Red Cell Salvage Research Articles

Blood conservation in the intensive care unit.

To describe blood conservation strategies for critically ill patients. By using a predefined strategy, we searched the electronic databases of Medline, EMBASE, CINAHL, the Cochrane database of systematic reviews, Cochrane central register of controlled trials, ACP Journal Club, Database of abstracts of reviews and effects, and HealthSTAR for descriptions and evaluations of strategies of blood conservation among critically ill patients. A number of blood conservation strategies have been used to prevent or treat anemia among critically ill patients. These include restrictive diagnostic phlebotomy using small-volume or pediatric phlebotomy tubes, point-of-care and inline bedside microanalysis, minimization of diagnostic sample waste, minimization of routine multiple daily phlebotomies, red blood cell salvage and antifibrinolytic agents for bleeding patients, consideration of removal of central venous and arterial catheters when no longer required for physiologic monitoring, threshold-based transfusion policy, and healthcare professional education. There are many strategies of blood conservation for critically ill patients. The effects of these strategies on phlebotomy volumes, hemoglobin and hematocrit levels, transfusion requirements, clinical outcomes, as well as intensive care unit and laboratory resources and costs should be further evaluated.

The Impact of Introducing an Autologous Intraoperative Transfusion Device to a Community Hospital

The purpose of this study was to determine the benefits and disadvantages of transfusing autologous blood during abdominal aortic aneurysm (AAA) surgery at a district general hospital with an intraoperative autologous transfusion device (Haemoccel ABT 350). In this retrospective study, 128 patients underwent abdominal aortic aneurysm repair between 1992 and 1999 by a single vascular surgeon. Ninety-three patients (60 autologous and 33 allogeneic) had elective AAA repair (group A) and 25 patients (4 autologous and 21 allogeneic) had emergency AAA repair (group B). Nine group A patients (7.6%) received their own salvaged blood and no other allogeneic blood. Although the mean estimated blood loss was higher in the autologous group of patients (NS), the intraoperative autologous transfusion device did not significantly reduce allogeneic blood usage in patients who had autologous transfusion in both elective and emergency groups. There was no difference in postoperative hemoglobin and hematocrit, ICU stay or hospital stay. In this study, red cell salvage was significantly more expensive than blood bank usage (p < 0.0001), yet it did not significantly reduce the needs of allogeneic blood. We concluded that the intraoperative autologous transfusion device is underused, not cost-effective and requires formulation of local guidelines.

Post-operative red cell salvage in total knee replacement

Post-operative cell salvage (PCS) reduces homologous blood use after knee replacement but liberal indication for transfusion in previous studies resulted in high homologous transfusion requirements. We evaluated PCS in patients undergoing knee replacement using a restrictive transfusion trigger (Hb <8.5 g/dl). Forty patients underwent knee replacement with either PCS ( n=20) or with standard wound drains ( n=20). Blood losses and transfusion requirements were recorded prospectively. Mean (SD) post-operative blood loss with PCS was 656 (317) ml, of which 433 (197) ml were re-infused. Control blood loss was comparable at 591 (328) ml. Blood transfusion was given to only one PCS patient; 2 U, and five controls who received a total of 12 U of homologous blood. Homologous transfusion was not necessary for most patients undergoing knee replacement when the indication for transfusion was restricted. PCS further decreased homologous blood requirements.

