Perioperative Cell Salvage Research Articles

Allogeneic blood transfusion and AIS surgery: how the NSQIP database can improve patient safety.

Describe the experience of one institution in modifying allogeneic blood transfusion protocols for AIS surgery in response to the results of ACS-NSQIP-PEDS comparative data in a retrospective cohort study. NSQIP data demonstrated that AIS patients at our hospital had a significantly greater risk of ALBT compared to similar institutions (OR 4.1). The ALBT protocol was then revised to initiate transfusion based on Hb/Hct level, clinical hypotension and/or discussion between surgeon and anesthesiologist. A retrospective analysis of perioperative ALBT and autologous cell salvage blood transfusion (CSBT) rates was performed for patients undergoing surgery before (Group A) and after (Group B) the implementation of the revised protocol. Two hundred and ninety patients constituted the study cohort, with 92 patients in Group A and 198 in Group B. Average total blood transfusion (ALBT + CSBT) per patient was significantly lower for Group B than Group A (313ml vs. 650ml, p < 0.01). ALBT per patient of Group B was significantly lower than Group A (85ml vs. 324ml, p < 0.01). 48% of patients received ALBT in Group A compared to only 18% in Group B. Recognition of excessive allogeneic transfusion rates in our institution through comparative data from the ACS-NSQIP-PEDS database resulted in the modification of transfusion parameters that led to a decrease in allogeneic transfusion rates for AIS patients. The current study highlights the value of a large, well-curated surgical database in optimizing clinical protocols and potentially improving overall surgical morbidity.

Returning the Blood and Saving the Supply, the Veteran Affairs Medical Center (VAMC) Experience

Abstract Introduction/Objective Blood conservation techniques such as perioperative autologous cell salvage (PACS) can reduce patient usage and exposure to allogeneic blood products during surgery. As all blood transfusions carry risk and cost, the avoidance of transfusion through PACS represents an opportunity to reduce risk of allogeneic transfusion related reactions or complications and reduce costs from blood product utilization. Although the benefits of PACS has been documented in the literature, quality assurance demonstrations of the blood volume returned to veteran patients undergoing surgeries with a high likelihood of significant blood loss are sparse; thus, we present the quality assurance study of PACS usage in a VAMC. Methods Quality assurance documentation from the American Red Cross (ARC) that provides autologous cell salvage services at the VAMC were examined from February 2017 to August 2018, for a total of 17 months examined. The procedure, estimated blood loss, and volume returned was documented as part of a quality assurance/improvement project. The volume returned was compared to the typical RBC volume (~250 mL) within a packed red blood cell volume (~350 mL). Results A total of 44 procedures took place corresponding usage of PACS. Of these 44 procedures, 15 had no estimated blood loss, and an additional 10 had too little estimated blood loss (&amp;lt;250 mL) for blood volume to be returned. Among the procedures with blood loss, an average of 864 mL of blood was lost (1230 mL when the low blood loss cases are excluded) with an average volume returned of 511 mL or the approximate equivalent of 2 units of RBCs when utilized. Two cases with significant estimated blood loss (5400 mL and 4850 mL) had 2250 mL and 2125 mL or about the equivalent of 9 RBC units each. The total volume returned to all patients was 9700 mL, or the equivalent RBC volume of 38-39 RBC units. Conclusion PACS is a procedure that can rapidly provide large quantities of autologous blood in surgeries with significant risk of bleeding. Blood salvage avoids or reduces the risks of allogeneic blood transfusion and reduces cost to the transfusion service as the autologous blood loss would not need to be replaced with allogeneic blood transfusions. PACS in the VAMC returned significant blood volumes to patients undergoing procedures with high risk of blood loss, therefore reducing allogeneic blood transfusion requirements in the veteran population.

Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018.

The use of cell salvage is recommended when it can be expected to reduce the likelihood of allogeneic (donor) red cell transfusion and/or severe postoperative anaemia. We support and encourage a continued increase in the appropriate use of peri-operative cell salvage and we recommend that it should be available for immediate use 24 h a day in any hospital undertaking surgery where blood loss is a recognised potential complication (other than minor/day case procedures).

Patient Blood Management in Hip Replacement Arthroplasty.

