Bacteriologic and endotoxin analysis of salvaged blood used in autologous transfusions during cardiac operations.

Autologous blood transfusion is a common method of reducing the need for heterologous blood transfusion during cardiac operations. Recently we investigated an outbreak of severe, nonsurgical postoperative bleeding among patients undergoing heart operations and receiving intraoperative transfusion of blood from a cell conservation device (Cell Saver System, Haemonetics Corp., Braintree, Mass.). As a result of this investigation, we conducted a prospective study to determine if bacterial or endotoxin contamination of the blood collected in the Cell Saver System and used for reinfusion during heart operations contributes to postoperative bleeding complications. Patients' blood samples were collected immediately before operation, at the end of cardiopulmonary bypass, 1 hour postoperatively, and from the Cell Saver System. All blood samples were cultured for bacteria, and all plasma samples were assayed for endotoxin. Preoperatively all patients having heart operations were without signs of infection, 33 of 37 blood cultures taken were negative, and none of the plasma samples had detectable endotoxin. After discontinuance of cardiopulmonary bypass but before delivery of blood from the Cell Saver System, bacteria and endotoxin were detected in 11 of 36 (30.6%) and five of 35 (14.3%) of the patients' blood samples, respectively. The blood aspirated from the open chest and collected by the Cell Saver System was culture positive in 30 of 31 (96.8%) samples, and seven of 29 (24.1%) contained endotoxin. One of 28 blood samples collected 1 hour postoperatively was culture positive, and five of 25 samples contained endotoxin. Of 61 total microorganisms isolated, 50 (82%) were coagulase-negative staphylococci, four (6.6%) aerobic diphtheroids, five (8.2%) anaerobic "diphtheroids" (Propionibacterium acnes), and two (3.2%) gram-negative bacilli. Plasma endotoxin concentrations ranged from 10 to 765 pg/ml. No signs of endotoxemia or unusual bleeding were observed intraoperatively or postoperatively in any of the 38 patients. Although blood collected in the Cell Saver System and used for reinfusion during heart operations often was contaminated with gram-positive bacterial commensals of the skin and low concentrations of endotoxin, no adverse effects were noted in the patients.     

Modification of the haemonetics cell saver for optional high flow rate autotransfusion

Intraoperative autotransfusion is a technique well-suited to major vascular surgery. It is most effective when salvage and reinfusion of shed blood can be accomplished at flow rates compatible with the degree of hemorrhage encountered in both elective and emergency procedures. Appropriate equipment modifications can render commercially available autotransfusion devices safer and more effective in the management of intraoperative blood loss. The Cell Saver, a device which concentrates and washes salvaged red blood cells, is limited in its potential as an autotransfusion device because of its slow reinfusion rate. A modification was devised which expands the flow capabilities of the Cell Saver and allows rapid reinfusion of autologous whole blood. The modified blood circuit has been employed in 10 major vascular cases with favorable results, thus demonstrating its efficacy in the management of massive hemorrhage during vascular repair. Guidelines for the safe and effective use of the modified unit are stressed.     

Perioperative autotransfusion with salvage blood in cancer surgery]

OBJECTIVES: Intraoperative blood cells salvage using a Cell Saver technique is controversial in oncologic surgery because tumor cells could be aspirated and reinfused to the patient. The goal of this review was to discuss the risk associated with this technique, and the way to minimize it. DATA SOURCES: A review of the literature has been made by questioning PubMed site (http://nbci.nlm.nih.gov) on the period of 1968 to 2000. The key words were: intraoperative blood salvage, blood transfusion, autologous, cancer. Cases reports have been excluded. STUDY SELECTION: Tumor cells aspirated and reinfused have been numbered in both experimental and clinical studies. In clinical studies, the outcome after intraoperative cells salvage/reinfusion has been compared to published data or historical groups of allogeneic transfusion, all in non randomized studies. DATA SYNTHESIS: Both experimental and clinical studies confirmed the presence of cancer cells in the blood either aspirated or reinfused. However, six clinical studies with limited number of patients did not show metastatic spread associated with Cell Saver. The addition of leukocyte filters reduces greatly this quantity of cancer cells. Irradiation of the pack did not destroy tumor cells but blocked their proliferative capacity. In the other hand, some infiltrative tumors were shown to have permanent cancer cells seeding, quantitatively superior to the seeding observed when a Cell Saver is used. CONCLUSION: It seems reasonable to use the Cell Saver in oncologic surgery, if possible with a leukocyte filter, not only in case of unexpected major bleeding (consensus), but also in programmed cases with high risk of huge hemorrhage.     

