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The economic benefits of cell salvage in obstetric haemorrhage
International Journal of Obstetric Anesthesia (2012) 21, 329–333 0959-289X/$ - see front matter c 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijoa.2012.05.003
ORIGINAL ARTICLE
www.obstetanesthesia.com
The economic benefits of cell salvage in obstetric haemorrhage C. Brearton, A. Bhalla, S. Mallaiah, P. Barclay Tom Bryson Department of Anaesthesia, Liverpool Women’s NHS Foundation Trust, Liverpool, UK ABSTRACT Background: Cell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period. Method: Cell salvage was introduced in the Liverpool Women’s NHS Foundation Trust in 2006. Data were collected from all cases in which it was set-up and included the volume of blood processed and returned and whether surgery was elective or emergency. Results: Between 1st January 2006 and 30th June 2011, cell salvage for collection was set-up 587 times and blood was returned in 137 patients. Total volume of blood returned was 47 143 mL, equivalent to 189 units of packed red cells. The return rate was higher for emergency than elective cases (P = 0.03). As the use of cell salvage has extended over time to include a greater proportion of patients, return rates have decreased (P < 0.0001). The volume of blood returned from cell salvage was significantly related to the estimated blood loss (P < 0.00001), with a best fit line described by estimated blood loss = 3.45x + 454, where x was the volume of blood returned. In 2011 total costs of cell salvage were £9245 for the equivalent of 83 units of blood. At the current price of £125 per unit of allogeneic blood this would have cost £10 375: a saving of £1130. No intraoperative or postoperative complications associated with cell salvage were seen. Conclusion: The routine use of cell salvage was associated with more salvaged blood being returned to patients, which offset the cost of collection sets when compared to the cost of using allogeneic blood. Cell salvage is an appropriate expenditure to reduce the use of allogeneic blood. c 2012 Elsevier Ltd. All rights reserved.
Keywords: Cell salvage; Obstetric haemorrhage; Autologous blood transfusion; Allogeneic blood transfusion
Introduction Obstetric haemorrhage is the leading worldwide cause of death in pregnant women.1 It now ranks sixth in direct causes of maternal death in the UK, where there were nine direct maternal deaths from obstetric haemorrhage during 2006–2008,2 as compared to 17 in the previous triennium.3 Although the mortality statistics for obstetric haemorrhage in the UK appear reassuring, figures from the Scottish Confidential Audit of Severe Maternal Morbidity (SCASMM) are less so and may demonstrate the true size of the problem.4 Major obstetric haemorrhage (MOH) was the commonest cause of severe maternal morbidity with a rate of 4.3 per 1000 births, occurring in 257 out of 345 reports (74%) of severe morbidity. The definition of MOH used by SCASMM was an estimated blood loss of P2500 mL, which is considerably higher than that used by the Royal College of Obstetricians and Gynecologists.5 Of 90 obstetric patients who required admission to an intensive care unit Accepted May 2012 Correspondence to: S. Mallaiah, Tom Bryson Department of Anaesthesia, Liverpool Women’s NHS Foundation Trust, Liverpool, UK. E-mail address: [email protected]
(ICU), MOH was the commonest indication (42 patients, 16% of all women with MOH). A recent national report from the Intensive Care National Audit and Research Centre (ICNARC) identified haemorrhage as the commonest reason for a ‘‘recently pregnant’’ woman to require ICU admission.6 Timely transfusion of blood and blood products plays a crucial part in the management of MOH. Transfusion of allogeneic blood is not without problems, including those of supply, misadministration, the risk of infection, and death.7 Cell salvage can reduce the exposure of women to the rare but recognised dangers of allogeneic blood, and is the only form of autologous transfusion that can be used reliably in pregnancy and the puerperium. It is recommended by the National Institute for Health and Clinical Excellence (NICE),8 the Association of Anaesthetists of Great Britain and Ireland (AAGBI)9 and recent editions of the UK confidential enquiries into maternal deaths.2,3 Cell salvage has been in use at our institution for obstetric patients since 2006. Several issues have been encountered, including its financial viability. On-going cell salvage observational data over a five-year period are presented, together with discussion on the effect of
330
Economics of cell salvage
the audit cycle on clinical practice and the audit process. The audit cycle has permitted assessment and improvement of the use of cell salvage, which has led to more salvaged blood being returned to patients, and permitted a financial evaluation of its use in obstetrics.
