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Fujioka I, Ichikawa Y, Nakajima Y, Kasahara M, Hattori M, Nemoto T. Efficiency of leukocyte depletion filters and micro-aggregate filters following intra-operative cell salvage during cesarean delivery. Int J Obstet Anesth 2019; 41:59-64. [PMID: 31358431 DOI: 10.1016/j.ijoa.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 06/07/2019] [Accepted: 07/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intra-operative cell salvage is not routinely used during cesarean delivery because it is not cost-effective for patients at low risk of hemorrhage and there are theoretical concerns about amniotic fluid embolism. Some guidelines recommend using leukocyte depletion filters to decrease the risk of amniotic fluid embolism before re-infusing salvaged blood, but these filters are not available in Japan. We compared the efficacy and safety of leukocyte depletion and micro-aggregate filters in combination with intra-operative cell salvage during cesarean delivery. METHODS Blood was collected in a Cell Saver 5 reservoir during cesarean delivery. Four samples were collected: pre-wash, post-wash, post-filtration with a leukocyte depletion filter and post-filtration with a micro-aggregate filter. Each sample was analyzed for amniotic fluid markers of zinc coproporphyrin-1 and sialyl-Tn, for fetal hemoglobin, and the sample underwent pathological examination for white blood cells and squamous cells. Post-filtration samples were compared using paired t-tests with P <0.05 indicating statistical significance. RESULTS Zinc coproporphyrin-1 and sialyl-Tn were negative at almost all sample points. Squamous cells decreased by 59.1% post-wash and 91.2% post-filtration using a leukocyte depletion filter. Leukocyte depletion filters removed 99.7% of white blood cells and were more effective in removing white blood cells than micro-aggregate filters (P=0.02). CONCLUSION Leucocyte depletion filters are more effective in removing white blood cells and squamous cells than micro-aggregate filters, and their introduction for intra-operative cell salvage during cesarean delivery should be considered in Japanese clinical practice.
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Affiliation(s)
- I Fujioka
- Department of Obstetrics and Gynecology, Japanese Red Cross Shizuoka Hospital, Japan.
| | - Y Ichikawa
- Department of Obstetrics and Gynecology, Japanese Red Cross Shizuoka Hospital, Japan
| | - Y Nakajima
- Department of Anesthesiology, Japanese Red Cross Shizuoka Hospital, Japan
| | - M Kasahara
- Department of Clinical Pathology, Japanese Red Cross Shizuoka Hospital, Japan
| | - M Hattori
- Department of Obstetrics and Gynecology, Japanese Red Cross Shizuoka Hospital, Japan
| | - T Nemoto
- Department of Obstetrics and Gynecology, Japanese Red Cross Shizuoka Hospital, Japan
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Abstract
Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.
