An economic analysis of costs associated with development of a cell salvage program

Current concepts in the use of cell salvage in obstetrics

PURPOSE OF REVIEW

The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed.

RECENT FINDINGS

Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage.

SUMMARY

Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.

Is a Patient Blood Management programme economically reasonable?

PURPOSE OF REVIEW

The value of healthcare is defined as the achieved health outcome in relation to the incurred costs. Patient Blood Management (PBM) is a multidisciplinary, evidence-based and patient-centred concept to optimize the patients' red blood cell mass, minimize blood loss and bleeding and to secure the physiological reserve, including the promotion of evidence-based transfusion strategies. This review describes the healthcare value and the cost effectiveness of single PBM measures as well as the implementation of comprehensive PBM programmes.

RECENT FINDINGS

Overall, measures improving surgical outcome and reducing hospital length of stay, such as intravenous iron supplementation in iron deficient anaemic patients, the use of antifibrinolytic agents for the treatment of bleeding, the use of cell salvage and adherence to an evidence-based transfusion strategy, are associated with cost savings.

SUMMARY

Although several single PBM measures have been shown to be effective and cost-efficient, it remains challenging to compare the results among differing healthcare systems.

Autotransfusion in low-resource settings: a scoping review

INTRODUCTION

Globally, haemorrhage is the leading cause of both maternal mortality and preventable trauma death. For patients suffering from haemorrhage, prompt blood transfusion can be life-saving; however, safe and sufficient blood is often lacking in low-resource settings (LRS). Autotransfusion (AT), in which the patient's own blood is collected and transfused back, is an established alternative to donor blood transfusions, although one that is primarily performed with advanced AT systems. Research on basic AT in LRS is scarce. Therefore, we aimed to consolidate all available information on the current use of basic AT in LRS and to identify AT techniques and devices described for use in such settings.

DESIGN

Scoping review.

METHODS

We systematically searched four key databases: PubMed, Web of Science, Global Health and Cochrane Library as well as several grey literature databases and databases of relevant organisations. The final search was conducted on 22 April 2019. We included all types of studies referring to any information on basic AT used or sought to be used in LRS, published in English and dated after 31 December 2008. We synthesised the data from the included studies, results were charted or summarised narratively.

RESULTS

Some 370 records were reviewed, yielding 38 included documents. We found a paucity of scientific evidence as well as contradictory information on the extent of AT use and that AT use is largely undocumented. The most commonly described indications were haemoperitoneum (primarily among obstetric patients) and haemothorax. We identified three AT techniques used in LRS. Additionally, two new devices and one filter are described for potential use in LRS.

CONCLUSIONS

Basic AT is practiced for certain obstetric and trauma indications. However, context-specific studies are needed to determine the technique's safety and effectiveness. Extent of use is difficult to assess, but our results indicate that basic AT is not a widely established practice in LRS. Future research should address the bottlenecks hampering basic AT availability. New AT devices for use in LRS are described, but their utility and cost-effectiveness remain to be assessed.

Efficacy of Intraoperative Blood Salvage in Cerebral Aneurysm Surgery

BACKGROUND

The use and effectiveness of intraoperative cell salvage has been analyzed in many surgical specialties. Until now, no data exist evaluating the efficacy of intraoperative cell salvage in cerebral aneurysm surgery.

AIM

To evaluate the efficacy and cost effectiveness of intraoperative cell salvage in cerebral aneurysm surgery.

METHODS

Data were collected retrospectively for all the patients who underwent cerebral aneurysm surgery at our institution between 2013 and 2019. Routinely, we apply blood salvage through autotransfusion. The cases were divided into a ruptured cerebral aneurysm group and a unruptured cerebral aneurysm group.

RESULTS

A total of 241 patients underwent cerebral aneurysm clipping. Of all the cerebral aneurysms, 116 were ruptured and 125 were unruptured and clipped electively. Age, location of the aneurysm, postoperative red blood cell count, intraoperative blood loss, and number of allogenic blood cell transfusions were statistically significantly different between the groups. The autotransfusion of salvaged blood could only be facilitated in eight cases with ruptured cerebral aneurysms and in none with unruptured cerebral aneurysms clipped electively (p < 0.01). Additionally, 35 patients with ruptured cerebral aneurysms and one patient with unruptured cerebral aneurysm required allogenic red blood cell transfusion after surgery, and 71 vs. 2 units of blood were transfused (p < 0.0001). In terms of cost effectiveness, a total of EUR 45,189 in 241 patients was spent to run the autotransfusion system, while EUR 13,797 was spent for allogenic blood transfusion.

CONCLUSIONS

The use of cell salvage in patients with unruptured cerebral aneurysm, undergoing elective surgery, is not effective.

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.

Editor's Choice - A Systemic Evaluation of the Costs of Elective EVAR and Open Abdominal Aortic Aneurysm Repair Implies Cost Equivalence

OBJECTIVE

The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered.

METHODS

A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998-2000) and a period of established EVAR (2010-2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs.

RESULTS

One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of €13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (€11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92).

CONCLUSION

Cost equivalence for EVAR and OR occurs at a device cost of €13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.

The Safety and Short-term Outcomes of Leukocyte Depleted Autologous Transfusions During Radical Cystectomy

OBJECTIVE

To examine long- and short-term outcomes using cell salvage with a commercially available leukocyte depletion filter following radical cystectomy in an oncologic population.

MATERIALS AND METHODS

One hundred and fifty-seven patients, 87 of whom received a cell salvage transfusion, were retrospectively identified from chart review. Ninety-day outcomes as well as long-term mortality and cancer recurrence data were collected. Chi-square, Student's t, or Mann-Whitney U tests were used as appropriate. Multivariable regressions of survival were performed with a Cox proportional-hazards model.

