Cell Salvage in PBM

TRASFUSIONI ED EMORECUPERO IN S.O.
ATTUALI LINEE GUIDA
E.Testa TFPC
Unità operativa di CCH
Direttore dott. E. Polesel
ULSS n. 9 Treviso -
dip. di Anestesia e Rianimazione
CORSI DIPARTIMENTALI
7 -14 / 06 / 2016
martedì 14 giugno 16

INTRODUZIONE
DIVERSI STUDI HANNO DIMOSTRATO COME
L’ENTITA’ - ANCHE MINIMA - DI TRASFUSIONE
SIA UN FATTORE DI RISCHIO INDIPENDENTE
DI COMPLICANZE POSTOPERATORIE
Keyvan Karkouti, Duminda N. Wijeysundera and W. Scott Beattie
Study
Risk Associated With Preoperative Anemia in Cardiac Surgery : A Multicenter Cohort
Print ISSN: 0009-7322. Online ISSN: 1524-4539
Copyright © 2008 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation
doi: 10.1161/CIRCULATIONAHA.107.718353
2008;117:478-484; originally published online January 2, 2008;Circulation.
http://circ.ahajournals.org/content/117/4/478
World Wide Web at:
The online version of this article, along with updated information and services, is located on the
ORIGINAL ARTICLE
Surgical Outcomes and Transfusion
of Minimal Amounts of Blood in the Operating Room
Victor A. Ferraris, MD, PhD; Daniel L. Davenport, PhD; Sibu P. Saha, MD, MBA;
Peter C. Austin, PhD; Joseph B. Zwischenberger, MD

Review Article
Efficacy of red blood cell transfusion in the critically ill:
A systematic review of the literature*
Paul E. Marik, MD, FACP, FCCM, FCCP; Howard L. Corwin, MD, FACP, FCCM, FCCP
In recent years red blood cell
(RBC) transfusion requirements
in western nations has been in-
creasing because of the increasing
burden of chronic disease in an aging
population, improvement in life-support
technology, and blood-intensive surgical
procedures (1, 2). In the United States
alone, nearly 15 million units of blood are
donated and 13 million units are trans-
fused annually (2). For much of the last
(3). On the other hand, it is now becom-
ing clear that there are other important,
less recognized risks of RBC transfusion
related to RBC storage effects and to im-
munomodulating effects of RBC transfu-
sions, which occur in almost all recipi-
ents (4). These immunomodulating*See also p. 2707.
From the Division of Pulmonary and Critical Care
Background: Red blood cell (RBC) transfusions are common in
intensive care unit, trauma, and surgical patients. However, the
hematocrit that should be maintained in any particular patient
because the risks of further transfusion of RBC outweigh the
benefits remains unclear.
Objective: A systematic review of the literature to determine
the association between red blood cell transfusion, and morbidity
and mortality in high-risk hospitalized patients.
Data Sources: MEDLINE, Embase, Cochrane Register of Con-
trolled Trials, and citation review of relevant primary and review
articles.
Study Selection: Cohort studies that assessed the independent
effect of RBC transfusion on patient outcomes. From 571 articles
screened, 45 met inclusion criteria and were included for data
extraction.
Data Extraction: Forty-five studies including 272,596 were
identified (the outcomes from one study were reported in four
separate publications). The outcome measures were mortality,
infections, multiorgan dysfunction syndrome, and acute respira-
tory distress syndrome. The overall risks vs. benefits of RBC
transfusion on patient outcome in each study was classified as (i)
risks outweigh benefits, (ii) neutral risk, and (iii) benefits out-
weigh risks. The odds ratio and 95% confidence interval for each
outcome measure was recorded if available. The pooled odds
ratios were determined using meta-analytic techniques.
Data Synthesis: Forty-five observational studies with a median
of 687 patients/study (range, 63–78,974) were analyzed. In 42 of
the 45 studies the risks of RBC transfusion outweighed the
benefits; the risk was neutral in two studies with the benefits
outweighing the risks in a subgroup of a single study (elderly
patients with an acute myocardial infarction and a hematocrit
<30%). Seventeen of 18 studies, demonstrated that RBC trans-
fusions were an independent predictor of death; the pooled odds
ratio (12 studies) was 1.7 (95% confidence interval, 1.4؊1.9).
Twenty-two studies examined the association between RBC
transfusion and nosocomial infection; in all these studies blood
transfusion was an independent risk factor for infection. The
pooled odds ratio (nine studies) for developing an infectious
complication was 1.8 (95% confidence interval, 1.5–2.2). RBC
transfusions similarly increased the risk of developing multi-
organ dysfunction syndrome (three studies) and acute respiratory
distress syndrome (six studies). The pooled odds ratio for devel-
oping acute respiratory distress syndrome was 2.5 (95% confi-
dence interval, 1.6–3.3).
Conclusions: Despite the inherent limitations in the analysis of
cohort studies, our analysis suggests that in adult, intensive care
unit, trauma, and surgical patients, RBC transfusions are associated
with increased morbidity and mortality and therefore, current trans-
fusion practices may require reevaluation. The risks and benefits of
RBC transfusion should be assessed in every patient before transfu-
sion. (Crit Care Med 2008; 36:2667–2674)
KEY WORDS: blood; blood transfusion; anemia; infections; im-
munomodulation; transfusion-related acute lung injury; acute re-
spiratory distress syndrome; mortality; systematic analysis; meta-
analysis
Morbidity and mortality risk associated with red blood cell
and blood-component transfusion in isolated coronary artery
bypass grafting*
Colleen Gorman Koch, MD, MS; Liang Li, PhD; Andra I. Duncan, MD; Tomislav Mihaljevic, MD;
Delos M. Cosgrove, MD; Floyd D. Loop, MD; Norman J. Starr, MD; Eugene H. Blackstone, MD
A
dministration of packed red
blood cells (PRBCs) has been
associated with morbidity and
mortality for both medical and
surgical patients (1–13). Transfusions are
(2, 8) and long-term mortality (12). Gong
et al. (14) recently demonstrated the as-
sociation between PRBC transfusion and
the development and increased mortality
from acute respiratory distress syndrome.
Our objectives were 1) to exam
whether each unit of PRBC transfu
perioperatively conferred increment
increased risk for mortality and m
morbid outcomes in a large homo
Objective: Our objective was to quantify incremental risk asso-
ciated with transfusion of packed red blood cells and other blood
components on morbidity after coronary artery bypass grafting.
Design: The study design was an observational cohort study.
Setting: This investigation took place at a large tertiary care
referral center.
Patients: A total of 11,963 patients who underwent isolated
coronary artery bypass from January 1, 1995, through July 1,
2002.
Interventions: None.
Measurements and Main Results: Among the 11,963 patients
who underwent isolated coronary artery bypass grafting, 5,814
(48.6%) were transfused. Risk-adjusted probability of developing
in-hospital mortality and morbidity as a function of red blood cell
and blood-component transfusion was modeled using logistic
regression. Transfusion of red blood cells was associated with a
risk-adjusted increased risk for every postoperative morbid ev
mortality (odds ratio [OR], 1.77; 95% confidence interval
1.67–1.87; p < .0001), renal failure (OR, 2.06; 95% CI, 1.87–2
p < .0001), prolonged ventilatory support (OR, 1.79; 95%
1.72–1.86; p < .0001), serious infection (OR, 1.76; 95% CI, 1.68–1
p < .0001), cardiac complications (OR, 1.55; 95% CI, 1.47–1
p < .0001), and neurologic events (OR, 1.37; 95% CI, 1.30–1.44;
.0001).
Conclusions: Perioperative red blood cell transfusion is
single factor most reliably associated with increased risk
postoperative morbid events after isolated coronary artery byp
grafting. Each unit of red cells transfused is associated w
incrementally increased risk for adverse outcome. (Crit Care
2006; 34:1608–1616)
KEY WORDS: blood cells; hemoglobin; complications; cardio
monary bypass; cardiovascular disease; mortality
Transfusion of fresh frozen plasma in critically ill surgical patients
is associated with an increased risk of infection
Babak Sarani, MD, FACS; W. Jonathan Dunkman, BA; Laura Dean; Seema Sonnad, PhD;
Jeffrey I. Rohrbach, RN, MSN; Vicente H. Gracias, MD, FACS
Objective: To determine whether there is an association be-
tween transfusion of fresh frozen plasma and infection in criti-
cally ill surgical patients.
Design: Retrospective study.
Setting: A 24-bed surgical intensive care unit in a university
hospital.
Patients: A total of 380 non-trauma patients who received
fresh frozen plasma from 2004 to 2005 were compared with 2,058
nontrauma patients who did not receive fresh frozen plasma.
Interventions: None.
Measurements and Main Results: We calculated the relative
risk of infectious complication for patients receiving and not
receiving fresh frozen plasma. T-test allowed comparison of av-
erage units of fresh frozen plasma transfused to patients with and
associated pneumonia without shock (relative risk 1.97, 1.03–
3.78), bloodstream infection with shock (relative risk 3.35, 1.69–
6.64), and undifferentiated septic shock (relative risk 3.22, 1.84–
5.61). The relative risk for transfusion of fresh frozen plasma and
all infections was 2.99 (2.28–3.93). The t-test revealed a signifi-
cant dose-response relationship between fresh frozen plasma and
infectious complications (p ‫؍‬ .02). Chi-square analysis showed a
significant association between infection and transfusion of fresh
frozen plasma in patients who did not receive concomitant red
blood cell transfusion (p < .01), but this association was not
significant in those who did receive red blood cells in addition to
fresh frozen plasma. The association between fresh frozen
plasma and infectious complications remained significant in the
multivariate model, with an odds ratio of infection per unit of
Allogeneic Blood Transfusion Increases the Risk of
Postoperative Bacterial Infection: A Meta-analysis
Gary E. Hill, MD, William H. Frawley, PhD, Karl E. Griffith, MD, John E. Forestner, MD, and
Joseph P. Minei, MD
Background: Immunosuppression is
a consequence of allogeneic (homologous)
tions that included only the traumatically
injured patient was included in a separate
subgroup of trauma patien
(range, 5.03–5.43), with all stud
The Journal of TRAUMA௡ Injury, Infection, and C

The New England
Journal of Medicine
© Copyright, 1999, by the Massachusetts Medical Society
VOLUME 340 FEBRUARY 11, 1999 NUMBER 6
A MULTICENTER, RANDOMIZED, CONTROLLED CLINICAL TRIAL
OF TRANSFUSION REQUIREMENTS IN CRITICAL CARE
PAUL C. HÉBERT, M.D., GEORGE WELLS, PH.D., MORRIS A. BLAJCHMAN, M.D., JOHN MARSHALL, M.D.,
CLAUDIO MARTIN, M.D., GIUSEPPE PAGLIARELLO, M.D., MARTIN TWEEDDALE, M.D., PH.D., IRWIN SCHWEITZER, M.SC.,
ELIZABETH YETISIR, M.SC., AND THE TRANSFUSION REQUIREMENTS IN CRITICAL CARE INVESTIGATORS
FOR THE CANADIAN CRITICAL CARE TRIALS GROUP*
ABSTRACT
Background To determine whether a restrictive
strategy of red-cell transfusion and a liberal strategy
produced equivalent results in critically ill patients,
we compared the rates of death from all causes at 30
ED-cell transfusions are a cornerstone of
critical care practice,1 but there are diver-
gent views on the risks of anemia and the
benefits of transfusion in this setting. One
important concern is that anemia may not be well
2,3
R
TRICC STUDY

ac-
ical
im-
nly
to
s in
nts
our
nts
dy14
ion
eful
var-
min-
ted
but
or-
disease than with other types of disease had attend-
ing physicians who declined to enroll them in our
study. Nevertheless, we believe that a restrictive strat-
egy can be implemented in patients with coronary
artery disease but should be considered with caution
in patients with acute myocardial infarction and un-
stable angina.
On the basis of our results, we recommend that
critically ill patients receive red-cell transfusions
when their hemoglobin concentrations fall below
7.0 g per deciliter and that hemoglobin concentra-
tions should be maintained between 7.0 and 9.0 g per
deciliter. The diversity of the patients enrolled in this
trial and the consistency of the results suggest that
our conclusions may be generalized to most critical-
ly ill patients, with the possible exception of patients
with active coronary ischemic syndromes.
Supported by the Medical Research Council of Canada and by an unre-
CONCLUSIONI

