Postoperative Shed Research Articles

Postoperative shed autologous blood reinfusion does not decrease the need for allogeneic blood transfusion in unilateral and bilateral total knee arthroplasty.

Postoperative shed autologous blood reinfusion techniques have been used for decades in total knee arthroplasty (TKA), but the effectiveness of this procedure is still a matter of debate. This multicenter retrospective study investigated the medical records of patients who underwent unilateral and bilateral TKA from January 1, 2015 to December 31, 2017 in three hospitals. According to whether postoperative shed autologous blood reinfusion was used, the patients were divided into the control group and the shed autologous blood reinfusion group. The volume of perioperative infusion of red blood cells and plasma, the blood transfusion-related costs, and the postoperative hospital stay were compared between the two groups of patients. A total of 200 unilateral and 74 bilateral TKA were included after successful matching. Among the patients who underwent unilateral TKA, the control group and the shed autologous blood reinfusion group had 95 and 91 patients, respectively, who received allogeneic blood infusion (P = 0.268). There was no significant difference in the number of units of allogeneic red blood cells infused (P = 0.154), while the transfusion-related cost was increased (P<0.001). The same phenomena were observed over the patients underwent bilateral TKA. Shed autologous blood reinfusion does not reduce the need for infusing allogeneic red blood cells. In addition, the procedure increases patient expense and may also lead to an extended postoperative hospital stay.

Low vacuum re-infusion drains after total knee arthroplasty: is there a real benefit?

Low vacuum re-infusion drains after total knee arthroplasty: is there a real benefit?

Efficacy and safety using autotransfusion system with postoperative shed blood following total knee arthroplasty in haemophilia

The purpose of this study was to evaluate the efficacy and safety of postoperative wound drain salvage and autotransfusion system in haemophilic patients undergoing elective total knee arthroplasty (TKA). No literature exists on reinfusing drained blood in patient with haemophilia undergoing TKA. Eighty-eight knees of 66 patients received cemented TKA due to end-stage haemophilic arthropathy (group I; with autotransfusion in 59 knees, group II; without autotransfusion in 29 knees). In group I, the postoperative shed blood was transfused within 6 h after surgery. The amount of blood drainage and reinfused blood, rate and amount of allogenic transfusion, postoperative change of haemoglobin level, prothrombin time (PT) and activated partial thromboplastin time were analysed. The mean postoperative blood drainage was 932 ± 479 mL in group I and 830 ± 492 mL in group II (P > 0.05). The mean volume of blood reinfused was 530 ± 265 mL in group I. Allogenic transfusion was needed in six knees (10.2%) of group I and eight knees (27.6%) of group II (P = 0.036). The mean volume of allogenic transfusion was 480 ± 49 mL in group I and 1041 ± 691 mL in group II (P > 0.05). Changes of all the laboratory results before and after TKA showed no statistically significant difference except PT was prolonged in group I (P = 0.008) at postoperative day 1. Moreover, there was no significant complication related to either reinfusion or allogenic transfusion in both groups. This study showed that reinfusion of drained blood is a simple, safe and efficacious method in patients with haemophilia undergoing TKA.

Could cost‐effectiveness of postoperative shed blood salvage after elective knee arthroplasty be improved?

TransfusionVolume 53, Issue 6 p. 1372-1373 LETTER TO THE EDITOR Could cost-effectiveness of postoperative shed blood salvage after elective knee arthroplasty be improved? Manuel Muñoz MD, PhD, Manuel Muñoz MD, PhD [email protected] Transfusion Medicine, School of Medicine, University of Málaga, MálagaSearch for more papers by this authorArturo Campos MD, Arturo Campos MD Department of Hematology, University Hospital “Virgen de la Victoria”, MálagaSearch for more papers by this authorElisa Martín-Montañez PhD, Elisa Martín-Montañez PhD Department of Pharmacology, School of Medicine, University of Málaga, Málaga, SpainSearch for more papers by this authorJosé Pavía MD, PhD, José Pavía MD, PhD Department of Pharmacology, School of Medicine, University of Málaga, Málaga, SpainSearch for more papers by this author Manuel Muñoz MD, PhD, Manuel Muñoz MD, PhD [email protected] Transfusion Medicine, School of Medicine, University of Málaga, MálagaSearch for more papers by this authorArturo Campos MD, Arturo Campos MD Department of Hematology, University Hospital “Virgen de la Victoria”, MálagaSearch for more papers by this authorElisa Martín-Montañez PhD, Elisa Martín-Montañez PhD Department of Pharmacology, School of Medicine, University of Málaga, Málaga, SpainSearch for more papers by this authorJosé Pavía MD, PhD, José Pavía MD, PhD Department of Pharmacology, School of Medicine, University of Málaga, Málaga, SpainSearch for more papers by this author First published: 10 June 2013 https://doi.org/10.1111/trf.12154Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. Volume53, Issue6June 2013Pages 1372-1373 RelatedInformation

Blood management and transfusion strategies in 600 patients undergoing total joint arthroplasty: an analysis of pre-operative autologous blood donation.

