- Email: [email protected]
Intraoperative autotransfusion
Intraoperative autotransfusion Lori Duff, RN
Lori Duff,RN, BSN, is an OR staff nurse at the UCLA Medical Center, Los Angeles. She received her BSN from California State College, Bakersfield.
1102
perating room nurses face additional responsibilities and challenges when using an autologous blood transfusion device to salvage a patient’s own blood for reinfusion. Advances in autotransfusion have eliminated adverse effects associated with homologous blood transfusions. But OR nurses need to be aware of the responsibilities and possible problems associated with intraoperative autotransfusion. Intraoperative autotransfusion is the collection, anticoagulation, filtration, and reinfusion of blood from an active bleeding site. Historically, autotransfusion had many pitfalls. Early attempts at autotransfusion were hampered by crude techniques. Blood was swabbed from the bleeding site, the swabs rinsed with saline, and the washings reinfused. In 1818, Blundell salvaged and reinfused vaginal blood from patients with postpartum hemorrhage, but his unsophisticated methods resulted in a 5090 mortality rate.’ In 1886, Duncan used autotransfusion to remove blood from an amputated leg and return it to the patient by femoral injection.* In 1914, Theis reported the first successful use of autologous transfusion in a patient with a ruptured ectopic p r e g n a n ~ yBy . ~ 1920, documentation of 164 cases of autotransfusion reflected a growing interest in the t e ~ h n i q u e .It~ was during the 1920s that suction to collect a patient’s escaping blood for reinfusion was introduced. Some patients receiving the suctioned blood, however, developed hemolysis from suctioning and subsequent hemoglobinuria. Interest in autotransfusion, however, dwindled by World War 11. The increased demand for blood was met by a large patriotic blood donor pool. Blood testing, typing, and crossmatching techniques were improved, making blood banks the answer to increased
AORN Journal, May 1983, V o l 3 7 , No 6
0
ne unit of autologous washed, packed cells is ready in six to ten minutes.
demand for blood. Not until the 1960s did interest in autotransfusion revive. Advances in cardiovascular surgery, the improved ability to care for trauma victims, and the large number of Vietnam war injuries are reasons why the demand for blood increased. In contrast, the blood donor pool declined. To combat this problem, companies began to design and develop autotransfusion devices. Basic features of the early systems included sterile collection (suction), a n ticoagulation, filtration, and reinfusion. Dyer introduced one of the first systems for intraoperatively salvaging blood in the mid 1 9 6 0 This ~~ system won him the annual Surgeon General’s award. His design consisted of two 1L glass bottles, fine mesh filters, a conventional blood infusion set, one set of suction tubing for hook-up to a wall suction, and another to the bleeding site. After the blood was collected, anticoagulated, and filtered, it was reinfused by gravity. Although Dyer’s system was successful, the blood collected from the surgical field was subject to considerable trauma because of vacuum suction. Also, the double reservoir was cumbersome and required considerable effort to prepare it for reuse. In 1970, Klebanoff reported his experience with autotransfusion in Vietnam, using an open heart pump and a sterile, filtered collection reservoir.6 Klebanoff s device was successful, but 1104
air embolism was a problem. Although the early autotransfusion devices did save lives, they had several problem^.^ They were capable of introducing air emboli into a patient when improperly used. Filtration was limited to macro debris. Red blood cells hemolysized by suctioning were, consequently, returned to the plasma as free hemoglobin and ruptured cells. This is known to be a potential cause of renal failure. Microembolism from activated platelets and coagulation abnormalities from activated clotting factors were also potential dangers. In 1975, an autotransfusion cell saver system was developed adding two features: hemoconcentration and cell washing. The end product, washed packed cells in saline, was free of anticoagulate, platelets, clotting factors, free hemoglobin, or cell stroma. Air embolism was no longer a problem. There was no limit to the number of units salvaged and transfused, as long as coagulation factors (in the form of fresh frozen plasma) were given to the patient. Basic features ofcell saver. Basic components of the cell saver include a special, double lumen suction tubing; a collecting reservoir; a delivery pump; and a centrifuge (Figs 1, 2, 3, 4, 5). A solution of heparin, 30,000 units in 1,000 cc of saline, is mixed with the aspirated blood at the tip of the double lumen suction tubing. The rate of anticoagulant flow, mixed according t o this formula, is
AORN Journal, May 1983, Vol37, No 6
Fig 2. Centrifuge well where blood is washed and packed.
