2.2 allogeneic platelet unit equivalents. Total MCTD did not differ between the groups. There were no differences in mean packed red blood cell, platelet, and plasma transfusion rates. Overall, 52% of the Pheresis group received ABT, versus 55% of the Control group. Fifty-three percent of the Pheresis group patients exhibited significant hemodynamic instability, versus 27% of the Control group (P < 0.05). This study was unable to show any reduction in MCTD or ABT, although the plateletpheresis technique may offset platelet dysfunction caused by aspirin or increased blood exposure to nonbiologic surfaces, or it may compensate for lack of antifibrinolytic use. The significantly increased incidence of hemodynamic instability in the Pheresis group means that the risk/benefit ratio must be determined for individual cardiac surgical units.
Although the results suggest that PRP is effective in reducing allogeneic RBC transfusion in adult patients undergoing elective surgery, there was considerable heterogeneity of treatment effects and the trials were of poor methodological quality. The available studies provided inadequate data for firm conclusions to be drawn regarding the impact of PRP on clinically important endpoints.