What is exactly is Shed Blood?

James D. Ferguson
Seattle, Washington
September 8th-10th ,2011
The 4 Major Components of Blood
The AABB recommendations and STS
Guidelines for cell salvaging
What are the make-up and components of
“Shed Blood”
Clearly identify what is “Shed Blood” and
what is “Cardiotomy blood”
It’s time for Perfusion and the Cardiac Surgery
arena to clearly define the term “SHED BLOOD”:
I propose the following definitions:
“Cardiotomy Blood” – is the franc whole blood
that accumulates inside the pericardium coming
directly from a great vessel or the open heart
itself and should be returned via the cardiotomy
suction (Pump Sucker)
“Shed Blood” – is the blood that has
accumulated OUTSIDE the pericardium including
chest tube drainage or blood lost from other
wound sites and is collected until the patient
stops bleeding and should be returned via a Cell
Sent to
the Cell
to the
Heart Lung
to patient
?Any Blood Lost Outside the Body During Cardiac Surgery?
Mortality & Morbidity
TRALI (Tx Related Acute Lung Injury)
LOS – infection, CA
Immunomodulation : the immune system is “Hyperactivated”
Increased # & length of ICU stays, ventilator times
Poor wound healing
Rehabilitation times & Readmissions
“Patients who receive multiple transfusions are at
risk for iron toxicity when the iron-carrying capacity
of the blood is exceeded”
-Aryeh Shander, MD Director of Care, Englewood
Hospital & Medical Center
In cardiac surgery some patients require blood
transfusions to compensate for the large blood
loss (Shed Blood) that occurs during the
2 common techniques exist to limit the amount
of “shed blood”:
The use of a pump sucker that returns the blood
back to the cardiopulmonary bypass (heart lung
machine) pump for quick return to general or
systemic circulation
The alternative technique is the use of a “cell
salvaging” device that collects, washes and reinfuses RBC’s to the patient also known as a
Autotransfusion system (ATS)
Are there components found in shed blood
that are harmful?
Do they pose a threat if re-infused back
into the patient’s circulation?
Is it of clinical significance? or are these
biological markers transient and reversible
in the patient?
The beneficial effects of shed blood reinfusion have been
subject to scrutiny concerning its benefits and consequences
A review of the current literature considering the use of shed blood during (CPB)
cardiopulmonary bypass will benefit the cardiac surgical team in providing safe
patient care, and help to enhance patient outcomes.
“should shed blood be used during cardiac surgeries, and if so, how to utilize
it effectively and safely to benefit the cardiac patient.”
Specifically, looking at the properties of shed blood, techniques for safe
reinfusion and potential patients benefits.
Clinical Perfusion Education
University of Nebraska Medical Center
-Proinflammatory mediators
-Activated cells and cellular debris
-Creatine Kinase-MB
-Increased plasma free hemoglobin
-Positive bacterial cultures
Debris present in the surgical field may be intentionally or unintentionally
aspirated into the cardiotomy reservoir and/or cell salvage devices.
 Heparin
or other
 Clot formations
 Fibrin Strands
 Lipid Emboli
 Tissue
JECT 2003;35:28-34
 Antibiotics
 Leukocytes
 Plasma
Free Hgb
 Bacterium
 Bone
 Should
we discard cardiotomy suction blood?
 What
measures can we take to avoid the use
of cardiotomy suction blood?
 Is
it possible to “treat” cardiotomy suction
Cardiotomy Blood Concerns
-Significant literature suggests that the use of shed blood returned
directly to the cardiotomy should only be used when extremely
necessary. (Journal of Cardiothoracic and Vascular Anesthesia 2004;21: 519-523)
-The increased concentrations of thrombin-antithrombin III complex
and fibrin degradation products indicated renewed systemic clotting
and fibrinolysis as a direct result of the retransfusion of suctioned
blood. (Ann Thorac Surg 1996;62:717-23)
-“The retransfusion of highly activated suctioned blood during CPB
exacerbates wound bleeding.” (Ann Thorac Surg 1995; 59: 901-07)
-Furthermore, coronary surgery without retransfusion of cardiotomy
suction blood and mediastinal shed blood reduces the postoperative
systemic inflammatory response. (Journal of Cardiothorac and Vasc Anesth 2004;21: 519523)
More Cardiotomy Blood Concerns
• “Recent studies have focused on the origins of thrombotic stimulus and the
possible role of retransfused suctioned blood from the thoracic cavities on the
activation of the extrinsic coagulation pathway.”