Fig 1. The cell saver machine.
adjusted so that 100 cc of heparin solution is added for each 500 cc of blood collected. The aspirated blood is then filtered through a 140-micron screen to remove fat, surgical debris, white blood cells, and platelets. The filtrate flows into a holding reservoir, which stores the salvaged blood until there is a sufficient quantity to process or while a unit is being centrifuged. From the reservoir, the filtrate is pumped into the centrifuge bowl using a roller pump. In this centrifugal processing chamber, blood is concentrated to a hematocrit of 50%to 60%.The end product, red blood cells, are washed with one liter of saline. The packed cells are then pumped into a reinfusion bag and transferred back to the patient. One unit of autologous washed, packed cells are returned to the patient in six to ten minutes. Advantages of autotransfusion. Intraoperative autotransfusion has numerous advantages: the risk of technical errors in blood
1106
Fig 3. Collecting reservoir and 140-micron screen.
typing a n d crossmatching a r e eliminated 0 possible adverse effects associated with homologous blood transfusions are eliminated dependence on homologous blood banks is diminished 0 blood obtained by intraoperative autotransfusion has more viable red blood cells because it has not undergone the biochemical changes that occur during storage. Autologous blood transfusion eliminates transfusion reactions and possible exposure to serum hepatitis, syphilis, malaria, brucellosis, immune deficiency syndrome (AIDS), and viral diseases. Fatalities related to these trans-
AORN Journal, M a y 1903, Vol 37, N o 6
fusion problems do occur. One hundred and thirteen deaths related to homologous transfusion were reported to the US Food and Drug Administration from April 1976 to January 1980. Sixty-one percent were related to clerical error, such as giving the wrong unit of blood, and 29% were due to hepatitis. The other 10%were due to miscellaneous problems, such as transfusion of incompatible blood because the need for blood was too acute to wait for crossmatching.* Autologous blood can significantly decrease demands upon homologous blood bank sources. The single most important problem that faces blood banks today is the disparity between the demand for blood and the supply of b10od.~ Less than 3% of the eligible donor pool in the United States donates.10 Physicians Flynn and Metzger said that when the cell saver was used in 125 cases, mostly spinal fusions, blood salvaged from the surgical wound averaged 54%. This was computed from red cell mass data based on preoperative hematocrits and assumed hematocrits of 60% for the cell saver units." Red blood cells obtained by intraoperative autotransfusion are equal to or superior to homologous red blood cells in oxygen-carrying ability. The major function of red blood cells is to transport hemoglobin, which carries oxygen from the lungs to the tissues. An important factor that makes autologous blood superior to homologous stored blood is the action of a substance called 2,3diphosphoglycerate (2,3-DPG). Hemoglobin is fixed tightly to oxygen; 2,3-DPG helps loosen the oxygen and move it off the red blood cells. Thus, a high level of 2,3-DPG facilitates the diffusion of oxygen into the tissues. It has been documented t h a t autologous washed cells have higher levels of 2,3DPG than stored blood and are most resistant to osmotic stress because 1108
Fig 4. Double lumen suction tubing.
younger, healthier cells survive the washing process.12 A variety of changes occur in homologous blood during storage (Table l).13 A transfused red blood cell regenerates 2,3-DPG in the recipient's circulation. But it takes three to eight hours for severely depleted cells to regenerate half the 2,3-DPG levels and approximately 24 hours for complete return of 2,3-DPG and normal hemoglobin funct i 0 n . 1 ~In severely compromised patients, the time it takes to regenerate homologous red cells is important. This is the patient who needs the cell saver. Disadvantages ofcell saver. There are several disadvantages of the cell saver: 0 an additional nurse o r perfusionist may be required to operate the device 0 the cell saver may malfunction, eg,, fail to wash blood cells effectively,, meaning the presence of red blood cells, platelets, and low hematocrits. If this happens, the salvaged blood must be washed again by the blood bank. substantial cost to patient when less than two units are salvaged the potential for infection if the presterilized, disposable components become contaminated by person preparing machine for use. Preparation time and costs of homologous blood versus autologous washed blood were compared a t the
AORN Journal, May 1983, Vol37, No 6
Fig 5. Some of the disposable components charged to patient: Centrifuge bowl and tubing, waste container, and blood bag.