Blood loss during total joint arthroplasty strongly influences the time to recover after surgery and the quality of the recovery. Blood conservation strategies such as pre-operative autologous blood donation and post-operative cell salvage are intended to avoid allogeneic blood transfusions and their associated risks. Although widely investigated, the real effectiveness of these alternative transfusion practices remains controversial. The surgery reports of 600 patients undergoing total joint arthroplasty (312 hip and 288 knee replacements) were retrospectively reviewed to assess transfusion needs and related blood management at our institute. Evaluation parameters included post-operative blood loss, haemoglobin concentration measured at different time points, ASA score, and blood transfusion strategies. Autologous blood donation increased the odds of receiving a red blood cell transfusion. Reinfusion by a cell salvage system of post-operative shed blood was found to limit adverse effects in cases of severe post-operative blood loss. The peri-operative net decrease in haemoglobin concentration was higher in patients who had predeposited autologous blood than in those who had not. The strengths of this study are the high number of cases and the standardised procedures, all operations having been performed by a single orthopaedic surgeon and a single anaesthesiologist. Our data suggest that a pre-operative autologous donation programme may often be useless, if not harmful. Conversely, the use of a cell salvage system may be effective in reducing the impact of blood transfusion on a patient's physiological status. Basal haemoglobin concentration emerged as a useful indicator of transfusion probability in total joint replacement procedures.

The cost of post-operative shed blood salvage after total knee arthroplasty: an analysis of 1,093 consecutive procedures.

Requirements for allogeneic red cell transfusion after total knee arthroplasty are still high (20-50%), and salvage and reinfusion of unwashed, filtered post-operative shed blood is an established method for reducing transfusion requirements following this operation. We performed a cost analysis to ascertain whether this alternative is likely to be cost-effective. Data from 1,093 consecutive primary total knee arthroplasties, managed with (reinfusion group, n=763) or without reinfusion of unwashed salvaged blood (control group, n=330), were retrospectively reviewed. The costs of low-vacuum drains, shed blood collection canisters (Bellovac ABT, Wellspect HealthCare and ConstaVac CBC II, Stryker), shed blood reinfusion, acquisition and transfusion of allogeneic red cell concentrate, haemoglobin measurements, and prolonged length of hospital stay were used for the blood management cost analysis. Patients in the reinfusion group received 152±64 mL of red blood cells from postoperatively salvaged blood, without clinically relevant incidents, and showed a lower allogeneic transfusion rate (24.5% vs. 8.5%, for the control and reinfusion groups, respectively; p =0.001). There were no differences in post-operative infection rates. Patients receiving allogeneic transfusions stayed in hospital longer (+1.9 days [95% CI: 1.2 to 2.6]). As reinfusion of unwashed salvaged blood reduced the allogeneic transfusion rate, both reinfusion systems may provide net savings in different cost scenarios (€ 4.6 to € 106/patient for Bellovac ABT, and € -51.9 to € 49.9/patient for ConstaVac CBCII). Return of unwashed salvaged blood after total knee arthroplasty seems to save costs in patients with pre-operative haemoglobin between 12 and 15 g/dL. It is not cost-saving in patients with a pre-operative haemoglobin >15 g/dL, whereas in those with a pre-operative haemoglobin <12 g/dL, although cost-saving, its efficacy could be increased by associating some other blood-saving method.

