Reinfusion of postoperative wound drainage in total joint arthroplasty

The Journal

Reinfusion

of Postoperative Wound in Total Joint Arthroplasty

of Arthroplasty

Vol. 9 No. 4 1994

Drainage

Red Blood Cell Survival and Coagulopathy Risk Richard L. Wixson, MD,* Hau C. Kwaan, MD,+ Stewart M. Spies, MD,+ and A. Michael Zimmer, PhD+

Abstract: Fifty patients with total joint arthroplasties (28 total hip arthroplasties. 11 total knee arthroplasties, and 11 bilateral total knee arthroplasties) received autotransfusions from their postoperative wound drainage. The blood was collected in a closed sterile drainage system without any additional anticoagulant. Pre- and postoperative measurements were made of the patient’s hemoglobin, platelets, fibrinogen, haptoglobin, fibrin degradation products, and D-dimer (a specific type of fibrin degradation product). Red blood cell survival was assessed in 16 of the patients by labeling the shed blood with 5’Cr sodium chromate prior to reinfusion. To control for fluid shifts, continued bleeding, and dilution effects of further transfusions in the immediate postoperative period, 10 patients also had their native blood labeled with “‘In oxime. In this study, the mean estimated blood loss was 1,062 mL ( 2 1,247) with a mean wound drainage of 836 mL (t 338). Of this, a mean of 450 mL ( +261) of blood was was given back to the patient in addition to routine, preoperative autologous donated blood. Six (12%) patients experienced transient fevers at the time of retransfusion. Detailed hematologic studies were performed on the shed blood in 19 patients. The collected blood was completely defibrinated, but did contain fibrin degradation products, as indicated by the D-dimer level, and hemolyzed blood as the haptoglobin was reduced. Even though the blood containing the above breakdown products was reinfused to the patients, there were no clinical manifestations of disseminated intravascular coagulation. Both the hemolyzed and defibrinated products were subsequently cleared by the body. After correcting for fluid and volume changes in the first 3 days, 66% (SEM, 5.3%) of the labeled red blood cell activity remained and was used to determine a mean red blood cell survival half-life of 40.6 days (SEM, 4.2). There was no significant change in the ” ‘In:5’ Cr: ratio in the first 24 hours, indicating that the initial drop in activity equally affected both the native red blood cell population and the labeled shed blood. There were no adverse clinical effects resulting from a transient coagulopathy. Autotransfusion of postoperative shed red blood cells is a safe method with reinfused cells that have a normal or increased lifespan. Key words: red blood cells, autotransfusion, autologous blood.

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With the frequent use of blood transfusion in total joint arthroplasty (TJA), the utilization of autologous blood has been advocated by many authors,’ This has generally taken the form of patients donating blood, which is stored before surgery,“-” or the retrieval of blood during surgery by aspiration of the wound.“-“’ The latter process has generally involved methods to anticoagulate the blood to prevent clotting, such as a system for washing and filtering the blood prior to retransfusion. The retransfusion of blood from the mediastinum and pleural cavities has been described as an effective and safe technique in cardiac surgery patients.6,‘7-” A number of authors have described intra- and postoperative blood salvage as applied to orthopedic surgery with TJA and spine surgery. 1”,20-25 Initially, an anticoagulant in the form of acid citrate dextrose was placed in a collection container. Due to the lack of available fibrinogen in the blood from wound drainage, 6,19.2’.26,27 it has been suggested that further anticoagulation of the collected blood was unnecessary. Faris et al. *’ found no difference between cases where anticoagulation with acid citrate dextrose was used and those without anticoagulation of the shed blood. A major concern in the retransfusion of blood salvaged from wound drainage is the possibility of initiating disseminated intravascular coagulation (DIC) due to the presence of fibrin breakdown products and other substances. Due to this, and concerns about fatty particles and other debris,*’ routine washing of the blood prior to retransfusing back to the patient has been advocated.“0,24 Once retransfused, there is little information about the viability of the reinfused red blood cells. Survival of washed red blood cells from intraoperative salvage has been shown to be the same as normal red blood cells.2’-3’ Using a closed collection system without anticoagulation, the goals of this study were to: (1) examine the efficacy of using salvaged blood from wound drainage as a source of autologous blood, (2) evaluate the safety of retransfusing wound drainage blood with the possibility of initiating DIC, and (3) apply double-labeling techniques to determine the longevity of the retransfused cells. Materials

