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Point of care hematocrit and hemoglobin in cardiac surgery: a review

Gerard J. Myers and Joe Browne
Perfusion 2007 22: 179
DOI: 10.1177/0267659107080826

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Perfusion 2007; 22: 179–183
Point of care hematocrit and hemoglobin
in cardiac surgery: a review
Gerard J Myers1 and Joe Browne2
1Cardiovascular Perfusion, QEII & IWK Health Science Centers, Halifax, Nova Scotia;
2Clinical Perfusion, Health Sciences Center, St. John’s, Newfoundland, Canada
The use of point-of-care blood gas analyzers in cardiac
surgery has been on the increase over the past decade.
The availability of these analyzers in the operating room
and post-operative intensive care units eliminates the
time delays to transport samples to the main laboratory
and reduces the amount of blood sampled to measure
such parameters as electrolytes, blood gases, lactates,
glucose and hemoglobin/hematocrit. Point-of-care ana-
lyzers also lead to faster and more reliable clinical deci-
sions while the patient is still on the heart lung machine.
Point-of-care devices were designed to provide safe,
appropriate and consistent care of those patients in need
of rapid acid/base balance and electrolyte management
in the clinical setting. As a result, clinicians rely on their
values to make decisions regarding ventilation, acid/base
management, transfusion and glucose management.
Therefore, accuracy and reliability are an absolute must
for these bedside analyzers in both the cardiac operating
room and the post-op intensive care units.
Clinicians have a choice of two types of technology to
measure hemoglobin/hematocrit during bypass, which
subsequently determines their patient’s level of hemodi-
lution, as well as their transfusion threshold. All modern
Introduction
One of the most frequently overlooked instruments
having an effect on a program’s overall transfusion
rate, is the point-of-care (POC) blood gas analyzer.
Over the past decade, many centers have been rely-
ing on POC blood gas analyzers to determine their
transfusion thresholds, using nadir hematocrit1,
which is considered to be the lowest hematocrit on
cardiopulmonary bypass (CPB). These analyzers are
usually located within the operating-room environ-
ment to allow for quick and accurate results of blood
gas analysis, electrolytes and hematology. They are
marketed as hand-held and desktop devices, as well
as the more portable devices designed to be moved
from area to area. POC devices have allowed the
Address for correspondence: Gerard J Myers RRT, CCP
Cardiovascular Perfusion Services 5th Floor, Cardiac OR, NHI
Campus, QEII Health Sciences Center, Halifax, Nova Scotia,
Canada. B3K 6A3. Tel: (902) 473-2198; Fax: (902) 473-8955.
E-mail: edit@ns.sympatico.ca
© 2007 SAGE Publications, Los Angeles, London, New Delhi and Singapore
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point-of-care blood gas analyzers measure hematocrit
using a technology called conductivity, while other simi-
lar devices measure hemoglobin using a technology
called co-oximetry. The two methods are analyzed and
compared in this review.
The literature indicates that using conductivity to measure
hematocrit during and after cardiac surgery could produce
inaccurate results when hematocrits are less than 30%,
and, therefore, result in unnecessary homologous red cell
transfusions in some patients. These inaccuracies are
influenced by several factors that are common and unique
to cardiopulmonary bypass, and will also be reviewed
here.
It appears that the only accurate, consistent and reliable
method to determine hemodilution and establish transfu-
sion thresholds based on nadir hematocrits during
cardiopulmonary bypass, and immediately post cardiac
surgery, is with the use of co-oximetry. Perfusion (2007)
22, 179–183.
Keywords: point of care, blood gas, conductivity,
co-oximetry, hematocrit, hemoglobin
physician and perfusionist to better manage their
bypass patients during CPB because they do not
have to wait extended periods of time to get their
results from the lab. Therefore, POC devices have
become a vital part of the patients’ overall care.
However, values given for hematocrits with POC
devices may lead to false highs or false lows if the
operator does not understand the conductometric
method used to measure this parameter. These inac-
curacies can result from several variables during the
course of bypass that will affect conductometric
measurements in the cardiac surgery setting.
Outside of fluorescent optical sensors, which are used
for hematocrit determinations in extracorporeal cir-
cuitry as venous blood passes through them, there
are three main electromechanical/chemical methods
of determining hematocrits.
The first is centrifugation, which is used as a ‘gold
standard’ by many laboratories to separate red cells
from plasma by using the forces of gravity.