Impact of shed blood products on stimulated cytokine release in an in vitro model of transfusion

Blood transfusion is reported to suppress the recipient's immune system. To avoid allogenic transfusion, post-operative shed blood retransfusion is a commonly used method. The aim of this study was to investigate the dose-related impact of post-operatively collected shed blood products on the stimulated cytokine release in an in vitro model of transfusion. Venous blood samples obtained from 20 patients undergoing hip arthroplasty were mixed with post-operatively collected unprocessed, processed, and irradiated shed blood as well as normal saline as a control. Shed blood was processed by centrifugation and separating the cellular fraction from the soluble fraction and washing the cellular fraction with phosphate buffered saline to eliminate any cell fragments and other substances. Mixing ratios were 1:3, 1:1, and 3:1. Endotoxin-stimulated release of Tumor Necrosis Factor-alpha (TNF-α) was measured after 24 h of culture by enzyme-linked immunosorbent assay. Unprocessed, irradiated shed blood and the soluble fraction caused a significant suppression of stimulated TNF-α release compared to control. The addition of the cellular shed blood fraction had no significant influence on the TNF-α release compared to control. Shed blood and its components caused a dose-independent immunomodulation as indicated by a suppressed stimulated TNF-α release. Leukocytes seem to play a minor role, as we observed a sustained suppression after transfusion of γ-irradiated shed blood. Only the elimination of soluble factors by centrifugation and followed by an additional washing step prevented the observed suppression of TNF-α. Thus, we assume that washing of shed blood can prevent potential detrimental effects.

Unwashed blood: is widespread use justified? A review of current knowledge

SUMMARYTotal hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with a considerable amount of total blood loss. This results in a significant postoperative decline in hemoglobin levels, and thereby the use of allogeneic blood transfusion (ABT), which is not a risk‐free therapy. Postoperative shed blood (PSB) salvage and retransfusion, after washing or filtering, was introduced as a unique blood saving concept to decrease perioperative blood loss, to maintain higher postoperative hemoglobin levels and to decrease the use of ABT. PSB reinfusion must be restricted to elective procedures with an anticipated postoperative blood loss between 750 mL and 1500 mL, allowing for the recovery of at least the equivalent of one unit of packed red cells, and used in conjunction with a defined ABT protocol. The results of a number of clinical and laboratory studies strongly suggest that reinfusion of unwashed PSB can reduce the requirements for ABT, and that most of the potential adverse effects of unwashed PSB are no more than theoretical. Therefore, reinfusion of unwashed PSB after THA and TKA is easy‐to‐use, safe, economic and clinically beneficial, as it may reduce ABT‐associated risks. The superiority of washed PSB over unwashed PSB in these procedures has not been demonstrated. All these make widespread use of unwashed PSB available for all patients and justified.

Hemolysis and red blood cell mechanical fragility in shed blood after total knee arthroplasty

There are several options for the salvage of postoperative shed red blood cells (RBCs). This study compared the characteristics of the returned RBCs collected using two different devices: one that washes and one that does not wash the collected RBCs. Forty patients undergoing first-time total knee arthroplasty consented to participate. Twenty patients were operated on by a surgeon who routinely uses a device that does not wash the shed RBCs (unwashed group), the other 20 patients were operated on by surgeons who routinely use a device that washes and concentrates the collected RBCs (washed group). A small quantity of postprocessing RBCs were collected immediately before reinfusion and the amount of plasma-free hemoglobin (PFHb), and the mechanical fragility index (MFI) of the returned RBCs were determined. The patients in both groups were well matched for age, sex, and length of stay. The mean percent hemolysis of the returned RBCs was not different between the unwashed and washed groups (1.22±0.30 vs. 1.24±0.42, p=0.895), while the mean total amount of returned PFHb was not different (0.51±0.12 g vs. 0.55±0.35 g, p<0.615). The ratio of total PFHb:total returned Hb was significantly lower for the washed group (0.0087±0.0023 vs. 0.0035±0.0011, p<0.0001). The MFI was higher in the washed group (1.71±0.55 vs. 0.53±0.42, p<0.001). The washing device returned more Hb to the patients relative to the amount of free Hb.

Hidden blood loss following total knee arthroplasty: an analysis of influential factors

