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Blood cell salvage during cesarean delivery
International Journal of Gynecology and Obstetrics 115 (2011) 161–163
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Blood cell salvage during cesarean delivery Justine V. Sullivan, Maria E. Crouch, Gary Stocken, Stephen W. Lindow ⁎ Hull York Medical School, North Yorkshire, UK
a r t i c l e
i n f o
Article history: Received 2 March 2011 Received in revised form 12 June 2011 Accepted 25 July 2011 Keywords: Blood transfusion Cell salvage Cell saver Elective cesarean delivery Hemorrhage Intraoperative cell salvage
a b s t r a c t Objective: To review the use of blood cell salvage performed during cesarean delivery. Methods: A retrospective review of the case notes of 107 patients who underwent blood cell salvage during cesarean delivery. A total of 102 women at high risk of hemorrhage were prepared preoperatively for cell salvage. A second group of 5 patients had cell salvage initiated intraoperatively owing to unexpected severe hemorrhage. Results: Of the 107 patients, 36 (33.6%) were re-infused with salvaged blood. There were no reported incidents of amniotic embolization or hemolytic disease. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. In elective procedures, patients were re-infused with salvaged blood averaging 28% of the volume of blood lost, without complications. Conclusion: Cell salvage was acceptable, beneficial, and without adverse events in both highrisk elective cesareans and emergency cesareans for unexpected hemorrhaging. The skills refined during use of cell salvage in elective cesareans were crucial for successful implementation during emergency situations. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The aim of blood cell salvage is to reduce the requirement for infusion with banked blood, and therefore the associated risks of prion disease [1,2], transfusion reactions [3], the possibility of increasing cancer incidence in recipients [4,5], and compliance problems based on ethical or religious grounds [6]. The technique reduces the requirement for scarce supplies of banked blood [7]. Cell salvage is not undertaken routinely during cesarean deliveries owing to concerns surrounding the risk of amniotic fluid embolization [6,7,9,10] or hemolytic disease [11] following reinfusion of amniotic fluid or fetal cells; this issue is still unresolved in the current literature [12–14]. Homologous blood transfusion is associated with an inherent risk of certain complications, as given in the Serious Hazards of Transfusion (SHOT) report [3]. The 1996–2009 figures show that there were 282 incorrect blood group transfusions and 3 transfusiontransmitted infections per year. There were 1279 cases with serious outcomes, including 73 major morbidities (excluding anti-D reactions), 1 mortality directly due to the blood transfusion, and 12 mortalities where transfusion reactions may have been implicated. The report also looked at 42 cases of autologous transfusions and concluded that there were minor or no morbidity results for these transfusions. These figures highlight the problems associated with homologous blood transfusions and the importance of finding
⁎ Corresponding author at: Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK. Tel.: + 44 1482 382769; fax: + 44 1482 382781. E-mail address: [email protected] (S.W. Lindow).
alternative sources for blood transfusion. Intraoperative blood cell salvage is at the forefront of this research. The potential for the use of cell salvage and autologous transfusion is important in obstetrics because it allows quick transfusion during serious hemorrhaging complications such as placenta previa, uterine rupture, or postpartum hemorrhage— the leading causes of maternal morbidity [15,16]. The “Green-top” guideline from the Royal College of Obstetricians and Gynaecologists estimates that there are 4000 cases of severe obstetric hemorrhage each year and that the majority require transfusion [17]. The guideline concluded that intraoperative cell salvage is recommended for women with a predicted blood loss of over 1500 mL, and that the technique should only be used by healthcare teams that have used the equipment regularly and have the expertise and experience. Cesarean delivery rates have reached an all-time high and are increasing by 1% each year; in the UK, more than 20% of women are now delivered by cesarean [18]. Local figures show that in 2009, out of a total of 5703 births, 53 women (0.93%) required a blood transfusion (S.W. Lindow, personal communication). Of these, 18 women had a cesarean delivery, which gives the rate of transfusions during cesarean as 1.4%. Previous studies have explored the safety and effectiveness of blood cell salvage used during scheduled elective cesarean deliveries for the risks of amniotic fluid embolism and hemolytic disease [19–21]. The use of leucodepletion filters has been shown to completely remove contaminants and fetal cells, which minimizes the risk of amniotic fluid embolism [6,8], and led to the UK's National Institute for Health and Clinical Excellence (NICE) publishing guidelines stating that these filters could be considered for use in obstetrics [13,14]. Previous studies have concentrated on these risks factors and concluded that cell salvage is safe for use during routine elective cesarean deliveries.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.009
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J.V. Sullivan et al. / International Journal of Gynecology and Obstetrics 115 (2011) 161–163
The next step in evaluating the performance of cell salvage is to assess its effectiveness in high-risk cesarean deliveries. The aim of the present study was to review the effectiveness of cell salvage used during cesarean deliveries, in both elective and emergency situations.
