Cell Salvage Device Research Articles

Impact of a cell salvage device on blood transfusions to dogs undergoing surgery at a referral veterinary hospital.

To determine the number of homologous blood transfusions received by canine surgical patients after introducing a cell salvage device (CSD), trends in surgeries requiring blood transfusion, and the incidence of transfusion reactions. Retrospective study. Single referral hospital. All dogs having surgery at a single center (November 2015 to February 2021). Medical records of dogs having surgical treatment, including those that received either an autologous or homologous blood transfusion, were reviewed. The surgical patients were the baseline population, and the 2 transfusion groups were compared within this population to analyze the trends. A total of 37 and 86 dogs received autologous and homologous blood transfusions, respectively. There was an upward trend in the number of total monthly blood transfusions. No significant increase in the monthly number of homologous transfusions was observed before or after acquisition of the CSD. There was also an upward trend in total monthly surgeries, including those with higher risks of hemorrhage. Dogs receiving homologous blood transfusions had a higher incidence of clinical signs consistent with transfusion reactions (6.98%). An upward trend in autologous blood transfusions was seen with the introduction of a CSD. Hospitals with large surgical caseloads at high risk of hemorrhage may see a decreased need for outsourced blood products with the use of the CSD. The device can lead to a more responsible use of an increasingly scarce resource and decrease the risk of a blood transfusion reaction in dogs.

The Use of Intraoperative Cell Salvage in Two-Stage Revision of Septic Hip Arthroplasties: A Double-Center Retrospective Study

(1) Background: intraoperative cell salvage (ICS) devices can provide a valuable contribution to patient blood management. An infection of the surgical site presents a formal contraindication to the use of ICS. To date, there is no recommendation for the use of ICS in the context of reimplantation in two-stage septic exchange arthroplasty. (2) Methods: at two hospitals of maximum endoprosthetic care, a retrospective evaluation of patients who had received ICS blood during reimplantation of hip arthroplasties was performed. Patients’ and surgical characteristics, intraoperative cultures, and the occurrence of septic complications in the short- and long-term follow-up were recorded. (3) Results: 144 patients were included. Detection of positive cultures during reimplantation occurred in 13 cases. A total of 127 patients showed no complication, 8 patients showed a non-specific septic complication, 6 patients a local persistence of infection, and 3 patients a possible bloodstream-associated infection. No significant correlation was found between the occurrence of complications and the detection of positive intraoperative cultures. (4) Conclusions: no clustering of septic complications due to the use of ICS during reimplantation was found. In the risk-benefit analysis, we considered the use of ICS during reimplantation to be indicated in terms of patient blood management, while the safety of the procedure during septic first-stage resection arthroplasty or septic one-stage exchange arthroplasty was not investigated. Given the paucity of comparative literature, further studies are needed on ideal patient blood management in the setting of septic revision arthroplasty.

Clinical Issues - May 2023.

Indications for use of intraoperative autologous red blood cell salvage Key words: intraoperative red blood cell salvage, autologous blood, blood loss, transfusion, collection. Contraindications for use of intraoperative autologous red blood cell salvage Key words: intraoperative red blood cell salvage, red blood cell lysis, relative contraindications, autologous red blood cells, cell salvage devices. Second victim phenomenon after adverse events Key words: second victim, support program, Second Victim Experience and Support Tool (SVEST), adverse event, personal integrity.

Cell Salvage at the ICU.

Patient Blood Management (PBM) is a patient-centered, systemic and evidence-based approach. Its target is to manage and to preserve the patient’s own blood. The aim of PBM is to improve patient safety. As indicated by several meta-analyses in a systematic literature search, the cell salvage technique is an efficient method to reduce the demand for allogeneic banked blood. Therefore, cell salvage is an important tool in PBM. Cell salvage is widely used in orthopedic-, trauma-, cardiac-, vascular and transplant surgery. Especially in cases of severe bleeding cell salvage adds significant value for blood supply. In cardiac and orthopedic surgery, the postoperative use for selected patients at the intensive care unit is feasible and can be implemented well in practice. Since the retransfusion of unwashed shed blood should be avoided due to multiple side effects and low quality, cell salvage can be used to reduce postoperative anemia with autologous blood of high quality. Implementing quality management, compliance with hygienic standards as well as training and education of staff, it is a cost-efficient method to reduce allogeneic blood transfusion. The following article will discuss the possibilities, legal aspects, implementation and costs of using cell salvage devices in an intensive care unit.

