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Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine
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CME Released: 10/13/2004
Valid for credit through: 10/13/2005, 11:59 PM EST
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Oct. 13, 2004 -- Reconstituted blood (packed red blood cells with fresh-frozen plasma) is preferred over fresh whole blood for priming the pump for neonatal heart surgery, according to the results of a randomized trial published in the Oct. 14 issue of the New England Journal of Medicine.
"In an attempt to reduce the coagulopathic and inflammatory responses seen after cardiopulmonary bypass, the use of fresh whole blood during heart operations has become the standard of care for neonates and infants at many institutions," write Steven S. Mou, MD, from the University of Texas Southwestern Medical Center in Dallas, and colleagues. "Proponents of this approach cite two main advantages over conventional priming with packed red cells and fresh-frozen plasma: improved postoperative hemostasis and decreased systemic inflammation that results in reduced postoperative edema formation and organ dysfunction. Opponents of the use of fresh whole blood point to logistic difficulties associated with its procurement and expedited testing, as well as the loss of blood-center inventory in the form of products of blood separation."
In this single-center, double-blind trial, children younger than one year who underwent open-heart surgery were randomized to receive either fresh whole blood collected not more than 48 hours previously (96 patients) or reconstituted blood (104 patients) for bypass-circuit priming.
Compared with the group that received fresh whole blood, the group that received reconstituted blood had a shorter stay in the intensive care unit (70.5 vs 97.0 hours; P = .04) and a smaller cumulative fluid balance at 48 hours (-6.9 vs 28.8 mL/kg of body weight; P = .003). Both groups were similar in early postoperative chest-tube output, blood-product transfusion requirements, and levels of serum mediators of inflammation and cardiac troponin I.
"The use of fresh whole blood for cardiopulmonary bypass priming has no advantage over the use of a combination of packed red cells and fresh-frozen plasma during surgery for congenital heart disease," the authors write. "Moreover, circuit priming with fresh whole blood is associated with an increased length of stay in the intensive care unit and increased perioperative fluid overload.... In our opinion, these clinical hazards outweigh the risk of the additional donor exposure associated with reconstituted-blood priming."
The authors note that there is an additional blood-center charge of U.S. $110 for reconstituted blood therapy, but the extended stay in the intensive care unit associated with the use of fresh whole blood priming would result in additional charges of U.S. $5,750.
J.D. and Hallie Young and the Morrison Trust of San Antonio, Texas, supported this study.
In an accompanying perspective, L. Henry Edmunds, MD, from the Hospital of the University of Pennsylvania in Philadelphia, reviews the 50-year history of cardiopulmonary bypass, and Dr. Edmunds suggests that the future lies in creating a nonthrombogenic blood-surface interface.
"Achieving control of the blood-surface interface without altering the composition of blood, however, is prerequisite for realizing the extraordinary and exciting possibilities introduced by the invention of the heart-lung machine," Dr. Edmunds writes. "A surface that is truly nonthrombogenic, which consists of or is similar to a monolayer of endothelial cells, opens the door to the development of intracorporeal devices that can replace diseased parts of the cardiovascular system or that can process blood as done by the lung, liver, and kidney."
N Engl J Med. 2004;351:1603, 1635-1644
