Options for blood saving,

peri-operative blood collection

Jnos Fazakas MD , PhD

Semmelweis 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)

Predeposit autologous
donation (PAD)
Autologous predeposit - full blood donation

Autologous predeposit - mechanical components donation

Autologous predeposit - full blood donation and separation

Predeposit autologous
donation (PAD)

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)

* HIV epidemic of the early 1980s.

Predeposit autologous
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 4C (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
Infection
Severe heart disease
Impaired blood
components
Risk of micoaggregate
formation
Warm and cold autoantibodies
Direct Coombs
positivity
HBV, HCV, HIV-1/2,
HTLV I/II, syphilis

Acute surgical
procedures
Significant
blood loss may
not occur

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
- internists expert report
physicians 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)

Transfusiologists
examination (every occasion)


BTS examination


Verifying
suitability !

tapping liver, spleen, lymph

node
circulation and respiratory
examinations
blood pressure, pulse

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)

Patients assent to




examination of blood sample

autologous blood donation
patient registries

Administration - PAD

If suitable
making arrangements for blood tests before
operation
patient registry physicians 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

=
type and quality of bag system

Homologous blood collection

type and quality of bag system

The rules of autologous blood collection

Autologous

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 patients 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/recipients
name
3. The donor/recipients
date of birth
4. The donor/recipients
health insurance
number (TAJ)

PAD procedure

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%

7 days

1 E back

1 E back

7 days

7 days

3 days

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 ?

PAD - blood products*

Autologous
blood
procedures for
homologous blood
RBC concentrate, resuspended
Fresh Frozen Plasma (FFP)
RBC concentrate, from apheresis,
resuspended in solution with adenine content
Platelet concentrate from apheresis

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)

Registry for 30 years

Personal data







name
birth name
address
date of birth
mothers name
health
insurance
number (TAJ)

Contact
 address
 telephone numbers
 e-mail address

Hospital/physician treating
the patient
 name, address, department of

Examinations
before blood
collection

the hospital
 physicians name, telephone
number, stamp number

weight
blood pressure, pulse
current Hgb

Medical record
 anamnesis
 laboratory test results
 internists opinion

BTS laboratory tests

Hgb
AB0,Rh(D)
antibody test

enzymatic, 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

Acute normovolemic
hemodilution (ANH )

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 )

1-3 units of whole blood are collected and the patients 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

Patients whothe
needs
ICSblood
give
consent
salvaged
caninformed
be centrifuged
and washed in a closed,
automated
system.
The transfusion documented and the patient monitored in the same way as
for any transfusion
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 patients ID band
The red cells are transfused through a 200 m screen filter, after 800 ml a
leucodepletion filter is indicated (C3a-C5a)

Indications for ICS in adults

and children
Surgery + anticipated blood loss is >20% of the patients BV

Elective or emergency surgery + major hemorrhage

concerns about cancer cell reinfusion and spread,

manufacturers do not recommend ICS in patients having surgery for
riskdisease.
factors for bleeding and low preoperative Hb concentration.
malignant
Extensive clinical experience suggests this is not a significant risk
Reinfuse the red cells through a leucodepletion filter
Patients with rare blood groups or multiple blood group antibodies for
whom it may be difficult to provide donor blood.

concerns about amniotic fluid embolism

the harvested red cells should be reinfused through a leucodepletion filter
Patients who do not accept donor blood transfusions but are prepared to
accept, and consent to, ICS (this includes most Jehovahs Witnesses

Intraoperative cell salvage

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

* 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

Intraoperative cell salvage

Hemocinetics
Cell Saver

C.A.T.S.
(Continuous
Auto
Transfusion
System )

Intraoperative cell salvage

HAEMONETICS
CELLSAVER
Collection
Wash
Concentration
8-10 min

FRESENIUS C.A.T.S.
Spiral pipe system
Continuous collection,
separation,
resuspendation,
concentration

Intraoperative cell salvage

In 1976, was introduced
by Haemonetics Corp.
and is known commonly
as "Cell Saver"

Intraoperative cell salvage

0 in 1995 Fresenius
introduced a continuous
autotransfusion system0

Intraoperative cell salvage

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

C.A.T.S.
WASHING PROGRAMS
Quality

Washing program

Flow rate

High Quality Wash

20 - 40 ml/min

Low Volume Wash

25 ml/min

Quality Wash

20 - 45 ml/min

High Flow Wash

30 - 70 ml/min

Emergency Wash

100 ml/min

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

C.A.T.S. (Fresenius)
Advantages

Elimination

2,3-DPG level
Normothermia
Normal pH
Potassium ion

(compared to vvs
concentration)

coagulopathy

Plasma
Platelets
WBC
Free Hgb
Cell debris
Activated factors
Intracellular enzymes

ICS - evidence

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

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


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



Collection of salvaged blood must be completed within 6 hours

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 Jehovahs Witnesses.

PCS - device

Hemovac
Orthopedic and cardiac surgery
45 mmHg vacuum
230 micron macro filter

Bellovac
orthopedic 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
Altered consciousness0, critically ill patients with temporary incapacity
clinicians must give life-saving treatment, including blood 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 the
patient 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 18
refuse 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

Thank you for your attention!