Blood Transfusion/Conservation

*B. Borghi, °LL. Lorenzini, **F. Stagni,**I. Bacchilega

 

*Head of Coordination of Research in Anaesthesia, IRCCS Rizzoli Orthopaedic Institute °Department of Surgical and Anaesthesiological Science University of Bologna (Dir. Prof. G.F. Di Nino) **Departmental Module Coordination of Research in Anaesthesia, IRCCS Rizzoli Orthopaedic Institute Bologna Italy

 

Abstract. The need for transfusion requires assessment of the expected blood loss and the patient’s needs. The most economical method should be used that meets the patient's transfusion needs: Transfusion requirements are a balance between expected blood loss and an individual’s reaction to that loss. A number of options exist for optimum  management:

A)        Predonation, acute preoperative haemodilution,  and postoperative oral iron supplementation

B)         Exogenous erythropoietin (rHuEPO) administration may be used in conjunction with or provide an alternative to predonation (eg in Jehovah's witnesses) . This is given in doses of 150-300 UI/kg daily or on alternate days preferably in combination with i.v. iron supplements (200-300 mg of iron polysaccharate/day).

C)        Sterile blood salvage during  surgery, which may be reinfused if Hb falls more than 2 g/dl.

D)        Hypotensive anaesthesia with a mean  arterial pressure of about 50 mm Hg which, when possible, is best aschieved by epidural anaesthesia.

E)         Monitoring of postoperative bleeding, and scavenging, sedimentation  and microfiltration of postoperative losses for the first 10 hours, and their reinfusion 

F)         Antithromboembolic prophylaxis in doses adapted to the patients’s body weight and haemocoagulation.

G)        Transfusion of predeposited autologous blood spread over the first 3 days after surgery.

Intraoperative and/or postoperative blood salvage during major surgery is an important  supplement to other  techniques of blood conservation.   Cooperation  between anaesthetists, surgeons and haematologists is indispensable in the perioperative management of the patient.

 

Introduction. The use of homologous blood products is well known to correlate with  the risks of immunological  complications  and infection from   contaminated  blood and may impair  the immune system of the recipient (1,2), with the subsequent increased risk of early (1) and late (2) complications. For autologous transfusion to be used effectively, sufficient blood must be predonated to cover all the patient’s needs. In elective  surgery,  the expected blood loss  for a given operation (intraoperative  + losses for the first five postoperative), weight, height and initial haemoglobin and heamatocrit  values. and the patient’s clinical condition, the amount of tolerated  bleeding can be calculated. If it is less than expected, the patient will not need any  blood transfusions. However when estimated losses are greater than those that the patient is likely to tolerate, the autologous blood may be transfused. In the latter case, it is necessary to design a programme to meet all the patient’s requirements for autologous transfusion. This may involve  predeposition of one or more units of blood and/or erythropoietin and/or intra and/or postoperative blood salvage. Predepositing of 1 unit results in the production of 180-200 ml (1 Unit of blood) of erythrocytes 15-20 days after donation. From over 20 years experience (3-10), at Rizzoli Orthopaedic Institute we choose the cheapest method to meet patient's transfusion needs for major orthopaedic surgery from  the following methods: predonation and/or exogenous erythropoietin (rHuEPO) and/or intra and/or postoperative red cells salvage (12).

Predepositing. Predepositing consists of taking one or more units of blood before surgery. At the same time erythropoietin stimulation can be initiated, using human recombinant erythropoietin or, more traditionally, by administering trivalent iron, haemoactive vitamins (B12, Folates, B6) and amino acid solutions, possibly intravenously to achieve total absorption and rapid effectiveness. To maintain isovolemia and to administer any drugs intravenously, an infusion of 500 ml of electrolyte solution is useful. Predeposited units are separated  by centrifugation into fresh frozen plasma and packed blood cells. The number and frequency of predeposits is established by the anaesthetist together with the haematologist  according to the patient's clinical condition (age, weight, basal haemoglobin, any co-existing diseases) and the type of surgery scheduled, and should be sufficient for transfusion needs (5-10).