Objective To study the characteristic and influential factor of the hidden blood loss after total knee arthroplasty (TKA) so as to provide a reference frame for clinical work. Methods There were 75 patients with osteoarthritis of the knee who were operated with unilateral primary TKA. The patients including 21 males and 54 females at a mean age of 68.7 years were retrospectively analyzed.The perioperative blood loss and the hidden blood loss following TKA were calculated by Gross formula. It was analyzed that if the perioperative blood loss and the hidden blood loss following TKA were affected by gender, haemostasis during operation with deflating tourniquet and reinfusion of the drained blood. Results The preoperative blood loss was (1551.3 ± 369.6) ml and the hidden blood loss was (792.3 ±228.6) ml. The hidden blood loss of male was significantly higher than that of female (P ＜ 0.05). The hidden blood loss was reduced by haemostasis during operation with deflating tourniquet (P ＜ 0.05) but was not affected by postoperative shed blood reinfusion. Conclusions The lowest value of Hct is a representative parameter for calculation of the hidden blood loss. There is no significant difference between male and female about the relative hidden blood loss. Haemostasis during operation with deflating tourniquet can reduce teh hidden blood loss but not affect the total perioperative blood loss. Reinfusion of the drained blood can reduce the transfusion rate but does not affect the total preoperative blood loss and the hidden blood loss. Key words: Arthroplasty,replacement,knee; Postoperative hemorrhage

Tranexamic acid for reducing transfusion requirements after total knee arthroplasty: can efficacy and cost ratios be improved?

We read with interest the large study on the use of tranexamic acid (TA) in 414 consecutive patients undergoing total knee arthroplasty (TKA) published by Lozano et al . in Vox Sanguinis [1]. The authors showed that the routine use of TA administration in the management of TKA was associated with significant reduction in allogeneic blood transfusion (ABT) rate and blood management costs [1]. More importantly, this study, which encompassed the largest number of patients reported so far, showed that TA did not seem to be associated with an increased rate of thromboembolic complications [6/215 (2·4%) vs. 3/199 (1·5%), for control and TA groups, respectively; P = 0·507]. We would like, however, to comment regarding data of efficacy and costs. First, the ABT rate in the control group (54%) is significantly higher than that observed in two recent series of TKA patients with similar age, gender distribution and preoperative haemoglobin (30%), and the same is true for patients receiving TA when compared to those receiving postoperative unwashed shed blood (USB, 0·78 ± 0·52 units per patient) or preoperative treatment with oral iron [2,3] (Table 1). One possible reason for these differences may the use of high vacuum drains (650 mmHg), which resulted in a higher estimated blood loss (2325 ± 1196 ml and 1592 ± 823 ml, for control and TA, respectively) [1], when compared to a similar study using low vacuum drains (100 mmHg; 1744 ± 804 ml and 1301 ± 621 ml, respectively) [4]. In this later study, the use of low vacuum drains with reinfusion resulted in an ABT rate of 12·2% (6/49), which was decreased to 2·2% (1/46) by its combination with TA [4]. Second, in their economical analysis, the official price of a red blood cell (RBC) unit in Catalonia, Spain ( a 97·63), was used [1]. However, this so-called ‘official price’ is indeed a ‘political price’ for blood interchange between autonomic communities within Spain, and it does not correspond to the actual production costs of a RBC unit. In addition, the costs of pre-transfusion tests and giving set were also not included. Therefore, in agreement with average cost within the European Union, we estimated an actual cost of a 320 for one RBC transfusion in Spain [5]. Using this figure, the use of TA in TKA reduced transfusion cost per patient to a 108 (Table 1), which favourably compared to the cost of a 177 per patient for USB return ( a 120 per USB collection device) [2], but not with that of preoperative oral iron plus restrictive transfusion protocol ( a 46 per patient) [3]. All together, these results

Surgical treatment of lateral sellar compartment cavernoma

To summarize and analyze the surgical treatment of lateral sellar compartment cavernoma (LSCC). The clinical data of 102 patients with LSCC who underwent surgical treatment from 1958 to 2006, 2 males and 80 females, aged 43.5 (11 approximately 69), were collected and analyzed. The operation patterns were divided into 4 stages based on the understanding of LSCC: first stage (1958 approximately 1988, with 32 cases) during which diagnosis was mainly bases on X-ray plain films, CT, and ordinary cerebral angiography, and most of the tumors were partially excised; second stage (1989 approximately 1997, with 18 cases) during which MRI, DSA, and microsurgery were widely used; third stage (1998 approximately 2003, with 36 cases) during which the neurological anatomy of the LSC and pathology of LSCC made headway, however, intra-operational bleeding was still a problem, and fourth stage (2004 approximately 2006, with 16 cases) during which relevant models were basically understood. Post-operative MRI shed that the tumor complete resection rates of the 4 stages were 4/32, 5/18, 17/36, and 12/16, and the subtotal resection rates were 3/32, 4/18, 10/36, and 2/16 respectively. The rest of the tumors were all partially removed. Not only the intra-operative blood loss but also the cranial nerve morbidity rate decreased dramatically in the 4th stage. The main postoperative complications included oculomotor nerve paralysis, abducent nerve palsy, and trigeminal nerve damages. No operation-related death occurred. Following the progress of LSCC study, the treatment of LSCC becomes mature. Radical removal of LSCC may be the best choice for LSCC patients by epidural approach via the skull base craniotomy with induced hypotension.