Methods Liverpool Women’s Hospital is a stand-alone tertiary referral obstetric unit with over 8000 deliveries per annum, and a caesarean section rate of almost 25%. Cell salvage was introduced into obstetric practice in a tiered fashion in 2006 using the Sorin Electa Concept machine (Sorin Group, Milan, Italy) with separately packaged disposable components for blood collection and for blood processing. In the early stages of introduction, only the blood collection system was set-up, and the blood processing system was used only if sufficient blood was collected to enable processing. Operating Department Practitioners (ODPs) were responsible for the set-up and management of intra-operative cell salvage, in addition to their other duties during surgery.10 A two-suction system was used at the beginning of caesarean delivery to avoid contamination with amniotic fluid. All processed blood was returned to the patient using a Pall LeukoGuard RS leukocyte depletion filter (Pall Corporation, Portsmouth, UK). An audit of cell salvage was approved by the hospital clinical audit committee. ODPs collected data which were entered into a database by the theatre cell salvage coordinator. Data included the number of set-ups, the volume of blood processed and returned to the patient, and the type of case (elective/emergency), and ran between 1st January 2006 until 30th June 2011. The use of cell salvage evolved over time. Initial data from 2006 to 2007 showed that the use of cell salvage
Fig. 1
was largely confined to those known to be at high risk of intraoperative bleeding. Between August 2008 and January 2009 a subset of 136 patients who received allogeneic blood transfusion was audited. Women undergoing elective caesarean delivery in a singleton pregnancy with breech presentation, a history of one previous caesarean delivery, previous perineal tear (maximum of one previous caesarean delivery) and maternal request for caesarean delivery with no other risk factors were found to be at minimal risk of allogeneic blood transfusion. The scope of cell salvage was therefore extended and used in all patients except those at minimal risk of bleeding.11
Statistical analysis Data were analysed using GraphPad Prism version 5.01 for Windows (GraphPad software, San Diego, CA) using Fisher’s exact test, v2 for trends and linear regression analysis.
Results From January 2006 to June 2011, cell salvage was set-up for collection in 587 patients. Salvaged blood was processed and returned to 137 patients. The total volume of blood returned over this time was 47 143 mL, the equivalent of 189 units of packed allogeneic red cells. Fig. 1 shows the change in use of cell salvage, the number of occasions on which salvaged blood was returned and the volume of blood returned to the patient over the study period. The ratio of set-up to returns varied with elective and emergency cases (Fig. 2). The return rate was higher in emergency compared to elective cases (P = 0.03). Return rates decreased over time as the use of cell salvage was extended to include
Cell salvage set-up, returns and total volumes of autologous blood re-transfused between 2006 and 2011.
C. Brearton et al.
331
Fig. 2 Percentage of cell salvage set-ups processed and returned to patients for all emergency and elective cases between 2006 and 2011.
Fig. 3 Correlation between volume of processed blood returned to the patient and estimated blood loss with the line of best fit (EBL = 3.45x + 454 mL).
