This topic will review definition, the indication, advantages, and potential complications - PowerPoint Presentation

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This topic will review definition, the indication, advantages, and potential complications of intraoperative and postoperative cell salvage

intraoperative and postoperative cell salvage

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Providing safe blood for transfusion remains a challenge despite advances in preventing transmission of hepatitis B, hepatitis C, AIDS/HIV, West Nile virus (WNV), and transfusion-transmitted bacterial infection. Human errors such as misidentifying patients and drawing blood samples from the wrong person present much more of a risk than transmissible diseases.

Autologous Transfusion

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Allogeneic blood transfusion has been associated with increased risk of: Tumour recurrence Postoperative infection Acute lung injury

Autologous Transfusion

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The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion to reduce its associated complications

Autologous Transfusion

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It is a major form of auto transfusionDefinition: Intraoperative blood collection, blood recovery or cell salvage, is a medical procedure involving recovering blood lost during surgery and re-infusing it into the same patient.

Intra-operative Cell salvage

(ICS)

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Sterile operating field is neededSeveral steps are involved including: - Suctioning of shed blood from the surgical field - Addition of anticoagulant as it is aspirated (heparin concentration30000 units per liter with slow addition:rate of 15cc per 100cc of collected blood)) -Separation and washing of RBCs with with 0.9% saline -Concentration the blood -Send the plasma, platelet and west component to waste bag -Reinfusion through the filters

PRACTICAL

CONSIDERATION FOR

ICS

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Several medical devices have been developed to assist in salvaging the patient's own blood in the perioperative settingThis process typically results in 225-mL units of saline-suspended RBCs with a hematocrit of 50% to 60% within 3 minutes

PRACTICAL CONSIDERATION FOR ICS

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It shall be stored under one of the following conditions before initiation of transfusion:a. At room temperature for up to 4 hours after terminating collectionb. At 1° C to 6° C for up to 24 hours, provided storage at 1° C to 6° C is begun within 4 hours of ending the collection

PRACTICAL

CONSIDERATION FOR

ICS

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Each unit collected intraoperatively shall be labeled with: The patient’s first name, Last name, Hospital identification number; The date and time of initiation of collection and of expiration;The statement “For Autologous Use Only.”Stored in blood bank

PRACTICAL

CONSIDERATION FOR

ICS

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1. Avoidance of allogeneic blood transfusion with attendant costs and risks: T- reaction T- transmitted infections and T- related complications.

Benefits of ICS

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2. Greater number of units available compered with other autologous blood conservation techniques which generally only provide 1-3 units of autologous bloodThus ICS has been applied effectively in a variety of surgical procedures with likelihood of significant blood loss more than 1000 ml including cardiac, vascular, orthopedic, urologic. Trauma, gynecologic and transplantation procedures

Benefits of ICS

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3. Time and cost saving, because salvage is always done in OR without direct involvement of the transfusion service and also eliminate the need for the patient to provide autologous donationIf there is uncertainty regarding the need for blood salvage, the collection disposables for a cell salvage device can be set up as a standby option potentially saving the cost of the bowel and the reinfusion bag as well as the personnel costs.

Benefits of ICS

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Can be used regardless of patient’s medical fitness. Life saving where there is uncontrolled bleeding. System accepted by some Jehovah’s Witnesses. may be life Saving in a patient with a rare blood type. may be useful in a patient with multiple RBC autoantibody when cross match compatible blood cannot readily be obtained.

Benefits of ICS

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Oxygen transport properties of recovered red cell are equivalent to stored allogenic red cells The survival of recovered RBCs appears to be at least comparable to that of transfused allogeneic RBCs

Benefits of ICS

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Air embolous which is a potentially serious problemHemolysisHigher plasma free hemoglobin in contrast to allogenic blood transfusion that may be due to inadequate washingPositive bacterial culture (clinical infection is rare)DIC

Side Effects of ICS

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Hemolysis of red cells can occur during suctioning from surface (vacuum not more than 150 torr is recommended or mechanical compression in roller pumps can produce hemolysis.) It also occur in Hemoglobinopathy

SIDE EFFECTS OF INTRAOPERATIVE RECOVERY

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Restricted to operations with high blood loss (>20 % of total blood volume). Only red cells are returned without platelets or plasma

Disadvantages

Intra-Operative Cell Salvage (ICS)

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Use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use

Disadvantages

Intra-Operative Cell Salvage (ICS)

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Presence of contraindicated fluids: Salvaged blood must never be mixed with fluids, such as sterile water or any hypotonic solution, because RBC hemolysis will occurs.Also Salvaged blood can not be used if solution that would be toxic with Iv administration could come into contact with the salvaged blood. Examples include AB irrigation or hydrogen peroxide, alcohol, or povidone- iodine soloution.Also Salvaged blood can not be used during suctioning of blood from the surgical field when there is any potential for simultanous collection of hemostatic products such as topical thrombin, fibrin glue, collagen sponge or any chance of admixture with methylmethacrylate(i.e. bone cement)

Absolute contraindication

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Bacterial infection: Decision about using intra operative blood salvage in patients with bacterial infections are made in case by case basis with consideration of relative risk and benefits for the individual patient, and with informed conscent.Although washing blood that contain bacteria cannot completely sterilize it, processing blood via cell salvage system and filtering it using a leukocyte reduction filter has been associated with 98-100 percent reduction in a variety of bacterial organism.

Relative contraindication

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Active Malignancy:Decision about using intra operative blood salvage in patients with active malignancy are made in case by case basis with consideration of relative risk and benefits for the individual patient, and with informed consent.Extensive cell washing does not remove malignant cell, however the leukocyte filtration process remove cell from salvaged blood similar to removal of bacteria.

Relative contraindication

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Obstetrics : possibility of maternal allommunization from contamination from incompatible fetal RBC. Anti-Rh(D) immunoglobulin should be administered after transfusion of salvaged blood in Rh(D) negative women when the fetus is Rh(D) positiveAmniotic fluid embolism avoid directly aspirating Amniotic fluid by waiting until it is no longer visibly apparent in the surgical field before beginning to use cell salvage suction.Hemoglobinoathy: theoretically risk of: sickling in sickle cell anemia or hemolysis in thalassemiaPheochrocytoma due to presence of theoretical risk of infusing of vasoactive material

Area of uncertainty

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Recovery of blood from surgical drain followed by re-infusion through a 40 microaggregate filter with or without washing process.Shed blood is collected into sterile canister and re-infused through a micro-aggregate filterRecovered blood is: diluted, partially hemolysed de-fibrinated and may contain high concentrate of cytokines

Postoperative Blood Collection

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Free HbRBC StromaMarrow fatToxic irritantTissue or debrisFibrin degradation productActivated coagulation factorsComplement

HARMFUL MATERIAL IN RECOVERED BLOOD

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Upper limit on the volume(1400 ml) of unprocessed blood can re-infusedMost common in orthopedic procedures such as hip or knee replacement.

RECOVERED BLOOD

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Transfusion should be within 6 hours of initiating collectionInfusion of potentially harmful material in recovered bloodAlthough two small studies reported complications, several larger studies reported no serious adverse effects when the drainage was passed through a standard 40-μm blood filter.

Postoperative Blood Collection

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Tissue oxygenation does NOT depend on hemoglobin concentration alone!Cardiac performancePulmonary functionO2 Binding CoefficientDemand of Tissue (physical activity)

Red Cell Transfusion- Is a clinical

decision

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