Blood salvage in cancer surgery?

[Cell salvage : Scientific evidence, clinical practice and legal framework]

Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.

Patient-controlled analgesia: An efficient therapeutic tool in the postoperative setting

Patient-controlled analgesia (PCA) is one of the newer techniques for pain management. It was developed in reaction to the large number of unsatisfied postoperative patients suffering from moderate to severe pain despite the availability of potent analgesic drugs. With PCA, patients are allowed to self-administer small analgesic doses into a running intravenous infusion, intramuscularly, subcutaneously or even into the spinal space. Clinical experience soon demonstrated that individual variability in pain intensity and analgesic needs was extremely large. Psychological factors seem to be as important as the surgical trauma. Opioid consumption is usually higher than with conventional regimens, but without serious side effects. Although patients generally prefer self-control, pain relief is not necessarily better than with well-conducted conventional techniques. In addition to routine clinical pain management, PCA has proven its importance in research, e.g. for pain measurement, to determine predictors of postoperative pain, to evaluate drug interactions and the concept of pre-emptive analgesia, or for pharmacokinetic designs. PCA has been extremely important in order to change the mind of physicians and nursing staff with respect to individual pain management strategies.