Table 1
more patients. (P < 0.0001). Data for 2011 relate to the first six months of the year, during which a total of 15 287 mL of cell salvaged blood was returned to patients. As in previous years, the percentage of set-ups that resulted in blood being returned to the patient was higher in emergency than in elective cases. Where sufficient blood was collected for processing, a linear relationship between the volume of cell salvaged blood returned to the patient and estimated blood loss (EBL) recorded at the time of surgery was found (F = 82.62, P < 0.00001) (Fig. 3). Linear regression analysis showed the line of best fit to be described by EBL = 3.45x + 454, where x is the volume of blood returned. Put another way, when EBL exceeded 454 mL, 1 mL of salvaged blood was returned for each additional 3.45 mL of blood loss. Fig. 3 also shows that in some patients much of the blood loss could not be collected using cell salvage; these were predominantly cases in which massive haemorrhage occurred before arrival in the operating room. Table 1 shows the individual amounts salvaged for each patient and the total equivalent number of units of blood for the first six months of 2011. The AAGBI guidelines state that 250 mL of cell salvaged red cells is equivalent to 1 unit of allogeneic packed red cells,9 and therefore these figures are illustrative of the total number of units of allogeneic blood whose use has been avoided through the use of cell salvage. The costs of consumable items for cell salvage, comprising a collection set and a processing set, are shown in Table 2. The total costs of cell salvage were £9245, which yielded an equivalent of 83 units of autologous blood. The cost of 83 units of allogeneic blood at the current UK price of £125 per unit12 is £10 375: a saving of £1130. If the 14 patients who received <250 mL of salvaged blood are excluded, the equivalent cost is £8625. All patients were seen by a member of the anaesthetic department 24 h after anaesthetic intervention. Those with an estimated blood loss of >2000 mL were managed in a maternal critical care unit. No patients who had cell salvaged blood returned to them over the audit period had any intra- or postoperative complications associated with cell salvage use. In particular, Pall Leukoguard leucocyte depletion filters were used in all cases, and no episodes of hypotension were associated with
Units equivalence of cell salvaged blood returned from January to June 2011
Range (mL)
Allogenic unit equivalence
Number of returns
Total unit equivalence
125–250 250–500 500–750 750–1000 1000–1250 1250–1500 Total
1 2 3 4 5 6
14 17 7 2 0 1
14 34 21 8 0 6 83
332 Table 2
Economics of cell salvage Running costs of cell salvage January to June 2011
Collection set Acid/citrate/dextrose solution Wash set Leucocyte depletion filter Cost per patient Number of patients Total cost
Collection only
Collection and processing
£24.00 £6.20 NA NA £30.20 169 £5103.80
£24.00 £6.20 £48.00 £20.40 £98.60 42 £4141.20
All figures include value added tax (VAT) at a rate of 20%.
their use. Rhesus negative mothers with Rhesus positive babies had a Kleihauer test performed postoperatively, and received Anti-D immunoglobulin to prevent isoimmunisation.
Discussion Our results show that the pattern of cell salvage use has changed in line with its acceptance as an essential component of surgical obstetric practice. From 2006 to 2008 cell salvage was used mainly for high-risk elective cases during daytime and early evenings when experienced anaesthetists and obstetricians were available. Data for 2006 were skewed by one patient with undiagnosed placenta accreta in whom estimated blood loss was in excess of 10 L, and who received 3030 mL of cell salvaged blood. The amount of blood returned by cell salvage declined over time, and by 2008 the financial viability of cell salvage was being questioned. This was thought to be due to the haemostatic effect of cell salvage, in which heightened awareness among obstetricians and altered behaviour favoured blood conservation techniques during elective surgery. Blood loss in emergency procedures continued to be high with very few patients receiving cell salvage. In 2009, additional training of ODPs allowed cell salvage to be available 24 h per day. Analysis of the first 100 cases that year showed that the return rate of cell salvaged blood was higher in emergency cases, and appeared cost neutral if the overall return rate was 1 in 6 of the overall collection rate.13 Cell salvage guidelines were updated in January 2010, and published by the Obstetric Anaesthetists’ Association guidelines group.11 Enhanced awareness of its use made it part of our World Health Organisation time-out checklist, with obstetricians requesting cell salvage whenever moderate to severe blood loss is anticipated. The return rates apparently increased in 2010. This artefact was due to failure to record set-up only cases for emergencies out-of-hours, and was confirmed by a discrepancy between the number of collection sets purchased and those recorded in the database. From 2011, patient identity stickers were placed with each use in a logbook attached to the cell salvage machine.
Cell salvage has now become routine practice in our operating rooms for high-risk cases such as those with postpartum haemorrhage or placenta praevia but is not used for patients at minimal risk of bleeding. Where moderate risk of bleeding exists, only the collection set is primed. This was shown to be financially viable as the equivalent cost of blood salvaged for the first six months of 2011 is close to the cost of disposable equipment. Capital investment involved in the purchase of equipment has not been considered in this article. A generic business case produced by the UK Cell Salvage Action Group that can be adapted to suit local requirements can be found at www.transfusionguidelines.org. The document also discusses staffing implications. In our unit, rostering of extra personnel to operate the cell saver was not routinely required. In cases of catastrophic haemorrhage, extra staff were called to attend. Some practitioners may question the return of only small volumes of cell salvaged blood to patients in whom transfusion of allogeneic blood would not have been considered. Thresholds for transfusion are required when considering allogeneic blood administration to ensure that the benefits of transfusion exceed the risks.14 Such considerations may not apply to red cells salvaged from the patient’s own circulation, where the main hazards are those of hypotension,15 or mislabelling if the bag is connected outside a single patient environment.7 The clinical value of cell salvage in obstetric haemorrhage is clearly established.2,9,12 In our unit, the liberal policy for setting-up cell salvage has increased the number of collection sets that are used, but the consequential increased volume of blood returned to the patient has offset the cost compared to the use of allogeneic blood This has helped to change the local hospital culture so that cell salvage is now accepted as an appropriate expenditure to reduce the use of allogeneic blood.
