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Blood Conservation in Adult Cardiac Surgery, What is the Way Forward in Today's Practice?

Not Applicable
Conditions
Blood Transfusion
Adult Cardiac Surgery
Interventions
Procedure: Retrograde Autologous Prime
Device: Cell Salvage
Registration Number
NCT02595385
Lead Sponsor
Belfast Health and Social Care Trust
Brief Summary

The aim of this study is to compare retrograde autologous priming (RAP) of the bypass circuit to cell salvage (CS) as part of blood conservation strategies in adult cardiac surgery. It hypothesizes that RAP is at least as effective as cell salvage in terms of blood conservation but at the same time more cost effective.

Detailed Description

Cardiac surgery is a major blood consumer. Current evidence shows there is no benefit from transfusion for haematocrits as low as 21% and the risk of death within 30 days of surgery is almost 6 times higher for patients who receive blood. In addition, transfused patients are more likely to experience increased infections and ischaemic complications like myocardial infarction, stroke and renal compromise. While it is agreed to avoid blood transfusion when feasible, there is no current consensus on the best strategy to maintain an acceptable haemocrit and minimise the need for allogenic blood transfusion. Two of the many strategies that have been employed are Retrograde Autologous Prime (RAP) of the bypass circuit and cell salvage (CS) with reinfusion of shed blood.

This study is a prospective, randomised controlled trial with 240 patients undergoing a single procedure adult cardiac surgery that will be randomised to either full crystalloid prime volume or RAP, with or without cell salvage. There will be four study arms;

1. RAP alone

2. Cell Salvage alone

3. RAP plus cell salvage

4. Control group

Results will follow analyse of the data using a logistic regression using a design matric with blood transfused as a key explanatory variable with scope to add in patient covariables. It is expected that date will be analysed after 100 patients and if significance is achieved then the study can be terminated.

The study will aim to identify those patients that receive a blood transfusion intra or post-operatively. Symptomatology from anaemia is subjective and hard to measure. The studies linking transfusion to cardiac surgery outcomes are retrospective; despite careful risk adjustment, it is possible that these associations reflect a tendency amongst clinicians to transfuse the most critically ill patients or miss another important confounder.

In 2001, Spiess referred to current transfusion practice as a 'silent epidemic'. His description is still accurate. In 2006, almost half of all patients undergoing coronary artery bypass grafting in the united states received blood transfusion and the probability of receiving blood is greater when procedures are more complex. Although the infectious risk of blood transfusion have been successfully minimised the weight of evidence increasingly suggests that transfusing less in stable patients could prevent a significant amount of morbidity and mortality. This study will help guide management in those in whom transfusion is avoidable.

Recruitment & Eligibility

Status
UNKNOWN
Sex
All
Target Recruitment
240
Inclusion Criteria
  • Less than 80 years of age
  • Undergoing single procedure surgery
  • Be on single anti-platelet therapy
  • To have stopped warfarin pre-operatively with a INR of <1.5
  • Have stable coronary disease
  • Have good Left Ventricular function
Read More
Exclusion Criteria
  • Redo procedures
  • Emergency Surgery
  • Be on dual antiplatelet therapy
  • Have pre-operative kidney dysfunction with eGFR <60ml/min
  • Have post-operative drainage >200ml per hour or require re-exploration for bleeding.
Read More

Study & Design

Study Type
INTERVENTIONAL
Study Design
SINGLE_GROUP
Arm && Interventions
GroupInterventionDescription
RAPRetrograde Autologous PrimeRetrograde Autologous Prime of the bypass circuit. To remove 500-900ML of fluid.
CSCell SalvageReinfusion of shed blood during the operation
RAP and CSCell SalvageRAP and CS used in combination
RAP and CSRetrograde Autologous PrimeRAP and CS used in combination
Primary Outcome Measures
NameTimeMethod
Number of units of packed red blood cells transfusedthrough study completion, an average of 2 weeks
Secondary Outcome Measures
NameTimeMethod
Adverse reaction to RAP measured by systolic BP <90mmHg during initiation of bypass.intra-operatively

Trial Locations

Locations (1)

Department of Medicine

🇬🇧

Belfast, United Kingdom

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