Which patients are more likely to benefit from postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures

Requirements for allogeneic blood transfusion (ABT) after total knee replacement (TKR) are still high (30-50%), and salvage of unwashed filtered postoperative shed blood (USB) may represent an alternative to ABT. We evaluated that patients are more likely to benefit of USB reinfusion after TKR. Data from 581 consecutive primary TKR, managed with (reinfusion group, n = 382) or without (control group, n= 199) reinfusion of USB, were retrospectively reviewed. Patients from reinfusion group received 119 +/- 88 ml of red blood cells from USB, without clinically relevant incidents, and showed a lower ABT rate (30.6% vs. 8.4%, for control and reinfusion groups, respectively; P = 0.001) (transfusion trigger, haemoglobin [Hb] < 9 g/dl). Differences in ABT rate between groups were significant for all preoperative Hb levels, except for Hb < or = 12 g/dl. A lower transfusion threshold (Hb < 8 g/dl) might have further decreased ABT rate (14.6% vs. 5.2%, respectively; P < 0.001), with differences being significant for preoperative Hb between 12 and 15 g/dl. There were no differences with respect to postoperative infection rate, but patients from reinfusion group had a shorter length of hospital stay (11 +/- 4 vs. 13 +/- 4 days, respectively; P= 0.001). Return of USB after TKR seems to reduce the need for ABT, especially in patients with preoperative Hb between 12 and 15 g/dl. There is little benefit of USB reinfusion for patients with preoperative Hb > 15 g/dl, whereas patients with preoperative Hb < 12 g/dl would probably benefit from the combination of USB with some other blood-saving method.

Effect of shed blood retransfusion on pulmonary perfusion after total knee arthroplasty: a prospective controlled study

Postoperative shed blood retransfusion (autotransfusion) is a commonly used salvage method following major surgical operations, such as total knee arthroplasty (TKA). The systemic effects of shed blood are still unclear. We studied the effect of residual substances in the retransfused shed blood, on lung perfusion after TKA. Fifteen unilateral and one bilateral TKAs were performed with autotransfusion (the study group) and 15 unilateral and three bilateral TKAs were performed in a control group. Lung X-rays, arterial blood gases (ABG), D-dimer values, and lung perfusion scintigraphies were performed preoperatively and postoperatively. A mean of 300.0 +/- 335.6 ml of bank blood was needed in the autotransfusion group and a mean of 685.7 +/- 365.5 ml of bank blood was needed in the control group (p=0.001). There was a postoperative segmental perfusion defect at the lateral segment of the superior lobe of the left lung in one patient of the control group and he also had risk factors for thrombosis. Although both groups had a decrease in lung perfusion postoperatively, there were no significant differences among the groups regarding the lung perfusion scintigraphy, chest X-rays, ABG, and D-dimer values. In conclusion, although pulmonary perfusion diminishes following TKA, shed blood retransfusion does not add any risk to pulmonary perfusion.

Impact of postoperative shed blood transfusion, with or without leucocyte reduction, on acute‐phase response to surgery for total knee replacement

In patients undergoing total knee replacement (TKR) most blood loss occurs postoperatively and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return, with or without leucocytes, on the acute-phase response (APR) after TKR. Forty-eight TKR patients, intended to receive postoperative USB, entered the study. Blood samples were obtained before and 6, 24, 72 h and 7 days after surgery, and from the USB before and after it passed through a 40-microm filter (Group F40) or a leucocyte-reduction filter (Group LRF). Haematimetric parameters, APR proteins (albumin, prealbumin, ceruloplasmin, haptoglobin, C-reactive protein), complement C3 and C4, and cytokines (IL-1beta, IL-6, IL-8, IL-10, and TNF-alpha) were measured in all samples. Twenty-eight patients (Group F40=14, Group LRF=14) received a mean of 1.2 USB units, without any clinically relevant incident, and did not need additional ABT. Sixteen out of the 20 remaining patients who received neither USB nor ABT served as a control group for the postoperative APR study. All patients showed the typical postoperative APR profile and there were no significant differences between groups for APR parameters, postoperative complications, or hospital stay. Postoperative blood salvage and return, with or without a LRF, after TKR does not present any clinically relevant side-effects and does not modify APR induced by surgery. These findings seem to confirm the clinical experience that postoperative USB return is safe and questions the beneficial effect of using LRF.

