Maternal outcomes following postpartum autotransfusion of blood lost during vaginal obstetric hemorrhage.

BACKGROUND: Autotransfusion following vaginal delivery has not been as widely adopted and existing data on this topic are limited to small case series. METHODS: This is a single-center retrospective matched cohort study. Deliveries exposed to autotransfusion during obstetric hemorrhage were matched to unexposed controls with obstetric hemorrhage who did not receive autotransfusion. The primary outcome was allogeneic transfusion of packed red blood cells. Planned secondary analyses included change in hemoglobin following delivery, composite maternal safety outcomes, and unplanned postpartum health care utilization. RESULTS: Thirty-six deliveries exposed to autotransfusion were matched to 144 unexposed controls. There was no significant difference in allogenic transfusion of packed red blood cells in the patients exposed to autotransfusion red with unexposed controls (adjusted OR 1.1; 95% CI 0.5-2.4). Deliveries that received autotransfusion had a less severe pre- to post-delivery decline in hemoglobin compared with unexposed controls across all values of QBL (p = .003). There were no significant differences in maternal morbidity outcomes evaluated in exposed versus unexposed deliveries. CONCLUSION: Autotransfusion in cases of vaginal obstetric hemorrhage did not attenuate rates of allogenic packed red blood cell transfusion but did result in a less severe pre- to postdelivery decline in hemoglobin at discharge. Autotransfusion cases did not have any markers of increased maternal morbidity when compared with a control group. These findings support emerging evidence indicating that autotransfusion of blood lost during vaginal obstetric hemorrhage is a safe and potentially effective tool for use in the management of obstetric hemorrhage.

Red Blood Cell Transfusion: 2023 AABB International Guidelines.

Importance: Red blood cell transfusion is a common medical intervention with benefits and harms. Objective: To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review: Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings: For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance: It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.

How do I perform cell salvage during vaginal obstetric hemorrhage?

BACKGROUND: Obstetric hemorrhage is a leading cause of preventable maternal mortality. To combat this, obstetric organizations worldwide recommend consideration of autotransfusion during severe peripartum bleeding to minimize allogenic transfusion. Current guidelines for autotransfusion in obstetrics are limited to patients undergoing cesarean birth. At present, women experiencing vaginal obstetric hemorrhage are excluded from many obstetric autotransfusion protocols. However, emerging data suggest that autotransfusion of vaginally shed blood is both safe and feasible in the obstetric patient population. METHODS AND MATERIALS: In this review, we will provide an overview of the current literature surrounding cell salvage of vaginally send blood and a detailed outline of our institution's blood collection protocol. RESULTS: Recent data suggests autotransfusion of vaginally shed blood is both safe and effective. DISCUSSION: Implementation of autotransfusion technology into the delivery room is a critical next step for the advancement of transfusion medicine in obstetrics. This review provides an overview of the data surrounding autotransfusion of vaginally shed blood during maternal hemorrhage and describes practical suggestions for how it can be effectively implemented into routine practice.

Autotransfusion of vaginally shed blood as a novel therapy in obstetric hemorrhage: A case series.

OBJECTIVE: To report maternal outcomes in a cohort of women who received autotransfusion of vaginally shed blood and to describe the feasibility of blood collection and cell salvage processing at the time of vaginal hemorrhage. STUDY DESIGN AND METHODS: We conducted a retrospective case series of patients who received autotransfusion of vaginally shed blood at the time of obstetric hemorrhage from January 2014 to August 2020. Maternal data and cell salvage utilization characteristics were abstracted from the electronic medical record. RESULTS: Sixty-four cases were identified in which autotransfusion of vaginally shed blood occurred during an obstetric hemorrhage. Median quantitative blood loss was 2175 ml (interquartile range 1500-2250 ml) with 89% of cases having a blood loss greater than 1000 ml. Patients on average received approximately 1.3 units of autologous blood product (384 ml, interquartile range 244-520 ml) and no direct adverse events were observed during transfusion. We observed heterogeneity in autologous blood volume across all values of quantitative blood loss. The need for allogenic blood transfusion was common and occurred in 72% of all cases (N = 46). There were no documented cases of maternal sepsis or severe infectious morbidity. CONCLUSION: In 64 cases where autotransfusion of vaginally shed blood occurred, autotransfusion was well tolerated. Heterogeneity in autologous blood volume collection likely represents the lack of standardized protocols for blood collection in the delivery room. Autotransfusion of vaginally shed blood is a feasible and reasonable technique to employ during severe obstetric hemorrhage.

Cell salvage in trauma.

