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Rajasekaran RB, Palmer AJR, Whitwell D, Cosker TDA, Pigott D, Zsolt O, Booth R, Gibbons MRJP, Carr A. The role of intraoperative cell salvage for musculoskeletal sarcoma surgery. J Bone Oncol 2021; 30:100390. [PMID: 34589408 PMCID: PMC8458974 DOI: 10.1016/j.jbo.2021.100390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 11/25/2022] Open
Abstract
Musculoskeletal sarcoma surgery involving the lower limb is associated with significant intraoperative blood loss, with more than 500 ml in 96% of patients. Salvaged blood was processed and re-infused in 94% of patients. An estimated one-fourth of intraoperative blood loss was returned to the patient through (Intraoperative cell salvage) ICS. Cytological analysis of imprints from leucodepletion filters(LDF) and reinfused blood did not reveal evidence of tumour cells.
Background The efficacy and safety of cell salvage for musculoskeletal sarcoma surgery have not been reported, and concerns over re-infusion of tumour cells remain. This study aims to i) describe the intra-operative blood loss and cell salvage reinfusion volumes for lower limb sarcoma and pelvic sarcoma procedures ii) and explore whether there is evidence of tumour cells in reinfused blood. Methods Retrospective analysis of 109 consecutive surgical procedures for biopsy-proven sarcoma or bone metastasis performed between 1 July 2015 and 30 October 2019. Salvaged blood was processed and reinfused when intraoperative blood loss exceeded 500 ml. Primary bone tumour (n = 86(79%)) and metastasis (n = 23(21%) constituted the study group and surgeries were classified under hemipelvectomy (n = 43(39%)), lower limb endoprosthesis replacement (LLE) (n = 50(46%)) and wide excision surgery (WE) (n = 16(15%)). Microscopic examination of imprint cytology of leuco-depletion(LD) filters, and peripheral smear examination was performed for reinfused blood. Results Median (IQR) intra-operative blood loss was 1750 (600–3000) ml for hemipelvectomy, 850 (600–1200) ml for LLE, and 1000 (550–2000) ml for WE. Salvaged blood was re-infused in 102 of 109 (94%) patients. The mean (SD) volume of re-infusion was 445(4 2 5) ml for hemipelvectomy, 206(1 3 1) ml for LLE, and 184(1 0 6) ml for WE. In total, 64 of 109 (59%) patients received an allogeneic red blood transfusion within 72 h of surgery. Cytology analysis of imprints taken from the filtered blood available in 95(87%) patients and peripheral smear examination of reinfused blood available in 32(29%) patients did not reveal evidence of tumour cells on microscopic examination of any samples. Conclusion Our study demonstrates that musculoskeletal sarcoma surgery is associated with significant blood loss, and cell salvage permits reinfusion of autologous blood in most patients. The cytological analysis did not reveal evidence of tumour cells in reinfused blood, consistent with other studies where cell salvage is used for cancer surgery.
