Economic evaluation of cell salvage in pediatric surgery

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

A Surgeon's Perspective on Blood Conservation Practice in Pediatric Cardiac Surgery

Blood conservation practice in pediatric cardiac surgery has not been consistently adopted as quality improvement in many centers despite known risks associated with allogeneic blood products, shortage of donors, and costs. There are many blood conservation strategies available which collectively minimize exposure to allogeneic transfusion by maximizing the use of autologous red cells. These strategies are safe, reproducible, and have been implemented in clinical practice collectively with great efficacy for all patient ages and complexity levels. Institutional commitment to a set guideline will improve their blood conservation practice and quality outcome. The purpose of this article is to provide early career and practicing congenital cardiac surgeons with practical information concerning blood conservation strategies which can be considered for implementation in any pediatric cardiac surgery program, and which may be of particular value in resource-limited programs.

Intraoperative blood salvage in proximal femur epiphysiolysis surgical treatment with hip controlled dislocation technique: a case series study

OBJECTIVES

To report a case series of Intraoperative Blood Salvage (IOS) in surgeries during the treatment for Slipped Capital Femoral Epiphysis (SCFE) with controlled dislocation of the hip, identifying its efficacy, complications, and the profile of patients with SCFE.

METHODS

Descriptive study reporting a case series, comprising patients seen between January 2016 and March 2018, diagnosed with SCFE, and treated with controlled surgical dislocation of the hip using IOS.

RESULTS

Sample comprised of 15 patients, with a mean age of 13.1 years. The most affected side was the left with 8 cases. None of the patients required allogeneic blood in the postoperative period. Mean pre- and postoperative hemoglobin were 13.2 and 11.2 g.dL-1, respectively, and mean hemoglobin difference was 1.8 g.dL-1. Mean pre- and postoperative hematocrit were 39.13% and 33.20%, respectively, and mean hematocrit difference was 5.52%. No intraoperative complications were observed. One patient presented vomiting and another one, wound infection in the postoperative period.

CONCLUSION

IOS was an alternative blood salvage approach and prevented allogeneic blood transfusion, enabling reduction of potential complications.

Comparative changes of pre-operative autologous transfusions and peri-operative cell salvage in the United States

BACKGROUND

With improved safety of allogeneic blood supply, the use of preoperative autologous donations (PADs) and perioperative autologous cell salvage (PACS) has evolved. This study evaluated temporal trends in PAD and PACS use in the United States.

METHODS

The National Inpatient Sample database, a stratified probability sample of 20% of hospitalizations in the United States, was used to compare temporal trends in hospitalizations reporting use of PADs and PACS from 1995 to 2015. Factors associated with their use were examined between 2012 and 2015 with use of multivariable Poisson regression. Sampling weights were applied to generate nationally representative estimates.

RESULTS

There was a steady decrease in hospitalizations reporting PAD transfusions from 27.90 per 100 000 in 1995 to 1.48 per 100 000 hospitalizations in 2015 (P-trend <.001). In contrast, PACS increased from a rate of 1.16 per 100 000 in 1995 to peak of 20.51 per 100 000 hospitalizations in 2008 and then steadily declined (P-trend<.001). Higher odds of PACS and PADs were observed in older patients, elective procedures (vs urgent), and urban teaching/nonteaching hospitals (vs rural hospitals) (P < .001). PACS was more common in hospitalizations in patients with higher levels of severity of illness as compared to those with minor severity (adjusted prevalence ratio [adjPR], 2.39; 95% confidence interval [CI], 2.08-2.73; P<.001), while PADs were performed less often in patients with higher underlying severity of illness (All Patient Refined Diagnosis Related Groups, 4 vs 1, adjPR, 0.61; 95% CI, [0.39-0.95]; P = .028).

CONCLUSIONS

There was a significant decrease in PAD red blood cell transfusions, while PACS has increased and subsequently decreased; PACS plays an important role in surgical blood conservation. The subsequent decline in PACS likely reflects further optimization of transfusion practice through patient blood management programs and improvement of surgical interventions.

Intra-operative cell salvage for cesarean delivery: a retrospective study using propensity score matched analysis

BACKGROUND

Obstetric hemorrhage is a major cause of maternal death during cesarean delivery. The objective of this retrospective observational study was to evaluate the efficacy and safety of intra-operative cell salvage (IOCS) in cesarean section.