PURPOSE OF REVIEW: The collection of shed blood and its reinfusion has been termed 'cell salvage' or 'autotransfusion'. This review will summarize the historical foundation of cell salvage and summarize recent literature associated with cell salvage use in trauma. RECENT FINDINGS: There have been no publications on cell salvage in trauma during the last 2 years. This is based on a PubMed search using the key words, 'cell salvage', 'autologous blood transfusion' and 'operative blood salvage'. Although the wars in Iraq and Afghanistan were ongoing, publications focused upon autotranfusion of unwashed blood from the hemothorax and on the resuscitation of the injured in remote settings. SUMMARY: Autotransfusion or cell salvage is markedly under utilized in trauma. Opportunities exist for significant blood savings if it is used more frequently. More research is clearly needed to assess the safety of autotransfusion in the traumatized patient.

Clinical Utility of Autologous Salvaged Blood: a Review.

INTRODUCTION: Autologous salvaged blood, commonly referred to as "cell saver" or "cell salvage" blood, is an important method of blood conservation. Understanding the mechanism of action and summarizing the existing evidence regarding the safety, efficiency, and the relative costs of cell salvage may help educate clinicians on how and when to best utilize autotransfusion. METHODS: This review focuses on issues concerning the quality of red blood cells (RBC), efficiency, and the cost effectiveness relative to autotransfusion. The key considerations of safe use and clinical applicability are described along with the challenges for wider dissemination. RESULTS: Cell salvage can reduce requirements for allogeneic transfusions, along with the associated risks and costs. Autologous salvaged RBCs provide high-quality transfusion, since the cells have not been subjected to the adverse effects of storage as occurs with banked blood. The risks for RBC alloimmunization and transfusion-related infectious diseases are also avoided. With a careful selection of cases, salvaged blood can be more cost effective than donor blood. Cell salvage may have a role in cardiac, major vascular, orthopedic, transplant, and trauma surgeries. However, there remain theoretical safety concerns in cases with bacterial contamination or in cancer surgery. CONCLUSION: In addition to other methods of blood conservation used in patient blood management programs, autologous salvaged blood adds value and is cost effective for appropriate surgical cases. Evidence suggests that autologous salvaged blood may be of higher quality and confer a cost reduction compared with the allogeneic banked blood, when used appropriately.

How do I perform cell salvage in obstetrics?

Maternal mortality in the United States is increasing. The leading cause of death is hemorrhage. Maternal hemorrhage can be profound, with entire blood volumes being lost. In most major blood loss surgery, autotranfusion (also known as cell salvage, cell saving, and intraoperative blood collection and readministration) is a technique that has been used to minimize allogeneic transfusion. Historically, autotransfusion has been considered contraindicated in the face of maternal hemorrhage because of a fear of incorporating amniotic fluid in the salvaged blood. Recent data suggests that this fear is unfounded, with several medical societies now recommending that autotransfusion be used during maternal hemorrhage. In this review, autotransfusion during maternal hemorrhage is discussed, and suggestions are made for how to make it most successful.

Patient blood management: recommendations rrom the 2018 Frankfurt consensus conference

What is the current evidence base for patient blood management (PBM) in adults, and what international clinical recommendations can be derived for preoperative anemia, red blood cell transfusion thresholds, and PBM implementation strategies? Diagnosis and management of preoperative anemia is crucial, and iron-deficient anemia should be treated with iron supplementation. Red blood cell transfusion thresholds for critically ill, clinically stable patients (hemoglobin concentration <7 g/dL), patients undergoing cardiac surgery (hemoglobin concentration <7.5 g/dL), patients with hip fractures and cardiovascular disease or risk factors (hemoglobin concentration <8 g/dL), and hemodynamically stable patients with acute gastrointestinal bleeding (hemoglobin concentration 7-8 g/dL) are relatively well defined, although the quality of evidence is moderate to low. Further high-quality research to support PBM is required for a range of clinical scenarios and implementation of PBM programs.

Red blood cell salvage analysis from clotted blood.

