(2024) 10:5
Morinaga et al. JA Clinical Reports
https://doi.org/10.1186/s40981-024-00689-1

JA Clinical Reports

Open Access

ORIGINAL ARTICLE

Association between intraoperative
blood salvage and coagulation disorder
after cardiopulmonary bypass
Masahiro Morinaga1, Kenji Yoshitani1* , Soshiro Ogata2, Satsuki Fukushima3 and Hitoshi Matsuda3

Abstract
Background This study investigated whether intraoperative blood salvage was associated with coagulation disorderdiagnosed by conventional coagulation tests and thromboelastography (TEG) after cardiopulmonary bypass (CPB).
Study design and methods This was a prospective, observational study. Ninety-two patients who underwent
cardiovascular surgery with CPB were enrolled. We evaluated coagulation function in patients with or without cell salvage blood transfusion at the following time points: before CPB, just after protamine administration, and 1 h after protamine administration. We evaluated platelet count, fibrinogen concentration, and TEG parameters. Patients wereconsidered to have coagulation disorder if one or more of the following criteria were present: (1) residual heparin, (2)low platelet count, (3) low fibrinogen level, (4) low clotting factor level, and (5) hyperfibrinolysis.
Results Fifty-three of 92 patients (57.6%) received intraoperative cell salvage. Coagulation disorder was observedin 56 of 92 patients (60.9%) after CPB. There was no significant difference between patients with or without intraoperative blood salvage in terms of the incidence of coagulation disorder (p = 0.542) or the total volume of bloodfrom the drain after CPB (p = 0.437). Intraoperative blood salvage was not associated with coagulation disorderdiagnosed by either TEG or conventional coagulation tests (odds ratio 1.329, 95% confidence interval: 0.549–3.213,
p = 0.547). There were no significant interactions between patients with or without intraoperative blood salvage
regarding coagulation parameters derived from TEG.
Conclusions The incidence of coagulation disorder and the total blood volume from the drain after CPB did not differ significantly between patients with or without intraoperative blood salvage.
Keywords Cardiac surgery, Cell salvage, Thromboelastgraphy, Coagulation disorder*Correspondence:
Kenji Yoshitani
ykenji@ncvc.go.jp
1
Department of Anesthesiology, National Cerebral and CardiovascularCenter, Osaka, Japan2
Department of Preventive Medicine and Epidemiology, National
Cerebral and Cardiovascular Center, Osaka, Japan3
Department of Cardiovascular Surgery, National Cerebral
and Cardiovascular Center, Osaka, Japan

Introduction
Blood products are in short supply worldwide [1], andtherefore it is crucial to reduce their use. Cardiac surgery is associated with a significant need for blood transfusions due to cardiopulmonary bypass (CPB), which
results in hemodilution and significant blood loss. In
general, with a liberal threshold in cardiac surgery, threeunits of red blood cells are transfused per surgery [2],and it would be optimal if this number were reduced.
Minimizing allogeneic blood transfusions is essential toprevent complications such as infection, immunomodulation, and transfusion-related acute lung injury [3]. One© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/.

Morinaga et al. JA Clinical Reports(2024) 10:5

way to reduce blood transfusions is to use intraoperative
blood salvage [4].
In cardiac surgery, blood in the CPB circuit remains
after weaning from CPB, and blood is also salvaged fromthe operating field. Autologous salvaged blood can betransfused after it has been washed and concentrated. It
has been reported that autologous salvaged blood transfusion reduces the use of allogeneic red blood cells andthere is no significant difference between the two typesof transfusion regarding the incidence of death or cardiovascular events [5]. On the other hand, there are reportsthat autologous salvaged blood transfusion leads to coagulation disorders [6–8]. Previous studies that reported
the development of coagulation disorder related to cellsalvage focused on high-risk patients [8]. By contrast,
the present study focused on patients undergoing elective cardiac surgery with CPB. We hypothesized that the
coagulation function of autologous salvaged blood would
be similar to that of allogeneic blood in elective cardiac
surgery.
We used viscoelastic monitoring with thromboelastography (TEG) and conventional coagulation tests toevaluate coagulation function after CPB [9], because acorrelation between thromboelastography measurements
and conventional laboratory tests has been reported inpatients with poor coagulation function [10]. Furthermore, thromboelastography evaluates multiple aspects
of clotting, including the rate of clot formation and clot
strength. This study compared coagulation function andpostoperative bleeding between patients who received
intraoperative cell salvage and those who did not.