Modern autotransfusion: Experience with a washed red cell processing technique

The technique of intraoperative autotransfusion utilizing the Haemonetics Cell Saver is described. This device separates and washes red blood cells removed from the surgical field. Advantages of this unit over others are that (1) no systemic anticoagulation is required, (2) circulatory fibrin debris is removed, (3) plasma hemoglobin is removed, and (4) any circulating anticoagulant is removed. Experience with 136 consecutive cases, 101 elective and 35 emergency, is reported. The only complication was coagulopathy, which occurred in 5.1 percent of the cases. It is easily treated with blood component therapy and occurs in those patients in whom greater than 3,500 cm³ of blood is autotransfused. The Cell Saver has proven an important adjunct in surgical patients in whom greater than 1,000 cm³ of blood will be lost, as well as in emergency patients. It provides an efficient, economical and safe method to autotransfuse blood.     

Danaparoid (Orgaran) zur Antikoagulation bei der maschinellen Autotransfusion mit Cell Saver 5 (Haemonetics)

We investigated Danaparoid Sodium (Orgaran) as anticoagulant using three different concentrations (9, 4,5 or 3 U/ml anticoagulant solution) for the use in the autotransfusion device Cell Saver 5 (Haemonetics). Fresh units of whole blood packs were mixed in the reservoir in a proportion of 5:1 with the anticoagulant solution. Having started the Cell Saver 5 in the automatic mode, the amount of Danaparoid in the retransfusion blood was determined (chromogenic Antifactor-Xa test). The lowest concentration of the anticoagulant was applied in 4 patients with Heparin-induced Thrombocytopenia Type II undergoing total hip arthroplasty. There was a correlation between the concentration in the reservoir and in the retransfusion blood. None of the patients showed a disturbance of his coagulation system. One of them had slight clotting in the reservoir. We recommend the use of the lower concentrations tested: 4,5 U/ml or, particularly for patients with renal insufficiency or low body weight or expected high retransfusion volumes, 3 U/ml as anticoagulant concentrations. If the autotransfusion device is used according to the manufacturer's instructions there may be virtually no risk of clotting in the Cell Saver or of inhibition of the coagulation system in the patient.     

Three cases of thoracic or thoracoabdominal aortic aneurysm successfully treated with cell saver

During a three-month period from January to March 1986, reconstructive surgery was performed on three patients with thoracic or thoracoabdominal aortic aneurysm using a temporary bypass procedure. To reduce the amount of blood transfusion required during operation, an autologous blood recovery system, Cell Saver, was used in these three cases. The amount of blood loss, including the blood passing through the Cell Saver, was 7,020g in Case 1, 6,600g in Case 2 and 16,700g in Case 3. The amount of blood transfusion given to these three cases was 1,400g, 4,400g and 6,800g, respectively. The results indicated that the ratio of transfused blood amount to blood loss during operation was successfully reduced to a level of 20-67% of two other cases with thoracoabdominal aortic aneurysm, operated upon without using Cell Saver. Cell Saver was especially effective in Case 3 in which the blood for transfusion was restricted, for it was difficult to collect enough donors to complete operation because of rare blood type of Rh(-) in this case. That is, Cell Saver withdrew 15,000ml of blood through the sucker from the patient and returned it as concentrated and washed RBC during operation.     