Perioperative blood transfusions are common in total hip arthroplasty because of preoperative anemia and perioperative blood loss. Perioperative anemia and the need for allogeneic blood transfusion are related with increased morbidity. To reduce perioperative allogeneic blood transfusion, keeping the preoperative hemoglobin level above 12.0 g/dL is important in orthopedic patients. By using the anti-fibrinolytic agent or perioperative cell salvage, reduce intraoperative blood loss is very important for the reduction of perioperative blood loss. As a transfusion trigger, low hemoglobin is another important target to reduce the transfusion rate. Because blood management is closely connected with prognosis, it has become a new challenge in orthopedic surgery.

The 2013 update of the "Seville Document": a Spanish multidisciplinary alliance for patient blood management.

The 2013 update of the "Seville Document": a Spanish multidisciplinary alliance for patient blood management.

Effects of cell salvage on erythrocyte 2,3‐disphosphoglycerate and G‐6‐PD levels and phosphatidylserine expression

The aim of this study was to investigate the contribution of the perioperative cell salvage process to the changes in erythrocyte 2,3-disphosphoglycerate (2,3-DPG) and glucose-6-phosphate dehydrogenase (G-6-PD) levels and phosphatidylserine (PS) expression using a self-control study comparing washed blood with venous blood. Thirty patients undergoing elective heart and blood vessel surgery were enrolled. Blood was collected and processed using a Fresenius continuous autotransfusion system device. 2,3-DPG and G-6-PD activities, as well as PS expression, from both venous and washed red blood cells (RBC) were measured. We also compared these indicators among washed RBC at 6 h, washed RBC at 0 h, and venous RBC. 2,3-DPG and G-6-PD activities in washed blood at 0 h were significantly higher than in venous RBC (2,3-DPG, venous vs. washed blood P < 0.05; G-6-PD, venous vs. washed blood P < 0.05). Flow cytometry results showed no differences between venous blood and washed RBC at 0 h (n = 23, P > 0.05). 2,3-DPG activity in washed RBC that were allowed to stand for 6 h decreased compared with that in venous blood (venous vs. washed blood at 6 h P < 0.01), whereas no significant difference was observed in G-6-PD activity (venous. vs. washed blood at 6 h P > 0.05). Compared with venous RBC, washed RBC from intraoperative cell salvage exhibited good oxygen-carrying and antioxidant capacities. However, the oxygen-carrying capacity of washed RBC that were allowed to stand for 6 h was not as good as that of venous RBC. Thus, we suggest that washed RBC that were left to stand for more than 6 h should not be reinfused.

Cell salvage for obstetric patients who decline blood transfusion – a national survey

Dear Sir, Parturients who decline blood transfusion are encountered and managed in all UK obstetric units. The majority are Jehovah’s witnesses (JWs) who refuse transfusion of blood and it’s major components due to religious belief, even when transfusion would be life saving. Major obstetric haemorrhage remains a leading cause of peripartum morbidity and mortality (Centre for Maternal and Child Enquiries, 2011). Refusal of blood products is associated with a six times increased risk for maternal death, and a 130 times increased risk for death due to obstetric haemorrhage (Van Wolfswinkel et al. 2009). This risk is greatest when operative delivery is required. There are many guidelines on the management of JW patients presenting for surgery. Specific to obstetrics is the recently updated care plan produced by the Hospital Information Services for Jehovah’s Witnesses (2011). Guidance universally advocates the use of cell salvage. The acceptability of autologous transfusion and the various forms of perioperative cell salvage is a personal decision for each JW. Some may specifically request that the system be set up to allow for continuous connectivity. This requires the system to be fully primed and the reinfusion bag to be connected to the patient via a cannula throughout (UK Cell Salvage Action Group, 2008). In this way, the JW’s blood does not lose continuity with the circulation. When no such specific request is received, cell salvage may be used in the usual way. Cell salvage can usually be organised for elective surgery, but the challenge is in providing a service to JW parturients when obstetric surgery is often emergency in nature, out-ofhours and haemorrhage rapid. This difficulty is exacerbated when obstetric theatres lie remote from a hospital’s main theatre complex. Significant resources in terms of equipment, training and personnel are required and this is unlikely to be available in all units. We sought to establish current UK obstetric cell salvage clinical practice when managing JWs. The survey was approved by the Obstetric Anaesthesia Association (OAA) Survey Subcommittee and subsequently distributed in December 2011 to all registered obstetric lead consultant anaesthetists through the OAA electronic survey