BACKGROUND: Blood clots discovered within body cavities intra-operatively are often manually broken up and placed in an autotransfusion device to recover autologous blood cells. This study evaluated the efficiency at which these red blood cells can be recovered from clot and to determine if these cells would be free of fibrin and clumping which might pose a risk of micro-emboli. MATERIALS AND METHODS: Whole blood was aliquoted into 25 mL volume samples. The blood was then allowed to clot, and after 24 hours the clotted blood was manually kneaded by hand for 1, 2, 3, or 5 minutes. One mL of the harvested blood was fixed and processed for scanning electron microscope imaging. Plasma from the rest of the sample was then separated and underwent spectrophotometry for analysis of relative free haemoglobin. RESULTS: Blood recovered from the clotted blood ranged from 60 to 80% as time increased from 1 to 5 minutes of kneading. Volume of erythrocytes recovered from 1 minute compared to 2 minutes was statistically significant but not significant between 2 minutes or any longer period of time. Imaging did not show any evidence of fibrin strands or significant cell fragmentation. Spectrophotometry showed a steady increase of observed absorption at 540 nm, indicative of free haemoglobin, as manual kneading time increased. DISCUSSION: Red blood cells were able to be efficiently recovered from clotted blood. Imaging studies did not show any evidence of red blood cells trapped within fibrin mesh.

Cell salvage for postpartum haemorrhage during vaginal delivery: a case series.

BACKGROUND: The safety and effectiveness of cell salvage for vaginal delivery is unknown. This case series aimed to assess the utility and adverse events related to the use of cell salvage for maternal haemorrhage during vaginal delivery. MATERIALS AND METHODS: A cohort study design was chosen, focused on postpartum haemorrhages that occurred after vaginal delivery for which cell salvage equipment was requested to be set up in the labour and delivery room outside of a sterile operating room environment. Variables recorded included duration of stay in hospital, occurrence of wound infections, sepsis, thromboembolic events, and amniotic fluid embolism. RESULTS: Of 28 cases of postpartum haemorrhage during vaginal deliveries involving the setup or use of cell salvage equipment, ten were associated with successful re-infusion of salvaged shed blood. These ten cases were compared to the 18 cases in which cell salvage equipment was set up, but insufficient shed blood was salvaged for re-infusion. There were no instances of postpartum sepsis, wound infection, or thromboembolism associated with the use of cell salvage for vaginal delivery. Although one case of suspected amniotic fluid embolism occurred, severe symptoms began prior to the infusion of salvaged blood. DISCUSSION: Infusion of salvaged shed blood collected from a vaginal delivery field is feasible. The outcomes of these cases do not exclude an unacceptably high risk of infection or embolic events. Trials evaluating the safety and effectiveness associated with the use of cell salvage in vaginal deliveries are justified.

Successful Resuscitation Following Massive Obstetric Hemorrhage in a Patient of the Jehovah's Witness Faith: A Case Report.

Hemorrhage is a leading cause of maternal morbidity and mortality worldwide. It is especially difficult to treat in patients of the Jehovah's Witness faith because they refuse certain blood products. This case report describes the resuscitation of a parturient Jehovah's Witness whose postcesarean delivery course was complicated by massive hemorrhage from unrecognized arterial bleeding in the intensive care unit with significant hemodynamic instability that necessitated an emergency bedside laparotomy. Her hemoglobin nadir was 1.5 mg/dL. The case demonstrates the key place of preprocedure planning, blood conservation, and coagulation factor management in this specific patient population.

Red blood cell salvage during obstetric hemorrhage.

OBJECTIVE: To describe which obstetric patients lose enough blood during postpartum hemorrhage to receive a reinfusion of intraoperative blood salvage. METHODS: Eight years of intraoperative blood salvage data from a regional tertiary care maternity hospital were analyzed. The volume of blood returned through intraoperative blood salvage was standardized to the volume of red blood cells in an allogeneic red blood cell unit from the blood bank. RESULTS: There were 884 obstetric hemorrhage cases in which intraoperative blood salvage was utilized. Sufficient blood was collected by intraoperative blood salvage to permit reinfusion in 189 of 884 (21%) patients. For patients in whom intraoperative blood salvage blood was reinfused, the mean ± standard deviation number of reinfused shed blood units was 1.2 ± 1.1 units. Although intraoperative blood salvage was most commonly performed on patients who underwent routine cesarean delivery (748/884 patients), only 13% of these patients received an intraoperative blood salvage reinfusion; 73% of the patients undergoing cesarean hysterectomy, 69% of those who had bleeding after cesarean delivery, and 53% of the patients who bled after vaginal delivery received an intraoperative blood salvage reinfusion (P<.001). CONCLUSION: Although intraoperative blood salvage was attempted on many patients, on only 21% of the women was a sufficient amount of intraoperative shed blood collected to proceed with reinfusion. Patients who experienced bleeding or who underwent a cesarean hysterectomy were the most likely to receive a reinfusion of intraoperative blood salvage-processed blood.

Intraoperative blood recovery.