blood bank of the University of California, Los Angeles, Hospitals and Clinics. One unit of homologous packed red blood cells costs the patient about $118. Use of the cell saver costs the patient approximately $300. Blood loss must therefore be greater than two units for the cell saver to be cost effective. Statistics a r e available on the amount of blood usually required for elective surgical procedures. They are useful guides for determining cell saver
candidates.15 The cell saver is usually not recommended for patients with grossly contaminated wounds and patients having bowel surgery with fecal spillage, because bacteria cannot be totally filtered out. Glover studied 14 patients who received blood contaminated by intestinal contents, urine, and/or bile. Eight patients survived the immediate postoperative period. Four of those patients had positive blood cultures within 24 hours of operation although none of the four developed sepsis.16 A cell saver is also contraindicated in cases involving malignant lesions because of the possibility of disseminating malignant cells. Nursing responsibilities. Using a cell saver places additional responsibilities upon both the scrub and circulating nurse. The scrub nurse can significantly increase the amount of blood salvaged from the operative site by diligently using suction, minimizing sponge use, aspirating all blood fragments, and frequently flushing the suction tip to prevent clots from forming.
Table 1
Biochemical changes in CPD adenine4 * packed red blood cells during storage Components
PH Plasma hemoglobin mg/lOO ml Plasma potassium mEq/L Plasma sodium MEq/L Dextrose mg/lOO ml Whole blood ammonia ATP O/O of normal 2,3-DPG % of normal
Days of storage 0 7
14
21
28
35
7.40 61.5 42.2 126.1 378.5 419.1 88% 80%
7.27 123.0 57.6 123.8 339.2 477.8 81O/O 45%
7.26 186.8 66.3 118.5 236.3 597.9 78% 17%
7.08 250.2 69.3 109.6 152.7 706.8 70% 9%
7.00 510.9 77.7 111.0 123.3 772.2 60% 2%
7.62 2.4 3.8 177.2 465.7 30.6 100% 100%
*An anticoagulant preservative Source: T A Bensinger,J Neher, C C Peck,unpublisheddata, LetterrnanArmy Instituteof Research,Presidioof San Francisco, 1979 (6 units of blood tested).
d) AORN Journal, May 1983, Vol37, No 6
1109
The circulating nurse often operates the cell saver. He or she needs a basic understanding of blood and blood components, hemoglobin and hematocrit, and anticoagulation. (See accompanying article, "Administering blood safely.") To act as the patient's advocate, he or she should be aware of the costs, benefits, and potential problems of autologous transfusion. Knowing the answers allows the nurse to collaborate effectively with the surgeon, ensuring quality patient care. For example, it is a nursing responsibility to inform the surgeon that the cell saver is contraindicated for a patient with an infection, and if used, an incident report should be filed. To protect both the patient and surgical team, the time may come when a written consent is required for use of the cell saver during all invasive surgical procedures. Summary. Because nursing assessments may determine when autotransfusion is advised or contraindicated, it is the nurse's responsibility to understand the procedures and problems associated with autotransfusion. The OR nurse cannot only serve as troubleshooter and educator, but also suggest protocols for adoption and selection of autotransfusion equipment and proton cols for patient use. Note8 1. J Blundell, "Experiments on the transfusion of blood by the syringe," Medico-ChirurgicalJournal 9 (1818) 56. 2. J Duncan, "On reinfusion of blood in primary and other amputations," British Medical Journal 1 (January 1886) 192-193. 3. G Klebanoff, J Phillips, W Evans, "Use of a disposable autotransfusionunit under varying conditions of contamination," American Journal of Surgery 120 (September 1970) 351-354. 4. /bid, 351. 5. R H Dyer, "lntraoperative autotransfusion: A preliminary report and new method," American Journal of Surgery 112 (December 1966) 874-878. 6. G Klebanoff, "Early experience with a disposable unit for the intraoperative salvage and reinfusion of blood loss (intraoperative autotransfu-