Benefits of postoperative shed blood reinfusion in patients undergoing unilateral total knee replacement

In patients undergoing total knee replacement (TKR), most of the measured blood loss occurs during the postoperative period, and 30-50% of these patients receive allogeneic blood transfusion (ABT). For this reason, the salvage and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to ABT in these patients. We have, therefore, evaluated the clinical utility of USB return in TKR patients, with a special focus on patients with mild anaemia. Data from 200 TKR patients (group 2) receiving USB within the first 6 postoperative hours (ConstaVac CBC II, Sryker) were prospectively collected. A retrospective series of 100 TRK patients served as the control group (group 1). USB return was possible in 162 patients who received a mean of 0.98+/-0.4 U/pte, without any clinically relevant incident. Return of USB decreased both the percentage of patients with ABT (48% vs 11%, for groups 1 and 2, respectively; p < 0.01) and the ABT units/patient index (1.31+/-1.27 vs 0.29+/-0.87 units/patient, respectively; p < 0.01). A transfusion protocol was not established, but there was no difference between groups with respect to either perioperative Hb levels or overall transfusion index, indicating that the transfusion criteria were uniform. However, for the subgroups of patients who needed ABT, the preoperative Hb level was 1 g/dL lower in those receiving USB (13.4+/-1.4 vs 12.4+/-1.2 g/dL; p < 0.05). There was no difference in the postoperative complication rate, and patients in group 2 recovered the ability to walk 1 day earlier, and their hospital stay was 3 days shorter than in group 1 (p < 0.01). Return of USB after TKR seems to shorten the hospital stay and effectively reduce postoperative requirements for ABT, especially in patients with preoperative Hb > or = 13 g/dL. For patients with preoperative Hb < 13 g/dL, although the return of USB also decreased the requirements for ABT, a further reduction will probably be obtained with the addition of another blood-saving method.

Transfusion of post-operative shed blood: laboratory characteristics and clinical utility.

Increased awareness of the potential hazards of allogenic blood transfusion, such as incompatibility reactions, metabolic and immunologic disorders, or transmission of viral diseases, has led to an emphasis on allogeneic blood alternatives. For orthopaedic surgery, several autologous transfusion modalities have emerged as alternatives to allogeneic blood transfusion, avoiding its immunomodulatory effects. Among them, transfusion or return of post-operative salvaged shed blood has become popular in major orthopaedic procedures. However, although the effectiveness of this blood-saving method is well documented, several authors have questioned its safety and recommended the use of washed blood. Therefore, this review analyses the haematologic characteristics of unwashed filtered shed blood, including metabolic status and survival of red blood cells, the components of the haemostatic system, the content of fat particles, bacterial and tumour cells and the possibility of their removal, the content of inflammatory mediators, and the effects on the patient's immune system. From data reviewed in this paper, it can be concluded that post-operative salvage of blood seems to be an excellent source of functional and viable red cells without many of the transfusion-related risks and with some immuno-stimulatory effects. In addition, from our experience, post-operative re-infusion of unwashed shed blood after major spine procedures has proved to reduce post-operative homologous transfusion requirements and to complement pre-operative autologous blood donation, without any clinically relevant complication.

Detection and removal of fat particles from postoperative salvaged blood in orthopedic surgery.

Although transfusion or return of salvaged shed blood has become popular in major orthopedic procedures, this blood-saving method is still controversial because shed blood may be contaminated with chemical and tissular debris, such as fat particles, which may increase the risk of fat embolism after bone surgery. In an effort to find an easy, reliable method for determination of both fat particle content and removal from shed blood, analyses of perioperative blood samples were performed with a cell counter (Technicon H3 [H3]) in orthopedic patients undergoing spinal fusion in which postoperative shed blood was collected and returned with a blood collection canister. A screen or surface filter was intercalated in the return line to eliminate microaggregates, fat particles, and/or WBCs. Fat particles in shed blood are clearly detected as a condensed, sigmoidal-shaped area at the right-hand side of the PMN zone in the channel in which the H3 measures particles according to their degree of lobularity. This signal can be reproduced by the addition of animal or vegetable fat to venous blood, but not by the addition of activated platelets or RBC membranes. Fat particles, together with WBCs and microaggregates, in shed blood were effectively removed by surface filters, whereas screen filters were not effective. The use of the TH3 seems to be an easy, reliable, and low-cost approach for monitoring fat particle content and removal from postoperative salvaged shed blood in orthopedic procedures.