Multicentre Cohort Study of Red Blood Cell Use for Revision Hip Arthroplasty and Factors Associated With Greater Risk of Allogeneic Blood Transfusion

Background. Revision hip arthroplasty (RHA) is associated with high rates of allogeneic blood transfusion (ABT). We aimed to determine factors associated with ABT in patients undergoing RHA in Scottish hospitals, with particular focus on perioperative cell salvage (PCS). Methods. A prospective observational cohort study of RHA procedures performed in 11 hospitals over 7 months was performed. We recorded predefined patient, surgeryrelated, and blood conservation factors that may influence perioperative ABT, together with postoperative haemoglobin (Hb) data and ABTs to day 7. We explored factors with strongest independent association with ABT during the perioperative period using multiple regression analysis. Results. Two hundred and ten cases were studied, of whom 58% received ABTs (mean 1.8 units), most of which (52%) occurred on the day of surgery. Eighty-eight (42%) patients received PCS, of whom 68 had red cells re-infused [mean re-infusion volume 312 ml (1st, 3rd quartile: 260, 363 ml)]. In unadjusted comparisons, patients receiving PCS had lower intraoperative (9% vs 40%) and total (55% vs 63%) exposure to ABTs. The mean (95% confidence interval) theatre blood loss was 1013 (899‐1128) ml and was higher for combined femoral/acetabular revision and femoral revision than other categories. The mean postoperative Hb transfusion trigger was 80 g litre 21 . In multivariable models, preoperative Hb [odds ratio (OR) 0.35; P,0.001], patient weight (OR 0.96; P¼0.004), operating theatre blood loss (OR 1.002; P,0.001), and re-infusion of PCS blood (OR 0.31; P¼0.02) were independent predictors of ABT exposure.

Multicentre cohort study of red blood cell use for revision hip arthroplasty and factors associated with greater risk of allogeneic blood transfusion

Revision hip arthroplasty (RHA) is associated with high rates of allogeneic blood transfusion (ABT). We aimed to determine factors associated with ABT in patients undergoing RHA in Scottish hospitals, with particular focus on perioperative cell salvage (PCS). A prospective observational cohort study of RHA procedures performed in 11 hospitals over 7 months was performed. We recorded predefined patient, surgery-related, and blood conservation factors that may influence perioperative ABT, together with postoperative haemoglobin (Hb) data and ABTs to day 7. We explored factors with strongest independent association with ABT during the perioperative period using multiple regression analysis. Two hundred and ten cases were studied, of whom 58% received ABTs (mean 1.8 units), most of which (52%) occurred on the day of surgery. Eighty-eight (42%) patients received PCS, of whom 68 had red cells re-infused [mean re-infusion volume 312 ml (1st, 3rd quartile: 260, 363 ml)]. In unadjusted comparisons, patients receiving PCS had lower intraoperative (9% vs 40%) and total (55% vs 63%) exposure to ABTs. The mean (95% confidence interval) theatre blood loss was 1013 (899-1128) ml and was higher for combined femoral/acetabular revision and femoral revision than other categories. The mean postoperative Hb transfusion trigger was 80 g litre(-1). In multivariable models, preoperative Hb [odds ratio (OR) 0.35; P<0.001], patient weight (OR 0.96; P=0.004), operating theatre blood loss (OR 1.002; P<0.001), and re-infusion of PCS blood (OR 0.31; P=0.02) were independent predictors of ABT exposure. PCS is an effective blood conservation strategy for RHA, especially for patients with preoperative anaemia, low body weight, or both.

Laboratory characteristics and clinical utility of post-operative cell salvage: washed or unwashed blood transfusion?