Table 1 Findings among the 36 patients who were re-infused with cell salvaged blood. Cesarean type
Mean blood loss, mL
Mean re-infusion volume, mL
Percentage re-infused
Elective cesarean (n = 21) Emergency cesarean (n = 15) Total
830 1897 1275
231 287 268
28 15 21
2. Patients and methods A retrospective study was conducted at Hull Royal Infirmary, Hull, UK, between January 25, 2007 and July 6, 2009. A total of 102 cesarean delivery patients who were deemed at high risk for hemorrhage (e.g. placenta previa, multiple repeat operations, antepartum hemorrhage) were prepared with the “Cell Saver 5+” (Haemonetics, Braintree, MA, USA) system. We also report on 5 patients who were not at risk of hemorrhage, but who experienced severe bleeding and for whom cell salvage was set up during the emergency cesarean. The blood cell salvage technique allows the suction of maternal blood lost intraoperatively to be filtered, washed, centrifuged, resuspended in saline, and then administered to the patient. A comprehensive description of the technique is described within the operation manual of Cell Saver 5 + —the latest version used for intraoperative cell salvage transfusion [22]. An overview of the technique is described below. Salvaged blood was only re-infused when the collection of fluid was greater than 800 mL. The technique was standardized by one of the authors (GS). The equipment included the Cell Saver 5+ system, 2 separate suction units, and patent intravenous access to the patient. Blood spilt at the time of surgery was collected in an isolated suction system, prepared as below, and re-infused as soon as possible both during and after surgery. Anticoagulant was drip fed (1 drop/s) into the operative field and allowed to mix with the shed maternal blood before being sucked (vacuum pressure −20 KPa) into a sterile reservoir. The mixture was filtered to remove larger blood clots and debris. Once enough blood/ anticoagulant was collected (usually 800 mL) it was centrifuged. The force supplied by this process allows larger, dense red blood cells (RBCs) to cling to the outer wall of the bowl, while all other blood components are discarded directly to the waste bag. The RBCs were washed with sterile isotonic sodium chloride (NaCl 0.9%) then reconcentrated and suspended in a NaCl 0.9% ready for re-infusion. The Cell Saver 5+ system was set up in accordance with the manufacturer's guidelines and only used in automatic mode function for all patients. The anticoagulant used initially was 1000 mL of NaCl 0.9% with 25 000 IU of heparin added; however, owing to changes in Trust guidelines, a pre-formulated solution is now used (ACD-A; Baxter Healthcare, Deerfield, IL, USA). Two suction units were used during surgery: one for maternal shed blood and the other to remove amniotic fluid. This technique reduces initial contamination [8,23]. Depending on bowl size selection of 225 mL or 125 mL capacity, the wash volume was 2000 mL or 1500 mL of NaCl 0.9%, respectively. Although this is twice the default setting, this practice is recommended by the manufacturers in obstetric patients. Swab washing was utilized where possible to increase re-infusion amount by 24%–39% [24]. The swabs were agitated in a sterile bowl of NaCl 0.9% then squeezed (not wrung out) to preserve the integrity of the RBCs. The blood–saline solution was then transferred to the reservoir for processing. A LeucoGuard RS leucocyte reduction filter (Pall, Port Washington. NY, USA) was used. The re-infusion was completed within the recommended 6-hour time limit (www.transfusionguidelines.org) once it had been prescribed by the anesthetist. Ethics approval was not sought for conduct of the study since it is a retrospective review of our current practice.