Blood transfusions carry risks. In a previous meta-
analysis of 45 studies evaluating the risks of blood
transfusion, 42 studies showed a signiﬁcant link to
mortality, infection, or adult respiratory distress
syndrome.3
3 Marik, P. E. and H. L. Corwin (2008). "Efﬁcacy of red blood cell transfusion in the
critically ill: a systematic review of the literature." Crit Care Med 36(9): 2667-74.
New Study Reveals Wide Variation in Blood Transfusion
Practices During Surgery

Blood transfusions carry risks. In a previous meta-
analysis of 45 studies evaluating the risks of blood
transfusion, 42 studies showed a signiﬁcant link to
mortality, infection, or adult respiratory distress
syndrome.3
3. Marik, P. E. and H. L. Corwin (2008). "Efﬁcacy of red blood cell transfusion in the
critically ill: a systematic review of the literature." Crit Care Med 36(9): 2667-74.
COMPLICANZE

Blood transfusions are also one of the largest
cost centers in hospitals. While the material
cost of blood ranges from $200 to $300 per
unit, the additional costs from storage, labor,
and waste result in an actual cost per unit
between $522 and $1,183.10 In addition to the
cost of blood itself, each unit of blood
transfused increases the cost of care, with even
higher costs incurred when patients are
transfused at higher hemoglobin levels.11
10 Shander, A.,A. Hofmann, et al. "Activity-based costs of blood transfusions in surgical
patients at four hospitals." Transfusion 50(4): 753-65.
11 Murphy, G. J., B. C. Reeves, et al. (2007). "Increased mortality, postoperative
morbidity, and cost after red blood cell transfusion in patients having cardiac surgery."
Circulation 116(22): 2544-52.

Blood transfusions are also one of the largest
cost centers in hospitals. While the material
cost of blood ranges from $200 to $300 per
unit, the additional costs from storage, labor,
and waste result in an actual cost per unit
between $522 and $1,183.10 In addition to the
cost of blood itself, each unit of blood
transfused increases the cost of care, with even
higher costs incurred when patients are
transfused at higher hemoglobin levels.11
10 Shander, A.,A. Hofmann, et al. "Activity-based costs of blood transfusions in surgical
patients at four hospitals." Transfusion 50(4): 753-65.
11 Murphy, G. J., B. C. Reeves, et al. (2007). "Increased mortality, postoperative
morbidity, and cost after red blood cell transfusion in patients having cardiac surgery."
Circulation 116(22): 2544-52.
COSTO REALE

variabilita’VOL 26, NO 4 AUGUST 2012
EDITORIAL
Variability in Transfusion Practice and Effectiveness of Strategies to Improve It
MORE THAN 150 YEARS have passed since Professor
William Guy delivered his Croonian Lectures on the
ication of the “numerical method,” more commonly known
statistics,” to the “science and art of medicine” at the Royal
ege of Physicians.1 The debate over whether medicine is
e a science or an art persists to this day. Although the exact
nition of medicine as a science versus an art is open to wide
rpretation,2 the science of medicine can be defined as the
owledge” accumulated over the years and the art of medi-
as the “skill” of the practitioner in applying the knowledge
dexterity in practice. The task of synthesizing up-to-date,
ence-based knowledge and conveying it to the clinicians is
self daunting. Hoping that clinicians adopt the knowledge
apply it effectively in caring for their patients is another
lenge. Indeed, this struggle spans almost every field and
ct of medicine (eg, cardiac surgery, a marvelous and in-
uingly complicated procedure requiring great skills; and the
declined from 2.4% to 1.9%, and the risks of postoperative
stroke, reoperation, and sternal wound infection all decreased
significantly.5 By contrast, the incidences of atrial fibrillation
and renal failure in these patients continued to increase during
the same study period, rising as high as 21.1% and 3.6%,
respectively.5
Cardiac surgeries are among the leading procedures using
allogeneic blood transfusions. In 2008, 7.1% of all units of red
blood cells (RBCs) and 12.1% of all units of platelets were used
in cardiac surgery services across the United States.6 Unfortu-
nately, allogeneic blood transfusions have been proposed as an
independent risk factor contributing to negative outcomes in
many patient populations, including those undergoing CABG
surgery.7-9 As a notable example, Murphy et al10 reviewed the
data of 98% of all adult patients undergoing cardiac surgery
from 1996 to 2003 in the UK and found RBC transfusion to be
T R A N S F U S I O N P R A C T I C E
The ongoing variability in blood transfusion practices in
cardiac surgery
Stephanie A. Snyder-Ramos,† Patrick Möhnle,† Yi-Shin Weng, Bernd W. Böttiger, Alexander Kulier,
daily, before, during, and after surgery until hospital
discharge.
RESULTS: Intraoperative RBC transfusion varied from
9 to 100 percent among the 16 countries, and 25 to
87 percent postoperatively (percentage of transfused
patients). Similarly, frequency of transfusion of FFP
varied from 0 to 98 percent intraoperatively and 3 to
95 percent postoperatively, and PLT transfusion from 0
to 51 and 0 to 39 percent, respectively. Moreover, there
were not only marked differences in transfusion rates
between centers in different countries but also in inter-
institutional comparison of multiple centers within
countries.
CONCLUSION: In cardiac surgical patients, marked
variability in transfusion practice exists between centers
in various countries and suggests differences in periop-
erative practice patterns as well as possible inappropri-
ate use. International standardization of perioperative
practice patterns as well as transfusion regimes
appears necessary.
Hospital for Anesthesiology and Intensive Care M
University of Graz, Graz, Austria; the Department
Medicine, University of California School of Medi
Francisco, California; the Multicenter Study of Per
Ischemia (MCSPI) Research Group, and the Ischem
and Education Foundation, San Bruno, California
Address reprint requests to: Stephanie A. Snyd
MD, c/o Ischemia Research and Education Found
Bayhill Drive, Suite 480, San Bruno, CA 94066; e-m
iref.org.
Supported by a grant from the Ischemia Rese
cation Foundation, San Bruno, CA.
The Ischemia Research and Education Found
vided all funding for execution of the study, collec
data, and analysis and publication of the findings
tion is an independent and not-for-profit entity.
*See Appendix 1 for a complete list of the inv
centers.
†Stephanie A. Snyder-Ramos and Patrick Mö
uted equally to the manuscript and share first aut
Received for publication July 17, 2007; revisio
December 10, 2007, and accepted December 14, 2
doi: 10.1111/j.1537-2995.2008.01666.x
TRANSFUSION 2008;48:1284-1299.
1284 TRANSFUSION Volume 48, July 2008

ORIGINAL CONTRIBUTION
Variation in Use of Blood Transfusion
in Coronary Artery Bypass Graft Surgery
Elliott Bennett-Guerrero, MD
Yue Zhao, PhD
Sean M. O’Brien, PhD
T. B. Ferguson Jr, MD
Eric D. Peterson, MD, MPH
James S. Gammie, MD
Howard K. Song, MD, PhD
Context Perioperative blood transfusions are costly and have safety concerns. As
result, there have been multiple initiatives to reduce transfusion use. However, th
degree to which perioperative transfusion rates vary among hospitals is unknown.
Objective To assess hospital-level variation in use of allogeneic red blood cell (RBC
fresh-frozen plasma, and platelet transfusions in patients undergoing coronary arte
bypass graft (CABG) surgery.
Design, Setting, and Patients An observational cohort of 102 470 patients u
dergoing primary isolated CABG surgery with cardiopulmonary bypass during cale
dar year 2008 at 798 sites in the United States, contributing data to the Society
logeneic red
sfused annu-
Numerous ob-
ents who un-
ave shown an
C transfusion
cluding mor-
ce utilization,
date, no large
fusion thresh-
ed in cardiac
ge to address
the study by
nstrated that was to assess use of RBC, fresh-frozen
plasma, and platelet transfusions in
s
u
Results At hospitals performing at least 100
at 408 sites), the rates of blood transfusion
0% to 97.5% for fresh-frozen plasma, and
able analysis including data from all 798 site
justment for patient-level risk factors, hospit
location (P=.007), academic status (P=.03)
ever, these 3 hospital characteristics combine
in hospital risk-adjusted RBC usage. Case m
tween hospitals in RBC usage.
Conclusion Wide variability occurred in th
blood products, independent of case mix, am
with cardiopulmonary bypass in US hospital
JAMA. 2010;304(14):1568-1575
plasma, and cryoprecipitate transfusions during coronary artery
bypass graft surgery: the Collaborative Hospital Transfusion
Study. Transfusion 1996;36:521–32
16. Stover EP, Siegel LC, Parks R, Levin J, Body SC, Spiess BD, Dambra
MN, Maddi R. Variability in Transfusion Practice for Coronary-Artery
Bypass-Surgery Persists Despite National Consensus Guidelines—a
23-Institution Study. Anesthesiology 1994;81:A1224
17. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C,
Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multi-
center, randomized, controlled clinical trial of transfusion re-
quirements in critical care. Transfusion Requirements in Critical
Care Investigators, Can Critical Care Trials Group [see com-
ments]. N Engl J Med 1999;340:409–17
18. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic
M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon
WC, Proudfit WL. Influence of the internal-mammary-artery
graft on 10-year survival and other cardiac events. N Engl
J Med 1986;314:1–6
19. Burfeind WR Jr, Glower DD, Wechsler AS, Tuttle RH, Shaw LK,
Harrell FE Jr, Rankin JS. Single versus multiple internal mammary
artery grafting for coronary artery bypass: 15-year follow-up of amartedì 14 giugno 16

A recent systematic evaluation of 494
studies concluded that 59% of transfusions
were "inappropriate" based on their impact
on patient outcomes.12
12 Shander, A., A. Fink, et al. (2011). "Appropriateness of allogeneic
red blood cell transfusion: the international consensus conference on
transfusion outcomes." Transfus Med Rev 25(3): 232-246 e53.

A recent systematic evaluation of 494
studies concluded that 59% of transfusions
were "inappropriate" based on their impact
on patient outcomes.12
12 Shander, A., A. Fink, et al. (2011). "Appropriateness of allogeneic
red blood cell transfusion: the international consensus conference on
transfusion outcomes." Transfus Med Rev 25(3): 232-246 e53.
APPROPRIATEZZA

Proceedings from the
National Summit on Overuse
September 24, 2012
Organized by The Joint Commission
and the American Medical Association-
Convened Physician Consortium for
Performance Improvement®
(PCPI®
)
Proceedings from the National Summit on Overuse
Embargoed
until July 8, 2013
Appropriate Blood Management
Chair, Aryeh Shander, M.D., Society for the Advancement
of Blood Management
While blood transfusions can be life-saving, they can also be associated
with risks ranging from worse patient outcomes to death. The evidence of
nagement
recommendations on interventions, practices, and methods aimed at
reducing overuse in these clinical areas.
Introduction
Sometimes overlooked or neglected as a leading contributor to problems
with quality and patient safety, overuse of medical interventions affects
millions of patients.1
Overuse has been described as the provision of
treatments that provide zero or negligible benefit to patients, potentially
exposing them to the risk of harm. While many medical procedures are
associated with tradeoffs between benefits and risks, the risks that are
incurred in instances of overuse are not balanced by benefits to patients.
Five subject areas that have triggered concerns about overuse and quality
were addressed by work groups convened for the summit by The Joint
Commission and the American Medical Association-Convened Physician
Consortium for Performance Improvement®
(PCPI®
):
• Antibiotics are often prescribed to treat viral upper respiratory infections
2.

