Better platelet function, less fibrinolysis and less hemolysis in re-transfused residual pump blood with the Ringer’s chase technique – a randomized pilot study

Olsson, Anki; Alfredsson, Joakim; Ramström, Sofia; Svedjeholm, Rolf; Kenny, Dermot; Håkansson, Eric; Berglund, Johan; Berg, Sören

doi:10.1177/0267659117733891

Cited by 6 publications

(8 citation statements)

References 17 publications

(20 reference statements)

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“…An alternative is to chase the residual blood into the circulation through the arterial cannula with Ringer's acetate solution. In a randomized study of 40 patients, 351 retransfusion of residual blood of the CPB circuit with the Ringer's chase technique was compared to the commonly used 'infusion bag' technique. In this study, the Ringer's chase technique was associated with betterpreserved platelet function, reduced haemolysis, fewer signs of coagulation and fibrinolysis.…”

Section: Description Of the Evidencementioning

confidence: 99%

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

Kunst

Milojevic

Boer

et al. 2019

British Journal of Anaesthesia

127

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Special Article responsible in the event of any contradiction, discrepancy and/or ambiguity between the EACTS, EACTA and EBCP Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the EACTS, EACTA and EBCP Guidelines fully into account when exercising their clinical judgement as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies; however, the EACTS, EACTA and EBCP Guidelines do not, in any way whatsoever, override the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and, where appropriate and/or necessary, in consultation with that patient and the patient's care provider. Nor do the EACTS, EACTA and EBCP Guidelines exempt health professionals from giving full and careful consideration to the relevant official, updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. The article has been co-published with permission in the British Journal of Anaesthesia, the European Journal of Cardio-Thoracic Surgery and the Interactive CardioVascular and Thoracic Surgery.

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Section: Description Of the Evidencementioning

confidence: 99%

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

Kunst

Milojevic

Boer

et al. 2019

British Journal of Anaesthesia

127

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“…Two grams of tranexamic acid (Pfizer AB, Sollentuna, Sweden) was given to all patients before and after CPB. The residual blood in the heart-lung machine was retransfused with the Ringer's chase-technique [16].…”

Section: Clinical Managementmentioning

confidence: 99%

Activated platelet aggregation is transiently impaired also by a reduced dose of protamine

Olsson

Alfredsson

Thelander

et al. 2019

Scandinavian Cardiovascular Journal

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Objectives: Protamine reduces platelet aggregation after cardiopulmonary bypass (CPB). We studied the inhibitory effect of a reduced protamine dose, the duration of impaired platelet function and the possible correlation to postoperative bleeding. Design: Platelet function was assessed by impedance aggregometry in 30 patients undergoing cardiac surgery with CPB at baseline, before protamine administration, after 70% and 100% of the calculated protamine dose, after 20 minutes and at arrival to the intensive care unit. Adenosine diphosphate (ADP), thrombin receptor activating peptide-6 (TRAP), arachidonic acid (AA) and collagen (COL) were used as activators. Blood loss was measured during operation and three hours after surgery. Results are presented as median (25th-75th percentile). Results: Platelet aggregation decreased markedly after the initial dose of protamine (70%) with all activators; ADP 89 (71-110) to 54 (35-78), TRAP 143 (116-167) to 109 (77-136), both p < .01; AA 25 (16-49) to 17 (12-24) and COL 92 (47-103) to 60 (38-81) U, both p < .05. No further decrease was seen after 100% protamine. The effect was transient and after twenty minutes platelet aggregation had started to recover; ADP 76 (54-106), TRAP 138 (95-158), AA 20 (10-35), COL 70 (51-93) U. Blood loss during operation correlated to aggregometry measured at baseline and after protaminization. Conclusions: Protamine after CPB induces a marked decrease in platelet aggregation already at a protamine-heparin ratio of 0.7:1. The impairment seems to be transient and recovery had started after 20 minutes.

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“…Finally, the 'Ringer's chase technique' protects platelet function in addition to less fibrinolysis and haemolysis. 16 The demonstrated perfusion strategy followed established techniques fulfilling class IIb recommendations verified by results from randomised clinical trials as summarised in the guidelines from EACTS and EACTA (European Association of Cardiothoracic Anaesthesiology). 29 It primarily included the use of a closed heparincoated CPB circuit, no retransfusion of shed blood and use of cell salvage, while the effects of reducing systemic heparinisation, together with the 'Ringer's chase technique' , remain unclassified.…”

Section: Discussionmentioning

confidence: 96%

“…At completion of CPB, the blood volume remaining in the circuit was displaced into the patient by adding 700 mL of Ringer’s acetate. 16 The residual blood volume post-CPB was salvaged.…”

Section: Methodsmentioning

confidence: 99%

Cardiopulmonary bypass and dual antiplatelet therapy: a strategy to minimise transfusions and blood loss

et al. 2019

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Background: Patients with preoperative dual antiplatelet therapy prior to coronary artery bypass surgery are at risk of bleeding and blood component transfusion. We hypothesise that an optimised cardiopulmonary bypass strategy reduces postoperative blood loss and transfusions. Methods: In total, 60 patients admitted for coronary artery bypass grafting with ticagrelor and aspirin medication withdrawn <96 hours before surgery were prospectively randomised into two equal sized groups. Cardiopulmonary bypass combined a closed Cortiva® heparin-coated circuit with low systemic heparinisation (activated clotting time < 250 seconds) and intraoperative cell salvage in the study group, whereas the control group used a Balance® coated open circuit, full systemic heparinisation (activated clotting time > 480 seconds) and conventional cardiotomy suction. This perfusion strategy was evaluated by the chest drain volume after 24 hours, perioperative haemoglobin and platelet loss accompanied by global coagulation assessments. Results: Patients in the study group demonstrated significantly better outcomes signified by lower blood loss 554 ± 224 versus 1,100 ± 989 mL (p < 0.001), reduced packed red cell transfusion 7% versus 53% (p < 0.001), reduced haemoglobin −28 ± 15 versus −40 ± 14 g/L (p = 0.004) and platelet loss −35 ± 36 versus −82 ± 67 × 109/L (p = 0.001). Indices of rotational thromboelastometry indicated shorter clotting times within the internal and external pathways. Adenosine diphosphate activated platelet function was within normal range based on Multiplate® aggregometry, while ROTEM® platelet analyses indicated inhibited function both preoperatively and post-bypass. Platelet inhibition by aspirin was verified throughout the perioperative period. Platelet function showed no intergroup differences. Conclusion: A stringent perfusion strategy reduced blood loss and transfusions in dual antiplatelet therapy patients requiring urgent surgery.

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Better platelet function, less fibrinolysis and less hemolysis in re-transfused residual pump blood with the Ringer’s chase technique – a randomized pilot study

Abstract: The handling of blood after CPB increases hemolysis, impairs platelet function and activates coagulation and fibrinolysis. The RC technique preserved the blood better than the commonly used IB technique.

Cited by 6 publications

References 17 publications

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery

Activated platelet aggregation is transiently impaired also by a reduced dose of protamine

Cardiopulmonary bypass and dual antiplatelet therapy: a strategy to minimise transfusions and blood loss

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