Potassium as a surrogate marker of debris in cell-salvaged blood

Centrifuge-based cell salvage systems have decreased the use of homologous blood transfusions. Although the evidence is anecdotal, the risk associated with the use of salvaged erythrocytes seems related to cellular and chemical contaminants. We sought to determine if potassium can be a surrogate marker for cellular debris and to measure the residual heparin level. Four units of expired whole blood were heparinized and concentrated with a Sequestra 1000 (Medtronics), Parker, CO) cell salvage device. The potassium, free hemoglobin, leukocyte, and platelet counts were sampled after each 250-mL normal saline wash aliquot, to a total wash volume of 1500 mL, whereas the heparin samples were obtained at wash volumes 0 and 1000 mL. Potassium, leukocyte, and platelet concentrations at wash volumes 0 and 250 mL were significantly greater than at all other volumes (P < 0.001). After 500 mL of saline wash, the change in these values was not significant. The mean (+/- SD) heparin levels (units/mL) at wash volumes 0 and 1000 mL were 10.2 (+/-3.1) and 0.11 (+/-0.02), respectively (P < 0.007). The r(2) values for free hemoglobin, leukocytes, and platelets versus potassium were 0.006, 0.992, and 0.995, respectively. No convenient test has been validated as an indicator of salvaged erythrocyte cleanliness. This in vitro study suggests that residual potassium concentration seems to be a good indicator of quality after washing with a contemporary intraoperative salvage system. IMPLICATIONS: No convenient test has been validated as an indicator of salvaged erythrocyte cleanliness. This in vitro study suggests that residual potassium concentration seems to be a good indicator of quality after washing with a contemporary intraoperative salvage system.     

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).     

Intraoperative blood salvage during liver resection: a randomized controlled trial

OBJECTIVE: A randomized controlled trial was conducted to clarify the effectiveness of intraoperative blood salvage in reducing blood loss. BACKGROUND: Although reduction of central venous pressure (CVP) is thought to decrease blood loss during liver resection, no consistently effective and safe method for obtaining the desired reduction of CVP has been established. METHODS: Living liver donors scheduled to undergo liver graft procurement were randomly assigned to a blood salvage group, in which a blood volume equal to approximately 0.7% of the patient's body weight was collected before the liver transection, or a control group. The surgeons were blinded to the randomization results. The primary outcome measure was blood loss during liver parenchymal division. A multivariate analysis was also performed. RESULTS: Seventy-nine donors were allocated intraoperatively to the blood salvage group (n = 40) or the control group (n = 39). The amount of blood loss during liver transection was significantly smaller in the blood salvage group than in the control group (median loss during transection, 140 mL vs. 230 mL, P = 0.034). The CVP at the beginning of the liver parenchymal division was significantly lower in the blood salvage group than in the control group (median, 5 cm H2O vs. 6 cm H2O, P = 0.005). The results of a multivariate analysis revealed that intraoperative blood salvage offered the advantage of reduced blood loss during liver parenchymal division (adjusted OR, 0.31; 95% CI, 0.11-0.85, P = 0.025). CONCLUSION: Modest intraoperative blood salvage significantly and safely reduced blood loss during hepatic parenchymal transection.     

Intraoperative cell salvage versus postoperative autologous blood transfusion in hip arthroplasty: a retrospective service evaluation

INTRODUCTION

A number of ways of reducing blood loss in arthroplasty have been explored, including preoperative autologous transfusion, intraoperative cell salvage and postoperative autologous transfusions. Both intraoperative blood salvage and postoperative retransfusion drains have been shown to be effective in reducing blood loss in total hip arthroplasty. In our department there was a change in practice from using postoperative retransfusion drains to intraoperative cell salvage. To our knowledge no study has directly compared using intraoperative blood salvage and postoperative retransfusion drains alone in total hip arthroplasty.

METHODS

This was a retrospective service evaluation including all primary hip arthroplasty performed under our care between January 2006 and December 2008. Patients were divided into two groups: Group A used a postoperative autologous blood transfusion (ABT) drain and Group B used intraoperative cell salvage.

RESULTS

A total of 144 patients were included in this study: 84 in Group A and 60 in Group B. The mean haemoglobin difference for Group A was 3.96g/dl (standard deviation [SD]: 1.52) and for Group B it was 3.46g/dl (SD: 1.42). The mean haematocrit difference for Group A was 0.12% (SD: 0.05) and for Group B it was 0.10% (SD: 0.04). Using an independent t-test for the comparison of means, a significant difference was found between Group A and B both in regards to haemoglobin difference (p=0.009) and haematocrit difference (p=0.046).

