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ATS TRAINING COURSE
Intraoperative blood salvage
To Start What is Blood?
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1- DEFINITION :
Autotransfusion is a process when a person receives their
own blood for a transfusion, instead of banked donor
blood. Blood can be pre-donated before a surgery, or can
be collected during and after the surgery using a device
commonly known as the Cell Salvage device. The Cell
Salvage device is utilized in surgeries where there is
expected a large volume blood loss. For example,
aneurysm, total joint replacements and spinal surgeries.
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2- HISTORY OF AUTOTRANSFUSION :
The first documented use of the procedure was in 1818 (James
Blundell ), and interest in the practice continued until the Second
World War, at which point blood supply became less of an issue,
due to the increased number of blood donors. Later, interest in the
procedure returned with new automated machinery being developed
for it. Autotransfusion is used in a number of cardiac, trauma and
orthopedic cases, amongst others, and it carries advantages,
including the reduction of infection risk and the provision of more
functional cells.
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3- INDICATIONS FOR AUTOTRANSFUSION:
Autotransfusion is intended for use in situations characterized by
the loss of one or more units of blood and may be particularly
advantageous for use in cases involving rare blood groups, risk of
infectious disease transmission, restricted homologous blood supply
or other medical situations for which the use of homologous blood is
contraindicated. Autotransfusion is commonly used intraoperatively
and postoperatively. Intraoperative autotransfusion refers to
recovery of blood lost during surgery or the concentration of fluid in
an extracorporeal circuit. Postoperative autotransfusion refers to the
recovery of blood in the extracorporeal circuit at the end of surgery
or from aspirated drainage.
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4- IN WHICH OPERATION CAN WE USE AUTOTRANSFUSION:

Cardiac: Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair /
Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
 Trauma: Subdural Hematoma, Chest Injuries, Liver Fractures, Kidney Fractures, Major
Vessel Lacerations, Aneurysms, Gun Shot Wounds, Stab Wounds, Extremity
Reimplantations, Splenectomy, Blunt Trauma (Thoracic or Abdominal)
 Orthopedic: Spinal Instrumentation, Spinal Fusion, Discectomie, Laminectomy, Total
shoulder replacement, Total hip replacement, Total knee replacement, Femur Fractures,
Open Reduction Internal Fixation Pelvic Fractures, IM Rodding
 Other: Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver
Transplant, Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic
Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, Hysterectomy (NonMalignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (NonMalignant)
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5- Contraindications
The use of blood recovered from the operative field is
contraindicated in the presence of bacterial contamination
or malignancy. The use of autotransfusion in the presence
of such contamination may result in the dissemination of
pathologic microorganisms and / or malignant cells. The
following statements reflect current clinical concerns
involving autotransfusion contraindications.
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5.1- Exceptions to those contraindications are under investigations:
5.1.1- Malignancy:

Blood irradiation for intraoperative autotransfusion in cancer surgery demonstration of efficient elimination of contaminating tumor
cells.
Hansen E, Knuechel R, Altmeppen J, Taeger K.
Department of Anesthesiology, University of Regensburg, Germany. Transfusion. 1999 Jun;39(6):608-15.

Intraoperative cell salvage during radical cystectomy does not affect long-term survival.
Nieder AM, Manoharan M, Yang Y, Soloway MS.
Department of Urology, University of Miami Miller School of Medicine, Miami, Florida 33140, USA. Urology. 2007 May;69(5):881-4.

Intraoperative blood salvage in cancer surgery: safe and effective?
Hansen E, Bechmann V, Altmeppen J.
Department of Anesthesiologie, University of Regensburg, Germany. Transfus Apher Sci. 2002 Oct;27(2):153-7.
According to our experience with more than 700 procedures the combination of blood salvage with blood irradiation also is very effective in
saving blood resources. With this autologous, fresh, washed RBC a blood product of excellent quality is available for optimal hemotherapy in
cancer patients.

Blood salvage use in gynecologic oncology.
Nagarsheth NP, Sharma T, Shander A, Awan A.
Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Medical Center, New York,
New York 10029-6574, USA. Transfusion. 2009 Oct;49(10):2048-53. Epub 2009 Jun 23.
In this series of patients undergoing surgery for malignancies on the gynecologic oncology service, blood salvage with LRF was not
definitively associated with hematogenous dissemination.
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5.1.2 Bacterial contamination:

Intraoperative blood salvage and leukocyte depletion during liver transplantation with bacterial contamination.
Liang TB, Li JJ, Li DL, Liang L, Bai XL, Zheng SS.
Department of Hepatobiliary and Pancreatic Surgery, Key Laboratory of Multi-organ Transplantation of Ministry of Public Health, Key Laboratory of
Organ Transplantation of Zhejiang Province, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Clin
Transplant. 2010 Mar 1;24(2):265-72. Epub 2009 Sep 24.
CONCLUSIONS: Autotransfusion devices with an additional LDF could significantly eliminate bacterial contaminants of shed blood during
OLT
Autologous transfusion of shed mediastinal blood after coronary artery bypass grafting and bacterial contamination.
Andreasen AS, Schmidt H, Jarløv JO, Skov R.
Department of Anesthesiology, Gentofte Hospital, Copenhagen, Denmark. Ann Thorac Surg. 2001 Oct;72(4):1327-30.
We found no significant difference in infection variables between patients with or without bacterial growth in the cultures. No patients suffered from
early postoperative infectious complications. CONCLUSIONS: There is no further contamination of the shed blood during the period between
initiating the autologous transfusion and the following morning.
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5.2.1: Recommandations:
Despite the many studies undergoing to bypass those contraindications all
major companies do not recommend the usage of there Autotransfusion
device in case of contamination or malignancy.
5.2.2 Emergency:
Although there are contraindications In life saving situations with the
consent of the surgeon, Autotransfusion can be utilized in the presence of
the previous stated contraindications i.e. sepsis, bowel contamination and
malignancy.
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6-Disadvantages
The disadvantage of autotransfusion is the depletion of plasma and
platelets. The washed autotransfusion system removes the plasma and
platelets, to eliminate activated clotting factors and activated platelets
which would cause coagulopathy if they were reinfused to the patient.
This disadvantage is only evident when very large blood losses occur. The
autotransfusionist monitors blood loss and will recommend the transfusion
of fresh frozen plasma (FFP) and platelets when the blood loss and return
of autotransfusion blood increases. Typically the patient will require FFP
and platelets as the estimated blood loss exceeds half of the patient's blood
volume. When possible diagnostic tests should be performed to determine
the need for any blood products (ie. PRBCs, FFP and Platelets).
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Advantages:
Substances washed out:
•High levels of 2,3 DPG
•Normothermic
•pH relatively normal
•Lower risk of Infectious Diseases
•Functionally superior cells
•Lower Potassium (compared to stored blood)
•Quickly available
•High RBC recovery over 90%
•High Hct concentration > 50%
•Plasma
•Platelets
•White Cells
•Anticoagulant Solution
•Plasma free Hemoglobin
•Cellular stroma
•Activated clotting factors
•Intracellular Enzymes
•Potassium
•Plasma bound Antibiotics
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WHY AUTOTRANSFUSION
IS BETTER THEN
STANDART
HOMOLOGOUS BLOOD
TRANSFUSION?
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
Effects of storage of
blood:
↓PH
↑K+
↓2,3DPG
↓Platelets, platelet function
lost by 48 hours.
↓Coagulations factors (V &
VIII
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PROBLEM RELATED TO THE TRANSFUSION OF HOMOLOGOUS BLOOD:



Transfusion reactions: Infections, viruses and most importantly Immunosupression / Immunomodulation
Transfusion-related acute lung injury (TRALI) is a serious complication of blood transfusions that is
thought to be most commonly caused by a reaction to White Blood Cell antibodies present primarily in
the plasma component of blood products
• When transfused, these antibodies can sometimes activate a type of White Blood Cell called a granulocyte,
which causes plasma to leak into the lungs, creating fluid accumulation, a condition referred to as acute
pulmonary edema
There is currently no screening test for the prevention of TRALI, and there is no single intervention that can
eliminate the risk of TRALI (1: 2000)
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Frequency and outcomes of blood products transfusion across procedures and clinical conditions
warranting inpatient care: an analysis of the 2004 healthcare cost and utilization project nationwide
inpatient sample database.
Morton J, Anastassopoulos KP, Patel ST, Lerner JH, Ryan KJ, Goss TF, Dodd SL. Stanford University Medical
Center, Stanford, CA, USA.
 The objective of this retrospective cohort study was to assess frequency and outcomes associated with
blood products transfusion. Data from the 2004 Nationwide Inpatient Sample database were used. Length
of stay (LOS), postoperative infections, noninfectious transfusion-related complications, in-hospital
mortality, and total charges were evaluated for transfused and nontransfused cohorts. Of the estimated
38.66 million discharges in the United States in 2004, 5.8% (2.33 million) were associated with blood
products transfusion. Average LOS was 2.5 days longer, and charges were $17 194 higher for the
transfused cohort (P < .0001). Odds of death were 1.7 times higher (P < .0001) and odds of infection 1.9
times higher (P < .0001) for the transfused cohort. Increased provider awareness and recognition of the
frequency and potential negative outcomes of blood products transfusion may encourage the adoption of
novel approaches to minimize intraoperative and early postoperative bleeding, reduce transfusion
requirements, and most important, improve patient-level postoperative outcomes and health-related
quality of life.
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Transfusions blamed for deaths after heart bypass
NEW YORK (Reuters Life) - Getting a blood transfusion during or after heart bypass
surgery may raise the risk of dying in the next few months after the operation, new
research suggests. Moreover, this may explain in part why women are more likely
than men to die after coronary artery bypass grafting (CABG), since women more
commonly need transfusions than men do.
"To the best of our knowledge, this is the first study to state that ... transfusions may be
the reason why women have a greater post-CABG mortality than men," Dr. Mary A.
M. Rogers, from the University of Michigan in Ann Arbor, said in a statement.
In a study of Michigan Medicare beneficiaries, 88 percent of female CABG patients
received a blood transfusion compared with 67 percent of male patients.
Patients who received a blood transfusion were 5.6-times more likely to die within 100
days of undergoing heart bypass surgery than were non-transfused patients,
the report indicates. © Reuters 2007. All Rights Reserved.
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Older Blood carries Greater Morbidity and Mortality
 Duration of red-cell storage and complications after cardiac surgery.
N England J Med 2008 Mar 20;358(12):1229-39. Koch CG, et al.

