The economic benefits of cell salvage in obstetric haemorrhage

Cell Salvage in Oncological Surgery, Peripartum Haemorrhage and Trauma

Oncological surgery, obstetric haemorrhage and severe trauma are the most challenging conditions for establishing clinical recommendations for the use of cell salvage. When the likelihood of allogeneic transfusion is high, the intraoperative use of this blood-saving technique would be justified, but specific patient selection criteria are needed. The main concerns in the case of oncological surgery are the reinfusion of tumour cells, thereby increasing the risk of metastasis. This threat could be minimized, which may help to rationalize its indication. In severe peripartum haemorrhage, cell salvage has not proven cost-effective, damage control techniques have been developed, and, given the risk of fetomaternal alloimmunization and amniotic fluid embolism, it is increasingly out of use. In trauma, bleeding may originate from multiple sites, coagulopathy may develop, and it should be evaluated whether re-transfusion of autologous blood collected from uncontaminated organ cavities would be feasible. General safety measures include washing recovered blood and its passage through leukocyte depletion filters. To date, no well-defined indications for cell salvage have been established for these pathologies, but with accurate case selection and selective implementation, it could become safe and effective. Randomized clinical trials are urgently needed.

Intraoperative cell salvage is associated with reduced allogeneic blood requirements and has no significant impairment on coagulation function in patients undergoing cesarean delivery: a retrospective study

OBJECTIVE

The aim of the study is to examine the association between Intraoperative cell salvage (ICS), allogeneic blood transfusion (ABT) and coagulation function in obstetrics.

METHODS

A total of 486 pregnant women undergoing cesarean delivery, of whom 157 were enrolled in this retrospective study. Patients were divided into ICS group (n = 101, ICS used during operation) and control group (n = 56, ICS not used during operation). Clinical data, including plasma prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (Fib) and thrombin time (TT) levels, were collected from all patients preoperatively (within 12-24 h) and postoperatively (within 6-12 h) and analyzed by t test, two-way repeated-measures ANOVA and Spearman's correlation.

RESULTS

The use of ICS is associated with lower requirement rate for ABT (P < .001), while the blood loss was similar between the two groups (P = .990). Mean volume of ICS transfusion was 432.65 mL. Compared to preoperative values, the postoperative PT and APTT levels were significantly increased, while Fib was decreased in the two groups (all P < .01). No significant difference in coagulation function was observed between groups in preoperative and postoperative phase (P > .05). Furthermore, PT, APTT and TT after surgery were not correlated with the transfused volume of salvaged blood (P > .05) while the levels of Fib were negatively correlated with the volume (P < .01). In addition, there were no transfusion reactions in both two groups.

CONCLUSIONS

Intraoperative cell salvage is correlated with reduced allogeneic blood requirements but did not impair blood coagulation significantly in patients undergoing cesarean delivery.

Intraoperative cell salvage as part of a blood conservation strategy in an obstetric population with abnormal placentation at a large Irish tertiary referral centre: an observational study

BACKGROUND

Haemorrhagic morbidity is more common in women with abnormal placentation, that is placenta praevia or morbidly adherent placenta. The incidence of abnormal placentation is increasing due to rising caesarean section rates. Concerns regarding blood safety, blood shortages and soaring costs of blood processing have generated growing enthusiasm for blood conservation strategies. The aim of our study was to look at intraoperative cell salvage (IOCS) use and allogeneic transfusion patterns in patients with abnormal placentation.

METHODS

Patients with abnormal placentation were identified from the hospital database over a 2-year period between 2015 and 2016. Information collected for those that had IOCS setup included estimated blood loss, volume of blood collected and returned, pre- and postoperative haemoglobin levels and use of allogeneic blood.

RESULTS

A total of 139 cases of abnormal placentation were identified. Abnormal placentation accounted for 62% of all cases of IOCS usage and was established for 53 patients with abnormal placentation. The re-transfusion rate was 18.5%. Five patients received IOCS blood only. The allogeneic transfusion rate was 7.5% in patients who had IOCS setup compared with 6.9% in those who did not (p = 1.00). Median blood loss was greater for patients who had IOCS blood returned compared with patients who had not (p = 0.004). The median volume of blood returned was 520 (114-608) mL. Preoperative haemoglobin levels were lower for patients who received a combination of cell salvage and allogeneic blood (p = 0.006).

CONCLUSIONS

IOCS contributed to a reduction or elimination of allogeneic transfusion for a proportion of this high-risk cohort and should be an integral component of a hospitals' blood conservation strategy.