3. Results The records of 107 patients for whom cell salvage was used during cesarean delivery were reviewed retrospectively: 102 who were at risk of hemorrhage and 5 who were not at risk. Of the 107 patients, 36 (33.6%) had the salvaged blood re-infused. The remaining 71 (66.4%) did not have sufficient blood loss to collect and re-infuse. Of the 36 patients who were re-infused, 31 (86.1%) were prepared for cell salvage before the operation, while 5 (13.9%) had cell savage initiated during the cesarean procedure owing to unexpected hemorrhage. Of the 31 prepared before the operation, 10 were emergency cases set up preoperatively for complications such as antepartum hemorrhage. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. The mean volume of blood lost from the 36 patients was 1274 mL. There was a difference in volume of blood lost dependent on whether the cesarean was elective (mean, 830 mL) or emergency (mean, 1897 mL) (Table 1). The mean volumes of re-infused blood were similar for both elective (231 mL) and emergency (287 mL) deliveries; however, of the total blood volume lost, the proportion of reinfused salvaged blood was higher in the elective group (28%) compared with the emergency group (15%); this was caused by the greater volume of blood lost in the emergency group, and because some of these patients were hemorrhaging before the cell salvage equipment had been set up. The volume re-infused as a percentage of the volume lost is an underestimate because the blood lost is diluted with liquor and the blood re-infused has a high hematocrit, usually greater than 50%, therefore allowing adequate transfusion. The mean volume of blood and fluid lost was 4000 mL in the patients who had cell salvage set up during the procedure compared with 834 mL in those who had cell salvage set up in advance of the cesarean (Table 2). Of the 31 patients who had preoperative set-up, 6 needed transfusion of stored blood (mean, 4.0 units), while 4 of the 5 intraoperative set-up patients needed transfusion (mean, 8.3 units. 4. Discussion The present study demonstrates how cell saver technology is used in our routine clinical practice. The results show that preoperative setTable 2 Comparison among the 36 re-infused patients who had cell salvage set up preoperatively or intraoperatively a.
Elective cesarean Emergency cesarean Blood/fluid loss, mL Preoperative hemoglobin, g/dL Postoperative hemoglobin, g/dL Drop in haemoglobin, g/dL Volume re-infused, mL Transfusion of stored blood (units blood) Duration of hospital stay, d a
b
Preoperative set-up (n = 31)
Intraoperative set-up (n = 5)
21 10 834.9 ± 423.9 10.9 ± 1.5 9.2 ± 1.9 (n = 30) 1.7 ± 1.6 (n = 30) 232.7 ± 71.9 4.0 ± 1.4 (n = 6) 4.0 ± 2.7
0 5 4000 ± 2179.5 8.1 ± 2.9 8.6 ± 2.0 − 0.5 ± 4.5 487.4 ± 323.0 8.3 ± 5.6 (n = 4) 8.8 ± 5.2
Values are given as mean ± SD unless otherwise indicated. One unit of stored blood is the result of a single donation and is not a constant volume. b
J.V. Sullivan et al. / International Journal of Gynecology and Obstetrics 115 (2011) 161–163
up in patients at high risk of hemorrhage is viable, where approximately 30% of patients were transfused. The experience and familiarity gained through preoperative set-up can be put to good practice when an emergency cesarean delivery is necessary. The confidence needed to use cell salvage quickly and easily can only be gained with repeated use—an aspect highlighted in the NICE guidelines [13]. It may be argued that definitive evidence is required before routine use of cell salvage techniques in all cesarean delivery patients is recommended. The advantage, however, is that in the absence of adverse events, the implementation of cell saver reduces the need to use precious banked blood. However, it is arguably unethical to carry out a study where a patient is denied autologous cell transfusion in favor of banked donor blood. The implementation speed of the cell saver technique once members of a team are experienced provides the additional benefit of rapid re-infusion, which can be much faster than acquiring supplies of banked blood. It should be noted that the elective verses emergency preoperative set-up cesarean groups were not equal (21 vs 10 patients, respectively) as a result of the study being a retrospective review of records. The successful use of cell salvage in the 5 women who required emergency blood transfusion due to unforeseen complications