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Archive:Autotransfusion

2008-06-12T19:51:56Z

74.137.13.53: /* Collection and processing of blood */

'''Autotransfusion''' <ref>{{Citation|last=Carey|first=J.|title=How to donate to yourself|journal=US News & World Report|volume=102|issue=21|year=1987|pages=59}}</ref> is when a person recieves their own blood for a transfusion, instead of banked donor blood. Auto means self. Blood can be predonated 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, aneuryms, 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 donor]]s. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of [[orthopedic]], [[Physical trauma|trauma]] and [[cardiac]] cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells.

==History==
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused a [[post-partum]] patient<ref>{{Citation|last=Schmidt|first=P.J.|title=Transfusion in America in the eighteenth and nineteenth century|journal=N Engl J Med|volume=279|year=1968|pages=1319}}</ref>. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patient's 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.<ref>{{Citation|last=Blundell|first=J.|title=Experiments on the transfusion of blood by syringe|journal=Medico-Chirurical Journal|volume=9|year=1918|pages=59}}</ref>

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.<ref>{{Citation|last=Duncan|first=J.|title=On re-infusion of blood in primary and other amputations|journal=Brit M J|volume=1|year=1886|pages=192}}</ref> A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured [[ectopic pregnancy]]<ref>{{Citation|last=Thies|first=H.J.|title=Zur Behandlung der Extrauteringraviditar|journal=Zbl Gynaek|volume=38|year=1914|pages=1190}}</ref>. 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.<ref>{{Citation|last=Lockwood|first=C.D.|title=Surgical treatment of bantis disease|journal=Surg Gynec Obstet|volume=25|year=1917|pages=188}}</ref> Interest in unrefined technique of autotransfusion continued through to the early 1940’s, and was applied to various procedures including treatment of ectopic pregnancy<ref>{{Citation|last=Maynard|first=R.L.|title=Case of ruptured extra-uterine pregnancy treated by autotransfusion|journal=JAMA|volume=92|year=1929|pages=1758}}</ref><ref>{{Citation|last=Rumbaugh|first=M.C.|title=Ruptured tubal pregnancy: report of a case in which life was saved by autotransfusion of blood|journal=Penn Med|volume=34|year=1931|pages=710}}</ref> hemothorax<ref>{{Citation|last=Brown|first=A.L.|title=Autotransfusion: use of blood from hemothorax|journal=JAMA|volume=96|year=1931|pages=1223}}</ref>, ruptured spleen<ref>{{Citation|last=Coley|first=B.L.|title=Traumatic rupture of spleen, splenectomy, autotransfusion|journal=Am J Surg|volume=4|year=1928|pages=34}}</ref><ref>{{Citation|last=Downing|first=W.|title=Autotransfusion following rupture of the spleen: case report|journal=J Iowa Med Soc|volume=24|year=1934|pages=246}}</ref>, perforating abdominal injuries<ref>{{Citation|last=Griswald|first=R.A.|title=The use of autotransfusion in surgery of the serous cavities|journal=Surg Gynec & Obstet|volume=77|year=1943|pages=167}}</ref>, and neurosurgical procedures<ref>{{Citation|last=Davis|first=L.E.|title=Experiences with blood replacement during or after major intra-cranial operations|journal=Surg Gynec Obstet|volume=40|year=1925|pages=310}}</ref>.

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 making [[blood 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.<ref>Nicholson E, 1988, Autolgous blood transfusion, Nurs Times, 13-19; 84(2):33-5 Jan 1988</ref> The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused.<ref>Autologous Blood Transfusion Education Program, Training Manual, Shiley Incorporated, Irvine CA, 1992</ref> 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.<ref>{{Citation|last=Klebanoff|first=G.|title=Early Clinical experience with a disposable unit for intraoperative salvage and reinfusion of blood loss (intraoperative autotransfusion)|journal=Am J Surg|volume=120|year=1970|pages=718–722}}</ref> 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 system|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.<ref>{{Citation|last=Wilson|first=J.D.|title=Autotransfusion during transurethral resection of the prostate: Technique and preliminary clinical evaluation|journal=Mayo Clinic Proceedings|volume=44|year=1969|pages=374}}</ref> In 1976, this system was introduced by Haemonetics Corporation and is know commonly as "Cell Saver"<ref>{{Citation|last=Healey|first=T.G.|title=AANA Journal course: New technologies in anesthesia: Update for nurse anesthetists- Intraoperative blood salvage|journal=AANA J|volume=57|issue=5|year=1989|pages=429–34}}</ref>. More recently in 1995 [[Fresenius]] introduced a continuous autotransfusion system.<ref>[http://www.fresenius-hemocare.com] Fresenius</ref>

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 patient's and can greatly reduce the risk of exposure to emergency surgical patient's. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.