Erythropoietin (rHuEPO). Administering rHuEPO may support (13) or be an alternative to predepositing for patients when clinical condition, religion (Jehovah’s Witness) (12) or logistics do not allow venesection. Mercuriali (15) showed that to achieve better tolerance to intra and postoperative bleeding, as well as faster regeneration of erythrocytes and a subsequent reduction in transfusion needs, the expansion of circulating erythrocyte mass can be carried out in a short time (5-6 days) by administering 100 UI/Kg/die of rHuEPO s.c. and iron i.v. from -4 to +2 days perioperatively. In our experience in young patients 200 UI/Kg of rHuEPO combined with at least 100 mg i.v. 2 times/day of iron saccharate may provide an increase in Hb of 8.6 g/dl in 24 days.

Intraoperative salvage. This procedure is carried out in elective and emergency surgery if intraoperative bleeding is such that there may be a need for blood products. The uncoagulated blood lost from the surgical wound is collected in a sterile environment. During surgery the d blood is collected in  a reservoir by the use of a dual channel aspiration cannula through which shed blood is aspirated and mixed with anticoagulant solution. In some types of orthopaedic surgery with a horizontal incision (parallel to the floor), blood is also collected in a collection bag connected to the lower end of the surgical wound (2,5). If there is a drop in the haemoglobin (Hb) concentration of over 2 g/dl (or even 1 g/dl if there is a high risk of the need for homologous transfusion, such as in anaemic, cardiopathic or underweight patients), a device for concentrating, washing and reinfusing blood cells (4,5) can be set up. There are Italian-made discontinuous-flow devices on the market (Compact-A, Electa Dideco, Mirandola - Modena - Italy) or imported discontinuous flow devices (Cell Saver 5 Haemonetisc, Brat and Cobe) and also continuous-flow (CATS Fresenium) systems. Our experience is limited to the discontinuous-flow devices made by Dideco and Haemonetics. The Dideco has a "Better Quality Wash" (BQW) program, that consists of alternating the mixing of the bowl contents with the physiological flow during washing to minimise the amount of free Hb. Orr and Blenko (14) using the Dideco Apparatus reported a higher osmotic pressure than homologous banked blood cells and McShane and colleagues (15) observed a higher concentration of 2,3 diphosphoglycerate, a more physiological concentration of potassium and pH, and a higher content of haemoglobin in blood washed with the Dideco Autotrans BT 795 compared with donated blood. Later Alleva and colleagues (16) reported less damage to red cells salvaged during operation with the Dideco Compact-A and cells recovered after operation with the Dideco BT 797 Recovery compared with cells predeposited in SAG-M and preserved in the refrigerator for 21 days at 4° C. This could explain the lack of correlation between intra and postoperative blood loss and the use of homologous blood observed with this device (5,8,10). Having the aspiration tube at the top, and not at the bottom, means the entire contents including any heavy microparticles (metal, cement, etc.) cannot be transferred from the reservoir into the bowl. The Cell Saver 5 Haemonetics has a few drawbacks that make it less useful in orthopaedic surgery than the Dideco. In particular there is the difficulty in checking malfunctions in the bowl due to the lack of light inside the compartment where it is housed. This makes it impossible to read how full the bowl is and check any malfunctions during washing, which increases the risk of error. The bowl itself is also too big (225 ml) for the needs of orthopaedic surgery. This means it is not always completely filled, which compromises and jeopardises the quality of the salvaged blood. Having the aspiration tube at the bottom means the entire contents including any heavy microparticles (metal, cement, etc.) are transferred from the reservoir into the bowl where they settle. This drawback may account for the three cases of hematuria with renal impairment, which lasted for 15 days, one case of oliguria  and two cases of liver impairment after 24 and 48 hours recorded at our institute when blood was salvaged and washed using the Haemonetics Cell Saver 5 during hip arthroplasty. After using this device, disconnecting the reservoir  from the bowl is difficult without leakage of blood and other material in the circuit; therefore there is a risk of biologically contaminating the environment and operator. Salvage procedures require operator control at every step, even for the highly automated systems (17 ). Unlike the Haemonetics Cell Saver 5, research has shown that the Continous Autotrasfusion System (CATS) is able to eliminate particles of fat from the salvaged blood (18). Furthermore, CATS only requires 30 ml of packed washed blood cells to function (19).

