Autotransfusion
Encyclopedia
Autotransfusion is a process when a person receives their own blood for a transfusion, instead of banked donor blood. Blood can be pre-donated before a surgery, or can be collected during and after the surgery using a device commonly known as the Cell Saver. The Cell Saver is utilized in surgeries where there is expected a large volume blood loss. For example, aneurysm, total joint replacements and spinal surgeries.
There are also small reservoir devices designed to collect the patients blood for return, such as the Orthopat and Constavacs.
The first documented use of the procedure was in 1818, and interest in the practice continued until the Second World War, at which point blood supply became less of an issue, due to the increased number of blood donors. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of orthopedic, trauma
and cardiac cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells.
s, risk of infectious disease transmission, restricted homologous blood supply or other medical situations for which the use of homologous blood is contraindicated. Autotransfusion is commonly used intraoperatively and postoperatively. Intraoperative autotransfusion refers to recovery of blood lost during surgery or the concentration of fluid in an extracorporeal circuit. Postoperative autotransfusion refers to the recovery of blood in the extracorporeal
circuit at the end of surgery or from aspirated drainage.
and platelet
s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated clotting factors and activated platelets which would cause coagulopathy
if they were reinfused to the patient. This disadvantage is only evident when very large blood losses occur. The autotransfusionist monitors blood loss and will recommend the transfusion of fresh frozen plasma
(FFP) and platelets when the blood loss and return of autotransfusion blood increases. Typically the patient will require FFP and platelets as the estimated blood loss exceeds half of the patient's blood volume. When possible diagnostic tests should be performed to determine the need for any blood products (i.e. PRBCs, FFP and Platelets).
l contamination
or malignancy. The use of autotransfusion in the presence of such contamination may result in the dissemination of pathologic microorganisms and / or malignant cells. The following statements reflect current clinical concerns involving autotransfusion contraindications.
cells from the surgical site. There are possible exceptions to this contraindication:
The use of Leukocyte reduction filters is recommended.
embolism
exists. Emerging literature suggests that amniotic fluid is being cleared during the wash cycle. It is possible that the utilization of autotransfusion in obstetrics may increase as more research is completed. However, if a patient is at risk for blood loss and is a Jehovah's witness, for example, the cell saver can be used with strict guidelines of irrigating profusely to remove amniotic fluid and then suctioning the blood that is being lost.
, bowel contamination and malignancy.
reservoir. The reservoir contains filter and has a capacity of between two and three liters of fluid. When a volume adequate to fill the wash bowl has been collected, processing may begin. The volume required to fill the bowl is dependent on the concentration of red cells collected (hematocrit) and size of the centrifuge wash bowl. But if the patients HCT (hematocrit) is normal, the amount needed to process a unit is roughly two times the bowl volume. Therefore, if the centrifuge processing bowl size is 250 ml, you will need roughly 500 ml of blood.
When aspirating the blood it is important to utilize the following technique whenever possible:
Following these techniques will help reduce hemolysis
of the red cells and will help increase the amount of red cells that will be salvaged.
type products are used, autotransfusion should be interrupted and a waste or wall suction source must be used. Autotransfusion can be resumed once these products are flushed from the surgical site. If Gelfoam, Surgicel, Thrombogen or Thrombostat are used, autotransfusion can continue, however direct suctioning of these products should be avoided. The clinically experienced autotransfusionist is familiar with the commonly used products and will know whether the autotransfusion must be interrupted.
is often used or encountered during primary or revision total joint replacement surgery. The cement when in the liquid or soft state should not be introduced into the autotransfusion system. When cement is being applied a waste or wall suction source must be used, however when the cement hardens autotransfusion may be resumed. The use of ultrasonic equipment during revision of total joints changes the cement to a liquid or soft state, which precludes the use of autotransfusion during the use of such equipment. Autotransfusion can only continue when the cement has hardened.
