HARDWARE REINFUSION OF AUTOBLOOD FOR POLYTRAUMA WITH MASSIVE BLOOD LOSS
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Massive blood loss, which accompanies opened reposition of pelvic bones and transpedicular fixation of the spine, is one of the pathogenetic factors of thrombogenesis. Considering the morphologic and structural degradation of donor red blood cells, they may realize the gas transport function not less than after 24 hours from the moment of entry to the recipient’s body [1]. Transfused donor red blood cells worsen the condition of microcirculation in the patient and create some premises for development of DIC and thrombotic complications, especially in cases of acute blood loss. Only autogenic blood precludes the recipient’s hypersusceptibility to various donor antigens. Therefore, there is a possibility for increasing its reinfusion rate [2, 3, 4]. The levels of metabolites in the blood (mainly, lactate) reflects the level of neurovegetative protection from surgical aggression [5, 6]. Time course of lactatemia is used as a criterion of efficient management and a predictor of worsening condition [7], but APACHE III allows objective estimation of changes in severity of patient’s condition [8].
Objective – to investigate the influence of the methods for replacement of blood loss on the values of central hemodynamics, metabolism, severity of state of patients and rates of thrombotic complications during operations relating to acute massive blood loss.
MATERIALS AND METHODS
The controlled randomized study included 60 patients with massive blood loss. The main group (n = 30) received hardware reinfusion of autoblood with use of the blood separators DIDECO Compact-A (Italy) or BRAT 2 (Sweden). The control group (n = 30) received blood replacement with the components of donor blood. Surgical interventions were conducted: opened reposition and internal fixation of the pelvic ring, the acetabulum and various types of spondylodesis in uncomplicated spine injuries in conditions of general anesthesia with ALV.
General blood analysis with calculation of all formed elements was conducted with the hematological analyzer Sysmex – Xti 2000 (Japan).
Control and monitoring of values of ECG, HR, non-invasive AP and SpO2 were realized with the monitors Space Labs 90651A (USA), U4000 F (China), Philips C3 (France). Blood oxygen saturation was conducted with estimation of SpO2 by means of Mini SPO2T (the model 503DX).
Central venous hemodynamics was estimated with tetrapolar rheography (TR) with the hardware-software rheographic device MITSAR-RHEO (Russia). Rheograms were analyzed with WINREO 1.0. The following values were estimated: heart rate (HR, beats per min), stroke volume (SV, ml), cardiac output (CO, l/min), cardiac index (CI, l/min/m2) and total peripheral vascular resistance (TPVR, c.u.). Oxygen consumption (VO2, ml/min/m2) was calculated with Fick's equation: VO2 = Ñ õ (ÑàÎ2 – ÑvÎ2) as a derivative of cardiac output and arteriovenous difference in oxygen levels [9].
Ultrasonic vascular examination was made with duplex scanning (DS) with the ultrasonic scanners My Lab Class C (Italy) and Sono Scape S6 (China) in the mode of gray scale and color mapping according to the common technique (three-dimensional scanning). The leg, popliteal and femoral veins were scanned with the lineal transducers (7.14 MHz), the iliac veins – with the convex transducer (3-5 MHz) [10].
RESULTS AND DISCUSSION
There were no differences in the volume of blood loss: 2,380 ± 320 ml in the main group, and 2,290 ± 229.m ml in the control group.
Donor packed red blood cells were not used in the main group. The control group received 978 ± 112.3 ml of donor packed red blood cells. Autoblood reinfusion required less volume of infusion-transfusion therapy (5,206 ± 178.4 ml) in comparison with the control group (5,912 ± 234.1 ml) that is explained by better hemodynamic and oxygen transport properties of autologous red blood cells.
For investigation of influence of the ways of blood loss replacement on the qualitative composition of peripheral blood over time we measured the values upon admission, at the level of blood loss, 6 and 24 hours after surgery (the table 1).
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Table 1 - The values of peripheral blood in the examined groups over time (Ì ± δ) |
| Note: * - p < 0.05, intergroup difference. |
Considering the received data one may conclude about higher laboratory values of peripheral blood at the level of blood loss and after surgery in the main group. It proves that one of the main advantages of hardware autohemotransfusion is reducing time before initiation of qualitative replacement of lost circulating blood.
Decreasing amount of red blood cells in the control group and the increasing difference in their contents (by 15 %) after 24 hours is possibly explained by earlier sequestration of transfused donor red blood cells in the recipient’s body. As result, the volume of donor packed red blood cells (transfused within 10 days after surgery) was 4 times lower in the main group (475 ± 88.33 ml) in comparison with the control group (2,031 ± 129.8 ml).