Intra-operative autologous blood management

The evolution of cardiac surgery has been accompanied by a wide variety of techniques and equipment available for blood conservation. It has also given us data that allows identification of preoperative risk factors for transfusion needs in other surgical specialties. There is however great diversity of opinion as to how this technology should be applied. Examples can be found in the literature of discrepancies between countries but also individual institutions . The authors encounter differences in opinion between practitioners regularly. The authors believe that the variance in opinion may be based on the experiences of single techniques and that a broader depth of practice is required to achieve best practices for intra-operative transfusion management. The most performed procedure in our experience is red cell salvage and processing with a cell-washing device (CS). There are two primary issues related to CS, cost and reduction in allogenic blood exposure. A recent meta-analysis has shown that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion peri-operatively, but post-operative cell salvage is only marginally effective in cardiac surgery. There are close analogies to be drawn from issues surrounding the whole picture of transfusion. Medical practice guidelines are frequently promoted as a way to improve the cost-effectiveness of healthcare. But non-compliance with guidelines is still a major issue. Guiding the decision to transfuse or autotransfuse can improve transfusion practices, but effective processes must first identify problem(s) in transfusion practice and then include the attending medical practitioner as an educational target. Process improvements that have been shown to be effective include, briefly meeting one-on-one with physicians, teaching at scheduled conferences, making daily clinical rounds of patients who receive transfusion, concurrently reviewing orders for transfusion before issue of the blood product, and installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements. The success of a change of practice patterns relies on hospital administration, education and feedback, written and immediately available guidelines, employment of specially trained personnel, and establishing long-standing actions. It is the authors' observation that the success of an intra-operation blood management program is twofold, early identification of patients and a multi-team approach of Surgeon, Haematologist, Transfusion services, Anaesthetist and Perfusionist. This team approach offers far greater depth for management of intra-operative blood conservation and transfusion practice. Interventions must be patient specific and targeted toward the best possible patients outcome.

Facteurs associés à la stratégie transfusionnelle au cours des anesthésies programmées pour arthroplastie de hanche ou de genou en France

Goal of the study: To determine over a whole country what are the factors associated with an intraoperative homologous blood transfusion and with the use of autologous techniques (preoperative autologous blood donation : PABD; acute normovolemic hemodilution: ANVH; intraoperative red cell salvage: IRCS). Study design: National enquiry using a large representative sample (3 days of anaesthesia in France). Methods: Univariate followed by multivariate analyses of data gathered in 1996 during the survey leaded by the French society of anaesthesia and intensive care (Sfar) and corresponding to 884 scheduled hip and knee prosthesis surgical procedures. Results: Factors associated with a decreased use of PABD programme were: 1- old age and high ASA physical status; 2- procedures of short duration. By contrast, an increased use of PABD was associated with anaesthetics in which a closed circuit had been used. Except for a significant association with increasing age and with absence of PABD used, no additional factor was found to be linked with ANVH. No factor among those studied was found related to the use of IRCS. Homologous blood transfusion was more frequently used in ASA ≥ 3 patients, in long duration surgeries while its use was decreased in patients with PABD (odds ratio for reduction by PABD : 4.4 〚95 % confidence interval : 2.2-8.8〛). Homologous blood transfusion was not related to the use of ANVH or IRCS. Conclusion: These data obtained from a large national survey confirm previously published studies and meta-analyses and are in agreement with current recommendations. An unexpected relation between PABD and closed circuit anaesthesia has been found.

Errors During Intraoperative Cell Salvage Because of Inappropriate Wash Solutions

Two case reports illustrate errors that can occur during intraoperative red blood cell salvage and emphasize the need for standardized procedures and quality improvement processes for this intervention.

The effect of acute normovolaemic haemodilution on blood transfusion requirements in abdominal aortic aneurysm repair.

to evaluate the impact of acute normovolaemic haemodilution (ANH) on the blood transfusion requirements in elective abdominal aortic aneurysm (AAA) repair in a single vascular unit. thirty-two patients underwent ANH during elective AAA repair between 1992 and 1997. The operation was performed by the same surgeon/anaesthetist team in 75% of cases. Their demographic details, type of aneurysm (infra-renal or supra-renal), preoperative blood cross match, use of intra-operative red cell salvage, blood loss, peri-operative bank blood requirements, pre-op and on-discharge haemoglobin levels and post-operative outcome were recorded. The results were compared to a group of 40 randomly selected patients (to represent the unit average) who underwent elective AAA repair by variable surgeon/anaesthetist teams without ANH in the same time period. there were more supra-renal AAA repairs in the ANH group (8/32) than in the non-ANH group (0/40, p<0.01). ANH patients required significantly less blood transfusion peri-operatively (median 2 units) than the non-ANH patients (median 3 units, p=0.02). There were no other significant differences between the variables measured. these results suggest that a dedicated team can achieve significant reductions in the use of heterologous blood transfusion compared to the vascular unit average experience by the effective use of ANH.