A comparison of Cell Saver versus ultrafilter during coronary artery bypass operations

A study was performed to evaluate two blood conservation techniques that can be used with high-volume crystalloid cardioplegia. Twenty-seven patients undergoing coronary artery bypass with high-volume crystalloid cardioplegia were randomized into two groups: In 12 Group I patients the coronary sinus effluent was drained into a Cell Saver and the recovered, washed red cells were then reinfused. In 15 Group II patients the coronary sinus effluent was absorbed systemically and excess volume was removed from the cardiopulmonary bypass circuit by an ultrafilter. These two groups were compared with a retrospective control group in which the cardioplegic solution had been evacuated from the right atrium and discarded. Both the techniques resulted in significant and equivalent red blood cell conservation compared with the retrospective control group. The ultrafilter was associated with less derangement of prothrombin time. More complete potassium removal was provided by the Cell Saver.     

Intraoperative autologous blood transfusion for hemoperitoneum resulting from ectopic pregnancy or ovarian bleeding during laparoscopic surgery.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of intraoperative autologous blood transfusion during laparoscopic surgery for hemoperitoneum in benign gynecologic disease. METHODS: The Cell Saver, Haemo Lite 2, an intraoperative autologous blood salvage device, was used in laparoscopic surgery on 18 patients with ectopic pregnancies or ovarian bleeding who had a large hemoperitoneum with/without severe anemia and hypovolemic shock. RESULTS: The blood loss was 1186 +/- 789 mL, and the volume of reinfused processed blood was 661 +/- 405 mL in ectopic pregnancy cases. The blood loss was 716 +/- 219 mL, and the volume of reinfused processed blood was 496 +/- 138 mL in ovarian bleeding. Laparoscopic surgery was performed and homologous blood transfusion was not required in any patient. No adverse reactions or procedural difficulties associated with the autologous blood transfusions occurred. CONCLUSIONS: Intraoperative autologous blood transfusion enabled the performance of laparoscopic surgery for large hemoperitoneum caused by ectopic pregnancies or ovarian bleeding without a homologous blood transfusion.     

Smart suction device for less blood trauma: a comparison with Cell Saver.

OBJECTIVE: The major source of hemolysis during cardiopulmonary bypass remains the cardiotomy suction and is primarily due to the interaction between air and blood. The Smart suction system involves an automatically controlled aspiration designed to avoid the mixture of blood with air. This study was set-up to compare this recently designed suction system to a Cell Saver system in order to investigate their effects on blood elements during prolonged intrathoracic aspiration. METHODS: In a calf model (n=10; mean weight, 69.3+/-4.5 kg), a standardized hole was created in the right atrium allowing a blood loss of 100 ml/min, with a suction cannula placed into the chest cavity into a fixed position during 6 h. The blood was continuously aspirated either with the Smart suction system (five animals) or the Cell Saver system (five animals). Blood samples were taken hourly for blood cell counts and biochemistry. RESULTS: In the Smart suction group, red cell count, plasma protein and free hemoglobin levels remained stable, while platelet count exhibited a significant drop from the fifth hour onwards (prebypass: 683+/-201*10(9)/l, 5 h: 280+/-142*10(9)/l, P=0.046). In the Cell Saver group, there was a significant drop of the red cell count from the third hour onwards (prebypass: 8.6+/-0.9*10(12)/l, 6 h: 6.3+/-0.4*10(12)/l, P=0.02), of the platelet count from the first hour onwards (prebypass: 630+/-97*10(9)/l, 1 h: 224+/-75*10(9)/l, P<0.01), and of the plasma protein level from the first hour onwards (prebypass: 61.7+/-0.6 g/l, 1 h: 29.3+/-9.1 g/l, P<0.01). CONCLUSIONS: In this experimental set-up, the Smart suction system avoids damage to red cells and affects platelet count less than the Cell Saver system which induces important blood cell destruction, as any suction device mixing air and blood, as well as severe hypoproteinemia with its metabolic, clotting and hemodynamic consequences.     