begins rotation and accelerates to the speed selected on the centrifuge speed control, typically 5,600 rpm. Simultaneously, the pump begins counterclockwise rotation, enabling the transfer of the reservoir contents to the wash bowl. The application of centrifugal force separates the components of the fluid according to their weight. The wash bowl filling continues until the buffy-coat reaches the shoulder of the wash bowl. The buffy-coat is the accumulation of platelets and white cell
s which appears during centrifugation as an interface between the red cells and supernatant. Some autotransfusion devices have automatic features including a buffy-coat sensor, which is calibrated to detect a full bowl and advance the process to the wash phase automatically.
s, intracellular enzyme
s, plasma, platelets, and white cells. The unwanted fluid passes out of the wash bowl and into a waste reservoir bag. Washing continues until the reinfuse button is depressed and the appropriate amount of wash solution has been delivered to the wash bowl. The wash phase is terminated when one to two liters of wash solution has been transferred, or the fluid transferred to the waste bag appears transparent (or both). An autotransfusion device with automatic features will pump the wash solution which was set by the autotransfusionist and then automatically proceed to the reinfuse phase.
Therefore, it is recommended to use a separate blood bag attached to the reinfusion bag. This second bag can then be disconnected, air purged from it, and then tied off before giving to anesthesia for reinfusion. Thus reducing the chances of an air embolism.
In accordance with Guidelines set by the American Association of Blood Banks the blood should be reinfused within 4 hours from washing.
autotransfusion suction line directly to the drain line placed at the conclusion of surgery. Postoperative autotransfusion begins in the operating room when the drain line is placed and the surgical site is closed. Typical postoperative cases are total knee
and hip replacement
s. Autotransfusion is continued and is effective while the patient actively bleeds during the immediate postoperative phase of recovery. Autotransfusion is ended when bleeding is stopped or is significantly slow, autotransfusion is discontinued by connecting an ordinary self draining device such as a Hemovac container to the drain line(s). Available for postoperative autotransfusion are universal bifurcated connectors which can accommodate two drain lines of any size, these connectors can be attached to the standard ten foot double lumen suction line for postoperative use.
ized saline
is add to the basin to prevent clotting and facilitate the release of red cells. The sponges are periodically wrung out and removed from the basin, the remaining solution can be suction into the autotransfusion reservoir so that the red cells can be recovered.
The ratio of heparinized saline is 5,000 units of Heparin per 1,000 ml of 0.9% Sodium Chloride. The heparin is removed during the autotransfusion process.
and Thrombin
to create a product known as autologous platelet gel (APG). This is an Autologous product which can be used for a variety of techniques including use as a hemostatic aid, a dural sealant and an aid to fusion of bone. Its applications are being widely studied and reported in the literature on a regular basis recently.
During the American Civil War
Union Army physicians are said to have administered four transfusions. In 1886, J. Duncan used autotransfusion during the amputation
of limbs by removing blood from the amputated limb and returning it to the patient by femoral injection. This method was apparently fairly successful.A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured ectopic pregnancy
. The earliest report in the American literature on the use of autotransfusion was by Lockwood in 1917 who used the technique during a splenectomy
for Banti syndrome. Interest in unrefined technique of autotransfusion continued through to the early 1940s, and was applied to various procedures including treatment of ectopic pregnancyhemothorax, ruptured spleen, perforating abdominal injuries, and neurosurgical procedures.
The interest in autotransfusion dwindled during World War Two, when there was a large pool of donors. After the war, blood testing, typing and crossmatching techniques were improved makingblood bank
s the answer to the increased demand for blood. In the 1960s, interest in autotransfusion revived. With the advances in all fields of surgery, new companies developed autotransfusion devices. Problems still arose, however, with air embolism, coagulopathy
and hemolysis. The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused. With the introduction of cardiopulmonary bypass in 1952, autotransfusion became an area of study. Klebanoff began a new era of autotransfusion by developing the first commercially available autotransfusion unit in 1968. His system, the Bentley Autotransfusion System aspirated, collected, filtered and reinfused autologous whole blood shed from the operative field. The problems with the Bentley system included the requirement of systemic anticoagulation of the patient, introduction of air embolism, and renal failure resulting from unfiltered particulate in the reinfused blood.