CASE REPORT

A 71-year-old woman, weighing 70 kg, presented for surgery to revise first the right and then the left femoral and acetabular cemented prostheses with uncemented hydroxy-apatite ceramic coated Furlong® components (Joint Replacement Instrumentation, London). Her medical history was of essential hypertension, stable angina pectoris and an uncomplicated myocardial infarction 5 years previously. There was no evidence of cardiac failure or cerebrovascular disease. Medications included metoprolol, glyceryl trinitrate spray and oral ferrous sulphate for 2 months before surgery. On examination her blood pressure was 130/70 mmHg with no signs of cardiac failure and no carotid bruits. Electrocardiogram revealed a left bundle–branch block, and the chest radiograph showed unfolding of the aorta with a normal cardiac shadow and lung fields. Urea and electrolytes were within normal limits and haemoglobin (Hb) was 141 g/litre (operation 1) and 140 g/litre (operation 2). The patient expressed a desire not to receive any blood or blood-related products at any time, and completed the requisite Jehovah's Witness documentation. It was agreed that she would undergo preoperative isovolaemic haemodilution and intraoperative salvage of red blood cells, maintaining continuity with her circulation at all times. On both occasions the patient was premedicated with oral temazepam 20 mg and a 5 mg glyceryl trinitrate skin patch. After inserting a radial arterial line, a total of 700 ml of blood was venesected into bags containing citrate for anticoagulation and kept in continuity with the patient's circulation. Blood pressure was maintained during venesection using two 3 mg ephedrine boluses before volume replacement with 1000 ml of Gelofusine® (Braun, Melsungen) was commenced. Anaesthesia was induced with thiopentone 200 mg and maintained with isoflurane and nitrous oxide in 40% oxygen. Muscle relaxation was achieved using vecuronium and the patient intubated after receiving alfentanil 0.5 mg. Her lungs were mechanically ventilated to an end tidal PaCO2 of 4.8–5.0 kPa. Intraoperative and postoperative analgesia was achieved on both occasions with a lumbar epidural catheter inserted at L1/2 interspace, using a continuous infusion of bupivacaine 1 mg/ml and fentanyl 2 μg/ml. Standard intraoperative monitoring included invasive blood pressure, central venous pressure and oesophageal temperature. A urethral catheter was inserted and body temperature maintained around 36°C using intravenous fluid warmers and a Warm Touch® (Gaymar, Hamburg). Intraoperative red blood cell salvage was achieved with a Haemonetics Cell Saver®5 (Haemonetics Corporation, Massachusetts), set up with a continuous circuit from the surgical sucker, through the filtration and reservoir units to an intravenous line in the patient using normal saline as a primer. Intraoperative systolic blood pressure was maintained between 90–100 mmHg. Surgery involved meticulous removal of all cement using cement splitting and extracting instruments under image intensifier control. Finally granulation tissue between cement and bone was curetted away to expose bleeding cancellous bone. There were no unexpected surgical complications. Intraoperative blood loss totalled 1250 ml (operation 1), and 1100 ml (operation 2). A total of 2000 ml of colloid was infused after isovolaemic haemodilution and before the completion of surgery, at which time an arterial blood gas sample revealed no significant metabolic acidosis on either occasion. After wound closure a total of 500 ml of Cell Saver®5 infusate with an estimated haematocrit of 0.55 was transfused. Finally the two 350 ml bags of autologous blood were infused slowly over the next few hours. Following extubation the patient was transferred to intensive care for overnight monitoring and continuous postoperative epidural analgesia. Investigations included full blood count, urea and electrolytes, coagulation profile, and arterial blood gases. Serial 12-lead electrocardiograms and cardiac enzymes revealed no evidence of myocardial ischaemia or infarction on either occasion. Demonstrable postoperative blood losses totalled approximately 500 ml for each operation. The lowest recorded Hb was 80 g/litre (operation 1), and 89 g/litre (operation 2), measured intraoperatively before infusing the Cell Saver®5 infusate. Figure 1 shows the Hb levels from the preoperative day through to discharge for both procedures. Aside from a 37% prolongation of prothrombin time and 27% prolongation of activated partial thromboplastin time on the first postoperative night, coagulation rapidly returned to normal values. The patient recovered uneventfully and despite persistent anaemia (Figure 1), was discharged home after 1 week on both occasions. Two-year follow-up confirms successful revision arthroplasties.