Hypotensive epidural anaesthesia. Combined with or as an alternative to blood salvage, hypotensive  epidural  anaesthesia can be used to provide a mean arterial  pressure of 50 mmHg and it can be used to reduce blood loss during major surgery. The technique combines extensive epidural blockade with an intravenous infusion of low-dose epinephrine. This results in arterial hypotension, but with preservation of central venous pressure, heart rate, stroke volume, cardiac output, and augmentation of blood flow to the lower extremity. The technique does not appear to adversely affect cardiac, renal, or cerebral function and is used safely in patients with hypertension, ischemic heart disease, and in the elderly. According to Sharrock (20), hypotensive epidural anaesthesia is safe and provides a number of advantages over conventional anaesthetic techniques for total hip replacement. A difference in mean arterial blood pressure of 10 mm Hg from 50 to 60 mm Hg during surgery for total hip arthroplasty under epidural anaesthesia has a measurable effect on intraoperative blood loss (21).

Postoperative salvage. Haematoma formation is avoided by draining the wound in every suture plane and, in lower limb surgery, an  elastic compression  bandage is applied to the limb up to the top of the thigh. This increases the volume  of blood in the deep veins, and also help to prevent deep vein thrombosis. The drainage tubes are connected to a salvage system and possibly also to a monitor, such as the BT 797 Recovery Dideco, to assess postoperative bleeding. This system consists of a pressure transducer, adjustable between +100 and +50 mmHg that activates a peristaltic pump connected to drainage tubes by a two pipes of different calibres. The larger pipe takes the blood from the drainage tubes to the stock bag, and the smaller one takes anticoagulant (ACD) to the pipe connecting the drainage tubes in a 1:10 ratio. The display, which has a memory, shows the amount of bleeding per hour for the first 8 hours and the pressure applied to the drainage tubes. There is an audio-visual alarm that goes off if bleeding exceeds 300 ml/hour. This enables the operator to intervene immediately in case of potentially dangerous early bleeding. In a study of patients having total knee or hip arthroplasty, the audio-visual alarm (activated if bleeding exceeds 300 ml in less than 60 minutes), detected patients with bleeding in progress that need to be followed more carefully. As a result, the rate of homologous transfusions and postoperative complications was almost the same as that of a group of patients that did not have haemorrhage (22).

In the last ten years at our institute five patients died as a result of haemorrhaging due to the absence of monitoring postoperative bleeding, and in at least 16 cases the alarm allowed early treatment of bleeding that posed a potential risk. The monitoring of bleeding from the drainage tubes with a device that has an acoustic and visual alarm is therefore useful in detecting those rare cases of severe haemorrhaging that can lead to the patient’s death (23).

Blood salvaged with the BT 797 Recovery Dideco system can be reinfused for about 8 hours, after sedimentation and microfiltration. Sedimentation in particular enables packed red cells to be reinfused and minimise the reinfusion of products of haemolysis, activated complement factors (particularly anaphylatoxins C3 and C5a) (7) that remain in the supernatant.

When should red cells and plasma be transfused? Washed blood cells salvaged intraoperatively must be reinfused immediately. The units of blood donated preoperatively should be reinfused over the first three days after the operation to make up for the drop in Hb that usually occurs after surgery (5), to increase the production of endogenous erythropoietin (24) and to reduce the need for transfusion (25). The reinfusion of units of autologous plasma is useful in the first 24 hours or at the end of surgery, should intraoperative bleeding exceed 30% of the circulating blood volume, thus avoiding over-infusion that may lead to hypervolemia and hypertension and increase postoperative bleeding. The transfusion of fresh packed homologous plasma is only indicated when bleeding is due to a deficiency of coagulation factors. Coagulation deficiency not associated with active bleeding is not corrected by plasma, and the dose of antithromboembolic prophylaxis then needs to be  considered (23,26). Because administering antithromboembolic drugs before surgery is not effective(26) this must be carried out after surgery and the dose should be adjusted to any hypocoagulation related to blood dilution. Not all of the predonated blood needs to be reinfused in patients without cerebro-vascular damage or heart disease when haemoglobin is over 11 g/dl. Homologous blood is transfused when there is symptomatic anaemia (vertigo, dizziness, postural hypotension, headache, insomnia, mental confusion, tachycardia, angina, dispnea), or if the rate of haemoglobin falls to below 6 g/dl (10 g/dl in patients with cerebro-vascular damage or heat disease), but always only after using all the autologous blood available and correcting any concomitant hypovolemia with crystalloid or colloid solution (7).