• Microembolization during cardiopulmonary bypass (CPB) can be detected in the
brain as lipid deposits that create small capillary and arteriolar dilations (SCADs)
with ischemic injury and neuronal dysfunction.
– SCAD density is increased with the use of cardiotomy suction to scavenge shed
– Use of a cell washer to scavenge shed blood during CPB decreases cerebral lipid
Ann of Thorac Surg 2000;70: 1296-1300
Webb, et al, looked at the infusion of such particles
after the shed blood was washed and then passed
the blood through a series of lipid and leukocyte
Their findings indicate that the use of processed blood
should be employed with consideration of at least a
40μm filter, and a filter with adequate microaggregate
retention capabilities.
Additionally, The use of such filters (lipid/leukocyte) of
at least 40μm would significantly reduce the potential
exposure to these microemboli
Brinke et al. in 2005 – Concluded that use of a
continuous autotransfusion system stabilizes the
performance of the transfusion leukocytedepletion filter and significantly enhances its
leukocyte and platelet removal efficiency. In
particular, neutrophils are efficiently removed
“The risk of stroke postoperatively is approximately
1-5%. Incidences rates for neurocognitive deficit,
however, vary markedly depending on the detection
method, although typically it is reported in at least
10% of Patients
Reducing cerebral injury during cardiac surgery
depends upon the surgical team’s ability to minimize
operative emboli of any source including GME from
entering the patient’s circulation (Venous line air)
To utilize shed blood effectively, eliminating these
microemboli are essential before reinfusing the
Clinical Perfusion Education
product into the patient.
University of Nebraska Medical Center
Separate Chamber
and Cardiotomy
Sorin D903 Avant
Dr Stump’s research on
cardiotomy blood is what changed
how Perfusion and the entire
Cardiac arena practices
What Caused the Change,
How it Changed, and Why
it Changed?????
 To
improve the quality of shed blood prior to
its autotransfusion during CPB.
 Two
potential strategies:
- Arterial line filtration (Cardiotomy)
- Processing blood with a cell washer (ATS)
Annals of Thoracic Surgery 2000;70:1296-1300
 Approved
by the Wake Forest University School
of Medicine Animal Care and Use Committee.
 24 mongrel dogs (28-35 kg) were studied.
 IV anesthesia with fentanyl and diazepam.
 Median sternotomy, left subclavian arterial and
bi-caval cannulation.
Annals of Thoracic Surgery 2000;70:1296-1300
 Initiated
Is it common to add the cardiotomy
blood to the arterial circuit??? Or
should it be added to the venous side
the dogs to 280C and after
CPB and
40 minutes CPB, rewarmed to 360C.
 Cardiotomy suction reservoir blood, OR processed cell
saver blood, returned through arterial circuit
 After 10 minutes recirculation of shed blood, dogs
euthanized, brains harvested, analyzed for SCAD
Annals of Thoracic Surgery 2000;70:1296-1300
Number of Cerebral Lipid Microemboli
and Shed Blood Return
SCADs s/cm2
4 1
No Shed
Cell Saver
Annals of Thoracic Surgery 2000;70:1296-1300
Sample Taken From
Shed Blood Returned
Scavenged blood is a source of cerebral lipid
Use of a cell washer to retrieve and process
scavenged blood appears to decrease
microembolic burden compared to cardiotomy
suction blood passing through arterial line filters
used in CPB. But are Lipids Normal?