The timely application of evidence-based
medical and surgical concepts designed
to maintain hemoglobin concentration,
optimize hemostasis and minimize blood
loss in an effort to improve patient
outcome.
SABM’s deﬁnition of Patient
Blood Management (PBM)

ATTENZIONE AL PAZIENTE,
NON
AL PRODOTTO EMATICO

3 PILASTRI DEL PBM
• PREOPERATORIO
• INTRAOPERATORIO
• POSTOPERATORIO
http://www.sabm.org/glossary/patient-blood-management

c
• Identify and manage bleeding risk
(past/family history, current medications,
etc)
• Minimise iatrogenic blood loss
• Procedure planning and rehearsal
• Preoperative autologous blood donation
(in selected cases or when patient
choice)
2nd Pillar
Minimise blood loss and bleeding
• As
re
• Co
pa
• Fo
pl
m
re
• Re
st
3rd
Harn
of a
PREOPERATORIO

Intraoperativetoperative
• Timing surgery with haematological
optimisation
• Meticulous
techniques
• Blood-spar
• Anaestheti
• Autologous
• Pharmaco
• Treat anaemia/iron deficiency
• Stimulate erythropoiesis
• Be aware of drug interactions that can
cause/increase anaemia
• Vigilant mo
post-opera
• Avoid seco
• Rapid warm
(unless hy
• Autologous
• Minimising
ntraindication for
aematological • Meticulous haemostasis and surgical
techniques
• Blood-sparing surgical techniques
• Anaesthetic blood-conserving strategies
• Autologous blood options
• Pharmacological/haemostatic agents
ficiency
sis
actions that can
mia
• Vigilant monitoring and management of
post-operative bleeding
• Avoid secondary haemorrhage
• Rapid warming – maintain normothermia
(unless hypothermia specifically indicated)
• Autologous blood salvage
• Assess/optimise patient’s physiological
reserve and risk factors
• Compare estimated blood loss with
patient-specific tolerable blood loss
• Formulate patient-specific management
plan using appropriate blood-conservation
modalities to minimise blood loss, optimise
red cell mass and manage anaemia
• Restrictive evidence-based transfusion
strategies
• Optimise cardiac output
• Optimise ventilation and oxygenation
strategies
Dow

Postoperative
• Treat anaemia/iron deficiency
• Stimulate erythropoiesis
• Be aware of drug interactions that can
cause/increase anaemia
• Vigilant monitorin
post-operative ble
• Avoid secondary
• Rapid warming –
(unless hypotherm
• Autologous blood
• Minimising iatroge
• Haemostasis/anti
• Prophylaxis of up
haemorrhage
• Avoid/treat infecti
• Be aware of adve
Fig 1 A multimodal approach to PBM (or blood conservation). Adapte
stimulating agents.
red cell mass and manage anaemia
strategies
• Optimise cardiac output
• Optimise ventilation and oxygenation
strategies
• Optimise tolerance of anaemia
• Treat anaemia
• Maximise oxygen delivery
• Minimise oxygen consumption
• Avoid/treat infections promptly
• Restrictive, evidence-based transfusion
strategies
http://bja.oxfordjDownloadedfrom
• Blood-sparing surgical techniques
• Anaesthetic blood-conserving strategies
• Autologous blood options
• Pharmacological/haemostatic agents
eat anaemia/iron deficiency
imulate erythropoiesis
e aware of drug interactions that can
use/increase anaemia
• Vigilant monitoring and management of
post-operative bleeding
• Avoid secondary haemorrhage
• Rapid warming – maintain normothermia
(unless hypothermia specifically indicated)
• Autologous blood salvage
• Minimising iatrogenic blood loss
• Haemostasis/anticoagulation management
• Prophylaxis of upper gastrointestinal
haemorrhage
• Avoid/treat infections promptly
• Be aware of adverse effects of medication
timodal approach to PBM (or blood conservation). Adapted from Hofmann and coll

2° PILASTRO
MINIMIZZARE LE PERDITE DI SANGUE DURANTE O
DOPO L’INTERVENTO CHIRURGICO
PREOPERATORIO:
PIANIFICAZIONE DELLA PROCEDURA
INTRAOPERATORIO:
OPZIONI PER IL SANGUE AUTOLOGO
POSTOPERATORIO:
RECUPERO SANGUE AUTOLOGO

AGENDA
• TECNICA
• INDICAZIONI / CONTROINDICAZIONI
• RISCHI /BENEFICI
• NELLA PRATICA....
A FRESH LOOK AT CELL SALVAGE

LA STORIA
JACK LATHAM nel 1971
fonda HAEMONETICS *
The Blood Management Company
con la convinzione che il sangue
fosse un farmaco che potesse
causare pericolo per il paziente.
Inventa la “BOWL di LATHAM”,
ispirandosi ai separatori del latte.
SEPARARE I COMPONENTI
EMATICI PER MINIMIZZARE IL
RISCHIO DA TRASFUSIONE

IL PARCO MACCHINE
Haemonetics Elite Fresenius Cats
Liva Nova - Xtra
(ex Sorin)
TECNICA

LA TECNICA
• TIPOLOGIE DI DEVICES
• A COSA PUO’ SERVIRE (non solo a recuperare GR!!)
• SOLUZIONI ANTICOAGULANTI
• LA TECNICA OPERATIVA (particolarità)
• LA TECNICA NEI CASI PARTICOLARI

6.1 Fixed Volume Bowl System
Figure 6. Examples of Fixed Volume Bowls*
*Bowls for different machines/processing volumes also exist.
The fixed volume bowl rotates at speeds of up to 6,000rpm, and processes the salvaged
blood in fixed volume batches. As anticoagulated whole blood is pumped into the spinning
bowl, the centrifugal force separates the blood into its components as the bowl fills. As
more blood is pumped into the bowl the RBCs are retained in the bowl while the
supernatant, which is made up of the remaining components plus the anticoagulant, is
expressed through the outlet port and into the waste bag.
When the machine detects an adequate amount of RBCs within the bowl, a wash solution
of IV normal saline (0.9% NaCl) is pumped into the bowl passing through the red cell layer
and displacing most of the remaining non
red cell component into the waste bag.
Excess IV normal saline (0.9% NaCl) is also
expressed through the outlet port and into
the waste bag.
The fixed volume bowl may be available
(Haemonetics) (Sorin) (Medtronic)
Whole blood
Waste
Figure 7. Separation of Red Blood
Cells in a Fixed Volume Bowl
*Bowls for different machines/processing volumes also exist.
The fixed volume bowl rotates at speeds of up to 6,000rpm, and processes the salvaged
blood in fixed volume batches. As anticoagulated whole blood is pumped into the spinning
bowl, the centrifugal force separates the blood into its components as the bowl fills. As
more blood is pumped into the bowl the RBCs are retained in the bowl while the
supernatant, which is made up of the remaining components plus the anticoagulant, is
expressed through the outlet port and into the waste bag.
When the machine detects an adequate amount of RBCs within the bowl, a wash solution
of IV normal saline (0.9% NaCl) is pumped into the bowl passing through the red cell layer
and displacing most of the remaining non
red cell component into the waste bag.
Excess IV normal saline (0.9% NaCl) is also
expressed through the outlet port and into
the waste bag.
The fixed volume bowl may be available
in a range of sizes (depending on the
manufacturer) to suit the anticipated blood
loss. In order to provide a consistent and
high quality end product, fixed volume
bowls require a predetermined volume of
RBCs to be reached within the bowl before
the machine will trip automatically into the
wash stage.
(Haemonetics) (Sorin) (Medtronic)
plasma
Whole blood
Waste
buffy coat
red blood cells
Figure 7. Separation of Red Blood
Cells in a Fixed Volume Bowl- disponibili in diverse “taglie”
in base alla quantità prevista di
sangue perso.
- è necessario un volume minimo
per riempire la campana
ed avere un prodotto ﬁnale
consistente e di buona qualità
CAMPANE AVOLUME FISSOTECNICA

DISCO AVOLUMEVARIABILE6.2 Variable Volume Disk System
Figure 8. Variable Volume Disk System
The variable volume disk (dynamic disk)
system is similar in principle to the fixed
volume bowl in the separation of RBCs
through centrifugation and washing
with IV normal saline (0.9% NaCl).
However, this system has an elastic silicone
diaphragm which permits a variable
volume of RBCs to be processed, i.e. it
does not require a set volume of RBCs for
processing to take place. The elastic
silicone diaphragm changes shape and size
during processing so that the machine
delivers an end product of variable volume
with a fixed haematocrit (Hct). The variable
volume disk system will process 100ml of
reservoir contents at a time. If the volume
of RBCs being drawn into the disk from the
reservoir is under 15mls, the system will
concentrate several batches of blood
before washing. This system is therefore
more advantageous for procedures where
lower volume blood losses occur or during
long procedures where the blood loss is
constant and slow.
(Haemonetics)
CAUTION
remove the safety benefits and will affect the consistent, high
quality end product offered by the automatic mode.
- diaframma elastico in silicone
- non richiede volume
prefissato di sangue per essere
riempita
- prodotto finale di volume
variabile con Ht fisso
PIU’ USATO PER IL RECUPERO
POSTOPERATORIO
TECNICA

SISTEMA ROTATORIO CONTINUO - FRESENIUS
6.3 Continuous Rotary System
Figure 9. Continuous Rotary System
The continuous rotary system works by continuously removing the supernatant and
concentrating and washing the RBCs. It requires only a very small volume of blood loss
to process, however, this does not automatically mean processing should progress.
The decision to process should always be made on an individual patient basis.
6.4 Stages of the Process
Opposite (Figure 10) is a description of each of the four main processing stages of the ICS
process. The fixed and variable volume systems follow a pattern similar to that described
below. In the continuous rotary system, washing, separation and reinfusion take place
(Fresenius)
Saline
(wash solution)
Anti-coagulated blood
in collection reservoir
Red blood cells
Rotating wash
chamber
Waste
- richiede volumi molto piccoli di sangue perso.
- separazione, lavaggio e reinfusione avvengono
contemporaneamente.
TECNICA

SEPARATORE CELLULARE
• ➤ RECUPERARE I GLOBULI ROSSI
• ➤ PLASMAFERESI PRE-OP.
➤ da SANGUE INTERO SEPARA GR (da reinfondere subito)
da PLASMA E PIASTRINE (da reinfondere dopo)
• ➤ GEL PIASTRINICO
da SACCA DI SANGUE INTERO SEPARA PPP, PRP, GR
da PRP +Trombina + Calcio = Gel Piastrinico
TECNICA
A cosa può servire:

Figure 3. The Coagulation Cascade
(Adapted from the American Association for Clinical Chemistry1
)
Surface Contact
XII XIIa
VIIa VII
XI XIa
X Xa. V
Phospholipid/Calcium
II IIa
Fibrinogen
Heparin Heparin
Fibrin Clot
FXIII
(Stabilises Clot)
IXa. VIII
Phospholipid/Calcium
IX
Heparin is an
antithrombin agent
and works by
inactivating thrombin,
preventing
conversion of
fibrinogen to fibrin
Citrate is a calcium
chelating agent and
works by binding free
calcium in the blood
preventing the
activation of clotting
factors
Initiated by
Intrinsic
Pathway
Extrinsic
Pathway
Measured
by the APTT
Measured
by the PT
Tissue Damage
EPARINA:
è un agente
antitrombinico
CITRATO:
è un agente chelante
del calcio
SOLUZIONI
ANTICOAGULANTI
CASCATA COAGULATIVA
oppure

www.vetla
PROTEINA C
PROTEINA S
LA CASCATA COAGULATIVA
VIA INTRINSECA
VIA ESTRINSECA
Superficie negativa
XII
HMWK
PK
XIIa
XI XIa
IX IXaCa
X
Xa
X
Ca
VIIIa
Fosfolipidi
Ca
Va
Fosfolipidi
II IIa (Trombina)
VIIa VIICa
Fattore III o
Fattore Tissutale o
Tromboplastina Tissutale
VIA COMUNE
Fibrinogeno FIBRINA
Ca
XIIIa
Attivazione del
Fattore indicato
IMPORTANZA DEL CALCIO
Ca

