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Froessler B, Weber I, Hodyl NA, Saadat-Gilani K. Dynamic changes in clot formation determined using thromboelastometry after reinfusion of unwashed anticoagulated cell-salvaged whole blood in total hip arthroplasty. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 13:448-54. [PMID: 26192786 PMCID: PMC4614298 DOI: 10.2450/2015.0311-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 04/22/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Cell salvage is a key part of patient blood management. Different techniques are available for salvaging blood. A new intra-operative autotransfusion filter system became available for reinfusion of unwashed whole blood. Concern exists regarding whether this technique induces coagulation disturbances, offsetting the benefits of the reinfusion of autologous blood. This study was designed to investigate the content of intra-operatively salvaged filtered blood and its impact after reinfusion on clot formation in patients undergoing primary hip arthroplasty. MATERIALS AND METHODS Twenty-five patients scheduled for primary total hip arthroplasty were enrolled in the study. Cell salvage was performed using a new intra-operative autotransfusion filter system. Before surgery and within 1 hour of reinfusion of 300 mL or more of salvaged whole blood, blood samples were taken to assess clot formation by thromboelastometry and standard laboratory-based coagulation profiling. Cytokine content of the salvaged blood was assessed by enzyme-linked immunosorbent assays. RESULTS Following reinfusion of 460 mL (median) of salvaged blood, thromboelastometry showed normal clot formation and did not indicate a coagulopathy. Clotting time, clot formation time, maximum firmness and maximum lysis all remained within the normal range. Standard laboratory coagulation tests were also normal in all patients before surgery and after reinfusion. Although monocyte chemoattractant protein-1 levels were higher than normal, all other measured cytokines were either undetectable or within the normal range. No adverse events were seen following cell salvage. DISCUSSION Reinfusion of unwashed salvaged whole blood did not alter clot formation in our patients. The results add to the knowledge about this approach and contribute to the growing body of evidence regarding the lack of adverse events when reinfusing unwashed shed blood in major orthopaedic procedures.
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Affiliation(s)
- Bernd Froessler
- Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, Australia
| | - Ingo Weber
- Department of Anaesthesia, Lyell McEwin Hospital, Elizabeth Vale, Australia
| | - Nicolette A. Hodyl
- The Robinson Research Institute, School of Paediatric and Reproductive Health, The University of Adelaide, Adelaide, Australia
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Pillar 2: Minimising bleeding and blood loss. Best Pract Res Clin Anaesthesiol 2013; 27:99-110. [DOI: 10.1016/j.bpa.2012.12.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 12/17/2012] [Indexed: 01/21/2023]
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Markar SR, Jones GG, Karthikesalingam A, Segaren N, Patel RV. Transfusion drains versus suction drains in total knee replacement: meta-analysis. Knee Surg Sports Traumatol Arthrosc 2012; 20:1766-72. [PMID: 22072326 DOI: 10.1007/s00167-011-1761-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Accepted: 10/28/2011] [Indexed: 01/19/2023]
Abstract
PURPOSE The use of autologous blood transfusion drains in orthopaedic surgery has been the subject of debate for several years. The aim of this meta-analysis was to review the use of autologous blood transfusion drains in total knee replacement. METHODS The primary outcomes were as follows: the number of patients requiring homologous blood transfusion, pre-operative haemoglobin and post-operative haemoglobin days 5-7. The secondary outcome measures for the meta-analysis were drainage volume, length of hospital stay, average number of units transfused per patient, post-operative wound infection, and deep vein thrombosis. RESULTS Eight randomised controlled trials met the inclusion criteria and were included in this analysis. Autologous transfusion drains were associated with a decrease in the number of patients requiring post-operative blood transfusion (pooled odds ratio = 0.36, 95% CI = 0.15-0.85, P = 0.02), the number of units transfused per patient (weighted mean difference = -0.84 (95% CI = -1.13 to -0.56), P < 0.0001), and length of hospital stay (weighted mean difference = -0.25 (95% CI = -0.48 to -0.01), P = 0.04). CONCLUSION The results of our study highlight both likely clinical and economic benefits within total knee replacement surgery. The clinical benefits of autologous transfusion drains in the total knee replacement surgery suggested by this meta-analysis include a reduced requirement for post-operative blood transfusion and a shorter length of hospital stay. However, further large-scale high-powered randomized controlled trials are recommended to further elucidate subtle effects of autologous drains on post-operative outcome following total knee replacement. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Sheraz R Markar
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals NHS Foundation Trust, 235 Euston Road, London NW1 2BU, UK.