RESULTS

Those who received a cell salvage transfusion did not show any differences in rate of cancer recurrence (23%) vs those who did not receive a cell salvage transfusion (24%; P = .85). There were also no differences noted in mortality rates between the 2 populations (12% vs 17%; P = .36). Furthermore, no differences were noted in postoperative complication rates, length of hospital stay, 90-day culture positive infections or readmissions (P >.05).

CONCLUSION

There are no significant differences in short-term or long-term patient outcomes between those who did and did not receive an intraoperative cell salvage transfusion. Cell salvage transfusions with a leukocyte depletion filter are safe and effective methods to reduce the need for allogeneic blood transfusions while controlling for the theoretical risk of metastatic spread.

The compliance with a patient-safety bundle for management of placenta accreta spectrum†

OBJECTIVE

Our objective was to evaluate the compliance with a patient-safety bundle for placenta accreta spectrum (PAS) by comparing the implementation of the components of the patient-safety bundle in the pre- and post-protocol time periods as a quality improvement project.

STUDY DESIGN

This is a before and after retrospective cohort study as a quality improvement report examining compliance with a multidisciplinary delivery approach for patients with suspected PAS between 2007 and 2018. This bundle involved a multidisciplinary approach with maternal-fetal medicine, gynecologic oncology, intervention radiology, obstetric anesthesia, neonatology, and blood bank. The primary outcome was incorporation of all six of the components of the bundle into a PAS procedure: (1) betamethasone, (2) gynecologic oncology intraoperative consult, (3) preoperative balloon catheters, (4) cell salvage technology in the operating room, (5) vertical skin incision, and (6) fundal or high transverse hysterotomy. Demographic, delivery, and patient outcome data were also collected.

RESULTS

There were 39 patients included in the study, 17 were pre-protocol and 22 were post-protocol. Patients were more likely to have a PAS suspected in the antenatal period during post protocol period (23.5 versus 90.9%, p < .0001), as well as having a placenta previa (35.3 versus 81.8%, p = .003), and receive betamethasone prior to delivery (23.5 versus 86.3%, p < .0001). Patients were delivered at an earlier gestational age in post protocol period (36.8 ± 2.52 versus 33.87 ± 2.4, p = .001). The primary outcome, adherence to all components of the patient-safety bundle, was more likely to occur in the post protocol period (0 versus 40.9%, p < .0001). Maternal and postoperative outcomes were not significantly different between groups.

CONCLUSIONS

We have successfully implemented a patient-safety bundle for PAS and have standardized the execution of multidisciplinary management for PAS at our institution.

How do I perform cell salvage in obstetrics?

Maternal mortality in the United States is increasing. The leading cause of death is hemorrhage. Maternal hemorrhage can be profound, with entire blood volumes being lost. In most major blood loss surgery, autotranfusion (also known as cell salvage, cell saving, and intraoperative blood collection and readministration) is a technique that has been used to minimize allogeneic transfusion. Historically, autotransfusion has been considered contraindicated in the face of maternal hemorrhage because of a fear of incorporating amniotic fluid in the salvaged blood. Recent data suggests that this fear is unfounded, with several medical societies now recommending that autotransfusion be used during maternal hemorrhage. In this review, autotransfusion during maternal hemorrhage is discussed, and suggestions are made for how to make it most successful.

Clinical pearls part 3: anaesthetic management of abnormally invasive placentation

PURPOSE OF REVIEW

Abnormal placentation is a clinical condition seen increasingly in the pregnant population. It is associated with significant morbidity and mortality, which may be mitigated through robust multidisciplinary care for these patients. The role of maternal critical care for these patients has largely been ignored in the literature.

RECENT FINDINGS

Advances in pharmacological management of bleeding with recent publications of large multicentre trials in addition to new technologies in the management of massive obstetric haemorrhage (MOH) have revolutionized the management of abnormal placentation. These include the use of tranexamic acid, interventional radiology, cell saver technology, and point-of-care coagulation tests. The role of maternal critical care for the optimization of postoperative complications and physiological derangements has not been considered widely in the literature. This article summarizes the current evidence for interventions and suggests a protocol for the management of these high-risk patients.

SUMMARY

A robust protocol outlining the key elements of the management of placenta accreta, including optimizing postoperative care, should be in place to promote desired outcomes.

Massive transfusions for critical bleeding: is everything old new again?

Massive transfusion or major haemorrhage protocols have been widely adopted in the treatment of critically bleeding patients. Following evidence that higher ratios of transfused plasma and platelets to red blood cells may offer survival benefits in military trauma patients, these ratios are now commonly incorporated into massive transfusion protocols. They more closely resemble the effects of whole blood transfusion, which in the second half of last century was largely replaced by individual blood component transfusion based on laboratory-guided indicators. However, high-quality evidence to guide transfusion support for critically bleeding patients across the range of bleeding contexts is lacking, including for both trauma and non-trauma patients. More data on major haemorrhage support and clinical outcomes are needed to inform guidelines and practice.

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.

Cell salvage for postpartum haemorrhage during vaginal delivery: a case series

BACKGROUND

The safety and effectiveness of cell salvage for vaginal delivery is unknown. This case series aimed to assess the utility and adverse events related to the use of cell salvage for maternal haemorrhage during vaginal delivery.

MATERIALS AND METHODS

A cohort study design was chosen, focused on postpartum haemorrhages that occurred after vaginal delivery for which cell salvage equipment was requested to be set up in the labour and delivery room outside of a sterile operating room environment. Variables recorded included duration of stay in hospital, occurrence of wound infections, sepsis, thromboembolic events, and amniotic fluid embolism.