As the Bentley system lost favor Wilson and associates proposed the use of a discontinuous flow centrifuge process for autotransfusion which would wash the red cells with normal saline solution. In 1976, this system was introduced by Haemonetics Corp. and is known commonly as "Cell Saver". More recently in 1995 Fresenius introduced a continuous autotransfusion system.
There are three types of systems: un-washed filtered blood; discontinuous flow centrifugal; and continuous flow centrifugal. The unwashed systems are popular because of their perceived inexpense and simplicity. However unwashed systems can cause increase potential for clinical complications. The washed system requires a properly trained and clinically skilled operator. It returns only red blood cells suspended in saline and is rarely associated with any clinical complications. The use of Autotransfusion process described in this documented reflects the washed discontinuous centrifugal system. This type of autotransfusion can practically eliminate the need for exposure to homologous blood in elective surgical patients and can greatly reduce the risk of exposure to emergency surgical patients. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.
There are also small reservoir devices designed to collect the patients blood for return, such as the Orthopat and Constavacs.
The first documented use of the procedure was in 1818, and interest in the practice continued until the Second World War, at which point blood supply became less of an issue, due to the increased number of blood donors. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of orthopedic, trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
and cardiac cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells.
Medical uses
Autotransfusion is intended for use in situations characterized by the loss of one or more units of blood and may be particularly advantageous for use in cases involving rare blood groupHuman blood group systems
The International Society of Blood Transfusion currently recognises 30 major blood group systems . Thus, in addition to the ABO antigens and Rhesus antigens, many other antigens are expressed on the red blood cell surface membrane...
s, risk of infectious disease transmission, restricted homologous blood supply or other medical situations for which the use of homologous blood is contraindicated. Autotransfusion is commonly used intraoperatively and postoperatively. Intraoperative autotransfusion refers to recovery of blood lost during surgery or the concentration of fluid in an extracorporeal circuit. Postoperative autotransfusion refers to the recovery of blood in the extracorporeal
Extracorporeal
An extracorporeal medical procedure is a medical procedure which is performed outside the body.-Circulatory procedures:A procedure in which blood is taken from a patient's circulation to have a process applied to it before it is returned to the circulation...
circuit at the end of surgery or from aspirated drainage.
Advantages
- High levels of 2,3 DPG
- Normothermic
- pH relatively normal
- Lower risk of Infectious Diseases
- Functionally superior cells
- Lower Potassium (compared to stored blood)
- Quickly available
Substances washed out
- Plasma
- Platelets
- White Cells
- Anticoagulant Solution
- Plasma free Hemoglobin
- Cellular stroma
- Activated clotting factors
- Intracellular Enzymes
- Potassium
- Plasma bound Antibiotics
Disadvantages
The disadvantage of autotransfusion is the depletion of plasmaBlood plasma
Blood plasma is the straw-colored liquid component of blood in which the blood cells in whole blood are normally suspended. It makes up about 55% of the total blood volume. It is the intravascular fluid part of extracellular fluid...
and platelet
Platelet
Platelets, or thrombocytes , are small,irregularly shaped clear cell fragments , 2–3 µm in diameter, which are derived from fragmentation of precursor megakaryocytes. The average lifespan of a platelet is normally just 5 to 9 days...
s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated clotting factors and activated platelets which would cause coagulopathy
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
if they were reinfused to the patient. This disadvantage is only evident when very large blood losses occur. The autotransfusionist monitors blood loss and will recommend the transfusion of fresh frozen plasma
Fresh frozen plasma
The term fresh frozen plasma refers to the liquid portion of human blood that has been frozen and preserved after a blood donation and will be used for blood transfusion...
(FFP) and platelets when the blood loss and return of autotransfusion blood increases. Typically the patient will require FFP and platelets as the estimated blood loss exceeds half of the patient's blood volume. When possible diagnostic tests should be performed to determine the need for any blood products (i.e. PRBCs, FFP and Platelets).