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SCHNEIDER SO, BIEDLER AE, BEHMENBURG F, VOLK T, RENSING H. Impact of shed blood products on stimulated cytokine release in an in vitro model of transfusion. Acta Anaesthesiol Scand 2012; 56:724-9. [PMID: 22571497 DOI: 10.1111/j.1399-6576.2012.02704.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Blood transfusion is reported to suppress the recipient's immune system. To avoid allogenic transfusion, post-operative shed blood retransfusion is a commonly used method. The aim of this study was to investigate the dose-related impact of post-operatively collected shed blood products on the stimulated cytokine release in an in vitro model of transfusion. METHODS Venous blood samples obtained from 20 patients undergoing hip arthroplasty were mixed with post-operatively collected unprocessed, processed, and irradiated shed blood as well as normal saline as a control. Shed blood was processed by centrifugation and separating the cellular fraction from the soluble fraction and washing the cellular fraction with phosphate buffered saline to eliminate any cell fragments and other substances. Mixing ratios were 1:3, 1:1, and 3:1. Endotoxin-stimulated release of Tumor Necrosis Factor-alpha (TNF-α) was measured after 24 h of culture by enzyme-linked immunosorbent assay. RESULTS Unprocessed, irradiated shed blood and the soluble fraction caused a significant suppression of stimulated TNF-α release compared to control. The addition of the cellular shed blood fraction had no significant influence on the TNF-α release compared to control. CONCLUSION Shed blood and its components caused a dose-independent immunomodulation as indicated by a suppressed stimulated TNF-α release. Leukocytes seem to play a minor role, as we observed a sustained suppression after transfusion of γ-irradiated shed blood. Only the elimination of soluble factors by centrifugation and followed by an additional washing step prevented the observed suppression of TNF-α. Thus, we assume that washing of shed blood can prevent potential detrimental effects.
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Affiliation(s)
- S. O. SCHNEIDER
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - A. E. BIEDLER
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - F. BEHMENBURG
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - T. VOLK
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
| | - H. RENSING
- Department for Anaesthesiology; Critical Care Medicine and Pain Therapy; Saarland University Hospital; Homburg; Germany
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Muñoz M, Slappendel R, Thomas D. Laboratory characteristics and clinical utility of post-operative cell salvage: washed or unwashed blood transfusion? BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2011; 9:248-61. [PMID: 21084005 PMCID: PMC3136591 DOI: 10.2450/2010.0063-10] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Accepted: 08/04/2010] [Indexed: 01/18/2023]
Affiliation(s)
- Manuel Muñoz
- International Group of Interdisciplinary Studies about Autotransfusion, Transfusion Medicine, Faculty of Medicine, University of Málaga, Spain.