Recovery of platelet-rich red blood cells and acquisition of convalescent plasma with a novel gravity-driven blood separation device.

ObjectivesOur objectives were to determine the separation characteristics and blood product quality of a gravity‐driven microfiltration blood separation system (HemoClear, The Netherlands).BackgroundA range of centrifugal blood separation devices, including intraoperative cell salvage devices (cell savers) and apheresis machines, are available to assist in preparing both allogenic and autologous blood products. These devices are expensive to operate and require extensive training.Methods and MaterialsNine whole blood units were collected under standard conditions and analysed for haematological parameters, thromboelastographic properties, platelet morphology and activation, and red blood cell (RBC) deformability and morphology. Three whole blood units were separated by means of the HemoClear device, into a liquid and cellular component. The cellular component was diluted with SAGM and cold stored for 14 days. To simulate cell salvage six whole blood units were diluted with isotonic saline, followed by multiple HemoClear separation rounds.ResultsThe recovery of both RBCs (100 ± 1.6%) and white blood cells (99 ± 4.5%) after undiluted filtration were very high, while platelet recovery was high (83 ± 3.0%). During the filtration, and cold storage after filtration storage both the non‐deformable RBC fraction and the RBC maximum elongation remained stable. Parameters of thromboelastography indicated that platelets remain functional after filtration and after 7 days of cold storage. In the cell salvage simulation the total protein load in the cellular fraction was reduced by 65 ± 4.1% after one washing round and 84 ± 1.9% after two consecutive washing rounds.ConclusionThe novel blood filter studied effectively separates whole blood into diluted plasma and platelet‐rich RBCs. Moreover, the device effectively washed diluted whole blood, driving over 80% of proteins to the liquid component.

An In Vitro Pilot Study Comparing the Novel HemoClear Gravity-Driven Microfiltration Cell Salvage System with the Conventional Centrifugal XTRA™ Autotransfusion Device.

Background In 2013, the World Health Organization reported a shortage of 17 million red blood cell units, a number that remains growing. Acts to relieve this shortage have primarily focused on allogeneic blood collection. Nevertheless, autologous transfusion can partially alleviate the current pressure and dependence on blood banking systems. To achieve this, current gold standard autotransfusion devices should be complemented with widely available, cost-efficient, and time-efficient devices. The novel HemoClear cell salvage device (HemoClear BV, Zwolle, Netherlands), a gravity-driven microfilter, potentially is widely employable. We evaluated its performance in the cardiac postoperative setting compared to the centrifugal XTRA™ autotransfusion device. Methods In a split-unit study (n = 18), shed blood collected 18 hours after cardiothoracic surgery was divided into two equal volumes. One-half was processed by the XTRA™ device and the other with the HemoClear blood separation system. In this paired set-up, equal washing volumes were used for both methods. Washing effectivity and cellular recovery were determined by measuring of complete blood count, free hemoglobin, complement C3, complement C4, and D-dimer in both concentrate as filtrate. Also, processing times and volumes were evaluated. Results The HemoClear and XTRA™ devices showed equal effectiveness in concentrating erythrocytes and leucocytes. Both methods reduced complement C3, complement C4, and D-dimer by ≥90%. The centrifugal device reduced solutes more significantly by up to 99%. Free hemoglobin load was reduced to 12.9% and 15.5% by the XTRA™ and HemoClear, respectively. Conclusion The HemoClear device effectively produced washed concentrated red blood cells comparably to the conventional centrifugal XTRA™ autotransfusion device. Although the centrifugal XTRA™ device achieved a significantly higher reduction in contaminants, the HemoClear device achieved acceptable blood quality and seems promising in settings where gold standard cell savers are unaffordable or unpractical.