Institutional variability in red blood cell conservation practices for coronary artery bypass graft surgery

Objective: To assess whether substantial institutional variability exists in red blood cell conservation practices associated with coronary artery bypass graft (CABG) surgery. Design: Prospective, randomized patient enrollment and data collection. Setting: Twenty-four U.S. academic institutions participating in the Multicenter Study of Perioperative Ischemia. Participants: A well-defined subset of primary CABG surgery patients (n = 713) expected to be at low risk for bleeding and exposure to allogeneic transfusion. Interventions: None (observational study). Measurements and Main Results: Frequency of use of red blood cell conservation techniques was determined among institutions. Correlation was determined between use of each technique and transfusion of allogeneic red blood cells and between use of each technique and median institutional blood loss. Significant variability ( p < 0.01) was detected in institutional transfusion practice with respect to the use of predonated autologous whole blood, normovolemic hemodilution, red cell salvage, and reinfusion of shed mediastinal blood. The frequency of institutional use of these techniques was not associated with allogeneic transfusion ( r 2 < 0.15) or blood loss ( r 2 < 0.10) in the low-risk population of patients examined. Conclusions: Institutions vary significantly in perioperative blood conservation practices for CABG surgery. Further study to determine the appropriate use of these techniques is warranted.

Plasma Levels of Eicosanoids after Transfusion of Intraoperatively Salvaged Blood

Background: The interest in autologous red blood cell salvage is increasing rapidly, but it is well known that platelets and white cells are activated during cell washing. Therefore, we aimed to determine whether or not eicosanoids transfused together with the salvaged blood are responsible for nonhemolytic immunological transfusion reactions. Materials and Methods: In 11 patients who underwent radical prostatectomy we studied the release of eicosanoids, prostaglandin E₂ (PGE₂) and thromboxane B₂ (TxB₂), in association with reinfusion of intraoperatively salvaged blood. Blood samples were taken before operation, on days 1 and 3 after operation and before and after cell washing. Results: There was a twofold increase in PGE₂ and a twentyfold increase in TxB₂ in the unwashed salvaged blood. Washing caused a reduction in eicosanoid plasma levels of up to 95%, but a significantly lower level in relation to its corresponding preoperative value was only found for PGE₂. After transfusion of an average of 420 ml RBC sediment from washed blood, the patients’ plasma concentrations of PGE₂ and TxB₂ on the 1st and 3rd postoperative day did not significantly differ compared to baseline values. Conclusion: Our data support the notion that RBC sediment from ‘salvaged’ and washed autologous blood contains increased amounts of PGE₂ and TxB₂. It remains, however, questionable if these passively infused eicosanoids become biologically active. According to our study, the PGE₂ and TxB₂ transfused are apparently not responsible for nonhemolytic immunological transfusion reactions.

Plasma Levels of Eicosanoids after Transfusion of Intraoperatively Salvaged Blood

Background: The interest in autologous red blood cell salvage is increasing rapidly, but it is well known that platelets and white cells are activated during cell washing. Therefore, we aimed to determine whether or not eicosanoids transfused together with the salvaged blood are responsible for nonhemolytic immunological transfusion reactions. Materials and Methods: In 11 patients who underwent radical prostatectomy we studied the release of eicosanoids, prostaglandin E2 (PGE2) and thromboxane B2 (TxB2), in association with reinfusion of intraoperatively salvaged blood. Blood samples were taken before operation, on days 1 and 3 after operation and before and after cell washing. Results: There was a twofold increase in PGE2 and a twentyfold increase in TxB2 in the unwashed salvaged blood. Washing caused a reduction in eicosanoid plasma levels of up to 95%, but a significantly lower level in relation to its corresponding preoperative value was only found for PGE2. After transfusion of an average of 420 ml RBC sediment from washed blood, the patients' plasma concentrations of PGE2 and TxB2 on the 1st and 3rd postoperative day did not significantly differ compared to baseline values. Conclusion: Our data support the notion that RBC sediment from ‘salvaged’ and washed autologous blood contains increased amounts of PGE2 and TxB2. It remains, however, questionable if these passively infused eicosanoids become biologically active. According to our study, the PGE2 and TxB2 transfused are apparently not responsible for nonhemolytic immunological transfusion reactions.

