Recebado anterógrado hemático como una herramienta de perfusión para la recuperación intensificada del paciente sometido a circulación extracorpórea

Resumen

Background: The Extracorporeal Therapies constitute a discipline of knowledge that, since the first successful cardiopulmonary bypass procedure, achieved in 1953, aims to provide an adequate cardiopulmonary support and a cardiopreservation, to provide a succesful outcome of the non-beating heart surgery. Despite the constant scientific and technological evolution, the enhanced recovery and the preservation of the cognitive performance of the patient still represent the main challenges of the process. Objectives: To evaluate if the application of the Hematic Antegrade Repriming (HAR) standardized procedure represents a safe and replicable measure to enhance the recovery of the patients under cardiopulmonary bypass. Methodology: A preliminary analysis of the benefits related to the application of HAR was performed in the first series of patients. To estimate the effect of the treatment, a propensity score Matching methodology was applied considering a retrospective cohort, with similar characteristics, as control group. Differences in early mortality, morbidity and bleeding were assessed, as well as the exposure to extended mechanical ventilation (10 hours) and ICU stay (>2 days), transfusión within the first 24h, transfusión until discharge and costs. Additionally, a prospective and randomized study, assessing the embolic impact, as well as the short and mid-term (4 months) changes in cognitive performance was performed in the context of a Clinical Trial, to determine the biosafety of HAR procedure. Results: HAR application reduced the exposure to any bioproducts until discharge in 59,87%,( p=0.001). Within the first 24 hours it avoided the transfusion of red blood cell in 47,55%, plasma, 10,31% and platelets, in 28,86% (p=0.001). In the period between the first 24 postoperative hours and discharge, HAR avoided the transfusión of red blood cells in 33.96% and plasma, in 3,99% (p<0.05). The incidence of extended mechanical ventilation was reduced in 13,89% and the early discharge from ICU (< 2 days) was increased in 16,28% (p<0.05). Differences in early morbidity, mortality and bleeding were not statistically significant. The minimum cost saving in direct expenses related to HAR exceeded 500 € per treated patient, that represented more than 1936 € per treated, in total costs. It´s application reduced in 7 times the exposure to embolic volumes >1 µl and a protective role against emboli, reducing the total volume delivered to the patient through the circuit in 74% (p<0.05). A slight cognitive performance decay in the early postoperative period as well as an improvement in the mid-term evaluation was found in treated, oppositely to controls that expressed a permanent decline (p<0.05). Conclusions: HAR is a strategy that may decrease the impact of cardiopulmonary bypass, by reducing the exposure to blood products during the process as well as the prolonged mechanical ventilation and ICU stay requirements and the related costs. On the other side HAR demonstrated to be a safe practice in terms of emboli and cognition. Furthermore, it presents a protective role against the embolic delivery during the CPB initiation as well as the short and mid-term cognitive performance decline. Further prospective and randomized studies are required to properly evaluate the influence of HAR in morbidity mortality, bleeding and validate the findings of the current research