Postoperative blood salvage and reinfusion in spinal surgery: blood quality, effectiveness and impact on patient blood parameters.

Although reinfusion of salvaged shed blood has become popular in major orthopaedic procedures, this blood saving technique is still controversial. In an effort to assess the functional and metabolic status of shed blood erythrocytes and the impact of postoperative shed blood reinfusion on allogenic blood requirements and patient's blood parameters, analyses of perioperative blood samples were performed in 28 consecutive orthopaedic patients undergoing spinal fusion, in which postoperative shed blood was collected and reinfused with the ConstaVac CBC II device. In comparison with a previous series of 31 patients, this procedure reduced allogenic blood requirements by almost 30% (P < 0.05), without any increase in postoperative complications. Postoperative shed blood presented lower haematological values and higher plasma-free haemoglobin (PFHB) levels than preoperative blood, without any disturbance in morphology, median corpuscular fragility (MCF) or erythrocyte adenosine triphosphate (ATP) and diphosphoglycerate (DPG) content. Serum concentrations of enzymes--glutamate-oxalacetate aminotransferase (GOT), glutamate-piruvate aminotransferase (GPT), creatine kinase (CK), lactate dehydrogenase (LDH)--and inflammatory cytokines (IL-1beta, IL-6) were elevated in shed blood. After reinfusion, there was no alteration in coagulation parameters or cytokine levels. Serum levels of some enzymes increased at the end of surgery and remained elevated at postoperative day 2 (CK) or 7 (GOT, LDH), with a higher increase if postoperative autotransfusion was used as a blood saving method. Therefore, caution should be taken when these serum enzyme levels are used for diagnosis. In conclusion, salvaged shed blood in orthopaedic procedures of the spine seems to be an excellent source of red cells which are not significantly damaged, keeping a normal functional and metabolic status, and reduces allogenic blood requirements without significant side effects.

Reinfusion of postoperative wound drainage in total joint arthroplasty: Red blood cell survival and coagulopathy risk

Fifty patients with total joint arthroplasties (28 total hip arthroplasties, 11 total knee arthroplasties, and 11 bilateral total knee arthroplasties) received autotransfusions from their postoperative wound drainage. The blood was collected in a closed sterile drainage system without any additional anticoagulant. Pre- and postoperative measurements were made of the patient's hemoglobin, platelets, fibrinogen, haptoglobin, fibrin degradation products, and D-dimer (a specific type of fibrin degradation product). Red blood cell survival was assessed in 16 of the patients by labeling the shed blood with 51Cr sodium chromate prior to reinfusion. To control for fluid shifts, continued bleeding, and dilution effects of further transfusions in the immediate post-operative period, 10 patients also had their native blood labeled with 111In oxime. In this study, the mean estimated blood loss was 1,062 mL (±1,247) with a mean wound drainage of 836 mL (±338). Of this, a mean of 450 mL (±261) of blood was was given back to the patient in addition to routine, preoperative autologous donated blood. Six (12%) patients experienced transient fevers at the time of retransfusion. Detailed hematologic studies were performed on the shed blood in 19 patients. The collected blood was completely defibrinated, but did contain fibrin degradation products, as indicated by the D-dimer level, and hemolyzed blood as the haptoglobin was reduced. Even though the blood containing the above breakdown products was reinfused to the patients, there were no clinical manifestations of disseminated intravascular coagulation. Both the hemolyzed and defibrinated products were subsequently cleared by the body. After correcting for fluid and volume changes in the first 3 days, 66% (SEM, 5.3%) of the labeled red blood cell activity remained and was used to determine a mean red blood cell survival half-life of 40.6 days (SEM, 4.2). There was no significant change in the 111In: 51Cr: ratio in the first 24 hours, indicating that the initial drop in activity equally affected both the native red blood cell population and the labeled shed blood. There were no adverse clinical effects resulting from a transient coagulopathy. Autotransfusion of postoperative shed red blood cells is a safe method with reinfused cells that have a normal or increased lifespan.