The development of complex surgical procedures for the treatment of a number of diseases has increased the demand for allogeneic blood. In hospitals, up to 50% of transfused blood units are used in the surgical setting and up to 60% of all transfusions are given to patients over 65 years old, an age group of patients who are excluded from altruistic blood donation in some countries1,2. The demand for allogeneic blood often exceeds the supply. The safety of allogeneic blood transfusion (ABT) in developed countries has improved dramatically, especially as a result of more restrictive criteria for donor selection and increased analytical screening of donated blood which have led to a decrease in the rate of transfusion-transmitted infections. However, “clerical mistakes” or administration of “wrong blood” are still too frequent (1/15,000-20,000 units)3,4. Liberal transfusion protocols (pre-transfusion haemoglobin [Hb] concentration > 9-10 g/dL) should, therefore, be avoided to further reduce the risk of infection and other complications such as incompatible haemolytic reactions, Graft-versus-Host Disease, metabolic disorders, Transfusion-Related Acute Lung Injury, and transfusion related immuno-modulation3,4. As for immuno-modulation, the results of three extensive studies involving more than 22,000 patients undergoing orthopaedic surgery strongly suggest that peri-operative ABT is associated with an increase in the risk of post-operative infection5–7. Overall concerns about the adverse effects of ABT have prompted the review of transfusion practices and the search for transfusion alternatives, such as pre-operative autologous blood donation, haemodilution, peri-operative cell salvage, recombinant human erythropoietin (rHuEPO) and iron, or anti-fibrinolytic administration8. The ultimate objective is to minimise exposure to ABT and, therefore, ABT-associated risks. The main objective of this review is to provide updated evidence on the quality, safety and efficacy of postoperatively salvaged shed blood (PSB) after major surgery. However, the results of a systematic review indicate that reinfusion of unwashed filtered PSB after cardiac surgery produces only a marginal benefit9 and can also cause significant adverse effects, so its use is not recommended10. We, therefore, shall focus mainly on the use of PSB in orthopaedic surgery, especially lower limb joint replacement.

Anemia and Patient Blood Management in Hip and Knee Surgery

A systematic search was conducted to determine the characteristics of perioperative anemia, its association with clinical outcomes, and the effects of patient blood management interventions on these outcomes in patients undergoing major orthopedic surgery. In patients undergoing total hip or knee arthroplasty and hip fracture surgery, preoperative anemia was highly prevalent, ranging from 24 +/- 9% to 44 +/- 9%, respectively. Postoperative anemia was even more prevalent (51% and 87 +/- 10%, respectively). Perioperative anemia was associated with a blood transfusion rate of 45 +/- 25% and 44 +/- 15%, postoperative infections, poorer physical functioning and recovery, and increased length of hospital stay and mortality. Treatment of preoperative anemia with iron, with or without erythropoietin, and perioperative cell salvage decreased the need for blood transfusion and may contribute to improved patient outcomes. High-impact prospective studies are necessary to confirm these findings and establish firm clinical guidelines.

Challenges of meeting the future blood transfusion requirement in England and Wales. Autologous blood transfusion could become an adjunct to the UK blood transfusion program in the future

SUMMARY As a resource, allogeneic blood has never been more in demand than it is today. Escalating elective surgery, an aging population, periodic shortages arising from a fall in supply, old and emerging threat of transfusion-transmissible infections and spiraling costs because of various safety introductions have all conspired to ensure that allogeneic blood remains very much a vital but limited asset to the National Health Service. However, there are increasing demands for alternatives/complementary strategies to allogeneic blood transfusion. Autologous transfusion, predeposit autologous donation, acute normovolemic hemodilution and perioperative cell salvage is reliable, cost-effective, safe, does not involve type and screen, not associated with isoimmunization to foreign proteins, is indicated in patients with rare blood groups or complex red cell antibodies, comes handy for some religious sect like the Jehovah's Witnesses as well as being suitable in a significant number of patients undergoing elective surgeries. Autologous transfusion improves postoperative microcirculation, tissue perfusion and reduces the risk of thromboembolism. Benchmarking transfusion activity, ensuring that it is clinically indicated and justified, will help eliminate inappropriate use of blood products and help conserve our allogeneic blood stock. Erythropoietin (EPO) has drastically and significantly altered red cell transfusion practices. There might be many patients groups who would benefit from the use of EPO analogues and thus help conserve the allogeneic blood stock for patients in whom EPO is contraindicated. There is need to formulate policies on ways to seriously and innovatively attract and retain new donors. The National Blood Service and indeed the Department for Health can do well by promoting the use of autologous blood and other alternatives therapies to complement the UK allogeneic blood transfusion program in a bid to solving the periodic and envisage future shortages in allogeneic blood particularly with an aging UK population and increasing concerns about safety arising from old and emerging transfusion-transmissible infections. This will maximize the use of the limited allogeneic blood resource particularly for patients in whom autologous blood transfusion is contraindicated.