Comparison of three autotransfusion devices for utilization in the pediatric population.

A device that may help attenuate the amount of homologous blood product given to pediatric cardiac surgical patients is the autotransfusion device. Three separate autotransfusion devices were selected for evaluation. The Sorin Xtra, Fresenius Continuous Autotransfusion System Plus (CATS*plus), and the Fresenius Continuous Autotransfusion System Smart (CATSmart) were evaluated based on the mechanical processes of each device, hematocrit value of the salvaged packed red cell product, time of processing, and the advantageous accessories with each device. Each of the autotransfusion devices were used to collect salvageable blood from the surgical field as well as to process residual blood from the cardiopulmonary bypass circuit after decannulation. The cell salvage process was performed in accordance with the manufacturer's instructions for use and the recommended settings for processing and washing. The Sorin Xtra device had the 55 mL bowl set up for all cases, while the Fresenius continuous autotransfusion systems utilized the standard disposable for each device. Each cell salvage device was employed during 30 pediatric cardiac surgery procedures, and data for each device, was broken down into four groups based on patient weight (0-10, 10-20, 20-40, and >40 kg). For all patient sizes, the Sorin Xtra tended to produce the greatest volume of cell saver product (55-825 mL) as compared to the CATS*plus and CATSmart devices (7-550 mL and 0-860 mL, respectively). The Continuous Autotransfusion System Smart tended to produce the highest hematocrit product, ranging from 44 to 81%. Through this evaluation, it was determined the continuous autotransfusion systems provided the highest hematocrit with the lowest recovered packed red cell volume, while the Sorin Xtra packed red cell product showed to have a lower hematocrit with a larger packed red cell volume. Each device proved effective within our pediatric population.

Heparin 'flush' induced thrombocytopenia triggered by total hip replacement: a case report.

BackgroundHeparin-induced thrombocytopenia (HIT) typically responds to heparin termination. Some types of HIT can persist after heparin discontinuation.Case summaryA 95-year-old woman was referred to the cardiology from orthopaedics because of acute limb ischaemia (ALI) 1 day after surgery of a femoral neck fracture. Despite thrombectomy, ALI relapsed the next day. She had been treated with intravenous antibiotics with a diagnosis of aspiration pneumonia for 1 week until 3 days before surgery, together with heparin flush twice a day. Of note, no intra-/post-operative heparin was administered, no cell salvage device, central venous, nor arterial catheters were used before development of ALI. The patient and her family refused reattempting invasive therapies; consequently, the patient continued to worsen and died on post-operative day 3. Diagnosis of autoimmune HIT, which was prompted by surgery without re-exposure to heparin, was confirmed posthumously.DiscussionThis case emphasizes the significance of suspecting autoimmune HIT in any patient presenting with thrombosis, even if the heparin exposure dates back more than a few days or even without heparin exposure.