RESULTS

Of 28 cases of postpartum haemorrhage during vaginal deliveries involving the setup or use of cell salvage equipment, ten were associated with successful re-infusion of salvaged shed blood. These ten cases were compared to the 18 cases in which cell salvage equipment was set up, but insufficient shed blood was salvaged for re-infusion. There were no instances of postpartum sepsis, wound infection, or thromboembolism associated with the use of cell salvage for vaginal delivery. Although one case of suspected amniotic fluid embolism occurred, severe symptoms began prior to the infusion of salvaged blood.

DISCUSSION

Infusion of salvaged shed blood collected from a vaginal delivery field is feasible. The outcomes of these cases do not exclude an unacceptably high risk of infection or embolic events. Trials evaluating the safety and effectiveness associated with the use of cell salvage in vaginal deliveries are justified.

Autologous Blood Transfusion for Postpartum Hemorrhage

Postpartum hemorrhage (PPH) is a leading contributor to maternal morbidity and mortality in the United States and globally. Although the rate of PPH is generally decreasing nationally, severity of PPH appears to be increasing, potentially related to the various comorbidities associated with women of childbearing age. There is increasing evidence of risks associated with allogeneic blood transfusion, which has historically been the classic therapeutic approach for treatment to PPH. Pregnant women are particularly susceptible to the implications of sensitization to red cell antigens, a common sequela to allogenic blood transfusion. Autologous blood transfusion eliminates the potential of communicable disease transmission as well as the conceivable threat of a blood transfusion reaction. Recent technological advances allow cell salvage coupled with the use of a leukocyte filter to be used as an alternative approach for improving the outcome for women experiencing a PPH. Modest changes in standard operating procedure and continued training in use and application of cell salvaged blood may assist in minimizing negative outcomes from PPH. Salvaged blood has been demonstrated to be at least equal and often superior to banked blood. We discuss nursing implications for application of this technology for women with PPH. Continued research is warranted to evaluate the impact that application of cell salvage with filtration has on the patient experiencing a PPH.

Influence of autologous blood transfusion in liver transplantation in patients with hepatitis B on the function and hemorheology of red blood cells

The present study aimed to characterize the function and hemorheology of red blood cells (RBCs) recovered during liver transplantation surgery in patients with hepatitis B and decompensation. A total of 15 hepatitis B patients with decompensation who underwent liver transplantation surgery were included in the present study. Blood samples were recovered during the liver transplantation surgery using an Autologous Blood Recovery System. The morphology and structure of RBCs were characterized and compared between pre-operative and recovered blood samples. In addition, the physiological functions of RBCs were measured and compared between pre-operative and recovered blood samples. No significant differences in the morphological score, 2,3-diphosphoglycerate, Na+K+-ATPase, Ca2+-ATPase, Mg2+-ATPase, malondialdehyde and osmotic fragility were identified between RBCs in the pre-operative and recovered blood samples. The level of free hemoglobin in RBCs of the recovered blood samples was significantly higher than in the pre-operative blood samples (P<0.05). Medium- and high-shear blood viscosities in the recovered blood samples were significantly lower than those observed in the pre-operative blood samples (P<0.05). Casson viscosity in the recovered blood samples was significantly higher compared with the pre-operative blood samples. However, no significant differences (P>0.05) in the low-shear blood viscosity, plasma viscosity, relative blood viscosity, erythrocyte aggregation index or Casson yield stress were identified between recovered and pre-operative blood samples. These findings suggested that autologous blood transfusion in liver transplantation surgery in patients with hepatitis B and decompensation had no significant influence on the morphology, structure, function and hemorheology of RBCs.

The use of intraoperative cell salvage in urologic oncology

Intraoperative cell salvage (IOCS) has been used in urologic surgery for over 20 years to manage intraoperative blood loss and effectively minimize the need for allogenic blood transfusion. Concerns about viability of transfused erythrocytes and potential dissemination of malignant cells have been addressed in the urologic literature. We present a comprehensive review of the use of IOCS in urologic oncologic surgery. IOCS has been shown to preserve the integrity of erythrocytes during processing and effectively provides cell filtration to mitigate the risk of tumor dissemination. Its use is associated with reduction in the overall need for allogenic blood transfusion, which clinically reduces the risk of hypersensitivity reactions and disease transmission, and may have important implications on overall oncologic outcomes. In the context of a variety of urologic malignancies, including prostate, urothelial, and renal cancer, the use of IOCS appears to be safe, without risk of tumor spread leading to metastatic disease or differences in cancer-specific and overall survival. IOCS has been shown to be an effective intraoperative blood management strategy that appears safe for use in urologic oncology surgery. The ability to reduce the need for additional allogenic blood transfusion may have significant impact on immune-mediated oncologic outcomes.

Experience of Intraoperative Cell Salvage in Surgical Correction of Spinal Deformity: A Retrospective Review of 124 Patients

The effect of intraoperative cell salvage (ICS) in surgical correction of spinal deformity remained controversial. This study was to quantitatively demonstrate its effect. In all, 124 patients having ICS in surgical correction of spinal deformity were included. These patients would be divided into 3 groups. Group 1-blood loss less than 15 mL/kg; group 2-between 15 and 37.5 mL/kg; and group 3-more than 37.5 mL/kg. The mean blood loss was 37.2 mL/kg and patients received 872.2 mL salvaged blood on average. The prevalence of intraoperative transfusion of allogenic RBC was 62.9% and the amount averaged 3.4 U. In groups 1 to 3, the prevalence of intraoperative allogenic transfusion was 23.5%, 66.7%, and 100%, respectively. Logistic analysis showed blood loss minus autotransfusion was of significance in predicting intraoperative transfusion, whereas the blood loss or autotransfusion alone was not, implicating an important role of ICS in saving allogenic RBC. The maximum decrease of hemoglobin after operation occurred in the third day, and the magnitude was 45.7 g/L. No severe complications related to ICS were observed. In summary, ICS could decrease the amount of allogenic transfusion in surgical correction of spinal deformity. However, in terms of reducing prevalence of allogenic transfusion, it had a protective effect only in patients with small blood loss.

