Red Cell Salvage Research Articles

What Are We Transfusing? Evaluating the Quality and Clinical Utility of Intraoperatively Salvaged Red Blood Cells in Spinal Deformity Surgery: A Nonrandomized Controlled Trial.

Intraoperative red blood cell (RBC) salvage is frequently used in contemporary spine surgery, despite clinical concern in its efficacy as a surrogate for blood-banked allogeneic packed RBCs (pRBCs). During spine surgery, salvaged RBCs (sRBCs) are exposed to injurious high-heat electrocautery, prolonged stasis, and abrasive pharmaceuticals, potentially making sRBCs a poor blood substitute. We therefore sought to scientifically and objectively define the quality of sRBCs in the context of complex spine surgery. This is a single-center, prospective, nonrandomized controlled trial of patients undergoing posterior-based multilevel thoracolumbar instrumented fusion for spinal deformity with planned use of intraoperative RBC salvage between June 2022 and July 2023. Surgeries were performed by fellowship-trained spinal neurosurgeons and orthopedic surgeons. The participants were split based on transfusion of sRBCs (given sufficient yield) vs no sRBC transfusion. Primary outcomes were RBC electrolyte composition, indices, deformability, and integrity, which were evaluated in comparison blood samples: Baseline, pRBC, and sRBC. Secondary outcomes were related to clinical effects of sRBC transfusion. Morphological assessment used Stimulated Raman Histology and machine learning. Deformability was assessed using ektacytometry. A total of 174 patients were included. The mean age was 50.2years ±25.4, 58.6% was female, the mean level fused was 10.0 ± 3.9, and 58.0% received sRBCs (median 207.0 mL). sRBCs differed significantly on standard laboratory measures, had a high proportion (30.7%) of shrunken and irregularly spiculated morphologies, and demonstrated abnormal deformability and relaxation kinetics. The hemolysis index was significantly elevated in sRBCs (2.9 ± 1.8) compared with Baseline samples and pRBCs (P < .01). Transfusion of sRBCs was associated with suboptimal resuscitation and provided no practical clinical benefit. RBCs salvaged during posterior thoracolumbar spine surgery are irreversibly injured, with hemolysis index exceeding Food and Drug Administration and Council of Europe transfusion standards in all samples, questioning their efficacy and safety as a blood substitute.

The impact of a bloodless medicine program on pancreatic resections: A single-institution experience incorporating patients with borderline-resectable and locally advanced pancreatic cancer

BackgroundPatients undergoing pancreatic resection who decline blood transfusion represent a clinical challenge. While bloodless medicine programs are valuable, their impact remains unclear, especially for those with borderline-resectable and locally advanced pancreatic ductal adenocarcinoma (PDAC). MethodsRetrospective review of institutional databases identified patients who did not accept blood transfusion and underwent pancreatic resection from 2013–2022. We collated hemoglobin values, interventions to minimize symptomatic anemia, and patient outcomes. ResultsThirteen patients were identified. Median age was 63 years (range: 52–75 years) and eight (61.5 %) were female. All procedures were performed electively for invasive malignancy with PDAC as the most common diagnosis (11/13; 84.6 %) and pancreaticoduodenectomy as the most common procedure (11/13; 84.6 %). Vascular involvement was common in the 11 patients with PDAC (borderline-resectable: 7/11; 63.6 % and locally advanced: 3/11; 27.3 %), as was the use of multi-agent chemotherapy (n = 10) and preoperative radiotherapy (n = 8) prior to surgery. Median blood loss was 400 mL (range: 100–2200 mL). Intraoperative measures included acute normovolemic hemodilution in one patient and red blood cell salvage in three patients. Median preoperative hemoglobin was 12.3 g/dL (range: 10.3–14.2 g/dL) and median nadir hemoglobin was 9.2 g/dL (range: 5.2–11.8 g/dL). Median hospital stay was 10 days (range: 6–42 days). Thirty-day mortality was 0 % and one-year overall survival was 69.2 % with median follow-up of 26.4 months. ConclusionPancreatic resections can be performed safely in patients who decline blood transfusion, even with borderline-resectable and locally advanced PDAC. Avoiding transfusions and employing blood-conservation techniques does not appear to detrimentally impact survival.

