Transfusion of intra-operative autologous whole blood: influence on complement activation and interleukin formation

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.

Effect of allogeneic blood transfusion on levels of IL-6 and sIL-R2 in peripheral blood of children with acute lymphocytic leukemia

Effect of allogeneic blood transfusion on the expression of interleukin-6 (IL-6) and soluble interleukin-2 receptor (sIL-2R) in peripheral blood of children with acute lymphoblastic leukemia (ALL) was investigated. A total of 91 ALL children admitted to Nanfang Hospital from June 2014 to January 2017 were selected as the study group. Patients were randomly divided into allogeneic blood transfusion group (n=38) and non-transfusion group (n=53). In addition, a total of 64 healthy children were also selected from June 2014 to January 2017 as the control group. Patients in allogeneic blood transfusion group were transfused with red blood cell suspension and machine-collected platelets, while patients in non-transfusion group were not treated with blood transfusion. Peripheral venous blood was collected before and at 4, 8 and 12 weeks after blood transfusion to prepare serum. Serum IL-6 and sIL-2R levels were measured by enzyme-linked immunosorbent assay (ELISA). Before transfusion, serum levels of IL-6 and sIL-2R were significantly lower in the study group than those in control group (p<0.05), and no significant differences in serum levels of IL-6 and sIL-2R were found between the allogeneic blood transfusion and non-transfusion group. After transfusion, serum levels of IL-6 and sIL-2R were stable for 12 weeks in the non-transfusion group, while IL-6 and sIL-2R levels were significantly increased in the allogeneic blood transfusion group. The results showed that serum level of IL-6 and sIL-2R was increased in ALL patients with allogeneic blood transfusion, which resulted in reduced antibody production and decreased cellular immunity. The patients had low immunity, and attention should be paid on the pathogen infection prevention.

The Reinfusion of Autogenous Shed Blood After Unilateral Total Knee Arthroplasty Using the Perioperative Autologous Transfusion System OrthoPAT

This study aims to explore the use of postoperative autogenous shed blood reinfusion using Orthopedic Perioperative Autotransfusion System (OrthoPAT) system in treating patients undergoing unilateral total knee arthroplasty (TKA). Fifty patients undergoing unilateral TKA were enrolled as the experimental group A and were treated with reinfusion of autologous shed blood within 6 hours after unilateral TKA using OrthoPAT. Accordingly, 50 patients undergoing unilateral TKA were selected as the experimental group B and were treated with allogeneic blood transfusion. Different indexes were observed at different times. Patients in both groups had relatively stable hemodynamics, and there was no postoperative coagulopathy. Prothrombin time, thrombin time, and activated partial thromboplastin time were lower, and fibrinogen was higher in group A than that in group B 24 hours after surgery (all P < 0.05). White blood cell, red blood cell, hemoglobin, hematocrit (Hct), and platelet count levels in group A were lower than those in group B 12 hours after surgery (all P < 0.05). The postoperative complications of the 2 groups have significant difference (P < 0.05). Postoperative autogenous shed blood reinfusion using OrthoPAT system in the treatment of patients undergoing unilateral TKA may improve the coagulation function of patients and reduce the rejection caused by standard allogeneic blood transfusion.

Dynamic changes in clot formation determined using thromboelastometry after reinfusion of unwashed anticoagulated cell-salvaged whole blood in total hip arthroplasty

BACKGROUND

Cell salvage is a key part of patient blood management. Different techniques are available for salvaging blood. A new intra-operative autotransfusion filter system became available for reinfusion of unwashed whole blood. Concern exists regarding whether this technique induces coagulation disturbances, offsetting the benefits of the reinfusion of autologous blood. This study was designed to investigate the content of intra-operatively salvaged filtered blood and its impact after reinfusion on clot formation in patients undergoing primary hip arthroplasty.

MATERIALS AND METHODS

Twenty-five patients scheduled for primary total hip arthroplasty were enrolled in the study. Cell salvage was performed using a new intra-operative autotransfusion filter system. Before surgery and within 1 hour of reinfusion of 300 mL or more of salvaged whole blood, blood samples were taken to assess clot formation by thromboelastometry and standard laboratory-based coagulation profiling. Cytokine content of the salvaged blood was assessed by enzyme-linked immunosorbent assays.

RESULTS

Following reinfusion of 460 mL (median) of salvaged blood, thromboelastometry showed normal clot formation and did not indicate a coagulopathy. Clotting time, clot formation time, maximum firmness and maximum lysis all remained within the normal range. Standard laboratory coagulation tests were also normal in all patients before surgery and after reinfusion. Although monocyte chemoattractant protein-1 levels were higher than normal, all other measured cytokines were either undetectable or within the normal range. No adverse events were seen following cell salvage.