is, in part, attributable to the experience gained in the management of the preoperative set-up patients; this enabled effective and rapid set-up and implementation of the cell salvage equipment in an intraoperative situation. The main concern regarding intraoperative cell salvage in obstetrics is the possible risk of an amniotic fluid embolism; however, no occurrence of this adverse event was observed in the present series of patients, which highlights the reduction in this complication by the implementation of leucocyte filters and double suction tubes during cell salvage. The present study confirms the safety of cell salvage in obstetrics and highlights the feasibility of using it in emergency situations when banked blood is not readily available. The future of the use of cell salvage in obstetrics now lies with the clinicians who must decide whether to implement it during elective cesarean deliveries, thereby preparing the team for emergency situations when immediate blood transfusion could save a woman's life. Conflict of interest The authors have no conflicts of interest. References [1] Hunter N, Foster J, Chong A, McCutcheon S, Parnham D, Eaton S, et al. Transmission of prion diseases by blood transfusion. J Gen Virol 2002;83(Pt 11):2897–905. [2] Alter HJ. Pathogen reduction: a precautionary principle paradigm. Transfus Med Rev 2008;22(2):97–102. [3] Serious Hazards of Transfusion. Annual Report 2009. http://www.shotuk.org/wpcontent/uploads/2010/07/SHOT2009.pdf. Published 2010.
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[4] Hjalgrim H, Edgren G, Rostgaard K, Reilly M, Tran TN, Titlestad KE, et al. Cancer incidence in blood transfusion recipients. J Natl Cancer Inst 2007;99(24):1864–74. [5] Brandt L, Brandt J, Olsson H, Anderson H, Möller T. Blood transfusion as a risk factor for non-Hodgkin lymphoma. Br J Cancer 1996;73(9):1148–51. [6] Catling SJ, Williams S, Fielding AM. Cell salvage in obstetrics: an evaluation of the ability of cell salvage combined with leucocyte depletion filtration to remove amniotic fluid from operative blood loss at caesarean section. Int J Obstet Anesth 1999;8(2):79–84. [7] Currie CJ, Patel TC, McEwan P, Dixon S. Evaluation of the future supply and demand for blood products in the United Kingdom National Health Service. Transfus Med 2004;14(1):19–24. [8] Sullivan I, Faulds J, Ralph C. Contamination of salvaged maternal blood by amniotic fluid and fetal red cells during elective Caesarean section. Br J Anaesth 2008;101(2):225–9. [9] Waters JH, Biscotti C, Potter PS, Phillipson E. Amniotic fluid removal during cell salvage in the cesarean section patient. Anesthesiology 2000;92(6):1531–6. [10] Clark SL, Hankins GD, Dudley DA, Dildy GA, Porter TF. Amniotic fluid embolism: analysis of the national registry. Am J Obstet Gynecol 1995;172(4 Pt 1):1158–67. [11] Rebarber A, Lonser R, Jackson S, Copel JA, Sipes S. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol 1998;179(3 Pt 1):715–20. [12] Geoghegan J, Daniels JP, Moore PA, Thompson PJ, Khan KS, Gülmezoglu AM. Cell salvage at caesarean section: the need for an evidence-based approach. BJOG 2009;116(6):743–7. [13] National Institute for Health and Clinical Excellence. IPG144 Intraoperative blood cell salvage in obstetrics—guidance. http://www.nice.org.uk/nicemedia/live/ 11038/30690/30690.pdf. Published 2005. Updated 2010. [14] National Institute for Health and Clinical Excellence. Interventional Procedures Advisory Committee. Interventional procedure overview of intraoperative blood cell salvage in obstetric procedures. http://www.nice.org.uk/nicemedia/live/ 11038/30689/30689.pdf. Published 2005. Updated 2010. [15] Confidential Enquiry into Maternal and Child Health. Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer—2003–2005. www. mdeireland.comhttp://www.mdeireland.com/pub/SML07_Report.pdf. Published 2007. [16] Royal College of Obstetricians and Gynaecologists. Postpartum Haemorrhage, Prevention and Management (Green-top 52). www.rcog.org.ukhttp://www.rcog. org.uk/womens-health/clinical-guidance/prevention-and-managementpostpartum-haemorrhage-green-top-52. Published 2009. [17] Royal College of Obstetricians and Gynaecologists. Blood Transfusions in Obstetrics (Green-top 47). www.rcog.org.ukhttp://www.rcog.org.uk/womenshealth/clinical-guidance/blood-transfusions-obstetrics-green-top-47. Published 2007. Updated 2008. [18] Royal College of Obstetricians