Reduction of exposure to plasticizers in stored red blood cell units

Plastic can be toxic and hazardous to an organism's health, but it is being widely used in our daily lives. Di-2-ethylhexyl-phthalate is the most common plasticizer in medical devices made of polyvinylchloride and is commonly found in soft bags storing red blood cell units. Di-2-ethylhexyl-phthalate and its degradation product mono-2-ethylhexyl-phthalate can migrate into human body fluids, for example, blood and tissues. The aim of the study was to assess the concentration of plasticizers in red blood cell units according to storage time and after mechanical rinsing using a cell salvage device. Levels of di-2-ethylhexyl-phthalate and mono-2-ethylhexyl-phthalate were analysed in 50 unwashed red blood cell units using liquid chromatography coupled with tandem mass spectrometry. In addition, phthalate concentrations were measured before and after mechanical rinsing in six more washed red blood cell units with storage times ranging between 36 and 56 days. A linear regression model was determined by the daily increase of di-2-ethylhexyl-phthalate and mono-2-ethylhexyl-phthalate in the stored red blood cell units subject to their storage time (range = 4-38 days), and the effect of mechanical rinsing on their phthalate concentration was calculated. A linear correlation was found between storage time of unwashed red blood cell units and the concentration of di-2-ethylhexyl-phthalate (p < 0.001) or mono-2-ethylhexyl-phthalate (p < 0.001). Stored red blood cell units older than 14 days had significantly higher concentrations of both contaminants than red blood cell units of shorter storage time (p < 0.001). Mechanical rinsing in washed red blood cell units attained a reduction in the di-2-ethylhexyl-phthalate and mono-2-ethylhexyl-phthalate concentration by a median of 53% (range = 18-68%; p = 0.031) and 87% (range = 68-96%; p = 0.031), respectively. Leaching of di-2-ethylhexyl-phthalate and mono-2-ethylhexyl-phthalate into red blood cell units depends on the duration of storage time. Plasticizers can be significantly reduced by mechanical rinsing using cell salvage devices, and thus, red blood cell units can be regenerated with respect to chemical contamination.

Cell salvage : Scientific evidence, clinical practice and legal framework

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes avaluable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides agood compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared apharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of aquality management system for cell salvage and regular quality controls. These quality controls include acontrol of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

Additional filtering of blood from a cell salvage device is not likely to show important additional benefits in outcome in cardiac surgery.

Several authors and manufacturers of cell salvage devices recommend additional filtering of processed blood before transfusion. There is no evidence to support this practice. Therefore, we compared the clinical outcome and biochemical effects of cell salvage with or without additional filtering. The patients, scheduled for coronary artery bypass grafting, valve replacement, or combined procedures were part of our randomized multicenter factorial study of cell salvage and filter use on transfusion requirements (ISRCTN 58333401). They were randomized to intraoperative cell salvage or cell salvage plus additional WBC depletion filter. We compared the occurrence of major adverse events (combined death/stroke/myocardial infarction) as primary outcome and minor adverse events (renal function disturbances, infections, delirium), ventilation time, and length of stay in the intensive care unit and hospital. We also measured biochemical markers of organ injury and inflammation. One hundred eighty-nine patients had cell salvage, and 175 patients had cell salvage plus filter and completed the study. Demographic data, surgical procedures, and amount of salvaged blood were not different between the groups. There was no difference in the primary outcome with a risk of 6.3% (95% confidence interval [CI], 3.34-11.25) in the cell salvage plus filter group versus 5.8% (95% CI, 3.09-10.45) in the cell salvage group, a relative risk of 1.08 (95% CI, 0.48- 2.43]. There were no differences in minor adverse events and biochemical markers between the groups. The routine use of an additional filter for transfusion of salvaged blood is unlikely to show important additional benefits.

Rapid bedside rejuvenation of red blood cell with an autologous cell salvage device.

During storage, red blood cells (RBCs) undergo physicochemical changes which affect the quality, function, and invivo survival of transfused packed RBCs (pRBC). Changes include decreased 2,3-diphosphoglycerate (2,3-DPG) levels, decreased ATP, changes in mechanical properties and oxidative injury. RBC rejuvenation is a method used to increase levels of 2,3-DPG and ATP in pRBCs. This process requires incubating the pRBCs with a rejuvenation solution and subsequent washing. Standard blood bank protocols using the COBE 2991 Cell Processor require several hours of preparation. The objective of this study was to verify if a bedside protocol for rejuvenating pRBC and washing with the Sorin Xtra autologous cell salvage system could be used. Outdated pRBC units were obtained and rejuvenated in a model operating suite using a dry air incubator for 1h at 37°C. Six units of pRBCs were pre-diluted with saline (1000ml) and six units were not pre-diluted with saline. All units were washed with normal saline (1000ml) using an apheresis-design cell salvage device in manual mode and wash volume set to 3000ml. Samples were collected and analyzed for standard RBC quality parameters at baseline and post-wash. Total pRBC wash efficiency was 94% ± 12% at a final hematocrit of 67.7±5.9% while maintaining post-wash hemolysis 0.24±0.12 %. Pre-dilution prior to washing did not confer statistically significant differences in final RBC quality parameters with the notable exceptions of calculated hemolysis and supernatant potassium levels (P<0.05). The washing process can be completed within 10min. The post-wash RBC parameters are appropriate for immediate transfusion to patients.

