Surgical blood conservation: Blood salvage
- Michael Avidan, MD
Michael Avidan, MD
- Section Editor — Surgical Critical Care; Trauma Anesthesia
- Professor of Anesthesiology and Surgery
- Washington University School of Medicine
- Arthur J Silvergleid, MD
Arthur J Silvergleid, MD
- Section Editor — Transfusion Medicine
- Affiliate Associate Professor, Department of Pathology and Cell Biology
- University of South Florida, College of Medicine
- Medical Director, OneBlood, Inc.
- Michele Heath, LP, CCP
Michele Heath, LP, CCP
- Durham VA Medical Center
- Section Editors
- Steven Kleinman, MD
Steven Kleinman, MD
- Section Editor — Transfusion Medicine
- Clinical Professor of Pathology
- University of British Columbia, Vancouver
- Jonathan B Mark, MD
Jonathan B Mark, MD
- Section Editor — Cardiac Anesthesiology
- Professor of Anesthesiology
- Duke University Medical Center
- Chief, Anesthesiology Service
- Veterans Affairs Medical Center
Surgical blood conservation techniques are used to reduce patient exposure to allogeneic blood during and after surgery. Techniques include preoperative autologous donation, intraoperative hemodilution, and blood salvage during surgery. This topic will review the indications, advantages, and potential complications of intraoperative blood salvage (ie, intraoperative autologous transfusion or intraoperative autotransfusion) and postoperative blood salvage.
Preoperative autologous donation and intraoperative hemodilution are discussed in detail separately. (See "Surgical blood conservation: Preoperative autologous blood donation" and "Surgical blood conservation: Intraoperative hemodilution".)
INTRAOPERATIVE BLOOD SALVAGE
We suggest intraoperative blood salvage in surgical procedures having a high likelihood of significant blood loss (>1000 mL), based on evidence that allogeneic transfusion and associated complications can be avoided .
Indications and benefits — Intraoperative blood salvage has the following potential benefits:
●Avoidance of allogeneic transfusion – The technique can be effective in avoiding or reducing allogeneic blood transfusion, with its attendant costs and risks (eg, transfusion reactions, transfusion-transmitted infections) . Thus, intraoperative blood salvage is presumed to be beneficial, although randomized trials have not demonstrated improved outcomes. In a 2010 systematic review including 75 trials (36 involving orthopedic procedures, 33 involving cardiac procedures, 6 involving vascular surgery), the absolute reduction in the use of allogeneic red blood cell transfusion was 21 percent (95% confidence interval [CI] 15-26 percent) . In a 2015 systematic review in emergency abdominal or thoracic trauma surgery (one trial; n = 44), the reduction in the use of allogeneic red blood cells in the cell salvage group was 4.7 units (95% CI 1.31-8.09 units) . These systematic reviews concluded that cell salvage did not increase the risk of adverse events, including mortality and infection [1,2]. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Risks and complications of transfusion'.)
- Carless PA, Henry DA, Moxey AJ, et al. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev 2010; :CD001888.
- Li J, Sun SL, Tian JH, et al. Cell salvage in emergency trauma surgery. Cochrane Database Syst Rev 2015; 1:CD007379.
- Brown CV, Foulkrod KH, Sadler HT, et al. Autologous blood transfusion during emergency trauma operations. Arch Surg 2010; 145:690.
- Singbartl G, Held AL, Singbartl K. Ranking the effectiveness of autologous blood conservation measures through validated modeling of independent clinical data. Transfusion 2013; 53:3060.
- Wang G, Bainbridge D, Martin J, Cheng D. The efficacy of an intraoperative cell saver during cardiac surgery: a meta-analysis of randomized trials. Anesth Analg 2009; 109:320.
- Raval JS, Nelson JB, Woldemichael E, Triulzi DJ. Intraoperative cell salvage in radical prostatectomy does not appear to increase long-term biochemical recurrence, metastases, or mortality. Transfusion 2012; 52:2590.
- Son M, Evanko JC, Mongero LB, et al. Utility of cell salvage in women undergoing abdominal myomectomy. Am J Obstet Gynecol 2014; 211:28.e1.
- Pasternak J, Nikolic D, Milosevic D, et al. An analysis of the influence of intra-operative blood salvage and autologous transfusion on reducing the need for allogeneic transfusion in elective infrarenal abdominal aortic aneurysm repair. Blood Transfus 2014; 12 Suppl 1:s182.
- Weltert L, Nardella S, Rondinelli MB, et al. Reduction of allogeneic red blood cell usage during cardiac surgery by an integrated intra- and postoperative blood salvage strategy: results of a randomized comparison. Transfusion 2013; 53:790.
