23 Fazakas Periop Blood Saving

Options for blood saving,

peri-operative blood collection

János Fazakas MD , PhDSemmelweis University

Department of Transplantation and Surgery, Budapest

Why do we need …?Options for blood saving, peri-operative blood collection

Options for blood saving,

peri-operative blood collection

Predeposit autologous donation (PAD)

Acute normovolemic hemodilution (ANH)

Intraoperative cell salvage (ICS)

Postoperative cell salvage (PCS)

•Autologous predeposit - full blood donation

•Autologous predeposit - full blood donation and separation

•Autologous predeposit - mechanical components donation

Predeposit autologous

donation (PAD)


donation (PAD)

•* HIV epidemic of the early 1980s.

Patients with rare blood groups or multiple blood group antibodies

Allogenic donor blood is difficult to obtain

Serious psychiatric risk → anxiety about exposure to donor blood

Patients who refuse donor blood transfusion, but accept PAD

• assessed by a ‘competent clinician’, usually a transfusion medicine specialist

• the same rules of hemovigilieance (adverse reaction-events reported)


donation (PAD)

Blood Safety and Quality Regulations:

PAD must be performed in a licensed blood establishment setting

PAD RBC storage-life of 35 days at 4°C (CAPD)

Healthy patients can donate up to 1-3 red cell units before elective surgery

Patients should be given iron supplements, folate, B12, EPO

•* HIV epidemic of the early 1980s.

Fundamental principles - PAD

Donor = Recipient

� Only in the case of general indication of transfusion

� Unused blood = hazardous waste

Advantage

� No allo-immunization

� Complication ↓

� No transfusion transmitted

infectious diseases

� No blood transfusion reaction

� Allogenic blood consumption ↓

To be considered

� Bacterial infections

� Technical faults

� Administration faults

� Expires

� Complex organization

Indications - PAD

Surgical procedures

� Before elective surgical

procedures

� Significant blood loss

may occur

Others0

� Rare blood group

� Hyperimmunization

� Tissue or organ donor

� Religion

Contraindications - PAD

• Acute surgical

procedures

• Significant

blood loss may

not occur

• Infection

• Severe heart disease

• Impaired blood

components

• Risk of micoaggregate

formation

• Warm and cold auto-

antibodies

• Direct Coombs

positivity

• HBV, HCV, HIV-1/2,

HTLV I/II, syphilis

• Hb less than 11 g/L

• Cardiovascular disorders

The Informed Consent Form - PAD

� Possibility

� Risk / benefit

� Significant blood loss may occur

� MedDRA System Organ Class

� ≥ 1/10 very common

� ≥ 1/100 to < 1/10 common

� ≥ 1/1000 to < 1/100 uncommon

� The informed consent documents must be clearly

written and understandable to donor/recipient!

PAD – questionnaire/registration form

Initiating procedure of PAD

� In written form! – questionnaire + registration form

� With medical records - laboratory tests

- internist’s expert report

physician’s request

BTS local institution

contracting hospital departments

� Blood tests can be performed only by BTS blood

suppliers.

BTS: Blood Transfusion Service

Preliminary tests before PAD

In Blood Transfusion Service lab

� Hgb

� ABO and Rh(D)

� testing for antibodies� enzymatic

� indirect Coombs

� direct Coombs

� HBV antigen and HCV, HIV 1-2, treponema antibody

→ in case of positivity the patient must be excluded

from analogous blood donation!

Suitability for PAD

� Internal examination

� Laboratory test

� Written request from the

institution sending the

patient (appendix I:

„Autologous blood donation

registration form”)

� BTS examination

� Transfusiologist’s

examination (every occasion)

� tapping liver, spleen, lymph

node

� circulation and respiratory

examinations

� blood pressure, pulseVerifying

suitability !

Identifying donor/recipient -PAD

� Photo identification document + authority ID (residential

address card)

photograph, full name, date of birth

� Health insurance card (TAJ in Hungary), EU card

� In case of children: 2 parents/authorized representatives

� Written (appendix II: „Informed consent form VAGY Information sheet”)

and oral information

� Medical record and general state of health (appendix III:

„Autologous blood donation questionnaire”)

� Patient’s assent to

� examination of blood sample

� autologous blood donation

� patient registries

Administration - PAD

� If suitable

→ making arrangements for blood tests before operation

→ patient registry – physician’s signature, stamp- collected blood volume

- blood substitute solution (which? how much?)