Use of Intraoperative Red Cell Salvage in the Contemporary Management of Placenta Accreta Spectrum Disorders

(Can J Anesth/J Can Anesth. 2023;70:1544–1546) Management of hemorrhage after cesarean delivery or cesarean hysterectomy is complex. Intraoperative red cell salvage (IOCS) is commonly used in other surgical settings and is increasingly used in obstetrics. The potential risks such as amniotic fluid embolism, bacteremia, sepsis, and coagulopathy in obstetrics remain poorly understood. This study assessed the use of IOCS in the management of placenta accreta spectrum (PAS) disorders.

Intraoperative red blood cell salvage in cancer surgery

Surgery in cancer patients may sometimes involve significant blood loss, and intraoperative red blood cell salvage is an effective technique that can reduce postoperative complications. Autologous reinfusion of red blood cells processed by a cell saver machine significantly reduces the number of red blood cell transfusions from donors. The use of leukocyte filters eliminates the possibility of tumor cell release into the patient’s circulation. This method is easy to use, however medical staff should be appropriately trained in cell salvage. Intraoperative red blood cell salvage can and should be used in the management of patients undergoing planned or emergency surgeries with expected blood loss &gt; 500 mL.

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.

Intraoperative Cell-Saver Caused More Autologous Salvage Hemolysis in a Hereditary Spherocytosis Patient Than in a Normal Erythrocyte Patient.

Hereditary spherocytosis is a common red blood cell disease caused by an inherited red blood cell membrane defect, leading to a spherical shape and propensity for hemolysis. There is a lack of reports on intraoperative autologous blood transfusion for hereditary spherocytosis patients. We hereby report our recent experience with using the Cell Saver® system for intraoperative red blood cell salvage on a hereditary spherocytosis patient. There was a drastic increase in salvaged blood free-hemoglobin compared with the preoperative sample (82.6 mg/dl vs. 6.2 mg/dl) which indicated severe hemolysis. Although our patient recovered smoothly with a normal liver and renal function test and reported no adverse reaction during follow-up, it is noteworthy that severe hemolysis could happen during the cell salvage process for patients with hemolytic anemia, as there are similar reports on sickle cell anemia, beta-thalassemia intermedia, and paroxysmal nocturnal hemoglobinuria. Therefore, more clinical attention and thorough research should be drawn into this perspective, namely, hemolysis during the red blood cell salvage process for patients with hemolytic anemia.

Efficacy of Red Cell Salvage Systems in Open Acetabular Surgery.

Over the past 50 years, treatment of displaced acetabular fractures has moved away from conservative treatment with bedrest to operative intervention to achieve anatomic reduction, stable fixation, and allow early range of motion of the hip. However, operative fixation is not without complications. Internal fixation of traumatic acetabular fractures has been coupled with large volume of blood loss both at the time of injury and surgery. This often results in the need for allogenic blood products, which has been linked to increase morbidity (Vamvakas and Blajchman, 2009). In an attempt to avoid the risk associated with allogenic blood transfusion numerous techniques and methods have been devised. Red blood cell salvage (CS) is an intraoperative blood salvage tool where blood is harvested from the operative field. It is washed to remove the plasma, white blood cells, and platelets. The red cells are resuspended in a crystalloid solution. If the hematocrit of the resuspended red blood cells is sufficient, it is transfused to the patient intravenously. The benefits of CS in major spine surgery, bilateral knee replacement, and revision hip surgery are well established (Goulet et al. 1989, Gee et al. 2011, Canan et al. 2013). However, literature reviewing the use of cell saver in orthopedic trauma surgery, specifically acetabular surgery is limited. Our institute performed a retrospective review of 63 consecutive operative acetabular fractures at a level one trauma center. Our study revealed that patients with blood loss of less than 400 mL were 13 times less likely to receive autologous blood, and patients with hemoglobin less than 10.5 were 5 times less likely to receive autologous transfusion (p < 0.05). We also found that no patients with a hemoglobin level less than 10.5 and EBL less than 400 mL received autologous blood return. Autologous blood transfusion had no effect on volume or rate of allogenic blood transfusion. We believed that if a patient's preoperative hemoglobin is less than 10.5 or expected blood loss is less than 400 mL, then CS should have a very limited role, if any, in the preoperative blood conservation strategy. We found ASA greater than 2, BMI greater than 24 and associated fracture type to be a risk factor for high blood loss.

Blood Conservation and Hemostasis in Cardiac Surgery: A Survey of Practice Variation and Adoption of Evidence-Based Guidelines.