==Literature==
Literature relating to autologous blood is extensive - numerous articles and letters have been written. The subject heading of "Blood Transfusion, Autologous" first appeared in 1971 in the [[Cumulated Index Medicus]]. The Cumulative Index to Nursing & Allied Health began the same title in 1983, and also added a new heading of "Blood Salvage" in 1993. The [[Hospital Literature Index]] began the heading "Blood Transfusion, Autologous" in 1985.

The concepts of [[bloodless]] medicine and [[surgery]] have recently been emerging in literature, books and course programs.

==Indications for autotransfusion==
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 group]]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. <ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

==Common cases==
===Orthopedic===
Spinal Instrumentation, Spinal Fusion, [[Discectomy]], [[Laminectomy]], Total [[shoulder replacement]], Total hip replacement, Total knee replacement, Femur Fractures, Open Reduction Internal Fixation Pelvic Fractures, IM Rodding

===Trauma===
Subdural [[Hematoma]], Chest Injuries, Liver Fractures, Kidney Fractures, Major Vessel Lacerations, [[Aneurysm]]s, Gun Shot Wounds, Stab Wounds, Extremity Reimplantations, Splenectomy, Blunt [[Physical trauma|Trauma]] (Thoracic or Abdominal)

[[===Cardiac===
Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair / Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
]]

===Other===
Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver [[Organ transplant|Transplant]],
Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, [[Hysterectomy]] (Non-Malignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (Non-Malignant)

==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 [[Blood plasma|plasma]] and [[platelet]]s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated [[clotting factor]]s 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 reaches half of the blood volume of the patient.
It should be noted that when a patient recieves banked donor blood that this blood is also in fact, only packed red blood cells, and has no coagulation factors. Therefore, if a patient loses more than half of their total blood volume, they will need to recieve FFP and platelets no matter if they are getting their own blood back or donated homologeous blood.

==Contraindications==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

The use of blood recovered from the operative field is contraindicated in the presence of [[bacteria]]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.

===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 [[cancer]] cells from the surgical site. There are possible exceptions to this contraindication:

*The surgeon feels complete removal of an encapsulated [[tumor]] 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 Leukocite reduction filters is recommended.

Autotransfusion is not normally used in [[C-Section]]s, because the possibility of an [[amniotic fluid]] [[embolism]] exists. The amniotic fluid may not be washed away during the wash phase of autotransfusion process. 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.

In life saving situations with the consent of the surgeon, autotransfusion can be utilized in the presence of the previous stated contraindications i.e. [[sepsis]], bowel contamination and malignancy.

==Collection and processing of blood==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 19</ref>
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 [[cardiotomy]] 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 250-300 ml of blood.

When aspirating the blood it is important to utilize the following technique when ever possible:

*Suction blood from pools rather than [[Skimmer (machine)|skimming]].
*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]] of the red cells and will help increase the amount of red cells that will be salvaged.

===Special considerations===
====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 [[collagen]] 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====
[[Cement]] 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.

===Processing===
====Prime phase====
When the "prime" button is pressed, the [[centrifuge]] 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 blood cell|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.

====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 [[antibiotic]]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.

====Reinfuse phase====
When the reinfuse function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of 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. In accordance with Guidelines set by the [[American Association of Blood Banks]] the blood should be reinfused within 6 hours from collection.

==Postoperative autotransfusion==
Postoperative autotransfusion is performed by connecting the double [[lumen]] 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 replacement|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.

==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 [[heparin]]ized [[Saline (medicine)|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. It has been estimated that 90% of the lost red cells can be returned when autotransfusion is performed in conjunction with the soaking of sponges.

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 processing so the exact ratio of Heparin used is not critical. <ref>{{Citation|last=Drago|first=S.S.|title=Banking on your own blood.|journal=Am J Nurs|volume=92|issue=3|year=1992|pages=61–4}}</ref><ref>Langone J, 1988, New methods for saving blood. Researchers are trying to reclaim, recycle and replenish it., Time, 5; 132(23):57, Dec 5, 1988</ref>

==Autotransfusion and religion==
Individuals of the [[Jehovah's Witness]] religion in particular refuse to accept Homologous and [[Autologous]] predonated blood. However some individual members may accept the use of autotransfusion. The process of autotransfusion 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 [[Calcium]] and [[Thrombin]] to create a product similar to [[Fibrin Glue]]. But unlike Fibrin Glue 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. If the fibrin gel procedure is not needed during the procedure the Platelet Rich Plasma can also be reinfused to the patient.