and Gynaecologists. The National Sentinel Caesarean Section Audit Report. www.rcog.org.ukhttp://www.rcog.org.uk/files/ rcog-corp/uploaded-files/nscs_audit.pdf. Published 2001. [19] Rebarber A, Lonser R, Jackson S, Copel JA, Sipes S. The safety of intraoperative autologous blood collection and autotransfusion during cesarean section. Am J Obstet Gynecol 1998;179(3 Pt 1):715–20. [20] Potter PS, Waters JH, Burger GA, Mraović B. Application of cell-salvage during cesarean section. Anesthesiology 1999;90(2):619–21. [21] Grange CS, Douglas MJ, Adams TJ, Wadsworth LD. The use of acute hemodilution in parturients undergoing cesarean section. Am J Obstet Gynecol 1998;178(1 Pt 1): 156–60. [22] Haemonetics. Working with the Haemonetics Cell Saver 5. http://www.medigal. com/files/Technical_support/Cell_Saver_5_user_manual_english.pdf. Published 2001. [23] Catling SJ, Freites O, Krishnan S, Gibbs R. Clinical experience with cell salvage in obstetrics: 4 cases from one UK centre. Int J Obstet Anesth 2002;11(2):128–34. [24] Haynes SL, Bennett JR, Torella F, McCollum CN. Does washing swabs increase the efficiency of red cell recovery by cell salvage in aortic surgery? Vox Sang 2005;88(4):244–8.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Blood cell salvage during cesarean delivery Justine V. Sullivan, Maria E. Crouch, Gary Stocken, Stephen W. Lindow ⁎ Hull York Medical School, North Yorkshire, UK
a r t i c l e
i n f o
Article history: Received 2 March 2011 Received in revised form 12 June 2011 Accepted 25 July 2011 Keywords: Blood transfusion Cell salvage Cell saver Elective cesarean delivery Hemorrhage Intraoperative cell salvage
a b s t r a c t Objective: To review the use of blood cell salvage performed during cesarean delivery. Methods: A retrospective review of the case notes of 107 patients who underwent blood cell salvage during cesarean delivery. A total of 102 women at high risk of hemorrhage were prepared preoperatively for cell salvage. A second group of 5 patients had cell salvage initiated intraoperatively owing to unexpected severe hemorrhage. Results: Of the 107 patients, 36 (33.6%) were re-infused with salvaged blood. There were no reported incidents of amniotic embolization or hemolytic disease. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. In elective procedures, patients were re-infused with salvaged blood averaging 28% of the volume of blood lost, without complications. Conclusion: Cell salvage was acceptable, beneficial, and without adverse events in both highrisk elective cesareans and emergency cesareans for unexpected hemorrhaging. The skills refined during use of cell salvage in elective cesareans were crucial for successful implementation during emergency situations. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The aim of blood cell salvage is to reduce the requirement for infusion with banked blood, and therefore the associated risks of prion disease [1,2], transfusion reactions [3], the possibility of increasing cancer incidence in recipients [4,5], and compliance problems based on ethical or religious grounds [6]. The technique reduces the requirement for scarce supplies of banked blood [7]. Cell salvage is not undertaken routinely during cesarean deliveries owing to concerns surrounding the risk of amniotic fluid embolization [6,7,9,10] or hemolytic disease [11] following reinfusion of amniotic fluid or fetal cells; this issue is still unresolved in the current literature [12–14]. Homologous blood transfusion is associated with an inherent risk of certain complications, as given in the Serious Hazards of Transfusion (SHOT) report [3]. The 1996–2009 figures show that there were 282 incorrect blood group transfusions and 3 transfusiontransmitted infections per year. There were 1279 cases with serious outcomes, including 73 major morbidities (excluding anti-D reactions), 1 mortality directly due to the blood transfusion, and 12 mortalities where transfusion reactions may have been implicated. The report also looked at 42 cases of autologous transfusions and concluded that there were minor or no morbidity results for these transfusions. These figures highlight the problems associated with homologous blood transfusions and the importance of finding
⁎ Corresponding author at: Hull Royal Infirmary, Anlaby Road, Hull, HU3 2JZ, UK. Tel.: + 44 1482 382769; fax: + 44 1482 382781. E-mail address: [email protected] (S.W. Lindow).