Blood conservation and hemostasis are integral parts of reducing avoidable blood transfusions and the associated morbidity and mortality. Despite the publication of blood conservation guidelines for cardiac surgery, evidence suggests persistent variability in practice patterns. Members of the Society of Cardiovascular Anesthesiologists (SCA) created a survey to audit conformance to existing guidelines and use the results to help narrow the evidence-to-practice gap. Members of the SCA and its Continuous Practice Improvement (CPI)- Blood Conservation Work Group developed a 48-item Blood Conservation and Hemostasis in Cardiac Surgery (BCHCS) survey. The questionnaire included the components of the Anesthesia Quality Institute's (AQI) composite measure AQI49. The survey was distributed to the entire SCA membership by e-mail via the Research Electronic Data Capture (REDCap) Consortium between the fall of 2017 and early 2018. Of 3152 SCA members, 536 returned surveys for a response rate of 17%. Most responders worked at academic institutions. The median transfusion trigger after cardiopulmonary bypass was hemoglobin (Hgb) 7.0 to 8.0 g/dL. There are 4 components to AQI49, and the composite conformance to all of them was low due to 1 specific component: the use of transfusion algorithms supplemented with point-of-care (POC) testing. There was good conformance to the other 3 components of AQI49: use of antifibrinolytics, minimization of hemodilution and use of red cell salvage. Overall, practices with a multidisciplinary patient blood management (PBM) team were the most successful in meeting all 4 AQI49 criteria. The survey demonstrated widespread adoption of several best practices, including the tolerance of lower hemoglobin transfusion triggers, use of antifibrinolytics, minimization of hemodilution, and use of red cell salvage. The survey also confirms that gaps remain in preoperative anemia management and the use of transfusion algorithms supplemented with POC hemostasis testing. Serial use of this survey can be used to identify barriers to implementation and audit the effectiveness of interventions described in this article. This instrument could also help harmonize local, regional, and national efforts and become an essential component of an implementation strategy for PBM in cardiac surgery.

Ultrasonic Bone Scalpel (USBS) Does Not Reduce Blood Loss During Posterior Spinal Fusion (PSF) in Patients with Adolescent Idiopathic Scoliosis (AIS): Randomized Clinical Trial.

Randomized Clinical Trial. The aim of this study was to compare the efficacy of USBS with standard-of-care surgical instruments during posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS) by evaluating the difference in estimated blood loss per level fused (EBL/level). PSF surgery for AIS is often associated with high blood loss. Use of an ultrasonic bone scalpel (USBS) has been proposed to reduce blood loss during scoliosis surgery. This was a single-blinded (patient-blinded), randomized, controlled superiority trial. We randomized 66 patients with AIS undergoing PSF to the control group (osteotome) or the experimental group (USBS). The primary outcome was intraoperative EBL/level obtained from red blood cell salvage reports. One-year follow-up was available for 57 of 62 (92%) of patients. EBL/level averaged 35 and 39 mL/level in the experimental and control groups, respectively [adjusted mean difference USBS - osteotome -8 mL/level, 95% CI: -16.4 to 0.3 mL/level, P = 0.0575]. There was no difference in curve correction [adjusted mean difference: -1.7%, 95% CI: -7.0 to 3.6%, P = 0.5321] or operative time [adjusted mean difference: -3.55 minutes, 95% CI: -22.45 to 15.46 min, P = 0.7089] between groups. Complications requiring change in routine postoperative care were noted in eight patients: two occurred in patients assigned to the experimental group and six occurred in patients assigned to the control group. There was no clinically significant difference in total blood loss, EBL/level, or complications between the two groups. In contrast to reports from other centers, at our high-volume spine center, USBS did not lead to reduced blood loss during PSF for AIS. These results may not be generalizable to centers with longer baseline operative times or higher baseline average blood loss during PSF for AIS.Level of Evidence: 1.

Application of intraoperative red cell salvage and autologous blood transfusion in cesarean section of pregnant women with central type of placenta previa

Objective To observe the safety and effect of intraoperative cell salvage and autologous blood transfusion during cesarean section with central placenta previa. Methods From April 2015 to March 2016, 25 pregnants with central placenta previa diagnosed by MRI and ultrasound and underwent selected caesarean section in the People′s Hospital of Wenzhou were included. When the amount of blood in the recovery tank was 450 mL or the obstetrician required, the wash and retransfusion device was started-up. Hb and Hct were measured before and after the parturient, and the blood was recovered. The blood loss, recovery of blood, blood transfusion, allogeneic RBC infusion and the side effects after transfusion and 42 d of postpartum were recorded. Results No serious complications were recorded in all pregnants. Five cases(20%) were only recovered and the autologous blood transfusion and transfusion of the allogeneic RBC were not carried out. In 14 cases(56%), only the autologous blood was returned to the puerpera. The volume of blood transfusion was 705 mL(430, 1 535). Six cases(24%) had massive bleeding during the operation, 3690 mL(1 900, 8 750), and the autologous blood transfusion volume was 2939 mL(1 167, 4 206), and the allogeneic RBC transfusion was 3.5U(1.5, 11.5). Conclusion Autologous blood transfusion can be used safely in the caesarean section of the central placenta previa, and can reduce the allogeneic RBC transfusion. Key words: Placenta previa; Cesarean section; Operative blood salvage; Erythrocytes; Hemoglobins; Hematocrit