1112
sion)," American Journal of Surgery 120 (December 1970) 718-722. 7. L C Stehling, H L Zauder, W Rogers, "lntraoperative autotransfusion," Anesthesiology 43 (September 1975) 337-345. 8. B A Myhre, "Fatalities from blood transfusion," Journal of the American Medical Association 224 (September 1980) 1333-1335. 9. D M Surgenor, "Progress toward a national blood system," New England Journal of Medicine 291 (July 4, 1974) 17-22. 10. W P Bartel, W Stelzner, J Higgins, "Attitudes underlying reluctance to donate blood," Transfusion 15 (May-June 1975) 275-277. 11. J C Flynn et al, "lntraoperative autotransfusion (IAT) in elective orthopaedic surgery," presented at American Academy of Orthopaedic Surgeons, Las Vegas, Nev, March 2, 1981. 12. M D Orr, J W Blenko, "Autotransfusion of concentrated, selected washed cells from the surgical field: A biochemical and physiological comparison with homologous cell transfusion," Proceeding of the Blood Conservation Institute, 1978. 13. T A Bensinger, J Neher, C C,Peck, unpublished data, Letterman Army Institute of Research, Presidio of San Francisco, 1979. 14. Frances K Widmann, ed, Technical Manual of the American Association of Blood Banks, 8th ed (Philadelphia: J B Lippincott, 1981) 52-53. 15. P D Mintz et al, "Expected hemotherapy in elective surgery," New York State Journal of Medicine 76 (April 1976) 532-537. 16. J L Glover et al, "Autotransfusion of blood contaminated by intestinal contents," Journal of the American College of Emergency Physicians 7 (April 1978) 142-144.
Infection control program open Spaces are available for the 1984-1985 academic year in the University of Virginia Graduate School of Arts and Sciences's expanded master's degree program in hospital epidemiology-infection control. For a catalog and application form, write to Admissions Office, Graduate School of Arts and Sciences, 437 Cabell Hall, University of Virginia, Charlottesville, Va 22903-3196.
AORN Journal, May 1983, V o l 3 7 , No 6
Lori Duff,RN, BSN, is an OR staff nurse at the UCLA Medical Center, Los Angeles. She received her BSN from California State College, Bakersfield.
1102
perating room nurses face additional responsibilities and challenges when using an autologous blood transfusion device to salvage a patient’s own blood for reinfusion. Advances in autotransfusion have eliminated adverse effects associated with homologous blood transfusions. But OR nurses need to be aware of the responsibilities and possible problems associated with intraoperative autotransfusion. Intraoperative autotransfusion is the collection, anticoagulation, filtration, and reinfusion of blood from an active bleeding site. Historically, autotransfusion had many pitfalls. Early attempts at autotransfusion were hampered by crude techniques. Blood was swabbed from the bleeding site, the swabs rinsed with saline, and the washings reinfused. In 1818, Blundell salvaged and reinfused vaginal blood from patients with postpartum hemorrhage, but his unsophisticated methods resulted in a 5090 mortality rate.’ In 1886, Duncan used autotransfusion to remove blood from an amputated leg and return it to the patient by femoral injection.* In 1914, Theis reported the first successful use of autologous transfusion in a patient with a ruptured ectopic p r e g n a n ~ yBy . ~ 1920, documentation of 164 cases of autotransfusion reflected a growing interest in the t e ~ h n i q u e .It~ was during the 1920s that suction to collect a patient’s escaping blood for reinfusion was introduced. Some patients receiving the suctioned blood, however, developed hemolysis from suctioning and subsequent hemoglobinuria. Interest in autotransfusion, however, dwindled by World War 11. The increased demand for blood was met by a large patriotic blood donor pool. Blood testing, typing, and crossmatching techniques were improved, making blood banks the answer to increased
AORN Journal, May 1983, V o l 3 7 , No 6
0
ne unit of autologous washed, packed cells is ready in six to ten minutes.