Acute Free-Iron Exposure Does Not Explain the Impaired Haemorheology Associated with Haemochromatosis

Introduction

Given the severity of the current imbalance between blood donor supply and recipient demand, discarded blood drawn from the routine venesections of haemochromatosis (HFE-HH) patients may serve as a valuable alternative source for blood banks and transfusion. We investigated whether functional or biochemical differences existed between HFE-HH and control blood samples, with particular focus upon the haemorheological properties, to investigate the viability of venesected blood being subsequently harvested for blood products.

Methods

Blood samples were collected from HFE-HH patients undergoing venesection treatment (n = 19) and healthy volunteers (n = 8). Moreover, a second experiment investigated the effects of a dose-response of iron (0, 40, 80, 320 mM FeCl₃) on haemorheology in healthy blood samples (n = 7). Dependent variables included basic haematology, iron status, haematocrit, red blood cell (RBC) aggregation (native and standardised haematocrit) and “aggregability” (RBC tendency to aggregate in a standard aggregating medium; 0.4 L/L haematocrit in a Dx70), and RBC deformability.

Results

Indices of RBC deformability were significantly decreased for HFE-HH when compared with healthy controls: RBC deformability was significantly decreased at 1–7 Pa (p < 0.05), and the shear stress required for half maximal deformability was significantly increased (p < 0.05) for HFE-HH. RBC aggregation in plasma was significantly increased (p < 0.001) for HFE-HH, although when RBC were suspended in plasma-free Dx70 no differences were detected. No differences in RBC deformability or RBC aggregation/aggregability were detected when healthy RBC were incubated with varying dose of FeCl₃.

Conclusion

HFE-HH impairs the haemorheological properties of blood; however, RBC aggregability was similar between HFE-HH and controls when cells were suspended in a plasma-free medium, indicating that plasma factor(s) may explain the altered haemorheology in HFE-HH patients. Acute exposure to elevated iron levels does not appear (in isolation) to account for these differences. Further consideration is required prior to utilising routine venesection blood for harvesting RBC concentrates due to the potential risk of microvascular disorders arising from impaired haemorheology.

Implementation of an obstetric cell salvage service in a tertiary women's hospital

INTRODUCTION

Intraoperative cell salvage (ICS) is an important aspect of patient blood management programmes. An ICS service was introduced at KK Women's and Children's Hospital, Singapore, from 2 May 2011 to 30 April 2013 to aid in the management of massive obstetric haemorrhage.

METHODS

With support from the Ministry of Health's Healthcare Quality Improvement and Innovation Fund, a workgroup comprising obstetricians, anaesthetists and nursing staff was formed to develop training requirements, clinical guidelines and protocols for implementing ICS using the Haemonetics Cell Saver 5. Pregnant women with an anticipated blood loss of > 1,000 mL during Caesarean delivery, a baseline haemoglobin level of < 10 g/dL, rare blood types and who had refused donor blood were recruited to the service after obtaining informed consent.

RESULTS

A total of 11 women were recruited to the ICS service; the primary indications were placenta praevia and placenta accreta. Median blood loss in these 11 patients was 1,500 (range 400-3,000) mL. In four patients, adequate autologous blood was collected to initiate processing and salvaged, processed blood was successfully reinfused (mean 381.3 [range 223.0-700.0] mL). Median blood loss among these four patients was 2,000 (range 2,000-3,000) mL. No adverse event occurred following autologous transfusion. Mean immediate postoperative haemoglobin level was 8.0 (range 7.1-9.4) g/dL.

CONCLUSION

The implementation of an obstetric ICS service in our institution was successful. Future studies should seek to address the cost-effectiveness of ICS in reducing allogeneic blood utilisation.

Cost savings of red cell salvage during cesarean delivery

OBJECTIVE

To use decision analysis to evaluate whether and under what conditions routine setup of intraoperative cell salvage during cesarean delivery is cost-saving.

METHODS

We developed a decision model to compare costs associated with two strategies for cesarean delivery: 1) routine setup of intraoperative cell salvage; or 2) standard care without intraoperative cell salvage. One-, two-, and three-way sensitivity analyses as well as Monte Carlo simulation were used to assess the robustness of our findings.

RESULTS

Among nonselected women undergoing cesarean delivery, our base case estimate was that 3.2% would require red blood cell transfusion. Under this assumption, cell salvage is cost-saving only if each woman requires at least 60 units. Conversely, if only two units on average are required, the probability of transfusion needs to be at least 58% for cell salvage to be cost-saving. In our base case analysis, setup of intraoperative cell salvage during routine cesarean deliveries is not cost-saving, increasing the cost per cesarean delivery by $223.80. We found that cell salvage would be cost-saving only in very high-risk scenarios. For example, severe maternal anemia or abnormal placentation, in which 54% and 75% of women are transfused three and two units per case, respectively, would make cell salvage cost-saving.

CONCLUSION

Setup of intraoperative cell salvage during cesarean delivery is cost-saving and should be considered only when there is a predictably high probability of transfusion or when a massive transfusion is reasonably likely.