Impact of intraoperative red blood cell salvage on transfusion requirements and outcomes in radical prostatectomy

Preoperative autologous blood donation lowers preoperative hemoglobin (Hb) levels, and the collected blood is frequently wasted. Intraoperative red blood cell (RBC) salvage provides fresher autologous blood in proportion to surgical blood loss, making cell salvage (CS) in radical prostatectomy (RP) feasible for study. This retrospective study compared two strategies to reduce allogeneic RBC transfusion requirements in RP: preoperative autologous donation (PAD) versus CS. Patients underwent RP by one surgeon at one institution during two comparable time periods in 2005 (PAD-Group 1) and 2006 (CS-Group 2). Group 1 patients (n = 40) underwent PAD, collecting 63 autologous RBC units; 36 units (57.1%) were reinfused and 27 (42.9%) were wasted. No Group 1 patient received allogeneic blood. Group 2 patients (n = 63) underwent intraoperative CS and received a mean of 287 mL of salvaged blood. In Group 2, two patients (3.2%) with preoperative Hb levels too low to permit autologous donation each received 2 units of allogeneic RBCs. Group 1 patients had significantly lower preoperative (-1.4 g/dL) and postoperative (-0.8 g/dL) Hb values compared to the CS group. There were no significant differences between groups in procedure times, length of stay, or numbers of cancer recurrences over the 24- to 36-month follow-up period. Perioperative CS can effectively replace PAD for RP patients, offering similar avoidance of allogeneic transfusion, with greater convenience and superior postoperative Hb levels.

Blood Management in Total Knee Arthroplasty: A Comparison of Techniques

Patients undergoing total knee arthroplasty (TKA) are at high risk for postoperative anemia and allogeneic blood transfusions. Risks associated with allogeneic blood exposure (ie, infection, fluid overload, and longer hospital stays) have prompted alternative blood management strategies. The main goal of this study was to evaluate whether a single change in the clinical blood management of patients undergoing TKA reduced the severity of postoperative anemia or the need for allogeneic blood transfusions. A second goal of this study was to assess the financial impact of the change on the institution. This study compared perioperative cell salvage, preoperative autologous blood donation, and the practice of using allogeneic blood alone in patients undergoing TKA. Clinical and financial data of 154 unique cases of primary TKA at the Mayo Clinic Arizona were retrospectively reviewed. Transfusion rates were 25%, 18%, and 52% respectively for patients in the cell salvage, preoperative autologous blood donation, and allogeneic blood only groups. Respective relative risk reductions were 51.9% (P=.007) and 65.4% (P=.002) with the use of cell salvage or preoperative autologous blood donation versus allogeneic alone. Cell salvage and preoperative autologous blood donation were found to significantly reduce the requirements for allogeneic blood transfusions; these techniques were found to be roughly equivalent in clinical benefit when compared to the use of allogeneic blood alone. The logistical advantages of cell salvage (ie, no preoperative blood donation, no risk of wasting blood units) were associated with greater costs to the institution.

Guidelines for policies on alternatives to allogeneic blood transfusion. 1. Predeposit autologous blood donation and transfusion

SUMMARY This is the first of a series of newly prepared guidelines on alternatives to allogeneic blood transfusion. Further guidelines including the use of cell salvage and of pharmacological approaches to blood conservation will be published in due course. Decades of clinical application demonstrate that it is quite feasible to auto-transfuse blood that has been collected and stored for an interval of up to 6 weeks in standard storage media, and that up to three standard collection volumes (approximately 500 mL) can be collected from normal-sized adults (over 50 kg) during that interval. Furthermore, systems have been developed to reduce risk to participants and to boost haemoglobin (Hb) production during and after the procedure. However, such pre-operative autologous donations (PAD) are not without risk, are of low clinical efficacy and are poorly cost-effective for the vast majority of patients in the UK. These guidelines update those previously issued by the BCSH and do not recommend the practice and use of PAD unless the clinical circumstances are exceptional. They also give an update on the legal regulatory circumstances pertaining to the UK following recent European Directives.

