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Neef V, Meybohm P, Zacharowski K, Kranke P. Current concepts in the use of cell salvage in obstetrics. Curr Opin Anaesthesiol 2024; 37:213-218. [PMID: 38391030 PMCID: PMC11062610 DOI: 10.1097/aco.0000000000001337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW The worldwide leading cause of maternal death is severe maternal hemorrhage. Maternal hemorrhage can be profound leading to an entire loss of blood volume. In the past two decades, Patient Blood Management has evolved to improve patient's care and safety. In surgeries with increased blood loss exceeding 500 ml, the use of cell salvage is strongly recommended in order to preserve the patient's own blood volume and to minimize the need for allogeneic red blood cell (RBC) transfusion. In this review, recent evidence and controversies of the use of cell salvage in obstetrics are discussed. RECENT FINDINGS Numerous medical societies as well as national and international guidelines recommend the use of cell salvage during maternal hemorrhage. SUMMARY Intraoperative cell salvage is a strategy to maintain the patient's own blood volume and decrease the need for allogeneic RBC transfusion. Historically, cell salvage has been avoided in the obstetric population due to concerns of iatrogenic amniotic fluid embolism (AFE) or induction of maternal alloimmunization. However, no definite case of AFE has been reported so far. Cell salvage is strongly recommended and cost-effective in patients with predictably high rates of blood loss and RBC transfusion, such as women with placenta accreta spectrum disorder. However, in order to ensure sufficient practical experience in a multiprofessional obstetric setting, liberal use of cell salvage appears advisable.
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Affiliation(s)
- Vanessa Neef
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hospital, Department of Anesthesiology, Intensive Care Medicine and Pain Therapy
| | - Peter Kranke
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
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Katz D, Griffel A, Granozio S, Koenig G, Lin HM. Impact of cell salvage on hematocrit and post-partum anemia in low hemorrhage risk elective cesarean delivery. Transfus Apher Sci 2024; 63:103923. [PMID: 38637253 DOI: 10.1016/j.transci.2024.103923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/02/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Postpartum anemia is a significant contributor to peripartum morbidity. The utilization of cell salvage in low risk cases and its impact on postpartum anemia has not been investigated. We therefore aimed to examine the impact of autologous blood transfusion/cell salvage in routine cesarean delivery on postoperative hematocrit and anemia. STUDY DESIGN AND METHODS Retrospective cohort study from a perfusion database from a large academic center where cell salvage is performed at the discretion of the obstetrical team. Data from 99 patients was obtained. All patients were scheduled elective cesarean deliveries that took place on the labor and delivery floor. Thirty patients in the cohort had access to cell salvage where autologous blood was transfused after surgery. Pre-procedural hemoglobin/hematocrit measurements were obtained along will postpartum samples that were collected on post-partum day one. RESULTS The median amount of blood returned to cell salvage patients was 250 mL [206-250]. Hematocrit changes in cell salvage patients was significantly smaller than controls (-1.85 [-3.87, -0.925] vs -6.4 [-8.3, -4.75]; p < 0.001). The odds of developing new anemia following surgery were cut by 74% for the cell salvage treatment group, compared to the odds for the control group (OR = 0.26 (0.07-0.78); p = 0.028) DISCUSSION: Despite losing more blood on average, patients with access to cell salvage had higher postoperative HCT, less postpartum anemia, and no difference in complications related to transfusion. The utilization of cell salvage for routine cesarean delivery warrants further research.