demand for blood. Not until the 1960s did interest in autotransfusion revive. Advances in cardiovascular surgery, the improved ability to care for trauma victims, and the large number of Vietnam war injuries are reasons why the demand for blood increased. In contrast, the blood donor pool declined. To combat this problem, companies began to design and develop autotransfusion devices. Basic features of the early systems included sterile collection (suction), a n ticoagulation, filtration, and reinfusion. Dyer introduced one of the first systems for intraoperatively salvaging blood in the mid 1 9 6 0 This ~~ system won him the annual Surgeon General’s award. His design consisted of two 1L glass bottles, fine mesh filters, a conventional blood infusion set, one set of suction tubing for hook-up to a wall suction, and another to the bleeding site. After the blood was collected, anticoagulated, and filtered, it was reinfused by gravity. Although Dyer’s system was successful, the blood collected from the surgical field was subject to considerable trauma because of vacuum suction. Also, the double reservoir was cumbersome and required considerable effort to prepare it for reuse. In 1970, Klebanoff reported his experience with autotransfusion in Vietnam, using an open heart pump and a sterile, filtered collection reservoir.6 Klebanoff s device was successful, but 1104
air embolism was a problem. Although the early autotransfusion devices did save lives, they had several problem^.^ They were capable of introducing air emboli into a patient when improperly used. Filtration was limited to macro debris. Red blood cells hemolysized by suctioning were, consequently, returned to the plasma as free hemoglobin and ruptured cells. This is known to be a potential cause of renal failure. Microembolism from activated platelets and coagulation abnormalities from activated clotting factors were also potential dangers. In 1975, an autotransfusion cell saver system was developed adding two features: hemoconcentration and cell washing. The end product, washed packed cells in saline, was free of anticoagulate, platelets, clotting factors, free hemoglobin, or cell stroma. Air embolism was no longer a problem. There was no limit to the number of units salvaged and transfused, as long as coagulation factors (in the form of fresh frozen plasma) were given to the patient. Basic features ofcell saver. Basic components of the cell saver include a special, double lumen suction tubing; a collecting reservoir; a delivery pump; and a centrifuge (Figs 1, 2, 3, 4, 5). A solution of heparin, 30,000 units in 1,000 cc of saline, is mixed with the aspirated blood at the tip of the double lumen suction tubing. The rate of anticoagulant flow, mixed according t o this formula, is
AORN Journal, May 1983, Vol37, No 6
Fig 2. Centrifuge well where blood is washed and packed.
Fig 1. The cell saver machine.
adjusted so that 100 cc of heparin solution is added for each 500 cc of blood collected. The aspirated blood is then filtered through a 140-micron screen to remove fat, surgical debris, white blood cells, and platelets. The filtrate flows into a holding reservoir, which stores the salvaged blood until there is a sufficient quantity to process or while a unit is being centrifuged. From the reservoir, the filtrate is pumped into the centrifuge bowl using a roller pump. In this centrifugal processing chamber, blood is concentrated to a hematocrit of 50%to 60%.The end product, red blood cells, are washed with one liter of saline. The packed cells are then pumped into a reinfusion bag and transferred back to the patient. One unit of autologous washed, packed cells are returned to the patient in six to ten minutes. Advantages of autotransfusion. Intraoperative autotransfusion has numerous advantages: the risk of technical errors in blood
1106
Fig 3. Collecting reservoir and 140-micron screen.