Annals of Thoracic Surgery 2000;70:1296-1300
A national survey conducted Just in Canada
demonstrated significant variation in the handling
and utilization of cardiotomy blood in various
Cardiac surgery centers
– 42%
routinely wash cardiotomy blood,
58% performed no processing, and 6%
utilized additional filtration
Perfusion 2005; 20(5):237-41
CONCLUSIONS: Prospective longitudinal
neuropsychological performance of
patients with coronary artery bypass
grafting did not differ from that of a
comparable nonsurgical control group
of patients with coronary artery
disease at 1 or 3 years after baseline
examination. This finding suggests that
previously reported late cognitive
decline after coronary artery bypass
grafting may not be specific to the use
of cardiopulmonary bypass, but may
also occur in patients with similar risk
factors for cardiovascular and
cerebrovascular disease.
Methods – 71 patients were enrolled undergoing isolated CABG
procedures. A Doppler ultrasound was recorded every 8
milliseconds of the inflow and outflow of the CPB circuit. S100B
were measured before surgery and 48 hours after surgery.
Results – Emboli leaving the CPB circuit was detected in 67
patients. The distribution of microemboli varied across patients.
Most patient had elevated S100B levels following surgery.
Conclusion – The authors showed an association between
the neurologic injury measured as S100B levels and
microemboli detected in the CPB circuit. They suggest
reductions in neurologic injury may result from redesign
of the CPB circuit to prevent emboli leaving the circuit
Methods: Seven Adult pigs were used. A shed blood surrogate
and radioactive triolein was produced to generate a lipid embolic
load. The surrogate blood was transfused to the R. atrium. The
animals arterial, pulmonary, R. and L. atrial pressures along with
cardiac output and dead space were measured. At the end an
increase in CO and Pulmonary pressure were pharmacologically
induced to try and flush out the lipid particles from the lungs
Results: A more than 30 fold increase in pulmonary vascular
resistance was observed with subsequent increase in pulmonary
artery pressure and decrease in CO and arterial pressure.
Conclusion: Infusion of blood containing lipid micro-emboli on
the venous side leads to acute, severe hemodynamic responses
that can be life threatening. Lipid particles will be trapped in
the lungs, leading to persistent effects on the pulmonary
vascular resistance.
Journal of Cardiothoracic Surgery 2009;4:48
The study showed Shed Mediastinal Blood (SMB) contains high levels of
enzymes that determine cardiac injury and infusion of this blood markedly
increased these levels
There was also increased levels of Plasma Free-Hgb and immature
The authors concluded the results support the idea that SMB
does cause a coagulopathy in some patients and has other
clearly undesirable consequences
Although, the study clearly showed that the authors collected
blood/fluid from the pleural space and this increased the
volume collected from this source rather than the heart and
mediastinum leading to high levels of Free-Hgb, Neutrophils,
and Cardiac enzymes
Background – Processing of pericardial shed blood with a cell-saving device was
Methods - Forty patients, 65 yrs and older, were prospectively randomized to
Results – The protein S100B levels averaged 0.06 ± 0.03 before surgery and 0.51 ±
Conclusions – The S100B was significantly higher in the control group
claimed to prevent lipid microembolization and to protect from neurocognitive
dysfunction after CPB
processing of pericardial shed blood with a cell-saving device or to conventional use
of a standard closed venous reservoir where cardiotomy blood was collected and
reinfused through the arterial circuit for the control group. Near-infrared
Spectroscopy before surgery and at the time of discharge from the hospital. The
also looked at protein S100B in all patients.
0.23 30 minutes after surgery compared with 0.076 ± 0.04 before surgery and 1.48
± 0.66 in the control patients.
vs. the cell saver group. Although the use of the cell-saving device
was NOT associated with higher brain oxygen saturation nor changes
in the stroke score but it was associated with lesser release of
nonspecific markers of brain injury
The Meta-Analysis
contained 31 randomized
studies and 2282 patients
Current evidence suggests that the use of a cell
saver reduces exposure to allogenic blood
products or red blood cell transfusions for
patients undergoing cardiac surgery. Subanalyses suggest that a cell saver may be
beneficial only when it is used for shed blood
and/or residual blood or during the entire
operative period. Processing cardiotomy
suction blood with a cell saver only during CPB
has no significant effect on blood conservation
and increases fresh frozen plasma transfusion.