Declaration of interest Sorin supplied free collection sets for the 2009 audit. S. Mallaiah had travel expenses paid by Sorin to speak about ‘Autologous Transfusion in Obstetrics’ at a scientific meeting accompanying the launch of the Sorin XTRA cell salvage machine in Maarsen, Netherlands, 17th November 2011.
C. Brearton et al.
References 1. The World Health Report 2005: make every mother and child count. World Health Organisation. http://www.who.int/whr/ 2005/en/index.html [accessed September 2011]. 2. Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203. 3. Lewis G, editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. 4. NHS quality improvement Scotland: Scottish audit of severe maternal morbidity 6th annual report 2008. http://healthcareimprovementscotland.org/programmes/reproductive,_maternal__ child/programme_resources/scasmm.aspx; 2008 [accessed September 2011]. 5. Royal College of Obstetricians and Gynaecologists green top guideline no. 52 prevention and management of postpartum haemorrhage. http://www.rcog.org.uk/files/rcog-corp/GT52PostpartumHaemorrhage0411.pdf; 2009 [accessed September 2011]. 6. Intensive care national audit & research centre report 2009: female admissions (aged 16–50 years) to adult, general critical care units in England, Wales and Northern Ireland, reported as ‘‘currently pregnant’’ or ‘‘recently pregnant’’ 1 January 2007 to 31 December 2007. http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/ Reports/ICNARC_obs_report_Oct2009.pdf; 2007 [accessed September2011].
333 7. Serious Hazards of Transfusion (SHOT) Steering Group. The 2010 annual SHOT report. http://www.shotuk.org/wp-content/ uploads/2011/10/SHOT-2010-Report1.pdf [accessed September 2011]. 8. National Institute for Health and Clinical Excellence: interventional procedure guidance 144: intraoperative blood cell salvage in obstetrics. http://www.nice.org.uk/nicemedia/live/11038/30690/ 30690.pdf [accessed September 2011]. 9. The Association of Anaesthetists of Great Britain and Ireland, safety guideline: blood transfusion and the anaesthetist. Intraoperative cell salvage. http://www.aagbi.org/sites/default/files/ cell%20_salvage_2009_amended.pdf; 2009 [accessed September 2001]. 10. The Association of Anaesthetists of Great Britain and Ireland guideline: the anaesthesia team. http://www.aagbi.org/sites/default/ files/anaesthesia_team_2010_0.pdf; 2010 [accessed September 2011]. 11. Mallaiah S. Liverpool Women’s NHS Foundation Trust: guidelines for cell salvage in obstetrics. http://www.oaa-anaes.ac.uk/ assets/_managed/editor/File/Guidelines/Cell%20salvage/cell%20 salvage%20guidelines_Mallaiah_Liverpool.pdf [accessed September 2011]. 12. National Health Service. Blood and transplant matters. http:// www.blood.co.uk/pdf/publications/blood_matters_34.pdf; 2011 [accessed September 2011]. 13. Pathak D, McDonald A, Barclay P, Mallaiah S. Use of cell salvage in caesarean section. Int J Obstet Anesth 2010;19:S10. 14. Better blood transfusion toolkit. http://www.transfusionguidelines.org.uk/index.aspx?Publication=BBT&Section=22&pageid= 1337 [accessed September 2011]. 15. Sreelakshmi TR, Eldridge J. Acute hypotension associated with leucocyte depletion filters during cell salvaged blood transfusion. Anaesthesia 2010;65:742–4.