and Methods

Fifty patients (24 women and 26 men) with TJAs (28 total hip arthroplasties [THAs], 11 total knee arthroplasties [TKAs], and 11 bilateral TKAs) received autotransfusions from their postoperative wound drainage. After obtaining informed consent, preoperative blood specimens were obtained for a

1994

complete blood count, including platelets, fibrinogen level, fibrin degradation products, D-dimer, and serum haptoglobin. At the conclusion of the surgical procedures, patients had both a deep (subfascial) and superficial (subcutaneous) drain placed that was connected to a closed, sterile collection unit (ConstA-Vat, Stryker, Kalamazoo, MI) without any additional anticoagulant. This system has an attached battery and vacuum pump that maintains a negative pressure of 75 mmHg (range, 36- 1 14 mmHg). Filters, with a pore size of 0.45 pm, prevent any bacteria from entering the system once the vacuum is rcmoved, prior to transferring the blood to an attached, standard, sterile blood collection bag for coagulation. The container is designed to retain the upper layer of its contents and exclude the reinfusion of any fatty particles. In the recovery room, specimens were obtained from both the patient’s blood and shed blood in the wound drainage collection container. Aerobic and anaerobic cultures were also taken of the collected blood. Further aliquots of blood were taken from the patient and shed blood for radiolabeling to evaluate red blood cell survival. Following labeling of the retrieved red blood cells, the wound drainage blood, along with the labeled red blood cells, was retransfused back into the patient. Additional blood specimens for both hematologic parameters and red blood cell survival were then obtained at 1 hour after transfusion, 24 hours, 3 days, 5 days, 2 weeks, and at several additional time intervals up to 9 weeks until an adequate number of data points were completed to determine the red blood cell survival for the patients. In order to retransfuse the shed blood from the wound drainage system, the collected blood had to be returned to the patient within a maximum of 8 hours of its collection. After 24 hours, any further blood drained was discarded rather than retransfused. Retransfusion was also stopped and drainage blood discarded if a febrile reaction occurred, when the temperature was above 38”C, whether the reaction was felt to be due to the blood or was part of the patient’s postoperative course. Prior to surgery, 43 of the 50 patients had donated autologous blood before surgery that was reinfused during the first 3 postoperative days. The mean amount of reinfused autologous blood was 982 ( ? 613) mL. During surgery, the patients with THAs also often received intraoperative autologous blood obtained from aspiration of the wound using the CellSaver device (Haemonetics, Rraintree, MA). For these patients, the mean amount of blood reinfused during surgery was 327 ( t 380) rnL.

Autotransfusion

Complete blood counts were performed using a Coulter Counter (Miami, FL). The serum haptoglobin was determined by radioimmunodiffusion assay using the NOR-Partigan Haptoglobin kit (Behring Diagnostics, Sommerville, NJ).’ Fibrinogen levels were analyzed by the Clauss method.33 The method for determining the fibrin degradation products was the hemagglutination inhibition immunoassay.4 The D-dimer level was analyzed by the latex agglutination slide method using a monoclonal antibody.35 Patient

