418
5. Christie AJ, Weinberger KA, Dietrich M. Silicone lymphadenopathy and synovitis. Complications of silicone elastomer finger joint prostheses. JAMA 1977; 237: 1463-64. 6. Gordon M, Bullough PG. Synovial and osseous inflammation in failed silicone-rubber prostheses. J Bone Joint Surg 1982; 64A: 574-80. 7. Worsing RA Jr, Engber WE, Lange TA. Reactive synovitis from particulate silastic. J Bone Joint Surg 1982; 64A: 581-85. 8. Rosenthal DI, Rosenberg AE, Schiller AL, Smith RJ. Destructive arthritis due to silicone: a foreign-body reaction. Radiology 1983; 149: 69-72. 9. Marquardt E. Drohender Plastiche bei Operationen Knochendurchspiessung am Kindlichen Oberarmstumpf: eine Vorläufige Mitteilung. Z Orthop 1976; 114: 711-14. 10. Martini AK, Marquardt E. Stump plasty on congenital amputations. Garyounis Med J 1980; 3 (suppl): 83-86. 11. Bernd L, Blasius K, Lukoschek M, Lucke R. The autologous stump plasty: treatment for bony overgrowth in juvenile amputees. J Bone Joint Surg 1991; 73B: 203-06.
Autotransfusion then and
now
Successful cardiac surgery depends heavily on the of blood and blood products. The perceived risks of blood transfusion have lately kindled an interest in blood conservation techniques such as salvage and reinfusion of the fluid shed from the wound. The simplest salvage method was described by Noon in 19781 and is marketed as the Sorenson system. He described an apparatus for intraoperative use whereby blood was first anticoagulated with citrate and then aspirated under aseptic conditions through two 170 um filters into a reservoir before infusion. As now used, the fluid that is drained is not anticoagulated because it has undergone natural defibrination in the chest. This fluid is similar to old bank blood in that it is virtually devoid of clotting factors, but additionally has a very low fibrinogen concentration. Unlike homologous blood and blood salvaged intraoperatively1 it has a low packed cell volume (typically 15-25%) and contains considerable amounts of free haemoglobin and products of clot lysis. In view of the nature of this fluid it is surprising that thrombocytopenia, coagulopathies/,3,5,6 or impaired renal function35 have not been clinically evident after reinfusion, but the investigations were carried out in patients who received modest volumes. With reinfusion of larger volumes platelet function is deranged,and mild coagulopathy has also been found. The observation that the thrombin time is extended in direct relation to the volume reinfused is especially noteworthy. These data need confirmation in patients who have greater postoperative losses-eg, those taking aspirin or undergoing reoperations, who may benefit most from this system. Worries about the possibility of producing a bleeding diathesis are overshadowed by concerns of increased infection risk. Schaff et aF reported that as many as one in six of infusates were culture positive. This was said to be irrelevant clinically since infection and positive blood cultures were not observed in patients with culture-positive mediastinal drainage fluid.2,5 Despite these reassurances the same investigators discarded the drain losses from 16-48% use
of the patients because there was insufficient volume collected during a fixed time; they also limited the use of the system in patients having valve surgery. The potential for bacterial contamination has led to the recommendation of a 6-hour upper limit on the time between collection of blood and its reinfusion.8 It follows that if there is only very slight postoperative bleeding because of careful surgical technique or pharmacological intervention with aprotinin,9 this infection risk will probably lead to the drain losses being discarded. If the user judges that haematological