ORIGINAL ARTICLE
www.obstetanesthesia.com
The economic benefits of cell salvage in obstetric haemorrhage C. Brearton, A. Bhalla, S. Mallaiah, P. Barclay Tom Bryson Department of Anaesthesia, Liverpool Women’s NHS Foundation Trust, Liverpool, UK ABSTRACT Background: Cell salvage is increasingly used in the management of major obstetric haemorrhage. Its financial considerations were evaluated over a 5-year period. Method: Cell salvage was introduced in the Liverpool Women’s NHS Foundation Trust in 2006. Data were collected from all cases in which it was set-up and included the volume of blood processed and returned and whether surgery was elective or emergency. Results: Between 1st January 2006 and 30th June 2011, cell salvage for collection was set-up 587 times and blood was returned in 137 patients. Total volume of blood returned was 47 143 mL, equivalent to 189 units of packed red cells. The return rate was higher for emergency than elective cases (P = 0.03). As the use of cell salvage has extended over time to include a greater proportion of patients, return rates have decreased (P < 0.0001). The volume of blood returned from cell salvage was significantly related to the estimated blood loss (P < 0.00001), with a best fit line described by estimated blood loss = 3.45x + 454, where x was the volume of blood returned. In 2011 total costs of cell salvage were £9245 for the equivalent of 83 units of blood. At the current price of £125 per unit of allogeneic blood this would have cost £10 375: a saving of £1130. No intraoperative or postoperative complications associated with cell salvage were seen. Conclusion: The routine use of cell salvage was associated with more salvaged blood being returned to patients, which offset the cost of collection sets when compared to the cost of using allogeneic blood. Cell salvage is an appropriate expenditure to reduce the use of allogeneic blood. c 2012 Elsevier Ltd. All rights reserved.
Keywords: Cell salvage; Obstetric haemorrhage; Autologous blood transfusion; Allogeneic blood transfusion
Introduction Obstetric haemorrhage is the leading worldwide cause of death in pregnant women.1 It now ranks sixth in direct causes of maternal death in the UK, where there were nine direct maternal deaths from obstetric haemorrhage during 2006–2008,2 as compared to 17 in the previous triennium.3 Although the mortality statistics for obstetric haemorrhage in the UK appear reassuring, figures from the Scottish Confidential Audit of Severe Maternal Morbidity (SCASMM) are less so and may demonstrate the true size of the problem.4 Major obstetric haemorrhage (MOH) was the commonest cause of severe maternal morbidity with a rate of 4.3 per 1000 births, occurring in 257 out of 345 reports (74%) of severe morbidity. The definition of MOH used by SCASMM was an estimated blood loss of P2500 mL, which is considerably higher than that used by the Royal College of Obstetricians and Gynecologists.5 Of 90 obstetric patients who required admission to an intensive care unit Accepted May 2012 Correspondence to: S. Mallaiah, Tom Bryson Department of Anaesthesia, Liverpool Women’s NHS Foundation Trust, Liverpool, UK. E-mail address: [email protected]
(ICU), MOH was the commonest indication (42 patients, 16% of all women with MOH). A recent national report from the Intensive Care National Audit and Research Centre (ICNARC) identified haemorrhage as the commonest reason for a ‘‘recently pregnant’’ woman to require ICU admission.6 Timely transfusion of blood and blood products plays a crucial part in the management of MOH. Transfusion of allogeneic blood is not without problems, including those of supply, misadministration, the risk of infection, and death.7 Cell salvage can reduce the exposure of women to the rare but recognised dangers of allogeneic blood, and is the only form of autologous transfusion that can be used reliably in pregnancy and the puerperium. It is recommended by the National Institute for Health and Clinical Excellence (NICE),8 the Association of Anaesthetists of Great Britain and Ireland (AAGBI)9 and recent editions of the UK confidential enquiries into maternal deaths.2,3 Cell salvage has been in use at our institution for obstetric patients since 2006. Several issues have been encountered, including its financial viability. On-going cell salvage observational data over a five-year period are presented, together with discussion on the effect of
330
Economics of cell salvage
the audit cycle on clinical practice and the audit process. The audit cycle has permitted assessment and improvement of the use of cell salvage, which has led to more salvaged blood being returned to patients, and permitted a financial evaluation of its use in obstetrics.
