Perioperative Blood Salvage Research Articles

Perioperative blood salvage as an alternative to predonating blood for primary total knee and hip arthroplasty

A total of 200 consecutive patients who underwent primary total knee or hip arthroplasty were reviewed to assess the efficacy of perioperative blood salvage and retransfusion. Five of 132 (3.8%) patients undergoing total knee arthroplasty and 3 of 68 (4.4%) patients undergoing total hip arthroplasty required allogeneic transfusion in addition to retransfusion of salvaged autologous blood. The risk of receiving allogeneic transfusion in addition to retransfusion of salvaged blood was 1.2% (2 of 173) in patients with a preoperative hematocrit of ≥37%. The risk of requiring allogeneic transfusion was 22% (6 of 27) in patients with a preoperative hematocrit of ≤37% (P≤.01). Perioperative blood salvage is safe and cost-effective and makes it possible to discontinue the practice of predonating blood for primary total knee arthroplasty and total hip arthroplasty in patients with a preoperative hematocrit >37%.

Rational Medical Decision Making Improves Efficacy and Cost-Efficiency in Autologous Transfusion: Preoperative Autologous Blood Donation, Perioperative Blood Salvage with Mechanical Processing, and Preoperative Autologous Plasmapheresis

Background: Restrictions in reimbursement rates urge physicians to critically reconsider their routine clinical practice. This study analyzes the effects resulting from changes of an autologous transfusion concept (ATC) with respect to efficacy and cost-efficiency. Patients and Methods: In concept one (CI), the former ATC, i.e. preoperative autologous blood donation (PABD), autologous plasmapheresis (APPH) to harvest autologous fresh frozen plasma (AFFP), and perioperative blood salvage with mechanically processed autologous transfusion (MAT), were applied routinely to patients undergoing elective major bone and joint surgery. In concept two (CII), the present ATC, PABD, and MAT were applied only if an increase in RBC mass (+RBC) of at least 1 RBC unit (190 ml) was expected. APPH was cancelled. Analysis considered direct/variable cost (d/v C), including disposables, consumables, volume substitution in PABD and APPH, type, screen and infectious/serological testing (PABD). Identical measures in CI and CII caused identical d/v C (PABD: EUR 36.05 per 1 PABD and EUR 60.10 per 2 PABDs; MAT: EUR 188.10 per patient; APPH: EUR 89.10 per patient). Results: Compared to CI, the total number of PABDs in CII increased by 62.9% (from 3,110 to 5,065) – i. e. from 1 PADB to 1.95 PABDs per patient (+95%) –, thereby causing an increase in total d/v C by EUR 40,087.– (35.8%) (from EUR 112,116.– to EUR 152,203.–). These changes together with an additional increase in the time interval between first PABD and surgery from 14 to 36 days caused an increase in total RBC regeneration by 151.3%. With respect to the individual patient, RBC mass increased by 208% (from 81 ml per patient in CI to 250 ml per patient in CII). This +RBC equaled 2,006 U of RBC. Net improvement of cost-efficiency amounted to a total of EUR 89,468.–. Compared to CI, the number of MAT sets consumed in CII decreased by 30.6% (from 2,690 to 1,866), resulting in a decline in total d/v C by EUR 154,994.– (from EUR 505,989.– to EUR 350,994.–). The number of MAT cycles per patient increased from 1.98 to 2.54, resulting in an increase in RBC recovery by 63 ml per patient (from 223 to 286 ml) and an improvement of cost-efficiency by approximately 22%. These changes equaled to net savings in d/v C of EUR 207,420.–. Contrary to CI, APPH was cancelled in CII, and thereby d/v C were reduced by EUR 468,289.–. Replacing AFFP for volume substitution by an artificial colloid, net savings in total d/v C equaled still to EUR 413,962.– (88.4%). When considering AFFP to be given for coagulation reasons in 20% and for volume substitution in 80%, savings in d/v C still amounted to EUR 237,469.– (50.7%). Altogether, the improvement of cost-efficiency resulted in savings of d/v C of EUR 534,357.–. Total fixed cost did not change. Conclusion: Rational medical decision making in autologous transfusion improved both efficacy and cost-efficiency solely by adapting these blood conservation measures to physiologic basics of erythropoiesis and by applying AFFP exclusively for coagulation reasons.