Postoperative autologous retransfusion of collected shed blood after total knee arthroplasty with the cell saver

AIM: The purpose of this study was to examine if it is possible to reduce transfusion of blood units by collecting shed blood with the Cell Saver for autologous retransfusion in total knee arthroplasty (TKA). METHOD: In 186 patients drainage blood was collected over a 6-h period after total knee arthroplasty with a Cell Saver system in order to make retransfusions if necessary. A tourniquet was used routinely throughout the operation. No preoperative blood donation was performed. In 19 patients preoperative haemoglobin levels were below 12 g/dL (group A, anaemic patients). In the other 167 patients (group B) the preoperative haemoglobin levels were higher. RESULTS: 4 patients (21 %) in group A received a homologous blood transfusion. Only 1 patient (0.6 %) in group B received one unit of erythrocyte concentrate (difference statistically significant, P < 0.001). In group A 8 patients (42 %) received 284 ml (145-621 ml) Cell-Saver concentrate on average, 38 patients (23 %) in group B received 358 mL (147-776 ml) Cell-Saver concentrate on average. CONCLUSION: With a risk lower than 1 % for patients without anaemia to get a homologous blood transfusion one can do without the more expensive preoperative blood donation in total knee arthroplasty if a tourniquet is used for the operation and a Cell Saver is used for facultative retransfusion of drainage blood.     

Intraoperative hemodilutional autotransfusion using a closed circuit for patients of Jehovah's Witness

We conducted hemodilutional autotransfusion using a closed circuit combined with a cell washing reinfusing system (Cell Saver) for two surgical patients of Jehovah's Witness. One was a 12 yr-old boy for extirpation of the teratoma in the anterior mediastinum and another was a 44 yr-old woman for left total hip replacement. The patients and their relatives had consented to the use of blood substitutes, hemodilutional autotransfusion using a closed circuit and Cell Saver. We devised a closed circuit system for hemodilutional autotransfusion combined with Cell Saver, in which two pumps for blood transfusion were used; one was for drawing blood from the femoral or the internal jugular vein and the other for returning blood to the peripheral vein. Blood volume in a bag interposed in the closed circuit was easily controlled by adjusting the speed of each pump. Blood collected from the surgical field by Cell Saver was also led to the bag. Acid citrate dextrose solution was infused into the closed circuit from the site close to the blood drawing. Both of our surgical patients were safely managed without homologus blood transfusion, although there remained some problems concerning the use of anticoagulants.     

Cell Saver: is it beneficial in scoliosis surgery?

Study design

Review of the use of Cell Saver in a non-randomized group of patients undergoing spinal fusion for scoliosis.

Objectives

To determine the efficacy of the use of Cell Saver for spinal fusions for scoliosis.

Summary of background data

Although Cell Saver is widely used in scoliosis surgery, it is not clear whether its use decreases the need for other transfusions or whether there are certain patients more likely to benefit from its use. The blood collected by Cell Saver intraoperatively is not always of sufficient volume to be returned to the patient, and there are no current guidelines addressing the amount that is likely to be returned to the patient.

Purpose

The purpose of this study was to determine: Does use of Cell Saver reduce the need for other transfusions in scoliosis surgery? Is there an amount of blood loss at which Cell Saver is likely to be returned?

Materials and methods

The study group consisted of 95 children who had undergone posterior spinal fusion between January 2002 and March 2004 with one of two surgeons. One surgeon used Cell Saver, the other surgeon did not. Of the total, 58 patients who underwent posterior spinal fusion with the use of Cell Saver (group 1) were compared with the 37 (group 2) who underwent the same procedure without the use of Cell Saver.

Results

Of those in group 1, 34 received Cell Saver blood back as an intraoperative autologous transfusion (IAT) (59%). Patients in the Cell Saver group were just as likely to receive non-Cell Saver transfusions as those in the control group (P = 0.12). Of the 39 patients who lost more than 500 cc of blood, 34 received IAT (87%). No patient who lost less than 500 cc of blood received IAT.

Conclusion

The use of Cell Saver does not reduce the need for other transfusions in scoliosis surgery. The amount of blood loss at which Cell Saver is likely to be returned is 500 cc. We demonstrated no benefit in the use of Cell Saver in our patient population.     