==References==
<references/>

==External links==
*Equipment manufacturers
**[http://www.soringroup-usa.com/ Sorin Group]
**[http://www.haemonetics.com/site/content/ Haemonetics]
**[http://www.fresenius-hemocare.com Fresenius]
**[http://www.davol.com/ Davol]
*Organizations
**[http://www.aabb.org/ American Association of Blood Banks]

==See also==
*[[Bloodless]]

[[Category:Blood]]
[[Category:Transfusion medicine]]
[[Category:Surgical procedures]]

Archive:Autotransfusion

2008-06-12T19:45:08Z

74.137.13.53: /* Malignancy */

'''Autotransfusion''' <ref>{{Citation|last=Carey|first=J.|title=How to donate to yourself|journal=US News & World Report|volume=102|issue=21|year=1987|pages=59}}</ref> is when a person recieves their own blood for a transfusion, instead of banked donor blood. Auto means self. Blood can be predonated 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, aneuryms, 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 donor]]s. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of [[orthopedic]], [[Physical trauma|trauma]] and [[cardiac]] cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells.

==History==
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused a [[post-partum]] patient<ref>{{Citation|last=Schmidt|first=P.J.|title=Transfusion in America in the eighteenth and nineteenth century|journal=N Engl J Med|volume=279|year=1968|pages=1319}}</ref>. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patient's 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.<ref>{{Citation|last=Blundell|first=J.|title=Experiments on the transfusion of blood by syringe|journal=Medico-Chirurical Journal|volume=9|year=1918|pages=59}}</ref>

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.<ref>{{Citation|last=Duncan|first=J.|title=On re-infusion of blood in primary and other amputations|journal=Brit M J|volume=1|year=1886|pages=192}}</ref> A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured [[ectopic pregnancy]]<ref>{{Citation|last=Thies|first=H.J.|title=Zur Behandlung der Extrauteringraviditar|journal=Zbl Gynaek|volume=38|year=1914|pages=1190}}</ref>. 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.<ref>{{Citation|last=Lockwood|first=C.D.|title=Surgical treatment of bantis disease|journal=Surg Gynec Obstet|volume=25|year=1917|pages=188}}</ref> Interest in unrefined technique of autotransfusion continued through to the early 1940’s, and was applied to various procedures including treatment of ectopic pregnancy<ref>{{Citation|last=Maynard|first=R.L.|title=Case of ruptured extra-uterine pregnancy treated by autotransfusion|journal=JAMA|volume=92|year=1929|pages=1758}}</ref><ref>{{Citation|last=Rumbaugh|first=M.C.|title=Ruptured tubal pregnancy: report of a case in which life was saved by autotransfusion of blood|journal=Penn Med|volume=34|year=1931|pages=710}}</ref> hemothorax<ref>{{Citation|last=Brown|first=A.L.|title=Autotransfusion: use of blood from hemothorax|journal=JAMA|volume=96|year=1931|pages=1223}}</ref>, ruptured spleen<ref>{{Citation|last=Coley|first=B.L.|title=Traumatic rupture of spleen, splenectomy, autotransfusion|journal=Am J Surg|volume=4|year=1928|pages=34}}</ref><ref>{{Citation|last=Downing|first=W.|title=Autotransfusion following rupture of the spleen: case report|journal=J Iowa Med Soc|volume=24|year=1934|pages=246}}</ref>, perforating abdominal injuries<ref>{{Citation|last=Griswald|first=R.A.|title=The use of autotransfusion in surgery of the serous cavities|journal=Surg Gynec & Obstet|volume=77|year=1943|pages=167}}</ref>, and neurosurgical procedures<ref>{{Citation|last=Davis|first=L.E.|title=Experiences with blood replacement during or after major intra-cranial operations|journal=Surg Gynec Obstet|volume=40|year=1925|pages=310}}</ref>.

