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Kurland DB, Alber D, Smith A, Ahmed S, Orringer D, Frempong-Boadu A, Lau D. What Are We Transfusing? Evaluating the Quality and Clinical Utility of Intraoperatively Salvaged Red Blood Cells in Spinal Deformity Surgery: A Nonrandomized Controlled Trial. Neurosurgery 2024:00006123-990000000-01301. [PMID: 39087785 DOI: 10.1227/neu.0000000000003131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 06/19/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Intraoperative red blood cell (RBC) salvage is frequently used in contemporary spine surgery, despite clinical concern in its efficacy as a surrogate for blood-banked allogeneic packed RBCs (pRBCs). During spine surgery, salvaged RBCs (sRBCs) are exposed to injurious high-heat electrocautery, prolonged stasis, and abrasive pharmaceuticals, potentially making sRBCs a poor blood substitute. We therefore sought to scientifically and objectively define the quality of sRBCs in the context of complex spine surgery. METHODS This is a single-center, prospective, nonrandomized controlled trial of patients undergoing posterior-based multilevel thoracolumbar instrumented fusion for spinal deformity with planned use of intraoperative RBC salvage between June 2022 and July 2023. Surgeries were performed by fellowship-trained spinal neurosurgeons and orthopedic surgeons. The participants were split based on transfusion of sRBCs (given sufficient yield) vs no sRBC transfusion. Primary outcomes were RBC electrolyte composition, indices, deformability, and integrity, which were evaluated in comparison blood samples: Baseline, pRBC, and sRBC. Secondary outcomes were related to clinical effects of sRBC transfusion. Morphological assessment used Stimulated Raman Histology and machine learning. Deformability was assessed using ektacytometry. RESULTS A total of 174 patients were included. The mean age was 50.2years ±25.4, 58.6% was female, the mean level fused was 10.0 ± 3.9, and 58.0% received sRBCs (median 207.0 mL). sRBCs differed significantly on standard laboratory measures, had a high proportion (30.7%) of shrunken and irregularly spiculated morphologies, and demonstrated abnormal deformability and relaxation kinetics. The hemolysis index was significantly elevated in sRBCs (2.9 ± 1.8) compared with Baseline samples and pRBCs (P < .01). Transfusion of sRBCs was associated with suboptimal resuscitation and provided no practical clinical benefit. CONCLUSION RBCs salvaged during posterior thoracolumbar spine surgery are irreversibly injured, with hemolysis index exceeding Food and Drug Administration and Council of Europe transfusion standards in all samples, questioning their efficacy and safety as a blood substitute.
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Affiliation(s)
- David B Kurland
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Daniel Alber
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Andrew Smith
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Shah Ahmed
- Department of Anesthesiology, New York University Langone Medical Center, New York, New York, USA
| | - Daniel Orringer
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Anthony Frempong-Boadu
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
| | - Darryl Lau
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
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Deng J, Zhou C, Xiao F, Chen J, Li C, Xie Y. Construction of a predictive model for blood transfusion in patients undergoing total hip arthroplasty and identification of clinical heterogeneity. Sci Rep 2024; 14:724. [PMID: 38184749 PMCID: PMC10771504 DOI: 10.1038/s41598-024-51240-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024] Open
Abstract
A precise forecast of the need for blood transfusions (BT) in patients undergoing total hip arthroplasty (THA) is a crucial step toward the implementation of precision medicine. To achieve this goal, we utilized supervised machine learning (SML) techniques to establish a predictive model for BT requirements in THA patients. Additionally, we employed unsupervised machine learning (UML) approaches to identify clinical heterogeneity among these patients. In this study, we recruited 224 patients undergoing THA. To identify factors predictive of BT during the perioperative period of THA, we employed LASSO regression and the random forest (RF) algorithm as part of supervised machine learning (SML). Using logistic regression, we developed a predictive model for BT in THA patients. Furthermore, we utilized unsupervised machine learning (UML) techniques to cluster THA patients who required BT based on similar clinical features. The resulting clusters were subsequently visualized and validated. We constructed a predictive model for THA patients who required BT based on six predictive factors: Age, Body Mass Index (BMI), Hemoglobin (HGB), Platelet (PLT), Bleeding Volume, and Urine Volume. Before surgery, 1 h after surgery, 1 day after surgery, and 1 week after surgery, significant differences were observed in HGB and PLT levels between patients who received BT and those who did not. The predictive model achieved an AUC of 0.899. Employing UML, we identified two distinct clusters with significantly heterogeneous clinical characteristics. Age, BMI, PLT, HGB, bleeding volume, and urine volume were found to be independent predictors of BT requirement in THA patients. The predictive model incorporating these six predictors demonstrated excellent predictive performance. Furthermore, employing UML enabled us to classify a heterogeneous cohort of THA patients who received BT in a meaningful and interpretable manner.