Sampling

Prior to reinfusion, 20 mL of salvaged blood was removed and labeled with 5’Cr sodium chromate.” Radiolabeling of blood was achieved using previously published recommended methods.” Following labeling, 20 mL of salvaged blood, with activities ranging from 50 to 107 uCi (61.5 2 17.1 uCi), was reinjected into the patients. An aliquot of the labeled blood was removed as a standard prior to injection. Normal values of red blood cell survival using these methods in our laboratory indicate a 50% survival of 28-32 days. Red blood cell survival was evaluated in 16 patients using 5’Cr sodium chromate. After the initial studies of these patients had been completed, it became apparent that there was an early dramatic drop in red blood cell survival during the first 24 hours. This could be due to the immediate effect of further blood loss, dilution with intravenous fluids, transfusion of other sources of blood, and fluid shifts. To evaluate this, a dual-tracer technique”.38 was used. Using the dual-tracer technique, an additional 8.5 mL of blood was taken from patients in the recovery room. Red blood cell labeling with “‘In oxime was achieved using the method outlined by Thorley et a1.3” Single- or dual-tracer blood samples were reinjetted into the patients after surgery. Blood samples (8- 10 mL) were collected into heparinized tubes at 5-l 5 minutes, 60 minutes, 24 hours, 3 days, 5 days, and a varied number of days after injection until a valid survival curve could be calculated. Red blood cell survival curves were corrected using the initial sample (5- 15 minutes) as the 100% value. Because of a more rapid elution of the ’ ’ ‘In oxime, this information allowed only a comparison of the survival of the native blood and the salvaged retransfused blood over the first 24 hours. Over this period, the 5’Cr: “‘In ratio was calculated to determine if the behavior of the native red blood cells was different from the retransfused red blood cells, while both populations were subjected to the same influences on their calculated survival.

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The data were summarized by calculating means, SDS, and SEMs. Whenever appropriate, statistical analysis was performed using Student’s r-test and ANOVA. For red blood cell survival, half-lives were calculated from the curves generated by linear regression analysis. Results The mean estimated blood loss was 1,062 ( + 1,247) mL, with a total mean wound drainage of 874 ( + 347) mL. The mean drainage on the day of surgery was 6 1 1 ( ? 279) mL. On the first postoperative day it was 23 1 ( + 20 1) mL, and on the second postoperative day it was 31 (? 75) mL. Of these amounts, a mean of 450 ( +261) mL of blood was given back to the patient in addition to routine autologous donated blood. Six (I 2%) patients experienced transient fevers (temperature > 38°C) at the time of retransfusion with no residual problems. When fever occurred, transfusion was stopped and the blood discarded. None of the aerobic or anaerobic cultures taken of blood from the drainage container grew any organisms. Table 1 indicates the values of the measured hematologic parameters for the patients. Not every patient had all of the studies completed. Reasons for incomplete data included insufficient blood retrieval, patient dropout, or Iogistic problems in obtaining all of the samples. Characteristics

of the Shed Blood

Morphology. Examinaiton of the blood smear by the Wright stain revealed the presence of fragmented red blood cells of less than 1.O% of the total red blood cell population (Fig. 1). These fragments were small, having a mean diameter of about 2 pm. The vast majority of the red blood cells were normal in shape and size. There was almost complete absence of platelets. The red blood cell fragments were misinterpreted by Coulter Counter as platelets and the data were discarded. Coagulation Factors. There was complete absence of fibrinogen, with elevated levels of fibrin degradation product (mean ? SD, 49.4 ? 39.8 pg/mL; normal, 2.1-7.7 kg/mL) and D-dimer (mean 2 SD, 62.1 t 65.4 kg/mL; normal, 0.5 FgimL) in all of the specimens tested, confirming defibrination of the salvaged blood. Evidence of Hemolysis. Although the morphologic finding of microfragments of red blood cells suggested the possibility of hemolysis, the haptoglobin level was within the low limits of normal blood

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1994

1. Hematologic Parametersof Patient Blood Samplesand Shed Blood

Preoperative

Hemoglohm (g/dL) Platelets ( x IO’) Fibrinogen (mg/dL) Haptoglobin (tng/dL) FDP (p@nL) D-dimer (&mL)

Vol. 9 No. 4 August

Recovery

Room

Mean

SD

Mean

SD

12.2 314 305 114 2.5 0

1.5 88 81 94 9.1 0

I0.Y 263 241 I62 19.4 I)