Centrifugation at high speeds for several minutes
will separate whole blood into an upper plasma
layer, a thin intermediate layer containing platelets
10.1177/0267659107080826
 Point of care hematocrit or hemoglobin in cardiac surgery
GJ Myers and J Browne
180
and white cells (referred to as the buffy coat) and a
lower red blood cell layer, which is reported to the
clinician as hematocrit.
The second method of hematocrit measurement,
called the Coulter Counter method, is also consid-
ered the ‘gold standard’ by many labs. This method
is often referred to as electrical particle counting,
because whole blood is diluted with saline and
forced through a narrow orifice, which causes the
red cells to pass in single file through a pair of elec-
trodes that measure electrical resistance and, subse-
quently, hematocrit. Measurements of electrical
resistance with the Coulter are not altered by plasma
components such as non-ionized molecules, elec-
trolytes and proteins. Both microhematocrit and
electrical particle counting are also considered
industry standards.
The third method, called electrical conductivity,
will be described next and is the focus of this look
into the field of POC transfusion trigger devices. Co-
oximeters are used to determine hemoglobin only
and will be described in this review as well.
Conductivity
All POC blood gas analyzers give their values for
hematocrit based on conductivity, which is the abil-
ity of a fluid to allow an electric current to pass
through it. The rate of electrical conduction is
reduced in plasma as the amount of formed ele-
ments (red cells) increase in this fluid, which is
recorded as an increased hematocrit.
The first tables to allow the calculation of hemat-
ocrit were utilized by Wilson in 1905.2 However, the
measurements of hematocrit using conductivity did
not become available to the clinician until the
1960s.3 Conductivity-based hematocrit is consid-
ered accurate for most clinical situations and most
physiologically normal patients. However, the accu-
racy of hematocrits using conductivity is affected by
changes in sodium levels, changes in protein con-
centrations, the use of plasma volume expanders,
the amount and types of anticoagulants used for
bypass and the presence of elevated white blood cell
counts.4–6 Unfortunately, all of the latter are condi-
tions created or present during cardiopulmonary
bypass and carry over into the immediate postoper-
ative period in the intensive care unit (ICU).
Since conductivity is the ability of a solution to
transmit electrical current through it, the electrolyte
and charged protein concentration of plasma, as
well as the presence of non-conducting cellular
components, will influence the ease that this current
passes through plasma.
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There are three essential factors that are needed to
be present to determine hematocrit when using con-
ductometric methods. These are temperature, elec-
trolytes and proteins.
1 Temperature – Due to the fact that blood has a
high temperature coefficient, it is essential to
maintain constant temperature of the sample.
This is done by the POC analyzer, which has a
built-in thermostat-regulated temperature cham-
ber. This temperature block eliminates any devia-
tion in temperature of the sample.
2 Electrolytes – The most abundant electrolyte in
plasma is sodium, which is used in the determi-
nation of hematocrit during conductivity.
Increases or decreases in sodium concentration
will affect red cell volume and, thus, hematocrit
measurements.
3 Protein – Conductivity assumes that the protein
concentration of plasma is at a constant ratio;
therefore, decreases or increases in serum protein
can alter results.
Co-oximetry
Co-oximeters are blood gas instruments that
utilize spectrophotometric analysis of blood
samples to obtain four hemoglobin moieties:
Oxyhemoglobin (O2Hb), Deoxyhemoglobin (HHb),
Carboxyhemoglobin (COHb) and Methemoglobin
(MetHb).
Development of spectrophotometry dates back to
the 1600s, which continued on with Lambert in
1760 and Beer in 1852, but the first spectrophoto-
metric measurements of blood did not take place
until the 1930s.7 The Beer-Lambert Law describes
the transmission and absorption of light as a func-
tion of the absorbing molecules in solution. The
co-oximetry system consists of a light source, a
series of lenses, several filters, mirrors that focus the
light beams, sample chamber, temperature regulated
block, hemolyzer, a monochromator and photodiode
detectors that emit electrons.
By heating a blood sample to 37°C in the temper-
ature-regulated box and allowing it to be hemolyzed
with high frequency vibrations, it produces a
translucent solution for analyzing. Light from the
lamp is then filtered and passes through the blood
sample. The transmitted light is then focused
through a grating that transmits the light into a spec-
trum. Specific wavelengths are then selected and
directed onto photodiodes to produce electric cur-
rents proportional to the light intensities.
Substances found in a sample that cause light to
scatter, other than hemoglobin, will create errors in

co-oximeters. The most common offenders are
high lipids and cell fragments from incomplete
hemolysis8.