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Affiliation(s)
- Jicai Deng
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China
- Department of Anesthesiology, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Chenxing Zhou
- Department of Spine and Osteopathy Ward, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Fei Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China
| | - Jing Chen
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China
| | - Chunlai Li
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China
| | - Yubo Xie
- Department of Anesthesiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, People's Republic of China.
- Guangxi Key Laboratory of Enhanced Recovery After Surgery for Gastrointestinal Cancer, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, People's Republic of China.
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Smith NK, Kim SJ, Simmons Q, Lin HM, Romano D, Boydston E, DeMaria S, Zerillo J. The Optimal Cell Salvage Settings to Maximize Hematocrit and Minimize Potassium Using the Cobe BRAT2 Autologous Blood Recovery Unit. J Cardiothorac Vasc Anesth 2021; 36:1893-1900. [PMID: 34446326 DOI: 10.1053/j.jvca.2021.07.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/16/2021] [Accepted: 07/22/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The objective was to determine the optimal cell saver device settings (infusion rate and wash rate) at which hematocrit is preserved and potassium and lactate are removed from banked red blood cells (RBC). DESIGN Red cells were washed using the Cobe BRAT 2 Autologous Blood Recovery Unit and sampled for electrolyte composition and hematocrit pre- and postwash. SETTING This was a single-center study. INTERVENTIONS Red cells were washed using six infusion rates (100-1,000 mL/min) and six wash rates (100-1,000 mL/min) for a total of 36 combinations. Hematocrit, potassium, glucose, and lactate were evaluated before and after washing. MEASUREMENTS AND MAIN RESULTS At wash rates ≤400 mL/min, hematocrit increased independent of infusion rate. At wash rates ≥400 mL/min, slower infusion rates were associated with higher hematocrit compared to faster infusion rates (p < 0.0001 for a wash rate 400-800 mL/min, p < 0.0005 for a wash rate 1,000 mL/min). Maximal wash speeds were associated with decreasing hematocrit. Infusion and wash rate were both independent predictors of potassium change; slower rates were associated with a larger decrease in potassium. Glucose decreased proportionally as infusion and wash rate decreased. Lactate did not show an association with either infusion or wash rate. CONCLUSION Red-cell washing produces higher hematocrit and lower potassium as infusion rate and wash rate decrease. A 340-mL unit of RBC can be processed in 4.26 minutes without loss of hematocrit or an increase in potassium when both infusion and wash rates are set to 400 mL/min.
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Affiliation(s)
- Natalie K Smith
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Sang J Kim
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Qasim Simmons
- Cardiovascular Perfusion Services, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Diana Romano
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elaine Boydston
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at, UCLA, Los Angeles, CA
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jeron Zerillo
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Vieira SD, da Cunha Vieira Perini F, de Sousa LCB, Buffolo E, Chaccur P, Arrais M, Jatene FB. Autologous blood salvage in cardiac surgery: clinical evaluation, efficacy and levels of residual heparin. Hematol Transfus Cell Ther 2021; 43:1-8. [PMID: 31791879 PMCID: PMC7910157 DOI: 10.1016/j.htct.2019.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/21/2019] [Accepted: 08/20/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Intraoperative blood salvage (cell saver technique) in cardiac surgery is universally used in surgical procedures with a marked risk of blood loss. The primary objectives of this study were to determine the concentration of residual heparin in the final product that is reinfused into the patient in the operating room and to evaluate the efficacy and safety of the cell saver technique. METHOD Twelve patients undergoing elective cardiac surgery were enrolled in this study. Using the XTRA Autotransfusion System, blood samples were collected from the cardiotomy reservoir, both prior to blood processing (pre-sample) and after it, directly from the bag with processed product (post-sample). Hematocrit and hemoglobin levels, the protein, albumin and residual heparin concentrations, hemolysis index, and the platelet, erythrocyte and leukocyte counts were measured. RESULTS Hematocrit and hemoglobin levels and red blood cell counts were higher in post-processing samples, with a mean variation of 54.78%, 19.81g/dl and 6.84×106/mm3, respectively (p<0.001). The mean hematocrit of the processed bag was 63.49 g/dl (range: 57.2-67.5). The residual heparin levels were ≤0.1IU/ml in all post-treatment analyses (p=0.003). No related adverse events were observed. CONCLUSION The reduced residual heparin values (≤0.1IU/ml) in processed blood found in this study are extremely important, as they are consistent with the American Association of Blood Banks guidelines, which establish target values below 0.5IU/ml. The procedure was effective, safe and compliant with legal requirements and the available international literature.
