Introduction of cell salvage to a large obstetric unit: the first six months

doi:10.1016/j.ijoa.2008.07.010

International Journal of Obstetric Anesthesia

Volume 18, Issue 2, April 2009, Pages 111-117

https://doi.org/10.1016/j.ijoa.2008.07.010 Get rights and content

Abstract

Background

We introduced red-cell salvage to our obstetric unit following a two-month period of training and education. We report a service evaluation of the first six months of activity from May to October 2007.

Methods

The indications for using cell salvage were: placenta praevia, suspected placental abruption, multiple pregnancy, multiple repeat caesarean, previous history of post partum haemorrhage, refusal of blood transfusion, caesarean section at full dilatation, low preoperative haemoglobin and at the discretion of the theatre team.

Results

The cell saver was used for 46 patients with a blood loss (median; range) of 800 (200–2000) mL and a heterologous transfusion rate of 22% (10 cases). Blood was processed and returned in 19 cases of which nine were emergency and 10 elective. The median volume (range) of blood returned was 390 (200–800) mL. For the unit as a whole the percentage of all theatre cases who received a heterologous transfusion fell from 10.2% for the equivalent time period in the preceding year to 7.9% during the six month period that cell salvage was in use (P = 0.126, χ²). There were no adverse reactions following the administration of processed blood.

Conclusion

We have successfully introduced cell salvage to our unit in a relatively short period of time and have used it for the largest series of patients reported in the UK.

Introduction

Cell salvage is a means by which the patients’ own blood can be recycled, reducing the requirement for heterologous blood with its attendant problems such as transmission of infection and transfusion reaction.1, 2, 3, 4, 5 Another advantage of blood obtained in this way is the likely improved survival and oxygen carrying ability of red cells compared to banked blood.⁶ There are also several cases in the literature where the technique has been used for Jehovah’s Witnesses.⁷ Although cell salvage has been used extensively in the fields of cardiac surgery, orthopaedics and trauma, use in obstetrics has been limited by concerns regarding amniotic fluid embolus and rhesus iso-imunisation.⁸

A recent review of the literature revealed several hundred published cases of the use of cell salvage in obstetrics without significant problems.⁹ In addition, its use at caesarean section has been endorsed by several official bodies including the Association of Anaesthetists of Great Britain and Ireland,¹⁰ the Obstetric Anaesthetists’ Association¹⁰ and the National Institute for Health and Clinical Excellence.¹¹

Many of the cases reported in the literature have concentrated on instances of massive haemorrhage;7, 12 this is variably defined as: blood loss of more than 1500 mL, a decrease in haemoglobin of more than 4 g/dL or acute transfusion requirement of more than four units.¹³ Cases of massive haemorrhage occur in approximately 5 per 1000 deliveries¹⁴ so are rare even in a unit such as ours with 7200 deliveries per year. Limiting the use of cell salvage to such cases may have led to insufficient opportunities for training and maintenance of skills. This is particularly important in our hospital as it does not contain any of the specialties that commonly use cell salvage. Consequently we had to set up our service so that the cell saver was run entirely by obstetric theatre staff and was not reliant on staff coming from elsewhere.

In our unit we therefore decided to use cell salvage at caesarean section whenever the blood loss was likely to necessitate blood transfusion. By doing so we hoped to prevent some patients from receiving any heterologous blood and to maintain the skills of theatre personnel. We have evaluated the introduction of a change in practice for which there is evidence derived from research. We have discussed this with the chair of the research ethics committee within our trust who agreed that it was not a research project and did not require ethical approval. Our intention in publishing this work is to help others considering the introduction of cell salvage.

Section snippets

Methods

The Jessop Wing Obstetric Unit is a tertiary referral centre with a resident anaesthetic trainee, cover from another anaesthetic trainee shared with other sectors and a dedicated anaesthetic consultant on call. It is attached to the rest of the hospital via a covered corridor. There was no prior experience of cell salvage use in our unit other than a cost analysis which we have previously reported.¹⁵ Consequently a period of preparation was required before the introduction of cell salvage. The

Results

The six months introductory period was from the beginning of May to the end of October 2007 and in that time the cell saver was used in 46 cases. The indications for using the cell saver in these cases are given in Table 1. Blood loss, expressed as median and range, for all patients (excluding a case of massive haemorrhage where blood loss was not documented) was 800 mL (200–2000) with a heterologous transfusion rate of 22% (10 cases). Blood was processed but not returned in three cases, for