and bacteriological safety are acceptable the remaining question is the efficacy of the system. Here the data are less persuasive. There are three randomised prospective studies among numerous reports. In the study by Schaff and colleagues2 donor blood requirements were halved in patients in whom the Sorenson system was used. Nonetheless, all patients also received donor blood in addition to their autologous transfusion. A similar 50% reduction in blood use was reported by Adan and colleagues who were likewise unable to avoid the use of donor blood completely Finally, the Cleveland Clinic experience with the Sorenson system was reported by Thurer et al.Surprisingly, in this study the patients allocated to the autotransfusion group received more donor blood than the controls. The explanations given were that multiple conservation techniques had limited the effects of reinfusion and that conserved red cell mass was diminished because of a low packed cell volume in the drain fluid. So what is the place of the Sorenson system? If used as originally intended it has an obvious role in blood conservation. Its use following cardiac surgery is less easy to justify. With low losses the fluid is discarded; with high losses a coagulopathy may develop and donor blood transfusion is not entirely prevented. Thus this system may simply exchange risks without a guaranteed benefit. 1. Noon GP. Intraoperative autotransfusion. Surgery 1978; 84: 719-21. 2. Schaff HV, Hauer JM, Bell WR, et al. Autotransfusion of shed mediastinal blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 1978; 75: 632-41. 3. Hartz RS, Smith JA, Green D. Autotransfusion after cardiac operations. J Thorac Cardiovasc Surg 1988; 96: 178-82. 4. Fuller JA, Buxton BF, Picken J, Harris RA, Davies MJ. Haematological effects of reinfused mediastinal blood after cardiac surgery. Med J Aust 1991; 154: 737-40. 5. Thurer RL, Lytle BW, Cosgrove DM, Loop FD. Autotransfusion following cardiac operations: a randomised prospective study. Ann Thorac Surg 1979; 27: 500-07. 6. Johnson RG, Rosenkranz KR, Preston RA, Hopkins C, Daggett WM. The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 1983; 36: 173-79. 7. Moore EE, Dunn EL, Breslich DJ, Galloway WB. Platelet abnormalities associated with massive autotransfusion. J Trauma 1980; 20: 1052-56. 8. Standards of Blood Banks and Transfusion Services. 13th ed. Arlington, Virginia: American Association of Blood Banks, 1989. 9. Royston D, Bidstrup BP, Taylor KM, Sapsford RN. Effect of aprotinin on need for blood transfusions after repeat open heart surgery. Lancet 1987; ii: 1289-91. 10. Adan A, Brutel de la Riviere A, Haas F, et al. Autotransfusion of drained mediastinal blood: a reappraisal. Thorac Cardiovasc Surg 1988; 36: 10-14.
5. Christie AJ, Weinberger KA, Dietrich M. Silicone lymphadenopathy and synovitis. Complications of silicone elastomer finger joint prostheses. JAMA 1977; 237: 1463-64. 6. Gordon M, Bullough PG. Synovial and osseous inflammation in failed silicone-rubber prostheses. J Bone Joint Surg 1982; 64A: 574-80. 7. Worsing RA Jr, Engber WE, Lange TA. Reactive synovitis from particulate silastic. J Bone Joint Surg 1982; 64A: 581-85. 8. Rosenthal DI, Rosenberg AE, Schiller AL, Smith RJ. Destructive arthritis due to silicone: a foreign-body reaction. Radiology 1983; 149: 69-72. 9. Marquardt E. Drohender Plastiche bei Operationen Knochendurchspiessung am Kindlichen Oberarmstumpf: eine Vorläufige Mitteilung. Z Orthop 1976; 114: 711-14. 10. Martini AK, Marquardt E. Stump plasty on congenital amputations. Garyounis Med J 1980; 3 (suppl): 83-86. 11. Bernd L, Blasius K, Lukoschek M, Lucke R. The autologous stump plasty: treatment for bony overgrowth in juvenile amputees. J Bone Joint Surg 1991; 73B: 203-06.