Potentially clinically relevant concentrations of Cefazolin, Midazolam, Propofol, and Sufentanil in auto-transfused blood in congenital cardiac surgery

BackgroundUse of donor blood in congenital cardiac surgery increases the risk for post-operative morbidity and mortality. To reduce the need for allogenic blood transfusion a technique for peri-operative mechanical red cell salvage is applied. Blood from the operation site is collected in a reservoir, processed, passed through a lipophilic filter and returned to the patient. Influence of this cellsaver system on coagulation, fibrinolysis and inflammatory markers is known. To our knowledge no studies have been performed on the effects of autotransfusion on drug concentrations. A clinically relevant drug dose could potentially be returned to the patient through the auto-transfused blood, leading to unwanted drug reactions post-operatively. We aimed to measure drug concentrations in blood salvaged from the operation site and in the auto-transfused blood to determine if a clinically relevant drug dose is returned to the patient.MethodsThe study was performed at the Department of Cardiothoracic Surgery of a tertiary university hospital. Blood samples were taken from the reservoir, after processing before the lipophilic filter, the auto-transfused blood, and the waste fluid. Samples were stored at − 80 C and drug concentration for sufentanil, propofol, midazolam and cefazolin were measured using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Drug concentrations measured in the reservoir and the auto-transfused blood were compared and the relative reduction was calculated for each patient.ResultsBlood samples were taken from 18 cellsaver runs in 18 patients, age 0–13 years. Drug concentrations in the reservoir were comparable to concomitant concentrations in the patient. For sufentanil 34% (median, IQR 27–50) of drug concentration was retained from the reservoir in the auto-transfused blood, for midazolam 6% (median, IQR 4–10), for cefazolin 5% (median, IQR 2–6) and for propofol 0% (median, IQR 0–0) respectively.ConclusionDepending on the drug, up to 34% of the drug concentration salvaged from the operation site is returned to the patient through autotransfusion, potentially causing unwanted drug reactions post-operatively. Additionally, influence of a cellsaver system should be considered in pharmacological research during and after congenital cardiac surgery and could result in dose adjustments in the postoperative phase.Trial registrationRegistration at the Dutch Trial Registry (NTR3579) at August 14 2012.

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.

Red blood cell salvage analysis from clotted blood.

Blood clots discovered within body cavities intra-operatively are often manually broken up and placed in an autotransfusion device to recover autologous blood cells. This study evaluated the efficiency at which these red blood cells can be recovered from clot and to determine if these cells would be free of fibrin and clumping which might pose a risk of micro-emboli. Whole blood was aliquoted into 25 mL volume samples. The blood was then allowed to clot, and after 24 hours the clotted blood was manually kneaded by hand for 1, 2, 3, or 5 minutes. One mL of the harvested blood was fixed and processed for scanning electron microscope imaging. Plasma from the rest of the sample was then separated and underwent spectrophotometry for analysis of relative free haemoglobin. Blood recovered from the clotted blood ranged from 60 to 80% as time increased from 1 to 5 minutes of kneading. Volume of erythrocytes recovered from 1 minute compared to 2 minutes was statistically significant but not significant between 2 minutes or any longer period of time. Imaging did not show any evidence of fibrin strands or significant cell fragmentation. Spectrophotometry showed a steady increase of observed absorption at 540 nm, indicative of free haemoglobin, as manual kneading time increased. Red blood cells were able to be efficiently recovered from clotted blood. Imaging studies did not show any evidence of red blood cells trapped within fibrin mesh.

