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.

Blood salvage in cardiac surgery

The aim of this study was to evaluate blood salvage provided by an intraoperative blood recovery system (IBRS) and a mediastinal drainage blood recovery system (MBRS) during and after cardiac surgery. Sixty-six patients undergoing aortocoronary bypass surgery were randomly assigned to three groups of 22 patients each. In group I, patients received only homologous blood (HB). Group II and group III patients received the blood content of the oxygenator after concentration by an IBRS at the end of the operation. In group III, patients also received their own mediastinal drainage blood, shed for 6 hours after operation, after concentration and washing in a MBRS. The patients were transfused with homologous blood if needed, in order to obtain a hematocrit of 28% at the end of operation, 30% the following day, and a hemoglobin level over 10 g/dL while on the cardiac surgery ward (8 to 10 days). The three groups were comparable with respect to age, body surface, preoperative and postoperative hematocrits, number of grafts, bypass duration, and postoperative mediastinal blood loss. The amount of HB that was transfused during the operation was significantly lower in groups II and III than in group I (P less than 0.0001). After the operation it was significantly lower in group II than in group I (P less than 0.05), and in group III versus group I. Thus, 13.6% of patients in group II and 38% of patients in group III did not require HB transfusion. No infection, renal dysfunction, or coagulation disorders were observed. It is concluded that the use of an IBRS allows a significant saving of HB. However, because it does not avoid all HB requirements, it should be associated with other techniques to avoid blood transfusion such as the MBRS or predonation.

[Tumor cell separation by cell saver and membrane filter passage]

Definite suspensions of malignant cells from three human tumor cells lines (bladder, prostate and renal cell carcinom) were passed through a cell saver (Althin Mediplast) and a leucozyte removal filter (PALL RC 100) under standard conditions. The examination of the solutions did not detect any malignant cells at all. If investigations with malignant cells in the blood will confirm these results, the use of intraoperative autotransfusion in urological tumor surgery would be possible.

Efficacy of intraoperative autotransfusion in primary total hip arthroplasty

The role of intraoperative autotransfusion in diminishing perioperative transfusion requirements was studied in 64 patients undergoing primary total hip arthroplasty. The total transfusions administered in a 3-day perioperative period were tabulated for the study group (in which intraoperative autotransfusion was utilized) and compared to that of the control group. Despite the use of the Cell Saver autotransfusion device, no significant difference was noted between the total units of blood transfused perioperatively in the two groups. Moreover, calculations of mean perioperative blood loss (intra- and postoperative) were not significantly different, nor was there any difference in mean hemoglobin concentrations between the two groups on the third postoperative day. All 64 patients received 4 units or less of banked blood in the perioperative period. The authors conclude that this modality of blood conservation is not necessary in primary hip arthroplasty and that a well planned autologous prebanking program should be sufficient in the vast majority of cases to avoid the use of banked homologous blood.

[Intra- and postoperative autotransfusion in hip joint surgery. Effectiveness, bacteriology]

The efficiency of intraoperative and postoperative autotransfusion with a cell separator, the elimination of a cephalosporin administered for prophylaxis of infection and bacterial contamination of the blood retransfused were studied in 56 patients undergoing hip arthroplasty (n = 33) or exchange reoperation of hip arthroplasty (n = 23). Intraoperatively only a limited amount of the lost erythrocytes could be retransfused: in hip arthroplasty 250 ml (median) packed red cells of 700 ml blood loss, in exchange reoperation 750 ml of 2200 ml. Postoperative autotransfusion was more effective: during the autotransfusion period (until 6 h after the beginning of the operation) 375 ml of 650 ml and 500 ml of 830 ml could be retransfused in the two groups. Cefuroxime was eliminated effectively from the autologous blood by the cell washing process, usually below the limit of detection. In the washed autologous red blood cells of 3 patients (= 5.4%) bacterial contamination could be demonstrated in low titres (less than or equal to 10/ml). No clinical signs of bacteremia were observed during retransfusion. Postoperative autotransfusion contributes considerably to the total amount of autologous erythrocytes retransfused. Bacterial contamination of the processed autologous blood is infrequent and probably without clinical significance.

[A comparison of autologous transfusion procedures in hip surgery]