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Affiliation(s)
- Raja Bhaskara Rajasekaran
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Antony J R Palmer
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Duncan Whitwell
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Thomas D A Cosker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
| | - David Pigott
- Consultant Anaesthetist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Orosz Zsolt
- Consultant Pathologist, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Robert Booth
- Transfusion Practitioner, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M R J P Gibbons
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), Nuffield Orthopaedic Centre, Windmill Road, Oxford OX3 7LD, UK
| | - Andrew Carr
- Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK
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Abstract
BACKGROUND Allogeneic blood transfusion is avoidable in many oncological interventions by the use of cell salvage or mechanical autotransfusion (MAT). As irradiation is elaborate and expensive, the safety of leucocyte depletion filters (LDF) for autologous blood from the surgical field might be a more acceptable alternative for the prevention of cancer recurrences. A previous meta-analysis could not identify an increased risk of cancer recurrence. The aim of this review article is to provide an update of a previous meta-analysis from 2012 as well as a safety analysis of cell salvage with LDF due to the improved data situation. MATERIAL AND METHODS This systematic review included all studies in PubMed, Cochrane, Cochrane Reviews and Web of Science on cell salvage or autotransfusion combined with outcomes, e.g. cancer recurrence, mortality, survival, blood transfusion, length of hospital stay (LOS) after the use of MAT without irradiation and with or without LDF. The grades of recommendations (GRADE) assessment of underlying evidence was applied. RESULTS A total of seven new observational studies and seven meta-analyses were found that compared unfiltered or filtered cell salvage with autologous predeposition, allogeneic transfusion or without any transfusion. No randomized controlled trials have been completed. A total of 27 observational and cohort studies were included in a meta-analysis. The evidence level was low. The risk of cancer recurrence in recipients of autologous salvaged blood with or without LDF was reduced (odds ratio, OR 0.71, 95% confidence interval, CI 0.58-0.86) as compared to non-transfused subjects, allogeneic or predeposited autologous transfusion. The transfusion rate could not be assessed due to the substantial selection bias and large heterogeneity. Cell salvage does not change mortality and LOS. Leucocyte depletion studies reported a removal rate of cancer cells in the range of 99.6-99.9%. CONCLUSION Randomized controlled trials on a comparison of MAT and allogeneic blood transfusion as well as LDF and irradiation would be desirable but are not available. From observational trials and more than 6300 subjects and various tumors, cell salvage in cancer surgery with or without LDF appears to be sufficiently safe. The efficacy of leucocyte depletion of autologous salvaged blood is equivalent to irradiation. Unavailability of radiation is not a contraindication for cell salvage use in cancer surgery. By usage of leucocyte depleted salvaged autologous blood, the risks of allogeneic transfusion can be avoided.
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White MJ, Hazard SW, Frank SM, Boyd JS, Wick EC, Ness PM, Tobian AAR. The evolution of perioperative transfusion testing and blood ordering. Anesth Analg 2015; 120:1196-203. [PMID: 25988630 DOI: 10.1213/ane.0000000000000619] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The evolution of modern anesthesia and surgical practices has been accompanied by enhanced supportive procedures in blood banking and transfusion medicine. There is increased focus on the preparation and the use of blood components including, but not limited to, preventing unnecessary type and screen/crossmatch orders, decreasing the time required to provide compatible red blood cells (RBCs), and reducing the waste of limited blood and personnel resources. The aim of this review is to help the anesthesiologist and surgical staff identify patients at highest risk for surgical bleeding. In addition, this review examines how anesthesia and transfusion medicine can efficiently and safely allocate blood components for surgical patients who require transfusions. The following databases were searched: PubMed, EMBASE, Google Scholar, and the Cochrane Library from January 1970 through March 2014. Subsequent reference searches of retrieved articles were also assessed. Several innovations have drastically changed the procedures by which blood is ordered, inventoried, and the speed in which blood is delivered for patient care. Before entering an operating room, patient blood management provides guidance to clinicians about when and how to treat preoperative anemia and intra- and postoperative strategies to limit the patient's exposure to blood components. Timely updates of the recommendations for blood orders (maximum surgical blood ordering schedule) have enhanced preoperative decision making regarding the appropriateness of the type and screen versus the type and crossmatch order. The updated maximum surgical blood ordering schedule reflects modern practices, such as laparoscopy, improved surgical techniques, and use of hemostatic agents resulting in a more streamlined process for ordering and obtaining RBCs. The electronic (computer) crossmatch and electronic remote blood issue have also dramatically reduced the amount of time required to obtain crossmatch-compatible RBCs when compared with the more traditional serologic crossmatch methods. These changes in blood banking methods have resulted in more efficient delivery of blood to surgical patients.
