**2.1 Pre-operative autologous blood donation**

The efficacy of pre-operative blood donation varies according to the time between blood collection and cardiac surgery. The current storage and preservation techniques allow us to collect and maintain 2 to 4 units of full blood or PRBCs. This efficacy can be enhanced by stimulation of erythropoiesis during blood donation, but this is used only selectively because of the potential of thrombotic cardiovascular events and costs [11, 12]. The use of erythropoietin is also limited by the necessity of starting its administration 3 weeks before surgery [13]. A short course erythropoietin was also used several days before cardiac

Modality Intervetion

Bleeding minimization Sophisticated technology of incision

Homeostasis optimization Controlled hemostasis ( blood fluidity )

Adherence to basic rule of transfusion Complying with lowest and safe level of

The efficacy of pre-operative blood donation varies according to the time between blood collection and cardiac surgery. The current storage and preservation techniques allow us to collect and maintain 2 to 4 units of full blood or PRBCs. This efficacy can be enhanced by stimulation of erythropoiesis during blood donation, but this is used only selectively because of the potential of thrombotic cardiovascular events and costs [11, 12]. The use of erythropoietin is also limited by the necessity of starting its administration 3 weeks before surgery [13]. A short course erythropoietin was also used several days before cardiac

Table 1.  Refinements of surgical methods Topical hemostatic agents Peroperative blood recuperation Postoperative blood salvage Early revision for surgical bleeding

Low priming volume and retrograde

Controlled hemodynamics ( blood

anemia for a given clinical case STS recommended transfusion point:

Internal environment (pH, blood gases,

priming after starting CPB

Ultrafiltration Minicircuits

pressure ) Normothermia

ionts, glycaemia )

Hb 7 ± 1 g/dl .

erythropoietin,

hemodiloution

Preoperative erythrocyte maximizing

Hemodilution minimization during

CPB

and/or blood conservation

operation in anemic patients (haemoglobin < 13 g/dl) without autologous predonation [14, 15]. In cardiac patients, there are certain contraindications for participation in autologous blood donation programmes; in addition to anaemia (haematocrit below 33%), they include critical aortic stenosis, idiopathic subaortal stenosis, ischaemic heart disease with unstable angina or with left main coronary artery stenosis, chronic NYHA class IV heart failure, ventricular rhythm disturbances on the day of blood collection and an acute heart attack. This all narrows the selection of candidates for autologous blood donation in cardiac surgery. The proportion of patients meeting the criteria for autotransfusion varies from 10% to 30%; however, some centres can indicate more patients in relation to the range of surgical procedures done and according to experience of the blood collection team.

#### **Intra-operative isovolaemic haemodilution**

Blood collection performed immediately before cardiac surgery for the purpose of acute isovolaemic haemodilution is also included in an autologous blood donation programme, thus permitting participation of the patients otherwise contraindicated for a standard programme [16]. A 500- to 1000-ml amount of blood is collected via a central venous catheter or an arterial line and is replaced by a colloid or crystalloid solution before cardiopulmonary bypass (CPB) surgery is commenced. For calculation of the final haematocrit (HCT) value, it is necessary to take the CPB dilutional effect (minimum of 1.3 l) into consideration. Usually, a dilution of 25% to 20 % HCT is used, which is also recommended because of a lower risk of damage to blood elements during extracorporeal perfusion. In some centres, 15% HCT is an accepted transfusion trigger in the patients who do not tolerate allogeneic blood transfusion [17, 18].

The advantage of intra-operative haemodilution is in that the lost blood contains lower red blood cell counts and a transfusion of fresh autologous blood supplies functional platelets. The only contraindication for intra-operative isovolaemic haemodilution is anaemia and haemodynamic instability. Patients with a cardiac disease and a haemoglobin level below 130 g/l may not be able to compensate for a temporary decrease in erythrocyte counts and may show signs of tissue hypoxia or symptoms of cardiac disease. This approach can be combined with blood processing by apheresis.

#### **Intra-operative apheresis**

It was first used in thoracic surgery in 1987. It is a medical technology in which the blood of a patient is passed through an apparatus that separates out plasma and platelets and returns the reminder to the circulation. The separated components are then ready for use at the time needed to complete their deficiency. During cardiac surgery with extracorporeal circulation, this technology can also salvage part of the platelets which are otherwise absorbed onto the inner surface of the extracorporeal tubing or can end as platelet-leukocytes micro-aggregates in the capillary beds. The anaesthesiologist can decide between plasma with platelets or a platelet concentrate requiring a slowly rocking shaker for short-term maintenance. Similarly to many blood recuperation devices, the apheresis technique is based on centrifugal force. The proportion of platelets in plasma depends on the spin rate (2400-3600 revolutions per min). The amount of plasma safely collected is related to the patient's clinical condition and usually equals to 20 % of the calculated plasma volume or 12 ml/kg body weight. The procedure design for replenishing intravascular volume, which differs from centre to centre, involves crystalloids and starch derivatives or albumin. When a larger amount of blood is collected, it is necessary to check the ionogram, pH value and free calcium and magnesium levels. The efficiency of both plasmapheresis and thrombopheresis has been evaluated in many studies. Some have reported lower requirements for allogeneic blood transfusion [19, 20, 21] as well as lower post-operative blood losses [22]. A positive effect of pre-operative plasmapheresis has been demonstrated by low tendency to pathological fibrinolysis [23]. On the other hand, other authors described a low efficacy of pre-operative apheresis in cardiac surgery [24] and related it to the pre-operative administration of an anticoagulation and platelet anti-aggregation therapy. The patients who, before surgery, have received coumarin derivatives, heparin and non-steroidal anti-phlogistic drugs do not benefit from plasmapheresis [25].


