Red Cell Salvage Research Articles

Anaphylatoxin and terminal complement complexes in red cell salvage

Thirteen patients undergoing elective orthopedic surgery were studied regarding anaphylatoxin (C3a and C5a) and terminal complement complex (TCC) formation in association with red cell salvage. The auto-transfusion equipment gave a centrifuged and washed erythrocyte fraction. The concentrations of C5a and TCC were not increased but elevated C3a levels were found in the suspension. After infusion of the erythrocyte fraction to the patient, no signs of systemic complement activation were observed. Thus, plasma levels of C3a, C5a and TCC were within the normal range in all the patients before and after autotransfusion. This study indicates that the complement system is activated in the cellsaver equipment. The washing procedure, however, seems to eliminate most of the anaphylatoxins and terminal complement complexes. No extensive systemic activation of complement seems to occur in association with autotransfusion to patients undergoing elective surgery.

Blood Conservation in Major Orthopedic Surgery

During an eight-year period, intraoperative autotransfusion was performed in 1922 operations. There were 476 primary hip arthroplasties, 1017 revision hip arthroplasties, 339 spinal procedures, and 90 vascular cases. There were no known complications related to autotransfusion in any of the cases. With proper technique, red cell salvage is approximately 58% effective, and intraoperative blood loss can be reduced by that amount. The first four years' experience with the preoperative autogeneic blood program is as follows. Using a combined program of predonation and primary hip arthroplasty, 72% of the revision hip arthroplasties and 81% of the spinal instrumentations required only autologous blood. A combined program of autologous donation and intraoperative autotransfusion is an excellent alternative to allogeneic blood replacement and a means of eliminating transfusion-related disease.

Hémodilution et autotransfusion peropératoire dans les prélèvements pour greffe de moelle osseuse

In order to avoid the infectious and immunological complications of homologous blood given to autologous bone marrow graft recipients, intraoperative haemodilution together with delayed salvage of the red blood cells contaminating the marrow graft were used prospectively over a period of 6 months. This was carried out in 74 patients, i.e. 2 allogenic and 72 autologous donors (mean age 27.2 ± 19.7 years). A mean of 13.66 ± 7.10 ml · kg −1 bone marrow were harvested. Fluid replacement was carried out, volume for volume, with a modified fluid gelatin (Plasmion®) (n = 73 ; 14.6 ± 6.6 ml · kg −1), glucose 5 % (n = 54 ; 9.64 ± 4.88 ml · kg −1) and Ringer solution (n = 33 ; 8.1 ± 3.3 ml · kg −1). No haemodynamic problems occured. Autologous blood transfusion was possible in 54 patients ; mean volume of bone marrow harvested was 631 ± 298 ml, and a mean of 293 ± 154 ml of blood was retransfused to the patients (mean haematocrit of the blood units : 0.536 ± 0.048). Nine of these patients were also given homologous blood. In the other 20, the volume of bone harvested marrow was significantly lower than in the autologous transfusion group (430 ± 202 ml ; p < 0.05), and red blood cell salvage was not possible ; only 3 patients received homologous blood. Finally only 16.2 % of the patients in this series were given homologous blood. It is concluded that intentional isovolaemic haemodilution together with autotransfusion of salvaged blood can reduce the need for homologous blood during bone marrow harvesting.

Operative red cell salvage and auto-transfusion

Operative red cell salvage and auto-transfusion

Autologous transfusion: A viable alternative

An increasingly popular alternative to homologous blood use and its associated risks is transfusion of the patient's own blood. The three methods of autotransfusion in use today are predeposit of autologous blood, immediate preoperative deposit with hemodilution, and intraoperative scavenging with red-cell salvage. Logistical concerns have led to underutilization of the first method. Preoperative deposit with hemodilution, involving simultaneous replacement of blood with colloid or crystalloid fluids to maintain plasma volume, is a more convenient procedure that may have hemodynamic advantages for the surgical patient. Scavenging from the operative field or from postsurgical drainage is an effective means of salvaging blood that would otherwise be lost and returning it in improved condition to the patient. Recent advances in processing equipment permit separation of red cells from plasma and cell washing to eliminate contaminants implicated in coagulation problems associated with earlier autotransfusion systems. Intraoperative scavenging can be invaluable in emergency surgery involving acute and rapid blood loss as well as in elective surgical procedures in which large blood needs are anticipated. Methods of collecting and processing autologous blood, along with associated benefits, risks, and indications, are reviewed.