CONCLUSIONS

We feel that intraoperative cell salvage provides a more efficient method of reducing blood loss than postoperative retransfusion in primary total hip replacement. A prospective randomised study would be useful to ascertain any clinical difference between the two methods.     

Intraoperative autologous blood salvage with cardiac surgery: an analysis of five years' experience in more than 3,000 patients.

STUDY OBJECTIVE: To analyze intraoperative autologous salvage of shed mediastinal blood and subsequent transfusion in cardiac surgery. DESIGN: Retrospective statistical analysis. SETTING: University hospital. PATIENTS: Three thousand twenty two patients undergoing cardiac surgery from 1984 to 1988. INTERVENTIONS: A review of anesthesia and transfusion records of all patients who underwent intraoperative salvage of shed blood and autologous transfusion using the Sorenson Receptal Auto Transfusion System (ATS) with saline wash prior to reinfusion in cardiac surgery. MEASUREMENTS AND MAIN RESULTS: The salvaged blood volume ranged from 36 to 2,795 ml, with a mean of 321 +/- 222 ml (SD). Eighteen percent of patients did not receive any homologous blood products during their hospitalization. Patients who received only salvaged autologous transfusion were younger, had higher preoperative hemoglobin and hematocrit values, had a larger body surface area, and had shorter surgeries compared with patients who received only homologous blood or both autologous and homologous blood. More blood products were given to patients who received salvaged autologous blood compared with those who did not. Patients who underwent normovolemic hemodilution prior to extracorporeal circulation with subsequent reinfusion received significantly fewer blood products. Ten preoperative and four intraoperative variables significantly influenced the salvaged volume. Previous cardiac surgery was the most significant preoperative variable, and repair of ventricular septal defect produced by myocardial ischemia was the most significant intraoperative variable. CONCLUSION: Considering the average salvaged volume and its current autologous transfusion-related expense, autologous blood salvage is potentially an economic benefit. Perioperative blood conservation requires a considerable commitment from surgeons, anesthesiologists, perfusionists, and intensive care physicians to be effective.     

术中自体血回输用于肿瘤患者的研究进展

术中自体血回输目前已广泛应用于各类手术患者的围术期血液保护。对于肿瘤患者，术中回收的自体血中可能存在循环肿瘤细胞，应用自体血回输具有潜在的肿瘤复发、转移的风险。因此，术中自体血回输能否用于肿瘤患者尚存争议。本文主要从术中自体血回输的应用现状、术中自体血回输在肿瘤患者手术中的应用、术中自体血回输对肿瘤患者预后的影响等方面进行综述，为肿瘤患者术中使用自体血回输提供参考。     

An experience of intraoperative blood salvage in emergency laparotomy for severe abdominal injury

A 34-year-old male patient, who had fallen from a balcony suffering liver injury, underwent emergency laparotomy for right liver lobectomy and portal vein repair. For the first two hours of operation, the blood loss exceeded 12,000 ml, and his hemoglobin level dropped to 2.6 g x dl(-1) despite administration of 30 units of packed red cells (MAP). At this point, no more MAP was available in our hospital. Then we decided to initiate intraoperative blood salvage in order to minimize the further loss of hemoglobin. For 26,200 ml of the total blood loss, 1160 ml of packed red cells were restored from 7600 ml of salvaged blood, and 46 units of MAP, 40 units of fresh frozen plasma and 20 units of platelets were administered. His postoperative course was not complicated by systemic infection. Although intraoperative blood salvage is proved to be useful for reducing allogenic transfusion, it is not recommended to be used in surgery for trauma because of a potential risk of serious systemic infection. Our experience, however, suggests that intraoperative blood salvage could be utilized as a life-saving means even in trauma surgery.     