Heparin washout in the pediatric Cell Saver bowl

The possibility of residual heparin in washed red cells transfused to neonatal or pediatric cardiac patients following bypass prompted a measurement of heparin concentrations. Samples were taken during 10 adult and 10 neonatal and pediatric bypass cases. Sample A was from the bypass circuit, Sample B from the Haemonetics Cell Saver bowl inlet before washing, Sample C from the Cell Saver bowl outlet after washing, and Sample D from the patient ten minutes after protamine. Heparin concentrations were measured by a chromogenic assay using activated Factor X. There was no significant difference between the adult and pediatric groups in the levels of heparin concentration on bypass, pre-washing and post-washing, and in the patients following protamine. In the pediatric group, only .002% of the pre-washed heparin remained after washing. This extremely low level of heparin (.0027 units/ml) is only 0.34 units in a 125 ml pediatric unit of Cell Saver blood. Based on post bypass patient samples, this has no clinical significance. Therefore, the Cell Saver can be used safely with neonates and pediatric patients without concern regarding residual heparin when properly processed.     

Cytological and bacteriological studies of intraoperative autologous blood in neurosurgery

BACKGROUND: To ensure the safety of salvaged blood in neurologic surgery, reinfused blood through the Cell Saver System (CSS) (Hemonetics) was investigated cytologically and bacteriologically. METHODS: Specimens of reinfused blood were cytologically examined with Papanicolaou or Giemsa stains. Reinfused blood and air in the operating theater were investigated by microbiologic techniques. The concentration of dust particles in the theater was determined. RESULTS: Tumor cells were positive in reinfused blood in 5 of 9 specimens with glioblastoma, in 2 of 8 with pituitary adenoma, and 1 of 13 with meningioma. The probability of migration of meningioma cells into reinfused blood was significantly low in comparison with that of glioma cells. Of the 30 specimens studied microbiologically, the bacterial growth was detected in salvaged blood of 14 specimens (46.7%) and in the air of the operating theater for 8 specimens (26.7%). In craniotomy, the contamination rate was 10 of 26 specimens of reinfused blood (38.5%). Most microorganisms were found to be staphylococci. No statistically significant correlation could be found between salvaged blood and air as to contamination or between reinfused blood and the concentration of dust particles in the theater as to bacteriologic results. No infectious complications were found after the operation, though salvaged blood through the CSS was reinfused in 37 patients without glioblastoma or transsphenoidal approach. CONCLUSIONS: The CSS cannot always entrap tumor cells. Salvaged blood should not be reinfused in the patients with glioblastoma or transsphenoidal surgery. None of the patients with reinfusion had any infectious complications. Reinfusion of salvaged blood seems to be safe in neurosurgery.     

Efficacy, complications, and cost of a comprehensive blood conservation program for cardiac operations.

We reviewed blood use in 118 consecutive patients who underwent primary, elective cardiac operations in 1989. In June 1989 we initiated a blood conservation program that included attempts to limit preoperative aspirin use, intraoperative phlebotomy and hemodilution, use of a cell conservation device (Electromedics, Inc., Englewood, Colo.) to concentrate residual oxygenator contents, reinfusion of chest drainage, and acceptance of a minimum hemoglobin level of 8.0 gm/dl in stable patients. Patient characteristics were similar for patients operated on both before (n = 58) and after (n = 60) initiation of the blood conservation program, except for age and preoperative aspirin use (both greater in postconservation patients). Fewer blood products were transfused (5.8 +/- 5.7 units per patient before conservation versus 4.0 +/- 7.4 units per patient after conservation; p = 0.005). More complete data were available for 82 patients (40 patients before conservation and 42 after conservation). In the postconservation patients, 20 of 42 had 575 +/- 140 ml of blood withdrawn before cardiopulmonary bypass and reinfused afterward, 26 of 42 had 806 +/- 376 ml of blood processed with the cell conservation device returned, and 21 of 42 patients had an average of 287 +/- 127 ml of chest drainage reinfused. Chest tube drainage, postoperative hematologic parameters, and the prevalence of complications were not significantly different between groups. Stepwise linear regression analysis identified intraoperative withdrawal of blood before cardiopulmonary bypass, bypass duration, and preoperative hematocrit value as predictors of blood use. Intraoperative withdrawal of blood before cardiopulmonary bypass is an important conservation measure, and its use should be expanded.     