typing a n d crossmatching a r e eliminated 0 possible adverse effects associated with homologous blood transfusions are eliminated dependence on homologous blood banks is diminished 0 blood obtained by intraoperative autotransfusion has more viable red blood cells because it has not undergone the biochemical changes that occur during storage. Autologous blood transfusion eliminates transfusion reactions and possible exposure to serum hepatitis, syphilis, malaria, brucellosis, immune deficiency syndrome (AIDS), and viral diseases. Fatalities related to these trans-
AORN Journal, M a y 1903, Vol 37, N o 6
fusion problems do occur. One hundred and thirteen deaths related to homologous transfusion were reported to the US Food and Drug Administration from April 1976 to January 1980. Sixty-one percent were related to clerical error, such as giving the wrong unit of blood, and 29% were due to hepatitis. The other 10%were due to miscellaneous problems, such as transfusion of incompatible blood because the need for blood was too acute to wait for crossmatching.* Autologous blood can significantly decrease demands upon homologous blood bank sources. The single most important problem that faces blood banks today is the disparity between the demand for blood and the supply of b10od.~ Less than 3% of the eligible donor pool in the United States donates.10 Physicians Flynn and Metzger said that when the cell saver was used in 125 cases, mostly spinal fusions, blood salvaged from the surgical wound averaged 54%. This was computed from red cell mass data based on preoperative hematocrits and assumed hematocrits of 60% for the cell saver units." Red blood cells obtained by intraoperative autotransfusion are equal to or superior to homologous red blood cells in oxygen-carrying ability. The major function of red blood cells is to transport hemoglobin, which carries oxygen from the lungs to the tissues. An important factor that makes autologous blood superior to homologous stored blood is the action of a substance called 2,3diphosphoglycerate (2,3-DPG). Hemoglobin is fixed tightly to oxygen; 2,3-DPG helps loosen the oxygen and move it off the red blood cells. Thus, a high level of 2,3-DPG facilitates the diffusion of oxygen into the tissues. It has been documented t h a t autologous washed cells have higher levels of 2,3DPG than stored blood and are most resistant to osmotic stress because 1108
Fig 4. Double lumen suction tubing.
younger, healthier cells survive the washing process.12 A variety of changes occur in homologous blood during storage (Table l).13 A transfused red blood cell regenerates 2,3-DPG in the recipient's circulation. But it takes three to eight hours for severely depleted cells to regenerate half the 2,3-DPG levels and approximately 24 hours for complete return of 2,3-DPG and normal hemoglobin funct i 0 n . 1 ~In severely compromised patients, the time it takes to regenerate homologous red cells is important. This is the patient who needs the cell saver. Disadvantages ofcell saver. There are several disadvantages of the cell saver: 0 an additional nurse o r perfusionist may be required to operate the device 0 the cell saver may malfunction, eg,, fail to wash blood cells effectively,, meaning the presence of red blood cells, platelets, and low hematocrits. If this happens, the salvaged blood must be washed again by the blood bank. substantial cost to patient when less than two units are salvaged the potential for infection if the presterilized, disposable components become contaminated by person preparing machine for use. Preparation time and costs of homologous blood versus autologous washed blood were compared a t the
AORN Journal, May 1983, Vol37, No 6
Fig 5. Some of the disposable components charged to patient: Centrifuge bowl and tubing, waste container, and blood bag.
blood bank of the University of California, Los Angeles, Hospitals and Clinics. One unit of homologous packed red blood cells costs the patient about $118. Use of the cell saver costs the patient approximately $300. Blood loss must therefore be greater than two units for the cell saver to be cost effective. Statistics a r e available on the amount of blood usually required for elective surgical procedures. They are useful guides for determining cell saver
candidates.15 The cell saver is usually not recommended for patients with grossly contaminated wounds and patients having bowel surgery with fecal spillage, because bacteria cannot be totally filtered out. Glover studied 14 patients who received blood contaminated by intestinal contents, urine, and/or bile. Eight patients survived the immediate postoperative period. Four of those patients had positive blood cultures within 24 hours of operation although none of the four developed sepsis.16 A cell saver is also contraindicated in cases involving malignant lesions because of the possibility of disseminating malignant cells. Nursing responsibilities. Using a cell saver places additional responsibilities upon both the scrub and circulating nurse. The scrub nurse can significantly increase the amount of blood salvaged from the operative site by diligently using suction, minimizing sponge use, aspirating all blood fragments, and frequently flushing the suction tip to prevent clots from forming.
Table 1
Biochemical changes in CPD adenine4 * packed red blood cells during storage Components
PH Plasma hemoglobin mg/lOO ml Plasma potassium mEq/L Plasma sodium MEq/L Dextrose mg/lOO ml Whole blood ammonia ATP O/O of normal 2,3-DPG % of normal
Days of storage 0 7
14
21
28
35
7.40 61.5 42.2 126.1 378.5 419.1 88% 80%
7.27 123.0 57.6 123.8 339.2 477.8 81O/O 45%
7.26 186.8 66.3 118.5 236.3 597.9 78% 17%
7.08 250.2 69.3 109.6 152.7 706.8 70% 9%
7.00 510.9 77.7 111.0 123.3 772.2 60% 2%
7.62 2.4 3.8 177.2 465.7 30.6 100% 100%
*An anticoagulant preservative Source: T A Bensinger,J Neher, C C Peck,unpublisheddata, LetterrnanArmy Instituteof Research,Presidioof San Francisco, 1979 (6 units of blood tested).