METHODS

We included a total of 361 patients diagnosed with central placenta previa who underwent cesarean section from May 2016 to December 2018. In this study, 196 patients received autologous transfusion using IOCS (IOCS group) and 165 patients accepted allogeneic blood transfusion (ABT group). Propensity score matched analysis was performed to balance differences in the baseline variables between the IOCS group and ABT group. Patients in the IOCS group were matched 1:1 to patients in the ABT group.

RESULTS

After propensity score matching, 137 pairs of cases between the two groups were successfully matched and no significant differences in baseline characteristics were found between the IOCS group and ABT group. Patients in the IOCS group were associated with significantly shorter length of hospital stay, compared with ABT group (8.9 ± 4.1 days vs. 10.3 ± 5.2 days, t = -2.506, P = 0.013). The postoperative length of hospital stay was 5.3 ± 1.4 days for patients in the IOCS group and 6.6 ± 3.6 days for those in the ABT group (t = -4.056, P < 0.001). The post-operative hemoglobin level in the IOCS group and ABT group was 101.3 ± 15.4 and 96.3 ± 16.6 g/L, respectively, which were significantly different (t = 2.615, P = 0.009). Allogeneic red blood cell transfusion was significantly lower at 0 unit (range: 0-11.5 units) in the IOCS group when compared with 2 units (range: 1-20 units) in the ABT group (P < 0.001).

CONCLUSIONS

This retrospective observational study using propensity score matched analysis suggested that IOCS was associated with shorter length of postoperative hospital stay and higher post-operative hemoglobin levels during cesarean delivery.

Selling the role of salvage: Cell salvage past and present

The use of transfused blood, be it from an allogenic (donor) or autologous (same patient) source, is not a new treatment and in fact has been experimented with since the mid 1800s. The role of cell salvage and re-infusion of a patient's own blood, however, has only begun to gain real popularity in the last 20 years, after the undertaking of several large scale meta-analyses which have shown that not only is autologous transfusion no less efficacious when compared to allogenic transfusion, but also potentially safer for a number of reasons. Autologous transfusion is also more cost effective overall and potentially quicker to initiate in an emergency situation. Despite the body of evidence to support the use of salvaged blood for transfusion, hesitation around its use still persists, with staff apprehension around set up of cell salvage equipment and general underestimation of intraoperative blood loss being key factors in its underuse.

Extensive cell salvage and postoperative outcomes following thoracoabdominal and descending aortic repair

OBJECTIVE

Cell salvage (CS) reduces intraoperative blood transfusion. However, it may cause deformity of the red blood cells and loss of coagulation factors, which may lead to unwanted sequelae. Thus, we hypothesized that extensive CS would lead to adverse outcomes after descending/thoracoabdominal aortic aneurysm (D/TAAA) repair.

METHODS

Between 1991 and 2017, 2012 patients undergoing D/TAAA repair were retrospectively reviewed. After we excluded patients without reported intraoperative CS amount, patients were enrolled in the study (N = 1474) and divided into 2 groups: low CS (salvaged units <40, N = 983) and high CS (salvaged units ≥40, N = 491). Analyses were performed to verify the extensive CS as the risk factor for adverse outcomes.

RESULTS

Preoperative demographics showed that the high-CS group had a significantly greater incidence of male patients (72% vs 58%), heritable aortic disease (24% vs 17%), redo (27% vs 20%), greater glomerular filtration rate (mL/min/1.73 m², 75 vs 66) and more extensive aneurysms (TAAA extent II-IV). The high-CS group had significantly more postoperative complications compared with the low-CS group, including respiratory failure, renal failure, cardiac complications, neurologic deficits, bleeding, and 30-day mortality. Multivariable analysis confirmed high CS was an independent risk factor for renal failure along with long bypass time, older age, and extent of repairs. There was an incremental risk of renal failure and 30-day mortality proportional to salvaged cell unit (P < .001 in both).

CONCLUSIONS

Increased salvaged cell units were associated with adverse postoperative outcomes after D/TAAA repairs. Risk of renal failure and mortality increased proportionally to the salvaged cell units.