Major surgery without blood transfusion

The practice of avoiding homologous blood transfusion has evolved from the desire to prevent disease transmission into a clinical technique with many patient benefits. These include improved immunological function, economic efficiency, and also patient choice.It is a technique that has benefits to offer patients with a wide range of pathologies, from multiple and rare alloantibodies, to carcinoma, and those undergoing surgery associated with massive blood loss. Familiarity and availability could see its wider application in major trauma, thereby reducing the burden on the blood transfusion service.Successful management of patients without blood transfusion requires knowledge of oxygen transport and the physiological response to anaemia. To avoid increasing patient risk, it is important not to exceed the tolerance limits of haemodilution. Patient selection is therefore essential in successfully avoiding blood transfusion.A number of strategies are available to reduce the need for blood transfusion. These strategies are maximally effective if combined to span the pre-operative, intra-operative, and post-operative periods. If time permits, pre-operative optimisation of haemoglobin is essential. Surgical, anaesthetic, and pharmacological techniques can reduce blood loss during surgery and must be employed.The peri-operative use of autologous blood reduces the incidence of homologous blood transfusion. Autologous blood can be procured from pre-operative donation, from acute normovolaemic haemodilution, and from intra-operative red cell salvage. Each technique has advantages and limitations. There is also a use for post-operatively collected autologous blood in appropriate circumstances.Continuing research is expanding the field of red cell substitutes that already offer limited benefit in avoiding blood transfusion.Major surgery without blood transfusion is an exciting and very real clinical prospect with many benefits for patient care. Success requires a well-planned team effort. As resources become more limited, this is a clinical technique that can only grow in its application.

Impact of Red Cell Salvage on Transfusion Requirements During Elective Abdominal Aortic Aneurysm Repair

Elective abdominal aortic aneurysm (AAA) surgery may result in substantial blood loss. Concerns regarding the safety, availability, and acceptability of homologous blood have led to initiatives toward reducing transfusion requirements at the time of aneurysm repair. This study was designed to determine if the routine use of intraoperative red cell salvage and autotransfusion resulted in a reduction in homologous transfusion at our institution. A retrospective review of elective AAA repairs in the years 1987, 1992, and 1997 was carried out. Demographic data, operative details, blood loss, hemoglobin levels, red cell salvage and return volumes, and transfusion requirements were recorded and compared across the study years. From this study we conclude that routine use of red cell salvage and autotransfusion is an effective means for reducing transfusion requirements in elective AAA repair.

Perioperative red cell salvage: a case for implementing the 1995 consensus statement.

Perioperative red cell salvage: a case for implementing the 1995 consensus statement.

Red cell salvage and reinfusion in pediatric bone marrow donors.