Materials and methods
This prospective, observational study collected data from
June 1, 2020, to September 30, 2021. Patients who underwent cardiac surgery with CPB were enrolled. Patientswith congenital heart disease or aged < 15 years were
excluded. Those with a planned surgery time > 8 h werealso excluded because long CPB leads to coagulation disorder. After approval of our institutional review board(R20013-3), written informed consent was obtained. All
patients underwent cardiac surgery with CPB using a cellsalvage device (Cell Savor Elite+, Heamonetics, Boston,
MA, USA, or CATSmart, Fresenius Kabi, Bad Homburg vor der Höhe, Germany), but some patients were
not transfused with cell salvaged blood on the surgeon’s
instructions. The patients were divided into two groups,
specifically those who did or did not receive intraoperative blood salvage (only to produce autologous blood).
Surgeons decided whether or not to use cell-salvaged
blood based on factors such as CPB time, deep hypothermia, the administration of allogenic transfusion during

Page 2 of 7

CPB, and hemostatic state. In the cell salvage group, allblood resulting from bleeding before and after CPB wascollected by cell salvaging; blood from bleeding during
CPB was collected during cardiotomy and processed bycell salvaging after CPB. In patients without cell salvage,
allogeneic transfusion was performed without blood processed by cell salvaging. Before CPB, we administered
300 units/kg of heparin and then checked whether theactivated coagulation time (ACT) was more than 300
s. If the ACT was less than 300 s, 2000 units of heparin
were added until the ACT surpassed 300 s., Protamine(3 mg/kg) was administered after CPB, and if the ACT
was more than 150 s, an additional 20 mg of protamine
was administered and the ACT was checked again. The
decision to administer tranexamic acid or not was left tothe discretion of the anesthesiologist in charge. Whentranexamic acid was administered, the loading dose was
20 mg/kg and the maintenance dose was 2 mg/kg/h during surgery.
Coagulation function was assessed at three-time
points: before CPB, just after protamine administration,and 1 h after protamine administration. To comprehensively evaluate coagulation function, we employedboth standard laboratory tests and thromboelastography, a blood viscoelasticity test. Standard laboratory
tests included prothrombin time (PT), activated partial
thromboplastin time (APTT), fibrinogen concentration,and platelet count. Four thromboelastography (TEG6s) measurements were obtained: kaolin thromboelastography (CK), heparinase kaolin thromboelastography(CKH), rapid thromboelastography (CRT), and functional fibrinogen (CFF). Three parameters were evaluatedfor each of these: reaction time (R), which indicates thetime from the start of the examination to initiation of clot
formation; maximum amplitude (MA), which reflects
maximum clot strength; and lysis rate-30 (LY30), which
represents the rate of clot lysis for 30 min at MA (Fig. 1).
To evaluate postoperative bleeding, we measured the volume of bleeding from the chest tube for 24 h.

Primary endpoint
The primary endpoint of this study was the association between intraoperative blood salvage and coagulation disorder following CBP. Coagulation disorder wasassessed using thromboelastography and standard laboratory tests [11–13] and was defined as a composite outcome consisting of residual heparin, low platelet countand function, low levels of fibrinogen and function, lowclotting factor level, and hyperfibrinolysis. This multifaceted definition results in a comprehensive assessment
and is a modified version of the composite outcome usedMorinaga et al. JA Clinical Reports(2024) 10:5

Page 3 of 7

Fig. 1 Typical results of thromboelastography. a Thromboelastography for normal coagulation function. b Thromboelastography for normal
coagulation disorders. CFF: functional fibrinogen; CK: kaolin thromboelastography; CKH: heparinase kaolin thromboelastography; CRT: rapid
thromboelastography; MA: maximum amplitude, which represents maximum clot strength. MA of (CRT−CFF) represents the coagulation functionof platelets by subtracting the coagulation function of fibrinogen from that of whole blood. R: reaction time, which represents the time to initiationof clot formation. R of (CKH−CK) indicates the degree of residual heparin. Since CKH measures coagulation function by antagonizing heparin,
subtracting CK represents the degree of residual heparinin previous studies. Each element of the composite outcome is defined below.
1. Residual heparin
CK R > 2 × CKH R
Residual heparin can be detected using CKH, whichmeasures coagulation function by antagonizing heparin.
If heparin remains, CK R is expected to be greater thanCKH R.
2. Low platelet count and function
Platelet count < 100,000/μL or CRT MA−CFF MA <35 mm
Low platelet count and function can be diagnosed
using either of the following criteria: a platelet
count < 100,000/μL or a difference between the
maximum amplitude (MA) of CRT (CRT MA) andthe MA of the coagulation function of fibrinogen(CFF MA) < 35 mm. CRT MA−CFF MA indicatessubtraction of the coagulation function of fibrinogen from that of whole blood and represents thecoagulation function of platelets.
3. Low fibrinogen level and function

