The Role of the Cell Saber in the Intraoperative Period in Response to Bleeding During the Postoperative Period

Introduction

Cardiac surgery is a complex surgical intervention that consumes a large number of blood products. Also, according to the American College of Cardiology and American Heart Association (ACC/AHA) these surgeries have a high percentage of complications or adverse reactions in the postoperative period, primarily hemorrhage [1]. Defining hemorrhage is difficult, especially when it comes to assessing criteria for blood transfusions [2].

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Hemorrhagic shock due to bleeding is considered as the loss of 20% or more of the circulating blood volume [3], although the study by Advance Trauma Life Support (ATLS®) considered it as the acute loss of circulating blood volume with clinical symptoms [4]. But regardless of the definition used, clinical trials it won’t be necessary the Higher Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa inhibitors (SYNERGY), determined the risk of hemorrhage is present in patients undergoing cardiac surgery [5]. Piednoir points to two causes: unsatisfactory surgical technique or secondary to hemostasis alterations [6]. During EC, hemostatic alterations occur, requiring a normovolemic hemodilution, which triggers a decrease in hemoglobin and hematocrit of the patient. On the other hand, the administration of high doses of heparin sodium to prevent blood clotting on the surface of the extracorporeal circuit. Furthermore, sodium heparin used in high doses to prevent blood clotting in the extracorporeal circuit surface can aggravate the homeostatic alterations and cause haemorrhage [7, 8] moreover, the protamine, can produce blood clotting disorders. Other elements that also influence the risk of bleeding and need to be taken into account are: advanced age, anemia, coagulation disorders, thrombocytopenia or antiplatelet therapies. In the case of hemorrhage of patients undergoing cardiac surgery with EC, the transfusion is a total or partial recovery of the blood, so it is necessary to assess their benefits [9]. Homologous blood transfusions can be packed erythrocytes or red blood cells, platelets and coagulation factors. Homologous blood transfusions have complications, ranging from the reaction to their components, up to the possibility of transmitting diseases [10]. There are authors [11, 12, 13, 14], that relate the transfusion with postoperative complications, and long- term morbidity. Numerous reports and cohort studies have related homologous blood transfusions with nosocomial infections, such as viral hepatitis C, T-virus, and herpes virus, human VIII Kaposi's sarcoma and HIV [15]. Despite of the extreme care and monitoring during the processes of donation and transfusion, these complications, although rare, are potentially serious [13], and although they have low incidence in developed countries, they represent an important problem in less developed ones. Ferraris [16], said that there is a widespread fear in society with regard to transfusions, having knowledge of the short- and long-term impacts, and that there are no laboratory tests to detect all the infectious agents, and the existing ones are not 100% effective. In this sense, despite the attempts of standardization through publication of various guides, manuals, and protocols of transfusion [17], each institution has its own health transfusion criteria. The recent study Transfusion requirements after cardiac surgery (TRACS), showed that the characteristics of the cardiovascular patient have to be taken into account. On the other hand, the scarcity of donations of blood products, resulting in insufficient reserves in blood banks, increases the need to develop procedures for the conservation of blood of the patient [18]. This need for blood transfusions [1], in cardiac surgery and its relationship with postoperative complications, and long-term morbidity, highlights the advisability of launching alternatives to reduce the need for transfusion of homologous blood products [19]. It is therefore interesting to investigate techniques such as the CS, which can be an alternative to reduce the need for transfusion of blood products in cardiac surgery [20, 21]. The CS is used as a fundamental strategy for saving of homologous blood, needed by patients after cardiac surgery, as declared by the autologous transfusion study Committee (AABB) [22], and many other studies that indicate that their use is safe, effective and efficient for the reduction of homologous blood transfusion [5, 6, 7, 8, 9]. In addition, the study by Booke [23], claim that the use of the CS in the surgical context, decreases by more than 90% the need for transfusion with blood products and poses a lesser risk for the cardiovascular patient and represents a lesser cost to the hospital [18, 19, 20, 21].

Methods

This research is observational and cross sectional and was carried out from January to October 2014our hospital. Patients scheduled by the cardiovascular service for cardiovascular surgery interventions under EC, and interventions where CS was going to be used as an alternative to homologous blood transfusion. The inclusion criteria were patients with age greater than or equal to 18 years to be accepted on a voluntary basis to participate in the study after having been verbally informed of the characteristics of the same and had signed the informed consent. Exclusion criteria: patients with clotting disorders, kidney failure, impaired liver function, with malignancies, HIV seropositive, hepatitis B - C, septic pathology. Patients with clotting disorders prior to surgery, with bleeding twelve hours before the scheduled surgery or reoperated on an emergency basis, Nursing & Healthcare International Journal

because they would be strong candidates to be transfused and could alter the collected data. Patients who did not accept their participation. We selected all the cardiovascular patients that were scheduled for cardiac surgery under EC, with use of the CS from January to October 2014, a total of 162 patients, data provided by Application for the management of the Demand.