Cell washing should be kept to a
minimum and limited to the pre- and
post- heparinization period. Coronary
suckers are a safe alternative to use
during the period of heparinization to
preserve franc autologous whole blood
and return it back to circulation. A
waste sucker should be kept in the field
of surgery for undesirable shed blood
and irrigant solutions.
Shander A, Moskowitz D, Rijhwani TS. The safety and efficacy of
"bloodless" cardiac surgery. Semin Cardiothorac Vasc Anesth.
Objective: During cardiopulmonary bypass (CPB), systemic coagulation is believed to become activated by blood
contact with the extracorporeal circuit and by retransfusion of pericardial blood. To which extent retransfusion
activates systemic coagulation, however, is unknown. We investigated to which extent retransfusion of pericardial
blood triggers systemic coagulation during CPB. Methods: Thirteen patients undergoing elective coronary artery
bypass grafting surgery were included. Pericardial blood was retransfused into nine patients and retained in four
patients. Systemic samples were collected before, during and after CPB, and pericardial samples before
retransfusion. Levels of prothrombin fragment F1+2 (ELISA), microparticles (flow cytometry) and non-cell bound
(soluble) tissue factor (sTF; ELISA) were determined. Results: Compared to systemic blood, pericardial blood
contained elevated levels of F1+2, microparticles and sTF. During CPB, systemic levels of F1+2 increased from 0.28
(0.25—0.37; median, interquartile range) to 1.10 (0.49—1.55) nmol/l ( p = 0.001). This observed increase was similar
to the estimated (calculated) increase ( p = 0.424), and differed significantly between retransfused and nonretransfused patients (1.12 nmol/l vs 0.02 nmol/l, p = 0.001). Also, the observed systemic increases of platelet- and
erythrocyte-derived microparticles and sTF were in line with predicted increases ( p = 0.868, p = 0.778 and p = 0.205,
respectively). Before neutralization of heparin, microparticles and other coagulant phospholipids decreased from
464 mg/ml (287—701) to 163 mg/ml (121—389) in retransfused patients ( p = 0.001), indicating rapid clearance
after retransfusion.
Conclusion: Retransfusion of pericardial blood does not activate systemic coagulation
under heparinization. The observed increases in systemic levels of F1+2,
microparticles and sTF during CPB are explained by dilution of retransfused
pericardial blood
Objective: Elimination of cardiotomy suction increases reliance on cell-saver
blood-conservation techniques. Reinfusion of processed cell-saver blood (PCSB)
even without using cardiotomy field suction may contribute to thrombin,
cytokines, platelet activators, and hemolytic factors measured systemically.
Design: This study was designed as a prospective, un-blinded observational study of patients undergoing first time,
non-emergent on-pump coronary artery bypass graft surgery. Setting: A university medical center. Participants:
Fourteen patients were enrolled after informed consent. Interventions: Arterial blood was sampled (1) before
cardiopulmonary bypass, (2) immediately after bypass, and (3) 4 hours after bypass. PCSB, using the AutoLog
(Medtronic, Inc, Minneapolis, MN), was sampled after bypass. Measurements and Main Results: Blood and PCSB levels
of prothrombin fragments 1.2, -thromboglobulin, interleukin- 6, interleukin-8, polymorphonuclear leukocyte-elastase,
neuron-specific enolase, and S-100 were assayed by using enzyme-linked immunosorbent assay. Paired comparisons
were performed by using paired t tests. Compared with post-bypass blood, processed cell-saver blood (prepatient
infusion) had higher levels of polymorphonuclear leukocytelastase, interleukin-8, neuron-specific enolase, and S-100
(p < 0.05).