Fibrinogen concentration < 1 g/L or CFF MA < 15 mm
Low fibrinogen level and function can be diagnosed
using either of the following criteria: a fibrinogenconcentration < 1 g/L or a CFF MA < 15 mm.
4. Low clotting factor level
CK R > 10 min
A low clotting factor level can be diagnosed using
CK, with a CK R > 10 min. CK utilizes kaolin to initiate coagulation, enabling a comprehensive assessment of coagulation function and verifying fundamental coagulation properties.
5. Hyperfibrinolysis
CRT LY30 > 7.5%
Hyperfibrinolysis can be diagnosed using a CRT
LY30 > 7.5%.
If one or more of the five criteria were met, thepatient was considered to have coagulation disorder.
Secondary endpoints

We assessed several secondary endpoints. First, we
determined whether the volume of allogeneic transfusion products and postoperative bleeding from thechest tube differed between patients with or withoutcell-savage transfusion. Second, we compared the allogeneic and intraoperative blood salvage groups in termsof the total number of autologous red blood cells andMorinaga et al. JA Clinical Reports(2024) 10:5

Page 4 of 7transfused platelets and the total amount of fresh frozen
plasma and blood from the chest tube. Third, we investigated potential interactions between the two groups
regarding the variables used to diagnose coagulation
disorder, including hemoglobin concentration, PT,
APTT, platelet count, CRT MA, CFF MA, CRT MA–
CFF MA, CRT LY30, CK R, CKH R, and CK R−CKH R.
Statistics

This was a preliminary, prospective study. Therefore, we did
not perform sample size calculations. We examined whether
intraoperative blood salvage was associated with coagulation disorder diagnosed based on residual heparin, lowplatelet count, low levels of fibrinogen or clotting factors,
and hyperfibrinolysis. We adjusted for possible confounders
such as age, sex, CPB time, redo surgery, aortic surgery, preoperative anticoagulation, antiplatelet therapy, and surgeons
who performed the procedure (10 main surgeons vs. others)
in a multivariable logistic regression analysis of the primary
endpoint. To prevent overfitting of the logistic regression,
we tested the association between intraoperative blood salvage and coagulation disorder, adjusting only for age andgender. In the analyses of the secondary endpoints, we useda mixed-effects model with patients as the random intercept
to identify interactions between variables used to diagnose
coagulation disorder. For the analysis of continuous variables, we used the Wilcoxon rank-sum test. We comparedcategorical variables using the chi-square test. We considered p < 0.05 as statistically significant. We performed all
statistical analyses with Stata 17 SE.

Results
Patients were enrolled in this study from June 2020 to
September 2021. Those who did not receive a homologous transfusion at the end of CPB were excluded. A

total of 381 patients were deemed eligible for this study;of these, 85 were excluded because they did not provide
informed consent, and 204 were excluded because they
had a planned surgery time > 8 h. Finally, 92 patientswere included in this study, of whom 53 underwent intraoperative blood salvage and 39 underwent autologoustransfusion. Coagulation disorder was observed in 56 of
92 patients (60.9%) after CPB.
Table 1 presents the patient characteristics of the twogroups, receiving intraoperative blood salvage and allogeneic transfusion. There were no significant differences
between the two groups.
Table 2 summarizes the coagulation status of the twogroups. Coagulation disorder occurred in 56 (34 and 22
with/without intraoperative blood salvage, respectively)of 92 patients overall. The two groups did not differ significantly regarding any of the five coagulation disordercomponents. The incidence of re-exploration within 24 h
was not significantly different between the two groups.
Table 2 Coagulation status in the intraoperative blood salvage
and allogeneic transfusion groups

Residual heparin (n)Intraoperative
blood salvage(n = 53)

Allogeneictransfusion(n = 39)

p value

1

2

0.387

Low platelet count (n)

22

15

0.768

Low fibrinogen (n)

1

0

0.388

Low clotting factor (n)

16

12

0.952

Hyperfibrinolysis (n)

0

0

n.s.