How about "The effect of intraoperative cell salvage on allogeneic blood transfusion for patients with placenta accreta"?: An observational study

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.

Haematological alterations in the cardiac patient after use of an autotransfusion system

OBJECTIVE

There are studies that declare blood recovered with the autotransfusion system that is potentially heparinised and mixed with other drugs, can cause haematological alterations in the patient, according to existing evidence. The proposal was to compare the haematological values of the patients before reinfusing red blood cells from the cell saver and 12h after reinfusion.

MATERIAL AND METHODS

Observational analytical study of 479 patients who underwent cardiac surgery where the cell saver was used. Haematological variables were collected before reinfusion and 12h after reinfusion.

RESULTS

Statistically significant haematological values before reinfusion and 12h after reinfusion were: haemoglobin (9.5 to 12.5g/dL), haematocrit (26 to 38%), platelets (214.2 to 164.210^3/μL), total proteins (7.6 to 5.1g/dL), PCR (8.5 to 22.1mg/L) and D-dimer (493.3 to 875.5μg/L) with P<.05.

CONCLUSIONS

With the use of the cell saver an increase was observed of haemoglobin, haematocrit, PCR and D-dimer values together with a decrease in platelet and total protein numbers.

Cost-effectiveness Analysis of Intraoperative Cell Salvage for Obstetric Hemorrhage

BACKGROUND

Cost-effectiveness analyses on cell salvage for cesarean delivery to inform national and societal guidelines on obstetric blood management are lacking. This study examined the cost-effectiveness of cell salvage strategies in obstetric hemorrhage from a societal perspective.

METHODS

Markov decision analysis modeling compared the cost-effectiveness of three strategies: use of cell salvage for every cesarean delivery, cell salvage use for high-risk cases, and no cell salvage. A societal perspective and lifetime horizon was assumed for the base case of a 26-yr-old primiparous woman presenting for cesarean delivery. Each strategy integrated probabilities of hemorrhage, hysterectomy, transfusion reactions, emergency procedures, and cell salvage utilization; utilities for quality of life; and costs at the societal level. One-way and Monte Carlo probabilistic sensitivity analyses were performed. A threshold of $100,000 per quality-adjusted life-year gained was used as a cost-effectiveness criterion.

RESULTS

Cell salvage use for cases at high risk for hemorrhage was cost-effective (incremental cost-effectiveness ratio, $34,881 per quality-adjusted life-year gained). Routine cell salvage use for all cesarean deliveries was not cost-effective, costing $415,488 per quality-adjusted life-year gained. Results were not sensitive to individual variation of other model parameters. The probabilistic sensitivity analysis showed that at the $100,000 per quality-adjusted life-year gained threshold, there is more than 85% likelihood that cell salvage use for cases at high risk for hemorrhage is favorable.

CONCLUSIONS

The use of cell salvage for cases at high risk for obstetric hemorrhage is economically reasonable; routine cell salvage use for all cesarean deliveries is not. These findings can inform the development of public policies such as guidelines on management of obstetric hemorrhage.

Does current evidence support the use of intraoperative cell salvage in reducing the need for blood transfusion in caesarean section?

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.

Retrospective analysis of community hospital red blood cell recovery procedures: improved utilization needed for effectiveness

BACKGROUND

Perioperative blood recovery (PBR) is an important component of patient blood management. We analyzed our experience providing PBR for community hospitals to determine procedure types and clinical variables associated with efficacy and cost-effectiveness.

STUDY DESIGN AND METHODS

PBR cases (>25,000) from January 2008 through December 2012 were analyzed. For each procedure type, the median number of returned red blood cell units (rRBCs) and ratio of cases with at least 1 to less than 1 rRBC unit were calculated. Clinical predictors of rRBC were identified by linear and logistic regression.

RESULTS

The overall median rRBC was 0.29 units despite median estimated blood loss (EBL) of 350 mL. Only three of 31 common procedure types had ≥1:<1 rRBC ratios near to or higher than 1. In nine of 31 common procedure types, at least 50% of cases had no rRBC return. Linear regression demonstrated significant association of rRBCs with increased EBL, longer operative duration, surgeon, PBR device type (autoLog vs. CS5), and decreasing age. EBL, autoLog use, high surgeon case volume, vascular procedures, and emergent versus elective procedures associated with higher odds of at least 1 rRBC.

CONCLUSION

Discrepancy between rRBC and EBL and high percentages of cases with no rRBC suggests that PBR technique and case selection need optimization. Identification of procedure types and variables associated with PBR efficacy (≥1 rRBC) should improve utilization of PBR. Association of autoLog use with higher rRBC warrants further investigation.