- RR, HR

� If not suitable

→ informing the patient in written form

→ informing the physician who sent the patient in written form

Blood collection - PAD

� Autologous Homologous blood collectiontype and quality of bag system type and quality of bag system

� The rules of autologous blood collection

The rules of homologous blood collection

+ direct supervision of a physician

+ ± substituting with infusion

+ collected blood volume (on one occasion) 450 ml (±10%)

≤ 12% of the patient’s blood volume (65-75 ml/ttkg x 0,12)

+ in case of apheresis:

thrombocytes, RBC, plasma

=

=

Labeling autologous blood

1. „Autotransfusion” label

2. The donor/recipient’s

name


date of birth


health insurance

number (TAJ)

� age 18-65 years

� weight > 10 kg

� pulse 50-110/min

� blood pressure systole: 100-180 Hgmm

diastole: < 100 Hgmm

� Hgb > 110 g/l

� Hct > 33%

PAD procedure

7 days 7 days 7 days 3 days

1 E back 1 E back

Medication - PAD

physician ≠ transfusiologist

1. checking iron level, oral iron

supplementation for autologous donor- one week before the first blood collection

- for 3 months after the last one

2. EPO ?

procedures for

homologous blood

PAD - blood products*

→ RBC concentrate, resuspended

→ Fresh Frozen Plasma (FFP)

→ RBC concentrate, from apheresis,

resuspended in solution with adenine content

→ Platelet concentrate from apheresis

Autologous

blood

What to do before retransfusion

� The recipient has to be identified unequivocally

- recognizing signature

� Check the identifying codes of blood preparation

� Perform AB0 and Rh(D) identification at bedside (recipient/preparation)

Personal data� name

� birth name

� address

� date of birth

� mother’s name

� health insurance

number (TAJ)

Registry – for 30 years

Contact�address� telephone numbers�e-mail address

Hospital/physician treating the patient

�name, address, department ofthe hospital

�physician’s name, telephone number, stamp number

Medical record�anamnesis� laboratory test results� internist’s opinion

Examinations before blood collection�weight�blood pressure, pulse�current Hgb

BTS laboratory tests�Hgb�AB0,Rh(D)�antibody testenzymatic, direct and indirect Coombs

�HBV antigen and HCV, �HIV 1-2, treponema antibody

Blood collection data�dates of each stages

�dates of blood

collections

� identification numbers

of blood/blood

components

• Bags of blood being removed

immediately before the initiation of

surgery,

• The infusion of volume expanders to

maintain normovolemia.

• Bags of blood being re-infused

during and/or immediately after the

surgery is completed.

Acute normovolemic

hemodilution (ANH )

Acute normovolemic

hemodilution (ANH )

1-3 units of whole blood are collected and the patient’s blood volume is maintained by the simultaneous infusion of crystalloid or colloid fluids.

• The blood is stored in the operating theatre at room temperature

• Reinfused at the end of surgery or if significant bleeding occurs

Risk of fluid overload, cardiac ischemia

Systematic reviews + trials → no significant reduction to transfusions

• other blood conservation techniques: ICS

Intraoperative cell salvage (ICS)the collection and reinfusion of blood spilled during surgery

Blood lost into the surgical field is anticoagulated with heparin or citrate and aspirated into a collection reservoir

Sponge filtration remove particulate debris

the salvaged blood can be centrifuged and washed in a closed, automated system.

Red cells suspended in sterile saline solution are produced, which must be transfused to the patient within 4 hours of processing.

the reinfusion bag should be labelled in the operating theatre with the minimum patient identifiers derived from the patient’s ID band

The red cells are transfused through a 200 µm screen filter, after 800 ml a leucodepletion filter is indicated (C3a-C5a)

� Patients who needs ICS → give informed consent

� The transfusion → documented and the patient monitored in the same way as

for any transfusion

Indications for ICS in adults

and children

Surgery + anticipated blood loss is >20% of the patient’s BV

Elective or emergency surgery + major hemorrhage

risk factors for bleeding and low preoperative Hb concentration.