Coagulopathy (n)

34

22

0.452

re-exploration (n)

3

0

0.131

Residual heparin: reaction time (R) for kaolin TEG (CK) less than half of R for
kaolin TEG with heparinase (CKH); low platelet: platelet count < 100,000/μL or
rapid TEG (CRT) maximum amplitude (MA)−TEG functional fibrinogen (CFF) MA< 35 mm; low fibrinogen: R for CK > 10 min

Table 1 Patient characteristics of the two groups
Intraoperative
blood salvage(n = 53)

Allogeneictransfusion(n = 39)

p valueAge (years)

73 (67, 78)

72 (60, 77)

0.34

Male sex

35 (66%)24 (62%)

0.66

Table 3 Allogeneic transfusion and bleeding

Height (cm)

164 (157, 170)

165 (152, 169)

0.96

Weight (kg)

62 (55, 69)

61 (52, 68)

0.92

Hypertension

35 (66%)23 (59%)0.49

Diabetes mellitus

5 (9%)

3 (8%)

0.77

Anticoagulation

12 (23%)15 (38%)0.10

Antiplatelet

11 (21%)7 (18%)

0.74

Intraoperative
blood salvage(n = 53)

Allogeneictransfusion(n = 39)

p value

RBC (mL)

560 (0–840)

560 (560–840)

0.066

FFP (mL)

480 (0–720)

480 (480–960)

0.066

Platelets (mL)

400 (0–500)

400 (0–400)

0.419

Blood from the drainfor 24 h (mL) in the ICU

825 (625–1195)

735 (495–960)

0.200

1288 (765–3563) 1103 (665–2561) 0.437

Redo surgery

10 (19%)10 (26%)

0.44

Aortic surgery

14 (26%)

14 (36%)

0.33

Blood from the drain
during the ICU stay (mL)

Valvular surgery

37 (70%)24 (62%)

0.41

Data are presented as medians (interquartile range)

Data are presented as medians (interquartile range) for age, height, and weight

FFP fresh frozen plasma, RBC red blood cell

Morinaga et al. JA Clinical Reports(2024) 10:5

Table 3 shows the total volume of allogeneic bloodtransfusion and blood from the chest tube for 24 h andduring the ICU stay. Neither parameter differed significantly between groups.
Figure 2 depicts the interactions between intraoperative blood salvage and allogeneic transfusion groups interms of hemoglobin concentration, platelet count,
fibrinogen concentration, PT, and APTT. There was aPage 5 of 7

significant interaction only for hemoglobin concentration (p = 0.045), suggesting that it differed significantly
by intraoperative blood salvage status. Figure 3 showsthat there were no interactions between the two groups
in any of the following: CRT MA; CFF MA; CRT MA- CFF MA; LY30 of CRT; CK R; CKH R; CK R-CKH R.
This indicates that these parameters did not differ significantly by intraoperative blood salvage status.

Fig. 2 Time course of changes in hemoglobin concentration, platelet count, and conventional hemostatic variables in the cell salvage
and allogeneic transfusion groups. Measurement points: 0, before cardiopulmonary bypass; 1, just after the administration of protamine; 2, 1 hafter the administration of protamine. CI: confidence interval

Fig. 3 Time course of changes in thromboelastography parameters in the cell salvage and allogeneic transfusion groups. Measurement points:
0, before cardiopulmonary bypass; 1, just after the administration of protamine; 2, 1 h after the administration of protamine. CFF: TEG functional
fibrinogen; CI: confidence interval; CK: kaolin TEG; CKH: heparinase kaolin TEG; CRT: rapid TEG; LY30: lysis rate for 30 min; MA: maximum amplitude; R:
reaction time

Morinaga et al. JA Clinical Reports(2024) 10:5

Page 6 of 7

Table 4 Characteristics associated with coagulation disorder
after intraoperative blood salvage
Odds ratio

p value

95% CI

Age

1.008

0.683

0.969–1.049

Sex

1.168

0.717

0.444–3.071

Anticoagulation therapy

0.766

0.546

0.268–2.191

Antiplatelet therapy

1.158

0.826

0.346–3.869

CPB time

0.999

0.796

0.990–0.007

Aortic surgery

1.113

0.860

0.338–3.668

Redo

1.141

0.824

0.357–3.646

Cell salvage

1.329

0.547

0.549–3.213

CI confidence interval, CPB cardiopulmonary bypass

Table 4 demonstrates that intraoperative blood salvage was not associated with coagulation disorder (oddsratio, 1.343; 95% confidence interval, 0.540–3.341; p =0.525). To test whether overfitting occurred in the logistic regression analysis in Table 4, we examined the association of intraoperative blood salvage and coagulation
disorder adjusted by only age and sex was similar (oddsratio, 1.36; 95% confidence interval, 0.584–3.186; p =0.474) with that in Table 4.