DISCUSSION

Reinfusion of unwashed salvaged whole blood did not alter clot formation in our patients. The results add to the knowledge about this approach and contribute to the growing body of evidence regarding the lack of adverse events when reinfusing unwashed shed blood in major orthopaedic procedures.

Influence of autologous and homologous blood transfusion on interleukins and tumor necrosis factor-α in peri-operative patients with esophageal cancer

OBJECTIVE

To explore the influence of different ways of blood transfusion on the expression levels of interleukins (IL) and tumor necrosis factor-α (TNF-α) inperi-operative patients with esophageal cancer.

MATERIALS AND METHODS

A total of 80 patients with esophageal cancer who underwent radical operations were selected as study patients and randomly divided into an observation group (treated with autologous blood transfusion) and control group (with homologous blood transfusion). Changes of intra-operative indexes and peri-operative blood indexes, from hemoglobin (Hb) and hematocrit value (Hct), to levels of inflammatory factors like interleukins-6 (IL-6), IL-8, IL-10 and tumor necrosis factor-α (TNF-α) were compared.

RESULTS

Operations for patients in both groups were successfully conducted, and no significant differences in mean surgical duration and intra-operative hemorrhage volume, fluid infusion volume and blood transfusion volume were detected (p>0.05). Compared with values before surgery, Hb and Hct levels decreased significantly while white blood cell count (WBC) increased 1, 5 and 7 d after operation (p<0.05, p<0.01). In addition, WBC was apparently higher in observation group than in control group 5 and 7 d after operation (p<0.01). Compared with before surgery, in the observation group, levels of IL-6, IL-8 and IL-10 had no significant differences after operation (P>0.05), but TNF-α level increased y (p<0.01), whereas in control group, IL-6 level had no significant difference (p>0.05), IL-8 level decreased obviously (p<0.05), IL-10 level increased markedly first and then decreased gradually as time passed but its level remained elevated (p<0.01), and TNF-α level increased first and then decreased, and there was no significant difference 7 d after operation (p>0.05).

CONCLUSIONS

Decreased IL-8 and increased IL-10 levels are two important reasons forimmunosuppression after homologous blood transfusion, whereas autologous blood transfusion can alleviate this while increasing the TNF-α level, which also has potential to improve anti-tumor immunity in the human body.

Favourable results of a new intraoperative and postoperative filtered autologous blood re-transfusion system in total hip arthroplasty: a randomised controlled trial

PURPOSE

A new intraoperative filtered salvaged blood re-transfusion system has been developed for primary total hip arthroplasty (THA) that filters and re-transfuses the blood that is lost during THA. This system is intended to increase postoperative haemoglobin (Hb) levels, reduce perioperative net blood loss and reduce the need for allogeneic transfusions. It supposedly does not have the disadvantages of intraoperative cell-washing/separating re-transfusion systems, such as extensive procedure, high costs and need for specialised personnel. To re-transfuse as much as blood as possible, postoperatively drained blood was also re-transfused.

METHODS

A randomised, controlled, blinded, single-centre trial was conducted in which 118 THA patients were randomised to an intraoperative autologous blood re-transfusion (ABT) filter system combined with a postoperative ABT filter unit or high-vacuum closed-suction drainage.

RESULTS

On average, 577 ml of blood was re-transfused in the ABT group: 323 ml collected intraoperatively and 254 ml collected postoperatively. Hb level was higher in the ABT vs the high-vacuum drainage group: 11.4 vs. 10.8 g/dl, p = 0.02 on day one (primary endpoint) and 11.0 vs. 10.4 g/dl, p = 0.007 on day three. Total blood loss was less in the autotransfusion group: 1472 vs. 1678 ml, p = 0.03. Allogeneic transfusions were needed in 3.6 % of patients in the ABT group and 6.5 % in the drainage group, p = 0.68.

CONCLUSION

The use of a new intraoperative ABT filter system combined with a postoperative ABT unit resulted in higher postoperative Hb levels and less total blood loss compared with a high-vacuum drain following THA.