Preoperative haemodilution.

In preoperative haemodilution, blood is withdrawn before surgery while normovolaemia is maintained by infusion of cell free fluid. A surgical bleeding then entails a smaller loss of red cells. Reinfusion of the saved blood maintains normovolaemia, raises hematocrit and decreases the need for donor blood. Dilutional anaemia may endanger the oxygenation of the tissues. Tissue oxygenation can be upheld by an augmented and redistributed cardiac output and by a raised oxygen extraction. These compensatory mechanisms are less efficient in the presence of vascular stenosis, in particular in the myocardium which relies virtually exclusively on coronary vasodilatation. Major contraindications to preoperative haemodilution are, apart from coronary insufficiency, ventricular failure and valvular disease. Deleterious increases in cardiac oxygen consumption and/or heart rate may result from e.g. hypovolaemia, arterial desaturation and painful stimuli. The haemodilution procedure requires knowledge and vigilance in all involved personnel and gives best results if combined with other blood saving measures, like blood predeposit and intraoperative red blood cell salvage.

Clinical implications of procoagulant and leukoattractant formation during intraoperative blood salvage.

Experiments using 21 dogs and red cell salvage equipment (Haemonetics Cell Saver, Haemonetics Corp, Braintree, Mass) were employed to study the formation and potency of procoagulant and leukoattractant material during experimental autologous blood salvage. Washed red cell suspensions were found to include toxic degradation products that had been released from a deposit of platelets and white cells adherent to the centrifuge bowl wall. When reinfused, these toxic products resulted in a "salvaged blood syndrome" of intravascular clotting and pulmonary damage. The pulmonary arterioles showed leukocyte margination and tangled fibrin skeins with occlusive thrombi. Intra-alveolar and perivascular hemorrhages, along with extensive pulmonary edema, were also observed. The formation of procoagulant and leukoattractant material could be markedly decreased when the red cell salvage technique incorporated the following precautions: (1) minimal dilution with saline (normal plasma protein levels), (2) a low calcium level, and (3) minimal platelet activation (avoidance of the aspiration of clotted blood just before processing).

Improving autologous blood harvest: recovery of red cells from sponges and suction.

The efficacy of red cell salvage was assessed under circumstances which simulated blood loss managed with sponges or suction. Expired banked blood was equally divided and processed by either suction, or absorbing the blood on a sponge followed by rinsing the sponge in saline. These two techniques were used to harvest washed, centrifuged erythrocytes. The volume, haematocrit and free haemoglobin concentration of the banked blood and the processed units were measured, and smears from all units were examined microscopically. The red cell mass was calculated as the product of the volume and haematocrit. The red cell mass recovered by suction and from sponges averaged 93% and 87% respectively. Blood lost in sponges can be recovered and used to increase the available autologous blood, thereby reducing the need for donor blood.

Liver transplantation in Jehovah's Witnesses: a case series

&#x0D; Introduction:&#x0D; Orthotopic liver transplantation (OLT) is a procedure characterized by high bleeding rates and a significant likelihood of exposure to blood products.&#x0D; Objectives:&#x0D; &#x0D; &#x0D; This case series shows the experience at a referral center for Jehovah's Witnesses (JW) with end-stage liver disease, undergoing OLT.&#x0D; Materials and methods:&#x0D; &#x0D; &#x0D; A search was conducted in our database of JW undergoing OLT between July 2007 and August 2012. The information about their pre-operative condition and progress up to 30 days post-transplantation.&#x0D; Results:&#x0D; &#x0D; &#x0D; Four subjects were identified (3F/1M) with an average age of 42 years (range 22-55). All of them received a multidisciplinary management which included pre-operative optimization of red cell mass, antifibrinolytic prophylaxis, and cell salvage (mean volume of 344mL [range 113-520]). The average intraoperative bleeding volume was of 625mL (range 300-1000). One of the patients presented with a primary graft dysfunction and died, while the rest had a normal postoperative course.&#x0D; Conclusion:&#x0D; &#x0D; &#x0D; It is possible to offer OLT to patients who refuse to receive allogeneic blood transfusions, through a comprehensive approach that includes perioperative hematologic optimization and the use of blood conservation measures, without a significant impact on the outcomes.&#x0D;