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 making [[blood 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.<ref>Nicholson E, 1988, Autolgous blood transfusion, Nurs Times, 13-19; 84(2):33-5 Jan 1988</ref> The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused.<ref>Autologous Blood Transfusion Education Program, Training Manual, Shiley Incorporated, Irvine CA, 1992</ref> 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.<ref>{{Citation|last=Klebanoff|first=G.|title=Early Clinical experience with a disposable unit for intraoperative salvage and reinfusion of blood loss (intraoperative autotransfusion)|journal=Am J Surg|volume=120|year=1970|pages=718–722}}</ref> 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 system|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.<ref>{{Citation|last=Wilson|first=J.D.|title=Autotransfusion during transurethral resection of the prostate: Technique and preliminary clinical evaluation|journal=Mayo Clinic Proceedings|volume=44|year=1969|pages=374}}</ref> In 1976, this system was introduced by Haemonetics Corporation and is know commonly as "Cell Saver"<ref>{{Citation|last=Healey|first=T.G.|title=AANA Journal course: New technologies in anesthesia: Update for nurse anesthetists- Intraoperative blood salvage|journal=AANA J|volume=57|issue=5|year=1989|pages=429–34}}</ref>. More recently in 1995 [[Fresenius]] introduced a continuous autotransfusion system.<ref>[http://www.fresenius-hemocare.com] Fresenius</ref>

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 patient's and can greatly reduce the risk of exposure to emergency surgical patient's. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.

==Literature==
Literature relating to autologous blood is extensive - numerous articles and letters have been written. The subject heading of "Blood Transfusion, Autologous" first appeared in 1971 in the [[Cumulated Index Medicus]]. The Cumulative Index to Nursing & Allied Health began the same title in 1983, and also added a new heading of "Blood Salvage" in 1993. The [[Hospital Literature Index]] began the heading "Blood Transfusion, Autologous" in 1985.

The concepts of [[bloodless]] medicine and [[surgery]] have recently been emerging in literature, books and course programs.

==Indications for autotransfusion==
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 group]]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. <ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

==Common cases==
===Orthopedic===
Spinal Instrumentation, Spinal Fusion, [[Discectomy]], [[Laminectomy]], Total [[shoulder replacement]], Total hip replacement, Total knee replacement, Femur Fractures, Open Reduction Internal Fixation Pelvic Fractures, IM Rodding

===Trauma===
Subdural [[Hematoma]], Chest Injuries, Liver Fractures, Kidney Fractures, Major Vessel Lacerations, [[Aneurysm]]s, Gun Shot Wounds, Stab Wounds, Extremity Reimplantations, Splenectomy, Blunt [[Physical trauma|Trauma]] (Thoracic or Abdominal)

[[===Cardiac===
Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair / Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
]]

===Other===
Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver [[Organ transplant|Transplant]],
Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, [[Hysterectomy]] (Non-Malignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (Non-Malignant)

==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 [[Blood plasma|plasma]] and [[platelet]]s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated [[clotting factor]]s 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 reaches half of the blood volume of the patient.
It should be noted that when a patient recieves banked donor blood that this blood is also in fact, only packed red blood cells, and has no coagulation factors. Therefore, if a patient loses more than half of their total blood volume, they will need to recieve FFP and platelets no matter if they are getting their own blood back or donated homologeous blood.

==Contraindications==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

The use of blood recovered from the operative field is contraindicated in the presence of [[bacteria]]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.

===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 [[cancer]] cells from the surgical site. There are possible exceptions to this contraindication:

*The surgeon feels complete removal of an encapsulated [[tumor]] 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 Leukocite reduction filters is recommended.

Autotransfusion is not normally used in [[C-Section]]s, because the possibility of an [[amniotic fluid]] [[embolism]] exists. The amniotic fluid may not be washed away during the wash phase of autotransfusion process. 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.

In life saving situations with the consent of the surgeon, autotransfusion can be utilized in the presence of the previous stated contraindications i.e. [[sepsis]], bowel contamination and malignancy.

==Collection and processing of blood==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 19</ref>
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 [[cardiotomy]] 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 and size of the centrifuge wash bowl.

When aspirating the blood it is important to utilize the following technique when ever possible:

*Suction blood from pools rather than [[Skimmer (machine)|skimming]].
*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]] of the red cells and will help increase the amount of red cells that will be salvaged.

===Special considerations===
====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 [[collagen]] 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====
[[Cement]] 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.

===Processing===
====Prime phase====
When the "prime" button is pressed, the [[centrifuge]] 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 blood cell|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.

====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 [[antibiotic]]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.

====Reinfuse phase====
When the reinfuse function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of 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. In accordance with Guidelines set by the [[American Association of Blood Banks]] the blood should be reinfused within 6 hours from collection.

==Postoperative autotransfusion==
Postoperative autotransfusion is performed by connecting the double [[lumen]] 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 replacement|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.

==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 [[heparin]]ized [[Saline (medicine)|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. It has been estimated that 90% of the lost red cells can be returned when autotransfusion is performed in conjunction with the soaking of sponges.