15 63 87 w 47 3 0

One Mean 10 3 I YO ‘03 I70 19 0 h.0

Twenty-four Hours

Hour SD

Mean

Five SD

IL 143 95 25 16.‘) 8.X

Days

Shed

Mean

SD

IO.5 25’) 42x 251 12.5 I)

20 I (II I ‘1’) Iii 17.5 iI

Mean Yl 0 (i IOX 4Y 4 b1 I

Blood SD I.8 0 0 44 3Y 8 65.4

The key hematologic parameters rncavured in the patients’ blatrd at varying p~Nq)eralivr tnterval, and 111the \hcd blood that ~a\ retnluwd back into the patient are indicated. In all patients, thr hemoglobin was tnamtained. There wc’rc virtually 111) fibrinogen or platclcts in the \hetl blood, with a transient reduction in the patients’ blood that rapidly recovcrcd. The dimintrhed haptoglobm in the \hcd blood indicated intrcased tree hemoglobin. The return to normal valucc (preoperative values are subnormal) after surgery indicated that the normal body mechanisms were adequate lor the tncreascd tree hemoglobm derived from both the operattvc procedure and rhe rctrancfusion of the ?hcd blood. Similarly. the fibrin degradation product5 (FDPI and 1).diner (a qpecifir FDP) wrre increased in both the shed and peripheral blood after wrgrry. They then rcturncd to lower Ievc/s.

(mean ? SD, 108 ? 44 mg/dL; normal, 100-300 mg/dL). This indicated that any red blood cell breakdown in the shed blood was minimal. Postoperative

Peripheral

Blood Changes

Among the 19 patients whose blood was sampled serially, the fibrinogen levels in 3 of them fell 1 hour after surgery, but returned to their respective baseline levels 24 hours later. The lowest l-hour postoperative fibrinogen level was 106 mg/dL. The fibrin degradation product levels were elevated in 5 of the 19 patients 1 hour after surgery and remained elevated 24 hours later. The highest level was 40 p-g/mL. The D-dimer level was elevated in only 7 of 15 patients, and 5 remained elevated 24 hours later. The highest level was 20 pg/mL. Platelet counts were normal after surgery. There was no clinical manifestation of DIC.

1. Photomicrographof a smearof shedblood showing red cell fragments.(A) Helmet cells (arrowhead), (B) microcyte (black arrow), and (C) small fragment (white arrow) (original magnification Fig.

x 1200).

Three of the 14 patients studied had reduced haptoglobin levels from their baseline, indicative of hemolysis, 1 hour after surgery, but all returned to normal 24 hours later. The lowest level was 38 mg/dL.

Red

Blood

Cell

Survival

Results

Red blood cell survival was assessed in 16 patients by labeling the shed blood with 5tCr sodium chromate prior to reinfusion. Analysis of red blood cell survival showed an immediate drop in the first 3 days, with 66% (SEM, 5.3%) of the labeled red blood cell activity remaining, We believed that this early drop in activity was due to fluid shifts, continued bleeding, and the dilution effects of further transfusion in the immediate postoperative period. Thorley et a1.38made this same observation in their description of the dual-labeling technique. After the first 3

Autotransfusion

0.11 0

/ 2

/ 4 DAYS

I 6 AFTER

/ I I 6 10 12 Cr-51 RBC INJECTION

/ 14

16

Fig. 2. 5’Cr sodium chromate red blood cell survival of reinfused shed blood in a single patient. Surgery was performed on day 0. This represents an acute drop in activity followed by a normal gradual decline in activity.