In the book Clinical Application of Blood Gases
by B.A. Shapiro,8 it states that ‘the co-oximeter is
the most accurate method available for measuring
the four clinically relevant hemoglobin moieties and
is considered the standard against which all other
methods must be compared’.
Figure 1 is a partial list of some manufacturers
and their devices used to measure either hematocrit
(conductivity) or hemoglobin (co-oximetry). Most of
the companies make both types and rely on the clin-
ical user to match the specific technology they offer
to the specific needs of their patients.
Conductivity in cardiac surgery
Cardiac surgery places the patient into a unique series
of physiologic changes due to the fluids used for main-
tenance of extracorporeal bypass, the exaggerated
dosages of pharmaceuticals needed to maintain home-
ostasis and the alterations in fluid dynamics
that occur in this controlled shock-like state.
Inaccuracies in conductometric hematocrits are
found in several situations, all of which are found
during extracorporeal circulation and in the imme-
diate postoperative period thereafter.
Effects of protein changes
Protein molecules, like red cells, offer mechanical
interference to the passage of an electrical current
through the solution, hence, when the protein con-
tent of blood is diminished with crystalloids, con-
ductivity will increase. In other words, when protein
concentrations are decreased during CPB by hemo-
dilution, conductometric measurements will give a
value for hematocrit that is falsely lower than the
actual hematocrit of that sample.4
This was well demonstrated by McMahon and
co-workers5 who examined the affect cell savers
have on the processed blood of 41 patients. The study
compared the hematocrit of salvaged intraoperative
Figure 1 Manufacturers and products.
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Point of care hematocrit or hemoglobin in cardiac surgery
GJ Myers and J Browne
181
Figure 2 Comparison of methods.
blood before it was processed by a cell saver, with
that same blood after the protein was removed
through cell washing. As shown in Figure 2, the
authors compared the laboratory standard Coulter
Counter with the microhematocrit (centrifuge) and
the Stat-Crit analyzer (conductivity).
Their conclusions were that devices that derive
hematocrit values using the conductivity method
would give falsely low readings in situations
where the serum protein is altered in the blood
sample.
Similar results were found by McNulty and co-
workers6 when they examined the hematocrit of
25 patients undergoing cardiopulmonary bypass
(CPB). Their study examined hematocrits using
a conductometric device, a device that corrected
conductometric results, a photometry device and
centrifugation under both in vivo and in vitro con-
ditions. Results indicated significant differences
between the uncorrected conductometric measure-
ments and the other devices. In fact, the study found
that, if present laboratory standards of quality con-
trol (QC) were strictly applied to the various instru-
ments they studied, the conductivity methods
would not be in conformance with the Clinical
Laboratories Improvements Act9 of 1988 (eg. expected
percentage difference between several instruments
measuring Hb is supposed to be ⫾7% of target
value).
Like the effects on protein, Rosenthal and Tobias10
compared conductivity derived hematocrits with
centrifuge, taking into account increased white cell
counts (WBC) with leukemia patients. They found
that poor conductivity in the presence of increased
white cell counts led to an overestimation of hema-
tocrit by 5.7%.
Effects of osmotic changes
The electrical resistance measurement of hematocrit
using conductivity is also dependant on the medi-
um (plasma) the red cells are suspended in. Osmotic
increases in plasma will influence the samples
determination of hematocrit by giving falsely low
hematocrit readings. This is believed to be the result
of fluid shifts out of the red blood cell when plasma
osmolarity is elevated. Fluid shifting of this nature
 Point of care hematocrit or hemoglobin in cardiac surgery
GJ Myers and J Browne
182
will temporarily cause red cells to shrink and
devices using conductivity to measure hematocrit
will read this as lower hematocrit values in that
sample.
During cardiopulmonary bypass, the use of vol-
ume expanders can also influence plasma osmolality
and, subsequently, create low hematocrit readings
when using conductivity.4 Various anticoagulants
also have the ability to change cell morphology due
to osmotic changes of red cells, which can influence
conductivity. Gotch et al.11 found that variations in
heparin concentrations in collected blood samples
may induce significant changes in conductometric
hematocrit determinations.
In a case reported by Stott et al.,4 they found the
admission hematocrit of a 13-year-old patient to be
21% using the Coulter Counter method and 13%
using conductivity. The only abnormalities in
the patient’s chemistry were high plasma osm-
olality (388 mosmol/kg) and elevated sodium
(173 mmol/L). To investigate the latter findings, in
vitro investigations by this group found that there
was a recorded 5.5% decrease in hematocrit for
every 100 mosmol/kg increase in osmolality when
comparing the latter two methods of hematocrit
determination.
