Cell salvage for minimising perioperative allogeneic blood transfusion

Efficacy of intraoperative blood salvage and autotransfusion in living-donor liver transplantation: a retrospective cohort study

BACKGROUND

Liver transplantation (LT) may be associated with massive blood loss and the need for allogeneic blood transfusion. Intraoperative blood salvage autotransfusion (IBSA) can reduce the need for allogeneic blood transfusion. This study aimed to investigate the effectiveness of blood salvage in LT.

METHODS

Among 355 adult patients who underwent elective living-donor LT between January 1, 2019, and December 31, 2022, 59 recipients without advanced hepatocellular carcinoma received IBSA using Cell Saver (CS group). Based on sex, age, model for end-stage liver disease (MELD) score, preoperative laboratory results, and other factors, 118 of the 296 recipients who did not undergo IBSA were matched using propensity score (non-CS group). The primary outcome was the amount of intraoperative allogenic red blood cell (RBC) transfusion. Comparisons were made between the two groups regarding the amount of other blood components transfused and postoperative laboratory findings.

RESULTS

The transfused allogeneic RBC for the CS group was significantly lower than that of the non-CS group (1,506.0 vs. 1,957.5 ml, P = 0.026). No significant differences in the transfused total fresh frozen plasma, platelets, cryoprecipitate, and estimated blood loss were observed between the two groups. The postoperative allogeneic RBC transfusion was significantly lower in the CS group than in the non-CS group (1,500.0 vs. 2,100.0 ml, P = 0.039). No significant differences in postoperative laboratory findings were observed at postoperative day 1 and discharge.

CONCLUSIONS

Using IBSA during LT can effectively reduce the need for perioperative allogeneic blood transfusions without causing subsequent coagulopathy.

The Use of Intraoperative Cell Salvage in Two-Stage Revision of Septic Hip Arthroplasties: A Double-Center Retrospective Study

(1) Background: intraoperative cell salvage (ICS) devices can provide a valuable contribution to patient blood management. An infection of the surgical site presents a formal contraindication to the use of ICS. To date, there is no recommendation for the use of ICS in the context of reimplantation in two-stage septic exchange arthroplasty. (2) Methods: at two hospitals of maximum endoprosthetic care, a retrospective evaluation of patients who had received ICS blood during reimplantation of hip arthroplasties was performed. Patients' and surgical characteristics, intraoperative cultures, and the occurrence of septic complications in the short- and long-term follow-up were recorded. (3) Results: 144 patients were included. Detection of positive cultures during reimplantation occurred in 13 cases. A total of 127 patients showed no complication, 8 patients showed a non-specific septic complication, 6 patients a local persistence of infection, and 3 patients a possible bloodstream-associated infection. No significant correlation was found between the occurrence of complications and the detection of positive intraoperative cultures. (4) Conclusions: no clustering of septic complications due to the use of ICS during reimplantation was found. In the risk-benefit analysis, we considered the use of ICS during reimplantation to be indicated in terms of patient blood management, while the safety of the procedure during septic first-stage resection arthroplasty or septic one-stage exchange arthroplasty was not investigated. Given the paucity of comparative literature, further studies are needed on ideal patient blood management in the setting of septic revision arthroplasty.

Effect of intraoperative hypovolemic phlebotomy on transfusion and clinical outcomes in patients undergoing hepatectomy: a retrospective cohort study

Background

There is no consensus on how to best achieve a low central venous pressure during hepatectomy for the purpose of reducing blood loss and red blood cell (RBC) transfusions. We analyzed the associations between intraoperative hypovolemic phlebotomy (IOHP), transfusions, and postoperative outcomes in cancer patients undergoing hepatectomy.

Methods

Using surgical and transfusion databases of patients who underwent hepatectomy for cancer at one institution (11 January 2011 to 22 June 2017), we retrospectively analyzed associations between IOHP and RBC transfusion on the day of surgery (primary outcome), and with total perioperative transfusions, intraoperative blood loss, and postoperative complications (secondary outcomes). We fitted logistic regression models by inverse probability of treatment weighting to adjust for confounders and reported adjusted odds ratio (aOR).