The direct cost of care among surgical inpatients at a tertiary hospital in south west Nigeria

Introduction

This study was conducted to assess the direct cost of care and its determinants among surgical inpatients at university College Hospital, Ibadan.

Methods

A retrospective review of records of 404 inpatients that had surgery from January to December, 2010 was conducted. Information was extracted on socio-demographic variables, investigations, drugs, length of stay (LOS) and cost of carewith a semi-structured pro-forma. Mean cost of care were compared using t-test and Analysis of variance (ANOVA). Linear regression analysis was used to identify determinants of cost of care. Level of significance of 5% was used. In year 2010 $1 was equivalent to 150 naira ($1=₦ 150).

Results

The median age of patients was 30 years with inter-quartile range of 13-42 years. Males were 257(63. 6%). The mean overall cost of care was ₦66,983 ± ₦31,985. Cost of surgery is about 50% of total cost of care. Patient first seen at the Accident and Emergency had a significantly higher mean cost of care of ß = ₦17,207(95% CI: ₦4,003 to ₦30,410). Neuro Surgery (ß=₦36,210), and Orthopaedic Surgery versus General Surgery(ß=₦10,258),and Blood transfusion (ß=₦18,493) all contributed to cost of care significantly. Increase of one day in LOS significantly increased cost of care by ₦2,372. 57.

Conclusion

The evidence evaluated here shows that costs and LOS are interrelated. Attempt at reducing LOS will reduce the costs of care of surgical inpatient.

Perceived barriers among physicians for stopping non-cost-effective blood-saving measures in total hip and total knee arthroplasties

BACKGROUND

Despite evidence that the blood-saving measures (BSMs) erythropoietin (EPO) and intra- and postoperative blood salvage are not (cost-)effective in primary elective total hip and knee arthroplasties, they are used frequently in Dutch hospitals. This study aims to assess the impact of barriers associated with the intention of physicians to stop BSMs.

STUDY DESIGN AND METHODS

A survey among 400 orthopedic surgeons and 400 anesthesiologists within the Netherlands was performed. Multivariate logistic regression was used to identify barriers associated with intention to stop BSMs.

RESULTS

A total of 153 (40%) orthopedic surgeons and 100 (27%) anesthesiologists responded. Of all responders 67% used EPO, perioperative blood salvage, or a combination. After reading the evidence on non-cost-effective BSMs, 50% of respondents intended to stop EPO and 53% to stop perioperative blood salvage. In general, barriers perceived most frequently were lack of attention for blood management (90% of respondents), department priority to prevent transfusions (88%), and patient characteristics such as comorbidity (81%). Barriers significantly associated with intention to stop EPO were lack of interest to save money and the impact of other involved parties. Barriers significantly associated with intention to stop perioperative blood salvage were concerns about patient safety, lack of alternatives, losing experience with the technique, and lack of interest to save money.

CONCLUSION

Physicians experience barriers to stop using BSMs, related to their own technical skills, patient safety, current blood management policy, and lack of interest to save money. These barriers should be targeted in strategies to make BSM use cost-effective.

De-implementation of expensive blood saving measures in hip and knee arthroplasties: study protocol for the LISBOA-II cluster randomized trial

Background

Despite evidence that erythropoietin and intra- and postoperative blood salvage are expensive techniques considered to be non-cost-effective in primary elective total hip and knee arthroplasties in the Netherlands, Dutch medical professionals use them frequently to prevent the need for allogeneic transfusion. To actually change physicians’ practice, a tailored strategy aimed at barriers that hinder physicians in abandoning the use of erythropoietin and perioperative blood salvage was systematically developed. The study aims to examine the effectiveness, feasibility and costs of this tailored de-implementation strategy compared to a control strategy.

Methods/Design

A cluster randomized controlled trial including an effect, process and economic evaluation will be conducted in a minimum of 20 Dutch hospitals. Randomisation takes place at hospital level. The hospitals in the intervention group will receive a tailored de-implementation strategy that consists of four components: interactive education, feedback in educational outreach visits, electronically sent reports on hospital performance (all aimed at orthopedic surgeons and anesthesiologists), and information letters or emails aimed at other involved professionals within the intervention hospital (transfusion committee, OR-personnel, pharmacists). The hospitals in the control group will receive a control strategy (i.e., passive dissemination of available evidence). Outcomes will be measured at patient level, using retrospective medical record review. This will be done in all hospitals at baseline and after completion of the intervention period. The primary outcome of the effect evaluation is the percentage of patients undergoing primary elective total hip or knee arthroplasty in which erythropoietin or perioperative blood salvage is applied. The actual exposure to the tailored strategy and users’ experiences will be assessed in the process evaluation. In the economic evaluation, the costs of the tailored strategy and the control strategy in relation to the difference in their effectiveness will be compared.

Discussion

This study will show whether a systematically developed tailored strategy is more effective for de-implementation of non-cost-effective blood saving measures than the control strategy. This knowledge can be used in national and international initiatives to make healthcare more efficient. It also provides more generalized knowledge regarding de-implementation strategies.

Trial registration

This trial is registered at the Dutch Trial Register NTR4044.

Pediatric preoperative blood ordering: when is a type and screen or crossmatch really needed?

BACKGROUND

Unnecessary testing for and ordering of blood products adds to overall healthcare costs.

OBJECTIVES

Determine intraoperative red blood cell (RBC) product utilization for pediatric procedures and costs associated with perioperative testing and ordering.

METHODS

A retrospective chart review captured perioperative blood testing and intraoperative transfusion data for patients <19 years of age who underwent noncardiac surgery over a 13-month period at one tertiary care hospital. The main outcome measure was cost associated with testing for blood products in patients undergoing procedures that had a zero rate of transfusion.