Release of inflammatory mediators in irradiated cell salvage blood and their biological consequences in human beings following transfusion

BACKGROUND AND OBJECTIVE: Irradiation of intraoperative cell salvage blood has recently been used to inactivate tumour cells before retransfusion, during cancer surgery. No information is available about a potential inflammatory response of the recipient to the retransfusion of irradiated intraoperative cell salvage blood. This pilot study was conducted to investigate the possible release of the pro-inflammatory mediators, tumour necrosis factor-alpha (TNF-alpha), interleukin-1beta (IL-1beta), eotaxin and monocyte chemo-attractant protein-1 (MCP-1), in the serum of recipients by intraoperative retransfusion of irradiated intraoperative cell salvage blood. METHODS: Nine patients undergoing gynaecological cancer surgery were included in this study. Intraoperative cell salvage blood was irradiated with 50 Gy and retransfused to the patient. Serum and intraoperative cell salvage blood concentrations of TNF-alpha, IL-1beta, eotaxin and MCP-1 were repeatedly analysed before and after retransfusion, respectively before and after irradiation. RESULTS: Traces of mediators were detected in intraoperative cell salvage blood but no increase due to irradiation was observed. Following transfusion of intraoperative cell salvage blood, minute quantities (all < 30 pg mL(-1) of mediators were detected in the serum of patients. However, there was no significant upregulation compared to serum values before retransfusion. CONCLUSIONS: These results provide evidence that retransfusion of irradiated intraoperative cell salvage blood might represent a blood-saving strategy in cancer surgery without an immunological inflammatory response as shown by a lack of upregulation of inflammatory mediators.     

Intraoperative cell salvage in infants undergoing elective cardiac surgery: a prospective trial

BACKGROUND: For a long time intraoperative cell salvage was considered not to be applicable in paediatric patients due to technical limitations. Recently, new autotransfusion devices with small volume centrifugal bowls and dedicated paediatric systems allow efficient blood salvage in small children. The purpose of this prospective non-randomised study was to determine the impact of intraoperative cell salvage on postoperative allogeneic blood products transfusion in infant patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS: Two consecutive cohorts (122 patients) were studied. The first cohort underwent procedures between January 2004 and July 2005 with only blood salvage from the residual volume. The second cohort consisted of patients operated on from August 2005 to December 2006, with additional use of intraoperative cell salvage. The following variables were analysed: peri- and postoperative blood loss, transfusion of homologous blood products and cell salvage product, haematological and coagulation data, measured before, during and after the operation. RESULTS: Additional intraoperative cell salvage significantly enhanced the amount of cell saving product available for transfusion (183+/-56 ml vs 152+/-57 ml, p=0.003) and significantly more patients in this group received the cell saving product postoperatively. Consequently, allogeneic blood transfusion was significantly reduced in volume as well as in frequency. We did not observe any adverse effects of intraoperative cell salvage. CONCLUSION: Intraoperative cell salvage, employed as an adjuvant technique to the residual volume salvage in infants undergoing first time cardiac surgery with cardiopulmonary bypass, was a safe and effective method to reduce postoperative allogeneic blood transfusion. Considering current cell salvage related expense and the cost reduction achieved by diminished allogeneic transfusion, intraoperative cell salvage in infants demonstrated no economic benefit.     

Eliminating homologous blood transfusions during abdominal aortic aneurysm repair

In order to eliminate homologous blood transfusions during abdominal aortic aneurysm (AAA) repair, increased usage of autologous predonation and intraoperative salvage is required. To determine what quantity of predonated blood is necessary to completely avoid the use of homologous blood, we reviewed the transfusion histories of 100 consecutive patients undergoing elective AAA repairs. A total of 445 units of blood were transfused, and the number of units required was directly proportional to the size of the aneurysm. One hundred sixty-six units of blood (37%) were homologous, and 279 units (63%) were autologous. Of the autologous units, 255 (91%) were from intraoperative salvage and 24 (9%) were predonated. Stratification of transfusions by size revealed that for aneurysms less than or equal to 7 cm, 132 units of homologous and 21 units of predonated blood were transfused (1.55 units per patient and 0.25 units per patient, respectively). For aneurysms greater than 7 cm, 34 units of homologous and 3 units of predonated blood were used (2.3 units per patient and 0.2 units per patient, respectively). From these data, it is concluded that predonation before surgery of a minimum of 2 units for patients with smaller aneurysms and 3 units for patients with larger aneurysms, combined with intraoperative salvage, should eliminate the need for any homologous blood transfusions associated with elective AAA repair.     

Autologous transfusions for orthopaedic procedures at a children's hospital.