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 processing so the exact ratio of Heparin used is not critical. <ref>{{Citation|last=Drago|first=S.S.|title=Banking on your own blood.|journal=Am J Nurs|volume=92|issue=3|year=1992|pages=61–4}}</ref><ref>Langone J, 1988, New methods for saving blood. Researchers are trying to reclaim, recycle and replenish it., Time, 5; 132(23):57, Dec 5, 1988</ref>

==Autotransfusion and religion==
Individuals of the [[Jehovah's Witness]] religion in particular refuse to accept Homologous and [[Autologous]] predonated blood. However some individual members may accept the use of autotransfusion. The process of autotransfusion 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 [[Calcium]] and [[Thrombin]] to create a product similar to [[Fibrin Glue]]. But unlike Fibrin Glue 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. If the fibrin gel procedure is not needed during the procedure the Platelet Rich Plasma can also be reinfused to the patient.

==References==
<references/>

==External links==
*Equipment manufacturers
**[http://www.soringroup-usa.com/ Sorin Group]
**[http://www.haemonetics.com/site/content/ Haemonetics]
**[http://www.fresenius-hemocare.com Fresenius]
**[http://www.davol.com/ Davol]
*Organizations
**[http://www.aabb.org/ American Association of Blood Banks]

==See also==
*[[Bloodless]]

[[Category:Blood]]
[[Category:Transfusion medicine]]
[[Category:Surgical procedures]]

Archive:Autotransfusion

2008-06-12T19:38:48Z

74.137.13.53:

'''Autotransfusion''' <ref>{{Citation|last=Carey|first=J.|title=How to donate to yourself|journal=US News & World Report|volume=102|issue=21|year=1987|pages=59}}</ref> is when a person recieves their own blood for a transfusion, instead of banked donor blood. Auto means self. Blood can be predonated 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, aneuryms, 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 donor]]s. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of [[orthopedic]], [[Physical trauma|trauma]] and [[cardiac]] cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells.

==History==
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused a [[post-partum]] patient<ref>{{Citation|last=Schmidt|first=P.J.|title=Transfusion in America in the eighteenth and nineteenth century|journal=N Engl J Med|volume=279|year=1968|pages=1319}}</ref>. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patient's 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.<ref>{{Citation|last=Blundell|first=J.|title=Experiments on the transfusion of blood by syringe|journal=Medico-Chirurical Journal|volume=9|year=1918|pages=59}}</ref>

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.<ref>{{Citation|last=Duncan|first=J.|title=On re-infusion of blood in primary and other amputations|journal=Brit M J|volume=1|year=1886|pages=192}}</ref> A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured [[ectopic pregnancy]]<ref>{{Citation|last=Thies|first=H.J.|title=Zur Behandlung der Extrauteringraviditar|journal=Zbl Gynaek|volume=38|year=1914|pages=1190}}</ref>. 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.<ref>{{Citation|last=Lockwood|first=C.D.|title=Surgical treatment of bantis disease|journal=Surg Gynec Obstet|volume=25|year=1917|pages=188}}</ref> Interest in unrefined technique of autotransfusion continued through to the early 1940’s, and was applied to various procedures including treatment of ectopic pregnancy<ref>{{Citation|last=Maynard|first=R.L.|title=Case of ruptured extra-uterine pregnancy treated by autotransfusion|journal=JAMA|volume=92|year=1929|pages=1758}}</ref><ref>{{Citation|last=Rumbaugh|first=M.C.|title=Ruptured tubal pregnancy: report of a case in which life was saved by autotransfusion of blood|journal=Penn Med|volume=34|year=1931|pages=710}}</ref> hemothorax<ref>{{Citation|last=Brown|first=A.L.|title=Autotransfusion: use of blood from hemothorax|journal=JAMA|volume=96|year=1931|pages=1223}}</ref>, ruptured spleen<ref>{{Citation|last=Coley|first=B.L.|title=Traumatic rupture of spleen, splenectomy, autotransfusion|journal=Am J Surg|volume=4|year=1928|pages=34}}</ref><ref>{{Citation|last=Downing|first=W.|title=Autotransfusion following rupture of the spleen: case report|journal=J Iowa Med Soc|volume=24|year=1934|pages=246}}</ref>, perforating abdominal injuries<ref>{{Citation|last=Griswald|first=R.A.|title=The use of autotransfusion in surgery of the serous cavities|journal=Surg Gynec & Obstet|volume=77|year=1943|pages=167}}</ref>, and neurosurgical procedures<ref>{{Citation|last=Davis|first=L.E.|title=Experiences with blood replacement during or after major intra-cranial operations|journal=Surg Gynec Obstet|volume=40|year=1925|pages=310}}</ref>.