Identification of Leiomyoma Cell Sheets in Peritoneal Washings Retrieved by an Intraoperative Red Blood Cell Salvage Device during Laparoscopic-Assisted Myomectomy with in-Bag Manual Tissue Extraction: A Pilot Study

Study ObjectiveTo examine whether peritoneal washings during laparoscopic-assisted myomectomy with in-bag manual tissue extraction can contain spilled leiomyoma cell sheets. DesignRetrospective observational study (Canadian Task Force classification II-2). SettingDepartments of Obstetrics and Gynecology and Diagnostic Pathology at a general hospital. PatientsTwenty-four women. InterventionsHysterotomy followed by complete enucleation by blunt and sharp dissection was performed. Enucleated myomas were placed into a retriever bag and extracted through a suprapubic or umbilical mini-laparotomic incision by manual morcellation with a surgical scalpel. A histological examination was performed to identify the dispersed leiomyoma cell sheets in trapped tissues on the surface of a defoaming sponge equipped in the reservoir of an intraoperative red blood cell salvage device, which was used to collect peritoneal washing fluid along with blood. Measurements and Main ResultsBag rupture was not observed in any case; however, apparent leiomyoma cell sheets were identified in 20 of 24 cases (83.3%). No devices or procedures that were used for myomectomy could completely prevent leiomyoma cells from appearing in the peritoneal washing fluid. ConclusionEven when careful in-bag tissue extraction of myomas was performed in laparoscopic-assisted myomectomy, dispersion of leiomyoma cell was identified in most cases. Further study is needed to show that the feasibility of rigorous washing to reduce the potential risk of leiomyoma cell dissemination.

Anesthetic management for intestinal transplantation: A decade of experience.

Intestinal transplantation (ITx) is the definitive therapy for patients suffering from intestinal failure. Previously published reports suggest that these cases should be managed perioperatively with the same intensive monitors and techniques as in liver transplantation. We retrospectively reviewed the anesthetic management of 67 isolated intestinal, intestinal-pancreas, and intestinal-kidney transplants over the previous decade (2005-2015) in our tertiary care institution. Patients were typically managed with a single arterial line, a single central venous catheter, and rarely intensive modalities such as a pulmonary artery catheter, a transesophageal echocardiography, a second arterial catheter or central venous catheter, a rapid infusion system, a cell salvage device, or viscoelastic testing. Significant hemodynamic derangements were rare, and the rate of postreperfusion syndrome was 8.96%. Our fluid administration type and volume and transfusion type and volume were similar to previous reports in which more intensive anesthetic management was employed. We demonstrate that ITx can safely occur without utilizing the intensive resources requisite for a liver transplant.

Does diathermy smoke contaminate processed salvaged blood in cardiac surgery?