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Affiliation(s)
- Marissa J White
- From the *Department of Pathology, Division of Transfusion Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; †Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland; ‡Department of Anesthesiology, Penn State College of Medicine, Hershey, Pennsylvania; and §Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Nagarsheth NP, Gupta N, Gupta A, Moshier E, Gretz H, Shander A. Responses of advanced directives by Jehovah's Witnesses on a gynecologic oncology service. J Blood Med 2015; 6:17-23. [PMID: 25565911 PMCID: PMC4284050 DOI: 10.2147/jbm.s70981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Objectives To review the responses of advance directives signed by Jehovah’s Witness patients prior to undergoing surgery at a gynecologic oncology service. Study design A retrospective chart review of gynecologic oncology patients undergoing surgery at a bloodless surgery center from 1998–2007 was conducted. Demographic, pathologic, and clinical data were recorded. The proportion of patients who accepted and refused various blood-derived products was determined and was compared to previously published results from a similar study of labor and delivery unit patients. Results No gynecologic oncology patients agreed to accept transfusions of whole blood, red cells, white cells, platelets, or plasma under any circumstance, whereas 9.8% of pregnant patients accepted transfusion (P=0.0385). However, 98% of gynecologic oncology patients agreed to accept some blood products, including fractions such as albumin, immunoglobulins, and clotting factors, while only 39% of pregnant patients agreed (P<0.0001). In addition, all gynecologic oncology patients (100%) accepted intraoperative hemodilution, compared to 55% of pregnant patients (P<0.0001). Conclusion Our results confirm the commonly held belief that the majority of Jehovah’s Witness patients refuse to accept major blood components. However, Jehovah’s Witness patients at a gynecologic oncology service will accept a variety of blood-derived products (minor fractions) and interventions designed to optimize outcomes when undergoing transfusion-free surgery. Patients presenting to a gynecologic oncology service respond differently to advanced directives related to bloodless surgery, as compared to patients from an obstetrical service.
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Affiliation(s)
- Nimesh P Nagarsheth
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA ; Englewood Hospital and Medical Center, Englewood, NJ, USA
| | - Nikhil Gupta
- Department of Urology, North Shore - Long Island Jewish Health Service, New Hyde Park, NY, USA
| | - Arpeta Gupta
- Department of Endocrinology, Diabetes and Metabolism, St Luke's Hospital of Kansas City, Kansas City, MO, USA
| | - Erin Moshier
- Department of Preventive Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Herbert Gretz
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, Mount Sinai Medical Center, New York, NY, USA
| | - Aryeh Shander
- Department of Anesthesiology, Englewood Hospital and Medical Center, Englewood, NJ, USA
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Thompson PA, May D, Choong PF, Tacey M, Liew D, Cole-Sinclair MF. Predicting blood loss and transfusion requirement in patients undergoing surgery for musculoskeletal tumors. Transfusion 2014; 54:1469-77. [DOI: 10.1111/trf.12532] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 10/18/2013] [Accepted: 10/19/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Philip A. Thompson
- Department of Hematology; St Vincent's Hospital, Melbourne; Victoria Australia
| | - Deborah May
- Department of Orthopedic Surgery; St Vincent's Hospital, Melbourne; Victoria Australia
| | - Peter F. Choong
- Department of Orthopedic Surgery; St Vincent's Hospital, Melbourne; Victoria Australia
- Department of Surgery; University of Melbourne; Parkville Victoria Australia
| | - Mark Tacey
- Collaborative Centre for Clinical Epidemiology, Biostatistics and Health Services Research; Parkville Victoria Australia
| | - Danny Liew
- Collaborative Centre for Clinical Epidemiology, Biostatistics and Health Services Research; Parkville Victoria Australia
- Department of Clinical Epidemiology; University of Melbourne; Parkville Victoria Australia
| | - Merrole F. Cole-Sinclair
- Department of Hematology; St Vincent's Hospital, Melbourne; Victoria Australia
- Department of Pathology; University of Melbourne; Parkville Victoria Australia