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Tanaka M, Matsuzaki S, Endo M, Kakigano A, Mimura K, Takiuchi T, Miyake T, Tomimatsu T, Ueda Y, Kimura T. Obstetric outcomes and acceptance of alternative therapies to blood transfusion by Jehovah’s Witnesses in Japan: a single-center study. Int J Hematol 2018; 108:432-437. [DOI: 10.1007/s12185-018-2490-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/26/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Zeng K, Huang W, Yu C, Wang R. How about "The effect of intraoperative cell salvage on allogeneic blood transfusion for patients with placenta accreta"?: An observational study. Medicine (Baltimore) 2018; 97:e10942. [PMID: 29851834 PMCID: PMC6392750 DOI: 10.1097/md.0000000000010942] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Intraoperative cell salvage (IOCS) for high-risk obstetric hemorrhage is now endorsed by a number of obstetric organizations. Most previous studies have focused on the safety of IOCS from case series and small controlled studies. Here, we describe the effect of IOCS on rates of allogeneic blood transfusion (ABT) under different degrees of bleeding during cesarean section in women with placenta accreta, which has seldom been reported in the literature.We conducted a retrospective analysis on the introduction of routine application of IOCS for the management of hemorrhage during cesarean section in women with placenta accreta. We identified 115 women, with prenatally diagnosed placenta accreta/increta/percreta before this change in practice, who served as controls, and 108 women who had IOCS applied during cesarean section.Compared with the control treatment, IOCS was significantly associated with a lower incidence of ABT (odds ratio, 0.179; 95% confidence interval, 0.098-0.328). Among the women with ≤3000 mL of bleeding, ABT was avoided in 80 (93.0%) of the 86 patients in the IOCS group, while 49 (50.0%) of the 98 controls required ABT. For women with an estimated blood loss >3000 mL, the reinfused IOCS blood may have helped prevent the need for ABT in 6 (28.6%) of the 21 patients, while all of the 17 controls required ABT. Subgroup analysis of coagulation function and the need for coagulation components showed no significant difference between the 2 groups (P > .05). Compared with the control treatment, IOCS was associated with a lower intraoperative volume of crystalloid (P < .01) and colloid infusion (P < .01) and a shorter length of postoperative hospital stay (P < .01) in patients with placenta accreta. In addition, there were no complications or adverse reactions in patients with placenta accreta who underwent IOCS.IOCS helped reduce the need for ABT and fluid transfusion in patients with placenta accreta and may be safe for use in obstetrics.
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Affiliation(s)
- Kui Zeng
- Department of Anaesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan
| | - Wei Huang
- Department of Anaesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan
| | - Chao Yu
- Department of Anaesthesiology, West China Second University Hospital, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Chengdu, Sichuan
| | - Rurong Wang
- Department of Anaesthesiology, West China Hospital of Sichuan University, Sichuan University, Chengdu, China
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Lier H, von Heymann C, Korte W, Schlembach D. Peripartum Haemorrhage: Haemostatic Aspects of the New German PPH Guideline. Transfus Med Hemother 2017; 45:127-135. [PMID: 29765296 DOI: 10.1159/000478106] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/07/2017] [Indexed: 12/30/2022] Open
Abstract
Summary Peripartum haemorrhage remains one of the main causes of maternal mortality world-wide. The German, Austrian and Swiss Societies of Gynaecology and Obstetrics have updated the current guidelines for the treatment of peripartum haemorrhage together with the German Society of Anaesthesiology and Intensive Care Medicine and the Society of Thrombosis and Haemostasis Research. The recommendations have been the result of a thorough review of the available scientific literature and a consensus process involving all members of the guideline group. A key element of the anaesthesiological and haemostatic management is the development of a multidisciplinary standard operating procedure combining surgical as well as medical and haemostatic treatments depending on the severity of bleeding. The guideline underscores the value of clinical and laboratory diagnostics of peripartum haemorrhage as early as possible, even pre-emptively. This allows for an early identification of causes of bleeding and a specific treatment. The guideline comprises evidence-based recommendations for the use of uterotonics, tranexamic acid and blood products such as factor concentrates, fresh frozen plasma, platelet concentrates, packed red blood cells, recombinant activated factor VII and desmopressin. In addition, recommendations for blood conservation strategies involving the use of cell salvage, permissive hypotension and transfusion triggers are given.