Perioperative blood salvage during surgical correction of craniosynostosis in infants

Surgical correction of craniosynostosis in infants is a very haemorrhagic procedure. The aim of this study was to determine whether the perioperative use of the continuous autotransfusion system (CATS) would reduce homologous transfusion during repair of craniosynostosis. Two groups of patients were studied according to the availability of the CATS in our hospital. The control group had surgery before the system was introduced and the study group had operations subsequently. Use of CATS was associated with a significant decrease in the median (95% confidence interval) volume of homologous blood transfused [413 (250-540) ml in the control group versus 317 (150-410) ml in the CATS group, P = 0.02] and in the median (95% confidence interval) number of packed red cell units transfused [2 (1-2) in the control group versus 1 (1-2) in the CATS group, P = 0.04] in the perioperative period. Use of CATS is associated with a reduction in homologous transfusion during the surgical correction of craniosynostosis in infants.

The Effects of Perioperative Blood Salvage and Autologous Blood Donation on Transfusion Requirements in Scoliosis Surgery

Fifty consecutive cases of surgical instrumentation and fusion for adolescent idiopathic scoliosis were prospectively studied to test the hypothesis that the use of predonated autologous blood combined with judicious perioperative blood salvage could decrease the amount of homologous blood needed. All cases had posterior instrumentation and fusion. Nineteen patients had their rib prominence resected with an average of 4.8 ribs per patient. Our protocol called for perioperative blood salvage with the cell saver and reinfusion of postoperative drained blood if more than 300 ml were drained in 4 hours. Two units of predonated autologous blood was made available. Hypotensive anesthesia and meticulous hemostasis kept the blood loss to a minimum. The average total blood loss was 1,055 ml. Blood loss per segment was 91 ml with an average of 11 segments fused per patient. Patients with rib resection had a blood loss of 1,105 ml, while those without had a blood loss of 955 ml. The cell saver blood returned per case was 391 ml with the hematocrit of the product averaging 46%. Twelve patients were reinfused an average of 300 ml of the postoperative drained blood. The predonated autologous blood was used as part of the intraoperative fluid management. In no patient was homologous blood needed. The average starting hematocrit was 35.6%, with the hematocrit at discharge (seventh day) being 32.4%. There were no complications or blood transfusion reactions. Our results suggest that judicious perioperative blood management may decrease the need for homologous blood transfusion in selected posterior idiopathic scoliosis surgery.

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Current Options and Approaches for Blood Management in Orthopaedic Surgery*†

Although the implementation of blood-screening measures has vastly reduced the risk of transmission of the human immunodeficiency virus through transfusion of donated blood products, several factors preclude the blood supply from achieving a zero-risk status. Patients who receive perioperative allogenic blood transfusions, for instance, have been reported to have higher rates of infection80,85,116 (although this finding remains controversial37,120) and perioperative blood loss, longer hospital stays26,40, more consecutive days of fever and administration of antibiotics, and a postoperative decrease in natural killer cells116. Furthermore, in a retrospective quantitative analysis of transfusion-associated immunomodulation, transfusion was the most important prognostic factor for postoperative infection13. Finally, the risk of transmission of infectious diseases, such as those caused by hepatitis-B and C viruses99 and to a lesser extent cytomegalovirus29 and Epstein-Barr virus129, as well as the risk of transfusion reactions, alloimmunization, and immunomodulation, remains substantive. Optimization of blood management is thus as important today as it was a decade ago, despite the markedly improved safety of allogenic blood. Cost-management pressures in the 1990s and continued public concern about the safety of the blood supply have precipitated a concerted movement among the operative specialties to refine the existing blood-conservation measures as well as to develop new approaches67,110. These efforts have included development of transfusion practice standards; improvement in the techniques of operative hemostasis; perioperative blood salvage; promotion of preoperative autologous blood donation; and, more recently, development of blood substitutes or temporary oxygen carriers (currently under investigation)11,28,101 and clinical utilization of recombinant human erythropoietin (epoetin alfa) to stimulate erythropoiesis (Table I)16,26,32,34,40,70,77,125. …

Intraoperative and postoperative blood salvage.