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Nagarsheth NP, Fenske SS, Shah A, Moshier E, Stahl R, Shander A. In vitro analysis of cell salvage blood collection with a laparoscopic suction device. J Minim Invasive Gynecol 2013; 20:104-6. [PMID: 23312250 DOI: 10.1016/j.jmig.2012.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 10/01/2012] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE To determine whether cell salvage blood collection with a laparoscopic suction device is inferior to use of a traditional Yankauer suction device. DESIGN Prospective, in vitro study. SETTING Academic teaching hospital. INTERVENTIONS Individual units of donated packed red blood cells were diluted with normal saline solution to a hematocrit level of 21%. The blood was divided into 2 equal parts and then suctioned with either a laparoscopic suction device or a Yankauer plastic suction catheter tip connected to double-lumen cell salvage tubing with a diluted heparin drip and a vacuum pressure of 100 mm Hg. Collected blood was processed with a cell salvage device. Red blood cell volume was calculated by multiplying the hematocrit level by the total volume of blood product at the time of testing. Mean hemolysis indexes were compared between the laparoscopic and Yankauer method of blood collection by use of a 2-sample t test. Assuming a clinically acceptable limit of loss to be 7%, percent loss in red blood cell volume was tested with a 95% one-sided confidence limit to assess noninferiority. MEASUREMENTS AND RESULTS The mean hemolysis index was 43.33 with laparoscopic suction method and 34.67 with the Yankauer suction method. The mean difference was 8.67 and was not considered significant (p = .074). The percent loss in red blood cell volume after collection and cell salvage processing was 33.2% with the laparoscopic suction method and 29.57% with the Yankauer method. The mean difference was 3.63% and was within the acceptable 7% loss limit for noninferiority (p = .0278). CONCLUSIONS Laparoscopic blood collection is not inferior to the standard Yankauer method for cell salvage collection.
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Affiliation(s)
- Nimesh P Nagarsheth
- Mount Sinai School of Medicine, Department of Obstetrics and Gynecology, 1176 Fifth Ave, New York, NY 10029, USA
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Shander A, Javidroozi M, Perelman S, Puzio T, Lobel G. From Bloodless Surgery to Patient Blood Management. ACTA ACUST UNITED AC 2012; 79:56-65. [DOI: 10.1002/msj.21290] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Simou M, Thomakos N, Zagouri F, Vlysmas A, Akrivos N, Zacharakis D, Papadimitriou CA, Dimopoulos MA, Rodolakis A, Antsaklis A. Non-blood medical care in gynecologic oncology: a review and update of blood conservation management schemes. World J Surg Oncol 2011; 9:142. [PMID: 22051161 PMCID: PMC3225312 DOI: 10.1186/1477-7819-9-142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Accepted: 11/03/2011] [Indexed: 11/29/2022] Open
Abstract
This review attempts to outline the alternative measures and interventions used in bloodless surgery in the field of gynecologic oncology and demonstrate their effectiveness. Nowadays, as increasingly more patients are expressing their fears concerning the potential risks accompanying allogenic transfusion of blood products, putting the theory of bloodless surgery into practice seems to gaining greater acceptance. An increasing number of institutions appear to be successfully adopting approaches that minimize blood usage for all patients treated for gynecologic malignancies. Preoperative, intraoperative and postoperative measures are required, such as optimization of red blood cell mass, adequate preoperative plan and invasive hemostatic procedures, assisting anesthetic techniques, individualization of anemia tolerance, autologous blood donation, normovolemic hemodilution, intraoperative cell salvage and pharmacologic agents for controlling blood loss. An individualised management plan of experienced personnel adopting a multidisciplinary team approach should be available to establish non-blood management strategies, and not only on demand of the patient, in the field of gynecologic oncology with the use of drugs, devices and surgical-medical techniques.
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Affiliation(s)
- Maria Simou
- Department of Obstetrics and Gynecology, Alexandra Hospital, School of Medicine, University of Athens, Greece
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Liumbruno GM, Bennardello F, Lattanzio A, Piccoli P, Rossetti G. Recommendations for the transfusion management of patients in the peri-operative period. II. The intra-operative period. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:189-217. [PMID: 21527082 PMCID: PMC3096863 DOI: 10.2450/2011.0075-10] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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OSARO ERHABOR, NJEMANZE CHIMA. Challenges of meeting the future blood transfusion requirement in England and Wales. Autologous blood transfusion could become an adjunct to the UK blood transfusion program in the future. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1778-428x.2010.01132.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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