Conclusions: Reinfusion of PCSB directly and independently contributes to
systemic elevations in interleukin-8, polymorphonuclear elastase, neuron-specific
enolase, and S-100B, augmenting and perhaps accentuating the postoperative
inflammatory response. Further evaluation and improvement in cell-salvaging
technology and processing techniques are warranted.
Munir Boodhwani, Howard J. Nathan, Fraser D. Rubens
On behalf of the Cardiotomy Investigators
Scientific Sessions 2006
Chicago, Illinois
November 13, 2006
The authors have no conflicts of interest to disclose
Processing of cardiotomy blood through ATS
washing and filtration results in coagulation
Increased PTT and TT
Increased INR
Decreased Fibrinogen
Decreased Clotting factors
Decreased Important Plasma Proteins
Cardiotomy blood processing results in increased
intra-operative and post-operative blood product
~ 0.43 PRBC units/patient
~ 0.94 non-RBC units/patient
Conclusions from Study
Contrary to expectations, processing of cardiotomy blood
before reinfusion results in greater blood product use
with greater postoperative bleeding in patients
undergoing cardiac surgery. There is no clinical evidence
of any neurologic benefit with this approach in terms of
postoperative cognitive function.
In the absence of a proven benefit in terms of neurological
protection or hemodynamic stability, we believe that there
is little to justify the routine use of this technique.
Munir Boodhwani, MD & Fraser D. Rubens, MD
Recent Evidence-Based Guidelines (JTCVS Aug 2006;132(2):283)
“Direct reinfusion to the CPB circuit of unprocessed blood exposed
to pericardial and mediastinal surfaces should be avoided
(Class I, Level B)
“Blood cell processing and secondary filtration can be considered to
decrease the deleterious effects of reinfused shed blood
(Class IIb, Level B)
This is the largest randomized, double-blinded study
examining the effects of cardiotomy blood processing
and can be used to inform the guidelines
Demonstrates the feasibility of double-blinding in trials
comparing interventions related to CPB
Blood salvage interventions:
Routine use of red cell salvage using centrifugation is helpful for
blood conservation in cardiac operations using CPB - (Level of
evidence A) I – A (When used appropriately)
During CPB, intraoperative autotransfusion, either with blood
directly from cardiotomy suction or recycled using centrifugation
to concentrate red cells, may be considered as part of a blood
conservation program - (Level of evidence C) IIb
Consensus suggests that some form of pump salvage and
reinfusion of residual pump blood at the end of CPB is reasonable
as part of a blood management program to minimize blood
transfusion - IIa (C)
Centrifugation of pump-salvaged blood, instead of direct
infusion, is reasonable for minimizing post-CPB allogenic red
blood cell (RBC) transfusion - IIa (A)
 So
what can we determine from all of these
 Cell Salvaging is good in a limited amount for
lipid removal?
 Shed blood Contains a plethora of bad stuff
Should this be reinfused?
Or Maybe not?
recommends the following general
indications for Cell Saving (CS):
The anticipated blood loss is 20% or more of
the patients estimated blood volume
Blood would ordinarily be cross-matched
More than 10% of patients undergoing the
procedure require transfusion
The mean transfusion for the procedure
exceeds 1 unit
This defines every Cardiac Surgery patient
Transfusion 2004;44:40S-44S
Abstract: Cell salvage devices are routinely used to process and wash red
blood cells (RBCs) shed during surgical interventions. Although the principle
theory of cell saving is the same, the actual process to achieve this is very different
from one device to another. The purpose of this study was to compare the quality of
washed, concentrated RBC produced by five very different cell saving devices, specifically the
Cobe BRAT 2, Medtronic Sequestra 1000, Haemonetics Cell Saver 5, Medtronic Autolog, and
the Fresenius CATS. Reservoir and washed red blood cells were analyzed for hematocrit (Hct),
platelets (PLT), leukocytes (WBC), potassium (K+), heparin, plasma-free hemoglobin (PFH),
RBC mass recovery and recovery rate. The Haemonetics and BRAT 2 had the highest RBC
recovery. All devices adequately removed heparin and potassium. The Medtronic Autolog
had the highest removal of platelets and PFH; whereas, the BRAT had the lowest. Although
the Autolog had the highest leukocyte removal, leukocytes were
not adequately
washed out by any of the autotransfusion devices.