Results

There were 522 instances of IOHP performed during 683 hepatectomies, with a mean (standard deviation) volume of 396 (119) mL. The IOHP patients had a 6.9% transfusion risk on the day of surgery compared with 12.4% in non-IOHP patients (aOR, 0.53; 95% confidence interval [CI], 0.29 to 0.98; P = 0.04). Total perioperative RBC transfusion tended to be lower in IOHP patients compared with non-IOHP patients (14.9% vs 22.4%, respectively; aOR, 0.72; 95% CI, 0.44 to 1.16; P = 0.18). In patients with a predicted risk of ≥ 47.5% perioperative RBC transfusion, 24.6% were transfused when IOHP was used compared with 56.5% without IOHP. The incidence of severe postoperative complications (Clavien–Dindo scores ≥ 3) was similar in patients whether or not IOHP was performed (15% vs 16% respectively; aOR, 0.97; 95% CI, 0.53 to 1.54; P = 0.71).

Conclusions

The use of IOHP during hepatectomy was associated with less RBCs transfused on the same day of surgery. Trials comparing IOHP with other techniques to reduce blood loss and transfusion are needed in liver surgery.

Supplementary Information

The online version of this article (10.1007/s12630-021-01958-8) contains supplementary material, which is available to authorized users.

The Current Practice of Adult Idiopathic Scoliosis Surgical Treatment Among Spine Surgeons in Saudi Arabia

Background: Scoliosis is a spinal deformity consisting of lateral curvature and rotation of the vertebrae. The goal of corrective scoliosis surgery is to restore alignment of the spine and maintain motion. However, there is no global agreement among spine surgeons on the best method of surgical intervention, and little is known about the variations in practice among spine surgeons in Saudi Arabia.

Objectives: The aim of this study is to examine the current surgical practices relating to adolescent idiopathic scoliosis and to establish the degree of variation and consensus among spine surgeons in Saudi Arabia.

Methods: This was a cross-sectional study conducted among spine surgeons in Saudi Arabia, using a self-administered questionnaire. The questionnaire addressed four areas: surgeons’ demographics, pre-operative assessment, operative assessment, and infection control practices. There were a total of 27 questions. Data was analyzed using statistical package for social sciences (SPSS) software (SPSS Inc., Chicago, IL, USA).

Results: A total of 150 surgeons were included in this study. Of these, 73 responded to the questionnaire (response rate: 48.6%), 46 (63.01%) of whom were fellows. All respondents were males, and 37 (51.39%) were aged between 30 and 40 years. Fifty five (75.34%) were orthopedic surgeons. The most commonly used pre-operative health assessment test was an echocardiogram. Sixty six (90%) surgeons requested scoliosis anteroposterior (AP) view and lateral radiograph for curvature between 40 degrees and 90 degrees, and 65 (89%) requested it for curvature greater than 90 degrees. For the posterior construct, 29 (45.31%) did not use cross-links for fewer than 10 levels, and 23 (35.94%) did not use cross-links for more than 10 levels. In addition to a local bone graft, the most commonly used transplant method was allograft 37 (50.68%). Fifty five (85.94%) respondents favored an all-screw pedicle construct over a hybrid construct.

Conclusion: A large variation in surgical practices was observed. This was especially apparent in practices including the use of cross-links, intra-operative cell salvage, and the intra-operative use of traction. Some degree of variation was observed in pre-operative imaging assessment practices. Surgical guidelines should be developed to build a consensus among surgeons. A unified surgical training curriculum may help in achieving this goal.

Efficacy and safety of using antifibrinolytic agents in spine surgery: a meta-analysis

PURPOSE

Spine surgery, particularly reconstructive surgery, can be associated with significant blood loss, and blood transfusion. Antifibrinolytic agents are used routinely to reduce bleeding in cardiac, orthopaedic, and hepatic surgery. The purpose of this study was to assess the efficacy and safety of using antifibrinolytic agents in reducing blood loss and blood transfusions in spine surgery.

METHODS

A systematic search of all related studies written in English published by October 2012 was conducted using the MEDLINE, EMBASE and the Cochrane Library databases. Randomized controlled trials that reported the drug dosage, total blood loss, blood transfusion and incidence of deep vein thrombosis as the primary outcome were included.

RESULTS

Nine studies involving 482 patients were identified. Patients receiving antifibrinolytic agents had reduced blood loss (WMD =-288.8, 95 % CI - 46.49, - 110.19; P = 0.002), reduced blood transfusion (WMD =-242.7, 95 % CI - 422.57, - 62.95; P = 0.008), reduced blood transfusion rate (RR 0.73, 95% CI 0.58, 0.93; p = 0.010) and no increase (RR 0.25, 95 % CI 0.03, 2.22; P = 0.21) in the risk of deep vein thrombosis.

CONCLUSIONS

We conclude that antifibrinolytic agents significantly decrease blood loss, blood transfusion, and there is no increase in the risk of deep vein thrombosisfor transfusion requirements in spine surgery.