Discussion

When setting up cell salvage at the Jessop Wing we discovered that our situation differs from many obstetric units where this technology is in use. We could not call upon the assistance of our colleagues in those specialties that most frequently use the technique, as they were in our sister hospital several miles away. Consequently we have had to set up a service that could be run entirely by staff within the unit. With this in mind, our intention was to try to target those patients most likely

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Cited by (30)

Transfusion Management of Obstetric Hemorrhage
2018, Transfusion Medicine Reviews
Obstetric hemorrhage is one of the leading, as well as one of the most treatable, causes of maternal morbidity and mortality worldwide. As obstetric hemorrhage often occurs in patients without risk factors, there is virtually unanimous agreement from obstetric professional societies to establish obstetric hemorrhage protocols in anticipation of these emergencies. These protocols involve multidisciplinary teams in which the transfusion service plays an essential and vital role. This manuscript will examine the epidemiology of obstetric hemorrhage, risk factors that may be present, and recommendations for these protocols, with a focus on massive transfusion protocols, laboratory testing, cell salvage and use of pharmacologic adjuvant therapy including tranexamic acid and factor concentrates.
Identification and Management of Obstetric Hemorrhage
2017, Anesthesiology Clinics
Intraoperative red cell salvage during obstetric surgery in 50 Japanese women
2015, International Journal of Gynecology and Obstetrics
Citation Excerpt :
In addition, ICS might have contributed to a reduction in the volume of ABT blood in the 16 women who did undergo ABT. In the literature [12–16], the percentage of patients who completely avoid ABT with the aid of ICS ranges from 6% to 97%. Placenta previa accreta—a life-threatening condition complicated by massive hemorrhage during parturition [17–20]—affected 14 women in the present study.
To determine the clinical usefulness of intraoperative cell salvage (ICS) in obstetrics.
A retrospective analysis was performed using data for 50 patients who had received ICS blood during obstetric surgery at 13 Japanese facilities between January 1, 2007 and December 31, 2013. The frequencies of ICS-associated adverse events, allogeneic blood transfusion (ABT), and preoperative autologous donation (PAD) were assessed.
Placenta previa was the indication for ICS in 42 (84%) women. The ICS blood was reinfused in all women (median 366 mL; range 80 to at least 3715). No ICS-associated adverse events occurred. The median estimated blood loss (EBL) was 2171 mL (range 574–47 000); 27 (54%) women lost at least 2000 mL. ABT was not used in 33 (66%) women. Among 26 women who lost at least 2000 mL of blood and were included in analyses, 12 (44%) did not receive ABT. EBL was linearly correlated with the total volume of transfused blood (P < 0.001).
ICS caused no adverse events among women at elevated risk of peripartum hemorrhage and might be safe for use in obstetrics.
The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation
2013, International Journal of Obstetric Anesthesia
Citation Excerpt :
Only two prospective studies have been made, one of which looked at low-risk caesarean delivery (mean volume of blood salvaged 363 ± 153 mL),25 and one with a heterogeneous group of patients with placenta previa, cesarean delivery, ectopic pregnancy and Jehovah’s Witnesses (median blood loss 3000 mL, median volume of blood reinfused 359 mL with a reinfusion rate of 40%).26 Five studies have assessed the efficacy of cell salvage, defined as avoidance/reduction of allogeneic blood use; the percentages of patients in whom allogeneic blood was not required ranged from 6% to 97.1%.19,21,23,25,26 This compares with 86.7% in the current study.
Although transfusion of autologous blood obtained from cell salvage has increased, its role in obstetric practice remains controversial. This case series reports the use of cell salvage in an attempt to avoid allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.
This prospective observational study, conducted in a large public maternity hospital, included 41 women with an antenatal diagnosis of placenta accreta, of whom 20 underwent cesarean hysterectomy and 15 received autologous blood after cell salvage. Intraoperative cell salvage was used for autologous blood transfusion, and salvaged blood was monitored for prewash and postfiltration squamous cells, fetal hemoglobin, and potassium concentration. Pre- and postoperative hemoglobin, platelet count and coagulation profile were compared.