Comparison of three autotransfusion devices for utilization in the pediatric population

Introduction:

A device that may help attenuate the amount of homologous blood product given to pediatric cardiac surgical patients is the autotransfusion device. Three separate autotransfusion devices were selected for evaluation. The Sorin Xtra, Fresenius Continuous Autotransfusion System Plus (CATS*plus), and the Fresenius Continuous Autotransfusion System Smart (CATSmart) were evaluated based on the mechanical processes of each device, hematocrit value of the salvaged packed red cell product, time of processing, and the advantageous accessories with each device.

Methods:

Each of the autotransfusion devices were used to collect salvageable blood from the surgical field as well as to process residual blood from the cardiopulmonary bypass circuit after decannulation. The cell salvage process was performed in accordance with the manufacturer’s instructions for use and the recommended settings for processing and washing. The Sorin Xtra device had the 55 mL bowl set up for all cases, while the Fresenius continuous autotransfusion systems utilized the standard disposable for each device.

Results:

Each cell salvage device was employed during 30 pediatric cardiac surgery procedures, and data for each device, was broken down into four groups based on patient weight (0-10, 10-20, 20-40, and >40 kg). For all patient sizes, the Sorin Xtra tended to produce the greatest volume of cell saver product (55-825 mL) as compared to the CATS*plus and CATSmart devices (7-550 mL and 0-860 mL, respectively). The Continuous Autotransfusion System Smart tended to produce the highest hematocrit product, ranging from 44 to 81%.

Discussion:

Through this evaluation, it was determined the continuous autotransfusion systems provided the highest hematocrit with the lowest recovered packed red cell volume, while the Sorin Xtra packed red cell product showed to have a lower hematocrit with a larger packed red cell volume. Each device proved effective within our pediatric population.

Surgical decision making around paediatric preoperative anaemia in low-income and middle-income countries

Prevalence of anaemia is high among children in low-income and middle-income countries. Anaemia is an important factor to consider preoperatively as low haemoglobin concentrations can have a negative effect on surgical outcomes and can also lead to surgeries being cancelled or postponed, which can have adverse health implications and stretch already limited resources in these countries. Additionally, blood transfusions to correct anaemia exposes children to safety issues. Therefore, where anaemia is known to be prevalent and resources are scarce, a contextually appropriate and relatively safe minimum haemoglobin concentration for proceeding to surgery could substantially improve patient management and efficiency of the health system. In this Review, we consider why paediatric anaemia is a major public health issue in low-income and middle-income countries, the value of preoperative testing of anaemia, and methods of optimising haemoglobin concentrations in the context of paediatric surgeries taking place in resource-limited settings.

Patient Blood Management in Pediatric Cardiac Surgery: A Review

Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.

Strategies for blood conservation in pediatric cardiac surgery

Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.

Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults

Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.

[Two-year experience with cell salvage in total hip arthroplasty]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Two-year experience with cell salvage in total hip arthroplasty

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Evaluation of the minimum volume of salvage blood required for the successful use of two different autotransfusion devices

BACKGROUND

Autotransfusion in pediatric anesthesia is beneficial in several clinical settings; however, more frequent usage is deterred by process-related costs and the fact that the absolute volume of blood returned may be minimal.

OBJECTIVE

Two autotransfusion devices (CATS, Fresenius Kabi AG, and Sorin Xtra, Sorin GmbH) with different technologies were evaluated to determine the minimum volume necessary to efficiently process salvage blood.

METHODS

Banked blood was diluted to simulate different clinical scenarios. Volume and red cell mass in returned blood were analyzed as a function of initial volume and red cell mass in the collection reservoir using incremental increases in the volume of blood added to the reservoir.

RESULTS

The volume of the returned processed blood for infusion was dependent on degree of dilution and blood volume in the reservoir. The CATS required a smaller initial minimum volume to process and successfully return; however, the Xtra provided a more efficient recovery at low initial collected volumes. Using test blood of various degrees of dilution, the CATS and Xtra were able to return blood for retransfusion after a mean initial red cell mass of 48.7 ml (±4.9 ml) and 53.7 ml (±5.0 ml) were processed, respectively.

CONCLUSIONS

Red cell mass rather than salvaged blood volume represents a reliable predictor of the successful use of an autotransfusion device. Measuring the hematocrit of the salvaged blood could improve the use of the devices. The investigated devices are likely to be roughly equivalent in effectiveness.