Evolution of the role of army transfusion services in the management of trauma patients and battle casualties with massive hemorrhage

Providing blood at the times of national emergencies and war-like scenarios is a challenge to the blood transfusion services. The dictum should be adequate bleeding, minimum storage time, quick transportation and maximum utilization of blood as soon as possible. For the successful implementation of its role, forward transfusion services should be fully mobile with integral transportation and communication systems. Supplementation of blood supplies has to be prompt, & for this adequate air transport facilities will have to be established. A rational approach to using blood products in patients with bleeding, requires an understanding of the principles of managing hemorrhagic shock. The main priorities are controlling hemorrhage and restoring adequate oxygen delivery to the tissues. Surgical control and treatment of coagulopathy are required to stop hemorrhage in these patients. Resuscitation with fluids and red cells are necessary to improve perfusion and oxygen delivery to tissues. Once patients are resuscitated and further bleeding is stopped, use of conservative transfusion triggers is recommended to avoid excessive transfusion and adverse outcomes. A host of new technologies are being developed that have the potential of reducing blood loss. These will help in reducing the transfusion requirements in trauma patients with massive hemorrhage.

Efficacy of tranexamic acid in reducing blood loss in posterior lumbar spine surgery for degenerative spinal stenosis with instability: a retrospective case control study

BACKGROUND

Degenerative spinal stenosis and instability requiring multilevel spine surgery has been associated with large blood losses. Factors that affect perioperative blood loss include time of surgery, surgical procedure, patient height, combined anterior/posterior approaches, number of levels fused, blood salvage techniques, and the use of anti-fibrinolytic medications. This study was done to evaluate the efficacy of tranexamic acid in reducing blood loss in spine surgery.

METHODS

This retrospective case control study includes 97 patients who had to undergo surgery because of degenerative lumbar spinal stenosis and instability. All operations included spinal decompression, interbody fusion and posterior instrumentation (4-5 segments). Forty-six patients received 1 g tranexamic acid intravenous, preoperative and six hours and twelve hours postoperative; 51 patients without tranexamic acid administration were evaluated as a control group. Based on the records, the intra- and postoperative blood losses were measured by evaluating the drainage and cell saver systems 6, 12 and 24 hours post operation. Additionally, hemoglobin concentration and platelet concentration were reviewed. Furthermore, the number of red cell transfusions given and complications associated with tranexamic acid were assessed.

RESULTS

The postoperative hemoglobin concentration demonstrated a statistically significant difference with a p value of 0.0130 showing superiority for tranexamic acid use (tranexamic acid group: 11.08 g/dl, SD: 1.68; control group: 10.29 g/dl, SD: 1.39). The intraoperative cell saver volume and drainage volume after 24 h demonstrated a significant difference as well, which indicates a less blood loss in the tranexamic acid group than the control group. The postoperative drainage volume at12 hours showed no significant differences; nor did the platelet concentration Allogenic blood transfusion (two red cell units) was needed for eight patients in the tranexamic acid group and nine in the control group because of postoperative anemia. Complications associated with the administration of tranexamic acid, e.g. renal failure, deep vein thrombosis or pulmonary embolism did not occur.

CONCLUSIONS

This study suggests a less blood loss when administering tranexamic acid in posterior lumbar spine surgery as demonstrated by the higher postoperative hemoglobin concentration and the less blood loss. But given the relatively small volume of blood loss in the patients of this study it is underpowered to show a difference in transfusion rates.

Coagulopathy in liver disease

The liver plays a central role in hemostasis, as it is the site of synthesis of clotting factors, coagulation inhibitors, and fibrinolytic proteins. The most common coagulation disturbances occurring in liver disease include thrombocytopenia and impaired humoral coagulation. Therapy's overall goal is not to achieve complete correction of laboratory value abnormalities but to gain hemostasis. Therapy with vitamin K may be a useful option in patients with increased prothrombin time due to vitamin K deficiency; in patients with malnutrition; in patients using antibiotics; and in patients with cholestatic liver disease, particularly prior to invasive procedures. Infusion of fresh frozen plasma is more often effective and is recommended in patients with liver disease before invasive procedures or surgery, as such patients require transient correction in their prothrombin time. Therapy with plasma exchange may be considered in patients who cannot be treated with fresh frozen plasma due to volume overload risk. In patients with severe coagulopathy and hypofibrinogenemia, cryoprecipitate therapy is ideal. Therapy with prothrombin-complex concentrate is seldom pursued in patients with liver disease due to high risk of thrombotic complications. Transfusions of platelets are appropriate for patients with thrombocytopenia (< 50,000/mm(3)) associated with active bleeding or before invasive procedures in which a short-term platelet count increase is noted. Trial with desmopressin may be considered before invasive procedures in patients with liver disease and with refractory and prolonged bleeding time. Recombinant activated factor VIIa administration is suggested for patients with significantly prolonged prothrombin time and contraindications to fresh frozen plasma therapy; however, this is expensive. Thrombopoietin and interleukin-11 are currently investigational for patients with thrombocytopenia of chronic liver disease. Liver transplantation completely restores impaired coagulation abnormalities and is the ultimate intervention that corrects coagulopathy of advanced liver disease and liver failure.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Transfusion-related acute lung injury: a literature review