days, there was a gradual decline in activity characteristic of standard red blood cell survival behavior. Figure 2 shows a typical survival curve from a patient that illustrates this phenomenon. Calculating the red blood cell survival after this patient had stabilized during the first 3 postoperative days gave a mean half-life of 40.6 days (SEM, 4.2). Normal values in our laboratory are 28-32 days. Using the one-sample t-test, this trend for a longer half-life was not statistically significant from our normal values of 30 t 2 days at P = .06. With the dual-labeling technique, 10 patients also had their native blood labeled simultaneously with ’ ’ ‘In oxime. The mean ’ ’ 1In:51 Cr ratio at 1 hour was 1.03 (+_0.07), and at 24 hours it was 1.12 (kO.21). Comparing these samples to an ideal population with a mean ratio value of 1 and assuming a similar variance, using the one-sample Student’s f-test, none of the samples from our test population showed a significant difference or change in their ’ ’ ‘In: 5’Cr ratio. This indicated that the drop in activity in the early postoperative period affected both the native cells and the retransfused cells equally and that the reinfused salvaged cells could survive in the body as long as the native red blood cells.

Discussion Amount of Blood Involved

With the continued need for blood transfusions in major orthopedic operations and the increased threat of transmission of diseases using banked blood, there has been major emphasis on using autologous sources of blood. In this study, the average patient

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received an additional unit of shed blood (mean, 450 mL). which otherwise would be lost. Similar amounts of recovered blood were described by others.2 1.24.25 In THAs, this amount can be much higher,2” so that additional intraoperative blood salvage may be beneficial. Since a tourniquet is used in TKA, postoperative collection of the drained blood is the only method that can be used for retrieval. Rather than letting the blood in the wound drainage be discarded, this method allows the red blood cells to be preserved for retransfusion. We observed a mean hemoglobin of 9 g/dL in the shed blood, allowing it to be an adequate source of red blood cells. Adverse

Reactions

In six (12%) of our patients, there was a febrile episode at the time of autotransfusion of the drained blood. Slagis et a1.2s found no difference between control patients receiving homologous blood products and those receiving washed postoperative wound drainage blood. Faris et al.” found that 2% of patients receiving shed blood within 6 hours had febrile reactions compared to 22% whose blood was collected 6-12 hours after surgery. Semkiw et a1.24 observed 76 cases where there was no febrile reaction with washed cells. Clements et al.,‘” in a comparison study, found one febrile reaction with unwashed cells and none with washed cells. They observed two patients with profound hypotension in the unwashed group, believed to be caused by acid citrate dextrose. In our study, no anticoagulant was used. In all of these studies, including ours, no deleterious effects were seen in patients who experienced a transient febrile reaction, As is the case of febrile reactions during other forms of transfusions, we suspect that the reaction may be due to cytokines derived from broken down leukocytes. Our current policy is to return all salvaged blood within 6 hours. Hematologic

Parameters

In 25 patients in which it was measured, serum fibrinogen levels were absent in their shed blood, similar to other studies. The collected blood was essentially defibrinated, obviating the need for any additional anticoagulant. Morphologic examination of Wright stained smears of the shed blood in this study showed no identifiable platelets. As expected from defibrinated blood, red blood cell fragments were seen. In contrast to the picture of DIC, there were very few fragmented red blood cells, totaling less than 1.0% of the total red blood cell population in shed blood. Furthermore, these fragments were quite small, with a mean diameter of approximately 1 pm. 4 major concern has been the reinfusion of fibrin/