BACKGROUND: Stored red cells undergo progressive structural and functional changes over time. We tested the hypothesis that serious
complications and mortality after cardiac surgery are increased when transfused red cells are stored for more than 2 weeks.
METHODS: We examined data from patients given red-cell transfusions during coronary-artery bypass grafting, heart-valve surgery, or both
between June 30, 1998, and January 30, 2006. A total of 2872 patients received 8802 units of blood that had been stored for 14 days or less
("newer blood"), and 3130 patients received 10,782 units of blood that had been stored for more than 14 days ("older blood"). Multivariable
logistic regression with propensity-score methods was used to examine the effect of the duration of storage on outcomes. Survival was
estimated by the Kaplan-Meier method and Blackstone's decomposition method.
RESULTS: The median duration of storage was 11 days for newer blood and 20 days for older blood. Patients who were given older units
had higher rates of in-hospital mortality (2.8% vs. 1.7%, P=0.004), intubation beyond 72 hours (9.7% vs. 5.6%, P<0.001), renal failure (2.7% vs.
1.6%, P=0.003), and sepsis or septicemia (4.0% vs. 2.8%, P=0.01). A composite of complications was more common in patients given older
blood (25.9% vs. 22.4%, P=0.001). Similarly, older blood was associated with an increase in the risk-adjusted rate of the composite outcome
(P=0.03). At 1 year, mortality was significantly less in patients given newer blood (7.4% vs. 11.0%, P<0.001).
CONCLUSIONS: In patients undergoing cardiac surgery, transfusion of red cells that had been stored for
more than 2 weeks was associated with a significantly increased risk of postoperative complications as
well as reduced short-term and long-term survival.
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Increased mortality, postoperative morbidity, and cost after red blood cell
transfusion in patients having cardiac surgery.
Circulation 2007 Nov 12 Murphy GJ, Reeves BC, Rogers CA,

BACKGROUND: Red blood cell transfusion can both benefit and harm. To inform decisions about transfusion,
we aimed to quantify associations of transfusion with clinical outcomes and cost in patients having cardiac
surgery. Methods and
RESULTS: Clinical, hematology, and blood transfusion databases were linked with the UK population register.
Additional hematocrit information was obtained from intensive care unit charts. Composite infection (respiratory
or wound infection or septicemia) and ischemic outcomes (myocardial infarction, stroke, renal impairment, or
failure) were prespecified as co-primary end points. Secondary outcomes were resource use, cost, and survival.
Associations were estimated by regression modeling with adjustment for potential confounding. All adult
patients having cardiac surgery between April 1, 1996, and December 31, 2003, with key exposure and outcome
data were included (98%). Adjusted odds ratios for composite infection (737 of 8516) and ischemic outcomes
(832 of 8518) for transfused versus non-transfused patients were 3.38 (95% confidence interval [CI], 2.60 to 4.40)
and 3.35 (95% CI, 2.68 to 4.35), respectively. Transfusion was associated with increased relative cost of
admission (any transfusion, 1.42 times [95% CI, 1.37 to 1.46], varying from 1.11 for 1 U to 3.35 for >9 U). At any
time after their operations, transfused patients were less likely to have been discharged from hospital (hazard
ratio [HR], 0.63; 95% CI, 0.60 to 0.67) and were more likely to have died (0 to 30 days: HR, 6.69; 95% CI, 3.66 to
15.1; 31 days to 1 year: HR, 2.59; 95% CI, 1.68 to 4.17; >1 year: HR, 1.32; 95% CI, 1.08 to 1.64).
CONCLUSIONS. Red blood cell transfusion in patients having cardiac surgery is strongly associated with both
infection and ischemic postoperative morbidity, hospital stay, increased early and late mortality, and hospital
costs.
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Two New Clinical Studies Show That Limited Exposure to Blood Transfusion Significantly
Increases Morbidity and Mortality After Surgery:
 1) Bernard AC et al. Intraoperative transfusion of 1U to 2U of packed red blood cells is
associated with increased 30-day mortality, surgical site infection, pneumonia, and sepsis in
general surgery patients. Journal of the American College of Surgeons. 2009; 208:931-937.
 (2) Surgenor SD et al, for the Northern New England Cardiovascular Disease Study Group. The
Association of Perioperative Red Blood Cell Transfusions and Decreased Long-Term Survival
After Cardiac Surgery. Anesthesia & Analgesia 2009; 108:1741-1746.