alternative sources for blood transfusion. Intraoperative blood cell salvage is at the forefront of this research. The potential for the use of cell salvage and autologous transfusion is important in obstetrics because it allows quick transfusion during serious hemorrhaging complications such as placenta previa, uterine rupture, or postpartum hemorrhage— the leading causes of maternal morbidity [15,16]. The “Green-top” guideline from the Royal College of Obstetricians and Gynaecologists estimates that there are 4000 cases of severe obstetric hemorrhage each year and that the majority require transfusion [17]. The guideline concluded that intraoperative cell salvage is recommended for women with a predicted blood loss of over 1500 mL, and that the technique should only be used by healthcare teams that have used the equipment regularly and have the expertise and experience. Cesarean delivery rates have reached an all-time high and are increasing by 1% each year; in the UK, more than 20% of women are now delivered by cesarean [18]. Local figures show that in 2009, out of a total of 5703 births, 53 women (0.93%) required a blood transfusion (S.W. Lindow, personal communication). Of these, 18 women had a cesarean delivery, which gives the rate of transfusions during cesarean as 1.4%. Previous studies have explored the safety and effectiveness of blood cell salvage used during scheduled elective cesarean deliveries for the risks of amniotic fluid embolism and hemolytic disease [19–21]. The use of leucodepletion filters has been shown to completely remove contaminants and fetal cells, which minimizes the risk of amniotic fluid embolism [6,8], and led to the UK's National Institute for Health and Clinical Excellence (NICE) publishing guidelines stating that these filters could be considered for use in obstetrics [13,14]. Previous studies have concentrated on these risks factors and concluded that cell salvage is safe for use during routine elective cesarean deliveries.
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.06.009
162
J.V. Sullivan et al. / International Journal of Gynecology and Obstetrics 115 (2011) 161–163
The next step in evaluating the performance of cell salvage is to assess its effectiveness in high-risk cesarean deliveries. The aim of the present study was to review the effectiveness of cell salvage used during cesarean deliveries, in both elective and emergency situations.