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fibrinogen degradation products. Several authors have advocated avoiding the defibrinated plasma fraction by using only the washed red blood cells derived from the shed blood. This would avoid potential complications due to activation of intravascular coagulation by procoagulants, bony debris, fatty particles, and possibly, methyl methacrylate monomers.““-‘5.39 We evaluated the safety of retransfusing salvaged blood by measuring the levels of both fibrin degradation products and the D-dimer in the shed blood and in the patients after retransfusion. The D-dimer is a specific breakdown product from cross-linked fibrin and its presence signifies defibrination. In 19 of 19 patients, the fibrin degradation products and D-dimer levels were elevated in the shed blood. The levels remained elevated for the first 24 hours and then declined. It should be noted that the source of the D-dimer and fibrin degradation products included the surgical wound, in addition to the reinfused blood. There were no clinical manifestations of DIC in any patients. Similar conclusions were made during the initial use of this method in cardiac surgery.h Faris et al.“’ found elevated levels of fibrin degradation products in shed blood regardless of anticoagulation. Griffith et a1.,4o in cardiac patients, also found elevated levels of fibrin degradation products in patients transfused with unwashed mediastinal shed blood as compared to patients whose blood was washed. None of these patients developed DIC or bleeding problems. In our study, although there were elevated levels of fibrin degradation products and D-dimer in the patients after reinfusion of the shed blood, the normal body mechanisms appeared adequate to compensate for the amount reinfused, as well as what was absorbed from the surgical wound. The process of bleeding into the wound and drainage out of the tubes into the storage device may injure the red blood cells and release free hemoglobin. Thus, there has also been concern about potential toxicity. Faris et al.” also found an elevated plasma hemoglobin in both the shed blood and patients after reinfusion. They concluded that the highest level seen (50 g/L) would not produce a hemoglobinuria in patients with adequate levels of haptoglobin. In this study, we measured the levels of haptoglobin, which binds the free hemoglobin, to assessthe body’s ability to process the increased amount from the retransfusion. The haptoglobin levels in 17 of 19 patients were decreased, while 2 showed no change. This suggested that there was significant hemolysis in all of the shed blood. In the 1-hour postoperative period, 7 of 14 patients’ haptoglobin levels had fallen from baseline, indicating hemolysis. The source of hemolysis included reinfused shed blood, as well as

1994

the hemoglobin absorbed from the wounds. The haptoglobin levels then returned to normal over the remaining postoperative period. The normal body mechanisms for disposing of free hemoglobin in the blood appeared to also clear the additional amount from the retransfusion. In the study, there were no clinical manifestations of any type of intravascular coagulation. This is in agreement with the other studies where nonwashed red blood cells were retransfused.‘O-z’,‘y Red Blood Cell Survival

The red blood cells collected in this process may be damaged in the wound, in the suction tubing, or in the collection container. To evaluate their viability and how well they survived the process, red blood cell survival studies using radioisotope labeling were performed. In our initial group of patients with red blood cell survival, a marked drop in activity was noted in the first 24 hours, with a mean of 66% of the initial radioactivity remaining. Following this initial drop, the activity of the remaining labeled cells appeared to be prolonged, with a half-life of 41 days, which, however, was not statistically significant from our normal values. This acute drop in activity was felt to be due to other factors after reinfusion of the labeled blood. The patients had continued bleeding into the wound, as well as further wound drainage. They also received additional intravenous fluids, as well as their preoperative donated autologous blood units, and experienced fluid shifts. In spinal surgery, using an intraoperative cell saver system in which the blood is aspirated, anticoagulated with heparin, washed, and centrifuged, red blood cell survival has been shown to be 52% at 24 days.3’ In this study, there was also a significant drop in red blood cell survival in the first 24 hours, while 43% of similarly tagged autologous cells and 43% of labeled homologous cells were alive at 24 days. To control for perioperative changes in blood volume and bleeding in cardiovascular surgery with the use of intraoperative blood salvage, Ansell et al.” compared native cells and salvaged cells with a duallabeling technique using indium and chromium. Based on the ’ ’ ‘In:5’Cr ratio, they found no difference in the survival of the two populations. Thorley et al., 18 in evaluating the use of two different methods of intraoperative blood salvage in aortic surgery, found no difference in survival based on the ’ ’ ‘In: “Cr ratio with blood from normal volunteers, native blood in patients during aortic surgery, and blood salvaged from the operative field. In our study, there was no significant change in the “‘In:5’Cr ratio using dual labeling to compare

Autotransfusion

native blood and wound drainage samples. This indicated that the initial drop in activity affected both the native red blood cell population and the labeled shed blood.