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Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Obstetrics, Gynecology, & Reproductive Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Annalin Griffel
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Granozio
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gary Koenig
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Obstetrics, Gynecology, & Reproductive Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Anesthesiology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Hung-Mo Lin
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, 06510, USA
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Mackeen AD, Sullivan MV, Berghella V. Evidence-based cesarean delivery: preoperative management (part 7). Am J Obstet Gynecol MFM 2024; 6:101362. [PMID: 38574855 DOI: 10.1016/j.ajogmf.2024.101362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/06/2024]
Abstract
Preoperative preparation for cesarean delivery is a multistep approach for which protocols should exist at each hospital system. These protocols should be guided by the findings of this review. The interventions reviewed and recommendations made for this review have a common goal of decreasing maternal and neonatal morbidity and mortality related to cesarean delivery. The preoperative period starts before the patient's arrival to the hospital and ends immediately before skin incision. The Centers for Disease Control and Prevention recommends showering with either soap or an antiseptic solution at least the night before a procedure. Skin cleansing in addition to this has not been shown to further decrease rates of infection. Hair removal at the cesarean skin incision site is not necessary, but if preferred by the surgical team then clipping or depilatory creams should be used rather than shaving. Preoperative enema is not recommended. A clear liquid diet may be ingested up to 2 hours before and a light meal up to 6 hours before cesarean delivery. Consider giving a preoperative carbohydrate drink to nondiabetic patients up to 2 hours before planned cesarean delivery. Weight-based intravenous cefazolin is recommended 60 minutes before skin incision: 1-2 g intravenous for patients without obesity and 2 g for patients with obesity or weight ≥80 kg. Adjunctive azithromycin 500 mg intravenous is recommended for patients with labor or rupture of membranes. Preoperative gabapentin can be considered as a way to decrease pain scores with movement in the postoperative period. Tranexamic acid (1 g in 10-20 mL of saline or 10 mg/kg intravenous) is recommended prophylactically for patients at high risk of postpartum hemorrhage and can be considered in all patients. Routine use of mechanical venous thromboembolism prophylaxis is recommended preoperatively and is to be continued until the patient is ambulatory. Music and active warming of the patient, and adequate operating room temperature improves outcomes for the patient and neonate, respectively. Noise levels should allow clear communication between teams; however, a specific decibel level has not been defined in the data. Patient positioning with left lateral tilt decreases hypotensive episodes compared with right lateral tilt, which is not recommended. Manual displacers result in fewer hypotensive episodes than left lateral tilt. Both vaginal and skin preparation should be performed with either chlorhexidine (preferred) or povidone iodine. Placement of an indwelling urinary catheter is not necessary. Nonadhesive drapes are recommended. Cell salvage, although effective for high-risk patients, is not recommended for routine use. Maternal supplemental oxygen does not improve outcomes. A surgical safety checklist (including a timeout) is recommended for all cesarean deliveries.
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Affiliation(s)
- A Dhanya Mackeen
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan).
| | - Maranda V Sullivan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Geisinger, Danville, PA (Drs Mackeen and Sullivan)
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA (Dr Berghella)
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Neef V, Friedrichson B, Jasny T, Old O, Raimann FJ, Choorapoikayil S, Steinbicker AU, Meybohm P, Zacharowski K, Kloka JA. Use of cell salvage in obstetrics in Germany: analysis of national database of 305 610 cases with peripartum haemorrhage. Br J Anaesth 2024:S0007-0912(23)00730-4. [PMID: 38267339 DOI: 10.1016/j.bja.2023.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND One of the leading causes of maternal death worldwide is severe obstetric haemorrhage after childbirth. Use of intraoperative cell salvage is strongly recommended by international guidelines on patient blood management. Recent data provide strong evidence that use of cell salvage in obstetrics is effective and safe in women with postpartum haemorrhage resulting in fewer transfusion-related adverse events and shorter hospital stay. We retrospectively analysed the use of cell salvage in bleeding women during delivery for a period of 10 yr in German hospitals. METHODS Data from the German Federal Statistical Office were used that covers all in-hospital birth deliveries from 2011 to 2020. Prevalence of peripartum haemorrhage (pre-, intra-, and post-partum haemorrhage), comorbidities, peripartum complications, administration of blood products, and use of cell salvage were analysed. RESULTS Of 6 356 046 deliveries in Germany, 305 610 women (4.8%) suffered from peripartum haemorrhage. Of all women with peripartum haemorrhage, postpartum haemorrhage was the main cause for major obstetric haemorrhage (92.33%). Cell salvage was used in only 228 (0.07%) of all women with peripartum haemorrhage (cell salvage group). In women undergoing Caesarean delivery with postpartum haemorrhage, cell salvage was used in only 216 out of 70 450 women (0.31%). CONCLUSION Cell salvage during peripartum haemorrhage is rarely used in Germany. There is tremendous potential for the increased use of cell salvage in peripartum haemorrhage nationwide.
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Affiliation(s)
- Vanessa Neef
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany.
| | - Benjamin Friedrichson
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Thomas Jasny
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Oliver Old
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Florian J Raimann
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Suma Choorapoikayil
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Andrea U Steinbicker
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Patrick Meybohm
- University Hospital Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg, Germany
| | - Kai Zacharowski
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
| | - Jan Andreas Kloka
- Goethe University Frankfurt, University Hopsital, Department of Anaesthesiologie, Intensive Care Medicine and Pain Therapy, Frankfurt, Germany
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Phillips JM, Larkin J, Waters JH, Tamura T, Sakamoto S. Maternal outcomes following postpartum autotransfusion of blood lost during vaginal obstetric hemorrhage. Transfusion 2024; 64:77-84. [PMID: 37997677 DOI: 10.1111/trf.17603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/25/2023]
Abstract
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.