Reduction of blood loss with the use of a new combined intra-operative and post-operative autologous blood transfusion system compared with no drainage in primary total hip replacement

Autologous retransfusion and no-drainage are both blood-saving measures in total hip replacement (THR). A new combined intra- and post-operative autotransfusion filter system has been developed especially for primary THR, and we conducted a randomised controlled blinded study comparing this with no-drainage. A total of 204 THR patients were randomised to autologous blood transfusion (ABT) (n = 102) or no-drainage (n = 102). In the ABT group, a mean of 488 ml (sd 252) of blood was retransfused. The mean lowest post-operative haemoglobin level during the hospital stay was higher in the autotransfusion group (10.6 g/dl (7.8 to 13.9) vs 10.2 g/dl (7.5 to 13.3); p = 0.01). The mean haemoglobin levels for the ABT and no-drainage groups were not significantly different on the first day (11.3 g/dl (7.8 to 13.9) vs 11.0 g/dl (8.1 to 13.4); p = 0.07), the second day (11.1 g/dl (8.2 to 13.8) vs 10.8 g/dl (7.5 to 13.3); p = 0.09) or the third day (10.8 g/dl (8.0 to 13.0) vs 10.6 g/dl (7.5 to 14.1); p = 0.15). The mean total peri-operative net blood loss was 1464 ml (sd 505) in the ABT group and 1654 ml (sd 553) in the no-drainage group (p = 0.01). Homologous blood transfusions were needed in four patients (3.9%) in the ABT group and nine (8.8%) in the no-drainage group (p = 0.15). No statistically significant difference in adverse events was found between the groups. The use of a new intra- and post-operative autologous blood transfusion filter system results in less total blood loss and a smaller maximum decrease in haemoglobin levels than no-drainage following primary THR.

Postoperative autologous blood transfusion drain or no drain in primary total hip arthroplasty? A randomised controlled trial

PURPOSE

Postoperative maintenance of high haemoglobin (Hb) levels and avoidance of homologous blood transfusions is important in total hip arthroplasty (THA). The introduction of a postoperative drainage autologous blood transfusion (ABT) system or no drainage following THA has resulted in reduction of homologous blood transfusion requirements compared with closed-suction drains. The purpose of this study was to examine which regimen is superior following THA.

METHODS

A randomised controlled blinded prospective single-centre study was conducted in which 100 THA patients were randomly allocated to ABT or no drainage. The primary endpoint was the Hb level on the first postoperative day.

RESULTS

The postoperative collected drained blood loss was 274 (±154) ml in the ABT group, of which 129 (±119) ml was retransfused (0-400). There was no statistical difference in Hb levels on the first postoperative day (ABT vs no drainage: Hb 11.0 vs 10.9 g/dl), on consecutive days (day 3: Hb 10.7 vs 10.2, p = 0.08) or in total blood loss (1,506 vs 1,633 ml), homologous transfusions, pain scores, Harris Hip Score, SF-36 scores, length of hospital stay or adverse events.

CONCLUSIONS

The use of a postoperative autologous blood retransfusion drain did not result in significantly higher postoperative Hb levels or in less total blood loss or fewer homologous blood transfusions compared with no drain.

Limit allogeneic blood use with routine re-use of patient's own blood: a prospective, randomized, controlled trial in total hip surgery

BACKGROUND

There are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results.

METHODOLOGY/PRINCIPAL FINDINGS

Two hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI -0.05-0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31-346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life.

CONCLUSIONS/SIGNIFICANCE

General low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is under-powered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00822588.

Proinflammatory cytokines and complement activation in salvaged blood from abdominal aortic aneurism surgery and total hip replacement surgery

BACKGROUND

Levels of proinflammatory mediators in unwashed salvaged blood from abdominal aortic aneurism (AAA) surgery are unknown. We hypothesized that there are higher levels of these mediators in unwashed blood salvaged in AAA surgery compared to hip replacement surgery.

STUDY DESIGN AND METHODS

Ten patients scheduled for AAA surgery (Group A) and 10 patients for total hip replacement surgery (Group H) were included. Blood samples from the autotransfusion set were obtained during surgery and arterial samples before, during, and 6 hours after surgery. Determination of interleukin (IL)-1β, IL-6, IL-8, tumor necrosis factor-α, activated complement 3 (C3a), and high-sensitivity C-reactive protein (CRP) were performed. Salvaged blood was not retransfused.

RESULTS

Levels (median [range]) of IL-8 in blood in the salvage system were higher in Group A versus Group H (215.3 [22.5-697.2] vs. 35.3 [16.7-66.6] pg/mL; p = 0.002). Higher levels of IL-6 were also seen in Group A versus Group H (60.0 [52.6-62.2] vs. 42.34 [19.4-62.2] pg/mL; p = 0.049). Levels of IL-6 in blood sampled during surgery were approximately fivefold higher in Group A versus Group H (p = 0.023), whereas approximately 70% higher levels of C3a were observed in Group H versus Group A (p = 0.021). Postoperative concentrations of IL-1β (p = 0.002), IL-6 (p = 0.001), and IL-8 (0.005) were higher in Group A versus Group H.

CONCLUSION

Salvaged blood in AAA surgery contains substantially higher levels of proinflammatory mediators compared to blood in total hip replacement surgery.