
==== Front
Acute Med Surg
Acute Med Surg
10.1002/(ISSN)2052-8817
AMS2
Acute Medicine & Surgery
2052-8817
John Wiley and Sons Inc. Hoboken

10.1002/ams2.70005
AMS270005
AMS-2024-0149.R2
Case Report
Case Report
Direct reinfusion of pericardial blood complications: A case of acute respiratory distress syndrome and disseminated intravascular coagulation
Xxxxx
Yasuda et al.
Yasuda Takuto https://orcid.org/0009-0003-8929-0787
1 tktysd@med.akita-u.ac.jp

Satoh Kasumi 1
Hirasawa Nobuhisa https://orcid.org/0000-0001-9329-0534
1
Okuyama Manabu 1
Nakae Hajime https://orcid.org/0000-0003-3733-3530
1
1 Department of Emergency and Critical Care Medicine Akita University Graduate School of Medicine Akita Japan
* Correspondence
Takuto Yasuda, Department of Emergency and Critical Care Medicine, Akita University Graduate School of Medicine, 1‐1‐1 Hondo, Akita 010‐8543, Japan.
Email: tktysd@med.akita-u.ac.jp

11 9 2024
Jan-Dec 2024
11 1 10.1002/ams2.v11.1 e7000519 8 2024
06 6 2024
30 8 2024
© 2024 The Author(s). Acute Medicine & Surgery published by John Wiley & Sons Australia, Ltd on behalf of Japanese Association for Acute Medicine.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Abstract

Background

Direct reinfusion of pericardial blood during cardiac surgery triggers a systemic inflammatory response. Although various inflammatory mediators have been identified as triggers, the role of damage‐associated molecular patterns (DAMPs) remains poorly understood. Despite guidelines recommending against this practice owing to its harmful effects, it is sometimes used in emergencies.

Case Presentation

A 72‐year‐old man with atrial fibrillation and cerebral infarction developed cardiac tamponade during catheter ablation. He underwent pericardial drainage and direct blood reinfusion. He was transferred to our ICU, where he developed acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC). Despite aggressive management, the patient died 41 days after admission.

Conclusion

This case highlights severe adverse events following direct reinfusion of pericardial blood. These findings suggest a significant role for DAMPs in mediating these inflammatory responses. Direct reinfusion of pericardial drainage blood should be avoided during emergencies to prevent life‐threatening complications.

Direct reinfusion of pericardial blood triggers systemic inflammatory responses, leading to severe complications like ARDS and DIC. Inflammatory mediators, including DAMPs, may have a significant role in these inflammatory reactions, highlighting the need to avoid this practice in emergencies.

blood coagulation disorders
cardiac tamponade
cytokines
HMGB1 protein
respiratory distress syndrome
source-schema-version-number2.0
cover-dateJanuary/December 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:11.09.2024
Yasuda T , Satoh K , Hirasawa N , Okuyama M , Nakae H . Direct reinfusion of pericardial blood complications: A case of acute respiratory distress syndrome and disseminated intravascular coagulation. Acute Med Surg. 2024;11 :e70005. 10.1002/ams2.70005
==== Body
pmcINTRODUCTION

The direct reinfusion of pericardial blood during cardiac surgery triggers a systemic inflammatory response. 1 While various inflammatory mediators have been identified in pericardial blood, the presence and role of damage‐associated molecular patterns (DAMPs) are still poorly understood.

Guidelines recommend against the direct reinfusion of pericardial blood owing to its potentially harmful effects. 2 However, this practice was once recognized for its utility before these adverse effects were appreciated. 3 Consequently, similar techniques are still employed in emergency scenarios such as cardiac tamponade, where access to emergency blood transfusions is limited.

Here, we describe a case of severe acute respiratory distress syndrome (ARDS) and disseminated intravascular coagulation (DIC) in a patient with cardiac tamponade who underwent direct reinfusion of drained pericardial blood, suggesting the potential involvement of DAMPs in such inflammatory responses.

CASE PRESENTATION

A 72‐year‐old man with a history of atrial fibrillation, cerebral infarction, and other conditions developed cardiac tamponade during catheter ablation at a previous hospital. Subsequently, pericardial drainage and reinfusion of the drained pericardial blood into a central venous catheter were initiated. Persistent pericardial bleeding was suspected, but his hemodynamic instability did not improve; therefore, he was transferred to our intensive care unit a few hours later. Before transfer, we instructed the previous physician to discontinue the direct reinfusion of pericardial drainage blood.