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Affiliation(s)
- Jaclyn M Phillips
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Division of Maternal Fetal Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Jacob Larkin
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Division of Maternal Fetal Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Jonathan H Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Takahiro Tamura
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Sara Sakamoto
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Division of Maternal Fetal Medicine, University of Pittsburgh Medical Center Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
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de Vries PLM, van den Akker T, Bloemenkamp KWM, Grossetti E, Rigouzzo A, Saucedo M, Verspyck E, Zwart J, Deneux-Tharaux C. Binational confidential enquiry of maternal deaths due to postpartum hemorrhage in France and the Netherlands: Lessons learned through the perspective of a different context of care. Int J Gynaecol Obstet 2023; 162:1077-1085. [PMID: 37177815 DOI: 10.1002/ijgo.14829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/14/2023] [Accepted: 04/12/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To learn lessons for maternity care by scrutinizing postpartum hemorrhage management (PPH) in cases of PPH-related maternal deaths in France and the Netherlands. METHODS In this binational Confidential Enquiry into Maternal Deaths (CEMD), 14 PPH-related maternal deaths were reviewed by six experts from the French and Dutch national maternal death review committees regarding cause and preventability of death, clinical care and healthcare organization. Improvable care factors and lessons learned were identified. CEMD practices and PPH guidelines in France and the Netherlands were compared in the process. RESULTS For France, new insights were primarily related to organization of healthcare, with lessons learned focusing on medical leadership and implementation of (surgical) checklists. For the Netherlands, insights were mainly related to clinical care, emphasizing hemostatic surgery earlier in the course of PPH and reducing the third stage of labor by prompter manual removal of the placenta. Experts recommended extending PPH guidelines with specific guidance for women refusing blood products and systematic evaluation of risk factors. The quality of CEMD was presumed to benefit from enhanced case finding, also through non-obstetric sources, and electronic reporting of maternal deaths to reduce the administrative burden. CONCLUSION A binational CEMD revealed opportunities for improvement of care beyond lessons learned at the national level.
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Affiliation(s)
- P L M de Vries
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Port-Royal Maternity Unit, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - T van den Akker
- Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, VU University, Amsterdam, The Netherlands
| | - K W M Bloemenkamp
- Department of Obstetrics, WKZ Birth Centre, Division Woman and Baby, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - E Grossetti
- Department of Obstetrics, Hospital group du Havre, Le Havre, France
| | - A Rigouzzo
- Department of Anesthesiology, Armand Trousseau Children's Hospital, Paris, France
| | - M Saucedo
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
| | - E Verspyck
- Department of Obstetrics and Gynaecology, University Hospital of Rouen, Rouen, France
| | - J Zwart
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - C Deneux-Tharaux
- Université Paris Cité, Inserm, Obstetrical, Perinatal and Paediatric Epidemiology Research Team (Epopé), CRESS, Paris, France
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Delgado C, Komatsu R. Patient Blood Management programs for post-partum hemorrhage. Best Pract Res Clin Anaesthesiol 2022; 36:359-369. [PMID: 36513431 DOI: 10.1016/j.bpa.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/08/2022] [Indexed: 12/15/2022]
Abstract
Patient blood management (PBM) strategies aim to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Because postpartum hemorrhage (PPH) is a leading cause of maternal mortality and blood product utilization, PBM principles can be applied in its therapeutic approach. First, pre-operative identification of risk factors for PPH and identification of peri-delivery anemia should be conducted. Iron supplementation should be used to optimize hemoglobin concentration before delivery; it can also be used to treat anemia in the postpartum period after severe PPH. Both acute normovolemic hemodilution and intraoperative cell salvage can be effective techniques to reduce allogeneic blood transfusion during or after surgical procedures. Furthermore, these strategies appear to be safe when used in the pregnant population.
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Affiliation(s)
- Carlos Delgado
- Department of Anesthesiology and Pain Medicine, University of Washington, 1959 NE Pacific Street, Box 356340, Seattle, WA 98195, USA.
| | - Ryu Komatsu
- Department of General Anesthesiology and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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