In Conclusion, although all cell- saving devices use the same theory
of centrifugation, the actual quality of the washed RBC product
differs widely from one device to another.
Provides intraoperative means of cell conservation
Helps to reduce Lipid microembolization in blood
Helps reduce some inflammatory response
Can serve as an autologous source of RBC’s reducing the need
for RBC transfusions
Used by religious groups and others who refuse blood
Autotransfusion Pitfalls
The potential problems that are found in processed shed blood
are that the platelets and WBC’s that remain in the end product
are now activated by the centrifugation process as well as the
potential emboli these device may create or enhance. Lastly the
viable platelet, clotting factors and plasma proteins are now
washed away.
“If only the processed red cells are replaced and no consideration
is given to the plasma or platelets lost, increased bleeding may
occur due to the dilution of the clotting factors and the loss of
Higher red cell
Higher 2,3 DPG
Reduced osmotic
Reduction in foreign
Reduction in
Potential for
Platelet damage
Loss of plasma and
coagulation factors
Loss of proteins COP
Higher concentration
of neutrophils
Perfusion 2003; 18: 115-121
Remove 70-90% of soluble contaminants from
salvaged blood
Fibrin(ogen) Split Products D-Dimers
Activated Complement Free Hgb
Activate Fibrinolytic Particles
Activated WBC – 30%-70% of activated WBC’s are
removed with a cell washer (the Medtronic Autolog
system removed the most)11
Proteolytic Enzymes
Marker Enzymes (CPK) Fats
Stroma, Cell Fragments
Bacteria and Endotoxins
Transfusion 2004;44:35S-39S
 Conclusions:
Little or no benefit in inhibiting inflammatory
No reduction in rate of neurological injury
Biological marker numbers reduced but no
clinical benefit
Evidence of increased transfusion rates and blood
loss during cardiac surgery
 Quality
 The
improves by process change:
Reduce RBC packing
Increase wash volume
Increase wash period
Increase wash frequency
Remove operator subjectivity
longer we wash the better the product
of RBC’s with the most bad stuff removed ???
It’s time for Perfusion and the Cardiac Surgery
arena to clearly define the term “SHED BLOOD”:
I propose the following definitions:
“Cardiotomy Blood” - is the franc whole blood
that accumulates inside the pericardium coming
directly from a great vessel or the open heart
itself and should be returned via the cardiotomy
suction (Pump Sucker)
“Shed Blood” – is the blood that has
accumulated OUTSIDE the pericardium including
chest tube drainage or blood lost from other
wound sites and is collected until the patient
stops bleeding and should be returned via a Cell
 We
are at a conundrum in cardiac surgery
about dealing with blood lost outside of the
 Current mind set is that everything goes to a
cell washer instead of trying to save the
whole blood
 We have swung the pendulum in the other
direction so far with Dr. Stump’s work dealing
with blood salvaging and we are still giving a
plethora of blood products
 We need to swing back to the middle and
find a way to preserve the whole blood and
all it’s components
Thank You For Your Attention!
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doing everything we can to conserve blood during bypass? A national survey.
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blood: an invitro study. Perfusion, 20, 335-341.
Carrier, M., Denault, A., Lavoie, J., & Perrault, L. P. (2006). Randomized
controlled trial of pericardial blood processing with a cell-saving device on
neurological markers in elderly patients undergoing coronary artery bypass
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(2003). Processing and transfusion of residual cardiopulmonary bypass volume:
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D. D. et al. (2000). Processing scavenged blood with a cell saver reduces
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