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Affiliation(s)
- Heiko Lier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Cologne, Cologne, Germany
| | - Christian von Heymann
- Department of Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Wolfgang Korte
- Centre for Laboratory Medicine and Haemostasis and Haemophilia Centre, St. Gallen, Switzerland
| | - Dietmar Schlembach
- Department of Obstetrics and Gynaecology, Vivantes Klinikum Neukölln, Berlin, Germany
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Lee PS, Kempner S, Miller M, Dominguez J, Grotegut C, Ehrisman J, Previs R, Havrilesky LJ, Broadwater G, Ellestad SC, Secord AA. Multidisciplinary approach to manage antenatally suspected placenta percreta: updated algorithm and patient outcomes. GYNECOLOGIC ONCOLOGY RESEARCH AND PRACTICE 2017; 4:11. [PMID: 28852530 PMCID: PMC5567476 DOI: 10.1186/s40661-017-0049-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Due to the significant morbidity and mortality associated with placenta percreta, alternative management options are needed. Beginning in 2005, our institution implemented a multidisciplinary strategy to patients with suspected placenta percreta. The purpose of this study is to present our current strategy, maternal morbidity and outcomes of patients treated by our approach. METHODS From 2005 to 2014, a retrospective cohort study of patients with suspected placenta percreta at an academic tertiary care institution was performed. Treatment modalities included immediate hysterectomy at the time of cesarean section (CHYS), planned delayed hysterectomy (interval hysterectomy 6 weeks after delivery) (DH), and fertility sparing (uterine conservation) (FS). Prognostic factors of maternal morbidity were identified from medical records. Complications directly related to interventional procedures and DH was recorded. Descriptive statistics were utilized. RESULTS Of the 21 patients with suspected placenta percreta, 7 underwent CHYS, 13 underwent DH, and 1 had FS with uterine preservation. Of the 20 cases that underwent hysterectomy, final pathology showed 11 increta, 7 percreta, and 2 inconclusive. 19/20 cases underwent interventional radiology (IR) procedures. Selective embolization was utilized in 14 cases (2/7 CHYS; 12/13 DH). The median time from cesarean section (CS) to DH was 41 [26-68] days. There were no cases of emergent hysterectomy, delayed hemorrhage, or sepsis in the DH group. Both estimated blood loss and number of packed red blood cell transfusions were significantly higher in the CHYS group. 3/21 cases required massive transfusion (2 CHYS, 1 FS) with median total blood product transfusion of 13 units [12-15]. The four IR-related complications occurred in the DH group. Incidence of postoperative complications was similar between both groups. Median hospital length of stay (LOS) after CHYS was 4 days [3-8] compared to DH cohort: 7 days [3-33] after CS and 4 days [1 -10] after DH. The DH cohort had a higher rate of hospital readmission of 54% (7/13) compared to 14% (1/7) CHYS, most commonly due to pain. There were no maternal deaths. CONCLUSION This multidisciplinary strategy may appear feasible; however, further investigation is warranted to evaluate the effectiveness of alternative approaches to cesarean hysterectomy in cases of morbidly adherent placenta.
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Affiliation(s)
- Paula S. Lee
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Samantha Kempner
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
| | - Michael Miller
- Department of Interventional Radiology, Duke University Hospital, Durham, USA
| | | | - Chad Grotegut
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Jessie Ehrisman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Rebecca Previs
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | - Laura J. Havrilesky
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
| | | | - Sarah C. Ellestad
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
| | - Angeles Alvarez Secord
- Department of Obstetrics and Gynecology, Duke University Hospital, Durham, North Carolina 27710 USA
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Duke University Hospital, Durham, USA
- Duke Cancer Institute, Durham, USA
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Does current evidence support the use of intraoperative cell salvage in reducing the need for blood transfusion in caesarean section? Curr Opin Obstet Gynecol 2015; 26:425-30. [PMID: 25259949 DOI: 10.1097/gco.0000000000000116] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW An important cause of maternal morbidity and direct maternal death is obstetric haemorrhage at caesarean section. Concerns regarding allogeneic blood safety, limited blood supplies and rising health costs have collectively generated enthusiasm for the utility of methods intended to reduce the use of allogeneic blood transfusion in cases of haemorrhage at caesarean section. This can be achieved by intraoperative cell salvage (IOCS). The aim of this review is to summarize and examine the evidence for the efficacy of IOCS during caesarean section, in women at risk of haemorrhage, in reducing the need for allogeneic blood transfusion. RECENT FINDINGS The majority of the evidence currently available is from case reports and case series. Although this evidence appears to support the use of IOCS in obstetrics, strong clinical evidence or economic effectiveness from clinical trials are essential to support the routine practice of IOCS in obstetrics. SUMMARY Current evidence is limited to reported case series and two small controlled studies. Overall, IOCS may reduce the need for allogeneic blood transfusions during caesarean section. Future large randomized trials are required to assess effectiveness, cost effectiveness and safety. The results of the current ongoing SALVO (A randomised controlled trial of intra-operative cell salvage during caesarean section in women at risk of haemorrhage) trial will shed light on these aspects.