- Odak S, Raza A, Shah N, Clayson A. Clinical efficacy and cost effectiveness of intraoperative cell salvage in pelvic trauma surgery. Ann R Coll Surg Engl 2013; 95:357.
- Greenky M, Shaner J, Rasouli MR, et al. Intraoperative blood salvage in revision total hip arthroplasty: who benefits most? J Arthroplasty 2014; 29:1298.
- Kim JM, Kim GS, Joh JW, et al. Long-term results for living donor liver transplant recipients with hepatocellular carcinoma using intraoperative blood salvage with leukocyte depletion filter. Transpl Int 2013; 26:84.
- Vonk AB, Meesters MI, van Dijk WB, et al. Ten-year patterns in blood product utilization during cardiothoracic surgery with cardiopulmonary bypass in a tertiary hospital. Transfusion 2014; 54:2608.
- Shenolikar A, Wareham K, Newington D, et al. Cell salvage auto transfusion in total knee replacement surgery. Transfus Med 1997; 7:277.
- Waters JH. Intraoperative blood recovery. ASAIO J 2013; 59:11.
- Di Rocco C, Tamburrini G, Pietrini D. Blood sparing in craniosynostosis surgery. Semin Pediatr Neurol 2004; 11:278.
- Chanda A, Smith DR, Nanda A. Autotransfusion by cell saver technique in surgery of lumbar and thoracic spinal fusion with instrumentation. J Neurosurg 2002; 96:298.
- Vega RA, Lyon C, Kierce JF, et al. Minimizing transfusion requirements for children undergoing craniosynostosis repair: the CHoR protocol. J Neurosurg Pediatr 2014; 14:190.
- International Hemoglobin Information Center variants list. Hemoglobin 1992; 16:127.
- Hughes DB, Ullery BW, Barie PS. The contemporary approach to the care of Jehovah's witnesses. J Trauma 2008; 65:237.
- Nieder AM, Simon MA, Kim SS, et al. Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovah's Witnesses. Int Braz J Urol 2004; 30:377.
- Garcia JH, Coelho GR, Feitosa Neto BA, et al. Liver transplantation in Jehovah's Witnesses patients in a center of northeastern Brazil. Arq Gastroenterol 2013; 50:138.
- Williamson KR, Taswell HF, Rettke SR, Krom RA. Intraoperative autologous transfusion: its role in orthotopic liver transplantation. Mayo Clin Proc 1989; 64:340.
- Warnock DF, Davison JK, Brewster DC, et al. Modification of the Haemonetics Cell Saver for optional high flow rate autotransfusion. Am J Surg 1982; 143:765.
- Davies L, Brown TJ, Haynes S, et al. Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model. Health Technol Assess 2006; 10:iii.
- Duffy G, Tolley K. Cost analysis of autologous blood transfusion, using cell salvage, compared with allogeneic blood transfusion. Transfus Med 1997; 7:189.
- Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus 2011; 9:139.
- Timberlake GA, McSwain NE Jr. Autotransfusion of blood contaminated by enteric contents: a potentially life-saving measure in the massively hemorrhaging trauma patient? J Trauma 1988; 28:855.
- Bland LA, Villarino ME, Arduino MJ, et al. Bacteriologic and endotoxin analysis of salvaged blood used in autologous transfusions during cardiac operations. J Thorac Cardiovasc Surg 1992; 103:582.
- Waters JH, Tuohy MJ, Hobson DF, Procop G. Bacterial reduction by cell salvage washing and leukocyte depletion filtration. Anesthesiology 2003; 99:652.
- Wollinsky KH, Oethinger M, Büchele M, et al. Autotransfusion--bacterial contamination during hip arthroplasty and efficacy of cefuroxime prophylaxis. A randomized controlled study of 40 patients. Acta Orthop Scand 1997; 68:225.
- Dzik WH, Sherburne B. Intraoperative blood salvage: medical controversies. Transfus Med Rev 1990; 4:208.
- Waters JH, Yazer M, Chen YF, Kloke J. Blood salvage and cancer surgery: a meta-analysis of available studies. Transfusion 2012; 52:2167.
- Kumar N, Lam R, Zaw AS, et al. Flow cytometric evaluation of the safety of intraoperative salvaged blood filtered with leucocyte depletion filter in spine tumour surgery. Ann Surg Oncol 2014; 21:4330.
- Perseghin P, Viganò M, Rocco G, et al. Effectiveness of leukocyte filters in reducing tumor cell contamination after intraoperative blood salvage in lung cancer patients. Vox Sang 1997; 72:221.