ANTICOAGULANTE
• EPARINA
- 30.000 UI/L soluzione ﬁsiologica.
- 60/80 gocce /min.
- Agisce attivando ANTITROMBINA III
anticoagulated before it enters the collection reservoir. If the rate of flow of the
anticoagulant is insufficient, the salvaged blood will clot. This may result in contamination
of the processed blood and/or may prevent processing. Types of anticoagulant used are:
• Heparin saline:
– 30,000iu heparin/1,000ml intravenous (IV) normal saline (0.9% NaCl)
– Heparin works by activating Antithrombin III which in turn inactivates both Factor
Xa and Factor IIa (Thrombin) in the coagulation cascade (Figure 11). This prevents
the conversion of Fibrinogen to Fibrin and the formation of clots.
– The recommended ratio is approximately 1:5 e.g. 20ml of anticoagulant to 100ml
of blood (check your machine manufacturer recommendations)
Figure 11. Heparin Mechanism of Action
Factor X Factor Xa
Factor II
(Prothrombin)
Factor IIa
(Thrombin)
Active
Antithrombin III Heparin
Inactive
Antithrombin III
Fibrinogen Fibrin
X
X

• ACD-A (CITRATO)
- soluzione pronta
- rapporto raccomandato 1:7 =
15ml. / 100 ml sangue ( 45-60 gocce / min. )
- agisce legando il calcio nel sangue
(importante cofattore nella cascata coagulativa)
It is advisable to increase the wash volume for procedures
CAUTION
Most systems have a minimum wash volume recommended by
the manufacturer. It is not advisable to decrease the wash
volume below this level.
attenzione all’uso di soluzioni contenenti
calcio
(Hartmann’s - Ringer),
può inibire l’effetto del citrato.
ANTICOAGULANTE
RACCOMANDATO IN PAZ. CON HIT

MAYO CLINIC
ROCHESTER - MINNESOTA
• Soluzione ACD-A 500 ml. + 9000 UI Eparina
(da letteratura e conferma tramite comunicazione personale)

ATTENZIONE
• EPARINA non dovrebbe essere usata in pazienti con carenza
di ATIII o pazienti con HIT
(Trombocitopenia Heparino-Indotta)
• Non usare ACD-A nei pazienti con funzionalità epatica
compromessa
• Non aspirare sangue mescolato a Ringer Lattato come
soluzione irrigante, quando si usa ACD come soluz.
anticoagulante

Key Points
• ICS has four key processing stages:
– Collection
– Separation
– Washing
where there is a high risk of contamination of salvaged
blood, e.g. obstetrics and orthopaedics. See Section 9 for
further details.
ICS can reduce and sometimes eliminate the need to
transfuse allogeneic (donor) RBCs. In cases where large
blood loss occurs, patients receiving ICS may still become
depleted of clotting factors and platelets. In such cases
transfusion of allogeneic (donor) components such as fresh
frozen plasma (FFP), platelets or cryoprecipitate may be
required.
CAUTION
punta dell’aspiratore: dovrebbe avere un
diametro grande (4mm.) per minimizzare il
danno da suzione
further details.
ICS can reduce and sometimes eliminate the need to
transfuse allogeneic (donor) RBCs. In cases where large
blood loss occurs, patients receiving ICS may still become
depleted of clotting factors and platelets. In such cases
transfusion of allogeneic (donor) components such as fresh
frozen plasma (FFP), platelets or cryoprecipitate may be
required.
CAUTION
vacuum : causa emolisi!
dovrebbe essere mantenuto a livelli più bassi
possibile. (< -150 mm.Hg )
further details.
CAUTION
testimoni di Jehovah: la preparazione del set
è particolare e dovrebbe essere discussa prima
LA TECNICA - INDICAZIONI

TECNICA DI ASPIRAZIONE
• EVITARE di aspirare aria insieme al sangue.
(i.e. when the suction tip is immersed in a pool of blood), even high vacuum levels do not
result in excessive RBC haemolysis. This supports increasing vacuum levels during excessive
bleeding.
However, when blood and air are aspirated, as occurs naturally during most of the ICS
process, even low vacuum levels result in excessive haemolysis and therefore reduces the
available RBCs for reinfusion.
Graph 1. Changes in Plasma Haemoglobin from Baseline Measurements1
0
100
200
300
400
500
600
Blood only
Blood and air
mg/dl
Vacuum (mmHg)
150
18
248
27
208
38
250
40
478
200 250 300
Hb plasmatica

Modiﬁcation of Suction-Induced Hemolysis During
Cell Salvage
Jonathan H. Waters, MD*
Brandon Williams, BS†
Mark H. Yazer, MD, FRCPC‡§
Marina V. Kameneva, PhD†ʈ
BACKGROUND: The efficiency of red blood cell collection during cell salvag
dictated by multiple variables, including suction pressure. In this study
attempted to determine the influence of suction pressure on the efficiency o
salvage and to identify methods for minimizing the impact of suction on salv
blood.
METHODS: Whole blood was placed in 60-mL aliquots either in a beaker or on
surface and suctioned at 100 and 300 mm Hg. The amount of hemolysis
measured and compared under the varying conditions. The experiments
repeated with the blood diluted with normal saline solution in a 1:1 mix.
RESULTS: Hemolysis ranged from 0.21% to 2.29%. Hemolysis was greatest w
whole blood was suctioned from a flat surface at 300 mm Hg. It was reduced w
the blood was diluted with saline. Blood suctioned from a surgical field during
salvage should be done with minimal suction pressures and with the go
minimizing blood–air interfaces.
CONCLUSIONS: Significant reduction of blood damage can be obtained by dilu
blood with normal saline while suctioning it from the surgical field. Alth
immediate hemolysis due to suctioning was not very high, the red blood
damage from suctioning produced by a dynamic blood–air interface m
adversely affect the efficiency of cell salvage.
(Anesth Analg 2007;104:684–7)
There are many benefits of autologous blood conser-
vation, including reduction of demands for allogeneic
blood (1), avoiding the costs of blood products, avoid-
ing the immunosuppressive effects of allogeneic trans-
fusion (2), reduced incidence of transfusion-related
which is mostly due to air bubbles mixing with
blood in the suction cannulae and the tubing conn
ing the surgical site with the salvage device. Th
aspirated with blood during suctioning produces
moving bubbles, which expand and collide in
Modiﬁcation of Suction-Induced Hemolysis Du
Cell Salvage
Jonathan H. Waters, MD*
Brandon Williams, BS†
Mark H. Yazer, MD, FRCPC‡§
Marina V. Kameneva, PhD†ʈ
BACKGROUND: The efficiency of red blood cell collectio
dictated by multiple variables, including suction pre
attempted to determine the influence of suction pressur
salvage and to identify methods for minimizing the impa
blood.
METHODS: Whole blood was placed in 60-mL aliquots eith
surface and suctioned at 100 and 300 mm Hg. The a
measured and compared under the varying condition
repeated with the blood diluted with normal saline solu
RESULTS: Hemolysis ranged from 0.21% to 2.29%. Hemo
whole blood was suctioned from a flat surface at 300 mm
the blood was diluted with saline. Blood suctioned from a
salvage should be done with minimal suction pressur
CONCLUSIONS: Significant reduction of blood damage can
blood with normal saline while suctioning it from the
immediate hemolysis due to suctioning was not very
damage from suctioning produced by a dynamic b
(Anesth Analg 2007;104:684–7)
D*
†
§
†ʈ
BACKGROUND: The efficiency of red blood cell collection during cell salvage is
dictated by multiple variables, including suction pressure. In this study, we
attempted to determine the influence of suction pressure on the efficiency of cell
salvage and to identify methods for minimizing the impact of suction on salvaged
blood.
METHODS: Whole blood was placed in 60-mL aliquots either in a beaker or on a flat
surface and suctioned at 100 and 300 mm Hg. The amount of hemolysis was
measured and compared under the varying conditions. The experiments were
repeated with the blood diluted with normal saline solution in a 1:1 mix.
RESULTS: Hemolysis ranged from 0.21% to 2.29%. Hemolysis was greatest when
whole blood was suctioned from a flat surface at 300 mm Hg. It was reduced when
the blood was diluted with saline. Blood suctioned from a surgical field during cell
salvage should be done with minimal suction pressures and with the goal of
CONCLUSIONS: Significant reduction of blood damage can be obtained by diluting
blood with normal saline while suctioning it from the surgical field. Although
immediate hemolysis due to suctioning was not very high, the red blood cell
damage from suctioning produced by a dynamic blood–air interface might
(Anesth Analg 2007;104:684–7)
ogous blood conser-
mands for allogeneic
ood products, avoid-
which is mostly due to air bubbles mixing with the
blood in the suction cannulae and the tubing connect-
ing the surgical site with the salvage device. The air
aspirated with blood during suctioning produces fast-
SIGNIFICATIVA RIDUZIONE DEL DANNO SE SI
AGGIUNGE SOL. FISIOLOGICA AL SANGUE DA
ASPIRARE DAL CAMPO OPERATORIO
NO ARIA CON IL SANGUE!

PER MASSIMIZZARE IL
RECUPERO
• “LAVAGGIO” DELLE GARZE
• “LAVAGGIO” DELL’ OSSIGENATORE (se
viene recuperato il sangue della CEC) o
CARDIOTOMO di raccolta.
• BASSI LIVELLI DI VACUUM
(per evitare l’emolisi)
• TECNICA DI ASPIRAZIONE (evitare aria)
ICSTechnicalFactsheet
SWAB WASHING
AREA of APPLICATION
STAFF
Theatre staff
PROCEDURE:
The efficiency of red cell recovery by cell salvage is very much dependent
on the ability to recover the blood lost in a useable form. During surgery,
blood loss can be removed from the operative site by a combination of
suction and swabs. Blood loss to swabs during surgery has been estimated
at between 30%1
and 50%2
of the total surgical blood loss. By washing
swabs, the blood that is normally discarded can be collected and the overall
efficiency of red cell recovery improved.3
SWAB WASHING
AREA of APPLICATION
STAFF
Theatre staff
The efficiency of red cell recovery by cell salvage is v
on the ability to recover the blood lost in a useable f
blood loss can be removed from the operative site
suction and swabs. Blood loss to swabs during surger
at between 30%1
and 50%2
of the total surgical blo
swabs, the blood that is normally discarded can be col
efficiency of red cell recovery improved.3

REVIEW ARTICLES
Cell salvage as part of a blood conservation strategy
in anaesthesia
A. Ashworth and A. A. Klein*
Department of Anaesthesia and Critical Care, Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK
* Corresponding author. E-mail: andrew.klein@papworth.nhs.uk
Key points
† Cell salvage reduces the
requirement for allogenic
blood transfusion.
† It should be considered
for surgery with an
anticipated blood loss of
.1000 ml.
† It can be used in cancer
surgery, but a leucocyte
depletion ﬁlter is
recommended.
Summary. The use of intraoperative cell salvage and autologous blood transfusion has
become an important method of blood conservation. The main aim of autologous
transfusion is to reduce the need for allogeneic blood transfusion and its associated
complications. Allogeneic blood transfusion has been associated with increased risk of
tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial
infarction, postoperative low-output cardiac failure, and increased mortality. We have
reviewed the current evidence for cell salvage in modern surgical practice and examined
the controversial issues, such as the use of cell salvage in obstetrics, and in patients with
malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to
be safe and effective at reducing allogeneic blood transfusion requirements in adult
elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged 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. Cell salvage should be considered in
British Journal of Anaesthesia 105 (4): 401–16 (2010)
Advance Access publication 28 August 2010 . doi:10.1093/bja/aeq244
ASAIO Journal 2013
Intraoperative Blood Recovery
JONATHAN H. WATERS
INDICAZIONI /CONTROINDICAZIONI