Contraindications
The use of blood recovered from the operative field is contraindicated in the presence of bacteriaBacteria
Bacteria are a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria have a wide range of shapes, ranging from spheres to rods and spirals...
l contamination
Contamination
Contamination is the presence of a minor and unwanted constituent in material, physical body, natural environment, at a workplace, etc.-Specifics:"Contamination" also has more specific meanings in science:...
or malignancy. The use of autotransfusion in the presence of such contamination may result in the dissemination of pathologic microorganisms and / or malignant cells. The following statements reflect current clinical concerns involving autotransfusion contraindications.
Contamination of the surgical site
Any abdominal procedure poses the risk of enteric contamination of shed blood. The surgical team must be diligent in observing for signs of bowel contamination of the blood. If there is a question of possible contamination the blood may be held until the surgeon determines whether or not bowel contents are in the surgical field. If the blood is contaminated the entire contents should be discarded. If the patient's life depends upon this blood supply it may be reinfused with the surgeon's consent, while washing with large amounts of NaCl .9% will reduce the bacterial contamination of the blood, it will not be totally eliminated.Malignancy
There is a possibility of the reinfusion of cancerCancer
Cancer , known medically as a malignant neoplasm, is a large group of different diseases, all involving unregulated cell growth. In cancer, cells divide and grow uncontrollably, forming malignant tumors, and invade nearby parts of the body. The cancer may also spread to more distant parts of the...
cells from the surgical site. There are possible exceptions to this contraindication:
- The surgeon feels complete removal of an encapsulated tumorTumorA tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
is possible. Blood may be aspirated from the surgical site, processed and reinfused with the surgeon's consent. - If an inadequate supply of blood exists, the washed red cells may be used to support the patient's vital signs with the surgeon's consent.
The use of Leukocyte reduction filters is recommended.
Obstetrics
Autotransfusion is not normally used in C-Sections, because the possibility of an amniotic fluidAmniotic fluid
Amniotic fluid or liquor amnii is the nourishing and protecting liquid contained by the amniotic sac of a pregnant woman.- Development of amniotic fluid :...
embolism
Embolism
In medicine, an embolism is the event of lodging of an embolus into a narrow capillary vessel of an arterial bed which causes a blockage in a distant part of the body.Embolization is...
exists. Emerging literature suggests that amniotic fluid is being cleared during the wash cycle. It is possible that the utilization of autotransfusion in obstetrics may increase as more research is completed. However, if a patient is at risk for blood loss and is a Jehovah's witness, for example, the cell saver can be used with strict guidelines of irrigating profusely to remove amniotic fluid and then suctioning the blood that is being lost.
Emergency
In life saving situations with the consent of the surgeon, autotransfusion can be utilized in the presence of the previous stated contraindications i.e. sepsisSepsis
Sepsis is a potentially deadly medical condition that is characterized by a whole-body inflammatory state and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues...
, bowel contamination and malignancy.
Collection and processing of blood
Utilizing a special double lumen suction tubing, fluid is aspirated from the operative field, and is mixed with an anticoagulant solution. Collected fluid is filtered in a sterile cardiotomyCardiotomy
A cardiotomy is a procedure where an incision is made in the heart.It can be used for suction during heart surgery....
reservoir. The reservoir contains filter and has a capacity of between two and three liters of fluid. When a volume adequate to fill the wash bowl has been collected, processing may begin. The volume required to fill the bowl is dependent on the concentration of red cells collected (hematocrit) and size of the centrifuge wash bowl. But if the patients HCT (hematocrit) is normal, the amount needed to process a unit is roughly two times the bowl volume. Therefore, if the centrifuge processing bowl size is 250 ml, you will need roughly 500 ml of blood.
When aspirating the blood it is important to utilize the following technique whenever possible:
- Suction blood from pools rather than skimmingSkimmer (machine)An oil skimmer is a machine that separates a liquid from particles floating on it or from another liquid. A common application is removing oil floating on water. These technologies are commonly used for oil spill remediation but are also commonly found in industry...
. - Keep the suction tip below the level of the air-blood interface.
- Avoid occluding the suction tip (i.e. using suction as a retractor).
