Autotransfusion device and cell salvage

OVERVIEW

  • collection system used to recycle blood from a bleeding patient

USE

Indications

  • haemothorax due to trauma — consider for any ICC insertion in trauma
  • surgery:
    — consider intraoperatively where significant blood loss (>1000 ml) is expected, where patients refuse allogeneic blood products or they are anaemic
    — primarily used for cardiac surgery, orthopedics, neurosurgery, vascular surgery and urology

Contra-indications

  • Don’t use the blood if it is likely to be contaminated
    — e.g. penetrating chest trauma, where a stab or gunshot could injure stomach or colon and violate the diaphragm
    — contaminated surgical field (e.g. sterile solution, malignancy, infection)
  • patient refusal

DESCRIPTION

Intercostal catheter system

  • Most chest drain collection systems have optional autotransfusion canisters that connect to the chest tube inline with the collection system
  • The canisters are used to collect shed blood
  • Blood filter
  • Filled canisters can then be hung like a bag of blood from the blood bank

Cell salvage intraoperatively

  • dedicated double-lumen suction device
    — one lumen suctions blood from the operative field
    — the other lumen adds a predetermined volume of heparinized saline to the salvaged blood
  • blood filter
  • reservoir
  • cell saver — separates components by centrifugation
  • saline for washing
  • waste products collection bag
  • collection bag for washed RBCs

METHOD OF USE

Intercostal catheter system

  • Connect the autotransfusion cannister to the chest tube collection system before the chest tube goes in (otherwise most of the blood will be lost)
  • Use an inline leucocyte depletion filter
  • No need to anticoagulate the blood (see blood composition in ‘other information’)
  • Most systems can be used to re-infuse shed blood up to 6 hours after collection without heparin or other products
  • Follow instructions for each specific type of collection system

Cell salvage intraoperatively

  • Double lumen suction device removes blood from operative field and mixes with heparinized saline
  • The anticoagulated blood is then passed through a filter and collected in a reservoir
  • Separation of the components is achieved by centrifugation
  • The RBCs are then washed and filtered across a semi-permeable membrane, which removes free haemoglobin, plasma, platelets, white blood cells, and heparin
  • The salvaged RBCs are then re-suspended in normal saline with a resultant haematocrit of 50–80%
  • The salvaged RBCs may be transfused immediately or within 6 h

COMPLICATIONS

  • blood loss if not connected properly
  • haemodilution (do not expect significant rise in Hb)
  • thrombocytopenia and coagulopathy (only if large volumes)
  • blood contamination and infection
  • contamination with drugs and cleansing solutions
  • incomplete washing/ inadequate filtration leading to contamination with activated leucocytes, cytokines, and other microaggregates
  • non-immune haemolysis (e.g. degradation over time, due to suction)
  • air embolus

OTHER INFORMATION

Composition of blood from intercostal catheter

  • The hemoglobin and haematocrit from the chest tube were lower than venous blood (Hgb by about 2 grams, Hct by 7.5%)
  • Platelet count was very low in chest tube blood
  • Potassium was higher (4.9 mmol/L), but not dangerously so
  • INR, PTT, TT, Factor V and fibrinogen were unmeasurable
    –> need to adhere to hemostatic resuscitation principles and administer FFP and platelets appropriately

Cardiac surgery

  • for cardiac surgery blood should be washed prior to re-infusion
  • re-infusion of unwashed blood after cardiac surgery produces only a marginal benefit and can cause significant adverse effects

References and Links

Journal articles

  • Salhanick M, Corneille M, Higgins R, Olson J, Michalek J, Harrison C, Stewart R, Dent D. Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg 202(6):817-822, 2011 PMID: 22137140
  • Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth. 2010 Oct;105(4):401-16. PMID: 20802228.

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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