OP61 - Metabolic acidosis after heart surgery and intraoperative red cell salvage

OP61 - Metabolic acidosis after heart surgery and intraoperative red cell salvage

Revisiting transfusion safety and alternatives to transfusion

Transfusion of blood products can be life saving when used appropriately. It carries however at the same time a potential for morbidity and mortality, depending on the patient, the product or the setting. Numerous strategies have been elaborated to minimize these risks, and in recent years, transfusion has no longer been regarded as essential for the management of a wide range of diseases. Uncomplicated surgeries in well-prepared patients can now be conducted without the use of transfusions. Questions about transfusion safety and shortage have led to extensive research on alternatives to blood transfusion, ranging from non-pharmacological to pharmacological solutions. Restrictive transfusion therapies, preoperative autologous blood donations, perioperative red cell salvage, acute normovolaemic haemodilution techniques or patient blood management are potential solutions where prothrombin complex or fibrinogen concentrates, synthetic anti-fibrinolytic agents, desmopressin, rFVIIa, or erythropoiesis stimulating agents may play a complementary pharmacologic role.

Red Blood Cell Salvage During Obstetric Hemorrhage

Objective To describe which obstetric patients lose enough blood during postpartum hemorrhage to receive a reinfusion of intraoperative blood salvage. Methods Eight years of intraoperative blood salvage data from a regional tertiary care maternity hospital were analyzed. The volume of blood returned through intraoperative blood salvage was standardized to the volume of red blood cells in an allogeneic red blood cell unit from the blood bank. Results There were 884 obstetric hemorrhage cases in which intraoperative blood salvage was utilized. Sufficient blood was collected by intraoperative blood salvage to permit reinfusion in 189 of 884 (21%) patients. For patients in whom intraoperative blood salvage blood was reinfused, the mean ± standard deviation number of reinfused shed blood units was 1.2 ± 1.1 units. Although intraoperative blood salvage was most commonly performed on patients who underwent routine cesarean delivery (748/884 patients), only 13% of these patients received an intraoperative blood salvage reinfusion; 73% of the patients undergoing cesarean hysterectomy, 69% of those who had bleeding after cesarean delivery, and 53% of the patients who bled after vaginal delivery received an intraoperative blood salvage reinfusion (P Conclusion Although intraoperative blood salvage was attempted on many patients, on only 21% of the women was a sufficient amount of intraoperative shed blood collected to proceed with reinfusion. Patients who experienced bleeding or who underwent a cesarean hysterectomy were the most likely to receive a reinfusion of intraoperative blood salvage-processed blood.

Oxygen carrying capacity of salvaged blood in patients undergoing off-pump coronary artery bypass grafting surgery: a prospective observational study.

BackgroundIntraoperative cell salvage (ICS), hereby referred to ‘mechanical red cell salvage’, has been widely used and proven to be an effective way to reduce or avoid the need for allogeneic red blood cells (RBCs)transfusion and its associated complications in surgeries involving major blood loss. However, little is known about the influence of this technique on the functional state of salvaged RBCs. Furthermore, there are no articles that describe the change of free hemoglobin (fHb) in salvage blood during storage, which is a key index of the quality control of salvaged blood. Therefore, in this study, the influence of ICS on the function of salvaged RBCs and the changes of salvaged RBCs during storage were studied with respect to the presence of oxyhemoglobin affinity (recorded as a P50 value) and the level of 2, 3-diphosphoglycerate (2, 3-DPG) and fHb by comparing salvaged RBCs with self-venous RBCs and 2-week-old packed RBCs.MethodsFifteen patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery were enrolled. Blood was collected and processed using a Dideco Electa device. The level of P50, 2, 3-DPG and fHB from salvaged RBCs, venous RBCs and 2-week-old packed RBCs was measured. We also measured the changes of these indicators among salvaged RBCs at 4 h (storage at 21–24 °C) and at 24 h (storage at 1–6 °C).ResultsThe P50 value of salvaged RBCs at 0 h (28.77 ± 0.27 mmHg) was significantly higher than the value of venous RBCs (27.07 ± 0.23 mmHg, p = 0.000) and the value of the 2-week-old packed RBCs (16.26 ± 0.62 mmHg, p = 0.000). P50 value did not change obviously at 4 h (p = 0.121) and 24 h (p = 0.384) compared with the value at 0 h. The 2, 3-DPG value of salvaged RBCs at 0 h (17.94 ± 6.91 μmol/g Hb) was significantly higher than the value of venous RBCs (12.73 ± 6.52 mmHg, p = 0.007) and the value of the 2-week-old packed RBCs (2.62 ± 3.13 mmHg, p = 0.000). The level of 2, 3-DPG slightly decreased at 4 h (p = 0.380) and 24 h (p = 0.425) compared with the value at 0 h. Percentage of hemolysis of the salvaged blood at 0 h(0.51 ± 0.27 %) was significantly higher than the level of venous blood (0.07 ± 0.05 %, p = 0.000) and the value of 2-week-old packed RBCs (0.07 ± 0.05 %, p = 0.000), and reached 1.11 ± 0.42 % at 4 h (p = 0.002) and 1.83 ± 0.77 % at 24 h (p = 0.000).ConclusionsThe oxygen transport function of salvaged RBCs at 0 h was not influenced by the cell salvage process and was better than that of the venous RBCs and 2-week-old packed RBCs. At the end of storage, the oxygen transport function of salvaged RBCs did not change obviously, but percentage of hemolysis significantly increased.