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Affiliation(s)
- Sérgio Domingos Vieira
- Banco de Sangue de São Paulo, São Paulo, SP, Brazil; Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil.
| | | | | | - Enio Buffolo
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Paulo Chaccur
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
| | - Magaly Arrais
- Hospital do Coração da Assoc. Sanatório Sírio, São Paulo, Brazil
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Palmer AJR, Lloyd TD, Gibbs VN, Shah A, Dhiman P, Booth R, Murphy MF, Taylor AH, Kendrick BJL. The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study. Anaesthesia 2020; 75:479-486. [PMID: 32037522 DOI: 10.1111/anae.14989] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2019] [Indexed: 12/29/2022]
Abstract
Cell salvage is an important component of blood management in patients undergoing revision hip arthroplasty surgery. However concerns regarding efficacy and patient selection remain. The aims of this study were to describe intra-operative blood loss, cell salvage re-infusion volumes and red blood cell transfusion rates for revision hip procedures and to identify factors associated with the ability to salvage sufficient blood intra-operatively to permit processing and re-infusion. Data were collected from a prospective cohort of 664 consecutive patients undergoing revision hip surgery at a single tertiary centre from 31 March 2015 to 1 April 2018. Indications for revision surgery were aseptic (n = 393 (59%)) fracture (n = 160 (24%)) and infection (n = 111 (17%)). Salvaged blood was processed and re-infused when blood loss exceeded 500 ml. Mean (SD) intra-operative blood loss was 1038 (778) ml across all procedures. Salvaged blood was re-infused in 505 of 664 (76%) patients. Mean (SD) re-infusion volume was 253 (169) ml. In total, 246 of 664 (37%) patients received an allogeneic red blood cell transfusion within 72 h of surgery. Patients undergoing femoral component revision only (OR (95%CI) 0.41 (0.23-0.73)) or acetabular component revision only (0.53 (0.32-0.87)) were less likely to generate sufficient blood salvage volume for re-infusion compared with revision of both components. Compared with aseptic indications, patients undergoing revision surgery for infection (1.87 (1.04-3.36)) or fracture (4.43 (2.30-8.55)) were more likely to generate sufficient blood salvage volume for re-infusion. Our data suggest that cell salvage is efficacious in this population. Cases where the indication is infection or fracture and where both femoral and acetabular components are to be revised should be prioritised.