A cell salvage device is used in cardiac surgery with the aim of reducing allogeneic blood transfusion. Suction of blood from the operating field used for the device is often accompanied by diathermy smoke. There is limited published research to know if this blood is then contaminated with clinically significant levels of harmful chemicals from this smoke. Postoperative cardiac surgery patients are already physiologically vulnerable, making the optimization of salvaged blood worth considering. Ten patients who had cardiac surgery using a cell salvage device from a single institution had samples taken from the processed blood just prior to transfusion. Samples were tested for carbon monoxide (CO), cyanide and benzene. Results were compared to preoperative co-oximetry results and normal adult laboratory reference ranges. Demographic data about the patients was collected, including the type of operation, gender, age, body mass index, smoking status and amount of salvaged blood collected and processed. Primary surgery was coronary artery bypass grafting (CABG) in three patients, mitral valve repair or replacement in three patients and one each of aortic valve replacement (AVR)/CABG, AVR/plication of the aorta, CABG/external wrapping of the aorta and valve-sparing root replacement. None were smokers. Neither the blood CO level prior to surgery nor in the processed salvaged blood was above the normal limit of 2% for non-smokers. There was no processed blood benzene found. Cyanide levels in the processed blood ranged from 1.8 to 44.1 μmol/l (where <8 μmol/l is considered within the normal adult laboratory limit). Despite the obvious limitations of the current study, it shows that cyanide levels can be found many times the normal level in processed salvaged blood. Whilst the total dose of cyanide is small, the potential impact may be clinically significant due to cyanide's effect on mitochondrial metabolism in the heart and brain.

A Novel Centrifugation Method Using a Cell Salvage Device Offers an Alternative to the Use of Leukocyte-Depleting Filters for Autologous Blood Transfusions

Autotransfusion protocols often use the use of costly filters, such as leukocyte-depleting filters (LDFs), to minimize reinfusion of activated leukocytes and inflammatory mediators associated with reperfusion injury (RI). LDFs are used extensively in hospital settings; however, they represent an additional capital expenditure for hospitals, as well as a constraint on the reinfusion rate of blood products for health-care providers. We compared a commonly used LDF to a novel centrifugation method employing a widely used cell salvage device. Complete blood counts and enzyme-linked immunosorbent assays (ELISAs) measuring tumor necrosis factor-α (TNF-α) and interleukin-2 (IL-2) were performed to compare the efficacy of these methodologies. The LDF removed, on average, 94% of all leukocytes, including 96% of neutrophils. The centrifugation method removed, on average, 89% of all leukocytes, including 91% of neutrophils and resulted in a highly concentrated red blood cell product. Our results suggest both methods offer equivalent leukocyte reduction. TNF-α was also comparably reduced following our novel centrifugation method and the LDF method and IL-2 levels were undetectable in all samples. These results indicate our novel centrifugation method may preclude the need for a LDF during select autotransfusion applications.

Laparoscopic Myomectomy Using a Cell Salvage Device: Do Patients Benefits from Its Use?

Laparoscopic Myomectomy Using a Cell Salvage Device: Do Patients Benefits from Its Use?

Intraoperative cell salvage during cardiac surgery is associated with reduced postoperative lung injury.

In addition to its blood-sparing effects, intraoperative cell salvage may reduce lung injury following cardiac surgery by removing cytokines, neutrophilic proteases and lipids that are present in cardiotomy suction blood. To test this hypothesis, we performed serial measurements of biomarkers of the integrity of the alveolar-capillary membrane, leucocyte activation and general inflammation. We assessed lung injury clinically by the duration of postoperative mechanical ventilation and the alveolar arterial oxygen gradient. Serial measurements of systemic plasma concentrations of interleukin-6 (IL-6), myeloperoxidase, elastase, surfactant protein D (SP-D), Clara cell 16 kD protein (CC16) and soluble receptor for advanced glycation endproducts (sRAGEs) were performed on blood samples from 195 patients who underwent cardiac surgery with the use of a cell salvage (CS) device (CS, n = 99) or without (CONTROL, n = 96). Postoperative mechanical ventilation time was shorter in the CS group than in the CONTROL group [10 (8-15) vs 12 (9-18) h, respectively, P = 0.047]. The postoperative alveolar arterial oxygen gradient, however, was not different between groups. After surgery, the lung injury biomarkers CC16 and sRAGEs were lower in the CS group than in the CONTROL group. Biomarkers of systemic inflammation (IL-6, myeloperoxidase and elastase) were also lower in the CS group. Finally, mechanical ventilation time correlated with CC16 plasma concentrations. The intraoperative use of a cell salvage device resulted in less lung injury in patients after cardiac surgery as assessed by lower concentrations of lung injury markers and shorter mechanical ventilation times.