Discussion
Intraoperative blood salvage was not found to be associated with coagulation disorder diagnosed by thromboelastography and conventional tests of coagulation
function. There were no significant differences in theincidences of the five components of the composite outcome we used to define coagulation. The total blood volume from the chest tube was similar between patientswith or without cell salvage after CPB. There was a significant interaction between the two groups in hemoglobin
concentration but not in the other conventional coagulation parameters.
The possibility of coagulation disorder occurring
because of intraoperative blood salvage has previously
been discussed. Recently, Adam and colleagues reported
a significant reduction in coagulation factors during thecell salvage-washing process [14]. However, they did notevaluate the systemic coagulation status after transfusing
cell-salvaged blood. Palla and colleagues reported that toachieve successful hemostasis, trough levels of coagulation factors must be at least 10–30% of their normal level[15]. Therefore, lower concentrations of coagulation factors do not always lead to coagulation disorder.
Rollins and colleagues reported a case of coagulation
disorder associated with massive intraoperative blood
salvage following aortic surgery [16]. In that case, thecell-salvaged blood that was transfused was obtained
from the mediastinal drains connected to the cell-saver

system. The authors suggested that an excessive dose ofheparin was administered before processing, resulting ina high APTT. Residual heparin from the cell saver should
be considered a reason for coagulation disorder.
Niranjan and colleagues demonstrated no significant
differences in coagulation markers, PT, APTT, and total
blood volume from the chest tube between patientswith or without intraoperative blood salvage in a randomized controlled trial [17]. These results are consistent with those of our study, suggesting that there might
be no differences in coagulation function resulting fromcell salvage or autologous transfusion.
On the other hand, Xie and colleagues demonstrated
that the incidences of excessive postoperative bleeding, residual heparin, and total impairment of blood
coagulation were significantly higher in patients withintraoperative blood salvage than in those without [8].
Their study enrolled patients at high risk of bleeding
who had liver dysfunction, hemoglobin levels < 13.0
g/dL, platelet counts < 50 × ­109/L, and aspirin intake
within 3 days or clopidogrel within 7 days before surgery, as these factors were considered by the authors topotentially cause coagulation disorder. By contrast, ourstudy included patients who underwent CPB, which led
to different results; there were no significant differencesin coagulation disorder between patients with or without intraoperative blood salvage, possibly because theunderlying risk in all patients was lower than in those
recruited by Xie and colleagues.
One strength of this study is the use of thromboelastography to evaluate coagulation function after CPB.
Conventional coagulation tests have limitations inassessing dynamic coagulation function in cardiac surgery. Thromboelastography evaluates all componentsof the coagulation cascade in whole blood and canalso assess total clot strength and the contribution ofplatelets and fibrinolysis [9]. We believe that our results
reflect clinically relevant coagulation function.
This study has several limitations. First, the numberof patients was small because this was a preliminary
study. We believe that this study will be significant interms of facilitating sample size calculations in future
RCTs and providing new insight into adverse events of
intraoperative blood salvage and associated confounding factors. The results provide a rationale for conducting an RCT to evaluate whether intraoperative blood
salvage leads to coagulation disorder. Second, this was aprospective, observational study. Although we adjusted
for known possible confounders, there might be residual bias due to unknown confounders.
In conclusion, no significant associations existed
between intraoperative blood salvage and coagulation
disorder after CPB.

Morinaga et al. JA Clinical Reports(2024) 10:5

Acknowledgements
Kenji Yoshitani received a research grant from H.U. Group Research Institute G.K.
Authors’ contributions
MM collected and interpreted the patient data. KY and SO performed statistical analyses and contributed significantly to the writing of the manuscript. All
authors read and approved the final manuscript.
Funding
Institutional funding (Base33)
Availability of data and materials
The datasets used and analyzed during the current study are available fromthe corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
Approval reference R23011
Date of Approval: 9 June, 2023
Name of Ethical Committee Chair: Koji Iihara at National Cerebral and Cardiovascular Center
Consent for publication
Written informed consent for publication was obtained.
Competing interests
Kenji Yoshitani received a research grant from H.U. Group Research Institute
G.K. No other authors have any COIs. The rest of the authors declare that they
have no competing interests.
Received: 19 December 2023 Revised: 9 January 2024 Accepted: 13
January 2024