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 making [[blood 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.<ref>Nicholson E, 1988, Autolgous blood transfusion, Nurs Times, 13-19; 84(2):33-5 Jan 1988</ref> The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused.<ref>Autologous Blood Transfusion Education Program, Training Manual, Shiley Incorporated, Irvine CA, 1992</ref> 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.<ref>{{Citation|last=Klebanoff|first=G.|title=Early Clinical experience with a disposable unit for intraoperative salvage and reinfusion of blood loss (intraoperative autotransfusion)|journal=Am J Surg|volume=120|year=1970|pages=718–722}}</ref> 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 system|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.<ref>{{Citation|last=Wilson|first=J.D.|title=Autotransfusion during transurethral resection of the prostate: Technique and preliminary clinical evaluation|journal=Mayo Clinic Proceedings|volume=44|year=1969|pages=374}}</ref> In 1976, this system was introduced by Haemonetics Corporation and is know commonly as "Cell Saver"<ref>{{Citation|last=Healey|first=T.G.|title=AANA Journal course: New technologies in anesthesia: Update for nurse anesthetists- Intraoperative blood salvage|journal=AANA J|volume=57|issue=5|year=1989|pages=429–34}}</ref>. More recently in 1995 [[Fresenius]] introduced a continuous autotransfusion system.<ref>[http://www.fresenius-hemocare.com] Fresenius</ref>

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 patient's and can greatly reduce the risk of exposure to emergency surgical patient's. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.

==Literature==
Literature relating to autologous blood is extensive - numerous articles and letters have been written. The subject heading of "Blood Transfusion, Autologous" first appeared in 1971 in the [[Cumulated Index Medicus]]. The Cumulative Index to Nursing & Allied Health began the same title in 1983, and also added a new heading of "Blood Salvage" in 1993. The [[Hospital Literature Index]] began the heading "Blood Transfusion, Autologous" in 1985.

The concepts of [[bloodless]] medicine and [[surgery]] have recently been emerging in literature, books and course programs.

==Indications for autotransfusion==
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 group]]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. <ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

==Common cases==
===Orthopedic===
Spinal Instrumentation, Spinal Fusion, [[Discectomy]], [[Laminectomy]], Total [[shoulder replacement]], Total hip replacement, Total knee replacement, Femur Fractures, Open Reduction Internal Fixation Pelvic Fractures, IM Rodding

===Trauma===
Subdural [[Hematoma]], Chest Injuries, Liver Fractures, Kidney Fractures, Major Vessel Lacerations, [[Aneurysm]]s, Gun Shot Wounds, Stab Wounds, Extremity Reimplantations, Splenectomy, Blunt [[Physical trauma|Trauma]] (Thoracic or Abdominal)

[[===Cardiac===
Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair / Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
]]

===Other===
Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver [[Organ transplant|Transplant]],
Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, [[Hysterectomy]] (Non-Malignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (Non-Malignant)

==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 [[Blood plasma|plasma]] and [[platelet]]s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated [[clotting factor]]s 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 reaches half of the blood volume of the patient.
It should be noted that when a patient recieves banked donor blood that this blood is also in fact, only packed red blood cells, and has no coagulation factors. Therefore, if a patient loses more than half of their total blood volume, they will need to recieve FFP and platelets no matter if they are getting their own blood back or donated homologeous blood.

==Contraindications==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

The use of blood recovered from the operative field is contraindicated in the presence of [[bacteria]]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.

===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 [[cancer]] cells from the surgical site. There are two possible exceptions to this contraindication:

*The surgeon feels complete removal of an encapsulated [[tumor]] 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.

Autotransfusion should not be used in [[C-Section]]s, because the possibility of an [[amniotic fluid]] [[embolism]] exists. The amniotic fluid may not be washed away during the wash phase of autotransfusion process.

The absolute contraindication to use of autotransfusion is the presence of amniotic fluid and/or [[meconium]]. In life saving situations with the consent of the surgeon autotransfusion can be successfully utilized in the presence of the previous stated contraindications i.e. [[sepsis]], bowel contamination and malignancy.

==Collection and processing of blood==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 19</ref>
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 [[cardiotomy]] 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 and size of the centrifuge wash bowl.

When aspirating the blood it is important to utilize the following technique when ever possible:

*Suction blood from pools rather than [[Skimmer (machine)|skimming]].
*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]] of the red cells and will help increase the amount of red cells that will be salvaged.