REVIEW ARTICLES
Cell salvage as part of a blood conservation strategy
in anaesthesia
A. Ashworth and A. A. Klein*
Department of Anaesthesia and Critical Care, Papworth Hospital, Papworth Everard, Cambridge CB23 3RE, UK
* Corresponding author. E-mail: andrew.klein@papworth.nhs.uk
Key points
† Cell salvage reduces the
requirement for allogenic
blood transfusion.
† It should be considered
for surgery with an
anticipated blood loss of
.1000 ml.
† It can be used in cancer
surgery, but a leucocyte
depletion ﬁlter is
recommended.
Summary. The use of intraoperative cell salvage and autologous blood transfusion has
become an important method of blood conservation. The main aim of autologous
transfusion is to reduce the need for allogeneic blood transfusion and its associated
complications. Allogeneic blood transfusion has been associated with increased risk of
tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial
infarction, postoperative low-output cardiac failure, and increased mortality. We have
reviewed the current evidence for cell salvage in modern surgical practice and examined
the controversial issues, such as the use of cell salvage in obstetrics, and in patients with
malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to
be safe and effective at reducing allogeneic blood transfusion requirements in adult
elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged 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. Cell salvage should be considered in
Advance Access publication 28 August 2010 . doi:10.1093/bja/aeq244
ASAIO Journal 2013
Intraoperative Blood Recovery
JONATHAN H. WATERS
INDICAZIONI /CONTROINDICAZIONI
tdOxford, UKTRFTransfusion0041-11322004 American Association of Blood BanksDecember 200444Supplement40S44SOriginal ArticleCELL SALVAGE INDICATIONS AND CONTRAINDICATIONSWATERS
Indications and contraindications of cell salvage
Jonathan H. Waters
ultiple strategies can be applied to avoid
allogeneic transfusion. The primary meth-
ods involve erythropoietin and iron supple-
mentation, preoperative autologousM
cardiotomy reservoir, a suction line, and an anticoagula
This collection or “stand-by” setup costs comparably
the reagent costs for typing and crossing 2 units. Thou
a major paradigm shift, hospitals should consider imp
40S TRANSFUSION Volume 44, December 2004 Supplement
ABBREVIATION: CS = cell salvage.
From the Department of General Anesthesiology and Clinical
Pathology, Cleveland Clinic Foundation, Cleveland, Ohio.
Address reprint requests to: Jonathan H. Waters, MD,
Department of General Anesthesiology, Cleveland Clinic
Foundation, 9500 Euclid Avenue, E31, Cleveland, OH 44195;
e-mail: watersj@ccf.org.
TRANSFUSION 2004;44:40S-44S.
blood loss are anticipated.
Accurately predicting the probability of sizable blood
loss and need for allogeneic transfusion is difﬁcult.
Because of this lack of predictability, implementation of
CS should start with a collection system which includes a
light of the
therapy, whic
Relative
range of mat
blood produ
readministra
include anyt
include steri
blood is wash
tion is aspira
will result in
taminants, ly
adequately w
into the CS s
adequate wa
and failure,

plasma, and cryoprecipitate. Anticipate coagulation factor
deficiency after more than 2 litres blood loss with continued bleed-
ing and repeat full blood count, prothrombin time, and activated
partial thromboplastin time and fibrinogen levels after the reinfu-
sion of each litre of salvaged blood in order to detect and appropri-
ately treat coagulapathy (Table 1).
General indications for cell salvage
(i) Anticipated intraoperative blood loss .1 litre or .20% of
blood volume.
(ii) Preoperative anaemia or increased risk factors for bleeding.
(iii) Patients with rare blood group or antibodies.
(iv) Patient refusal to receive allogeneic blood transfusion.
(v) The American Association of Blood Banks suggest cell
salvage is indicated in surgery where blood would ordinarily
be cross-matched or where more than 10% of patients under-
going the procedure require transfusion.
allo
fixe
requ
pro
was
cran
plas
Sp
Cel
enc
ord
in p
pro
afte
Hom
safe
Perioperative cell salvage
Lakshminarasimhan Kuppurao MD DA DNB FRCA
Michael Wee BSc (Hons) MBChB FRCA
The National Blood Service for England col-
lects, tests, processes, stores, and issues 2.1
million blood donations each year, and the
optimal use of this scarce resource is of para-
mount importance. Allogeneic red blood cell
(RBC) transfusion is associated with well-
known adverse effects. These include febrile,
anaphylactic, and haemolytic transfusion reac-
Key points
Complications of allogeneic
transfusion are rare but can
be life threatening.
There is a drive to reduce
allogeneic blood transfusion
due to cost and scarcity.
Cell salvage should be used
e cell salvage
purao MD DA DNB FRCA
s) MBChB FRCA
The National Blood Service for England col-
lects, tests, processes, stores, and issues 2.1
million blood donations each year, and the
optimal use of this scarce resource is of para-
mount importance. Allogeneic red blood cell
(RBC) transfusion is associated with well-
known adverse effects. These include febrile,
anaphylactic, and haemolytic transfusion reac-
tions, transfusion-related acute lung injury, and
transfusion-associated circulatory overload. In
addition, although rare, there are infection risks
of viral, bacterial, parasitic, or prion trans-
mission. In the laboratory setting, allogeneic
involves filtering and washing to remove con-
taminants. Red cells are retained, while the
plasma, platelets, heparin, free haemoglobin,
and inflammatory mediators are discarded with
the wash solution. This process may be discon-
tinuous or continuous, and the resulting red
cells are finally resuspended in normal saline at
a haematocrit of 50–70%, and reinfused into
the patient. Once primed, the cell salvage
machine should be used within 8 h to prevent
infective complications.
Benefits of cell salvage
Matrix reference 1A06
evolved since its inception in the 1960s.
Initially, cell salvage was limited to simply fil-
tering blood loss during surgery by gravity.
More modern devices collect blood to which is
added heparinized normal saline or citrate
anticoagulant. Processing the collected blood
activation of intravascular coagulation
increased capillary permeability causing
lung injury and renal failure. This syndr
related to the dilution of salvaged blood
large quantities of saline solution,
creates deposits of cellular aggregates
doi:10.1093/bjaceaccp/mkq017 Advance Access publication 26 M
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 10 Number 4 2010
& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

INDICAZIONI
E SELEZIONE DEL PAZIENTE
• PAZIENTI ADULTI E PEDIATRICI SOTTOPOSTI A CHIRURGIA
ELETTIVA O D’EMERGENZA DOVE LE PERDITE EMATICHE SONO
STIMATE ESSERE >20%VOLEMIA O > di 1 L.
• PAZIENTI CON GRUPPI RARI O ANTICORPI MULTIPLI, PER CUI SIA
DIFFICILE AVERE SANGUE ALLOGENICO
• PAZIENTI CON ANEMIA PREOPERATORIA O AUMENTATO RISCHIO
DI SANGUINAMENTO
• PAZIENTI CHE RIFIUTANO SANGUE ALLOGENICO
• AABB suggerisce che il CS è indicato nelle chirurgie dove più del 10% dei
pazienti sottoposti a quel tipo di chirurgia richiede una trasfusione o più di
una unità di sangue.

Clinical Education Series: Cell Saver®5/5+
Complications of and Contraindications to
Perioperative Autotransfusion
AABB Guidelines for Blood Recovery and Reinfusion in
Surgery and Trauma
Many contraindications are relative and the risk/benefit factor must be
determined for each patient. The decision to use peri operative
autotransfusion is the responsibility of the surgeon in charge.
Refer to Table 2 for specific substances and their effects.
Table 2: Complications of and Contraindications to Perioperative Blood Recovery*
Substance Effects Recommended Action
Pharmacologic Agents
A. Clotting Agents
1. Microfibrillar Products May cause platelet aggregation Avoid aspiration when product is bein
Examples: and clot formation. used.
Avltene", Helitene® Reported to pass through a Resumption is an option after copious
Oxycel", microaggregate filter into the blood irrigation with 0.9% sodium chloride
Gelfoarn'" Powder, tnstat" stream, causing emboli. solution to an alternate suction sourc
MCH
Molte controindicazioni sono relative e il fattore rischio/
beneﬁcio deve essere determinato per ciascun paziente.
La decisione di usare l’autotrasfusione peri
operatoria è responsabilità del chirurgo che
ha in cura il paziente.

CONTROINDICAZIONI
RELATIVE PIUTTOSTO CHE ASSOLUTE
pochi dati supportano il danno delle controindicazioni proposte
Many contraindications to blood salvage are not as defini-
tive as those just described. This would include blood aspi-
rated from contaminated or septic wounds, obstetrics, and
malignancy.
The impact of blood salvage processing on blood that has
been bacterially contaminated was first investigated by Bou-
dreaux,21
who inoculated expired units of blood with bacteria
and found that washing was capable of reducing contamina-
tion to 5–23% of the starting contamination. In a similar study,
Waters et al.22
found an approximately 99% reduction in
be attractive26,27
When applying blood salv
peripartum period, shed blood can be con
bacteria, amniotic fluid, and fetal blood. Am
tamination is feared because of the theoreti
create an iatrogenic amniotic fluid embolus
amniotic fluid embolus rarely occurs (1:8000–
eries), making definitive study impossible. T
to look at surrogate markers, which might be
the syndrome. Waters et al.28
demonstrated
depletion filters along with cell washing w
squamous cells to an extent comparable to
tion of these cells in a maternal blood sampl
separation. From this study it was conclude
bination of blood salvage washing and filt
a blood product comparable to circulating
with the exception of the fetal hemoglobin
Support for the use of blood salvage in obste
now encompasses 390 reported cases where
nated with amniotic fluid has been washed
tered without filtration.29–31
Malignancy
The last area of controversy is blood salvag
gery. Administration of tumor-laden blood from
would also seem to be contradictory to a go
come; however, during tumor surgery, hem
semination of cancer cells is common.32–34
In
demonstrated that a high percentage of patien
cancer surgery have circulating tumor cells b
Table 4. Proposed Contraindications to Blood Salvage
Pharmacologic agents
Clotting agents (avitene, surgicel, gelfoam, etc.)
Irrigating solutions (betadine, antibiotics meant for topical use)
Methylmethacrylate
Contaminants
Urine
Bone chips
Fat
Bowel contents
Infection
Amniotic fluid
Methylmethacrylate
Hematologic disorders
Sickle cell disease
Thallassemia
Miscellaneous
Carbon monoxide (electrocautery smoke)
Catecholamines (pheochromocytoma)
Oxymetazoline (afrin)
Quando si decide di non usare CS
bisogna farlo alla luce dei rischi
conosciuti dati dall’alternativa:
il sangue allogenico

INDICAZIONI CONTROVERSE
• OSTETRICIA
• CHIRURGIA
TUMORALE
• CONTAMINAZIONE
BATTERICA
ons to blood salvage is extensive
ontraindications are relative rather
s that little data exist to support the
ontraindications. When a decision
ood salvage, it needs to be consid-
isks associated with the alternative
c blood.
ns to blood salvage encompass a
t, if incorporated into the salvaged
tially injure the patient upon read-
raindications would include any-
ll lysis. This would include sterile
nd alcohol. If blood is washed with
nic solution is aspirated into a col-
result in red cell hemolysis. In the
ants, lysed cells will be washed out
washed but it is best to avoid incor-
vage system. If the blood is admin-
washing, it could result in renal
ecreases in hematocrit, elevations
nase level, increases in total serum
sseminated intravascular coagula-
.19,20
o blood salvage are not as defini-
d. This would include blood aspi-
or septic wounds, obstetrics, and
vage processing on blood that has
ated was first investigated by Bou-
important.
It is important to keep in mind that during the course of
most operations, a bacteremia is present related to the surgical
trauma. Broad-spectrum antibiotics are routinely used to man-
age this routine bacteremia. Several studies have suggested
that these drugs add additional safety when contaminated sal-
vaged blood is readministered.23,24
Dzik and Sherburne,25
in a review of the controversies sur-
rounding blood salvage, pointed out that allogeneic transfu-
sion leads to an increase in infection rate and that when faced
with bacterial contamination of salvaged blood, a clinical
decision needs to be made as to which therapy offers the
least risk to the patient. Known risk exists with allogeneic
blood, yet only theoretical risk is associated with salvaged
blood. Until data is generated supporting the theoretical risk
of salvaged in these circumstances, it seems reasonable to
avoid the known risk of allogeneic blood through the use of
blood salvage.
Obstetrics
One of the leading causes of death during childbirth is
hemorrhage, so the use of blood salvage would naturally
be attractive26,27
When applying blood salvage during the
peripartum period, shed blood can be contaminated with
bacteria, amniotic fluid, and fetal blood. Amniotic fluid con-
tamination is feared because of the theoretical potential to
create an iatrogenic amniotic fluid embolus. Unfortunately,
amniotic fluid embolus rarely occurs (1:8000–1:30,000 deliv-
RISCHI CONOSCIUTI
SANGUE ALLOGENICO
VS RISCHI TEORICI
CS !!

