THE INFLUENCE OF ACUTE PREOPERATIVE PLASMAPHERESIS ON COAGULATION TESTS, FIBRINOLYSIS, BLOOD-LOSS AND TRANSFUSION REQUIREMENTS IN CARDIAC-SURGERY

Objective: Withdrawal of autologous plasma and reinfusion after cardio pulmonary bypass (CPB) offers the opportunity of improving patients' h aemostasis and reducing homologous blood consumption in cardiac surger y. The influence of acute, preoperative plasmapheresis (APP) on coagul ation tests, fibrinolysis, blood loss and transfusion requirements was investigated in elective aortocoronary bypass patients. Methods: Fort y patients were randomized to a control or pheresis group. The pheresi s group had platelet-rich plasmapheresis (PRP-group, n=20) performed b efore incision and the platelet-rich plasma (PRP) was returned after C PB. The control group (n=20) was managed without pheresis. All patient s had serial coagulation studies, including prothrombin split products (F-1/F-2), fibrinopeptide A (FPA), protein C (PC), thrombomodulin (TM ), tissue-plasminogen-activator (t-PA), plasminogen-activator-inhibito r (PAI 1), fibrinopeptide B beta 15-42 (FPB beta 15-42), haemoglobin a nd platelet counts determined intra- and postoperatively. Chest tube d rainage and transfusion requirements were recorded. Results: APP had n o negative effects on the quality of PRP. The platelet count of the wi thdrawn autologous plasma was 239+/-33 x 10(9)/l. From the end of the operation (after retransfusion of autologous plasma) until the first p ostoperative day platelet counts were significant higher in the PRP-gr oup (P >0.05). Plasma concentrations of modified antithrombin III (ATM ), F-1/F-2 and FPA increased (166-290% from baseline) and PC- and TM-a ntigen decreased (11-49% from baseline) to a different extent for both groups throughout CPB. t-PA-activity increased intraoperatively peaki ng at the end of CPB (PRP-group: 4.8+/-0.8 IU/ml, control-group: 8.1+/ -2.3 IU/ml)(P >0.05). With onset of CPB PAI-1 levels decreased and wer e further reduced after CPB in control patients in comparison to PRP-p atients (P <0.05). FPB beta 15-42 occurred in peak concentrations afte r neutralisation of heparin by protamine. Only PRP-patients showed bas eline values of coagulation and fibrinolytic parameters on the next mo rning (P <0.05). Total postoperative blood loss during the first 24 h was 503+/-251 ml (PRP-group) and 937+/-349 ml in the control-group (P <0.05). None of the PRP-patients received allogeneic blood, whereas fi ve control-patients received 11 units of packed red cells (P <0.05). C onclusions: The findings suggest that in elective cardiac surgery hepa rin cannot prevent generation of both thrombin and fibrin, born throug hout CPB and postoperatively. The use of PRP withdrawn immediately pre operatively is an attractive technique to reduce allogeneic blood usag e and preoperative blood loss, especially in patients in whom withdraw al of autologous whole blood cannot be performed. (C) 1997 Elsevier Sc ience B.V.