Table 1 Findings among the 36 patients who were re-infused with cell salvaged blood. Cesarean type
Mean blood loss, mL
Mean re-infusion volume, mL
Percentage re-infused
Elective cesarean (n = 21) Emergency cesarean (n = 15) Total
830 1897 1275
231 287 268
28 15 21
2. Patients and methods A retrospective study was conducted at Hull Royal Infirmary, Hull, UK, between January 25, 2007 and July 6, 2009. A total of 102 cesarean delivery patients who were deemed at high risk for hemorrhage (e.g. placenta previa, multiple repeat operations, antepartum hemorrhage) were prepared with the “Cell Saver 5+” (Haemonetics, Braintree, MA, USA) system. We also report on 5 patients who were not at risk of hemorrhage, but who experienced severe bleeding and for whom cell salvage was set up during the emergency cesarean. The blood cell salvage technique allows the suction of maternal blood lost intraoperatively to be filtered, washed, centrifuged, resuspended in saline, and then administered to the patient. A comprehensive description of the technique is described within the operation manual of Cell Saver 5 + —the latest version used for intraoperative cell salvage transfusion [22]. An overview of the technique is described below. Salvaged blood was only re-infused when the collection of fluid was greater than 800 mL. The technique was standardized by one of the authors (GS). The equipment included the Cell Saver 5+ system, 2 separate suction units, and patent intravenous access to the patient. Blood spilt at the time of surgery was collected in an isolated suction system, prepared as below, and re-infused as soon as possible both during and after surgery. Anticoagulant was drip fed (1 drop/s) into the operative field and allowed to mix with the shed maternal blood before being sucked (vacuum pressure −20 KPa) into a sterile reservoir. The mixture was filtered to remove larger blood clots and debris. Once enough blood/ anticoagulant was collected (usually 800 mL) it was centrifuged. The force supplied by this process allows larger, dense red blood cells (RBCs) to cling to the outer wall of the bowl, while all other blood components are discarded directly to the waste bag. The RBCs were washed with sterile isotonic sodium chloride (NaCl 0.9%) then reconcentrated and suspended in a NaCl 0.9% ready for re-infusion. The Cell Saver 5+ system was set up in accordance with the manufacturer's guidelines and only used in automatic mode function for all patients. The anticoagulant used initially was 1000 mL of NaCl 0.9% with 25 000 IU of heparin added; however, owing to changes in Trust guidelines, a pre-formulated solution is now used (ACD-A; Baxter Healthcare, Deerfield, IL, USA). Two suction units were used during surgery: one for maternal shed blood and the other to remove amniotic fluid. This technique reduces initial contamination [8,23]. Depending on bowl size selection of 225 mL or 125 mL capacity, the wash volume was 2000 mL or 1500 mL of NaCl 0.9%, respectively. Although this is twice the default setting, this practice is recommended by the manufacturers in obstetric patients. Swab washing was utilized where possible to increase re-infusion amount by 24%–39% [24]. The swabs were agitated in a sterile bowl of NaCl 0.9% then squeezed (not wrung out) to preserve the integrity of the RBCs. The blood–saline solution was then transferred to the reservoir for processing. A LeucoGuard RS leucocyte reduction filter (Pall, Port Washington. NY, USA) was used. The re-infusion was completed within the recommended 6-hour time limit (www.transfusionguidelines.org) once it had been prescribed by the anesthetist. Ethics approval was not sought for conduct of the study since it is a retrospective review of our current practice.
3. Results The records of 107 patients for whom cell salvage was used during cesarean delivery were reviewed retrospectively: 102 who were at risk of hemorrhage and 5 who were not at risk. Of the 107 patients, 36 (33.6%) had the salvaged blood re-infused. The remaining 71 (66.4%) did not have sufficient blood loss to collect and re-infuse. Of the 36 patients who were re-infused, 31 (86.1%) were prepared for cell salvage before the operation, while 5 (13.9%) had cell savage initiated during the cesarean procedure owing to unexpected hemorrhage. Of the 31 prepared before the operation, 10 were emergency cases set up preoperatively for complications such as antepartum hemorrhage. Of the 31 patients for whom cell salvage was prepared preoperatively, only 6 patients required transfusion of banked blood. The mean volume of blood lost from the 36 patients was 1274 mL. There was a difference in volume of blood lost dependent on whether the cesarean was elective (mean, 830 mL) or emergency (mean, 1897 mL) (Table 1). The mean volumes of re-infused blood were similar for both elective (231 mL) and emergency (287 mL) deliveries; however, of the total blood volume lost, the proportion of reinfused salvaged blood was higher in the elective group (28%) compared with the emergency group (15%); this was caused by the greater volume of blood lost in the emergency group, and because some of these patients were hemorrhaging before the cell salvage equipment had been set up. The volume re-infused as a percentage of the volume lost is an underestimate because the blood lost is diluted with liquor and the blood re-infused has a high hematocrit, usually greater than 50%, therefore allowing adequate transfusion. The mean volume of blood and fluid lost was 4000 mL in the patients who had cell salvage set up during the procedure compared with 834 mL in those who had cell salvage set up in advance of the cesarean (Table 2). Of the 31 patients who had preoperative set-up, 6 needed transfusion of stored blood (mean, 4.0 units), while 4 of the 5 intraoperative set-up patients needed transfusion (mean, 8.3 units. 4. Discussion The present study demonstrates how cell saver technology is used in our routine clinical practice. The results show that preoperative setTable 2 Comparison among the 36 re-infused patients who had cell salvage set up preoperatively or intraoperatively a.
