Letters to the Editor
Table 1. Contingency Table for Propofol Vial Coring with Blunt Fill Needles: Straight Versus Acute Angle Puncture No core 177 228 405
Perpendicular puncture Angle puncture Total
Core 73 41 114
Total 250 269 519
References 1. Roth JV. How to enter a medication vial without coring. Anesth Analg 2007;104:1615 2. Chaudry T, Serdiuk A: Coring and fragmentation may occur with rubber cap and blunt needles. APSF Newsletter 2013; 27: 68 3. Kirkpatrick CJ, Lehr HA, Otto M, Bittinger F, Rangoonwala R: Clinical implications of circulating particulate contamination of parenteral injections: a review. Critical Care and Shock 1999: 166–73 4. Nyabadza M. Preventing latex sensitisation and foreign body micro-emboli. Anaesthesia 2001;56:705
salvaged blood in cardiac surgery patients. Anesth Analg 2014;118:1179–87 2. Harm SK, Waters JH, Lynn P, Dyga R, Raval JS, DiMarco RF, Yazer MH. Changes in mechanical fragility and free hemoglobin levels after processing salvaged cardiopulmonary bypass circuit blood with a modified ultrafiltration device. J Extra Corpor Technol 2012;44:21–5 3. Beckmann S, Lynn P, Miller S, Harris R, DiMarco RF, Ross JE. Evaluation of coagulation factors and platelet function from an off-line modified ultrafiltration technique for postcardiopulmonary bypass circuit blood recovery. Perfusion 2013;28:214–22 4. McNair E, McKay W, Qureshi AM, Rosin M, Gamble J, Dalshaug G, Mycyk T, Prasad K. Outcomes and biochemical parameters following cardiac surgery: effects of transfusion of residual blood using centrifugation and multiple-pass hemoconcentration. J Cardiothorac Vasc Anesth 2013;27:1174–80 DOI: 10.1213/ANE.0000000000000620
DOI: 10.1213/ANE.0000000000000599
In Response
Still Missing Something Huge To the Editor
A
lthough we thank Frank et al. for characterizing the difference in red cell deformability between stored allogeneic blood and autologous salvaged blood after transfusion in patients undergoing cardiac surgery,1 there is still a vital element missing that is critical to recovering salvaged blood. When cardiopulmonary bypass is concluded, patients have on average a hematocrit of 25%, but approximately 75% of this salvaged blood volume is discarded to a waste bag. In other words, what is not mentioned is the loss of essential autologous plasma, rich with functional platelets, fibrinogen, and other essential clotting factors and proteins. Currently, new modalities exist to treat this loss associated with autologous salvaged blood. Multipass ultrafiltration (or off-line MUF) performed at the conclusion of cardiopulmonary bypass preserves these valuable coagulation factors, proteins, and platelets. This process requires little time, causing no delay to surgery, mediastinal closure, or protamine reversal, and immediately improves coagulation parameters.2–4 Ben Miller, MD Kai Engstad, MD Randy Bissinger, MD John Ross, MD Scott R. Beckmann, CCP Department Cardiovascular Anesthesia Salem Hospital Salem, Oregon [email protected] David Moskowitz, MD CV Anesthesia Englewood Medical Center Englewood, New Jersey REFERENCES 1. Salaria ON, Barodka VM, Hogue CW, Berkowitz DE, Ness PM, Wasey JO, Frank SM. Impaired red blood cell deformability after transfusion of stored allogeneic blood but not autologous
April 2015 • Volume 120 • Number 4
Beckmann et al.1 raise an important issue regarding patient blood management during cardiac surgery, which is the conservation of autologous blood. Our original article2 and their letter1 agree that reusing fresh autologous blood is preferred over transfusion with stored allogeneic blood. Our study demonstrated that salvaged (and washed) fresh red blood cells (RBCs) are of higher quality compared with stored allogeneic RBCs because RBC cell membrane deformability is preserved. In fact, we have previously shown that despite the 42-day storage limit, 21 days may be the threshold for RBC storage, beyond which deformability is impaired, and that this structural change in the cell membrane may be irreversible after transfusion.3 The exact method used for conserving autologous blood, whether it be blood salvaged using washed RBCs, modified ultrafiltration,4 or some other method of hemoconcentration, is an important topic for discussion, specific to blood conservation in patients undergoing cardiac surgery. Although RBC cell membrane deformability after ultrafiltration has not specifically been studied, there is convincing evidence suggesting that this method of blood conservation reduces transfusion requirements and perioperative morbidity.5 We also recognize the evidence suggesting that coagulation may be better preserved with hemoconcentrated blood compared with salvaged washed blood.4 Any method used to return fresh autologous RBCs to the circulation, thus reducing the need for stored allogeneic transfusions, would seem to be desirable for a variety of reasons, and on this point, we agree completely with Beckmann et al. Steven M. Frank, MD Viachaslau M. Barodka, MD Department of Anesthesiology/Critical Care Medicine The Johns Hopkins Medical Institutions Baltimore, Maryland [email protected] Herbert L. Harness, CCP Department of Perfusion The Johns Hopkins Medical Institutions Baltimore, Maryland
www.anesthesia-analgesia.org