Methods Liverpool Women’s Hospital is a stand-alone tertiary referral obstetric unit with over 8000 deliveries per annum, and a caesarean section rate of almost 25%. Cell salvage was introduced into obstetric practice in a tiered fashion in 2006 using the Sorin Electa Concept machine (Sorin Group, Milan, Italy) with separately packaged disposable components for blood collection and for blood processing. In the early stages of introduction, only the blood collection system was set-up, and the blood processing system was used only if sufficient blood was collected to enable processing. Operating Department Practitioners (ODPs) were responsible for the set-up and management of intra-operative cell salvage, in addition to their other duties during surgery.10 A two-suction system was used at the beginning of caesarean delivery to avoid contamination with amniotic fluid. All processed blood was returned to the patient using a Pall LeukoGuard RS leukocyte depletion filter (Pall Corporation, Portsmouth, UK). An audit of cell salvage was approved by the hospital clinical audit committee. ODPs collected data which were entered into a database by the theatre cell salvage coordinator. Data included the number of set-ups, the volume of blood processed and returned to the patient, and the type of case (elective/emergency), and ran between 1st January 2006 until 30th June 2011. The use of cell salvage evolved over time. Initial data from 2006 to 2007 showed that the use of cell salvage
Fig. 1
was largely confined to those known to be at high risk of intraoperative bleeding. Between August 2008 and January 2009 a subset of 136 patients who received allogeneic blood transfusion was audited. Women undergoing elective caesarean delivery in a singleton pregnancy with breech presentation, a history of one previous caesarean delivery, previous perineal tear (maximum of one previous caesarean delivery) and maternal request for caesarean delivery with no other risk factors were found to be at minimal risk of allogeneic blood transfusion. The scope of cell salvage was therefore extended and used in all patients except those at minimal risk of bleeding.11
Statistical analysis Data were analysed using GraphPad Prism version 5.01 for Windows (GraphPad software, San Diego, CA) using Fisher’s exact test, v2 for trends and linear regression analysis.
Results From January 2006 to June 2011, cell salvage was set-up for collection in 587 patients. Salvaged blood was processed and returned to 137 patients. The total volume of blood returned over this time was 47 143 mL, the equivalent of 189 units of packed allogeneic red cells. Fig. 1 shows the change in use of cell salvage, the number of occasions on which salvaged blood was returned and the volume of blood returned to the patient over the study period. The ratio of set-up to returns varied with elective and emergency cases (Fig. 2). The return rate was higher in emergency compared to elective cases (P = 0.03). Return rates decreased over time as the use of cell salvage was extended to include
Cell salvage set-up, returns and total volumes of autologous blood re-transfused between 2006 and 2011.
C. Brearton et al.
331
Fig. 2 Percentage of cell salvage set-ups processed and returned to patients for all emergency and elective cases between 2006 and 2011.
Fig. 3 Correlation between volume of processed blood returned to the patient and estimated blood loss with the line of best fit (EBL = 3.45x + 454 mL).
Table 1
more patients. (P < 0.0001). Data for 2011 relate to the first six months of the year, during which a total of 15 287 mL of cell salvaged blood was returned to patients. As in previous years, the percentage of set-ups that resulted in blood being returned to the patient was higher in emergency than in elective cases. Where sufficient blood was collected for processing, a linear relationship between the volume of cell salvaged blood returned to the patient and estimated blood loss (EBL) recorded at the time of surgery was found (F = 82.62, P < 0.00001) (Fig. 3). Linear regression analysis showed the line of best fit to be described by EBL = 3.45x + 454, where x is the volume of blood returned. Put another way, when EBL exceeded 454 mL, 1 mL of salvaged blood was returned for each additional 3.45 mL of blood loss. Fig. 3 also shows that in some patients much of the blood loss could not be collected using cell salvage; these were predominantly cases in which massive haemorrhage occurred before arrival in the operating room. Table 1 shows the individual amounts salvaged for each patient and the total equivalent number of units of blood for the first six months of 2011. The AAGBI guidelines state that 250 mL of cell salvaged red cells is equivalent to 1 unit of allogeneic packed red cells,9 and therefore these figures are illustrative of the total number of units of allogeneic blood whose use has been avoided through the use of cell salvage. The costs of consumable items for cell salvage, comprising a collection set and a processing set, are shown in Table 2. The total costs of cell salvage were £9245, which yielded an equivalent of 83 units of autologous blood. The cost of 83 units of allogeneic blood at the current UK price of £125 per unit12 is £10 375: a saving of £1130. If the 14 patients who received <250 mL of salvaged blood are excluded, the equivalent cost is £8625. All patients were seen by a member of the anaesthetic department 24 h after anaesthetic intervention. Those with an estimated blood loss of >2000 mL were managed in a maternal critical care unit. No patients who had cell salvaged blood returned to them over the audit period had any intra- or postoperative complications associated with cell salvage use. In particular, Pall Leukoguard leucocyte depletion filters were used in all cases, and no episodes of hypotension were associated with