Although

not statistically

significant,

the trend to-

ward a subsequent prolonged life span of the red

blood cells may be due to a younger cell population resulting from the lossof aged cells during the trauma

of collection

and salvage. Also, due to the preopera-

tive donation of autologous blood, these patients had

been generating

new red blood cells, which would

be expected to increase the percentage of younger red blood cells. The population of cells transfused

from the wound drainage may have an increased viability over the normal population.

Conclusion The purpose of the study was to determine the safety and efficacy of postoperative wound drainage for autotransfusion in TJA patients. Our major conclusions were that, following an initial drop-off, red blood cell survival was normal or somewhat prolonged, and there were no adverse clinical effects resulting from a transient coagulopathy. Both the hemolyzed and defibrinated products were subsequently cleared by the body. Autotransfusion of postoperative shed red blood cells is a safe method, with reinfused cells having a normal or increased life span.

Acknowledgment The authors wish to acknowledge the contribution of Monique Zarndt, RN, BSN, Nurse Coordinator, Northwestern Memorial Hospital, Chicago, IL.

References 1. Council on Scientific Affairs, American Medical Association: Council report: autologous blood transfusions.JAMA 256:2378, 1986 2. Eckardt JJ, Gossett TC, Amstutz HC: Autologous transfusion and total hip arthroplasty. Clin Orthop 132:39, 1978 3. Haugen RK, Heill GE: A large-scaleautologousblood program in a community hospital: a contribution to the community blood supply. JAMA 257: 1211, 1987 4. Mallory TH, Kennedy M: The useof banked autologousblood in total hip replacementsurgery. Clin Orthop 117:254, 1976 5. OwingsDV, Krusill MS, Thurer RL, Donovan LM: Autologousblood donationsprior to elective cardiacsurgery. JAMA 262: 1963, 1989

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6. Schaff HV, HauerJM, Bell W et al: Autotransfusion of shedmediastinalblood after cardiac surgery.J Thorac CardiovascSurg 5:632, 1978 7. ThomsonJD, CallaghanJJ, Savory CGet al: Prior deposition of autologous blood in elective orthopaedic surgery. J Bone Joint Surg 69A:320, 1987 8. Woolson ST,Marsh JS, TannerJB: Transfusionof previously deposited autologous blood for patients undergoing hip-replacement surgery. J Bone Joint Surg 69A:325, 1987 9. Woolson ST, Watt JM: Use of autologous blood in total hip replacement.J BoneJoint Surg73A:76, 1991 10. Flynn JC, Mezger CR, CsencitzTA: Intraoperative autotransfusion in spinal surgery. Spine 7:432, 1982 Il. GargaroJM, Walls CE: Efficacy of intraoperative autotransfusion in primary total hip arthroplasty. J Arthroplasty 6: 157, 1991 12. Goulet JA, Bray TJ, TimmermanLA et al: Intraoperative autologoustransfusionsin orthopaedicspatients. J Bone Joint Surg 71A:3, 1989 13. Mann DC, Wilham MR, Brower EM, Nash CL: Decreasinghomologousblood transfusionin spinalsurgery by use of the cell saver and predepositedblood. Spine 14: 1296, 1989 14. Turner RH, Steady HM: Cell washing in orthopedic surgery. p. 43. In Haurer JM, Thurer RL, DawsonRD (eds): Autotransfusion. Elsevier, New York, 1981 15. Williamson KR, TaswellHF: Indicationsfor intraoperative blood salvage.J Clin Apheresis5: 100, 1990 16. Wilson Maj WJ: Intraoperative autologoustransfusion in revision total hip arthroplasty. J Bone Joint Surg 71A:8, 1989 17. Blankenship HB, Wallace FD, Pacific0 AD: Clinical application of closed-looppostoperativeautotransfusion. Med Prog Technol 16:89, 1990 18 Breyer RH, EnglemanRM, RousouJA, LemeshowS: Blood conservation for myocardial revascularization. J Thorac CardiovascSurg 93:5 12, 1987 19. Shaff HV, Hauer JM, GardnerTJ et al: Routine useof autotransfusionfollowing cardiacsurgery: experience in 700 patients. Ann Thorac Surg 27:493, 1979 20. ClementsDH, SculcoTP, Burke SW et al: Salvageand reinfusion of postoperativesanguineouswound drainage. J Bone Joint Surg 74A:646, 1992 21. Faris PM, Ritter MA, Keating EM, Valeri CR: Unwashed filtered shed blood collected after knee and hip arthroplasties.J Bone Joint Surg 73A: 1169, 1991 22. Groh GI, Buchert PI<, Allen WC: A comparisonof transfusionrequirementsafter total knee arthroplasty using the Solcotrans autotransfusion system. J Arthroplasty 3:281, 1990 23. Martin JW, Whiteside LA, Milliano MT, Reedy ME: Postoperative blood retrieval and transfusion in cementlesstotal knee arthroplasty. J Arthroplasty 7:205, 1992 24. Semkiw LB, Schurman DJ, Goodman SB, Woolson ST: Postoperativeblood salvageusmg the cell saver after total joint arthroplasty. J Bone Joint Surg 71A: 823, 1989 25. SlagisSV, BenjaminJB, Volz R, Giordano GF: Postop-