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Affiliation(s)
- A J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - T D Lloyd
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - V N Gibbs
- NHS Blood and Transplant, Oxford, UK
| | - A Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - P Dhiman
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - R Booth
- Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M F Murphy
- NHS Blood and Transplant and NIHR Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A H Taylor
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B J L Kendrick
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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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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Seyfried TF, Gruber M, Bitzinger D, Pawlik MT, Breu A, Graf BM, Hansen E. Performance of a new-generation continuous autotransfusion device including fat removal and consequences for quality controls. Transfus Med 2017; 27:292-299. [PMID: 28524547 DOI: 10.1111/tme.12421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 03/10/2017] [Accepted: 04/17/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Cell salvage plays a key role in blood conservation. To maintain high performance, quality management is recommended. Accordingly, a new-generation autotransfusion device was tested for its performance and compared with its predecessor. Two different calculations of quality parameters were applied. MATERIALS AND METHODS In an experimental study, the continuous autotransfusion devices CATSmart and Continuous Autotransfusion System (C.A.T.S) plus were tested using banked blood adjusted to a haematocrit of 20% and anticoagulated with heparin 5 U/L. Test blood was processed using an emergency programme, a high-quality programme/smart wash programme and a low-volume wash programme. Samples were taken after the production of 200 mL of red blood cells (RBC) and after the final emptying of the separation chamber. In an additional set of tests, blood containing 1·25% fat was processed with both devices to examine fat removal. RESULTS Both devices demonstrated an equally high performance with regards to product hematocrit (Hct); RBC recovery; and elimination rates of protein, heparin and fat. The high fat elimination rate (>99·8%) reported for C.A.T.S plus was confirmed for CATSmart, regardless of the used programme. Samples taken during the ongoing process show a higher haematocrit and RBC recovery rate than samples taken after the final emptying of the separation chamber. Interface sensors were not affected by fat in the blood. CONCLUSIONS The new-generation autotransfusion device CATSmart is not inferior to its predecessor and shows high performance with regards to RBC recovery, plasma and fat elimination in all programme modes. Samples for quality controls should be taken during blood processing.
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Affiliation(s)
- T F Seyfried
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - M Gruber
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - D Bitzinger
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - M T Pawlik
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - A Breu
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - B M Graf
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
| | - E Hansen
- Department of Anesthesiology, University Hospital Regensburg, Regensburg, Germany
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Buys WF, Buys M, Levin AI. Reinfusate Heparin Concentrations Produced by Two Autotransfusion Systems. J Cardiothorac Vasc Anesth 2017; 31:90-98. [DOI: 10.1053/j.jvca.2016.06.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Indexed: 11/11/2022]
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Sullivan IJ, Faulds JN. Assessment of intra-operative cell salvage haemolysis in the obstetric and orthopaedic clinical setting, in comparison with allogeneic blood. Transfus Med 2014; 24:280-5. [DOI: 10.1111/tme.12147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 07/22/2014] [Accepted: 07/24/2014] [Indexed: 12/01/2022]
Affiliation(s)
- I. J. Sullivan
- Blood Transfusion Department
- Patient Blood Management Department; Royal Cornwall Hospital Trust; Truro UK
| | - J. N. Faulds
- Patient Blood Management Department; Royal Cornwall Hospital Trust; Truro UK
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Sullivan IJ, Faulds JN. Lactate dehydrogenase and Haemolysis Index as quality control markers of haemolysis in intra-operative cell salvage. Transfus Med 2013; 23:326-9. [PMID: 23849190 DOI: 10.1111/tme.12065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/17/2013] [Accepted: 06/18/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The aim of this investigation was to explore the potential use of the tests lactate dehydrogenase (LDH) and Haemolysis Index as haemolysis markers in intra-operative cell salvage (ICS) blood in comparison to plasma free haemoglobin levels. BACKGROUND Quality control (QC) should be seen as a fundamental part of any ICS blood conservation programme, however, due to lack of available knowledge, familiarity and experience, QC is still a comparatively new subject. A QC pilot scheme is currently being undertaken by the Royal Cornwall Hospital in association with the UK Cell Salvage Action Group to explore potential markers that can be used to assess the quality of blood obtained from ICS. This test list should be available to all ICS users and achievable within financial budgets. Currently this proposed test list includes a full blood count, a protein marker such as urine albumin/microalbumin and heparin monitoring. Haemolysis testing is another key marker. METHODS/MATERIALS Samples were collected from ICS processed blood and allogeneic SAGM leucodepleted red cell units and processed for plasma free haemoglobin, LDH and Haemolysis Index. RESULTS There was a very strong correlation between plasma free haemoglobin and LDH (0.960), and plasma free haemoglobin and the Haemolysis Index (0.944). CONCLUSION We have shown that the LDH and Haemolysis Index tests are suitable and reliable alternatives for measuring haemolysis from samples obtained from ICS or allogeneic blood. We have incorporated the LDH test into our Hospital's ICS QC package and recommend that this test is considered for all ICS QC samples.
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Affiliation(s)
- I J Sullivan
- Blood Transfusion Laboratory; Blood Conservation Department, Royal Cornwall Hospital Trust, Truro, Cornwall, UK
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