The cell composition of the prepared concentrate of autologous red blood cells was similar to whole blood. The mean values for red blood cells were 4.4 ± 0.2 ´ 1012/l, hematocrit – 41 ± 2 %, hemoglobin – 126.2 ± 5.9 g/l, platelets – 8.2 ± 1.42 ´ 109/l.
The values of hemodynamics are the important criteria for adequate replacement of blood loss. After consideration of influence of the program of infusion-transfusion therapy with hardware autohemotransfusion on the state of hemodynamics in patients with acute massive blood loss one may conclude that such technique allows reducing time of arresting shock by means of normalizing values of central and peripheral hemodynamics in early postsurgical period. The hemodynamic values at the level of blood loss did not change significantly and showed the loss of volemic intravascular volume (the table 2).
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Table 2 ‒ The values of central hemodynamics in the patients in postsurgical period (M ± δ) |
| Note: * - p < 0.05, intergroup difference; | ||
| ** - p < 0.05, difference between basic values in the group. |
Decrease in stroke volume (SV) in the control group was compensated by increasing HR. The statistically significant difference was found in MAP, HR and TPVR between the groups. Considering the higher total volume of infusion-transfusion therapy in the control group, the decrease in these values is explained by faster replacement of the cell composition of the blood with use of autoblood reinfusion in the main group. Since the blood is a non-Newtonian fluid, it is characterized by different velocity of the rate and different viscosity in dependence on hematocrit; here also shearing rate changes during making influence on the vascular endothelium. Anemia leads to decreasing blood viscosity that resulted in 13 % decreasing TPVR and 10 % decreasing systemic arterial pressure in comparison with the study group. Such changes evened out in the postsurgical period. It is possibly associated with transfusion of donor blood.
The conducted study did not find any statistically significant differences in values of oxygen status upon admission and at the level of blood loss. Upon hospital admission the delivery (DO2) and consumption of oxygen (VO2) were within the low values. It was associated with moderate anemia and hypovolemia with some decrease in cardiac output. Oxygen delivery decreased at the level of blood loss in both groups, with less intense decrease in the main group in comparison with the control one. It is due to more rapid replacement of blood loss by means of reinfusion of autologous red blood cells that results in early normalization of oxygen transport function by means of normalizing hemic component in the main group.
The response of sympathetic system to blood loss causes some disorders in tissue capillary blood flow, gas exchange and lactate accumulation. The increasing lactate levels in the blood of the patients of the control group was reliably higher (4.9 ± 0.8 mmol/l) in comparison with the main group (3.6 ± 0.4 mmol/l) both at the level of blood loss and in early postsurgical period. It means the insufficient level of neurovegetative protection from surgical aggression in the control group. After consideration of previously identified decrease in the values of central hemodynamics and oxygen consumption in the control group one may conclude that tactics of transfusion therapy with donor blood does not provide adequate replacement of blood loss.
APACHE III was used for estimation of severity of the patients’ condition in massive blood loss. The comparative estimation of severity of condition after 2-6 hours after surgery show adequacy of tactics of infusion-transfusion therapy (the table 3).
| Table 3 ‒ State severity according to APACHE III in the patients in the groups (M ± δ) |
Severity of postsurgical condition in the main group has changed towards positive direction by 5.86 %. The control group showed the worsening condition by 11.6 % from the basic level, with 19.2 % difference from the main group. The clinical manifestations included arterial hypotony, tachycardia and prolonged ALV in comparison with the presurgical period. The laboratory examination showed severe anemia, hypoproteinemia, some disorders of acid-base balance. The change in severity of condition is associated with the technique of blood loss replacement considering the absence of differences in basic condition, patterns and magnitude of blood loss.
The patients received DS within the postsurgical period. A total of 36 cases (73.5 %) of venous thrombosis were identified. The rates of thrombotic complications and occlusive thrombosis were 34 % (χ2 = 5.424, ð = 0.020) and 16 % lower (p > 0.05) in the main group. There were no floating embolic thrombosis and events of PE (the table 4).
| Table 4 ‒ Thrombotic complications in the patients with massive blood loss |
Early replacement of the volume and the qualitative characteristics of circulating blood is one of the most important objectives in treatment of massive blood loss.
CONCLUSION
1. Use of intrasurgical hardware reinfusion of red blood cells results in faster and more adequate replacement of acute massive blood loss, with restoration of hematological and biochemical values of the blood in early postsurgical period.
2. Stabilization of systemic hemodynamics and oxygen transport allows decreasing severity of condition in massive blood loss and results in decreasing rate of thrombotic complications.