Surgical blood conservation: Intraoperative and postoperative blood salvage
- 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.
After preoperative autologous donation and intraoperative hemodilution, intraoperative and postoperative blood salvage are the third and fourth components of a complete blood conservation program. (See "Surgical blood conservation: Preoperative autologous blood donation" and "Surgical blood conservation: Intraoperative hemodilution".)
In salvage techniques, blood that is shed during or after surgery (or trauma) is retrieved, processed in some fashion, and returned to the patient. Processing can be as simple as filtration or, most commonly, involves centrifugation and washing prior to re-transfusion.
INTRAOPERATIVE BLOOD SALVAGE
Intraoperative blood salvage (IBS) is also known as intraoperative autologous transfusion, intraoperative salvage, or intraoperative autotransfusion. IBS is unique among autologous transfusion methods because of its capacity to provide immense quantities of autologous blood very rapidly. In comparison, preoperative collection is limited by time constraints and patient tolerance, hemodilution is limited by blood volume and hemodynamic considerations, and postoperative salvage is limited by mechanical problems and concern about microbial contamination. IBS can be utilized throughout a surgical procedure and can replace blood in proportion to the volume lost. In certain situations, most notably liver transplantation, the rate and volume of replacement may be extraordinary .
Technology — The modern era of IBS technology began in the mid-1970s when the two currently available salvage systems – a centrifuge-based cell salvage instrument and a passive canister collection system (used with or without supplementary washing) – were introduced. The first commercially available instrument that could concentrate and wash salvaged red cells was the Cell Saver, introduced in 1974. Cell Saver technology has become so widely accepted (through five generations of Cell Savers) that virtually all similar IBS instruments are referred to as "cell savers."
The procedure starts with the surgeon aspirating blood from the surgical field through a suction wand attached to dual-channel tubing; this allows anticoagulant and blood to be mixed as the blood is aspirated. The aspirated blood is collected in a reservoir (usually a cardiotomy reservoir) until there is sufficient blood for processing. At this point, the salvaged blood is pumped into the centrifuge bowl, where it is concentrated and then washed with an isotonic electrolyte solution, most often saline. The processed red cell suspension is then pumped from the centrifuge bowl into an infusion bag. Modern cell salvage instruments can process a full reservoir of blood and provide 225 mL of washed, saline-suspended red cells with a hematocrit of 50 percent or more in approximately three minutes. Thus, a massively bleeding patient can be provided with the equivalent of 12 units of banked blood per hour.
- Williamson KR, Taswell HF, Rettke SR, Krom RA. Intraoperative autologous transfusion: its role in orthotopic liver transplantation. Mayo Clin Proc 1989; 64:340.
- Griffith LD, Billman GF, Daily PO, Lane TA. Apparent coagulopathy caused by infusion of shed mediastinal blood and its prevention by washing of the infusate. Ann Thorac Surg 1989; 47:400.
- Breyer RH, Engelman RM, Rousou JA, Lemeshow S. Blood conservation for myocardial revascularization. Is it cost effective? J Thorac Cardiovasc Surg 1987; 93:512.
- 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.
- Hallett JW Jr, Popovsky M, Ilstrup D. Minimizing blood transfusions during abdominal aortic surgery: recent advances in rapid autotransfusion. J Vasc Surg 1987; 5:601.
- Goulet JA, Bray TJ, Timmerman LA, et al. Intraoperative autologous transfusion in orthopaedic patients. J Bone Joint Surg Am 1989; 71:3.
- Hart OJ 3rd, Klimberg IW, Wajsman Z, Baker J. Intraoperative autotransfusion in radical cystectomy for carcinoma of the bladder. Surg Gynecol Obstet 1989; 168:302.
- MacIvor D, Nelson J, Triulzi D. Impact of intraoperative red blood cell salvage on transfusion requirements and outcomes in radical prostatectomy. Transfusion 2009; 49:1431.
- Jurkovich GJ, Moore EE, Medina G. Autotransfusion in trauma. A pragmatic analysis. Am J Surg 1984; 148:782.
- Brown CV, Foulkrod KH, Sadler HT, et al. Autologous blood transfusion during emergency trauma operations. Arch Surg 2010; 145:690.
- Silva PD, Beguin EA Jr. Intraoperative rapid autologous blood transfusion. Am J Obstet Gynecol 1989; 160:1226.
- Rogers DM, Crookston KP. The approach to the patient who refuses blood transfusion. Transfusion 2006; 46:1471.
- Cimochowski GE, Gray DW, Fardin R. Implosion/explosion of a Bentley cardiotomy reservoir during autotransfusion with a cell saver. J Extra-corporeal Technol 1985; 17:130.
- Nagarsheth NP, Sharma T, Shander A, Awan A. Blood salvage use in gynecologic oncology. Transfusion 2009; 49:2048.
- 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.
- 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.
- Dzik WH, Sherburne B. Intraoperative blood salvage: medical controversies. Transfus Med Rev 1990; 4:208.
- Esper SA, Waters JH. Intra-operative cell salvage: a fresh look at the indications and contraindications. Blood Transfus 2011; 9:139.
- 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.
- Kongsgaard UE, Wang MY, Kvalheim G. Leucocyte depletion filter removes cancer cells in human blood. Acta Anaesthesiol Scand 1996; 40:118.
- Hansen E, Bechmann V, Altmeppen J. Intraoperative blood salvage in cancer surgery: safe and effective? Transfus Apher Sci 2002; 27:153.
- 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.
- Bull BS, Bull MH. The salvaged blood syndrome: a sequel to mechanochemical activation of platelets and leukocytes? Blood Cells 1990; 16:5.
- AABB. Standards for Perioperative Autologous Blood Collection and Administration, 5th ed, 2013.
- Lane TA. Blood salvage in cardiovascular surgery. In: Perioperative Autologous Transfusion, Stehling L (Ed), American Association of Blood Banks, Arlington, VA 1991. p.67.
- Andrews NJ, Bloor K. Autologous blood collection in abdominal vascular surgery. Assessment of a low pressure blood salvage system with particular reference to the preservation of cellular elements, triglyceride, complement and bacterial content in the collected blood. Clin Lab Haematol 1983; 5:361.
- Adan A, Brutel de la Rivière A, Haas F, et al. Autotransfusion of drained mediastinal blood after cardiac surgery: a reappraisal. Thorac Cardiovasc Surg 1988; 36:10.
- Semkiw LB, Schurman DJ, Goodman SB, Woolson ST. Postoperative blood salvage using the Cell Saver after total joint arthroplasty. J Bone Joint Surg Am 1989; 71:823.
- Umlas J, Foster RR, Dalal SA, et al. Red cell loss following orthopedic surgery: the case against postoperative blood salvage. Transfusion 1994; 34:402.
- 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.
- Warner C. The use of the orthopaedic perioperative autotransfusion (OrthoPAT) system in total joint replacement surgery. Orthop Nurs 2001; 20:29.
- INTRAOPERATIVE BLOOD SALVAGE
- Indications and advantages
- - Absolute contraindications
- - Relative contraindications
- - Malignancy and bacteremia
- Product quality
- Cost effectiveness
- POSTOPERATIVE BLOOD SALVAGE
- Cardiac surgery
- Orthopedic surgery
- SUMMARY AND RECOMMENDATIONS
- Intraoperative salvage
- Postoperative salvage