Discussion
The technical difference between POC devices that
use conductivity and co-oximetry has been previ-
ously described.12 All POC analyzers using conduc-
tivity are equipped with easy to use algorithms or
correction factors that mathematically correct the
hematocrit values during CPB. These correction fac-
tors are recommended to the user when measuring
hematocrit with condumetric devices during car-
diac surgery. However, when discussing algorithms,
a quote from the I-STAT Corporation web site
(http://www.i-stat.com/products/ctisheets/714178-
01G.pdf) reads as follows: “The CPB algorithm
assumes that cells and plasma are diluted equally
and that the pump priming solution has no added
albumin or other colloid or packed red blood cells”.
This indicates that the hematocrit may or may not
be accurate, depending on the conduct of bypass. In
other words, the accuracy of a parameter that could
determine that patient’s likelihood of being trans-
fused with banked blood may be the operator’s
responsibility. On the other hand, to quote the Bayer
RapidPoint 400 series operators’ manual, “calculat-
ed hematocrits should not be used as the sole
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determinant of hematological disorders during
cardiopulmonary bypass”.
In clinical practice, the transfusion threshold will
vary from institution to institution, but evidence
suggests that going below a hematocrit of 20% or
hemoglobin of 7.0 g/dl may result in adverse out-
comes and increases in hospital mortality.13 We,
therefore, have to assume that a difference of only
1.0 g/dl in hemoglobin or a difference of only 3% in
hematocrit would lead to a patient being transfused
with banked red cells during or post CPB.
Hopfer and co-workers14 did an in vitro compari-
son of hematocrit between the I-STAT (conductivity)
and the HemoCue (photometry) analyzers under
simulated bypass conditions (crystalloid hemodilu-
tion), using the GenS (Coulter Counter) as the control.
Photometry hematocrit results correlated exactly
with the Coulter Counter, but conductometric
results were lower by as much as 2.0 g/dl for hemo-
globin and 4% for hematocrit.
Steinfelder-Visscher and co-workers15 did a
prospective in vivo investigation during CPB in
88 patients over a six-month period. Hematocrit
measurements were compared between the Gem
Premier 3000 (conductivity) and the Sysmex 2100
(Coulter Counter). They found that 37/55 samples
that had hematocrit values below 20% using con-
ductivity, actually had hematocrit values above 20%
when measured by the Sysmex. They concluded that,
when using conductivity, 67% of the 55 patients
deemed below the transfusion threshold would
have been unnecessarily transfused.
Finally, in another prospective, randomized trial
during CPB, Prichard and co-workers16 evaluated
hematocrit in 20 patients using the ABL 77 (conduc-
tivity) with the ABL-720 (co-oximetry) and the
Beckman LH 750 (Coulter Counter). The mean
hematocrit, using conductivity, was 19.8 ⫾ 5.9%,
while the mean calculated hematocrit-using co-
oximetry was 24.1 ⫾ 5.6% and the mean hematocrit
with the Coulter Counter was 23.8 ⫾ 5.6%. This is a
respective inaccuracy in hematocrit values of 4.3%
and 4.0% when using conductivity.
The evidence is clear that POC devices using
conductivity to measure hematocrit are reliable in
most clinical settings where there is no large varia-
tion in protein concentrations, no abnormally
increased lipid profiles or white cell counts and no
large use of volume expanders or osmotically active
agents. Unfortunately, the latter may be every day
occurrences in the cardiac surgery operating room.
To quote Stott and co-workers,4 “Conductivity
measurements provide accurate hematocrit results

for physiologically normal subjects . . . but not for
some intensive care and surgical patients”. In order
to avoid patients being unnecessarily transfused,
perfusionists and other clinicians must be aware of
the effects conductivity can have on their unique
patient population, and take appropriate measures to
counteract these therapeutic-altering discrepancies.
This is not only true in the cardiac operating room,
but in the immediate postoperative ICU as well.
As previously stated by Shapiro (8), measurement
of hemoglobin with co-oximetry is the most accurate
method available to determine this important trans-
fusion parameter. The hazards of using POC hemat-
ocrit as our transfusion trigger is, it may lead to
inadvertent or premature red cell administration to
our patients, and concern about unnecessary med-
ical/legal concerns. Therefore, if we are going to
offer the most accurate and consistently reliable
diagnostic methods to determine transfusion for car-
diac surgery patients based on nadir hematocrit, the
use of hematocrit based on co-oximetry-derived
hemoglobin values is critical.
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