Chylothorax. Chylothorax is an accumulation of fluid in the pleural cavity from a thoracic duct lesion. The liquid is rich in triglycerides, chylomicrons, liquids, electrolytes, proteins, lipid soluble vitamins and lymphocytes (mainly T cells): about 2-3 litres loss of chyle a day can lead to severe malnutrition and immunodeficiency. Chylothorax, is managed initially for 3-4 weeks with negative pressure pleural drainage combined with enteral fasting and total parenteral nutrition. The fluid can be reinfused  as follows: the thoracic drainage tube is connected to a large capacity (3000 ml) sterile reservoir (BT 844 Dideco) which is connected to an electronic peristaltic pump with adjustable aspiration (BT 797 Recovery Dideco). This apparatus is able to both quantify and memorise hourly chyle loss. It is periodically activated to draw the chyle from the reservoir, store it in a bag, then to pass it through a 40 micron filter and directly to reinfuse into one of the patient's veins. This system was used for 10 days enabling 23,400 ml of chyle containing lymphocytes and proteins to be reinfused, allowing the protein level to normalise and without any variation of TPN nor any need for homologous plasma transfusions (27).

 

Table 1: Studies of autotransfusion in orthopaedic surgery

 

 

Legend: THA = Total Hip Arthroplasty; TKA = Total Knee Arthroplasty; HR = Hip Revision; SF= Spine Fusion; IOBS = Intra Operative Blood Salvage; POBS = Post Operative
Blood Salvage; KR = Knee Revision

 

Table 1 shows a list of the literature concerning the use of predepositing, intraoperative salvage and postoperative salvage in major orthopaedic surgery, used separately or in combination, and the rate of the use of only autologous blood.

 

Conclusion

Published literature and our experience suggest that in unselected patients, blood salvage separately or combined is not able to eliminate the risk of homologous blood transfusions (tab.1). Transfusion  requirements are estimated from the assessment of expected and tolerated perioperative blood loss. The cheapest method should be selected to meet the patient's transfusion needs: A) Predonation and the support, if necessary, of iron i.v. B) Exogenous erythropoietin (rHuEPO) as support for or as an alternative to predepositing (Jehovah's witnesses). C) Sterile collection of blood lost during surgery, which is reinfused if Hb falls more than 2 g/dl. D) Intraoperative hypotension when possible with epidural hypotension with medial arterial pressure about 50 mm Hg. E) Monitoring of postoperative bleeding and reinfusing of red cells lost during the first 8 postoperative hours after sedimentation and microfiltration if blood loss exceeded 200 ml. F) Antithromboembolic prophylaxis in doses adapted to body weight and haemocoagulation state. G) Spread of predeposited ARBC over the first 3 days after surgery. H) Transfusion of HRBC in case of symptomatic anaemia, after excluding hypovolemia by monitoring clinical conditions after each unit transfused. If necessary (Jehovah's witnesses, rare groups, immunised patients) based on our experience, the following steps may also be taken: - preoperatively the haematocrit can be taken over 50% up to 58% (Hb about 20 g/dl) by rHuEPO; - a medial arterial pressure of 50 mm Hg is achieved intraoperatively by epidural hypotension; haematocrit can be reduced to below 15% (Hb 5 g/dl) or even to 10% (Hb about 3 g/dl). The haematocrit can be lowered to below 27% when there is no cerebro-vascular or coronary heart disease. To reduce haematological complications related to orthopaedic surgery to a minimum, cooperation between anaesthetists, surgeons and haematologists is indispensable in the perioperative management of the patient.

 

 

References

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