RESULTS

The intraoperative transfusion rate for 8620 noncardiac pediatric procedures was 2.78%. Of 8380 nontransfused patients, 707 (8.4%) had type and screen, and of those, 420 (5%) were crossmatched for RBC products in preparation for surgery. The 10 surgical procedures that had the highest perioperative blood testing but no instances of transfusion were as follows: colostomy or ileostomy takedown, spinal cord untethering, tunneled catheter placement, laparoscopic Nissen fundoplication, elbow reduction and fixation, lumbar puncture, suboccipital craniectomy, hip arthrogram, percutaneous intravascular central line, and tonsillectomy and adenoidectomy. Procedures with low transfusion probability and high crossmatch testing were ventriculoperitoneal shunt revision and growing rod distraction. For all nontransfused patients, the cost of obtaining type and screen was $31,815, and the cost for crossmatch was $25,200.

CONCLUSION

Patients may undergo preoperative type and screen or crossmatch for procedures rarely associated with transfusion. Historic transfusion probability may be used to predict need for transfusion for specific surgical procedures and reduce unnecessary perioperative testing and associated costs.

Economic evaluation of cell salvage in pediatric surgery

BACKGROUND

Red blood cells are a scarce resource with demand outstripping supply. Use of intraoperative red cell salvage (CS) - the process of collecting shed blood during surgery and reinfusing it to patients - is often used as an effective blood conservation strategy. However, little is known about the economic impact of CS during pediatric surgery.

METHODS

A decision tree model was used to estimate the transfusion-related costs per patient (2010 USD) from a healthcare system perspective of four transfusion strategies among children undergoing elective orthopedic or cardiac surgery: (i) CS followed by allogeneic transfusion, (ii) CS followed by autologous transfusion, (iii) allogeneic transfusion alone, and (iv) autologous transfusion alone.

RESULTS

Cell salvage and allogeneic transfusion was the least expensive strategy (USD 883.3) followed by CS and autologous blood transfusion (USD 1,269.7), allogeneic transfusion alone (USD 1,443.0), and autologous transfusion alone (USD 1,824.7). Savings associated with CS use persisted in separate analyses of orthopedic and cardiac surgery, as well as in one-way and probabilistic sensitivity analyses.

CONCLUSIONS

Use of CS, particularly along with allogeneic blood transfusion, appears cost-saving and cost-effective in pediatric surgery.

Blood management

Blood management is a system-based comprehensive approach that uses evidence-based medicine to facilitate an environment to encourage an appropriate use of blood products in the hospital setting. The ultimate goal of a blood-management program is to improve patient outcomes by integrating all available techniques to ensure safety, availability, and appropriate allocation of blood products. It is a patient-centered, multidisciplinary, multimodal, planned approach to the management of patients and blood products.

Blood loss, predictors of bleeding, transfusion practice and strategies of blood cell salvaging during liver transplantation

Blood loss during liver transplantation (OLTx) is a common consequence of pre-existing abnormalities of the hemostatic system, portal hypertension with multiple collateral vessels, portal vein thrombosis, previous abdominal surgery, splenomegaly, and poor “functional” recovery of the new liver. The intrinsic coagulopathic features of end stage cirrhosis along with surgical technical difficulties make transfusion-free liver transplantation a major challenge, and, despite the improvements in understanding of intraoperative coagulation profiles and strategies to control blood loss, the requirements for blood or blood products remains high. The impact of blood transfusion has been shown to be significant and independent of other well-known predictors of posttransplant-outcome. Negative effects on immunomodulation and an increased risk of postoperative complications and mortality have been repeatedly demonstrated. Isovolemic hemodilution, the extensive utilization of thromboelastogram and the use of autotransfusion devices are among the commonly adopted procedures to limit the amount of blood transfusion. The use of intraoperative blood salvage and autologous blood transfusion should still be considered an important method to reduce the need for allogenic blood and the associated complications. In this article we report on the common preoperative and intraoperative factors contributing to blood loss, intraoperative transfusion practices, anesthesiologic and surgical strategies to prevent blood loss, and on intraoperative blood salvaging techniques and autologous blood transfusion. Even though the advances in surgical technique and anesthetic management, as well as a better understanding of the risk factors, have resulted in a steady decrease in intraoperative bleeding, most patients still bleed extensively. Blood transfusion therapy is still a critical feature during OLTx and various studies have shown a large variability in the use of blood products among different centers and even among individual anesthesiologists within the same center. Unfortunately, despite the large number of OLTx performed each year, there is still paucity of large randomized, multicentre, and controlled studies which indicate how to prevent bleeding, the transfusion needs and thresholds, and the “evidence based” perioperative strategies to reduce the amount of transfusion.

A cost study of postoperative cell salvage in the setting of elective primary hip and knee arthroplasty

BACKGROUND

The increasing costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as postoperative red blood cell (RBC) salvage. This study provides a cost comparison of transfusing washed postoperatively salvaged RBCs using an orthopedic perioperative autotransfusion device (OrthoPat, Haemonetics Corporation) versus unwashed shed blood and banked allogeneic blood.

STUDY DESIGN AND METHODS

Cell salvage data were retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Mean unit costs were calculated for washed salvaged RBCs, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic RBCs.

RESULTS

No initial capital investment was required for the establishment of the postoperative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $1827.41, $1167.41, and $2609.44, respectively.

CONCLUSION

This analysis suggests that transfusing washed postoperatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed postoperatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.

Cost-effectiveness of using recombinant activated factor VII as an off-label rescue treatment for critical bleeding requiring massive transfusion

BACKGROUND

Recombinant activated factor VII (rFVIIa) is widely used as an off-label rescue treatment for patients with nonhemophilic critical bleeding.