===Special considerations===
====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 [[collagen]] 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====
[[Cement]] 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.

===Processing===
====Prime phase====
When the "prime" button is pressed, the [[centrifuge]] 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 blood cell|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.

====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 [[antibiotic]]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.

====Reinfuse phase====
When the reinfuse function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of 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. In accordance with Guidelines set by the [[American Association of Blood Banks]] the blood should be reinfused within 6 hours from collection.

==Postoperative autotransfusion==
Postoperative autotransfusion is performed by connecting the double [[lumen]] 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 replacement|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.

==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 [[heparin]]ized [[Saline (medicine)|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. It has been estimated that 90% of the lost red cells can be returned when autotransfusion is performed in conjunction with the soaking of sponges.

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 processing so the exact ratio of Heparin used is not critical. <ref>{{Citation|last=Drago|first=S.S.|title=Banking on your own blood.|journal=Am J Nurs|volume=92|issue=3|year=1992|pages=61–4}}</ref><ref>Langone J, 1988, New methods for saving blood. Researchers are trying to reclaim, recycle and replenish it., Time, 5; 132(23):57, Dec 5, 1988</ref>

==Autotransfusion and religion==
Individuals of the [[Jehovah's Witness]] religion in particular refuse to accept Homologous and [[Autologous]] predonated blood. However some individual members may accept the use of autotransfusion. The process of autotransfusion 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 [[Calcium]] and [[Thrombin]] to create a product similar to [[Fibrin Glue]]. But unlike Fibrin Glue 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. If the fibrin gel procedure is not needed during the procedure the Platelet Rich Plasma can also be reinfused to the patient.

==References==
<references/>

==External links==
*Equipment manufacturers
**[http://www.soringroup-usa.com/ Sorin Group]
**[http://www.haemonetics.com/site/content/ Haemonetics]
**[http://www.fresenius-hemocare.com Fresenius]
**[http://www.davol.com/ Davol]
*Organizations
**[http://www.aabb.org/ American Association of Blood Banks]

==See also==
*[[Bloodless]]

[[Category:Blood]]
[[Category:Transfusion medicine]]
[[Category:Surgical procedures]]

Archive:Autotransfusion

2008-06-12T19:30:29Z

74.137.13.53:

'''Autotransfusion''' <ref>{{Citation|last=Carey|first=J.|title=How to donate to yourself|journal=US News & World Report|volume=102|issue=21|year=1987|pages=59}}</ref> is when a person recieves their own blood for a transfusion, instead of banked donor blood. Auto means self. Blood can be predonated 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, aneuryms, 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 donor]]s. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of [[orthopedic]], [[Physical trauma|trauma]] and [[cardiac]] cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells. By contrast, a disadvantage of the process is the loss of [[platelet]]s.

==History==
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused a [[post-partum]] patient<ref>{{Citation|last=Schmidt|first=P.J.|title=Transfusion in America in the eighteenth and nineteenth century|journal=N Engl J Med|volume=279|year=1968|pages=1319}}</ref>. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patient's 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.<ref>{{Citation|last=Blundell|first=J.|title=Experiments on the transfusion of blood by syringe|journal=Medico-Chirurical Journal|volume=9|year=1918|pages=59}}</ref>

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.<ref>{{Citation|last=Duncan|first=J.|title=On re-infusion of blood in primary and other amputations|journal=Brit M J|volume=1|year=1886|pages=192}}</ref> A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured [[ectopic pregnancy]]<ref>{{Citation|last=Thies|first=H.J.|title=Zur Behandlung der Extrauteringraviditar|journal=Zbl Gynaek|volume=38|year=1914|pages=1190}}</ref>. 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.<ref>{{Citation|last=Lockwood|first=C.D.|title=Surgical treatment of bantis disease|journal=Surg Gynec Obstet|volume=25|year=1917|pages=188}}</ref> Interest in unrefined technique of autotransfusion continued through to the early 1940’s, and was applied to various procedures including treatment of ectopic pregnancy<ref>{{Citation|last=Maynard|first=R.L.|title=Case of ruptured extra-uterine pregnancy treated by autotransfusion|journal=JAMA|volume=92|year=1929|pages=1758}}</ref><ref>{{Citation|last=Rumbaugh|first=M.C.|title=Ruptured tubal pregnancy: report of a case in which life was saved by autotransfusion of blood|journal=Penn Med|volume=34|year=1931|pages=710}}</ref> hemothorax<ref>{{Citation|last=Brown|first=A.L.|title=Autotransfusion: use of blood from hemothorax|journal=JAMA|volume=96|year=1931|pages=1223}}</ref>, ruptured spleen<ref>{{Citation|last=Coley|first=B.L.|title=Traumatic rupture of spleen, splenectomy, autotransfusion|journal=Am J Surg|volume=4|year=1928|pages=34}}</ref><ref>{{Citation|last=Downing|first=W.|title=Autotransfusion following rupture of the spleen: case report|journal=J Iowa Med Soc|volume=24|year=1934|pages=246}}</ref>, perforating abdominal injuries<ref>{{Citation|last=Griswald|first=R.A.|title=The use of autotransfusion in surgery of the serous cavities|journal=Surg Gynec & Obstet|volume=77|year=1943|pages=167}}</ref>, and neurosurgical procedures<ref>{{Citation|last=Davis|first=L.E.|title=Experiences with blood replacement during or after major intra-cranial operations|journal=Surg Gynec Obstet|volume=40|year=1925|pages=310}}</ref>.