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Abstract
OBJECTIVE To use decision analysis to evaluate whether and under what conditions routine setup of intraoperative cell salvage during cesarean delivery is cost-saving. METHODS We developed a decision model to compare costs associated with two strategies for cesarean delivery: 1) routine setup of intraoperative cell salvage; or 2) standard care without intraoperative cell salvage. One-, two-, and three-way sensitivity analyses as well as Monte Carlo simulation were used to assess the robustness of our findings. RESULTS Among nonselected women undergoing cesarean delivery, our base case estimate was that 3.2% would require red blood cell transfusion. Under this assumption, cell salvage is cost-saving only if each woman requires at least 60 units. Conversely, if only two units on average are required, the probability of transfusion needs to be at least 58% for cell salvage to be cost-saving. In our base case analysis, setup of intraoperative cell salvage during routine cesarean deliveries is not cost-saving, increasing the cost per cesarean delivery by $223.80. We found that cell salvage would be cost-saving only in very high-risk scenarios. For example, severe maternal anemia or abnormal placentation, in which 54% and 75% of women are transfused three and two units per case, respectively, would make cell salvage cost-saving. CONCLUSION Setup of intraoperative cell salvage during cesarean delivery is cost-saving and should be considered only when there is a predictably high probability of transfusion or when a massive transfusion is reasonably likely.
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Morikawa M, Kuramoto A, Nakayama M, Oguchi H, Hasegawa M, Funakoshi T, Furukawa S, Hirayama E, Kanagawa T, Kaji T, Kasai M, Konishi Y, Yamamoto SI, Itakura A, Maeda M, Kobayashi T, Minakami H. Intraoperative red cell salvage during obstetric surgery in 50 Japanese women. Int J Gynaecol Obstet 2014; 128:256-9. [DOI: 10.1016/j.ijgo.2014.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 08/25/2014] [Accepted: 10/20/2014] [Indexed: 11/28/2022]
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Elagamy A, Abdelaziz A, Ellaithy M. The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation. Int J Obstet Anesth 2013; 22:289-93. [DOI: 10.1016/j.ijoa.2013.05.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 04/05/2013] [Accepted: 05/20/2013] [Indexed: 11/25/2022]
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Rogers WK, Wernimont SA, Kumar GC, Bennett E, Chestnut DH. Acute hypotension associated with intraoperative cell salvage using a leukocyte depletion filter during management of obstetric hemorrhage due to amniotic fluid embolism. Anesth Analg 2013; 117:449-52. [PMID: 23749444 DOI: 10.1213/ane.0b013e3182938079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Amniotic fluid embolism (AFE) is a rare but catastrophic obstetric complication that can lead to profound coagulopathy and hemorrhage. The role of cell salvage and recombinant human Factor VIIa (rFVIIa) administration in such cases remains unclear. We present a case of AFE and describe our experience with the use of cell salvage and rFVIIa administration during the resuscitation. Cell salvage and transfusion through a leukocyte depletion filter was attempted after the diagnosis of AFE was made, but the attempted transfusion was immediately followed by hypotension and a worsening of hemodynamics. rFVIIa, on the contrary, was used with clinical improvement in coagulopathy and without apparent adverse thrombotic effect.
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Affiliation(s)
- William Kirke Rogers
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave., B6/319 CSC, Madison, WI 53792-3272, USA.
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