In the general surgery study, researchers evaluated 125,177 patients from 121 hospitals and
showed that after adjusting for all risk variables, transfusion of a single unit of blood increased
30-day mortality by 32% and morbidity (pneumonia, sepsis, or surgical site infection) by 23%.
Transfusion of two units of blood increased the mortality risk by 38% and morbidity risk by
40%. In the cardiac surgery study, researchers evaluated long-term survival of 9,079 patients at
eight hospitals and showed that transfusion of one or two units of blood increased six-month
mortality 67% and five-year mortality 16% .
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“More than 75 million units of blood are donated each year throughout
the world. A significant proportion of these expose recipients of blood
and blood products to unnecessary risk”
WHO (World Health Organization)
BLOOD TRANSFUSION SAFETY
Information Sheet for National Health Authorities
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…the solution? Cell washing
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
Efficacy and cost-effectiveness of cell saving blood autotransfusion in
adult lumbar fusion.
C. Savvidou, S. N. Chatziioannou, A. Pilichou, S. G. Pneumaticos
 summary.
The objective of this study was to explore the use of cell saver blood autotransfusion in spinal surgery
and to evaluate the efficacy and cost-effectiveness of cell saver blood autotransfusion during lumbar
spine fusion in adults. Specific indications for the use of cell saver in adult lumbar fusion surgery have
not yet been clearly determined. A total of 50 consecutive candidates for posterolateral fusion with
internal fixation were prospectively randomized into either receiving perioperatively cell saving
autotransfusion (Group A: 25 patients) or not (Group B: 25 patients). The use of cell saving technique did
not exclude the use of allogenic blood transfusion. Surgical indications were spinal stenosis,
spondylolisthesis, adolescent idiopathic scoliosis, degenerative scoliosis and fractures. Medical and
financial data were recorded. A cost-analysis was performed. Patients in Group A received 880 ± 216 mL
from cell saver and 175 ± 202 mL allogenic blood. The patients in Group B received 908 ± 244 mL
allogenic blood. Blood volumes data collected were expressed in mean ± SD values. The cost of blood
transfusion in Group A was 995 ±€447 per patient and 1220 ± 269 in Group B (P < 0.05). In elective lumbar
fusion blood requirements can be satisfied with the use of autotransfusion. The use of cell saver appears
to be useful and cost-effective during most elective lumbar fusions.
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N.B.:
For every 1 liter of Crystalloid given:
Only 250 mls will stay Intravascular within 30 minutes, the rest of the
750mls will cross extravascularly causing Organ Edema/Dysfx
dropping the Viscosity and COP.
It’s a lot easier to add volume than it is to take it off!
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Platelet sequestration and autologous platelet gel
Many of the newest autotransfusion machines are programmable to provide
separation of blood into three groups; Red Cells, Platelet Poor Plasma, and Platelet
Rich Plasma. Blood can be drawn from the patient just prior to surgery and then
separated. The separated blood components which have been sequestered can be
stored during the surgical procedure. The Red Cells and Platelet Poor Plasma can be
given back to the patient through Intravenous transfusion during or after surgery.
The Platelet Rich Plasma can be mixed with Calcium and Thrombin to create a
product known as autologous platelet gel (APG). This is an Autologous product
which can be used for a variety of techniques including use as a hemostatic aid, a
dural sealant and an aid to fusion of bone. Its applications are being widely studied
and reported in the literature on a regular basis recently.
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Most Importantly remember!
“If its not yours its an Organ Transplant” with consequences, so try and do your best to avoid it!
Your decisions effect the patient for the rest of their life!
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Thank you for your time!
Questions?
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