CONTROINDICAZIONI RELATIVE
• QUALSIASI COSA CHE PROVOCHI LA LISI CELLULARE
(betadine , acqua ossigenata, alcol, soluz. ipertoniche o ipotoniche -
Ringer Lattato usato come irrigante quando viene usato ACD)
• SITO INFETTO - antibiotici appropriati
• SECREZIONI GASTRICHE O PANCREATICHE
• VERSAMENTI PLEURICI
• COLLE - AGENTI EMOSTATICI
• OSTETRICIA
• CHIRURGIA TUMORALE
• ANEMIA FALCIFORME (scelta individuale - consulto ematologo)

AZIONI CORRETTIVE
• EVITARE L’ASPIRAZIONE DIRETTA (sito infetto, liquido
amniotico, disinfettante, colla, grasso.....)
• IRRIGARE IL SITO CHIRURGICO CON ABBONDANTE
SOL. FISIOLOGICA e riprendere l’uso
• LAVAGGIO EMAZIE MIGLIORATO
• FILTRO DELEUCOCIZZANTE (chir. tumorale e ostetricia)

INDICAZIONI CONTROVERSE
•OSTETRICIA
•CHIRURGIA ONCOLOGICA

USO CS IN OSTETRICIA
APPROVATO DA:
- CMACE (Center for Maternal and Child Enquiries)
- OAA (Obstetrics Anesthetists’ Association)
- AAGBI (The Association of Anesthetists of G.B. & Ireland)
- NICE (National Institute of Clinical Excellence)
Intraoperative blood cell salvage in obstetrics
Issue date: November 2005
Information about NICE Interventional
Procedure Guidance 144
in obstetrics
Understanding NICE guidance –
information for people considering
the procedure, and for the public

OSTETRICIA
• FILTRO DELEUCOCIZZANTE
Anesthesiology
2000; 92:1531–6
© 2000 American Society of Anesthesiologists, Inc.
Lippincott Williams & Wilkins, Inc.
Amniotic Fluid Removal during Cell Salvage in the
Cesarean Section Patient
Jonathan H. Waters M.D.,* Charles Biscotti, M.D.,† Paul S. Potter M.D.,‡ Eliot Phillipson M.D.§
Background: Cell salvage has been used in obstetrics to a
limited degree because of a fear of amniotic fluid embolism. In
this study, cell salvage was combined with blood filtration using
a leukocyte depletion filter. A comparison of this washed, fil-
tered product was then made with maternal central venous
blood.
Methods: The squamous cell concentration, lamellar body
count, quantitative bacterial colonization, potassium level, and
fetal hemoglobin concentration were measured in four sequen-
tial blood samples collected from 15 women undergoing elec-
tive cesarean section. The blood samples collected included (1)
unwashed blood from the surgical field (prewash), (2) washed
blood (postwash), (3) washed and filtered blood (postfiltra-
tion), and (4) maternal central venous blood drawn from a
P < 0.01). No significant differences existed between the post-
filtration and maternal samples for each of these parameters.
Fetal hemoglobin was in higher concentrations in the postfil-
tration sample when compared with maternal blood (1.9 [1.1–
2.5] vs. 0.5% [0.3–0.7] ). Potassium levels were significantly less
in the postfiltration sample when compared with maternal (1.4
[1.0–1.5] vs. 3.8 mEq/l [3.7–4.0]).
Conclusions: Leukocyte depletion filtering of cell-salvaged
blood obtained from cesarean section significantly reduces par-
ticulate contaminants to a concentration equivalent to maternal
venous blood. (Key words: Autologous blood; autotransfusion;
embolism; obstetrics.)
CELL-SALVAGE technology has been applied in numer-
1531
ring Cell Salvage in the
S. Potter M.D.,‡ Eliot Phillipson M.D.§
a
In
ng
fil-
us
dy
nd
n-
ec-
1)
ed
ra-
a
rs
P < 0.01). No significant differences existed between the post-
filtration and maternal samples for each of these parameters.
Fetal hemoglobin was in higher concentrations in the postfil-
tration sample when compared with maternal blood (1.9 [1.1–
2.5] vs. 0.5% [0.3–0.7] ). Potassium levels were significantly less
in the postfiltration sample when compared with maternal (1.4
[1.0–1.5] vs. 3.8 mEq/l [3.7–4.0]).
Conclusions: Leukocyte depletion filtering of cell-salvaged
blood obtained from cesarean section significantly reduces par-
ticulate contaminants to a concentration equivalent to maternal
venous blood. (Key words: Autologous blood; autotransfusion;
embolism; obstetrics.)
CELL-SALVAGE technology has been applied in numer-
ous different clinical situations; however, it has not beenmartedì 14 giugno 16

lnrerno~ronal Journal o/ Obsretrrc Anes/hesu (1999) 8.79 84
0 1999 Harcourt Brace&Co. Ltd
ORIGINAL ARTICLE
Cell salvage in obstetrics: an evaluation of the ability of cell
salvage combined with leucocyte depletion filtration to remove
amniotic fluid from operative blood loss at caesarean section
S.J.Catling, S.Williams, A. M. Fielding*
Department ofAnaesthetics, Singleton Hospital and *Morriston Hospital, Swansea, Wales
SUMMARY: During 27 elective caesarean sections, operative blood loss was collected and processed using the
Haemonetics Cell Saver 5 and filtered by Pall RC 100 leucocyte depletion filtration. The efficiency of removal of
amniotic fluid, and the degree.of contamination with fetal red cells were assessedin the resulting ‘cleaned’ blood.
Cell saver processing effectively removed a-fetoprotein from the red cells of 14 patients whose amniotic fluid was
removed by separate suction and from nine of the 13 patients whose amniotic fluid was aspirated into the cell
saver along with operative blood loss. Cell saver processing and leucocyte depletion filtration completely removed
trophoblastic tissue and white cells, but fetal squames were still clearly present in 10, and possibly in 14 samples
after processing and fully removed in only two specimens. Amorphous debris was present in all samples after
processing. The maximum mass of fetal red cells contaminating any patient’s total salvaged blood was 19 ml
(range 2-19 ml). Had this been re-transfused into a rhesus-incompatible mother it would have required 2500 i.u.
(500 pg) anti-D immunoglobulin to prevent rhesus-immunization of the mother. Contamination of processed
caesarean section blood with fetal red cells and fetal squames is defined and its clinical implications discussed,
with an overview of the development and current status of cell salvage. Autotransfusion by cell salvage with
leucocyte depletion filtration should be considered in life-threatening obstetric haemorrhage and offered to
Jehovah’s Witnesses.
fetal red cells during elective Caesarean section
I. Sullivan1*, J. Faulds2 and C. Ralph2
1
Department of Haematology and 2
Department of Anaesthesia, Royal Cornwall Hospital Trust,
Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, UK
*Corresponding author. E-mail: ian.sullivan@rcht.cornwall.nhs.uk
Background. Cell salvage in obstetrics is still a controversial subject and has yet to be fully
embraced. The aim of this exploratory study was to measure amniotic fluid (AF), heparin,
and fetal red cell contamination of washed filtered salvaged maternal blood and to investigate
differences based on the number of suction devices used.
Methods. Patients undergoing elective Caesarean section were assigned alternately to one of
two groups. In Group 1, all blood and AF was collected with one suction. In Group 2, AF was
aspirated to waste with a second separate suction device before collection of any blood.
Results. In both groups, alpha-fetoprotein (AFP), squames cells, and heparin were significantly
reduced (P,0.001) by the washing and filtering process. Mean AFP levels post-filtration were
2.58 IU ml21
in Group 1 and 3.53 IU ml21
in Group 2. Squames cells were completely
removed in all but two cases. Fetal red blood cells were still present in the final product, range
0.13–4.35%. In Group 1, haemoglobin and haematocrit were higher than in Group 2, with
lower white blood cell, AFP, and fetal red cell counts.
Conclusions. This study adds to the growing body of evidence that there is little or no
possibility for AF contamination to enter the re-infusion system when used in conjunction with
a leucodepletion filter.
Br J Anaesth 2008; 101: 225–9
Keywords: blood, salvage; equipment, cell saver; transfusion, autotransfusion
OBSTETRICS
Contamination of salvaged maternal blood by amniotic fluid and
fetal red cells during elective Caesarean section
I. Sullivan1*, J. Faulds2 and C. Ralph2
1
Department of Haematology and 2
Department of Anaesthesia, Royal Cornwall Hospital Trust,
Royal Cornwall Hospital, Truro, Cornwall TR1 3LJ, UK
*Corresponding author. E-mail: ian.sullivan@rcht.cornwall.nhs.uk
Background. Cell salvage in obstetrics is still a controversial subject and has yet to be fully
embraced. The aim of this exploratory study was to measure amniotic fluid (AF), heparin,
and fetal red cell contamination of washed filtered salvaged maternal blood and to investigate
doi:10.1093/bja/aen135 Advance Access publication May 30, 2008