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HORSTMANN WIEGERG, SLAPPENDEL ROBERT, VAN HELLEMONDT GIJSG, CASTELEIN RENEM, VERHEYEN CEESC. Safety of retransfusion of filtered shed blood in 1819 patients after total hip or knee arthroplasty. ACTA ACUST UNITED AC 2010. [DOI: 10.1111/j.1778-428x.2010.01130.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Muñoz M, Kühlmorgen B, Ariza D, Haro E, Marroquí A, Ramirez G. Which patients are more likely to benefit from postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures. Vox Sang 2007; 92:136-41. [PMID: 17298576 DOI: 10.1111/j.1423-0410.2006.00868.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Requirements for allogeneic blood transfusion (ABT) after total knee replacement (TKR) are still high (30-50%), and salvage of unwashed filtered postoperative shed blood (USB) may represent an alternative to ABT. We evaluated that patients are more likely to benefit of USB reinfusion after TKR. PATIENTS AND METHODS Data from 581 consecutive primary TKR, managed with (reinfusion group, n = 382) or without (control group, n= 199) reinfusion of USB, were retrospectively reviewed. RESULTS Patients from reinfusion group received 119 +/- 88 ml of red blood cells from USB, without clinically relevant incidents, and showed a lower ABT rate (30.6% vs. 8.4%, for control and reinfusion groups, respectively; P = 0.001) (transfusion trigger, haemoglobin [Hb] < 9 g/dl). Differences in ABT rate between groups were significant for all preoperative Hb levels, except for Hb < or = 12 g/dl. A lower transfusion threshold (Hb < 8 g/dl) might have further decreased ABT rate (14.6% vs. 5.2%, respectively; P < 0.001), with differences being significant for preoperative Hb between 12 and 15 g/dl. There were no differences with respect to postoperative infection rate, but patients from reinfusion group had a shorter length of hospital stay (11 +/- 4 vs. 13 +/- 4 days, respectively; P= 0.001). CONCLUSIONS Return of USB after TKR seems to reduce the need for ABT, especially in patients with preoperative Hb between 12 and 15 g/dl. There is little benefit of USB reinfusion for patients with preoperative Hb > 15 g/dl, whereas patients with preoperative Hb < 12 g/dl would probably benefit from the combination of USB with some other blood-saving method.
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Affiliation(s)
- M Muñoz
- GIEMSA, School of Medicine, University of Málaga, Campus de Teatinos s/n, 19071 Málaga, Spain.
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Muñoz M, Cobos A, Campos A, Ariza D, Muñoz E, Gómez A. Post-operative unwashed shed blood transfusion does not modify the cellular immune response to surgery for total knee replacement. Acta Anaesthesiol Scand 2006; 50:443-50. [PMID: 16548856 DOI: 10.1111/j.1399-6576.2006.00977.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients undergoing total knee replacement (TKR), most blood loss occurs post-operatively, and the return of unwashed filtered shed blood (USB) from post-operative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return on the cellular immune response (CIR) after TKR. PATIENTS AND METHODS Forty TKR patients, intended to receive post-operative USB, entered the study. Blood samples were obtained before and 6 h, 24 h, 72 h and 7 days after surgery, and from USB, after it had been passed through a 40-microm filter. Full blood cell counts, lymphocyte subsets and immunoglobulins (IgA, IgG, IgM) were measured in all samples. A set of clinical data was collected from each patient. RESULTS Twenty-four of the 25 patients received a mean of 1.2 USB units and did not need additional ABT (USB group). Twelve of the 15 remaining patients who received neither USB nor ABT served as a control group for the post-operative CIR study. All patients showed a post-operative decrease in T-cell and natural killer (NK) cell counts, but not B-cell counts, and there were no significant differences between the groups with regard to CIR parameters, post-operative infection or hospital stay. CONCLUSIONS Post-operative salvage and return of USB after TKR does not seem to increase the post-operative infection rate or hospital stay, and does not modify CIR induced by surgery. These findings add to the clinical experience that post-operative USB return, as a source of autologous blood, is safe, and questions the beneficial effect of blood washing.
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Affiliation(s)
- M Muñoz
- GIEMSA, School of Medicine, University of Málaga, Malaga, Spain.