d) AORN Journal, May 1983, Vol37, No 6
1109
The circulating nurse often operates the cell saver. He or she needs a basic understanding of blood and blood components, hemoglobin and hematocrit, and anticoagulation. (See accompanying article, "Administering blood safely.") To act as the patient's advocate, he or she should be aware of the costs, benefits, and potential problems of autologous transfusion. Knowing the answers allows the nurse to collaborate effectively with the surgeon, ensuring quality patient care. For example, it is a nursing responsibility to inform the surgeon that the cell saver is contraindicated for a patient with an infection, and if used, an incident report should be filed. To protect both the patient and surgical team, the time may come when a written consent is required for use of the cell saver during all invasive surgical procedures. Summary. Because nursing assessments may determine when autotransfusion is advised or contraindicated, it is the nurse's responsibility to understand the procedures and problems associated with autotransfusion. The OR nurse cannot only serve as troubleshooter and educator, but also suggest protocols for adoption and selection of autotransfusion equipment and proton cols for patient use. Note8 1. J Blundell, "Experiments on the transfusion of blood by the syringe," Medico-ChirurgicalJournal 9 (1818) 56. 2. J Duncan, "On reinfusion of blood in primary and other amputations," British Medical Journal 1 (January 1886) 192-193. 3. G Klebanoff, J Phillips, W Evans, "Use of a disposable autotransfusionunit under varying conditions of contamination," American Journal of Surgery 120 (September 1970) 351-354. 4. /bid, 351. 5. R H Dyer, "lntraoperative autotransfusion: A preliminary report and new method," American Journal of Surgery 112 (December 1966) 874-878. 6. G Klebanoff, "Early experience with a disposable unit for the intraoperative salvage and reinfusion of blood loss (intraoperative autotransfu-
1112
sion)," American Journal of Surgery 120 (December 1970) 718-722. 7. L C Stehling, H L Zauder, W Rogers, "lntraoperative autotransfusion," Anesthesiology 43 (September 1975) 337-345. 8. B A Myhre, "Fatalities from blood transfusion," Journal of the American Medical Association 224 (September 1980) 1333-1335. 9. D M Surgenor, "Progress toward a national blood system," New England Journal of Medicine 291 (July 4, 1974) 17-22. 10. W P Bartel, W Stelzner, J Higgins, "Attitudes underlying reluctance to donate blood," Transfusion 15 (May-June 1975) 275-277. 11. J C Flynn et al, "lntraoperative autotransfusion (IAT) in elective orthopaedic surgery," presented at American Academy of Orthopaedic Surgeons, Las Vegas, Nev, March 2, 1981. 12. M D Orr, J W Blenko, "Autotransfusion of concentrated, selected washed cells from the surgical field: A biochemical and physiological comparison with homologous cell transfusion," Proceeding of the Blood Conservation Institute, 1978. 13. T A Bensinger, J Neher, C C,Peck, unpublished data, Letterman Army Institute of Research, Presidio of San Francisco, 1979. 14. Frances K Widmann, ed, Technical Manual of the American Association of Blood Banks, 8th ed (Philadelphia: J B Lippincott, 1981) 52-53. 15. P D Mintz et al, "Expected hemotherapy in elective surgery," New York State Journal of Medicine 76 (April 1976) 532-537. 16. J L Glover et al, "Autotransfusion of blood contaminated by intestinal contents," Journal of the American College of Emergency Physicians 7 (April 1978) 142-144.
Infection control program open Spaces are available for the 1984-1985 academic year in the University of Virginia Graduate School of Arts and Sciences's expanded master's degree program in hospital epidemiology-infection control. For a catalog and application form, write to Admissions Office, Graduate School of Arts and Sciences, 437 Cabell Hall, University of Virginia, Charlottesville, Va 22903-3196.
AORN Journal, May 1983, V o l 3 7 , No 6