Red blood cell salvage during obstetric hemorrhage.

To describe which obstetric patients lose enough blood during postpartum hemorrhage to receive a reinfusion of intraoperative blood salvage. Eight years of intraoperative blood salvage data from a regional tertiary care maternity hospital were analyzed. The volume of blood returned through intraoperative blood salvage was standardized to the volume of red blood cells in an allogeneic red blood cell unit from the blood bank. There were 884 obstetric hemorrhage cases in which intraoperative blood salvage was utilized. Sufficient blood was collected by intraoperative blood salvage to permit reinfusion in 189 of 884 (21%) patients. For patients in whom intraoperative blood salvage blood was reinfused, the mean ± standard deviation number of reinfused shed blood units was 1.2 ± 1.1 units. Although intraoperative blood salvage was most commonly performed on patients who underwent routine cesarean delivery (748/884 patients), only 13% of these patients received an intraoperative blood salvage reinfusion; 73% of the patients undergoing cesarean hysterectomy, 69% of those who had bleeding after cesarean delivery, and 53% of the patients who bled after vaginal delivery received an intraoperative blood salvage reinfusion (P<.001). Although intraoperative blood salvage was attempted on many patients, on only 21% of the women was a sufficient amount of intraoperative shed blood collected to proceed with reinfusion. Patients who experienced bleeding or who underwent a cesarean hysterectomy were the most likely to receive a reinfusion of intraoperative blood salvage-processed blood.

Failure of Intraoperative Red Cell Salvage: A Patient with Sickle Cell Disease and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) Syndrome

Cell salvage is a process whereby the bloodshed from the operative field is collected and returned to the patient. It can be especially useful when allogeneic red blood cell (RBC) units are not readily available such as when the recipient has multiple alloantibodies. We report on the anesthesia and transfusion strategies for managing a pregnant patient with sickle cell disease (SCD) with HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome. A pregnant patient with twins at 30 weeks of gestation was admitted in an SCD crisis. She subsequently developed HELLP syndrome and required urgent cesarean delivery; however, she had multiple RBC antibodies complicating the immediate provision of crossmatched RBC units. Cell salvage was used to capture the blood shed during her procedure while the blood bank was searching for compatible RBCs units. Despite multiple interventions designed to optimize the cell salvage procedure for the unique challenges of a patient with SCD, the salvaged RBCs hemolyzed and could not be reinfused. Cell salvage in an obstetric patient with SCD in an acute crisis and superimposed HELLP was unable to recover intact and useable RBCs. Further studies into methods of optimizing the procedure for use in this context are warranted. Close communication between the clinical teams treating the patient and the transfusion service is required so that the RBC transfusion requirements can be anticipated; this is especially important when the patient has multiple antibodies.

Intraoperative red cell salvage during obstetric surgery in 50 Japanese women

ObjectiveTo determine the clinical usefulness of intraoperative cell salvage (ICS) in obstetrics. MethodsA retrospective analysis was performed using data for 50 patients who had received ICS blood during obstetric surgery at 13 Japanese facilities between January 1, 2007 and December 31, 2013. The frequencies of ICS-associated adverse events, allogeneic blood transfusion (ABT), and preoperative autologous donation (PAD) were assessed. ResultsPlacenta previa was the indication for ICS in 42 (84%) women. The ICS blood was reinfused in all women (median 366mL; range 80 to at least 3715). No ICS-associated adverse events occurred. The median estimated blood loss (EBL) was 2171mL (range 574–47 000); 27 (54%) women lost at least 2000mL. ABT was not used in 33 (66%) women. Among 26 women who lost at least 2000mL of blood and were included in analyses, 12 (44%) did not receive ABT. EBL was linearly correlated with the total volume of transfused blood (P<0.001). ConclusionICS caused no adverse events among women at elevated risk of peripartum hemorrhage and might be safe for use in obstetrics.