4. intraoperative and postoperative cell salvage
This topic will review definition, the indication, advantages, and potential complications of intraoperative and postoperative cell salvage

5. Autologous Transfusion
Providing safe blood for transfusion remains a challenge despite advances in preventing transmission of hepatitis B, hepatitis C, AIDS/HIV, West Nile virus (WNV), and transfusion-transmitted bacterial infection.
Human errors such as misidentifying patients and drawing blood samples from the wrong person present much more of a risk than transmissible diseases.

6. Autologous Transfusion
Allogeneic blood transfusion has been associated with increased risk of:
Tumour recurrence
Postoperative infection
Acute lung injury

7. Autologous Transfusion
The main aim of autologous transfusion is
to reduce the need for allogeneic blood transfusion
to reduce its associated complications

8. Intra-operative Cell salvage (ICS)
It is a major form of auto transfusion
Definition:
Intraoperative blood collection, blood recovery or cell salvage, is a medical procedure involving recovering blood lost during surgery and re-infusing it into the same patient.

9. PRACTICAL CONSIDERATION FOR ICS
Sterile operating field is needed
Several steps are involved including:
- Suctioning of shed blood from the surgical field
- Addition of anticoagulant as it is aspirated (heparin concentration30000 units per liter with slow addition:rate of 15cc per 100cc of collected blood))
-Separation and washing of RBCs with with 0.9% saline
-Concentration the blood
-Send the plasma, platelet and west component to waste bag
-Reinfusion through the filters

10. PRACTICAL CONSIDERATION FOR ICS
Several medical devices have been developed to assist in salvaging the patient's own blood in the perioperative setting
This process typically results in 225-mL units of saline-suspended RBCs with a hematocrit of 50% to 60% within 3 minutes

11. PRACTICAL CONSIDERATION FOR ICS
It shall be stored under one of the following conditions before initiation of transfusion:
a. At room temperature for up to 4 hours after terminating collection
b. At 1° C to 6° C for up to 24 hours, provided storage at 1° C to 6° C is begun within 4 hours of ending the collection

12. PRACTICAL CONSIDERATION FOR ICS
Each unit collected intraoperatively shall be labeled with:
The patient’s first name,
Last name,
Hospital identification number;
The date and time of initiation of collection and of expiration;
The statement “For Autologous Use Only.”
Stored in blood bank

13. Benefits of ICS
1. Avoidance of allogeneic blood transfusion with attendant costs and risks:
T- reaction
T- transmitted infections and
T- related complications.

14. Benefits of ICS
2. Greater number of units available compered with other autologous blood conservation techniques which generally only provide 1-3 units of autologous blood
Thus ICS has been applied effectively in a variety of surgical procedures with likelihood of significant blood loss more than 1000 ml including cardiac, vascular, orthopedic, urologic. Trauma, gynecologic and transplantation procedures

15. Benefits of ICS
3. Time and cost saving, because salvage is always done in OR without direct involvement of the transfusion service and also eliminate the need for the patient to provide autologous donation
If there is uncertainty regarding the need for blood salvage, the collection disposables for a cell salvage device can be set up as a standby option potentially saving the cost of the bowel and the reinfusion bag as well as the personnel costs.

16. Benefits of ICS Can be used regardless of patient’s medical fitness.
Life saving where there is uncontrolled bleeding.
System accepted by some Jehovah’s Witnesses.
may be life Saving in a patient with a rare blood type.
may be useful in a patient with multiple RBC autoantibody when cross match compatible blood cannot readily be obtained.

17. Benefits of ICS
Oxygen transport properties of recovered red cell are equivalent to stored allogenic red cells
The survival of recovered RBCs appears to be at least comparable to that of transfused allogeneic RBCs

18. Side Effects of ICS
Air embolous which is a potentially serious problem
Hemolysis
Higher plasma free hemoglobin in contrast to allogenic blood transfusion that may be due to inadequate washing
Positive bacterial culture (clinical infection is rare)
DIC

19. SIDE EFFECTS OF INTRAOPERATIVE RECOVERY
Hemolysis of red cells can occur during suctioning from surface (vacuum not more than 150 torr is recommended or mechanical compression in roller pumps can produce hemolysis.)
It also occur in Hemoglobinopathy

20. Disadvantages Intra-Operative Cell Salvage (ICS)
Restricted to operations with high blood loss (>20 % of total blood volume).
Only red cells are returned without platelets or plasma

21. Disadvantages Intra-Operative Cell Salvage (ICS)
Use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use

22. Absolute contraindication
Presence of contraindicated fluids:
Salvaged blood must never be mixed with fluids, such as sterile water or any hypotonic solution, because RBC hemolysis will occurs.
Also Salvaged blood can not be used if solution that would be toxic with Iv administration could come into contact with the salvaged blood.
Examples include AB irrigation or hydrogen peroxide, alcohol, or povidone- iodine soloution.
Also Salvaged blood can not be used during suctioning of blood from the surgical field when there is any potential for simultanous collection of hemostatic products such as topical thrombin, fibrin glue, collagen sponge or any chance of admixture with methylmethacrylate(i.e. bone cement)

23. Relative contraindication
Bacterial infection: Decision about using intra operative blood salvage in patients with bacterial infections are made in case by case basis with consideration of relative risk and benefits for the individual patient, and with informed conscent.
Although washing blood that contain bacteria cannot completely sterilize it, processing blood via cell salvage system and filtering it using a leukocyte reduction filter has been associated with percent reduction in a variety of bacterial organism.

24. Relative contraindication
Active Malignancy:
Decision about using intra operative blood salvage in patients with active malignancy are made in case by case basis with consideration of relative risk and benefits for the individual patient, and with informed consent.
Extensive cell washing does not remove malignant cell, however the leukocyte filtration process remove cell from salvaged blood similar to removal of bacteria.

25. Area of uncertainty Obstetrics :
possibility of maternal allommunization from contamination from incompatible fetal RBC.
Anti-Rh(D) immunoglobulin should be administered after transfusion of salvaged blood in Rh(D) negative women when the fetus is Rh(D) positive
Amniotic fluid embolism
avoid directly aspirating Amniotic fluid by waiting until it is no longer visibly apparent in the surgical field before beginning to use cell salvage suction.
Hemoglobinoathy: theoretically risk of: sickling in sickle cell anemia
or hemolysis in thalassemia
Pheochrocytoma due to presence of theoretical risk of infusing of vasoactive material

26. Postoperative Blood Collection
Recovery of blood from surgical drain followed by re-infusion through a 40 microaggregate filter with or without washing process.
Shed blood is collected into sterile canister and re-infused through a micro-aggregate filter
Recovered blood is:
diluted,
partially hemolysed
de-fibrinated
and may contain high concentrate of cytokines

27. HARMFUL MATERIAL IN RECOVERED BLOOD
Free Hb
RBC Stroma
Marrow fat
Toxic irritant
Tissue or debris
Fibrin degradation product
Activated coagulation factors
Complement

28. RECOVERED BLOOD
Upper limit on the volume(1400 ml) of unprocessed blood can re-infused
Most common in orthopedic procedures such as hip or knee replacement.

29. Postoperative Blood Collection
Transfusion should be within 6 hours of initiating collection
Infusion of potentially harmful material in recovered blood
Although two small studies reported complications, several larger studies reported no serious adverse effects when the drainage was passed through a standard 40-μm blood filter.

30. Red Cell Transfusion- Is a clinical decision!!!
Tissue oxygenation does NOT depend on hemoglobin concentration alone!
Cardiac performance
Pulmonary function
O2 Binding Coefficient
Demand of Tissue (physical activity)