USO CS IN UROLOGIA
Intraoperative red blood cell salvage during
radical prostatectomy or radical cystectomy
1 Guidance
1.1 Intraoperative red blood cell salvage is an
efficacious technique for blood replacement and
its use is well established in other areas of surgery.
The evidence on safety is adequate. The
procedure may be used during radical
prostatectomy or radical cystectomy provided
normal arrangements are in place for clinical
governance and audit.
1.2 Clinicians wishing to undertake intraoperative red
blood cell salvage during radical prostatectomy or
radical cystectomy should ensure that patients
understand the possible risks and benefits of the
procedure compared with those of allogeneic
blood transfusion, and provide them with clear,
written information. In addition, use of the
Institute’s information for patients (‘Understanding
NICE guidance’) is recommended (available from
www.nice.org.uk/IPG258publicinfo).
2.2 Outline of the procedure
2.2.1 Blood lost during radical prostatectomy or radical
cystectomy is aspirated from the surgical field
using a suction catheter. The blood is then filtered
to remove debris. The filtered blood is washed or
spun and the red blood cells are resuspended in
saline, for transfusion during or after the
operation. A leukocyte depletion filter is nearly
always used; this is thought to minimise the risk of
re-infusion of malignant cells that may be present
in the aspirate. A number of different devices are
available for this procedure.
Issue date: April 2008
NHS
National Institute for
Health and Clinical Excellence
Sections 2.3 and 2.4 describe efficacy and safety
outcomes which were available in the published
literature and which the Committee considered
as part of the evidence about this procedure. For
more details, refer to the Sources of evidence.
section 3.2).
2.1.2 Intraoperative red blood cell salvage offers an
alternative to allogeneic or pre-donated
autologous blood transfusion. It may also be
useful in the treatment of patients who object
to allogeneic blood transfusion on religious or
other grounds.
perioperative imm
2.4 Safety
2.4.1 A non-randomise
were treated with
similar rates of bio
recurrence in 265
Interventional procedure guidance 258
Interventional procedures guidance makes recommendations on the safety and efficacy of a proce
does not cover whether or not the NHS should fund a procedure. Decisions about funding are tak
bodies (primary care trusts and hospital trusts) after considering the clinical effectiveness of the p
whether it represents value for money for the NHS.
Interventional procedures guidance is for healthcare professionals and people using the NHS in En
Scotland and Northern Ireland. This guidance is endorsed by NHS QIS for implementation by NHSS
Intraoperative red blood cell salvage during
radical prostatectomy or radical cystectomy
1 Guidance
1.1 Intraoperative red blood cell salvage is an
efficacious technique for blood replacement and
its use is well established in other areas of surgery.
The evidence on safety is adequate. The
procedure may be used during radical
prostatectomy or radical cystectomy provided
normal arrangements are in place for clinical
governance and audit.
1.2 Clinicians wishing to undertake intraoperative red
blood cell salvage during radical prostatectomy or
2.2 Outline of the procedure
2.2.1 Blood lost during radical prostatectomy or radic
cystectomy is aspirated from the surgical field
using a suction catheter. The blood is then filter
to remove debris. The filtered blood is washed o
spun and the red blood cells are resuspended in
saline, for transfusion during or after the
operation. A leukocyte depletion filter is nearly
always used; this is thought to minimise the risk
re-infusion of malignant cells that may be prese
in the aspirate. A number of different devices a
available for this procedure.
NHS
National Institute fo
Health and Clinical Excellenc
Intraoperative red blood ce
radical prostatectomy or ra
1 Guidance 2.2
Healtcience, LtdOxford, UKBJUBJU International1464-4096BJU InternationalApril 2003
ticle
AGE DURING RADICAL RETROPUBIC PROSTATECTOMY
The use of cell salvage during radical retropubic
prostatectomy: does it influence cancer recurrence?
M. DAVIS, M. SOFER, O. GOMEZ-MARIN*, D. BRUCK and M.S. SOLOWAY
Departments of Urology and *Epidemiology, University of Miami, School of Medicine, Miami, Florida, USA
Accepted for publication 28 November 2002
blood using a commercial cell saver; 264
receiving only autologous transfusion; and
level and Gleason score. In the multivariate
logistic regression analysis, the initial PSA,
OBJECTIVE
ience, LtdOxford, UKBJUBJU International1464-4096BJU InternationalApril 2003
cle
GE DURING RADICAL RETROPUBIC PROSTATECTOMY
The use of cell salvage during radical retropubic
prostatectomy: does it influence cancer recurrence?
M. DAVIS, M. SOFER, O. GOMEZ-MARIN*, D. BRUCK and M.S. SOLOWAY
Departments of Urology and *Epidemiology, University of Miami, School of Medicine, Miami, Florida, USA
Accepted for publication 28 November 2002
blood using a commercial cell saver; 264
receiving only autologous transfusion; and
57 with no transfusion. Disease recurrence
was defined as a prostate-specific antigen
(PSA) level of >0.2 ng/mL. Bivariate and
multivariate logistic regression analyses were
used to assess and compare the risk of cancer
recurrence in the three groups. Covariates
used in the multivariate analyses included
Gleason score, preoperative PSA level, seminal
vesicle involvement and surgical margins.
RESULTS
level and Gleason score. In the multivariate
logistic regression analysis, the initial PSA,
Gleason score, seminal vesicle involvement
and surgical margins, but not transfusion
group, were independent predictors of
recurrence.
CONCLUSION
Cell salvage during RRP does not influence
the recurrence of prostate cancer. Cell
salvage is a safe method of transfusion during
RRP.
OBJECTIVE
To assess whether there is a difference in the
biochemical recurrence rate in patients who
had radical retropubic prostatectomy (RRP)
with or without cell salvage transfusion.
PATIENTS AND METHODS
The records of 769 consecutive patients
undergoing RRP between 1992 and 1998
were retrospectively reviewed. Patients having
adjuvant hormonal treatment, postoperative
external beam radiotherapy, or a follow-up ofmartedì 14 giugno 16

INTRAOPERATIVE CELL SALVAGE DURING RADICAL
PROSTATECTOMY IS NOT ASSOCIATED WITH GREATER
BIOCHEMICAL RECURRENCE RATE
ALAN M. NIEDER, ADRIENNE J. K. CARMACK, PAUL D. SVED, SANDY S. KIM,
MURUGESAN MANOHARAN, AND MARK S. SOLOWAY
ABSTRACT
Objectives. To evaluate the risk of long-term biochemical recurrence for patients who receive cell-salvaged
blood. Radical retropubic prostatectomy (RRP) is historically associated with the potential for significant
blood loss. Different blood management strategies include blood donation, hemodilution, preoperative
erythropoietin, and intraoperative cell salvage (IOCS). Oncologic surgeons have been reluctant to use IOCS
because of the potential risk of tumor dissemination.
Methods. We retrospectively analyzed an RRP database and compared those who did and did not receive
cell-salvaged blood by baseline parameters, pathologic outcomes, and biochemical recurrence. We also
stratified our patients according to the risk of recurrence.
Results. A total of 1038 patients underwent RRP between 1992 and 2003. Of these, 265 (25.5%) received
cell-salvaged blood and 773 (74.5%) did not. The two groups had similar baseline characteristics. No
differences were found between the two groups when compared by risk of seminal vesicle invasion or
positive surgical margins. Those who received cell-salvaged blood had a lower risk of extraprostatic
extension. The median follow-up for all patients was 40.2 months. The overall risk of biochemical recurrence
at 5 years for those who did and did not receive cell-salvaged blood was 15% and 18%, respectively (P ϭ
0.76). No significant differences were found in the risk of biochemical recurrence when patients were
stratified according to low, intermediate, and high risk.
Conclusions. IOCS is a safe and effective blood management strategy for patients undergoing RRP. The risk
of biochemical recurrence was not increased for those who received cell-salvaged blood. Concerns about
spreading tumor cells by way of IOCS would seem unwarranted. UROLOGY 65: 730–734, 2005. © 2005
Elsevier Inc.
INTRAOPERATIVE CELL SALVAGE IN RADICAL
RETROPUBIC PROSTATECTOMY
CHRISTINE L. GRAY, CHRISTOPHER L. AMLING, GREGORY R. POLSTON, CURTIS R. POWELL, AND
CHRISTOPHER J. KANE
ABSTRACT
Objectives. To investigate the efficacy and safety of intraoperative cell salvage with autotransfusion using
leukocyte reduction filters in patients undergoing radical retropubic prostatectomy (RRP).
Methods. Between September 1996 and March 1999, 62 patients (age range 48 to 70 years) with clinically
localized prostate cancer underwent RRP with intraoperative cell salvage as the sole blood management
technique. Salvaged blood was passed through a leukocyte reduction filter before autotransfusion. The 62
cell salvage patients were compared with a cohort who predonated 1 to 3 U autologous blood (n ϭ 101). The
estimated blood loss, preoperative and postoperative hematocrit, need for homologous transfusion, and
biochemical recurrence rates were compared between the two groups. The progression-free survival rates
were compared using the Kaplan-Meier method.
Results. No difference was found in preoperative prostate-specific antigen level, pathologic stage, or
estimated blood loss between the cell salvage and autologous predonation groups. The preoperative and
postoperative hematocrit levels were higher in the cell salvage group (42.7% versus 39.6% and 31.3%
versus 27.9%, respectively; P Ͻ0.001 for each). The homologous transfusion rates were lower in the cell
ADULT UROLOGY
age and autologous
ow-up of these pa-
onclusions about the
but the early recur-
increased with ICS.
ells had occurred in
ssion of tumor bur-
was not observed in
use no clinical recur-
p, PSA was used as a
use of a serum PSA
as a marker for bio-
een supported.27
blood is expensive,
nient for the patient.
iable, depending on
hnical support staff,
he disposables to re-
tion is $100, plus an
than contemporary, the allogeneic transfusion cri-
teria may have differed. Because both cohorts un-
derwent surgery in the 1990s, after the require-
ments for transfusion were made more stringent,
this is unlikely. Our criteria, namely symptomatic
anemia or Hct less than 30% in patients with car-
diac disease, were identical for both groups.
CONCLUSIONS
ICS is an effective and safe technique for blood
management in patients undergoing radical pros-
tatectomy. Compared with patients using autolo-
gous blood predonation, it results in higher preop-
erative and postoperative Hct levels and a lower
homologous transfusion rate. Additionally, ICS
does not appear to increase early biochemical re-
currence rates in radical prostatectomy patients.

Intraoperative red cell salvage in metastatic spine surgeryAsian Spine JournalAsian Spine Journal 167
Role of Intraoperative Red Cell Salvage and
Autologus Transfusion in Metastatic Spine Surgery:
A Pilot Study and Review of Literature
Harinder Gakhar, Munzer Bagouri, Rajendranath Bommireddy, Zdenek Klezl
Department of Trauma and Orthopaedics, Royal Derby Hospital, Derby, UK
Clinical Study Asian Spine J 2013;7(3):167-172 • http://dx.doi.org/10.4184/asj.2013.7.3.167
Asian Spine JournalAsian Spine Journal
TATM 2001;3(6):25-28
Use of the Cell Saver
in Oncologic Surgery
TATM Vol 3 n°6 31/01/02 11:21 Page 25
TATM 2001;3(6):25-28
TATM Vol 3 n°6 31/
S U M M A R Y
1
HEAD, DEPARTMENT OF GENERAL CANCER SURGERY
DOMINIQUE ÉLIAS1
,
VALÉRIE BILLARD2
, VALÉRIE LAPIERRE3
TATM 2001;3(6):25-28
Use of the cell saver in oncologic surgery i
reinfusion of cancer cells remaining in the
and clinical studies have indeed confirmed
packed red cells. However, six clinical stud
showed no metastatic spread after process
adjunctive use of a leukocyte depletion fil
Use of the Cell Saver
in Oncologic Surgery
(
TATM Vol 3 n°6 31/01/02 11:21 Page 25
B L O O D M A N A G E M E N T
Blood salvage use in gynecologic oncology_02256 2048..2053
Nimesh P. Nagarsheth, Tarun Sharma, Aryeh Shander, and Ahsan Awan
ND: Blood salvage allows for collection
ng of surgical blood loss with the eventual
washed red blood cells (RBCs) back to the
use of blood salvage in patients undergo-
or malignancy is off-label. Controversy
he risk of potential cancer dissemination
m the reinfusion of the processed blood, but
available to confirm this risk. Recent
demonstrated that filtering the salvaged
a leukoreduction filter (LRF) significantly
e number of cancer cells in the recovered
in a variety of cancer types.
B
lood management optimizes outcomes in
patients undergoing surgical procedures who
wish to avoid allogeneic transfusion.1
Blood
management is the philosophy to improve
patient outcomes by integrating all available techniques
to reduce or eliminate allogeneic blood transfusions. It is a
patient-centered, multidisciplinary, multimodal, planned
approach to patient care.2
Using a series of interventions
and management strategies related to this goal, patients
who were previously considered extremely high risk or
inoperable without a blood transfusion can now undergo
complex surgical procedures with acceptable outcomes.3
Blood salvage (also known as intraoperative autolo-
BBREVIATIONS: CT = computed tomography;
RF(s) = leukoreduction filter(s).
om the Division of Gynecologic Oncology, Department of
bstetrics, Gynecology and Reproductive Science and the
epartment of Anesthesiology and Critical Care Medicine,
nglewood Hospital and Medical Center, Englewood, New
rsey; and the Mount Sinai School of Medicine, New York,
ew York.
Address reprint requests to: Nimesh P. Nagarsheth, Division
Gynecologic Oncology, Department of Obstetrics, Gynecology
d Reproductive Science, Mount Sinai Medical Center, 1176
fth Avenue, Box 1173, New York, NY 10029-6574; e-mail:
mesh.nagarsheth@gmail.com.
Received for publication January 7, 2009; revision received
pril 8, 2009; and accepted April 10, 2009.
doi: 10.1111/j.1537-2995.2009.02256.x
TRANSFUSION 2009;49:2048-2053.