A randomized trial of tranexamic acid in combination with cell salvage plus a meta-analysis of randomized trials evaluating tranexamic acid in off-pump coronary artery bypass grafting

We sought to evaluate the effectiveness of tranexamic acid in off-pump coronary artery bypass grafting surgery, either when used in combination with mechanical cell salvage or when used alone. One hundred patients were randomized to either 2 g of tranexamic acid as an intravenous bolus before sternotomy or to placebo. Intraoperative and postoperative cell salvage was used in all patients. The primary end point was early postoperative blood loss (within 4 hours). To evaluate the efficacy of tranexamic acid in isolation, we also performed a meta-analysis of 4 randomized trials identified from a systematic literature search. The primary end point of the meta-analysis was red cell transfusion. In our randomized trial patients in the tranexamic acid group had a significant reduction in early postoperative blood loss, (median difference, 50 mL; 95% confidence interval, 15-100 mL; P < .01); however, there was no reduction in the frequency of blood component transfusion. Patients in the placebo group received a significantly larger volume of autotransfused red cells (median difference, 120 mL; 95% confidence interval, 0-220 mL; P = .02). The meta-analysis demonstrated a significant reduction in red cell transfusions in patients receiving tranexamic acid compared with those receiving placebo (risk ratio, 0.48; 95% confidence interval, 0.24-0.97; P = .041). There was also a reduction in the frequency of any allogeneic blood component transfusion, as well as a highly significant reduction in postoperative blood loss, in patients receiving tranexamic acid (P < .001). Tranexamic acid reduces blood loss and transfusion requirements in off-pump coronary artery bypass grafting surgery. A reduction in allogeneic blood transfusion was not evident in the presence of perioperative cell salvage. These data support the routine use of tranexamic acid in off-pump coronary artery bypass grafting surgery.

Abstracts for the British Congenital Cardiac Association Annual Meeting: The Barbican, London, 24–25 November 2005: Oral Presentations: Perioperative red cell salvage in paediatric cardiac surgery

Objective: In recent years blood transfusion has become a debated health care issue. To minimise exposure to infectious agents and reduce bank blood transfusion requirements, leucocyte filtration and perioperative red cell salvage (RCS) are increasingly used in paediatric patients. We hypothesised RCS would reduce the need for additional blood products in children following cardiopulmonary bypass (CPB). Methods: Patients undergoing routine or emergency cardiac surgery requiring CPB over a study period of 3 months were included prospectively in the analysis. Haemoglobin, platelet count, coagulation screen and heparin levels were performed before, immediately after surgery and 24 hours later. RCS was performed in theatre according to surgical and anaesthetic preference. Red cells were salvaged from the surgical site, anticoagulated, washed and following resuspension in saline reinfused into the patient within 4 hours. The incidence of post-operative bleeding (&gt;10 ml/kg/hr) was recorded, as was the need for additional red blood cells, platelets and fresh frozen plasma (FFP). The need for blood products was at the discretion of the consultant intensivist. Statistical analysis was performed using student t-test and Chi squared methods. Significance was accepted as p &lt; 0.05. Results: Thirty-five consecutive patients (34.54 ± 43.55 months, 13.48 ± 14.39 kg) were included in the analysis. A total of 17 infants &lt;12 months were included, 9/24 who received RCS and 8/11 who did not (p 0.052). Cyanotic heart disease was seen in 40%. RCS was performed in 24 of 35 patients, who were significantly older (44.2 ± 44.1 vs. 13.6 ± 25.5, p 0.02) and heavier (16.6 ± 16.2 vs. 6.7 ± 4.7, p 0.01). No difference was seen in the prevalence of cyanosis between the two groups. Post-operative bleeding was seen in 21% who underwent RCS and 40% in those who did not (p 0.33). The need for additional red blood cells was significantly reduced in those who received RCS, 37.5% vs. 91%, p 0.003, as was the use of FFP, 8.3% vs. 45.5%, p 0.02. There was no difference in the need for platelet transfusion, p 0.2. Discussion: In this study RCS was performed on 68.5% of children following CPB. RCS significantly reduced the need for further blood and FFP transfusion, although this was not related to post-operative bleeding. This has important implications for both exposure to infectious agents and health economics. That children who underwent RCS were older and heavier may be related to the complexity of surgery and CPB in younger patients, although infants were represented in both groups. A further analysis of potential health and economic benefits in a homogenous group is needed.