STUDY DESIGN AND METHODS

Using data from the intensive care unit, transfusion service, and death registry, the long-term survival after using rFVIIa and the associated cost per life-year gained in a consecutive cohort of patients with critical bleeding requiring massive transfusion (≥ 10 red blood cell [RBC] units in 24 hr) were assessed. rFVIIa was only used as a lifesaving treatment when conventional measures had failed.

RESULTS

Of the 353 patients with critical bleeding requiring massive transfusion, 81 (23%) required rFVIIa as a lifesaving rescue treatment. The patients requiring rFVIIa received a greater number of transfusions (number of units: RBCs, 18 vs. 12; fresh-frozen plasma, 16 vs. 10; platelets, 4 vs. 2; p < 0.001) and had a shorter survival time (24 months vs. 33 months; p = 0.002) than those who did not require rFVIIa. The total cost per life-year gained of massive transfusion and incremental cost of rFVIIa as a lifesaving treatment were US$1,148,000 (£711,760; 95% confidence interval [CI], US$825,000-US$1,471,000) and US$736,000 (£456,320; 95% CI, US$527,000-US$945,000), respectively. The incremental costs of rFVIIa increased with severity of illness and transfusion requirement and were greater than the usual acceptable cost-effective limit (<US$100,000 per life-year) for most patients with critical bleeding.

CONCLUSIONS

As a lifesaving treatment for critical bleeding, the incremental cost of rFVIIa was high. Careful patient selection is critical to balance the potential benefits of rFVIIa in an individual patient against the cost to the community.

Intraoperative use of cell saver on patients undergoing open abdominal aortic aneurysm surgical repair: a Greek hospital experience

Perioperative use of a cell saver device can serve as a cost-beneficial alternative to the transfusion method, especially in countries where the cost of a single unit of blood is high. The purpose of this study, conducted in a Greek hospital, was to calculate the cost benefit of using a cell saver device to salvage intraoperative blood during open surgical abdominal aortic aneurysm repair or open aortofemoral bypass for occlusive disease. This retrospective study measured the amounts of salvaged blood and reinfused blood encountered during the procedure and then calculated the cost benefit of cell saver use. With the cost of a unit of blood purchased in Greece about €450 ($585), the blood units salvaged and reinfused were calculated at a mean cost benefit of €754 ($980) per case.

The introduction of intra-operative cell salvage in obstetric clinical practice: a review of the available evidence

Intra-operative blood salvage is common practice in many surgical specialties but its safety is questioned with concerns about the risks of contamination of recovered blood with amniotic fluid and of maternal-foetal alloimmunization. However, the role of cell salvage as a blood-saving measure in this clinical setting is progressively acquiring relevance thanks to the growing body of evidence regarding its quality and safety. Modern cell savers remove most particulate contaminants and leukodepletion filtering of salvaged blood prior to transfusion adds further safety to this technique. Amniotic fluid embolism is no longer regarded as an embolic disease and the contamination of the salvaged blood by foetal Rh-mismatched red blood cells can be dealt with using anti-D immunoglobulin; ABO incompatibility tends to be a minor problem since ABO antigens are not fully developed at birth. Maternal alloimmunization can be caused also by other foetal red cell antigens, but it should also be noted that the risk of alloimmunization of the mother from allogeneic transfusion may be even greater. Therefore the use of cell savers in obstetric clinical practice should be considered in patients at high risk for haemorrhage or in cases where allogeneic blood transfusion is difficult or impossible.

Suction conditions for minimizing the production of free hemoglobin during blood salvage using an autotransfusion apparatus

Background

Three kinds of conditions should be considered to reduce free hemoglobin production using an autologous cell salvage device. They are the negative suction pressure, the size of suction tip, and the air contact during suction. We want to examine which condition is the most important factor to produce free hemoglobin.

Methods

One pack of red blood cell and one pack of fresh frozen plasma with the same blood type were mixed. They were aspirated based on the two suction pressure (-150 mmHg or -300 mmHg), three sizes of suction tips, and the two conditions of air contact, in which the suction tip was located in the surface of blood or in the middle of the blood. Seven ml sized EDTA tube was used to collect 5 ml blood. All the procedure repeated ten times. Free hemoglobin, total hemoglobin, and hematocrit were measured. Hemolysis ratio was calculated with following formula. Hemolysis ratio = (new free hemoglobin production) × (100-hematocrit) / (total hemoglobin).

Results

Free hemoglobin production and hemolysis ratio were increased when the suction tip was positioned in the surface than when it was in the middle of the blood. The pressure of negative suction and three kinds of the suction tips did not influence the production of free hemoglobin nor the hemolysis ratio.

Conclusions

The air contact is the most important factor to reduce hemolysis using autologous cell salvage device. Suction pressure or suction tip diameter have little influence to produce hemolysis.

Phase II comparison study of intraoperative autotransfusion for major oncologic procedures

BACKGROUND

Intraoperative autotransfusion (IOAT) has been avoided in oncologic surgery because of possible tumor cell dissemination. Through a prior Phase I study, we demonstrated that malignant cells are not present in blood filtered for IOAT. We hypothesized that autotransfusion could be safely used for patients undergoing major oncologic procedures and reduce the need for allogeneic blood.

MATERIALS AND METHODS

A Phase II, IRB-approved, prospective evaluation was conducted of patients undergoing gastrointestinal oncologic procedures. All procedures were conducted with blood salvaged for IOAT, and the collected volume was autotransfused if it was >100 ml. Quality of life (QoL) was assessed by questionnaire at regular intervals.