955
Table 1. Contingency Table for Propofol Vial Coring with Blunt Fill Needles: Straight Versus Acute Angle Puncture No core 177 228 405
Perpendicular puncture Angle puncture Total
Core 73 41 114
Total 250 269 519
References 1. Roth JV. How to enter a medication vial without coring. Anesth Analg 2007;104:1615 2. Chaudry T, Serdiuk A: Coring and fragmentation may occur with rubber cap and blunt needles. APSF Newsletter 2013; 27: 68 3. Kirkpatrick CJ, Lehr HA, Otto M, Bittinger F, Rangoonwala R: Clinical implications of circulating particulate contamination of parenteral injections: a review. Critical Care and Shock 1999: 166–73 4. Nyabadza M. Preventing latex sensitisation and foreign body micro-emboli. Anaesthesia 2001;56:705
salvaged blood in cardiac surgery patients. Anesth Analg 2014;118:1179–87 2. Harm SK, Waters JH, Lynn P, Dyga R, Raval JS, DiMarco RF, Yazer MH. Changes in mechanical fragility and free hemoglobin levels after processing salvaged cardiopulmonary bypass circuit blood with a modified ultrafiltration device. J Extra Corpor Technol 2012;44:21–5 3. Beckmann S, Lynn P, Miller S, Harris R, DiMarco RF, Ross JE. Evaluation of coagulation factors and platelet function from an off-line modified ultrafiltration technique for postcardiopulmonary bypass circuit blood recovery. Perfusion 2013;28:214–22 4. McNair E, McKay W, Qureshi AM, Rosin M, Gamble J, Dalshaug G, Mycyk T, Prasad K. Outcomes and biochemical parameters following cardiac surgery: effects of transfusion of residual blood using centrifugation and multiple-pass hemoconcentration. J Cardiothorac Vasc Anesth 2013;27:1174–80 DOI: 10.1213/ANE.0000000000000620
DOI: 10.1213/ANE.0000000000000599
In Response
Still Missing Something Huge To the Editor
A
lthough we thank Frank et al. for characterizing the difference in red cell deformability between stored allogeneic blood and autologous salvaged blood after transfusion in patients undergoing cardiac surgery,1 there is still a vital element missing that is critical to recovering salvaged blood. When cardiopulmonary bypass is concluded, patients have on average a hematocrit of 25%, but approximately 75% of this salvaged blood volume is discarded to a waste bag. In other words, what is not mentioned is the loss of essential autologous plasma, rich with functional platelets, fibrinogen, and other essential clotting factors and proteins. Currently, new modalities exist to treat this loss associated with autologous salvaged blood. Multipass ultrafiltration (or off-line MUF) performed at the conclusion of cardiopulmonary bypass preserves these valuable coagulation factors, proteins, and platelets. This process requires little time, causing no delay to surgery, mediastinal closure, or protamine reversal, and immediately improves coagulation parameters.2–4 Ben Miller, MD Kai Engstad, MD Randy Bissinger, MD John Ross, MD Scott R. Beckmann, CCP Department Cardiovascular Anesthesia Salem Hospital Salem, Oregon [email protected] David Moskowitz, MD CV Anesthesia Englewood Medical Center Englewood, New Jersey REFERENCES 1. Salaria ON, Barodka VM, Hogue CW, Berkowitz DE, Ness PM, Wasey JO, Frank SM. Impaired red blood cell deformability after transfusion of stored allogeneic blood but not autologous
April 2015 • Volume 120 • Number 4
Beckmann et al.1 raise an important issue regarding patient blood management during cardiac surgery, which is the conservation of autologous blood. Our original article2 and their letter1 agree that reusing fresh autologous blood is preferred over transfusion with stored allogeneic blood. Our study demonstrated that salvaged (and washed) fresh red blood cells (RBCs) are of higher quality compared with stored allogeneic RBCs because RBC cell membrane deformability is preserved. In fact, we have previously shown that despite the 42-day storage limit, 21 days may be the threshold for RBC storage, beyond which deformability is impaired, and that this structural change in the cell membrane may be irreversible after transfusion.3 The exact method used for conserving autologous blood, whether it be blood salvaged using washed RBCs, modified ultrafiltration,4 or some other method of hemoconcentration, is an important topic for discussion, specific to blood conservation in patients undergoing cardiac surgery. Although RBC cell membrane deformability after ultrafiltration has not specifically been studied, there is convincing evidence suggesting that this method of blood conservation reduces transfusion requirements and perioperative morbidity.5 We also recognize the evidence suggesting that coagulation may be better preserved with hemoconcentrated blood compared with salvaged washed blood.4 Any method used to return fresh autologous RBCs to the circulation, thus reducing the need for stored allogeneic transfusions, would seem to be desirable for a variety of reasons, and on this point, we agree completely with Beckmann et al. Steven M. Frank, MD Viachaslau M. Barodka, MD Department of Anesthesiology/Critical Care Medicine The Johns Hopkins Medical Institutions Baltimore, Maryland [email protected] Herbert L. Harness, CCP Department of Perfusion The Johns Hopkins Medical Institutions Baltimore, Maryland
www.anesthesia-analgesia.org
955