Results

Of the 478 (100 %) patients scheduled by the cardiovascular surgery service, 162 were included (33.8 % ), 316 (66.2 %) patients were excluded in whom: 254 (53.2 %) the CS was not used in the absence considerable blood loss, 1 (0.2 %) had bleeding twelve hours before the scheduled surgery; 8 (1.6 %) had blood clotting disorders prior to the surgery; 5 (1 %) were infected with hepatitis B; 2 (0.5 %) were hepatitis C virus carriers; 2 (0.5 %) had neoplasms; 2 (0.5 %) were infected with the HIV virus; 34 (7.1 %) had to be reoperated on an emergency basis and 8 (1.6 %) did not sign the informed consent. We analyzed the data of 162 patients, 96 males (59.3 %) and 66 females (40.7 %), with a mean age of 61.99 years. Cardiovascular diagnoses we encountered were: aortic valvular disease (37.7 %) more than two cardiovascular pathologies (28.3 %) coronary arteriosclerosis (17.3 %), mitral valve disease (14.2 %) and tricuspid valve disease (2.5 %).Cardiovascular procedures we encountered were: replacement / repair of the aortic valve (37.7 %) more than two surgical procedures in the same patient (27.1 %), of replacement / repair of the mitral valve (15.4 %), coronary bypass (17.3 %) and replacement / repair of the tricuspid valve (2.5 %). The CS: the average volume of autologous blood recovered and processed was 1800 ml, being 580 ml of red blood cells, the average volume obtained and reinfused again in the patient.

Discussion

With respect to the profile of the patients studied in regard to gender, our results are consistent with the statistics provided in the European forum of cardiovascular disease (ECVD) [24], affect slightly more men than women, in his study 59.3 % males and 40.7 %

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women. According to the National Statistics Institute (INE) [25], this is relative, because in the next decade, the percentages will match in both sexes, CVD being more frequent in advanced ages, where the number of women with CVD is higher than the number of men. In regards to age, the study SYNTAX [17], reports that it is a factor to take into account in patients after heart surgery, being its greatest prevalence at 75 years, in both sexes. Our patients had an average of 62 years. This shows that there is a tendency of younger patients to undergo cardiac surgery compared with the American studies. Despite the fact that all the patients studied arrived at the operating room with analytical values within the normal range, due to blood loss, there is a lowering of the hemoglobin, hematocrit, total proteins and platelets that remain low during the postoperative period. However, with the re-infusion of red blood cells from the CS, these values increase. The use of the CS did not cause problems in the recovery of autologous blood. We agree with the studies of Manjuladevi [26] and others [27], and who claim that the use of the CS is an effective and safe measure to save intraoperative blood. According to the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) [28], the CS is effective in cardiac surgery scenarios, although difficult to assess, because the decision to use the CS is based mainly on the availability and preference of the nurse perfusionist. Despite the difficulties mentioned, the use of CS in the patient’s operated heart, reduces the bleeding rates (according to our results, 28%), compared to those in which it is not used, increasing the possibility of bleeding by 60% [29]. We can assume, that from limited data and in an attempt to avoid the homologous blood transfusion in cardiac surgery under EC, the use of new technologies such as CS, need solid evidence to support its use [3, 4, 13, 18]. Despite the fact that in Spain, the CS has been introduced as an alternative to homologous blood transfusions, any intervention that is part of a strategy for blood presservation, needs a critical analysis in regards to cost-effectiveness. To provide scientific evidence for use of the CS, more comparative tests are necessary to evaluate the relative efficacy, security, and cost effectiveness of the CS in different surgical procedures. Our study is a starting point. The American Heart Association and the American College of Cardiology (AHA/ACC) [1] points out that it is reasonable to carry out any study demonstrating satisfactory reduction of hemorrhage in cardiac surgery, as it provides scientific evidence to programs aimed at the conservation of blood.

Conclusions

Patients who underwent surgery with EC and using the CS 30% of patients had no episodes of bleeding in the immediate postoperative period, compared to other studies that claim that 60% of patients were suffering bleeding if not using the CS. And the profile of patients treated were mainly men of advanced age and overweight, with medical diagnosis of aortic valvular disease which underwent surgery for aortic valve surgery, with analytical values within the normal parameters in the preoperative period, which fell below intraoperatively and remained in that range in the postoperative period.