Red cell salvage in orthopedic surgery

SUMMARYThe increasing number of surgical procedures has raised the demand for allogeneic blood to a level that often exceeds supply. Moreover, 10% of all transfusions are given in the orthopedic surgery setting, requiring the avoidance of liberal transfusion criteria to further reduce the risk of infection and other complications. As a result, a series of blood‐conservation measures have been developed. In this article, we review the use of autologous transfusion in orthopedic surgery, with a special focus on perioperative red cell salvage.From data reviewed, it can be concluded that perioperative salvage of blood, either intraoperative cell salvage or postoperative cell salvage, seems to be an excellent source of functional and viable red cells, without many of the transfusion‐related risks and with few side effects. The effectiveness of perioperative cell salvage to reduce exposure to allogeneic blood is greatly enhanced by the implementation of a restrictive transfusion protocol and the association with other blood‐sparing strategies [preoperative autologous blood donation (PABD), erythropoietin, intravenous iron], especially in anemic patients. Moreover, perioperative cell salvage may reduce the number of required PABD units or render PABD unnecessary. Finally, although formal cost‐effectiveness studies on perioperative cell salvage are lacking, based on current allogeneic blood transfusion costs, it is generally accepted that the equivalent of at least one unit of blood needs to be recovered for these techniques to be cost‐effective. Therefore, these procedures should be used on a case‐by‐case basis.

Survey of the implementation of the recommendations in the Health Service Circular 2002/009 ‘Better Blood Transfusion’

This report describes the results of questionnaire surveys in 2003 and 2004 on the implementation of the recommendations of the Health Service Circular (HSC) 'Better Blood Transfusion' 2002/009 for improving transfusion practice. These followed a similar survey in 2001 to determine the progress with the implementation of recommendations in the previous Health Service Circular (HSC) 'Better Blood Transfusion' 1998/224. There was a disappointing response rate (47%) to the 2003 survey and evidence for incomplete compliance with the action plan. It was repeated in April 2004 with a systematic approach to encouraging returns, and the response rate was 95%. The results indicate progress in the implementation of Better Blood Transfusion between 2001 and 2004 in relation to increases in the proportion of hospitals with Hospital Transfusion Committees, the training of some staff groups, the number of hospitals with transfusion practitioners, the development of protocols for the use of blood and audit activity. However, the results also indicate the need for further progress in the training of some staff groups, particularly nurses and doctors, the development of Hospital Transfusion Teams, the development of protocols for the appropriate use of blood, the provision of information to patients and the use of peri-operative cell salvage. This information should be used to plan further local, regional and national initiatives to implement the Better Blood Transfusion action plan and improve transfusion practice.

A survey of autologous blood transfusion practices in Germany

This survey was designed to evaluate the use of autologous blood transfusion techniques in Germany in 2000 and to identify how the use of these techniques has changed over the past 5 years. Questionnaires were mailed to the chief anaesthesiologists of 400 randomly selected German hospitals with > or =25 surgical beds. Information was sought about the current and past use of preoperative autologous blood donation (PABD), acute preoperative haemodilution and peri-operative blood salvage. Data were requested for the calendar year 2000. Three hundred and forty-three (86%) completed questionnaires were returned. PABD, haemodilution and peri-operative blood salvage were used by 85, 54 and 67% of respondents, respectively. Thirty-seven per cent of PABD users reported that PABD use declined, 28% reported that it increased and 34% reported that it remained unchanged over the past 5 years. The proportions of those reporting declining vs. increasing use of PABD did not differ significantly (P = 0.09). Sixty per cent of users of haemodilution reported that its use declined, 10% reported that it increased and 29% reported that it remained unchanged over the past 5 years. Sixteen per cent of hospitals that were equipped with cell-washing devices reported that the use of these devices declined, 47% reported that it increased and 37% reported that it remained unchanged over the past 5 years. The results indicate that autologous blood transfusion techniques were widely used in Germany in 2000, with PABD being the most common technique. The use of PABD did not change significantly, the use of haemodilution declined markedly and the use of peri-operative cell salvage increased markedly during the past 5 years before the survey.