Autotransfusion then and
now
Successful cardiac surgery depends heavily on the of blood and blood products. The perceived risks of blood transfusion have lately kindled an interest in blood conservation techniques such as salvage and reinfusion of the fluid shed from the wound. The simplest salvage method was described by Noon in 19781 and is marketed as the Sorenson system. He described an apparatus for intraoperative use whereby blood was first anticoagulated with citrate and then aspirated under aseptic conditions through two 170 um filters into a reservoir before infusion. As now used, the fluid that is drained is not anticoagulated because it has undergone natural defibrination in the chest. This fluid is similar to old bank blood in that it is virtually devoid of clotting factors, but additionally has a very low fibrinogen concentration. Unlike homologous blood and blood salvaged intraoperatively1 it has a low packed cell volume (typically 15-25%) and contains considerable amounts of free haemoglobin and products of clot lysis. In view of the nature of this fluid it is surprising that thrombocytopenia, coagulopathies/,3,5,6 or impaired renal function35 have not been clinically evident after reinfusion, but the investigations were carried out in patients who received modest volumes. With reinfusion of larger volumes platelet function is deranged,and mild coagulopathy has also been found. The observation that the thrombin time is extended in direct relation to the volume reinfused is especially noteworthy. These data need confirmation in patients who have greater postoperative losses-eg, those taking aspirin or undergoing reoperations, who may benefit most from this system. Worries about the possibility of producing a bleeding diathesis are overshadowed by concerns of increased infection risk. Schaff et aF reported that as many as one in six of infusates were culture positive. This was said to be irrelevant clinically since infection and positive blood cultures were not observed in patients with culture-positive mediastinal drainage fluid.2,5 Despite these reassurances the same investigators discarded the drain losses from 16-48% use
of the patients because there was insufficient volume collected during a fixed time; they also limited the use of the system in patients having valve surgery. The potential for bacterial contamination has led to the recommendation of a 6-hour upper limit on the time between collection of blood and its reinfusion.8 It follows that if there is only very slight postoperative bleeding because of careful surgical technique or pharmacological intervention with aprotinin,9 this infection risk will probably lead to the drain losses being discarded. If the user judges that haematological and bacteriological safety are acceptable the remaining question is the efficacy of the system. Here the data are less persuasive. There are three randomised prospective studies among numerous reports. In the study by Schaff and colleagues2 donor blood requirements were halved in patients in whom the Sorenson system was used. Nonetheless, all patients also received donor blood in addition to their autologous transfusion. A similar 50% reduction in blood use was reported by Adan and colleagues who were likewise unable to avoid the use of donor blood completely Finally, the Cleveland Clinic experience with the Sorenson system was reported by Thurer et al.Surprisingly, in this study the patients allocated to the autotransfusion group received more donor blood than the controls. The explanations given were that multiple conservation techniques had limited the effects of reinfusion and that conserved red cell mass was diminished because of a low packed cell volume in the drain fluid. So what is the place of the Sorenson system? If used as originally intended it has an obvious role in blood conservation. Its use following cardiac surgery is less easy to justify. With low losses the fluid is discarded; with high losses a coagulopathy may develop and donor blood transfusion is not entirely prevented. Thus this system may simply exchange risks without a guaranteed benefit. 1. Noon GP. Intraoperative autotransfusion. Surgery 1978; 84: 719-21. 2. Schaff HV, Hauer JM, Bell WR, et al. Autotransfusion of shed mediastinal blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 1978; 75: 632-41. 3. Hartz RS, Smith JA, Green D. Autotransfusion after cardiac operations. J Thorac Cardiovasc Surg 1988; 96: 178-82. 4. Fuller JA, Buxton BF, Picken J, Harris RA, Davies MJ. Haematological effects of reinfused mediastinal blood after cardiac surgery. Med J Aust 1991; 154: 737-40. 5. Thurer RL, Lytle BW, Cosgrove DM, Loop FD. Autotransfusion following cardiac operations: a randomised prospective study. Ann Thorac Surg 1979; 27: 500-07. 6. Johnson RG, Rosenkranz KR, Preston RA, Hopkins C, Daggett WM. The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 1983; 36: 173-79. 7. Moore EE, Dunn EL, Breslich DJ, Galloway WB. Platelet abnormalities associated with massive autotransfusion. J Trauma 1980; 20: 1052-56. 8. Standards of Blood Banks and Transfusion Services. 13th ed. Arlington, Virginia: American Association of Blood Banks, 1989. 9. Royston D, Bidstrup BP, Taylor KM, Sapsford RN. Effect of aprotinin on need for blood transfusions after repeat open heart surgery. Lancet 1987; ii: 1289-91. 10. Adan A, Brutel de la Riviere A, Haas F, et al. Autotransfusion of drained mediastinal blood: a reappraisal. Thorac Cardiovasc Surg 1988; 36: 10-14.
