Every 20 minutes at 32C degree.

Use it in most patients, except patients with large surface area and high haemoglobins, or in unstable patients.

We have a blood conservation protocol in our OR and ICU, so we do it on all our patients. We do it both on the arterial and if possible on the venous side. (As long as the patient tolerates it). Sometimes a little “help” from the anesthesiologist brings the blood pressure up and allows us to do retrograde autologous priming even in borderline hemodynamics.

Retrograde autologous priming (RAP) is a blood conservation technique used to limit the severity of hemodilution during cardiopulmonary bypass and reduce perioperative transfusions. It is a safe technique and may have a beneficial effect on postoperative outcomes. We use it in selected cases

I've incorporated autologous retrograde priming (ARP) in patients who demonstrate adequate stability of hemodynamics and who have adequate colloidal oncotic pressure based upon serum proteins. In the era when this became more of a standard, patients were hemodiluted, had post-cath lab or ICU coagulopathies and cardiac dysfunction related to an acute or care induced event.

CPB systems were of a somewhat larger priming volume and iatrogenic hemodilution was the issue. ARP today is still highly valid and has the same benefit to the patient - unstable and otherwise, as the new volume shift is less, incurring less hemodilution, maintaining an iso-oncotic fluid balance, less visceral organ ischemia (due to edema) and overall better vascular dynamics while on CPB.

It can be "done on all patients" while addressing the parameters that identify quality perfusion management. ARP in my practice of over 12,000 procedures is usually also coupled with isovolumic hemodilution (via autologous donation) when appropriate (on CPB HCT 30 +/- 5%).

Having a fresh unit of autologous blood preserved properly and stored in the OR at 22 deg C (any lower in my experience has shown 2,3 DPG to be significantly impaired for up to 8 hours post infusion, and impacting O2 uptake and transfer).

I am a strong proponent for having a completely rational reason for doing anything- re-exploring what is habit, tradition, "because I was told to!", and so forth

is always an obligation of the health care professional- especially for our colleagues who maintain life at a seminal level every day, around the clock.

In my institution we occasionally use RAP (Calafiore priming). Just in case of left main critical occlusion (more than 90%) or in mitral valve surgery to reduce CPB times.

We use it on all adult patients and any pediatrics patient where we do not have to add blood to the prime, usually > 8 Kg. In a retrospective review, we found that it decreases blood transfusion by one unit of RBC during the hospital stay. RAP volume in adults is usually between 800-1000 ml.

Usually all patients we do using CPB except unstable patients. arterial as well as venous autologus priming done and it is not 100% prime volume replacement in all cases. we do it as much as possible stable hemodynamics allows us...but most of the time it is nearly 75-90% target achieved. advantage known to all of us.

in our unit we use this technic only in pediatric cardiac surgery and essentially in ASD closure

We never use this technic in case of LVOTO

When the bypass time is long enough we prefer to use hemofiltration technic rather than RAP

It is an effective method to limit hemodilution at the beginning of CPB. Although its efficacy has been questioned it is routinely carried out at my istitution with the exception of those cases in which hemodynamic instability or hypovolemia contraindicate its use.

It often is necessary to infuse vasopressors to maintain an acceptable arterial blood pressure during this process.

It could be an acceptable method to limit the deleterious effect of reduced oncotic power of the prime solition since rhe retraction of starches from the market.

Although it widespread use, its benefit in terms of effectiveness in reducing transfusions is still controversial.

1. Rosengart TK, DeBois W, O'Hara M, et al: Retrograde autologous priming for cardiopulmonary bypass: A safe and effective means of decreasing hemodilution and transfusion requirements, J Thorac Cardiovasc Surg 115:426438, 1998.

2. Murphy GS, Szokol JW, Nitsun M, et al: The failure of retrograde autologous priming of the cardiopulmonary bypass circuit to reduce blood use after cardiac surgical procedures, Anesth Analg 98:1201–1207, 2004.

Retrograde autologous priming (RAP) is employed in our institution, especially for patients with low body surface area (BSA). We use both arterial and venous RAP when patients tolerate it. We do not use it widely in unstable patients or in urgent cases. Retrograde autologous priming of the CPB circuit is considered as a blood conservation strategy as you can read in 2011 Update to The Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists Blood Conservation Clinical Practice Guidelines with level of evidence B – IIb (Ann Thorac Surg 2011;91:944–82). Usually, we associate it with other perfusion interventions such as miniaturized circuits or vacuum-assisted venous drainage.

We use it in every case when hemodynamically possible. Not in patients who have an unusual high hematocrit value, where hemodilution is more necessary.

We use very rarely RAP. May be 5% or less - usually in adults with low weight and low hematocrit, even less in pediatric patients.

We use a mini-circuit that is only 900 ccs of prime, so we basically use RAP on all CPB patients and use alpha agents to maintain BP if necessary. This minimizes hemodilution and use of intra-operative transfusion ( see Emery et al, Innov 2012)

It is used arbitrary at our place, depending on the staff preference (not a standard). But I try to use it when ever possible, and in conjunction with autologous blood removal (1-2 units, even 3 units in a big polycytheamic adult) before heparine to return after protamine. Main reason is contraction of donor blood products use. alpha mimetics are not harmfull when used shortly...in anesthetized patient at 34-32 degrees Cent.

I agree with Evgeny's approach and in the right patients have used this in conjunction with a long term plan for autologous donation over a 2-3 week period in patients where blood banking is difficult or limited. In this I am able to obtain 5-6 units of fresh autologous blood over this time period without distress.

The key is proper planning. This is especially an advantage when prime limited technologies are unavailable.

We are routinely doing the retrograde drainage of the priming solution with autologous blood from the aortic cannulation. We have found a significant reduction in hemodilution during CPB. It is very useful in presence of polycythemia to bring down hematocrit to 35 to 45%. Hypotension is often the limiting factor. Autologous blood is only collected when the hematocrit is high and then this blood collected is always transfused after the protamine injection. It has significantly brought down the use of blood product in our patients.

We "RAP" all our patients except those who are unstable and those who are dramatically dry. We only RAP the venous line and purge the excess crystalloid