Twenty women underwent caesarean hysterectomy. Cell-salvaged blood was collected in 18 women and re infused in 15 women (83.3%). The mean volume of reinfused salvaged blood was 1476 ± 247 mL. Mean potassium concentrations (1.4 ± 1.2 versus 3.7 ± 0.42 mEq/L) and median squamous cell counts (0 [0–1] versus 8 [3–12]/high power field) were significantly lower postfiltration compared to prewash values. There were no instances of intraoperative or postoperative amniotic fluid embolism, hypotension, sepsis or coagulopathy. Of the 15 women who received autologous blood, 13 (86.7%) did not require allogeneic red blood cell transfusion.
Autologous transfusion of salvaged blood can be used to minimize allogeneic transfusion in women undergoing cesarean hysterectomy for placenta accreta.
The introduction of intra-operative cell salvage in obstetric clinical practice: A review of the available evidence
2011, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
In case reports, the median amount of salvaged blood transfused is 500 mL [38,41,43,49,51–55,58,59,64]. This data is confirmed by six larger studies accounting for almost 300 patients transfused with mean or median amounts of SB not exceeding 2 units [44,47,50,60–62]. In 46% of the cell saving procedures (380/826) either blood loss was not enough to be processed or SB was not enough to be transfused; in seven large studies (Table 1) the re-transfusion rate of autologous SB ranges from 36 to 100% [44,47,50,56,60–62].
Intra-operative blood salvage is common practice in many surgical specialties but its safety is questioned with concerns about the risks of contamination of recovered blood with amniotic fluid and of maternal–foetal alloimmunization. However, the role of cell salvage as a blood-saving measure in this clinical setting is progressively acquiring relevance thanks to the growing body of evidence regarding its quality and safety. Modern cell savers remove most particulate contaminants and leukodepletion filtering of salvaged blood prior to transfusion adds further safety to this technique. Amniotic fluid embolism is no longer regarded as an embolic disease and the contamination of the salvaged blood by foetal Rh-mismatched red blood cells can be dealt with using anti-D immunoglobulin; ABO incompatibility tends to be a minor problem since ABO antigens are not fully developed at birth. Maternal alloimmunization can be caused also by other foetal red cell antigens, but it should also be noted that the risk of alloimmunization of the mother from allogeneic transfusion may be even greater. Therefore the use of cell savers in obstetric clinical practice should be considered in patients at high risk for haemorrhage or in cases where allogeneic blood transfusion is difficult or impossible.
Intraoperative cell salvaged blood as part of a blood conservation strategy in Caesarean section: Is fetal red cell contamination important?
2011, British Journal of Anaesthesia
Cell salvage is used in obstetric surgery as part of a blood conservation strategy in our Trust. This carries a theoretical risk of amniotic fluid embolism and also a risk of fetal red cells being present in the re-infusion, resulting in alloimmunization. In this study, we attempted to quantify the risk of antibody formation from re-infusion of autologous blood after Caesarean section.
Women presenting for elective Caesarean section were routinely requested to consent for collection of blood by cell salvage, using one suction device. If an adequate volume of blood was collected, it was processed and, if clinically appropriate, re-infused via a leucodepletion filter. Women who received a re-infusion were followed up to test for antibody formation.
Seventy women consented for re-infusion and follow-up. The median volume re-infused was 324 ml (range 118–1690 ml). The median fetal red cell contamination was 0.8 ml (range 0.2–12.9 ml). All re-infusions were given without adverse clinical signs. No antibodies were detected in 48 follow-up samples. One positive anti-S antibody was detected.
The implementation of a blood conservation strategy which includes the use of intraoperative cell salvage appears safe and can contribute to a reduction in the number of blood transfusions to the obstetric population. We remain uncertain of the significance of fetal red cell contamination.

View all citing articles on Scopus

^☆: Presented in part at the Obstetric Anaesthetists’ Association Annual Meeting, Belfast: May 2008.

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Original articleIntroduction of cell salvage to a large obstetric unit: the first six months☆

Abstract

Background

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Lancet

Lancet

Int J Obstet Anesth

Int J Obstet Anesth

Semin Perinatol

Int J Obstet Anesth

Am J Obstet Gynecol

Am J Obstet Gynecol

Br J Anaesth

Br J Anaesth

Variant Creutzfeldt-Jakob disease: risk of transmission by blood transfusion and blood therapies

Haemophilia

Cell salvage in obstetrics: the time has come

Br J Obstet Gynaecol

Original article
Introduction of cell salvage to a large obstetric unit: the first six months☆