We conducted a critical review of the use of autologous transfusions in orthopaedics at a tertiary-care children's hospital. The cases of 198 children who deposited blood before an orthopaedic operation were analyzed. There were 175 children who were enrolled in the program of preoperative deposit of autologous blood who later needed transfusion of blood; 73 per cent of them received only autologous blood. Seventy patients also had intraoperative salvage. We were unable to document a proved benefit of intraoperative salvage of blood in this group of patients. Forty patients had some difficulty donating autologous blood preoperatively, but these problems were rarely serious. Major human errors occurred in thirteen patients and resulted in some patients receiving homologous transfusions while autologous blood components were still available. Fifty-five (40 per cent) of all of the transfusions were administered in clinical circumstances that failed to meet generally accepted criteria for transfusion, and fifty-four (38 per cent) of the postoperative transfusions also failed to meet these criteria. This was true of the homologous transfusions in the study as well. Although an autologous blood transfusion is a generally safe procedure, it is not without risk, and human errors can occur. In light of the potential complications, surgeons should adhere to the standard indications for transfusion when administering autologous blood.     

Use of intraoperative blood salvage during orthotopic liver transplantation

Human liver transplantation is a developing surgical technique that requires a large volume of blood support. There are no published results of the use of intraoperative blood salvage in liver transplantation. We used automated intraoperative blood salvage during 13 initial consecutive human liver transplants. The procedures required a median of 32 units of packed red blood cell support, of which an average of 45% was supplied by intraoperative salvage. The percent of the total blood use provided by intraoperative salvage increased with increasing total blood needs. Intraoperative blood salvage applied to liver transplantation resulted in a net savings of blood and hospital costs of approximately $1,000 per procedure.     

Perioperative autotransfusion and its correlation to hemostasis and coagulopathies

The use of autologous blood techniques affords the reduction or elimination of homologous blood transfusions for most patients. In addition, for certain religious faiths such as Jehovah's Witnesses or those patients with rare blood types, intraoperative salvage and return of the patient's own blood is the only source of available blood. Autologous blood salvage in the perioperative period includes: hemodilution; intraoperative salvage of lost blood; postoperative collection of shed blood. Perioperatively, autologous blood is salvaged and returned and the volumes involved do not create any hematological problems for the patient. In those cases involving large volumes of blood being processed and returned to the patient, the autotransfusionist must be aware of the possible alterations that may occur in the patient's coagulation system. The collection and reinfusion of wound drainage fluids from operative sites has the potential to cause severe bleeding problems. This paper will present an overview of autologous blood salvage techniques in the perioperative period along with a review of the clinical effects of autotransfusion on hemostasis. Also discussed will be possible coagulopathies that can be caused by returning collected autologous blood.     

Blood loss minimization and blood salvage techniques for complex spinal surgery

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.     

Bloodless surgery in a patient with thalassemia minor. Usefulness of erythropoietin, preoperative blood donation and intraoperative blood salvage

A patient with thalassemia minor and idiopathic scoliosis was scheduled for posterior vertebral arthrodesis. The diagnosis of thalassemia minor was made during the preoperative assessment. Preoperative blood cell count displayed the following data: red blood count 5.4 x 106/microL, haemoglobin 11.6 g/dL and hematocrit 36.9%. As corrective surgery for scoliosis is associated with major blood loss, the patient was scheduled for preoperative treatment with human recombinant erythropoietin (rHuEPO), autologous blood donation, intraoperative blood cell salvage and administration of tranexamic acid. The use of rHuEPO was intended to increase hemoglobin (12.1 g/dL) levels at the moment of surgery following the donation of 2 autologous blood units. 1000 mL of salvaged blood were processed. The output line of the blood cell salvage machine did not show any sign of increased red cell haemolysis. The postoperative course was uneventful and the patient was discharged from the postoperative intensive care unit on day 7 after surgery with no allogenic blood transfusion. No references detailing the use of rHuEPO and autologous blood donation preoperatively in patients with thalassemia minor and only one case report discussed the utility of intraoperative blood cell salvage in a patient with thalassemia intermedia. Although further experience is needed, this case report suggests that even for patients with thalassemia minor, methods focused on allogenic blood salvage can be used safely.     

A prospective comparison of clamping the drain or post-operative salvage of blood in reducing blood loss after total knee arthroplasty

We undertook a prospective, randomised study in order to evaluate the efficacy of clamping the drains after intra-articular injection of saline with 1:500 000 adrenaline compared with post-operative blood salvage in reducing blood loss in 212 total knee arthroplasties. The mean post-operative drained blood volume after drain clamping was 352.1 ml compared to 662.3 ml after blood salvage (p < 0.0001). Allogenic blood transfusion was needed in one patient in the drain group and for three in the blood salvage group. Drain clamping with intra-articular injection of saline with adrenaline is more effective than post-operative autologous blood transfusion in reducing blood loss during total knee arthroplasty.     