*4.12. LC-MS/MS Analysis*

Resolved protein samples were analyzed using QTRAP® 6500 LC-MS/MS System (AB Sciex LLC, Framingham, MA, USA). Mass spectrometric data were searched against the NCBI database with a taxonomy restriction to 2019 human proteins (172,061 sequences; 53,783,369 residues, 27 July 2020) using MASCOT V2.0 (Matrix Sciences, London, UK).

#### *4.13. Data Analysis*

A bar diagram was plotted for the cytotoxicity test to visualize the "mean percent of inhibition ± standard error" of cell proliferation using Microsoft® Excel 2019 software. The significance of the lactucin doses was compared with control sample data and calculated by "one-way ANOVA" using "IBM® SPSS® Statistics 26". Significant difference at *p* 0.05, 0.01, 0.001, and 0.0001 was calculated and expressed with different Asterix "\*" numbers on the chart or the data table legend. IC50 was calculated by plotting the Log10 dose on *X*-axis versus the Normalized response on the *Y*-axis in Graph Pad Prism 7. Cell cycle cytometry data were analyzed using ModFit LT™ (Version 5.0.9). Apoptosis compensation calculation and data analysis were done using CytExpert™ (Version <IP_ADDRESS>). Protein concentrations were calculated in Microsoft® Excel 2019. WB bands were quantified using ImageJ® (Version 1.52a) and analyzed using Graph Pad Prism 7. NMR data was analyzed, the structure was predicted using MestReNova™, and the chemical structure was made using ChemDraw® Professional. LC-MS/MS results analyzed in MASCOT were combined with WB markers data, and functional enrichment was performed to predict the involved molecular pathway using DAVID Bioinformatics resources [36,37].

#### **5. Conclusions**

In developing anticancer therapy, discovering natural compounds and their mechanisms are the new frontier. They can concurrently affect multiple cell lines, and are helpful in attending to metastasized cancers, while still possessing molecular specificity towards different oncogenes and tumor suppressors. Herein, we reported cytotoxic, cell cycle inhibitory, and apoptosis-inducing properties of Lactucin in A549 and H2347 cells for the first time. We also narrowed down Lactucin's potential target in the A549 cell as MAPK/ERK pathway. Lactucin exerts its effect by lowering the carbon metabolism necessary for metastasized tumor development. To the best of our knowledge, this study was the first attempt at identifying Lactucin's anticancer mechanism in the lung cancer cell line.

**Supplementary Materials:** The following supporting information can be downloaded at: https: //www.mdpi.com/article/10.3390/molecules27217358/s1, Figure S1: Functional enrichment of ABPP and WB peptides using DAVID Bioinformatics resources predicted Lactucin's interaction with several "Central carbon metabolism in cancer" pathways enzymes (the chart is from KEGG database); Figure S2: Downregulation of the MEK-ERK signaling pathway in NSCLC leads to upregulation of p53 and DNA repair, which downgrade increased carbon consumption-related enzymes (the chart is from KEGG database, red star *p* < 0.05).

**Author Contributions:** K.M.S.U.I. and Y.T. wrote the first draft and developed the figures and tables. F.X. contributed to the writing and argument development. Y.X. and B.W. jointly made critical revisions and approved the final version. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was supported by the Agricultural Science and Technology Innovation Program of Institute of Food Science and Technology, Chinese Academy of Agricultural Sciences (CAAS-ASTIP-G2022-IFST-07 fund; and the CAMS Innovation Fund for Medical Science (CIFMS), grant number 2021-1-I2M-028.

**Institutional Review Board Statement:** Not applicable.

**Informed Consent Statement:** Not applicable.

**Data Availability Statement:** The data presented in this study are available on request from the corresponding author.

**Acknowledgments:** We are incredibly grateful to Yu Tian for her help in constructing the Lactucin probe. We thank Boting Wen and Yulu Wang for the helpful discussion.

**Conflicts of Interest:** There are no conflict of interest to declare.

**Sample Availability:** Source of the compound Lactucin is described in the materials method section.


*Supporting open minds since 2005*

Electroencephalography - From Basic Research to Clinical Applications http://dx.doi.org/10.5772/intechopen.87425 Edited by Hideki Nakano

#### Contributors

Boulenouar Mesraoua, Musab Ali, Rola HM Khodair, Yazan Nofal, Dirk Deleu, Hassan Al Hail, Gayane Melykian, Osama Elalamy, Covanis Athanasios, Jesús Pastor, Lorena Vega-Zelaya, Elena Martin Abad, Raafat Hammad Seroor Jadah, Julián González, Almudena González, Manuel Santapau, Hideki Nakano, Liljana Bozinovska, Adrjan Bozinovski, Subha D. Puthankattil, Alexandre Magno da Rocha Vianna, Ali Akbar Asadi-Pooya

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