References
1. Roberts N, James S, Delaney M, Fitzmaurice C. The global need andavailability of blood products: a modelling study. Lancet Haematol.
2019;6:e606–e15.
2. Mazer CD, Whitlock RP, Fergusson DA, Hall J, Belley-Cote E, Connolly K,
et al. Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J
Med. 2017;377:2133–44.
3. Kilic A, Whitman GJ. Blood transfusions in cardiac surgery: indications,risks, and conservation strategies. Ann Thorac Surg. 2014;97:726–34.
4. Vonk AB, Meesters MI, Garnier RP, Romijn JW, van Barneveld LJ, Heymans
MW, et al. Intraoperative cell salvage is associated with reduced postoperative blood loss and transfusion requirements in cardiac surgery: acohort study. Transfusion. 2013;53:2782–9.
5. Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of an intraoperative cell saver during cardiac surgery: a meta-analysis of randomized
trials. Anesth Analg. 2009;109:320–30.
6. Rollins KE, Trim NL, Luddington RJ, Colah S, Klein A, Besser MW, et al.
Coagulopathy associated with massive cell salvage transfusion following
aortic surgery. Perfusion. 2012;27:30–3.
7. Scrascia G, Rotunno C, Nanna D, Rociola R, Guida P, Rubino G, et al. Pump
blood processing, salvage and re-transfusion improves hemoglobin
levels after coronary artery bypass grafting, but affects coagulative andfibrinolytic systems. Perfusion. 2012;27:270–7.
8. Xie Y, Shen S, Zhang J, Wang W, Zheng J. The efficacy, safety and costeffectiveness of intra-operative cell salvage in high-bleeding-risk cardiac
surgery with cardiopulmonary bypass: a prospective randomized andcontrolled trial. Int J Med Sci. 2015;12:322–8.
9. Haas T, Fries D, Tanaka KA, Asmis L, Curry NS, Schochl H. Usefulnessof standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence? Br J Anaesth.
2015;114:217–24.

Page 7 of 7

10. Lloyd-Donald P, Vasudevan A, Angus P, Gow P, Martensson J, Glassford N,
et al. Comparison of thromboelastography and conventional coagulation tests in patients with severe liver disease. Clin Appl Thromb Hemost.
2020;26:1076029620925915.
11. Diprose P, Herbertson MJ, O’Shaughnessy D, Deakin CD, Gill RS. Reducing
allogeneic transfusion in cardiac surgery: a randomized double-blind
placebo-controlled trial of antifibrinolytic therapies used in addition to
intra-operative cell salvage. Br J Anaesth. 2005;94:271–8.
12. Shen S, Zhang J, Wang W, Zheng J, Xie Y. Impact of intra-operative cellsalvage on blood coagulation in high-bleeding-risk patients undergoingcardiac surgery with cardiopulmonary bypass: a prospective randomized
and controlled trial. J Transl Med. 2016;14
13. Shore-Lesserson L, Manspeizer HE, DePerio M, Francis S, Vela-Cantos F,
Ergin MA. Thromboelastography-guided transfusion algorithm reducestransfusions in complex cardiac surgery. Anesth Analg. 1999;88:312–9.
14. Adam EH, Funke M, Zacharowski K, Meybohm P, Keller H, Weber CF.
Impact of intraoperative cell salvage on blood coagulation factor
concentrations in patients undergoing cardiac surgery. Anesth Analg.
2020;130:1389–95.
15. Palla R, Peyvandi F, Shapiro AD. Rare bleeding disorders: diagnosis andtreatment. Blood. 2015;125:2052–61.
16. Campbell J, Holland C, Richens D, Skinner H. Impact of cell salvage during
cardiac surgery on the thrombelastomeric coagulation profile: a pilot
study. Perfusion. 2012;27:221–4.
17. Niranjan G, Asimakopoulos G, Karagounis A, Cockerill G, Thompson M,
Chandrasekaran V. Effects of cell saver autologous blood transfusion on
blood loss and homologous blood transfusion requirements in patients
undergoing cardiac surgery on- versus off-cardiopulmonary bypass: arandomised trial. Eur J Cardiothorac Surg. 2006;30:271–7.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.