Patients with rare blood groups or multiple blood group antibodies for whom it may be difficult to provide donor blood.

Patients who do not accept donor blood transfusions but are prepared to accept, and consent to, ICS (this includes most Jehovah’s Witnesses

• concerns about cancer cell reinfusion and spread,

• manufacturers do not recommend ICS in patients having surgery for

malignant disease.

• Extensive clinical experience suggests this is not a significant risk

• Reinfuse the red cells through a leucodepletion filter

• concerns about amniotic fluid embolism

• the harvested red cells should be reinfused through a leucodepletion filter

CONTRAINDICATIONS� Sepsis

� Malignant tumour *

� Contamination:• betadine, hydrogen-peroxide, alcohol

• distilled water, water

• non-parenteral antibiotics

• fibrin gel, collagen based hemostasis

• meconium, amniotic fluid *

• urine

• stomach content

• bile

Intraoperative cell salvage

* Reinfuse the red cells through a leucodepletion filter

Diagram of the set up of a

standard cell salvage circuit

A. Ashworth, and A. A. Klein Br. J. Anaesth. 2010;105:401-416


� Hemocinetics ®

Cell Saver

� C.A.T.S.®

(Continuous

Auto

Transfusion

System )

HAEMONETICS

CELLSAVER

Collection

Wash

Concentration

8-10 min

FRESENIUS C.A.T.S.

Spiral pipe system

Continuous collection,

separation,

resuspendation,

concentration



In 1976, was introduced

by Haemonetics Corp.

and is known commonly

as "Cell Saver"

0 in 1995 Fresenius

introduced a continuous

autotransfusion system0




C.A.T.S.

WASHING PROGRAMS

20 - 45 ml/minQuality Wash

100 ml/minEmergency Wash

30 - 70 ml/minHigh Flow Wash

25 ml/minLow Volume Wash

20 - 40 ml/minHigh Quality Wash

Flow rateWashing programQuality

anticoagulation: Na-heparin 15000 NE/500 ml + 0,9 % NaCl solution

C.A.T.S. ® (Fresenius)

Advantages� 2,3-DPG level↑

� Normothermia

� Normal pH

� Potassium ion ↓

(compared to vvs

concentration)

Elimination� Plasma

� Platelets

� WBC

� Free Hgb

� Cell debris

� Activated factors

� Intracellular enzymes

coagulopathy

ICS - evidence


Postoperative cell salvage (PCS)

� Orthopedic procedures (knee or hip replacement) and in scoliosis surgery

� The filtration systems for reinfusion of unwashed red cells are used when expected blood losses is 500 →→→→ 1000 ml

� Blood is collected from wound drains and then either filtered or washed in an automated system before reinfusion to the patient

� Collection of salvaged blood must be completed within 6 hours

� Clinical staff must be trained and competency assessed to use the device

� Accurately document the collection and label the pack at the bedside.

� The reinfusion must be monitored and documented in the same way as donor transfusions.

� * Is acceptable to most Jehovah’s Witnesses.

PCS - device

� HemovacOrthopedic and cardiac surgery

45 mmHg vacuum

230 micron macro filter

� Bellovacorthopedic and spine surgery

90 mmHg vacuum

200 micron macro-filter in the bag

80 and 40 micron micro-filter - transfusions set

Maximum 6 hours (700 -1500 ml); do not filter bacterial contamination

Mental competence and

refusal of transfusion

� 0unless there is clear evidence of prior refusal such as an Advance Decision Document. The patient record should document the indication for transfusion and thepatient should be informed of the transfusion when mental capacity is regained (and their future wishes should be respected)

� 0the parents or legal guardians of a child under 18refuse blood transfusion, the opinion of the treating clinician is life-saving or essential for the well-being of the child, a Specific Issue Order (or national equivalent) can be rapidly obtained from a court0

� 0all hospitals should have policies that describe how to do this, without delay, 24 hours a day0

• Altered consciousness0, critically ill patients with temporary incapacity

clinicians must give life-saving treatment, including blood transfusion

Thank you for your attention!

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23 Fazakas Periop Blood Saving