- Edelman MJ, Potter P, Mahaffey KG, et al. The potential for reintroduction of tumor cells during intraoperative blood salvage: reduction of risk with use of the RC-400 leukocyte depletion filter. Urology 1996; 47:179.
- Catling S, Williams S, Freites O, et al. Use of a leucocyte filter to remove tumour cells from intra-operative cell salvage blood. Anaesthesia 2008; 63:1332.
- Kumar N, Chen Y, Zaw AS, et al. Use of intraoperative cell-salvage for autologous blood transfusions in metastatic spine tumour surgery: a systematic review. Lancet Oncol 2014; 15:e33.
- Kumar N, Ahmed Q, Lee VK, et al. Can there be a place for intraoperative salvaged blood in spine tumor surgery? Ann Surg Oncol 2014; 21:2436.
- Allam J, Cox M, Yentis SM. Cell salvage in obstetrics. Int J Obstet Anesth 2008; 17:37.
- Dhariwal SK, Khan KS, Allard S, et al. Does current evidence support the use of intraoperative cell salvage in reducing the need for blood transfusion in caesarean section? Curr Opin Obstet Gynecol 2014; 26:425.
- Rainaldi MP, Tazzari PL, Scagliarini G, et al. Blood salvage during caesarean section. Br J Anaesth 1998; 80:195.
- Jackson SH, Lonser RE. Safety and effectiveness of intracesarean blood salvage. Transfusion 1993; 33:181.
- Grimes DA. A simplified device for intraoperative autotransfusion. Obstet Gynecol 1988; 72:947.
- Morikawa M, Kuramoto A, Nakayama M, et al. Intraoperative red cell salvage during obstetric surgery in 50 Japanese women. Int J Gynaecol Obstet 2015; 128:256.
- Tevet A, Grisaru-Granovsky S, Samueloff A, Ioscovich A. Peripartum use of cell salvage: a university practice audit and literature review. Arch Gynecol Obstet 2012; 285:281.
- Ralph CJ, Sullivan I, Faulds J. Intraoperative cell salvaged blood as part of a blood conservation strategy in Caesarean section: is fetal red cell contamination important? Br J Anaesth 2011; 107:404.
- Rebarber A, Lonser R, Jackson S, et al. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol 1998; 179:715.
- King M, Wrench I, Galimberti A, Spray R. Introduction of cell salvage to a large obstetric unit: the first six months. Int J Obstet Anesth 2009; 18:111.
- Thomas D. Facilities for blood salvage (cell saver technique) must be available in every obstetric theatre. Int J Obstet Anesth 2005; 14:48.
- Milne ME, Yazer MH, Waters JH. Red blood cell salvage during obstetric hemorrhage. Obstet Gynecol 2015; 125:919.
- Elagamy A, Abdelaziz A, Ellaithy M. The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation. Int J Obstet Anesth 2013; 22:289.
- Parry N, Junghans C, Skelton V, Okunuga A. Audit of cell salvage use in obstetric patients: adding experience. Int J Obstet Anesth 2010; 19:238.
- McDonnell NJ, Kennedy D, Long LJ, et al. The development and implementation of an obstetric cell salvage service. Anaesth Intensive Care 2010; 38:492.
- Goucher H, Wong CA, Patel SK, Toledo P. Cell Salvage in Obstetrics. Anesth Analg 2015; 121:465.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynecologists Number 76, October 2006: postpartum hemorrhage. Obstet Gynecol 2006; 108:1039.
- Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta (Reaffirmed February 2016). Obstet Gynecol 2012; 120:207.
- Waters JH, Lukauskiene E, Anderson ME. Intraoperative blood salvage during cesarean delivery in a patient with beta thalassemia intermedia. Anesth Analg 2003; 97:1808.
- Smith DF, Mihm FG, Mefford I. Hypertension after intraoperative autotransfusion in bilateral adrenalectomy for pheochromocytoma. Anesthesiology 1983; 58:182.
- Kelleher A, Davidson S, Gohil M, et al. A quality assurance programme for cell salvage in cardiac surgery. Anaesthesia 2011; 66:901.
- Spahn DR, Bouillon B, Cerny V, et al. Management of bleeding and coagulopathy following major trauma: an updated European guideline. Crit Care 2013; 17:R76.
- Hansen E, Hansen MP. Reasons against the retransfusion of unwashed wound blood. Transfusion 2004; 44:45S.
- Gruber M, Breu A, Frauendorf M, et al. Washing of banked blood by three different blood salvage devices. Transfusion 2013; 53:1001.