Following these techniques will help reduce hemolysis
Hemolysis
Hemolysis —from the Greek meaning "blood" and meaning a "loosing", "setting free" or "releasing"—is the rupturing of erythrocytes and the release of their contents into surrounding fluid...
of the red cells and will help increase the amount of red cells that will be salvaged.
Antibiotic irrigation
Antibiotics which are plasma bound can be removed during the autotransfusion wash cycle, however topical antibiotics which are typically not plasma bound may not be washed out during autotransfusion, and may actually become concentrated to the point of being nephrotoxic.Topical coagulant products
When Avitene, Hemopad, Instat, or collagenCollagen
Collagen is a group of naturally occurring proteins found in animals, especially in the flesh and connective tissues of mammals. It is the main component of connective tissue, and is the most abundant protein in mammals, making up about 25% to 35% of the whole-body protein content...
type products are used, autotransfusion should be interrupted and a waste or wall suction source must be used. Autotransfusion can be resumed once these products are flushed from the surgical site. If Gelfoam, Surgicel, Thrombogen or Thrombostat are used, autotransfusion can continue, however direct suctioning of these products should be avoided. The clinically experienced autotransfusionist is familiar with the commonly used products and will know whether the autotransfusion must be interrupted.
Orthopaedic bone cement
CementCement
In the most general sense of the word, a cement is a binder, a substance that sets and hardens independently, and can bind other materials together. The word "cement" traces to the Romans, who used the term opus caementicium to describe masonry resembling modern concrete that was made from crushed...
is often used or encountered during primary or revision total joint replacement surgery. The cement when in the liquid or soft state should not be introduced into the autotransfusion system. When cement is being applied a waste or wall suction source must be used, however when the cement hardens autotransfusion may be resumed. The use of ultrasonic equipment during revision of total joints changes the cement to a liquid or soft state, which precludes the use of autotransfusion during the use of such equipment. Autotransfusion can only continue when the cement has hardened.
Prime phase
When the "prime" button is pressed, the centrifugeCentrifuge
A centrifuge is a piece of equipment, generally driven by an electric motor , that puts an object in rotation around a fixed axis, applying a force perpendicular to the axis...
begins rotation and accelerates to the speed selected on the centrifuge speed control, typically 5,600 rpm. Simultaneously, the pump begins counterclockwise rotation, enabling the transfer of the reservoir contents to the wash bowl. The application of centrifugal force separates the components of the fluid according to their weight. The wash bowl filling continues until the buffy-coat reaches the shoulder of the wash bowl. The buffy-coat is the accumulation of platelets and white cell
White blood cell
White blood cells, or leukocytes , are cells of the immune system involved in defending the body against both infectious disease and foreign materials. Five different and diverse types of leukocytes exist, but they are all produced and derived from a multipotent cell in the bone marrow known as a...
s which appears during centrifugation as an interface between the red cells and supernatant. Some autotransfusion devices have automatic features including a buffy-coat sensor, which is calibrated to detect a full bowl and advance the process to the wash phase automatically.
Wash phase
The wash phase begins when the wash bowl is appropriately filled with red cells. The autotransfusion devices with automatic features, when operated in the automatic mode will advance to the wash phase without action from the autotransfusionist. The pump continues a counterclockwise rotation and clamps adjust, enabling the transfer of wash solution to the wash bowl. The washing phase removes cellular stromata, plasma free hemoglobin, anticoagulant solution, activated clotting factors, any plasma bound antibioticAntibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
s, intracellular enzyme
Enzyme
Enzymes are proteins that catalyze chemical reactions. In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules, called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates...
s, plasma, platelets, and white cells. The unwanted fluid passes out of the wash bowl and into a waste reservoir bag. Washing continues until the reinfuse button is depressed and the appropriate amount of wash solution has been delivered to the wash bowl. The wash phase is terminated when one to two liters of wash solution has been transferred, or the fluid transferred to the waste bag appears transparent (or both). An autotransfusion device with automatic features will pump the wash solution which was set by the autotransfusionist and then automatically proceed to the reinfuse phase.