The risks associated with transfusion can be minimized with autologous blood. The efficiency of preoperative deposit, preoperative hemodilution and intra- and postoperative autotransfusion in reducing homologous transfusions has been demonstrated. There seem to be few studies, however, that compared the different methods of autologous transfusion. This study was designed to evaluate the comparative efficiency of these methods. PATIENTS AND METHODS. Sixty-four patients scheduled for total hip arthroplasty were randomly divided into four groups: group I--preoperative autologous deposit: group II--preoperative hemodilution; group III--intra- and postoperative autotransfusion; group IV--control. Preoperative autologous donations were stored in CPDA-1 buffer. Three units of 450 ml were requested. A predonation hemoglobin (Hb) concentration of 11 g dl was required. Surgery was carried out in the 5th week after the first donation. Preoperative hemodilution to Hb 9 g/dl was carried out after induction of anesthesia and initial circulatory stabilization. A cell separator was used for intra- and postoperative autotransfusion. Postoperative autotransfusion of drainage blood was continued until 6 h after the beginning of the operation. Polygeline was used for volume resuscitation. If the Hb concentration fell below 9 g/dl in the operating room and intensive care unit or below 10 g/dl in the general ward, autologous blood or homologous packed red cells were transfused. Autologous blood collected with the cell separator was retransfused at the end of the operation and after the autotransfusion period irrespective of the actual Hb concentration. RESULTS. The general data of the patients, blood loss, and Hb concentration at the beginning of the study and postoperatively were comparable in the four groups. Homologous transfusion requirements amounted to 0 (0-1250) ml (median, range) packed red cells in group I (preoperative deposit). 500 (0-2000) ml in group II (hemodilution), 125 (0-1000) ml in group III (autotransfusion) and to 500 (0-1500) ml in group IV (control). In group I 14 of 16 patients, in group II 1 of 16, in group III 8 of 16 patients, in group IV 5 of 15 patients did not require homologous transfusion. The difference between group I and IV was significant (p = 0.004 and p = 0.003). Global coagulation tests, antithrombin III, and total serum protein were comparable in the four groups. DISCUSSION. The efficiency of preoperative hemodilution to reduce homologous transfusion requirements is limited]. In the present study, as in two other recent studies, hemodilution did not reduce homologous transfusion requirements. Autotransfusion with a cell separator can save approximately 50% of the erythrocytes lost during hip arthroplasty and 70% of the drainage loss. The homologous transfusion requirements for the autotransfused group reported here were less than in the control group; the difference, however, was not statistically significant. Patients participating in preoperative autologous deposit did not require homologous blood for hip arthroplasty in 62%-70% of cases in other investigations; in the present study 88% of the patients did not require homologous blood. CONCLUSION. Under the conditions studied, preoperative autologous deposit was the most efficient method of autologous transfusion for hip arthroplasty. It should be employed primarily.

Malignant ascites: etiology, diagnosis, and treatment

One of the most uncomfortable and potentially compromising symptoms of many types of cancer is ascites. Unfortunately, ascites usually occurs at a stage when cure is no longer possible and palliation is the primary treatment goal. Modern surgical advances offer the possibility of peritoneovenous shunting. This procedure can offer relief from those symptoms that may significantly alter the performance of daily living activities and for continued participation in usual life-styles.

CATR: a new generation of autologous blood transfusion

As the field of surgery advances and the conservative use of banked blood transfusion increases the need for postoperative autotransfusion has increased. By using the CATR, the patient's demands for blood can be more adequately met without causing further complications for the patient. This article presents one method for postoperative cardiothoracic autotransfusion and describes its advantages and risks. A Nursing Plan of Care is included.

[Ways of economizing on homologous blood. Concepts of autologous blood transfusion]

Transfusion of homologous blood may be associated with various complications. In this review, the authors present concepts of prevention of homologous blood transfusion. Different autotransfusion techniques are discussed, i.e., predeposit of autologous blood, plasmapheresis, normovolaemic haemodilution, blood salvage with/without cell washing, postoperative blood salvage of drainage blood, anaesthesia and surgical techniques as well as drugs for minimizing blood loss. The third part of the essay deals with indications of each technique depending on the surgical field. The authors conclude with unanswered questions and problems of the future.

[Autologous blood transfusion and the problem of "safe" blood]

A conception of "safe" blood has been proposed based on autohemotransfusions with the use of the methods of preparation of autologous blood, preoperative isovolemic hemodilution and intraoperative blood salvage. For the latter method special apparatus are needed, while the two former methods are easily performable without complex equipment and high expenses. The wide use of autohemotransfusions is considered as the most reasonable alternative under conditions of diminution of donor number, increased hazard of transmission of some infections through homologous blood transfusions.

[Clinical experience of autotransfusion of shed mediastinal blood using a new chest drainage unit]

The autotransfusion system (ATS) of shed mediastinal blood is expected as one of the techniques for non-blood open heart surgery. The ATS which has been used previously for this purpose required such items as cardiotomy reservoir, vacuum bottle, infusion pump and was complicated to manipulate. This time we have used a new chest drainage unit, Sentinel Seal Autotransfusion System (Sherwood Medical Co.), and report our clinical experience. This unit consists of two component parts. One is a blood collection bag which is later used for reinfusion of shed blood. The other part is a regular chest drainage unit with the water seal which protects pleural cavity from atmosphere. We used this system for 24 cases of open heart surgery and studied about the hematological and biochemical changes after reinfusing the shed blood postoperatively. There were no complications and side effects related to the reinfusion. The unit we have used is simple to handle and is useful when returning shed blood. We believe that this unit is quite safe for clinical use and that it will become a new strong support for non-blood open heart surgery.