Additional postoperative cell salvage of shed mediastinal blood in cardiac surgery does not reduce allogeneic blood transfusions: a cohort study.

Does additional postoperative collection and processing of mediastinal shed blood with a cell salvage device reduce the number of allogeneic blood transfusions compared to intraoperative cell salvage alone? A single-centre cohort study in which adult patients with coronary artery bypass grafting or aortic valve replacement were allocated to either a C.A.T.S(®) group with intraoperative blood processing only or a CardioPat(®) group with both intra- and postoperative blood processing. The primary endpoint was the number of allogeneic blood transfusions during hospital admission. The study included 99 patients; 50 in the C.A.T.S(®) and 49 in the CardioPat(®) group.There was no difference in the number of red blood cells (RBC) (C.A.T.S(®) group 43 units versus CardioPat(®) 50 units, p=0.74), fresh frozen plasma (C.A.T.S(®) 8 units versus CardioPat(®) 8 units, p=1.00) or platelets (C.A.T.S(®) 5 units versus CardioPat(®) 4 units, p=1.00) transfused during the hospital stay.Cardiac creatinine kinase (CK-MB) and troponin levels did not differ between the groups although a significant time effect (p<0.001) was present. Creatinine kinase (CK) levels were not different between the groups three hours after arrival in the intensive care unit (ICU) (CardioPat(®) group versus C.A.T.S(®) group, p=0.17). But, compared to the C.A.T.S(®) group on the first (350 [232-469] IU/L) and second postoperative days (325 [201-480] IU/L), the increase in CK levels was more in the CardioPat(®) group on the first (431 [286-642] IU/L, p=0.02) and second postoperative days (406 [239-760] IU/L, p=0.05), resulting in a difference between the groups (p=0.04) CONCLUSIONS: Postoperative cell salvage does not reduce transfusion requirements compared to intraoperative cell salvage alone, but results in elevated total CK levels that suggest haemolysis.

Antifibrinolytic Use and Blood Transfusions in Pediatric Scoliosis Surgeries Performed at US Children’s Hospitals

Retrospective cohort study using the Pediatric Health Information Systems database. To determine the association between antifibrinolytic use and red cell transfusions in spinal fusion operations performed at 37 US Children's Hospitals. Evidence from randomized clinical trials and systematic reviews suggests that antifibrinolytic therapy can significantly reduce blood loss in children undergoing scoliosis surgery; however, the effectiveness of these agents as used in surgeries performed at US children's has not been studied. We included children aged 0-18 years with diagnoses indicating adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis (NMS) for whom a spinal fusion procedure was performed between January 1, 2006 and September 30, 2009. Patients with malignancy, trauma, coagulation disorders, or for whom a cell salvage device was employed were excluded. Multilevel logistic regression was used to determine associations between ε-aminocaproic acid (EACA), tranexamic acid (TXA), and aprotinin (APR) use and blood transfusions, controlling for patient and surgery characteristics. Cohorts consisted of 2722 AIS and 1547 NMS procedures. Antifibrinolytic use varied across hospitals (AIS 3.3%, interquartile range, 0%-42%; NMS 12 interquartile range, 0%-46%), and was significantly associated with NMS, posterior fusion, number of vertebrae fused. Overall, 15% of children received EACA, 7% TXA, and 2% APR. The median hospital-specific rate of red cell transfusions was 24% for AIS and 43% for NMS. In AIS operations, EACA use, but not TXA use, was associated with significantly lower odds of transfusion (odds ratio, 0.42; P<0.001 vs. odds ratio, 1.0; P=0.8). In NMS operations, neither EACA nor TXA use was associated with a decrease in odds of red cell transfusions. The effectiveness of antifibrinolytics as used outside of clinical trials is unclear and should continue to be explored. Future prospective research is needed to evaluate which administration protocols will most benefit patients, as well as to determine the comparative effectiveness of these drugs in the context of other blood conservation strategies.