Allogeneic transfusion, or transfusion of blood banked blood has been associated with a litany of complications for the recipient. These complications plus associated cost has led to the development of a concept called "patient blood management," which recognizes that allogeneic transfusion may be necessary; however, all effort should be expended at minimizing its need. Central to reducing or eliminating the need for allogeneic transfusion is the process called "blood salvage." This process involves collection of shed surgical blood, its washing and filtering, and its readministration. This process can take place in the intraoperative or postoperative period. This article describes the technology, how it works, and how to maximize the utility of the system.

Iron deficiency anemia in women across the life span.

Anemia is a global health issue with disproportionately high prevalence in women. In addition to being an independent risk factor for decreased quality of life and increased morbidity and mortality, anemia in women has been linked to unfavorable outcomes of pregnancy and other issues for children born to anemic women. Iron deficiency is the leading cause of anemia in many populations. Guidelines recommend proactive screening for anemia, particularly in the preoperative setting. Once anemia is diagnosed, treatment should be based on etiology (most commonly, iron deficiency followed, in order of prevalence, by inflammation or chronic disease). Iron supplementation (oral and intravenous) offers safe and effective treatment for anemia associated with iron deficiency. Anemia of chronic disease may be more challenging to treat, and attention must be given to the underlying disease, along with use of hematinic agents. Given its enormous impact on the health and well-being of women and the availability of simple and effective treatment options, anemia should never be left unmanaged.

Changes in mechanical fragility and free hemoglobin levels after processing salvaged cardiopulmonary bypass circuit blood with a modified ultrafiltration device.

Modified ultrafiltration (MUF) is available for the salvage of post-cardiopulmonary bypass circuit blood. This study evaluated the extent of hemolysis, the mechanical fragility index (MFI), and the amount of plasma free hemoglobin (PFHb) created after processing with the MUF device. Several RBC parameters were measured on pre- and post-MUF device processed samples of blood from 12 patients undergoing cardiac surgery. The MFI and total amount of PFHb did not change significantly between the pre- and post-processing samples: MFI, pre: .19 +/- .06 versus post: .19 +/- .06, p = .76; total amount of PFHb, pre: .24 +/- .21 g versus post: .20 +/- .12 g, p = .42. There was significantly more hemolysis in the post-processing samples compared with the pre-processing samples, .33 +/- .24% versus .96 +/- .48%, respectively, p < .001. Although percent hemolysis was increased following processing with the MUF device, the total amount of PFHb and RBC sublethal injury were not increased. The clinical significance of these findings needs to be determined.

Blood salvage and cancer surgery: a meta-analysis of available studies.

BACKGROUND: Intraoperative blood salvage (IBS) is a technique that is frequently used in major blood loss surgery. Classically, it is avoided during cancer surgery where a fear exists of entraining cancer cells into the shed blood. In this study, all reports of this practice were collected to determine if this fear is warranted. STUDY DESIGN AND METHODS: A literature search was performed including the search phrases "blood salvage,""intraoperative blood salvage,""cell salvage,""cell saver,""cell saving,""autotransfusion," and "autologous transfusion." Data extracted from suitable papers included the authors' names, publication year, cancer type, exclusion criteria, sample size, length of follow-up, and the mean patient age. The primary endpoint of this meta-analysis was a comparison of the odds ratio (OR) for cancer recurrence or the development of metastases. RESULTS: Eleven studies were included in the analysis. The pooled summary of the OR was 0.65 (95% confidence interval, 0.43-0.98; p = 0.0391) using a random-effects model. Measures of heterogeneity, Q-statistics (p= 0.1615) and I(2) (30.90%), did not indicate a high degree of between-study variability. CONCLUSIONS: While significant variability existed between studies, this meta-analysis suggests that outcomes after the use of IBS are not inferior to traditional intraoperative allogeneic transfusion. An adequately powered prospective, randomized trial of IBS use is required to determine its true risk during cancer surgery.

A cost study of postoperative cell salvage in the setting of elective primary hip and knee arthroplasty.

BACKGROUND: The increasing costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as postoperative red blood cell (RBC) salvage. This study provides a cost comparison of transfusing washed postoperatively salvaged RBCs using an orthopedic perioperative autotransfusion device (OrthoPat, Haemonetics Corporation) versus unwashed shed blood and banked allogeneic blood. STUDY DESIGN AND METHODS: Cell salvage data were retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Mean unit costs were calculated for washed salvaged RBCs, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic RBCs. RESULTS: No initial capital investment was required for the establishment of the postoperative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $1827.41, $1167.41, and $2609.44, respectively. CONCLUSION: This analysis suggests that transfusing washed postoperatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed postoperatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.