Möglichkeiten zur Einsparung von Fremdbluttransfusionen bei operativen Eingriffen

Alternative techniques to reduce the need for homologous blood transfusions are clinically available for several years. Actually a decision of our federal constitutional court (Bundesgerichtshof) outlined the medicolegal importance of autologous blood transfusion concepts. Pre-operative donation of red cells and/or plasma, acute normovolemic hemodilution, and intraoperative blood salvage and retransfusion will be discussed in terms of effectiveness, advantages, indications, and contraindications. In an emergency hemorrhage situation only the intraoperative blood salvage and retransfusion is available. The other autologous concepts are important in elective surgery.     

Intraoperative red blood-cell salvage in revision hip surgery. A case-matched study

BACKGROUND: Revision hip arthroplasty is commonly associated with substantial blood loss and the subsequent need for transfusion. This leads to an increased risk of blood-borne infection and hemolytic reactions. The purpose of this study was to demonstrate whether the use of intraoperative red blood-cell salvage in revision hip arthroplasty reduces the overall rate of allogeneic transfusion. METHODS: Forty-seven patients who had undergone revision hip arthroplasty with the use of intraoperative cell salvage were identified. A computer database was used to individually match these patients, for age, sex, and eleven operative variables, to control patients who had undergone revision hip arthroplasty in the same unit without intraoperative cell salvage. Data gathered included the total allogeneic transfusion requirement for each patient, preoperative and postoperative hemoglobin levels, and operative time. RESULTS: The total allogeneic transfusion requirement was significantly lower in the group that had intraoperative cell salvage than in the control group (median, 2 compared with 6 U of packed red blood cells, p = 0.0006), with a median reduction in allogeneic transfusion of 4 U. There was no significant difference in preoperative or postoperative hemoglobin levels between the groups. CONCLUSIONS: The use of intraoperative cell salvage significantly lowered the allogeneic transfusion requirement, which can lead to substantial cost savings. To our knowledge, this is the first study in which the use of intraoperative red blood-cell salvage in revision hip arthroplasty was evaluated by matching patients on the basis of age, sex, and operative variables.     

Perioperative red blood cell salvage in spine surgery. A prospective analysis.

Reinfusion of perioperative blood loss was studied in 150 spinal surgery patients to evaluate its efficacy in reducing transfusion requirements. Three groups of 50 consecutive patients were observed. Group A had no blood salvage and served as a control group, Group B used Cell Saver for intraoperative blood salvage, and Group C used Cell Saver intraoperatively and Solcotrans postoperatively for salvage of postoperative drainage. The three groups had similar demographics, preoperative hematocrits (HCT), operative blood loss, and postoperative drainage. Serial HCTs through the fifth postoperative day showed no significant difference between groups. Total transfusion requirements of homologous and prebanked autologous blood were reduced 35% in Group B and 68% in Group C when compared to control group A. These differences are statistically significant. The combination of intraoperative and postoperative blood salvage was highly effective in reducing the need for transfused blood.     

Clinical efficacy and cost effectiveness of intraoperative cell salvage in pelvic trauma surgery

Introduction

Pelvic acetabular injuries are associated with significant blood loss. This is compounded by multiple surgical interventions including definitive fracture fixation, which put patients at further risk of postoperative transfusion. We use intraoperative cell salvage routinely as a blood conservation strategy to address this issue. This is a prospective evaluation of the clinical efficacy and cost effectiveness of using intraoperative cell salvage in patients with pelvic acetabular injuries.

Methods

Data were collected prospectively for all the patients who underwent pelvic acetabular fracture fixation at our institution. A total of 30 patients (25 men, 5 women) with a mean age of 41 years (range: 31–79 years) were assessed over a period of 10 months.

Results

The mean preoperative and postoperative haemoglobin levels were 11.8g/dl and 9.9g/dl respectively. The mean intraoperative blood loss was 1,232.5ml (range: 150–2,693ml). The mean amount of blood salvaged and retransfused through a cell saver was 388ml. Of the 30 patients, 14 (47%) required transfusion after surgery and 26 units of blood were transfused. In terms of cost effectiveness, a total of £2,572 in 30 patients or £86 per patient were saved.

Conclusions

We found intraoperative cell salvage to be clinically efficacious and cost effective in patients with pelvic acetabular injuries.