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An Improved Technique for Autotransfusion of Shed Mediastinal Blood
HOW TO DO IT
An Improved Technique for
Autotransfusion of Shed Mediastinal Blood Delos M. Cosgrove, M.D., Daniel M. Amiot, C.C.P., and John J. Meserko, B.S., C.C.P.,M.B.A. ABSTRACT A technique for autotransfusion of shed mediastinal blood using the cardiotomy reservoir is d e scribed that offers several advantages over currently available autotransfusion systems. To reduce transfusion requirements associated with cardiac surgery, techniques have been developed to salvage shed blood. In 1978, Schaff and co-workers [l] described autotransfusion of shed mediastinal blood. They demonstrated the safety and efficacy of this technique, as did Thurer and associates (21 the following year. Johnson and colleagues [3]found that autotransfusioncan reduce blood requirements for cardiac surgical patients. Acceptance of the application of this concept has been slow because of problems with the present means of implementation. The currently available devices are inconvenient to use, costly, and prone to obstruction by clots, and have the potential for bacterial contamination. In 1980, Weniger and associates [4] reported using the cardiotomy reservoir for autotransfusion of shed mediastinal blood. The cardiotomy reservoir alleviates these problems, and its use has become routine: it has been employed in more than 2,000 patients at The Cleveland Clinic.
Technique After the cardiotomy reservoir has served its original function as an integral part of the cardiopulmonary bypass circuit, the unit is configured to serve as a receptacle for postoperative mediastinal drainage. Bypass tubing is removed from the inlet ports, and they are sealed with sterile caps. These inlet ports will eventually be connected to the tubes draining the mediastinum. The cardiotomy outlet tubing is removed and replaced with an adapter that converts the 9.5-mm port to standard intravenous tubing. At the conclusion of the operation, the chest tubes are attached to the inlet ports of the cardiotomy, which allows the chest tube drainage to pass through a 20-um filter. The filtered blood collects in the bottom of the cardiotomy reservoir, ready for reinfusion. The desired amount of negative pressure is applied to the cardiotomy reservoir, and collected blood is reinfused usFrom the Department of Thoracic and Cardiovascular Surgery and the Department of Cardiovascular Perfusion, The Cleveland Clinic Foundation, Cleveland, OH.
Fig I. Blood collected in the cardiotomy reservoir is reinfused hourly using a standard infusion pump.
ing a standard infusion pump (Fig 1). Every hour, mediastinal drainage is measured and the infusion pump is adjusted to deliver this amount of blood during the next hour. Reinfusion is continued as long as the patient has substantial chest tube drainage. The cardiotomy reservoir continues to function as a chest bottle until the chest tubes are removed. This technique maintains hemodynamic stability by immediate reinfusion of lost blood and reduces the potential for bacterial contamination by minimizing extracorporealtime and maintaining a closed system. In approximately 1%of patients, the cardiotomy filter becomes obstructed with clot. When this occurs, satisfactory chest tube drainage may be prevented. To alleviate the problem, a shunt is placed between the nonfiltered rapid prime port and the filtered portion of the cardiotomy. This shunt maintains constant negative pressure on the chest tube, even when the filter becomes obstructed with clot (Fig 2).
Accepted for publication Dec 7, 1984.
Comment
Address reprint requests to Lh.Cosgrove, The Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44106.
Conversion of the cardiotomy reservoir to a mediastinal drainage system, chest tubes with connecting tubing,
519
520 The Annals of Thoracic Surgery Vol 40 No 5 November 1985
CLOTTED FILTER
C L O T T E D FILTER WITH SHUN1
costs by 108% for one autotransfusion, 172% for two autotransfusions, and 201% for three autotransfusions. The cardiotomy reservoir system offers several advantages over other currently available methods of autotransfusion. First, the risk of contamination is decreased by maintenance of a closed system. Second, the integral 20-pm filter provides improved filtration of mediastinal drainage. Third, greater hemodynamic stability is achieved by the continuous relnfusion of shed blood. Fourth, the system is cost-effective, and it is readily accepted by the nursing personnel because it is easy to use and minimal labor is required. Finally, the system is applicable for use in patients who are Jehovah’s Witnesses.
References
Fig 2 . A shunt between the nonfiltered rapid prime port and the filtered portion of the cardwtomy reservoir maintains negative intrathoracic pressure if the filter becomes occluded with clot.