Empty phase
When the Empty function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of (emptying) the wash bowl contents to the reinfusion bag. An autotransfusion device with automatic features will pump the blood into the reinfusion bag and stop when the bowl is emptied. The centrifuge bowl must come to a complete stop before the pump begins a clockwise rotation to empty the bowl. Once the bowl is emptied, the "stop" button can be pressed to complete the cycle, or the "prime" button can be pressed to start a new cycle. The reinfusion bag attached to the autotransfusion wash set should not be used for high pressure infusion back to the patient. The reinfusion bag contains a significant amount of air, careful monitoring should take place during reinfusion to avoid the potential of air embolism.Therefore, it is recommended to use a separate blood bag attached to the reinfusion bag. This second bag can then be disconnected, air purged from it, and then tied off before giving to anesthesia for reinfusion. Thus reducing the chances of an air embolism.
In accordance with Guidelines set by the American Association of Blood Banks the blood should be reinfused within 4 hours from washing.
Postoperative autotransfusion
Postoperative autotransfusion is performed by connecting the double lumenLumen (anatomy)
A lumen in biology is the inside space of a tubular structure, such as an artery or intestine...
autotransfusion suction line directly to the drain line placed at the conclusion of surgery. Postoperative autotransfusion begins in the operating room when the drain line is placed and the surgical site is closed. Typical postoperative cases are total knee
Knee replacement
Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. It may be performed for other knee diseases such as rheumatoid arthritis and psoriatic arthritis...
and hip replacement
Hip replacement
Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant. Hip replacement surgery can be performed as a total replacement or a hemi replacement. Such joint replacement orthopaedic surgery generally is conducted to relieve arthritis pain or fix severe...
s. Autotransfusion is continued and is effective while the patient actively bleeds during the immediate postoperative phase of recovery. Autotransfusion is ended when bleeding is stopped or is significantly slow, autotransfusion is discontinued by connecting an ordinary self draining device such as a Hemovac container to the drain line(s). Available for postoperative autotransfusion are universal bifurcated connectors which can accommodate two drain lines of any size, these connectors can be attached to the standard ten foot double lumen suction line for postoperative use.
Soaking sponges
In some institutions to maximize the effectiveness of autotransfusion and provide the best conservation and return of red cells the soaking of sponges is employed. During the surgical procedure the blood soaked sponges are collected and placed in a sterile basin by the surgical team, sterile heparinHeparin
Heparin , also known as unfractionated heparin, a highly sulfated glycosaminoglycan, is widely used as an injectable anticoagulant, and has the highest negative charge density of any known biological molecule...
ized saline
Saline (medicine)
In medicine, saline is a general term referring to a sterile solution of sodium chloride in water but is only sterile when it is to be placed intravenously, otherwise, a saline solution is a salt water solution...
is add to the basin to prevent clotting and facilitate the release of red cells. The sponges are periodically wrung out and removed from the basin, the remaining solution can be suction into the autotransfusion reservoir so that the red cells can be recovered.
The ratio of heparinized saline is 5,000 units of Heparin per 1,000 ml of 0.9% Sodium Chloride. The heparin is removed during the autotransfusion process.
Society and culture
Individuals of the Jehovah's Witness religion in particular refuse to accept Homologous and Autologous pre-donated blood. However some individual members may accept the use of autotransfusion by means of the Cell Saver. The process of autotransfusion using the Cell Saver is modified to maintain a continuous circuit of blood which maintains continuous contact with the body. This process when carefully explained to the patient may be acceptable when a patient refuses based on religious beliefs.Platelet sequestration and autologous platelet gel
Many of the newest autotransfusion machines are programmable to provide separation of blood into three groups; Red Cells, Platelet Poor Plasma, and Platelet Rich Plasma. Blood can be drawn from the patient just prior to surgery and then separated. The separated blood components which have been sequestered can be stored during the surgical procedure. The Red Cells and Platelet Poor Plasma can be given back to the patient through Intravenous transfusion during or after surgery. The Platelet Rich Plasma can be mixed with CalciumCalcium
Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...
and Thrombin
Thrombin
Thrombin is a "trypsin-like" serine protease protein that in humans is encoded by the F2 gene. Prothrombin is proteolytically cleaved to form thrombin in the first step of the coagulation cascade, which ultimately results in the stemming of blood loss...
to create a product known as autologous platelet gel (APG). This is an Autologous product which can be used for a variety of techniques including use as a hemostatic aid, a dural sealant and an aid to fusion of bone. Its applications are being widely studied and reported in the literature on a regular basis recently.