We evaluated the use of a semi-automated processing technique to salvage red blood cells from pediatric bone marrow donors to minimize the risk of severe anemia following bone marrow harvest and ABO incompatibility in the recipient. Sixty healthy, HLA-matched, pediatric donors of bone marrow hematopoietic cells with a median age 8.0 years (2-19) were studied. Thirteen of the donor-recipient pairs were ABO incompatible. There were 60 recipients with a median age of 8.6 years (2 months to 20.8 years). Bone marrow was harvested under general anesthesia, filtered in the operating room and then transferred to the stem cell laboratory for processing. Samples were obtained for cell count, CD34+ quantification, colony assay, viability, and bacteriologic cultures before and after processing. The cells were processed in a semi-automated closed system (Stericel, Terumo) by density gradient separation with Ficoll-Hypaque and then washed. Two aliquots were obtained: one containing the mononuclear cell layer to be infused to the recipient and the other the washed red cells to be infused to the donor. The median volume harvested was 608 +/- 40.42 ml (278-1409), while the final volume infused was 174 +/- 10.75 ml (30.2-380) P < 0.0001, representing a decrease of 72% of the volume infused. The nucleated cell count harvested was 1.6 x 10(10) +/- 0.1 (0.56-3.2), while the count infused was 6.9 x 10(9) +/- 0.1 (0.12-5.4) P < 0.0001. The median mononuclear cell count (MNC) per kg harvested was 0.67 x 10(8) +/- 0.05 (0.18-2.0) vs an infused cell number of 1.3 x 10(8) MNC/kg +/- 0.1 (0.6-33.6) P < 0. 0001. The CD34+ cells harvested were 2.8 x 10(6)/kg +/- 0.1 (0.25-10.2) vs an infused number of 6.0 x 10(6)/kg +/- 0.5 (0.84-31.0) P < 0.0001. The viability before and after processing was 99%. Red cell salvage performed in a semi-automated closed system is safe and reduces the risk of post-bone marrow harvest anemia in pediatric donors, decreases the volume infused into the donor and enriches the mononuclear and CD34+ cell population, without affecting hematopoietic reconstitution.

Blood conservation in hip trauma.

Patients with hip or pelvic fractures experience significant blood loss as a result of the fracture and from the surgery that subsequently is performed. The emergent and unplanned nature of fracture surgery precludes the use of preoperative blood donation and the optimization of chronic medical problems. Blood transfusion frequently is required to maintain adequate tissue O2 delivery in these injured patients. However, the administration of allogeneic blood causes other problems, including a well documented increase in the risk of infectious complications. Perioperative measures to minimize blood loss such as hypotensive anesthesia and red blood cell salvage are important, but often are inadequate to prevent the need for blood transfusion. Recently, erythropoietin therapy has been shown to stimulate hematopoiesis in patients with hip fractures. The authors discuss their experience with blood loss management in these patients with hip injuries, including aggressive Fe replacement therapy and the use of recombinant human erythropoietin.

Double volume exchange transfusion for ABO incompatible liver transplantation in paediatric patients: intraoperative and preoperative approach.

Double volume blood exchange transfusions (DBVET) were used to reduce the serum antibody levels in six paediatric patients receiving ABO incompatible hepatic allografts. In four patients, the exchange transfusions took place on the ward prior to surgery. In three of these four patients who had titres measured, the anti-A IgM titres fell from 1024 to 64, 64 to 8, and 128 to 16, respectively. The anti-A IgG titres fell from 32 to 16 and 512 to 64 in two patients, but rose from 16 to 32 in the third. In two patients DBVET were performed intraoperatively using a rapid infusion device. The IgM titres fell from 256 to 32 and 64 to 1, respectively, and the IgG titres fell from 16 to 4 and 2 to 0. Intraoperative DBVET can acutely and effectively reduce blood group antibodies. Intraoperative DBVET may reduce graft ischaemia time and allow red blood cell salvage.

Consensus conference on autologous transfusion. Perioperative red cell salvage.

Consensus conference on autologous transfusion. Perioperative red cell salvage.

The role of the transfusion medicine consultant.

Over the last 15 years, the field that was once known as blood banking has evolved into the discipline of transfusion medicine. Because of AIDS and a greater appreciation of other transfusion-transmitted diseases, attitudes toward transfusion therapy have changed significantly. Advances in the understanding of the pathophysiology of anemia and thrombocytopenia, as well as new tools for transfusion support have created new roles for the transfusion medicine physician. The transfusion medicine consultant has the opportunity to influence and improve transfusion safety, and contribute positively to cost containment by providing expertise as an educator, auditor of blood component usage, and providing leadership or oversight of therapeutic modalities (such as autologous transfusion, intraoperative red cell salvage, and therapeutic apheresis).

Red blood cell salvage during hip replacement and abdominal aortic surgery. (Short communication).

Autotransfusion of shed blood during surgery has now been used for more than a decade. In the recent years the development of safe and fast operating equipment for red blood cell salvage (1, 3) has led to a widespread use of autotranfusion.