358

26.

27. 28.

29.

30.

31

32.

33.

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erative blood salvage in total hip and knee arthroplasty. J Bone Joint Surg 73B:59 1, 1991 Bell W: Hematologic aspect of autotransfusion. p, 4. In Hauer JM, Thurer RL, Vanson RD et al (eds): Autotransfusion. Elsevier, New York, 198 I Bell W: The hematology of autotransfusion. Surgery 84:695, 1978 Adan A, Brute1 del al Riviera A, Hass F et al: Autotransfusion of drained mediastinal blood after cardiac surgery: a reappraisal. Thorac Cardiovasc Surg 36: 10, 1988 Ansell J, Parrilla N, King M et al: Survival of autotransfused red blood cells recovered from the surgical field during cardiovascular operation>. J Thorac Cardiovasc Surg 84:387, 1982 Buth H, Raines JK, Kilodny GM, Darling RC: Effects of intraoperative autotransfusion and red cell survival. Surg Forum 25:276, 1975 Ray JM, Flynn JC, Bierman AH: Erythrocyte survival following intraoperative autotransfusion in spinal surgery: an in vivo comparative study and five year update. Spine 11:879, 1986 Becker W: Determination of antisera titrates using the single radial immunodiffusion method. Immunochctn 17:237, 1957 Clauss VA: Gerinnungsphysiologische schnellmethode zur bestimmung des fibrogens. Acta Haemet 17: 237, 1957

1994 34. Mersky C. KleinerJ, Johnson AJ: Quantitative estimation of split products of fibrinogen in human sera. Blood 28: 1, 1966 35. Urano T, Kamiya T, Sakagushi S et al: FibrinoSenolysis and fibrinolysis in normal voluntet~rs and patients with thrombosis after infusion of urokinasc. Throtnb Res 39: 145, lY85 36. Necheles TF, Weinstein IM, Leroy CV: Radioactive sodium chromate for the study of survival of red blood cell\. Part I. The effect of radioactive sodium chromate on red cells. J Lab Clin Med 42:358, 1Y53 37. International Committee for Standardization in Hcmatology: Recommended method for ratiioi>otope red cell survival studies. Br J Haematol 45:65Y, 1YXO 38. Thorley PJ, Shaw A, Kent I’ et al: Lhal [racer technique to measure salvaged red ccl1 survival following dutolransfusion in aortic surgery. Nucl Mcd Comtnun 11:36Y, lY90 39. Gannon DM, Lombardi AV. Mallory TH CI al: An evaluation of the efficacy of po\topcrative blood salvage after total joint arthroplasty. .I Arthroplasty I : 109, 1Y86 40. Griffith LD, Billman GF, Daily PO, Lane TA: Apparent coagulopathy by infusion of shed tnediastinal blood and its prevention by washing of the infusate. Ann Thorac Surg 47:440, 198Y