Intraoperative blood salvage during liver transplantation in patients with hepatocellular carcinoma: efficiency of leukocyte depletion filters in the removal of tumor cells

BACKGROUND: Intraoperative blood salvage (IBS) reduces homologous transfusion in orthotopic liver transplantation (OLT), but may carry with it the risk of reinfusing tumor cells in patients with hepatocellular carcinoma (HCC). The use of leukocyte depletion filters (LDFs) for the removal of tumor cells is rarely reported in clinical OLT. The aims of this study were to evaluate the frequency of tumor cell contamination in surgical field during OLT for HCC recipients and to investigate the efficiency of additional LDFs for eliminating tumor cells from IBS. METHODS: Thirty-two HCC patients with preoperatively elevated serum alpha-fetoprotein (AFP) underwent OLT. The blood from the surgical field was collected and processed by an autotransfusion device (Cell Saver 5), followed by 2 consecutive LDF filtrations. The HCC cells in IBS samples and filtered samples were determined using a nested RT-PCR technique to detect the AFP mRNA. RESULTS: The shed blood samples from 20 (62.5%) of the 32 HCC patients were contaminated with HCC cells and 15 of them remained positive after Cell Saver processing. Patients within the Milan or UCSF criteria were less likely to have HCC cell contamination and the contaminated HCC cells were more likely to be removed by the Cell Saver in these patients as compared to other patients (P<0.01). After filtration through an additional LDF, most cases (13/15) became negative except for those with ruptured tumors (P<0.05). CONCLUSIONS: Our results suggest that blood filtration with the LDF can efficiently remove tumor cells and the use of an additional LDF after use of the Cell Saver could markedly reduce the risk of tumor cell reintroduction during the OLT in HCC recipients with nonruptured tumors.     

Autologous transfusion: an alternative to transfusion with banked blood during surgery for cancer

Autologous blood transfusion in surgery for cancer has been avoided because of the metastatic potential of reinfused malignant cells. This study determined whether viable tumour cells remain in the red cell concentrate after separation and whether blood transfusion filters remove these tumour cells before reinfusion. Units of banked blood were inoculated with tumour cell lines: breast cancer SKBr3; colon cancer COLO 320; lymphoma Daudi; erythroleukaemia K562. After processing with the Cell Saver, aliquots of the red cell concentrate and waste saline wash were examined for tumour cells and cultured. Tumour cells from all four cell lines were identified in the red cell concentrate but not in the waste saline wash. All the cell lines except Daudi grew from the red cell concentrate. Experiments on two of the cell lines (SKBr3 and COLO 320) were performed in which the red cell concentrate was either unfiltered (control) or filtered with SQ40S blood transfusion filter or RC100 leucocyte depletion filter. Both cell lines were present in the control samples and after filtration with SQ40S filters, and cells from these samples grew normally in culture. No tumour cells were evident after filtration with the RC100 filters and no growth of either cell line was found after 1 week in culture. The Cell Saver in combination with RC100 filters may be suitable for use during the surgical treatment of malignant disease.     