Units equivalence of cell salvaged blood returned from January to June 2011
Range (mL)
Allogenic unit equivalence
Number of returns
Total unit equivalence
125–250 250–500 500–750 750–1000 1000–1250 1250–1500 Total
1 2 3 4 5 6
14 17 7 2 0 1
14 34 21 8 0 6 83
332 Table 2
Economics of cell salvage Running costs of cell salvage January to June 2011
Collection set Acid/citrate/dextrose solution Wash set Leucocyte depletion filter Cost per patient Number of patients Total cost
Collection only
Collection and processing
£24.00 £6.20 NA NA £30.20 169 £5103.80
£24.00 £6.20 £48.00 £20.40 £98.60 42 £4141.20
All figures include value added tax (VAT) at a rate of 20%.
their use. Rhesus negative mothers with Rhesus positive babies had a Kleihauer test performed postoperatively, and received Anti-D immunoglobulin to prevent isoimmunisation.
Discussion Our results show that the pattern of cell salvage use has changed in line with its acceptance as an essential component of surgical obstetric practice. From 2006 to 2008 cell salvage was used mainly for high-risk elective cases during daytime and early evenings when experienced anaesthetists and obstetricians were available. Data for 2006 were skewed by one patient with undiagnosed placenta accreta in whom estimated blood loss was in excess of 10 L, and who received 3030 mL of cell salvaged blood. The amount of blood returned by cell salvage declined over time, and by 2008 the financial viability of cell salvage was being questioned. This was thought to be due to the haemostatic effect of cell salvage, in which heightened awareness among obstetricians and altered behaviour favoured blood conservation techniques during elective surgery. Blood loss in emergency procedures continued to be high with very few patients receiving cell salvage. In 2009, additional training of ODPs allowed cell salvage to be available 24 h per day. Analysis of the first 100 cases that year showed that the return rate of cell salvaged blood was higher in emergency cases, and appeared cost neutral if the overall return rate was 1 in 6 of the overall collection rate.13 Cell salvage guidelines were updated in January 2010, and published by the Obstetric Anaesthetists’ Association guidelines group.11 Enhanced awareness of its use made it part of our World Health Organisation time-out checklist, with obstetricians requesting cell salvage whenever moderate to severe blood loss is anticipated. The return rates apparently increased in 2010. This artefact was due to failure to record set-up only cases for emergencies out-of-hours, and was confirmed by a discrepancy between the number of collection sets purchased and those recorded in the database. From 2011, patient identity stickers were placed with each use in a logbook attached to the cell salvage machine.
Cell salvage has now become routine practice in our operating rooms for high-risk cases such as those with postpartum haemorrhage or placenta praevia but is not used for patients at minimal risk of bleeding. Where moderate risk of bleeding exists, only the collection set is primed. This was shown to be financially viable as the equivalent cost of blood salvaged for the first six months of 2011 is close to the cost of disposable equipment. Capital investment involved in the purchase of equipment has not been considered in this article. A generic business case produced by the UK Cell Salvage Action Group that can be adapted to suit local requirements can be found at www.transfusionguidelines.org. The document also discusses staffing implications. In our unit, rostering of extra personnel to operate the cell saver was not routinely required. In cases of catastrophic haemorrhage, extra staff were called to attend. Some practitioners may question the return of only small volumes of cell salvaged blood to patients in whom transfusion of allogeneic blood would not have been considered. Thresholds for transfusion are required when considering allogeneic blood administration to ensure that the benefits of transfusion exceed the risks.14 Such considerations may not apply to red cells salvaged from the patient’s own circulation, where the main hazards are those of hypotension,15 or mislabelling if the bag is connected outside a single patient environment.7 The clinical value of cell salvage in obstetric haemorrhage is clearly established.2,9,12 In our unit, the liberal policy for setting-up cell salvage has increased the number of collection sets that are used, but the consequential increased volume of blood returned to the patient has offset the cost compared to the use of allogeneic blood This has helped to change the local hospital culture so that cell salvage is now accepted as an appropriate expenditure to reduce the use of allogeneic blood.