Transfusion-related acute lung injury (TRALI) is a serious and potentially fatal complication of transfusion of blood and blood components. TRALI is under-diagnosed and under-reported because of a lack of awareness. A number of models have been proposed to explain the pathogenesis of TRALI: an antibody mediated model; a two-event biologically active mediator model; and a combined model. TRALI can occur with any type of blood product and can occur with as little as one unit. Its presentation is similar to other forms of acute lung injury and management is predominantly supportive. The main strategy in combating TRALI is prevention both through manipulation of the donor pool and through clinical strategies directed at reducing transfusion of blood products including, but not limited to, evidence-based lower transfusion thresholds. This article presents a review of TRALI and addresses the definition, pathology, pathogenesis, clinical manifestations, treatment and prevention of the syndrome.

Timing of re-transfusion drain removal following total knee replacement

INTRODUCTION

The use of postoperative drains following total knee replacement (TKR) has recently been modified by the use of re-transfusion drains. The aim of our study was to investigate the optimal time for removal of re-transfusion drains following TKR.

PATIENTS AND METHODS

The medical records of 66 patients who had a TKR performed between October 2003 and October 2004 were reviewed; blood drained before 6 h and the total volume of blood drained was recorded.

RESULTS

A total of 56 patients had complete records of postoperative drainage. The mean volume of blood collected in the drain in the first 6 h was 442 ml. The mean total volume of blood in the drain was 595 ml. Therefore, of the blood drained, 78% was available for transfusion.

CONCLUSION

Re-transfusion drains should be removed after 6 h, when no further re-transfusion is permissible.

Perioperative complications of radical retropubic prostatectomy

The opinions and assertions contained herein are the private views of the authors and are not to be construed as reflective of the views of the US Army or the Department of Defense. Radical retropubic prostatectomy has long been considered one of the most difficult procedures in the urologist's armamentarium. Therefore, we performed a thorough review of recent literature regarding intraoperative and postoperative complications. The intent of this effort is to review established data regarding the most frequently seen complications and to highlight recent developments regarding the prevention or treatment of such complications.

Cost and utilization of blood transfusion associated with spinal surgeries in the United States

The purpose of this study was to examine factors associated with the utilization and cost of blood transfusion during and post-spinal fusion surgery. A retrospective, observational study of 42,029 inpatients undergoing spinal fusion surgery in United States hospitals participating in the Perspective( Comparative Database for inpatient use was conducted. Descriptive analysis, logistic regression, and ordinary least squares (OLS) regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion (ABT). Hospitalization costs were $18,690 (SD=14,159) per patient, erythropoietin costs were $85.25 (SD=3,691.66) per patient, and topical sealant costs were $414.34 (SD=1,020.06) per patient. Sub-analysis of ABT restricted to users revealed ABT costs ranged from $312.24 (SD=543.35) per patient with whole blood to $2,520 (SD=3,033.49) per patient with fresh frozen plasma. Patients that received hypotensive anesthesia (OR,1.61; 95% CI, 1.47-1.77), a volume expander (OR,1.95; 95% CI, 1.75-2.18), autologous blood (OR, 2.04; 95% CI, 1.71-2.42), or an erythropoietic agent (OR=1.64; 95% CI, 1.27-2.12) had a higher risk of ABT. Patients that received cell salvage had a lower risk of transfusion (OR=0.40; 95% CI, 0.32-0.50). Most blood avoidance techniques have low utilization or do not reduce the burden of transfusion associated with spinal fusion.