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MUNOZ MANUEL, CAMPOS ARTURO, MUNOZ ENCARNACION, CARRERO ANTONIO, CUENCA JORGE, GARCIA-ERCE JOSEANTONIO. Red cell salvage in orthopedic surgery. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1778-428x.2006.00007.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Muñoz M, Cobos A, Campos A, Ariza D, Muñoz E, Gómez A. Impact of postoperative shed blood transfusion, with or without leucocyte reduction, on acute-phase response to surgery for total knee replacement. Acta Anaesthesiol Scand 2005; 49:1182-90. [PMID: 16095461 DOI: 10.1111/j.1399-6576.2005.00765.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In patients undergoing total knee replacement (TKR) most blood loss occurs postoperatively and return of unwashed filtered shed blood (USB) from postoperative drainage may represent an alternative to allogeneic blood transfusion (ABT). We evaluated the impact of USB return, with or without leucocytes, on the acute-phase response (APR) after TKR. PATIENTS AND METHODS Forty-eight TKR patients, intended to receive postoperative USB, entered the study. Blood samples were obtained before and 6, 24, 72 h and 7 days after surgery, and from the USB before and after it passed through a 40-microm filter (Group F40) or a leucocyte-reduction filter (Group LRF). Haematimetric parameters, APR proteins (albumin, prealbumin, ceruloplasmin, haptoglobin, C-reactive protein), complement C3 and C4, and cytokines (IL-1beta, IL-6, IL-8, IL-10, and TNF-alpha) were measured in all samples. RESULTS Twenty-eight patients (Group F40=14, Group LRF=14) received a mean of 1.2 USB units, without any clinically relevant incident, and did not need additional ABT. Sixteen out of the 20 remaining patients who received neither USB nor ABT served as a control group for the postoperative APR study. All patients showed the typical postoperative APR profile and there were no significant differences between groups for APR parameters, postoperative complications, or hospital stay. CONCLUSIONS Postoperative blood salvage and return, with or without a LRF, after TKR does not present any clinically relevant side-effects and does not modify APR induced by surgery. These findings seem to confirm the clinical experience that postoperative USB return is safe and questions the beneficial effect of using LRF.
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Affiliation(s)
- M Muñoz
- Department of Clinical Chemistry, GIEMSA, School of Medicine, Univeristy of Malaga, Malaga, Spain.
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Muñoz M, García-Vallejo JJ, Ruiz MD, Romero R, Olalla E, Sebastián C. Transfusion of post-operative shed blood: laboratory characteristics and clinical utility. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2004; 13 Suppl 1:S107-13. [PMID: 15138860 PMCID: PMC3592179 DOI: 10.1007/s00586-004-0718-0] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2004] [Accepted: 03/13/2004] [Indexed: 11/26/2022]
Abstract
Increased awareness of the potential hazards of allogenic blood transfusion, such as incompatibility reactions, metabolic and immunologic disorders, or transmission of viral diseases, has led to an emphasis on allogeneic blood alternatives. For orthopaedic surgery, several autologous transfusion modalities have emerged as alternatives to allogeneic blood transfusion, avoiding its immunomodulatory effects. Among them, transfusion or return of post-operative salvaged shed blood has become popular in major orthopaedic procedures. However, although the effectiveness of this blood-saving method is well documented, several authors have questioned its safety and recommended the use of washed blood. Therefore, this review analyses the haematologic characteristics of unwashed filtered shed blood, including metabolic status and survival of red blood cells, the components of the haemostatic system, the content of fat particles, bacterial and tumour cells and the possibility of their removal, the content of inflammatory mediators, and the effects on the patient's immune system. From data reviewed in this paper, it can be concluded that post-operative salvage of blood seems to be an excellent source of functional and viable red cells without many of the transfusion-related risks and with some immuno-stimulatory effects. In addition, from our experience, post-operative re-infusion of unwashed shed blood after major spine procedures has proved to reduce post-operative homologous transfusion requirements and to complement pre-operative autologous blood donation, without any clinically relevant complication.
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Affiliation(s)
- M Muñoz
- Department of Biochemistry and Molecular Biology, School of Medicine, University of Málaga, Málaga, Spain.
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