Declaration of interest Sorin supplied free collection sets for the 2009 audit. S. Mallaiah had travel expenses paid by Sorin to speak about ‘Autologous Transfusion in Obstetrics’ at a scientific meeting accompanying the launch of the Sorin XTRA cell salvage machine in Maarsen, Netherlands, 17th November 2011.
C. Brearton et al.
References 1. The World Health Report 2005: make every mother and child count. World Health Organisation. http://www.who.int/whr/ 2005/en/index.html [accessed September 2011]. 2. Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–08. The eighth report on confidential enquiries into maternal deaths in the United Kingdom. BJOG 2011;118(Suppl. 1):1–203. 3. Lewis G, editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer 2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH; 2007. 4. NHS quality improvement Scotland: Scottish audit of severe maternal morbidity 6th annual report 2008. http://healthcareimprovementscotland.org/programmes/reproductive,_maternal__ child/programme_resources/scasmm.aspx; 2008 [accessed September 2011]. 5. Royal College of Obstetricians and Gynaecologists green top guideline no. 52 prevention and management of postpartum haemorrhage. http://www.rcog.org.uk/files/rcog-corp/GT52PostpartumHaemorrhage0411.pdf; 2009 [accessed September 2011]. 6. Intensive care national audit & research centre report 2009: female admissions (aged 16–50 years) to adult, general critical care units in England, Wales and Northern Ireland, reported as ‘‘currently pregnant’’ or ‘‘recently pregnant’’ 1 January 2007 to 31 December 2007. http://www.oaa-anaes.ac.uk/assets/_managed/editor/File/ Reports/ICNARC_obs_report_Oct2009.pdf; 2007 [accessed September2011].
333 7. Serious Hazards of Transfusion (SHOT) Steering Group. The 2010 annual SHOT report. http://www.shotuk.org/wp-content/ uploads/2011/10/SHOT-2010-Report1.pdf [accessed September 2011]. 8. National Institute for Health and Clinical Excellence: interventional procedure guidance 144: intraoperative blood cell salvage in obstetrics. http://www.nice.org.uk/nicemedia/live/11038/30690/ 30690.pdf [accessed September 2011]. 9. The Association of Anaesthetists of Great Britain and Ireland, safety guideline: blood transfusion and the anaesthetist. Intraoperative cell salvage. http://www.aagbi.org/sites/default/files/ cell%20_salvage_2009_amended.pdf; 2009 [accessed September 2001]. 10. The Association of Anaesthetists of Great Britain and Ireland guideline: the anaesthesia team. http://www.aagbi.org/sites/default/ files/anaesthesia_team_2010_0.pdf; 2010 [accessed September 2011]. 11. Mallaiah S. Liverpool Women’s NHS Foundation Trust: guidelines for cell salvage in obstetrics. http://www.oaa-anaes.ac.uk/ assets/_managed/editor/File/Guidelines/Cell%20salvage/cell%20 salvage%20guidelines_Mallaiah_Liverpool.pdf [accessed September 2011]. 12. National Health Service. Blood and transplant matters. http:// www.blood.co.uk/pdf/publications/blood_matters_34.pdf; 2011 [accessed September 2011]. 13. Pathak D, McDonald A, Barclay P, Mallaiah S. Use of cell salvage in caesarean section. Int J Obstet Anesth 2010;19:S10. 14. Better blood transfusion toolkit. http://www.transfusionguidelines.org.uk/index.aspx?Publication=BBT&Section=22&pageid= 1337 [accessed September 2011]. 15. Sreelakshmi TR, Eldridge J. Acute hypotension associated with leucocyte depletion filters during cell salvaged blood transfusion. Anaesthesia 2010;65:742–4.