and autotransfusion of any amount of blood costs approximately $35.50. On the other hand, the Sorenson autotransfusionsystem (“spedMediastinal Drainage” List X45302-01; SR 79-138S; Salt Lake City, VT)increases
1. Schaff HV, Hauer JM,Bell WR, et al: Autotransfusion of shed mediastinal blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 75632, 1978 2. Thurer RL, Lytle BW, Cosgrove DM,Loop FD:Autotransfusion following cardiac operations: a randomized, prospective study. Ann Thorac Surg 27500, 1979 3. Johnson RG, Rosenkrantz KR, Preston RA, et ak The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 36A73, 1983 4. Weniger J, von der Emde J, Schricker KT, Blechsdunidt J: Retransfusionvon Drainageblut nach herzchirurgischen Eingnffen. Langenbecks Arch Chir 351229, 1980
An Improved Technique for
Autotransfusion of Shed Mediastinal Blood Delos M. Cosgrove, M.D., Daniel M. Amiot, C.C.P., and John J. Meserko, B.S., C.C.P.,M.B.A. ABSTRACT A technique for autotransfusion of shed mediastinal blood using the cardiotomy reservoir is d e scribed that offers several advantages over currently available autotransfusion systems. To reduce transfusion requirements associated with cardiac surgery, techniques have been developed to salvage shed blood. In 1978, Schaff and co-workers [l] described autotransfusion of shed mediastinal blood. They demonstrated the safety and efficacy of this technique, as did Thurer and associates (21 the following year. Johnson and colleagues [3]found that autotransfusioncan reduce blood requirements for cardiac surgical patients. Acceptance of the application of this concept has been slow because of problems with the present means of implementation. The currently available devices are inconvenient to use, costly, and prone to obstruction by clots, and have the potential for bacterial contamination. In 1980, Weniger and associates [4] reported using the cardiotomy reservoir for autotransfusion of shed mediastinal blood. The cardiotomy reservoir alleviates these problems, and its use has become routine: it has been employed in more than 2,000 patients at The Cleveland Clinic.
Technique After the cardiotomy reservoir has served its original function as an integral part of the cardiopulmonary bypass circuit, the unit is configured to serve as a receptacle for postoperative mediastinal drainage. Bypass tubing is removed from the inlet ports, and they are sealed with sterile caps. These inlet ports will eventually be connected to the tubes draining the mediastinum. The cardiotomy outlet tubing is removed and replaced with an adapter that converts the 9.5-mm port to standard intravenous tubing. At the conclusion of the operation, the chest tubes are attached to the inlet ports of the cardiotomy, which allows the chest tube drainage to pass through a 20-um filter. The filtered blood collects in the bottom of the cardiotomy reservoir, ready for reinfusion. The desired amount of negative pressure is applied to the cardiotomy reservoir, and collected blood is reinfused usFrom the Department of Thoracic and Cardiovascular Surgery and the Department of Cardiovascular Perfusion, The Cleveland Clinic Foundation, Cleveland, OH.
Fig I. Blood collected in the cardiotomy reservoir is reinfused hourly using a standard infusion pump.
ing a standard infusion pump (Fig 1). Every hour, mediastinal drainage is measured and the infusion pump is adjusted to deliver this amount of blood during the next hour. Reinfusion is continued as long as the patient has substantial chest tube drainage. The cardiotomy reservoir continues to function as a chest bottle until the chest tubes are removed. This technique maintains hemodynamic stability by immediate reinfusion of lost blood and reduces the potential for bacterial contamination by minimizing extracorporealtime and maintaining a closed system. In approximately 1%of patients, the cardiotomy filter becomes obstructed with clot. When this occurs, satisfactory chest tube drainage may be prevented. To alleviate the problem, a shunt is placed between the nonfiltered rapid prime port and the filtered portion of the cardiotomy. This shunt maintains constant negative pressure on the chest tube, even when the filter becomes obstructed with clot (Fig 2).
Accepted for publication Dec 7, 1984.
Comment
Address reprint requests to Lh.Cosgrove, The Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44106.
Conversion of the cardiotomy reservoir to a mediastinal drainage system, chest tubes with connecting tubing,
519
520 The Annals of Thoracic Surgery Vol 40 No 5 November 1985
CLOTTED FILTER
C L O T T E D FILTER WITH SHUN1
costs by 108% for one autotransfusion, 172% for two autotransfusions, and 201% for three autotransfusions. The cardiotomy reservoir system offers several advantages over other currently available methods of autotransfusion. First, the risk of contamination is decreased by maintenance of a closed system. Second, the integral 20-pm filter provides improved filtration of mediastinal drainage. Third, greater hemodynamic stability is achieved by the continuous relnfusion of shed blood. Fourth, the system is cost-effective, and it is readily accepted by the nursing personnel because it is easy to use and minimal labor is required. Finally, the system is applicable for use in patients who are Jehovah’s Witnesses.
References
Fig 2 . A shunt between the nonfiltered rapid prime port and the filtered portion of the cardwtomy reservoir maintains negative intrathoracic pressure if the filter becomes occluded with clot.
and autotransfusion of any amount of blood costs approximately $35.50. On the other hand, the Sorenson autotransfusionsystem (“spedMediastinal Drainage” List X45302-01; SR 79-138S; Salt Lake City, VT)increases
1. Schaff HV, Hauer JM,Bell WR, et al: Autotransfusion of shed mediastinal blood after cardiac surgery: a prospective study. J Thorac Cardiovasc Surg 75632, 1978 2. Thurer RL, Lytle BW, Cosgrove DM,Loop FD:Autotransfusion following cardiac operations: a randomized, prospective study. Ann Thorac Surg 27500, 1979 3. Johnson RG, Rosenkrantz KR, Preston RA, et ak The efficacy of postoperative autotransfusion in patients undergoing cardiac operations. Ann Thorac Surg 36A73, 1983 4. Weniger J, von der Emde J, Schricker KT, Blechsdunidt J: Retransfusionvon Drainageblut nach herzchirurgischen Eingnffen. Langenbecks Arch Chir 351229, 1980