[Effectiveness of the Cell Saver and salvage from ultrafiltered extracorporeal circulation in heart surgery]

The efficiency of two intraoperative techniques of blood saving were compared prospectively. During a period of eight months, in 120 adults patients undergoing heart surgery with a cardiopulmonary bypass (CPB). They all had blood removed before the start of CPB for isovolaemic haemodilution. They were randomly assigned to two groups (n = 60 for each): for group A patients, blood was salvaged during surgery before the start of the CPB, during cardioplegia, and from the CPB circuit at the end of surgery, using a Cell Saver 1V (Haemonetics), and returned to the patient in theatre or in intensive care; in group B patients, blood in the CPB circuit at the end of surgery was ultrafiltered and returned to the patient at the same time as 0.8 mg.kg-1 protamine sulfate. The same anaesthetic protocol was used in all the patients (flunitrazepam, phenoperidine and pancuronium bromide). There was no significant difference between the two groups in the volume of blood removed at the start of surgery (9.12 +/- 2.01 ml.kg-1 (A) vs. 8.85.2.22 ml.kg-1 (B)), in the amounts of replacement fluid (Haemaccel, 4% albumin) given to maintain volaemia, and in postoperative blood loss Red cell count, haemoglobin level and haematocrit were higher in the Cell Saver group at the third postoperative hour and on the first postoperative day, whereas fibrinogen levels and platelet count were higher in the ultrafiltration group at the same times. A mean of 1.02 +/- 1.71 homologous blood units were given to group A and 1.45 +/- 1.71 in group B (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Hematopoietic stem cell processing and storage

The techniques to collect, process, and store HSC in anticipation of transplantation are now widely available. Important unresolved issues revolve around the as yet imperfect identification and classification of totipotential progenitors. However, much progress has been and will continue to be made despite this limitation. Research priorities of present and future stem cell processing laboratories should include: 1. Optimization of liquid (nonfrozen) storage techniques. This will permit more complex cell-specific manipulations, such as T-lymphocyte subset selection, isolation of CD34+ populations, treatment in vitro with growth factors, gene transfer experiments, and long-range transport of HSC, to be performed while preserving HSC integrity. 2. A better understanding of the regulation and kinetics of peripheral blood and umbilical cord HSC, to allow optimum collection procedures that do not require marrow harvesting. 3. An intensive study into the optimum conditions of collection, processing, and storage of megakaryocytic progenitors to decrease the long platelet-transfusion dependency of the myeloablated patient. 4. A search for a simple in vitro correlate of engraftment potential of a stem cell preparation. This will greatly improve the quality control functions of the laboratory as well as contribute to better patient selection for transplantation.

[Effective autotransfusion thanks to cooperation]

A 61-year-old female patient scheduled for major vascular surgery had several diseases, including cardiovascular, pulmonary, renal and hepatic insufficiency. Prior operations--major vascular surgery, strumectomy--had led in most cases to severe bleeding complications owing to a known inherited thrombopathia. Therefore, it was questionable whether an operation would be possible at all. Coordination of three medical departments (vascular surgery, anesthesiology and hematology) created an individual transfusion program. Over a period of 6 weeks, autologous blood was collected in the Anesthesiology Department by means of the so-called leap-frog technique, resulting in the availability of 4 units of autologous packed cells plus 9 units of autologous fresh frozen plasma by the day of surgery. During the operation we used a Shiley autotransfusion device (Autotrans). Two days before the preoperation substitution with homologous thrombocytes was started (one highly concentrated unit per day). This was continued until the 4th postoperative day. Operative procedure performed included reconstruction of iliac artery, bilateral profunda plastic and iliac-femoral cross-over bypass grafting. Only autologous blood products were utilized; apart from thrombocytes no further homologous derivatives were required. The patient had a normal recovery period with no episodes of bleeding or hematoma. There was no need for a long hospital stay. The case presented stresses the importance of good cooperation between physicians for successful treatment of our patients in general and effective use of autotransfusion in particular.

Intraoperative autotransfusion in reconstructive hip joint surgery of patients with rheumatoid arthritis and ankylosing spondylitis

The efficacy of a simple, low-cost device designed for intraoperative blood salvage and reinfusion, known as the Sorensen system, was studied during 24 hip joint operations in adult patients suffering from rheumatoid arthritis or ankylosing spondylitis. The total need for homologous blood was reduced to 28%, compared with a matched control group of patients who had previously undergone hip surgery by homologous blood replacement. In primary hip-replacement operations, the need for blood was met either completely by autotransfused blood or by the addition of 1 or 2 units of homologous blood. In revision arthroplasties, the maximal need for homologous blood was 6 units owing to a greater blood loss during operation. Postoperative changes in several hematologic variables measured were all very small. The autotransfusion system proved easy and safe to operate. No patients manifested complications. In our experience, the system may be considered an underutilized resource in rheumatological surgery.