- Konig G, Waters JH. Washing and filtering of cell-salvaged blood - does it make autotransfusion safer? Transfus Altern Transfus Med 2012; 12:78.
- Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth 2010; 105:401.
- American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology 2015; 122:241.
- Matsuda K, Nozawa M, Katsube S, et al. Activation of fibrinolysis by reinfusion of unwashed salvaged blood after total knee arthroplasty. Transfus Apher Sci 2010; 42:33.
- Moonen AF, Knoors NT, van Os JJ, et al. Retransfusion of filtered shed blood in primary total hip and knee arthroplasty: a prospective randomized clinical trial. Transfusion 2007; 47:379.
- Sarkanović ML, Gvozdenović L, Savić D, et al. Autologous blood transfusion in total knee replacement surgery. Vojnosanit Pregl 2013; 70:274.
- Thomas D, Wareham K, Cohen D, Hutchings H. Autologous blood transfusion in total knee replacement surgery. Br J Anaesth 2001; 86:669.
- Jones HW, Savage L, White C, et al. Postoperative autologous blood salvage drains--are they useful in primary uncemented hip and knee arthroplasty? A prospective study of 186 cases. Acta Orthop Belg 2004; 70:466.
- Oremus K, Sostaric S, Trkulja V, Haspl M. Influence of tranexamic acid on postoperative autologous blood retransfusion in primary total hip and knee arthroplasty: a randomized controlled trial. Transfusion 2014; 54:31.
- Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Brown JR, et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944.
- de Haan J, Schönberger J, Haan J, et al. Tissue-type plasminogen activator and fibrin monomers synergistically cause platelet dysfunction during retransfusion of shed blood after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1993; 106:1017.
- Svenmarker S, Engström KG. The inflammatory response to recycled pericardial suction blood and the influence of cell-saving. Scand Cardiovasc J 2003; 37:158.
- Roberts SR, Early GL, Brown B, et al. Autotransfusion of unwashed mediastinal shed blood fails to decrease banked blood requirements in patients undergoing aortocoronary bypass surgery. Am J Surg 1991; 162:477.
- Spanier T, Tector K, Schwartz G, et al. Endotoxin in pooled pericardial blood contributes to the systemic inflammatory response during cardiac surgery. Perfusion 2000; 15:427.
- Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, et al. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007; 83:S27.
- Dial S, Nguyen D, Menzies D. Autotransfusion of shed mediastinal blood: a risk factor for mediastinitis after cardiac surgery? Results of a cluster investigation. Chest 2003; 124:1847.
- Body SC, Birmingham J, Parks R, et al. Safety and efficacy of shed mediastinal blood transfusion after cardiac surgery: a multicenter observational study. Multicenter Study of Perioperative Ischemia Research Group. J Cardiothorac Vasc Anesth 1999; 13:410.
- Wiefferink A, Weerwind PW, van Heerde W, et al. Autotransfusion management during and after cardiopulmonary bypass alters fibrin degradation and transfusion requirements. J Extra Corpor Technol 2007; 39:66.
- Vonk AB, Meesters MI, Garnier RP, et al. Intraoperative cell salvage is associated with reduced postoperative blood loss and transfusion requirements in cardiac surgery: a cohort study. Transfusion 2013; 53:2782.
- Linden JV, Kaplan HS, Murphy MT. Fatal air embolism due to perioperative blood recovery. Anesth Analg 1997; 84:422.
- Engelhardt W, Blumenberg D. [Risks and side effects of intraoperative autotransfusion]. Beitr Infusionsther 1991; 28:317.
- AABB. Standards for Perioperative Autologous Blood Collection and Administration, 5th ed, 2013.
- Weiskopf RB. Erythrocyte salvage during cesarean section. Anesthesiology 2000; 92:1519.
- Szpisjak DF, Potter PS, Capehart BP. Economic analysis of an intraoperative cell salvage service. Anesth Analg 2004; 98:201.
- INTRAOPERATIVE BLOOD SALVAGE
- Indications and benefits
- - Absolute contraindications
- - Relative contraindications
- - Areas of uncertainty
- - Overview of the procedure
- - Washed versus unwashed blood
- Salvaged washed red cells
- Salvaged unwashed blood
- Storage and handling
- POSTOPERATIVE BLOOD SALVAGE
- Major orthopedic procedures
- Cardiac surgery
- POTENTIAL COMPLICATIONS
- ESTABLISHING A BLOOD SALVAGE PROGRAM
- SUMMARY AND RECOMMENDATIONS