Elective cesarean Emergency cesarean Blood/fluid loss, mL Preoperative hemoglobin, g/dL Postoperative hemoglobin, g/dL Drop in haemoglobin, g/dL Volume re-infused, mL Transfusion of stored blood (units blood) Duration of hospital stay, d a
b
Preoperative set-up (n = 31)
Intraoperative set-up (n = 5)
21 10 834.9 ± 423.9 10.9 ± 1.5 9.2 ± 1.9 (n = 30) 1.7 ± 1.6 (n = 30) 232.7 ± 71.9 4.0 ± 1.4 (n = 6) 4.0 ± 2.7
0 5 4000 ± 2179.5 8.1 ± 2.9 8.6 ± 2.0 − 0.5 ± 4.5 487.4 ± 323.0 8.3 ± 5.6 (n = 4) 8.8 ± 5.2
Values are given as mean ± SD unless otherwise indicated. One unit of stored blood is the result of a single donation and is not a constant volume. b
J.V. Sullivan et al. / International Journal of Gynecology and Obstetrics 115 (2011) 161–163
up in patients at high risk of hemorrhage is viable, where approximately 30% of patients were transfused. The experience and familiarity gained through preoperative set-up can be put to good practice when an emergency cesarean delivery is necessary. The confidence needed to use cell salvage quickly and easily can only be gained with repeated use—an aspect highlighted in the NICE guidelines [13]. It may be argued that definitive evidence is required before routine use of cell salvage techniques in all cesarean delivery patients is recommended. The advantage, however, is that in the absence of adverse events, the implementation of cell saver reduces the need to use precious banked blood. However, it is arguably unethical to carry out a study where a patient is denied autologous cell transfusion in favor of banked donor blood. The implementation speed of the cell saver technique once members of a team are experienced provides the additional benefit of rapid re-infusion, which can be much faster than acquiring supplies of banked blood. It should be noted that the elective verses emergency preoperative set-up cesarean groups were not equal (21 vs 10 patients, respectively) as a result of the study being a retrospective review of records. The successful use of cell salvage in the 5 women who required emergency blood transfusion due to unforeseen complications is, in part, attributable to the experience gained in the management of the preoperative set-up patients; this enabled effective and rapid set-up and implementation of the cell salvage equipment in an intraoperative situation. The main concern regarding intraoperative cell salvage in obstetrics is the possible risk of an amniotic fluid embolism; however, no occurrence of this adverse event was observed in the present series of patients, which highlights the reduction in this complication by the implementation of leucocyte filters and double suction tubes during cell salvage. The present study confirms the safety of cell salvage in obstetrics and highlights the feasibility of using it in emergency situations when banked blood is not readily available. The future of the use of cell salvage in obstetrics now lies with the clinicians who must decide whether to implement it during elective cesarean deliveries, thereby preparing the team for emergency situations when immediate blood transfusion could save a woman's life. Conflict of interest The authors have no conflicts of interest. References [1] Hunter N, Foster J, Chong A, McCutcheon S, Parnham D, Eaton S, et al. Transmission of prion diseases by blood transfusion. J Gen Virol 2002;83(Pt 11):2897–905. [2] Alter HJ. Pathogen reduction: a precautionary principle paradigm. Transfus Med Rev 2008;22(2):97–102. [3] Serious Hazards of Transfusion. Annual Report 2009. http://www.shotuk.org/wpcontent/uploads/2010/07/SHOT2009.pdf. Published 2010.
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