Intraoperative autotransfusion. Experience in 725 consecutive cases

Autologous intraoperative transfusion employing the Haemonetics Cell Saver is reported in 725 patients from a general hospital population, of which 75% were cardiovascular patients. The remaining cases included various orthopedic procedures, splenectomy, craniotomy, ectopic pregnancies, Caesarian sections, and exploratory laparotomy. On occasion, this method was utilized in trauma and in pediatric surgery. The product of washed red blood cells gave an average yield of 573 cc per case with an average hematocrit of 55 cc/dl available for autologous infusion. In 100 consecutive open heart procedures operated prior to the Cell Saver period, an average of 1.97 units of bank blood was utilized during operation, as compared with 0.75 units in 100 consecutive cases studied employing the Cell Saver (p less than 0.0001). Homologous blood utilization during cardiac surgery declined more than 50% with the use of the Cell Saver. Quality control was monitored scrupulously and included special precautions against air embolism, abnormal coagulation, and sepsis. The overall mortality rate was 2.8%, and in no instance was mortality or morbidity ascribable to the autologous transfusion. Numerous advantages offered by autotransfusion include prevention of sensitization of the recipient to various antigens in donor erythrocytes, leucocytes, platelets, and plasma, and avoidance of transfusion-transmitted diseases, especially viral hepatitis. Additionally, autologous blood, the only perfectly compatible product, provided immediate availability while conserving blood bank resources. In circumstances in which the intraoperative blood loss exceeded 1000 cc in the adult, its use was observed to be cost-effective. In the present study, autotransfusion proved safe, efficient, and in some instances life saving.     

Open-heart surgery in Jehovah's Witnesses

During a 7-year period, 11 adult members of the religious sect Jehovah's Witnesses underwent cardiac surgery with extracorporeal circulation. No homologous blood transfusions were given. Blood-conserving procedures were employed, viz. initial collection of autologous blood, haemofiltration or processing (Cell Saver) of blood collected during extracorporeal circulation and reinfusion of shed mediastinal blood. The total perioperative blood loss averaged 1080 ml (15 ml/kg body weight), equalling 19% of total body blood volume. The mean haemoglobin on discharge from hospital was 11.0 g/100 ml. There was no perioperative mortality. Postoperative pulmonary function was good and there was no serious morbidity. Jehovah's witnesses with serious, surgery-necessitating heart disease can be offered operation comprising recognized blood-conserving procedures.     

Blood conservation for myocardial revascularization. Is it cost effective?

A total of 284 patients undergoing myocardial revascularization were prospectively studied to determine if the use of intraoperative autotransfusion or intraoperative autotransfusion plus postoperative reinfusion of shed mediastinal blood decreased transfusion requirements and the use of one or both techniques was cost effective. The Haemonetics Cell Saver System was used for intraoperative autotransfusion and the Sorenson Receptaseal autotransfusion system for postoperative reinfusion of shed mediastinal blood. During Phase 1, the Cell Saver System was used for 57 patients and 93 patients served as a control group. During Phase 2, the Cell Saver System plus the autotransfusion system were used in 43 patients and 91 patients were in the control group. Separate parallel analyses to compare the blood conservation groups to control groups were conducted for each phase of the study. The patient groups were comparable with regard to age, sex, preoperative red cell mass, preoperative hematocrit value, number of bypasses, and use of internal mammary grafts. Blood conservation techniques resulted in significant reductions in the use of bank blood. During Phase 1, Cell Saver System patients received an average of 2.8 units of packed cells versus 4.7 units for control patients. Transfusion was avoided entirely in 14% of Cell Saver System patients compared to 3% of control patients. During Phase 2, patients subjected to both the Cell Saver System and the autotransfusion system received an average of 1 unit of packed red cells versus 3 units for control patients. Transfusion was required in only 42% of patients subjected to both the Cell Saver System and the autotransfusion system compared to 85% of control patients. Multiple logistic regression analysis confirmed that the use of the Cell Saver System in Phase 1 and the Cell Saver System and autotransfusion system in Phase 2 were each independently predictive of decreased transfusion requirements. The total "blood-related costs" (including cost for all bank blood products plus Receptaseal and Cell Saver System equipment) was slightly lower for the blood conservation patients in both Phase 1 ($555.00 versus $615.00, no significant difference) and Phase 2 ($373.00 versus $426.00, no significant difference). Intraoperative use of the Cell Saver System is associated with substantial savings of bank blood, and the addition of postoperative reinfusion of shed mediastinal blood results in further bank blood savings. The use of blood conservation techniques is cost effective; that is, the costs incurred for the blood conservation equipment are more than offset by the resultant dollar savings for blood products.