Surgical patients present unique opportunities for reducing allogeneic transfusions via perioperative blood salvage. Intraoperative cell saver techniques enable the collection of autologous blood from the surgical field and cardiopulmonary bypass circuit for return to the patient. Washing and hemoconcentration creates a product with an average hematocrit of 50% that carries normal erythrocyte survival, with minimal coagulation factors of platelets. Postoperative autotransfusion of shed blood from chest tubes or surgical drains enables additional blood conservation, reducing allogeneic transfusions by as much as 50%. Both intermittent and continuous autotransfusion systems using standard chest drainage equipment are available that require minimal setup and maintenance at the bedside. The hematocrit of shed blood is 20-25%, with depletion of clotting factors and platelet function. Potential advantages of perioperative blood salvage include the ready availability of large volumes of patient-compatible blood, with optimal oxygen-carrying capacity, that is virtually free from the risk of viral contamination. Specific indications, contraindications, and techniques for the salvage and administration of these vital products are presented.

Prospective randomized evaluation of blood salvage techniques for primary total hip arthroplasty

A controlled, randomized, prospective study was performed evaluating the need for perioperative blood salvage for primary total hip arthroplasty patients who had donated autologous blood before surgery. One hundred fifty-three patients able to donate at least 2 units of autologous blood were divided into four groups. In group 1 (35 patients), intraoperative and postoperative Cell-Saver (Haemonetics, Braintree, MA) was employed. In group 2 (40 patients), a postoperative Solcotrans (Smith & Nephew Richards, Memphis, TN) reinfusion protocol was followed. In group 3 (40 patients), a closed-suction Hemovac drain (Zimmer, Warsaw, IN) was placed. In group 4, (38 patients), no drain was used. Decisions for transfusion were based on clinical and laboratory parameters and made in conjunction with medical consultation. All autologous blood was routinely reinfused. There was no statistically significant difference in transfusion requirements or wound complications among the four groups. Hemoglobin and hematocrit changes between groups also were not statistically significant, but a power test suggested insufficient patient numbers for absolute reliability of this observation. Only five patients (3.3%) in this study received homologous blood. Four of these patients were in the Solcotrans group and one was in the Cell-Saver group. Two reoperations were performed: one for hematoma (Solcotrans group) and one for a sewn-in drain. It is concluded that expensive perioperative blood salvage techniques are usually not needed in patients who have a primary total hip arthroplasty without cement and who have donated 2 units of blood before operation.

The use of autologous blood. The National Blood Resource Education Program Expert Panel

The risk of transmitting disease through blood transfusions continues to fall as additional blood donor screening and testing measures are implemented. Nevertheless, when a blood transfusion is needed during the perioperative period, autologous blood is the safest option for eligible patients. Three methods for obtaining autologous blood to use during or after a planned surgical procedure are preoperative autologous blood donation, perioperative blood salvage, and acute normovolemic hemodilution. These techniques can be used alone or in combination to decrease or eliminate a patient's exposure to homologous blood. However, because all transfusions carry some health risk and blood administration costs, autologous blood should not be collected or reinfused indiscriminately. Autologous blood services should be used for eligible patients who are likely to require a transfusion but should not be employed for minor procedures in which transfusion is unlikely.

Autotransfusion. Perioperative blood salvage, in nonheparinized patients

Autotransfusion. Perioperative blood salvage, in nonheparinized patients