History
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused apost-partumpatient. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patients with postpartum hemorrhage. By swabbing the blood from the bleeding site and rinsing the swabs with saline, he found that he could re-infuse the result of the washings. This unsophisticated method resulted in a 75% mortality rate, but it marked the start of autologous blood transfusion.During the American Civil War
American Civil War
The American Civil War was a civil war fought in the United States of America. In response to the election of Abraham Lincoln as President of the United States, 11 southern slave states declared their secession from the United States and formed the Confederate States of America ; the other 25...
Union Army physicians are said to have administered four transfusions. In 1886, J. Duncan used autotransfusion during the amputation
Amputation
Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventative surgery for...
of limbs by removing blood from the amputated limb and returning it to the patient by femoral injection. This method was apparently fairly successful.A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
. The earliest report in the American literature on the use of autotransfusion was by Lockwood in 1917 who used the technique during a splenectomy
Splenectomy
A splenectomy is a surgical procedure that partially or completely removes the spleen.-Indications:The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight...
for Banti syndrome. Interest in unrefined technique of autotransfusion continued through to the early 1940s, and was applied to various procedures including treatment of ectopic pregnancyhemothorax, ruptured spleen, perforating abdominal injuries, and neurosurgical procedures.
The interest in autotransfusion dwindled during World War Two, when there was a large pool of donors. After the war, blood testing, typing and crossmatching techniques were improved makingblood bank
Blood bank
A blood bank is a cache or bank of blood or blood components, gathered as a result of blood donation, stored and preserved for later use in blood transfusion. The term "blood bank" typically refers to a division of a hospital laboratory where the storage of blood product occurs and where proper...
s the answer to the increased demand for blood. In the 1960s, interest in autotransfusion revived. With the advances in all fields of surgery, new companies developed autotransfusion devices. Problems still arose, however, with air embolism, coagulopathy
Coagulopathy
Coagulopathy is a condition in which the blood’s ability to clot is impaired. This condition can cause prolonged or excessive bleeding, which may occur spontaneously or following an injury or medical and dental procedures.The normal clotting process depends on the interplay of various proteins in...
and hemolysis. The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused. With the introduction of cardiopulmonary bypass in 1952, autotransfusion became an area of study. Klebanoff began a new era of autotransfusion by developing the first commercially available autotransfusion unit in 1968. His system, the Bentley Autotransfusion System aspirated, collected, filtered and reinfused autologous whole blood shed from the operative field. The problems with the Bentley system included the requirement of systemic anticoagulation of the patient, introduction of air embolism, and renal failure resulting from unfiltered particulate in the reinfused blood.
As the Bentley system lost favor Wilson and associates proposed the use of a discontinuous flow centrifuge process for autotransfusion which would wash the red cells with normal saline solution. In 1976, this system was introduced by Haemonetics Corp. and is known commonly as "Cell Saver". More recently in 1995 Fresenius introduced a continuous autotransfusion system.
There are three types of systems: un-washed filtered blood; discontinuous flow centrifugal; and continuous flow centrifugal. The unwashed systems are popular because of their perceived inexpense and simplicity. However unwashed systems can cause increase potential for clinical complications. The washed system requires a properly trained and clinically skilled operator. It returns only red blood cells suspended in saline and is rarely associated with any clinical complications. The use of Autotransfusion process described in this documented reflects the washed discontinuous centrifugal system. This type of autotransfusion can practically eliminate the need for exposure to homologous blood in elective surgical patients and can greatly reduce the risk of exposure to emergency surgical patients. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.
External links
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