Acute hemorrhage is one of the most important causes of perioperative death in patients with severe trauma, visceral rupture, and surgical accidents. In the past, when rescuing patients with acute hemorrhage, the most important measure was to import stock allogeneic homologous whole blood or component blood products, which potentially reduced cardiac function or even induced heart failure, secondary bleeding tendency, hyperkalemia, immunosuppression, allergy and contamination, but did save many lives.
In recent years, with the increasing understanding of bleeding as well as transfusion, especially the discovery of blood transfusion and blood-borne diseases such as viral hepatitis, syphilis, HIV infection, etc., transfusion can transmit diseases is gaining more and more attention, clinical transfusion can be said to be cautious, but it can not eliminate the problem at all. The only effective measure to prevent blood-borne diseases is to reduce the chances of transfusion.
The application of blood conservation techniques such as pre-major surgery autologous blood reserve, acute isotonic hemodilution, high volume hemodilution, and intraoperative autologous blood recovery/retrieval has significantly reduced the incidence of transfusion and blood-borne diseases, and there have been many related studies in recent years. Since 2000, our hospital has adopted the German Feisenus 2000 autologous blood recovery system to recover/return autologous blood during surgery for patients with hemorrhage, and all patients have safely passed the surgery period without any death due to bleeding or transfusion complications, as reported below.
From March 2000 to October 2007, autologous blood recovery/retrieval technique was performed in 184 patients with acute hemorrhage during resuscitation surgery, including 68 cases of abdominal/retroperitoneal hemorrhage due to rupture of parenchymal organs such as liver, spleen, kidney and mesenteric vascular injury caused by car accident/stabbing injury; 89 cases of ectopic pregnancy with spontaneous rupture and intraperitoneal hemorrhage; 13 cases of intraperitoneal hemorrhage due to spontaneous rupture of corpus luteum during menstruation; 3 cases of ruptured bleeding due to accidental intraoperative injury to the subclavian vein, inferior vena cava, renal hilum and other large vessels;
There were 4 cases of Bu-ga syndrome; 6 cases of thoracic/abdominal aortic aneurysm angioplasty; 1 case of hemorrhage during adrenal pheochromocytoma resection. The patients’ ages ranged from 15 to 67 years; their weights ranged from 64.8 to 78.2 kg; all had poor general conditions before surgery, and hemorrhagic shock over 90% had been diagnosed before admission to the operating room.
(I) Anesthesia methods.
(1) Inhalation anesthesia group 125 cases, after entering the room, at least two open venous access, closed mask positive pressure pure oxygen denitrogenation at the same time, slow sedation imipramine, fentanyl, etomidate/ketamine, vancomycin induction until the patient falls asleep, after sufficient muscle relaxation, transoral bright vision endotracheal intubation, connected to anesthesia machine, inhalation of low concentration isoflurane/sevoflurane with 50% N2O;
(2) 59 cases in the static inhalation combined anesthesia group were induced as in the inhalation anesthesia group, with continuous intravenous drip of 0.1% ketamine, combined inhalation of 50% N2O, and intermittent inhalation of low concentration isoflurane/sevoflurane; in both groups, 1/2 intubated dose of vancoxon was intermittently injected intraoperatively to maintain inotropic relaxation, and IPPV was used to control ventilation mechanically and adjust ventilation volume to keep PETCO2 at 35-45 mmHg.
(B) Autologous blood recovery, washing, separation and reinfusion: The German-made Feisenus type autologous blood recovery system was used, and the detergent was 0.9% saline from Baxter (50,000 u of anticoagulation with sodium heparin in 1000 ml of saline). A negative pressure suction device is used to collect uncontaminated blood from the patient’s body cavity along with anticoagulated heparin solution into a special blood recovery reservoir for storage, with a 1:5 ratio of anticoagulant drip rate to blood aspiration.
When the recovered blood in the reservoir reaches a certain volume (400-600mL), the washing system is turned on and repeatedly washed, and the washing process is continuously anticoagulated, and the washed red blood cell concentrate is returned to the patient. For those who have difficulty in maintaining circulation, appropriate amount of frozen human plasma is infused at the same time.
Throughout the washing process, the operator can directly visually estimate the number of red blood cells in the recovered blood roughly, and if the number of red blood cells is low, the washing can be suspended. The operation process of collection, washing, filtration and reinfusion can be repeatedly started until the end of the procedure. The cell debris, free hemoglobin (Hb) and anticoagulated washing solution generated during washing are shunted into special waste bags. In the recovery and washing and filtration process, the negative suction pressure (≤150 cmH20) and centrifuge speed (≤400 r/min) are appropriately grasped to reduce the rate of red blood cell destruction as much as possible to ensure the oxygen-carrying capacity of the returned red blood cells after washing and reduce the free Hb blocking the renal tubules and causing acute renal function damage. The risk of acute renal function damage.
When recovering blood adsorbed on gauze and blood pads, do not squeeze the gauze/blood pads, it is recommended to gently wash the adsorbed gauze/blood pads by dipping them in physiological saline to minimize artificial damage and destruction of red blood cells. After washing, the concentrated red blood cells are recovered into the blood storage bag and mixed with appropriate amount of saline or sorbitol Ringer’s solution to start the transfusion. Recovery, washing and separation are a continuous process, and can be recovered, washed and directly transfused back to the patient at the same time.