CHIRURGIA TUMORALE
• IRRADIAZIONE DELLE EMAZIE 50 Gy (1,2 -2,2 Gy x
alcuni min.) - 12 Log reduction probabilità di cellule tumorali
residue minore del 99,97%
(E. Hansen - Regensburgh, D)
• FILTRO DELEUCOCIZZANTE
(J. H.Waters - Pittsburgh, PA)

Intraoperative blood salvage in cancer surgery:
safe and effective?
Ernil Hansen *, Volker Bechmann, Juergen Altmeppen
Department of Anesthesiologie, University of Regensburg, D-93042 Regensburg, Germany
Abstract
To support blood supply in the growing field of cancer surgery and to avoid transfusion induced immunomodulation
caused by the allogeneic barrier and by blood storage leasions we use intraoperative blood salvage with blood irra-
diation. This method is safe as it provides efficient elimination of contaminating cancer cells, and as it does not
compromise the quality of RBC. 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.
Ó 2002 Elsevier Science Ltd. All rights reserved.
1. Introduction
The demand for blood in cancer surgery is high
and increasing. Problems with the supply of com-
patible blood are not uncommon in these patients
that previously have seen surgery and transfusions.
Some transfusion risks are especially relevant to
cancer patients like immunomodulation with im-
donations suffers from the poor predictability of
intraoperative blood loss leading to a waste of
autologous blood, or to insufficient supply. Im-
munosuppression is not only caused by the allog-
eneic barrier, but also by cell lesions during blood
storage at low temperature [2], relevant to both
allogeneic and autologous banked blood. In ad-
dition, growth factors are released during storage
www.elsevier.com/locate/transci
Intraoperative blood salvage in cancer surgery
safe and effective?
Ernil Hansen *, Volker Bechmann, Juergen Altmeppen
Department of Anesthesiologie, University of Regensburg, D-93042 Regensburg, Germany
act
support blood supply in the growing field of cancer surgery and to avoid transfusion induced imm
d by the allogeneic barrier and by blood storage leasions we use intraoperative blood salvage w
www.elsevier.
Transfusion and Apheresis Science 27 (2002) 153–157
Fig. 1. Transfusion risks most relevant to cancer patients.
E. Hansen et al. / Transfusion and Apheresis Science 27 (2002) 153–157
più di 700 casi
irradiazione GRC
50Gy
diminuzione cellule
tumorali Log 12
ottima qualità,
sopravvivenza,
funzione

amounts of compatible blood, and to save blood
resources for trauma patients. Thus, IBSBI is a
eﬃcacious method to save blood in cancer pa-
tients, and to reduce allogeneic transfusions.
under sterile conditions, and knowing that after
anticoagulation can be processed to a blood
product of such high quality, certainly would
prefer to have his own blood saved.
Table 1
Saving blood in cancer surgery by IBSBI (University of Regensburg, 1/95-4/01)
Tumor n Blood loss (l) Salvaged blood (units) Banked blood (% patients)
ENT tumors 14 1.3 1.8 14%
Oesophageal ca. 32 1.5 1.9 23%
Gastic ca.a
47 1.6 2.8 19%
Colorectal ca.a
96 1.4 2.3 11%
Liver resection 128 2.0 2.6 18%
Liver transplant. 18 2.6 3.2 58%
Pancreatic ca. 69 1.8 2.5 18%
Renal ca. 14 1.3 1.6 10%
Abd. Sarkoma 23 1.6 2.0 16%
Pulmonal metast.a
29 1.5 1.9 20%
Bone tumors 49 2.2 3.3 40%
Spinal metast. 112 3.1 3.7 42%
Others 79 1.7 2.2 29%
Meningeoma 12 1.4 2.1 17%
Total 722 1911
a
Only cases with high blood loss.
156 E. Hansen et al. / Transfusion and Apheresis Science 27 (2002) 153–157
CASITRATTATI CON RIO
UNIVERSITA’ REGENSBURG

2011 Update to The Society of Thoracic Surgeons
and the Society of Cardiovascular Anesthesiologists
Blood Conservation Clinical Practice Guidelines*
The Society of Thoracic Surgeons Blood Conservation Guideline Task Force:
Victor A. Ferraris, MD, PhD (Chair), Jeremiah R. Brown, PhD, George J. Despotis, MD,
John W. Hammon, MD, T. Brett Reece, MD, Sibu P. Saha, MD, MBA,
Howard K. Song, MD, PhD, and Ellen R. Clough, PhD
The Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion:
Linda J. Shore-Lesserson, MD, Lawrence T. Goodnough, MD, C. David Mazer, MD,
Aryeh Shander, MD, Mark Stafford-Smith, MD, and Jonathan Waters, MD
The International Consortium for Evidence Based Perfusion:
Robert A. Baker, PhD, Dip Perf, CCP (Aus), Timothy A. Dickinson, MS,
Daniel J. FitzGerald, CCP, LP, Donald S. Likosky, PhD, and Kenneth G. Shann, CCP
Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, Kentucky (VAF, SPS), Department of
Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (JW), Departments of Anesthesiology and Critical
Care Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey (AS), Departments of Pathology and Medicine,
Stanford University School of Medicine, Stanford, California (LTG), Departments of Anesthesiology and Cardiothoracic Surgery,
Montefiore Medical Center, Bronx, New York (LJS-L, KGS), Departments of Anesthesiology, Immunology, and Pathology, Washington
University School of Medicine, St. Louis, Missouri (GJD), Dartmouth Institute for Health Policy and Clinical Practice, Section of
Cardiology, Dartmouth Medical School, Lebanon, New Hampshire (JRB), Department of Cardiothoracic Surgery, Wake Forest School of
Medicine, Winston-Salem, North Carolina (JWH), Department of Anesthesia, St. Michael’s Hospital, University of Toronto, Toronto,
Ontario (CDM), Cardiac Surgical Research Group, Flinders Medical Centre, South Australia, Australia (RAB), Department of Surgery,
Medicine, Community and Family Medicine, and the Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical
School, Hanover, New Hampshire (DSL), SpecialtyCare, Nashville, Tennessee (TAD), Department of Cardiac Surgery, Brigham and
Women’s Hospital, Harvard University, Boston, Massachusetts (DJF), Division of Cardiothoracic Surgery, Oregon Health and Science
University Medical Center, Portland, Oregon (HKS), Department of Cardiothoracic Surgery, University of Colorado Health Sciences
Center, Aurora, Colorado (TBR), Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina (MS-S), and
The Society of Thoracic Surgeons, Chicago, Illinois (ERC)
Background. Practice guidelines reflect published liter- Methods. The search methods used in the current
pro-
bolic
ports
with
213].
t re-
lica-
that
om-
g, or
per-
ICU
Two
ship
pa-
volv-
diac
tar-
mbo-
able [227], and addition of factor concentrates augments
multiple other interventions. Fractionated factor concen-
trates, like factor IX concentrates or one of its various
forms (Beriplex or factor VIII inhibitor bypassing activ-
ity), are considered “secondary components” and may be
acceptable to some Jehovah’s Witness patients [222].
Addition of factor IX concentrates may be most useful in
the highest risk Jehovah’s Witness patients.
d) Blood Salvage Interventions
EXPANDED USE OF RED CELL SALVAGE USING CENTRIFUGATION
Class IIb.
1. In high-risk patients with known malignancy who
require CPB, blood salvage using centrifugation of
blood salvaged from the operative field may be
considered since substantial data support benefit in
patients without malignancy, and new evidence
suggests worsened outcome when allogeneic trans-
fusion is required in patients with malignancy.
(Level of evidence B)
In 1986, the American Medical Association Council on
Scientific Affairs issued a statement regarding the safety
of blood salvage during cancer surgery [228]. At that
time, they advised against its use. Since then, 10 obser-
vational studies that included 476 patients who received
blood salvage during resection of multiple different tumor
types involving the liver [229–231], prostate [232–234],
uterus [235, 236], and urologic system [237, 238] support the
use of salvage of red cells using centrifugation in cancer
patients. In seven studies, a control group received no
transfusion, allogeneic transfusion, or preoperative autolo-
end of CPB is reasonable as part of a bl
agement program to minimize blood tr
(Level of evidence C)
2. Centrifugation instead of direct infusion o
pump blood is reasonable for minimizing
allogeneic RBC transfusion. (Level of evi
Most surgical teams reinfuse blood from t
poreal circuit (ECC) back into patients at the
as part of a blood conservation strategy. Cu
blood salvaging techniques exist: (1) direct
post-CPB circuit blood with no processing;
cessing of the circuit blood, either by centrifu
ultrafiltration, to remove either plasma com
water soluble components from blood before
Ann Thorac Surg FERRARIS
2011;91:944–82 STS BLOOD CONSERVATION REVISION
10 studi osservazionali su 476 pazienti
operati per diverse patologie tumorali
supportano l’uso del cell saver
molti reports indicano che i
pazienti che hanno ricevuto
trasfusioni allogeniche hanno un
maggior rischio di recidiva
due recenti metanalisi
suggeriscono che questo
rischio è doppio

PAURA:
• presenza cellule tumorali nel sangue recuperato
MA
• E’ NORMALE che durante chirurgia tumorale vi sia
disseminazione di cellule cancerose.*
• Di queste cellule circolanti solamente lo 0,01- 0,000001%
hanno la probabilità di formare lesioni metastatiche. °
fluid and fetal red cells during elective Caesarean section. British Journal of Anaesthesia 101 (2):
225–9 (2008)
(36) Waters JH, Biscotti C,: Amniotic fluid removal during cell salvage in the cesarean section
patient. Anesthesiology 2000; 92: 1531-6
(37) Sullivan I, J Faulds, C Ralph: Contamination of salvaged maternal blood by amniotic fluid and
fetal red cells during elective Cesarean Section. British Journal of Anaesthesia 101 (2): 225–9
(2008)
(38) Catling SJ, Williams S, Fielding A M : Cell salvage in obstetrics: an evaluation of the ability of
cell salvage combined with leucocyte depletion filtration to remove amniotic fluid from operative
blood loss at caesarean section. Int J Obst Anesth 8: 79 -84 (1999)
(39) Jackson SH, Lonser RE: Safety and effectiveness of intracesarean blood salvage. Transfusion
33: 181, 1993.
(40) Rainaldi MP, Tazzari PL, Scagliarini G, Borghi B, Conte R: Blood salvage during caesarean
section. Br J Anaesth 80: 195–198, 1998.
(41) Oefelein MG, Kaul K, Herz B, et al: Molecular detection of prostate epithelial cells from the
surgical field and peripheral circulation during radical prostatectomy. J Urol 155: 238–242, 1996.
(42) Weiss L: Metastatic inefficency: causes and consequences. Cancer Rev 3: 1-24, 1986
(43) Edelman MJ, Potter P, Mahaffey KG, Frink R, Leidich RB: The potential for reintroduction of
*
°

RISCHI
http://www.asiageographic.com/primum/view_ﬁlm.htm

PERCHE’ IL RIO È IMPORTANTE DAL P.TO DI
VISTA DELLA SICUREZZA
PER IL PAZIENTE?⚠
• perchè riduce l’esposizione alle trasfusioni allogeniche e a
molti dei rischi ad esse associate !!
RISCHI da errore umano e/o di sistema
⚠possono essere prevenuti e/o corretti
RISCHI legati alla natura dei prodotti ematici,
non sono evitabili se non evitando le trasfusioni allogeniche
⚠⚠
⚠

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