On arrival at our hospital, his vital signs were as follows: blood pressure was 81/44 mmHg with norepinephrine support at 0.11 μg/kg/min, pulse rate was 64 beats/min in sinus rhythm, respiratory rate was 29 breaths/min, oxygen saturation was 84% with 10 L/min of oxygen, and body temperature was 36.4°C. The patient was intubated for prolonged hemodynamic instability and respiratory failure, and artificial ventilation was initiated. Laboratory tests at the time of admission are shown in Table 1. These results indicated marked coagulopathy requiring transfusion therapy. Subsequently, as his blood pressure stabilized, cardiac tamponade was managed conservatively. On the second day of hospitalization, his respiratory failure temporarily improved, and he was extubated. However, on the third day, renal function worsened, and laboratory tests showed creatinine, 4.32 mg/dL, and blood urea nitrogen, 52.1 mg/dL. Continuous hemodialysis was initiated for acute kidney injury (AKI). On the fourth day, his overall condition deteriorated further, leading to cardiac arrest; however, he was resuscitated promptly and his spontaneous circulation resumed. At that time, under an FIO2 of 1.00, the arterial blood gas analysis showed pH 7.07, PaCO2 62 mmHg, PaO2 52 mmHg, and HCO3 −18.0 mmol/L. The patient was reintubated because of worsening respiratory failure and computed tomography revealed diffuse infiltrates in both lungs (Figure 1). Ultrasonic echocardiography revealed no obvious abnormalities in the cardiac function, and the patient was diagnosed with ARDS. The pericardial drain was removed on the fifth day, but the pericardial drainage blood contained high levels of Interleukin‐6 (IL‐6), 2850 pg/mL, and high mobility group box‐1 (HMGB‐1), 59.8 ng/mL [reference range: 1.65 ± 0.04 ng/mL]. It has been suggested that the direct return of pericardial fluid containing these inflammatory cytokines and DAMPs may induce organ failure, such as DIC, AKI, and ARDS. The patient temporarily recovered after systemic glucocorticoid therapy and prone positioning for ARDS, but multiple organ failures progressed due to complications of catheter‐related bloodstream infection and cytomegalovirus pneumonia. Despite aggressive management, including artificial ventilation, acute blood purification therapy, and transfusion therapy, his condition deteriorated, resulting in his death 41 days after admission.

TABLE 1 Laboratory findings on the first day of hospitalization.

Laboratory test	Value	Reference range	
White blood cell count, /μL	12,100	3300–8600	
Hemoglobin, g/dL	11.0	13.7–16.8	
Platelet count, /μL	39,000	158,000–348,000	
Prothrombin time‐international normalized ratio	2.62	0.9–1.1	
Activated partial thromboplastin time, second	107.1	22.5–37.5	
D‐dimer, μg/mL	194.70	<1.00	
Fibrinogen, mg/dL	<50.0	200–400	
Total bilirubin, mg/dL	2.5	0.4–1.5	
Aspartate aminotransferase, U/L	45	13–30	
Alanine aminotransferase, U/L	22	10–42	
Blood urea nitrogen, mg/dL	22.2	8–20	
Creatinine, mg/dL	1.29	0.65–1.07	
Sodium, mEq/L	144	138–145	
Potassium, mEq/L	5.8	3.6–4.8	
Calcium, mg/dL	5.9	8.8–10.1	
C‐reactive protein, mg/dL	0.10	0–0.14	

FIGURE 1 Images of the progress after the direct reinfusion of pericardial blood. (A) Non‐contrast chest computed tomography 1 hour after the start of direct reinfusion of pericardial blood shows no abnormalities. (B) Non‐contrast chest CT 3 days after admission shows diffuse infiltrates in both lungs.

DISCUSSION

This case highlights the potential for adverse events caused by direct return of pericardial blood. Pericardial suction blood in cardiac surgery contains many inflammatory markers, which can be effectively reduced using cell salvage techniques. 1

In other words, returning untreated pericardial blood directly into the body causes systemic inflammatory reactions. In this case, high levels of IL‐6 were detected in pericardial drainage blood. IL‐6 is an important inflammatory cytokine that contributes to the systemic inflammatory response in ARDS. 4 The direct reinfusion of this blood may have led to multiple organ failure, including ARDS and DIC.

Similarly, HMGB‐1 was abundant in pericardial drainage blood. HMGB‐1 is known as one of the DAMPs, which include substances such as ATP, extracellular cold‐inducible RNA‐binding protein (eCIRP), histones, heat shock proteins (HSPs), extracellular RNAs (exRNAs), and cell‐free DNA (cfDNA). 5 They are endogenous molecules released from cells under stress or damage, which activate immune responses. This activation can lead to local inflammation for tissue repair or, if excessive, systemic inflammation and remote organ failure. In this case, myocardial cell damage due to catheterization may have led to the release of various DAMPs, which will be discussed with a focus on HMGB‐1 below. Once outside the cell, HMGB‐1 activates a range of immune cells, triggering an increase in inflammatory cytokines, promoting inflammation, and exacerbating tissue damage. 6 In the context of ARDS, HMGB‐1 aggravates the inflammatory response in the lungs, leading to increased permeability, fluid accumulation, and impaired gas exchange. 7 Similarly, in DIC, HMGB‐1 contributes to the abnormal clotting cascade, promoting widespread coagulation and bleeding complications. 8 Therefore, in this case, DAMPs and inflammatory cytokines may have been involved in the systemic inflammatory response, including ARDS and DIC.

Although limited data exist on the removal of DAMPs by cell salvage, it has been reported that up to 99% of unfractionated heparin can be removed using this method. 9 Since HMGB‐1 is similar in mass to unfractionated heparin, it is presumed that HMGB‐1 can also be effectively eliminated through cell salvage based on centrifugation. Thus, pericardial blood return via cell salvage may be free of HMGB‐1 and performed safely. In addition to medically induced cardiac tamponade, as in this case, direct reinfusion of pericardial drainage blood should not be performed in situations where rapid access to transfusion resources is difficult.

CONCLUSION

Direct reinfusion of pericardial drainage blood should be avoided during cardiac surgery because of its adverse effects. Additionally, it should not be performed in emergency situations, such as cardiac tamponade. The systemic inflammatory response induced by this procedure involves various inflammatory mediators, and DAMPs may play a role in this process.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

Approval of the research protocol: As the article type of this manuscript was a case report, an ethics committee was not consulted. This study was conducted according to the principles of the Declaration of Helsinki.

Informed consent: Informed consent was obtained from the patients.

Registry and the Registration No. of the study/trial: N/A

Animal Studies: N/A

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article because no datasets were generated or analyzed in the current study.
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