(C) Intraoperative monitoring: Blood pressure (BP), electrocardiogram (ECG) and oxygen saturation (Sp02) were monitored in all patients. 129 patients (70.1%) had invasive radial artery manometry and 91 patients (49.5%) had CVP monitoring via internal jugular vein to guide intraoperative fluid therapy. In patients with high volume of outflow, arterial blood was collected intermittently and blood gas analysis was performed, and the pH was adjusted to normal or near normal according to the results of blood gas analysis.
(iv) Intraoperative fluid therapy: According to the changes of hemodynamic parameters (arterial blood pressure, CVP) of patients, appropriate amount of plasma substitute, crystalloid, stock blood and other blood component preparations were supplemented.
Results
From March 2000 to October 2007, a total of 184 patients with traumatic and/or spontaneous visceral rupture and unexpected acute intraoperative hemorrhage were treated with the autologous blood recovery/retrieval technique, with a mean operative time of 5.46±2.42 (4.5-11.5) h; bleeding (estimated) volume of 1,350-14,750 ml, mean 2492.31±1873.59 mL; a total of nearly 270,000 ml of blood was recovered in the whole group, with an average volume of 1,152.46 mL of blood returned, up to 8,300 ml; 93 cases (50.5%) required intraoperative transfusion of stock blood, with an average of 611.38±215.68 mL, and 67 cases (36.4%) were not transfused with stock blood.
The mean intraoperative input of colloid fluid was 1398.77±591.28 mL; crystalloid 1480.77±1062.83 mL. 119 cases (64.7%) used vasoactive drugs intraoperatively. 35.3%% did not use any vasoactive drugs. In this group, 11 cases (5.97%) of intraoperative/postoperative hematuria, transfusion reaction and postoperative infection were safely passed through the operation.
Discussion
Laboratory examination of blood recovered via blood recovery machine revealed that after treatment, the blood was concentrated and the Hct, red blood cell count and Hb content were significantly higher than that of the recovered raw blood. Platelet count, glutamate transaminase, total protein and urea nitrogen levels were also reported to be significantly lower than that of the recovered raw blood. The patient’s temperature change profile was not different from normal postoperative.
RBC count, Hb level, Hct and WBC count were significantly lower than preoperative indicators at 1 week postoperatively. Platelet count, although lower than preoperative at 1 d postoperatively, recovered to preoperative level at 1 week postoperatively. The total protein level was lower than normal 1 d after surgery, and returned to normal 1 week after surgery. There were no significant changes in the postoperative liver and kidney function indexes, postoperative whole blood activation clotting time and postoperative trauma drainage.
A blood washing process can be completed in 5-6 minutes by applying the blood recycling machine, and for emergency hemorrhage surgery such as parenchymal organ rupture and spontaneous rupture of ectopic pregnancy, washing and transfusion can be done while recycling, and no cross-matching blood test is required, which gains time for saving patients’ lives. In particular, during the SARS epidemic in May 2003, when blood supply was extremely scarce, autologous blood recovery/retransfusion technology was used to perform rescue surgeries for 18 patients with traumatic liver/spleen rupture and ectopic pregnancy/spontaneous rupture of corpus luteum, and the application of this technology played an important role in saving patients’ lives at the first time during the special period.
In the process of autologous blood recovery, a large amount of platelets, coagulation factors, plasma proteins and other biologically active substances are removed during washing and filtration, therefore, attention should be paid to the appropriate amount of plasma, albumin, platelets, and acid-base and electrolyte balance when transfusing back a large amount of concentrated red blood cell suspension. Some authors suggest that if the transfusion of washed RBCs ≥ 3,000 ml, 5 units of recovered washed RBCs should be transfused with 1 unit of platelet homogenate for each transfusion. In our group, the transfusion volume was up to 8,300 ml, and peptidase and/or small doses of fisetin were used empirically to regulate the balance of bleeding and coagulation processes, and no cases of serious bleeding tendency were seen intraoperatively or postoperatively.
The principle of aseptic operation should be followed to avoid hematogenous infections caused by human factors. Tumor resection and contaminated surgery are contraindicated for blood recovery techniques. Even so, it is still difficult to avoid the exposure of blood to the external environment and various possible pyrogenic agents during blood recovery. It is recommended that prophylactic antibiotics be applied to those who intend to perform autologous blood recovery, or who estimate a large recovery/return volume, and broad-spectrum antibiotics can be given intraoperatively.
Summary.
(1) Scientific, rational and timely use of blood recovery/retransfusion techniques during resuscitation surgery in patients with acute hemorrhage can effectively reduce the rate of perioperative allogeneic transfusion, especially in patients with acute hemorrhage due to visceral rupture, intraoperative accidental injury, and hemorrhagic shock, reduce the amount of transfused allogeneic homologous blood and/or stock blood, and control the occurrence of several transfusion-related complications and blood-borne diseases as mentioned before, which is undoubtedly beneficial to patient recovery.
(2) Autologous blood recovery/retransfusion can save the patient’s life in the first place, gain valuable time for subsequent treatment, and conserve blood sources, reduce waste, and alleviate the economic burden of patients and society. This method is increasingly accepted by more and more patients and their families, and should become part of the daily work of the anesthesiology department.
(3) The technique is recommended to be used with caution for those whose blood is likely to be contaminated such as those diagnosed with malignant tumors, serious systemic infections, and ruptured cavernous organs. In case of life-threatening emergencies, the pros and cons should be weighed and the evidence-based medical theory should be comprehensively considered.