Resource utilization and costs of blood management services associated with knee and hip surgeries in US hospitals

This article assesses the use and costs of blood transfusion during knee and hip surgery through a retrospective observational study of 92,223 discharged inpatients who had undergone knee or hip surgery from July 1, 2003, through June 30, 2004; a sample of US hospitals that participated in the Perspective Comparative Database (Premier Inc., Charlotte, NC) was used. Descriptive and multivariate analyses were performed to determine the use and costs of allogeneic blood transfusion (ABT). The average cost of ABT per user ranged from $387 (SD=$952) for red blood cells to $6585 (SD=$11,162) for cryoprecipitate. Utilization rates in the sample were as follows: antifibrinolytics, 0.14%; topical sealants, 3.24%; volume expanders, 3.89%; erythropoietin agents, 5.08%; and hypotensive anesthesia, 22.28%. Patients who were given volume expanders ($133.73, SD=$23.00, P<.01) or erythropoietin ($177.72, SD=$34.61, P<.01) had higher costs associated with ABT than did those who did not use volume expanders or erythropoietin. Patients who received hypotensive anesthesia (odds ratio [OR]=1.96; 95% confidence interval [CI], 1.87-2.06), a volume expander (OR=1.71; 95% CI, 1.57- 1.85), a topical sealant (OR=1.61; 95% CI, 1.45-1.79), or an erythropoietic agent (OR=2.30; 95% CI, 2.06-2.57) had a greater likelihood of ABT. Investigators concluded that most transfusion reduction techniques are underused, or they do not reduce the burden of ABT associated with knee or hip surgery.

Does washing swabs increase the efficiency of red cell recovery by cell salvage in aortic surgery?

BACKGROUND AND OBJECTIVES

We investigated the contribution of swab washing to the efficiency of red cell recovery by intraoperative cell salvage (ICS) in 10 patients undergoing elective aortic aneurysm repair.

MATERIALS AND METHODS

Volumes and haemoglobin (Hb) concentrations were recorded in the blood recovered by direct suction and from washed swabs, both before and after processing with a Haemonetics Cell Saver 5.

RESULTS

The mean +/- standard deviation (SD) estimated blood loss was 991 +/- 403 ml, resulting in a mean +/- SD salvaged RBC volume of 380 +/- 124 ml. The median [interquartile (IQR) range] Hb collected from suction was 84.9 (61.8-131.4) g, of which 50.1 (45-71.5) g was returned to the patient after processing, a median yield of 68 (49-77)%. The swab wash produced a median (IQR) Hb of 39.4 (28.4-64.9) g, of which 26.2 (16.8-31) g was reinfused, a 67 (33-98)% yield. Swab wash thus contributed with a median (IQR) of 31 (24-39)% of the total RBC recovery.

CONCLUSIONS

Washing swabs improves the efficiency of red cell recovery by ICS.

An overview of blood-sparing techniques used in spine surgery during the perioperative period

The problems linked to blood loss and blood-sparing techniques in spine surgery have been less studied than in other fields of orthopedics, such as joint-replacement procedures. Decreasing bleeding is not only important for keeping the patient's hemodynamic equilibrium but also for allowing a better view of the surgical field. In spine surgery the latter aspect is especially important because of the vicinity of major and highly fragile neurologic structures. The techniques and agents used for hemostasis and blood sparing in spinal procedures are mostly similar to those used elsewhere in surgery. Their use is modulated by the specific aspects of spinal approach and its relation to the contents of the spinal canal. Blood-sparing techniques can be divided into two categories based on their goals: either they are aimed at decreasing the bleeding itself, or they are aimed at decreasing the need for homologous transfusion. Various hemodynamic techniques, as well as systemic and local drugs and agents, can be used separately or in combination, and their use in the field of spine surgery is reported. The level of evidence for the efficacy of many of those methods in surgery as a whole is limited, and there is a lack of evidence for most of them in spine surgery. However, several blood-saving procedures and drugs, as well as promising new agents, appear to be efficient, although their efficacy has yet to be assessed by proper randomized controlled trials.

Intraoperative blood management in joint replacement surgery

Interest is growing in blood conservation and avoidance of transfusion in patients undergoing orthopedic surgery, especially in the field of joint replacement. Several methods have proven successful in reducing intraoperative blood loss, which can translate into lessened allogeneic and autologous transfusion requirements. Available techniques include acute normovolemic hemodilution, hypotensive anesthesia, intraoperative blood salvage, specialized cautery, topical hemostatic agents, and pharmacologic agents given in the perioperative period. The greatest potential benefit arises in operations with greater expected blood loss or in special situations such as in patients with religious issues, bilateral joint replacement, coagulation disorders, or significant preoperative anemia.