RESULTS

A total of 92 patients were enrolled with median age of 56 years. The most commonly performed procedures were hepatectomy (47%) and pancreaticoduodenectomy (26%). The median preoperative hemoglobin (Hgb) was 13.1 (range, 9-16), and the median estimated blood loss was 350 ml (range, 20-4000 ml). Of the 92 total patients, 32 (35%) received IOAT with a median volume of 255 ml (range, 117-1499 ml). Multivariate analysis identified that patients with preoperative Hgb >11 g/dl (P = .02), and blood loss of 400-900 ml (P = .03) benefited from IOAT with a reduction in postoperative blood transfusion rate. Patients with discharge Hgb >10 g/dl showed higher mean QoL scores throughout their recovery. At a median follow-up of 18 months, the rates of recurrence in the IOAT and the non-IOAT groups were equivalent (38 vs. 39%, P = .9).

CONCLUSIONS

Intraoperative autotransfusion can be used safely and effectively for major oncologic procedures. Furthermore, degree of discharge anemia is associated with lower quality of life in patients undergoing oncologic gastrointestinal surgery.

Cell salvage as part of a blood conservation strategy in anaesthesia

The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.

Are cell salvage and autologous blood transfusion safe in endonasal surgery?

OBJECTIVE

Endoscopic transnasal approaches to the skull base and intracranial disease are an emerging subspecialty. The limits of this approach are often dictated by exposure and blood loss. Cell salvage techniques are widely used in other surgical fields. However, in otolaryngology, questions remain regarding its safety because work is performed in a contaminated field. In this literature review, we present the evidence for perioperative cell saver blood transfusion in potentially contaminated fields and the need for further investigation of its use in endonasal surgery.

DATA SOURCES

MEDLINE and Evidence Based Medicine Reviews databases were searched for relevant articles.

REVIEW METHODS

All English articles discussing autologous blood transfusion in endonasal surgery were reviewed.

RESULTS

Despite a wide search pattern, no articles that discuss this topic were found in the English literature. Therefore, we went on to present data on the general use of cell saver blood in contaminated fields.

CONCLUSION

Cell saver blood is widely accepted in surgery. It offers many advantages in elective operations in which blood loss is expected to be significant. Cell saver blood has been transfused from contaminated fields in other forms of surgery without an associated increase in morbidity. There is good evidence that antibiotic prophylaxis is mandatory in this setting. There is no direct evidence that cell salvage blood is safe in endonasal surgery. Cell salvage is part of a multimodality approach, including the use of hypotensive anesthesia, topical procoagulants, a dedicated team with appropriate equipment, and a good surgical technique with a focus on hemostasis.

Efficacy of intraoperative red blood cell salvage and autotransfusion in the treatment of acetabular fractures

OBJECTIVES

To determine if cell saver (CS) use in patients with acetabular fractures reduces the volume or rate of allogeneic blood transfused intraoperatively and postoperatively and if this translated to a decrease in blood-related charges to the patient.

DESIGN

Retrospective review.

SETTING

Level 1 trauma center.

PATIENTS

One hundred eighty-six patients with operatively treated acetabular fractures.

INTERVENTION

All patients underwent open reduction internal fixation of their acetabular fracture. The decision to use CS was at the surgeon's discretion.

MAIN OUTCOME MEASUREMENTS

The volume and rate of intraoperative and postoperative allogeneic blood transfused and blood-related charges were evaluated.

RESULTS

CS was used in 60 cases (32%), and the average volume of blood autotransfused was 345 mL. No differences were observed in the rates (58.3% vs 48%, P = 0.1883) or the mean volumes (770 vs 518 mL, P = 0.0537) of intraoperative and postoperative allogeneic blood transfusions between the CS and the non-CS groups. Total blood-related charges in the CS group were significantly higher than that in the nonCS group ($1958 vs $694, P < 0.0001). Subanalyses based on fracture pattern, injury severity score, body mass index, days to surgery, and estimated blood loss were performed. In each subanalyses, no differences were observed in intraoperative and postoperative transfusion rates and volumes, and total blood-related charges were higher in the CS groups.

CONCLUSIONS

In the routine use of CS in acetabular surgery, there was no reduction in the volume or rate of allogeneic blood transfused intraoperatively or postoperatively. However, blood-related charges were significantly increased.

The utility of the perioperative autologous transfusion system OrthoPAT in total hip replacement surgery: a prospective study

BACKGROUND

Total hip replacement (THR) is associated with a significant perioperative blood loss, and 30-50% of these patients receive allogeneic blood transfusion (ABT). We evaluated the clinical utility of washed shed blood (WSB) return to reduce ABT in THR patients.

STUDY DESIGN AND METHODS

Data from 108 consecutive THR patients were prospectively collected. WSB salvage and reinfusion (OrthoPAT) was intended for 60 (Reinfusion group), whereas the remaining 48 patients served as control group. Patients received ABT if haemoglobin <8 g/dl or clinical signs and symptoms of acute anemia.

RESULTS

WSB return was possible in 49 patients (205 +/- 151 ml of erythrocyte/patient), without any clinically relevant incident. Return of WSB decreased both the ABT rate (48 vs. 15%, for control and reinfusion groups, respectively; P = 0.001) and the ABT index (371 +/- 154 ml RBC vs. 53 +/- 117 ml RBC, respectively; P = 0.001), without differences between cemented and uncemented THR. In addition, patients from reinfusion group showed a trend to lower postoperative infection rate (10 vs. 2%, respectively; P = 0.086).

CONCLUSIONS

Perioperative salvage and return of WSB in THR seems to effectively reduce the requirements for ABT. However, for patients with preoperative Hb < 13 g/dl, some additional blood saving method should be associated to WSB return.