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 making [[blood 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.<ref>Nicholson E, 1988, Autolgous blood transfusion, Nurs Times, 13-19; 84(2):33-5 Jan 1988</ref> The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused.<ref>Autologous Blood Transfusion Education Program, Training Manual, Shiley Incorporated, Irvine CA, 1992</ref> 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.<ref>{{Citation|last=Klebanoff|first=G.|title=Early Clinical experience with a disposable unit for intraoperative salvage and reinfusion of blood loss (intraoperative autotransfusion)|journal=Am J Surg|volume=120|year=1970|pages=718–722}}</ref> 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 system|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.<ref>{{Citation|last=Wilson|first=J.D.|title=Autotransfusion during transurethral resection of the prostate: Technique and preliminary clinical evaluation|journal=Mayo Clinic Proceedings|volume=44|year=1969|pages=374}}</ref> In 1976, this system was introduced by Haemonetics Corporation and is know commonly as "Cell Saver"<ref>{{Citation|last=Healey|first=T.G.|title=AANA Journal course: New technologies in anesthesia: Update for nurse anesthetists- Intraoperative blood salvage|journal=AANA J|volume=57|issue=5|year=1989|pages=429–34}}</ref>. More recently in 1995 [[Fresenius]] introduced a continuous autotransfusion system.<ref>[http://www.fresenius-hemocare.com] Fresenius</ref>

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 patient's and can greatly reduce the risk of exposure to emergency surgical patient's. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.

==Literature==
Literature relating to autologous blood is extensive - numerous articles and letters have been written. The subject heading of "Blood Transfusion, Autologous" first appeared in 1971 in the [[Cumulated Index Medicus]]. The Cumulative Index to Nursing & Allied Health began the same title in 1983, and also added a new heading of "Blood Salvage" in 1993. The [[Hospital Literature Index]] began the heading "Blood Transfusion, Autologous" in 1985.

The concepts of [[bloodless]] medicine and [[surgery]] have recently been emerging in literature, books and course programs.

==Indications for autotransfusion==
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 group]]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. <ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

==Common cases==
===Orthopedic===
Spinal Instrumentation, Spinal Fusion, [[Discectomy]], [[Laminectomy]], Total [[shoulder replacement]], Total hip replacement, Total knee replacement, Femur Fractures, Open Reduction Internal Fixation Pelvic Fractures, IM Rodding

===Trauma===
Subdural [[Hematoma]], Chest Injuries, Liver Fractures, Kidney Fractures, Major Vessel Lacerations, [[Aneurysm]]s, Gun Shot Wounds, Stab Wounds, Extremity Reimplantations, Splenectomy, Blunt [[Physical trauma|Trauma]] (Thoracic or Abdominal)

[[===Cardiac===
Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair / Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
]]

===Other===
Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver [[Organ transplant|Transplant]],
Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, [[Hysterectomy]] (Non-Malignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (Non-Malignant)

==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 sole disadvantage of autotransfusion is the depletion of [[Blood plasma|plasma]] and [[platelet]]s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated [[clotting factor]]s 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 reaches half of the blood volume of the patient.

==Contraindications==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

The use of blood recovered from the operative field is contraindicated in the presence of [[bacteria]]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.

===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 [[cancer]] cells from the surgical site. There are two possible exceptions to this contraindication:

*The surgeon feels complete removal of an encapsulated [[tumor]] 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.

Autotransfusion should not be used in [[C-Section]]s, because the possibility of an [[amniotic fluid]] [[embolism]] exists. The amniotic fluid may not be washed away during the wash phase of autotransfusion process.

The absolute contraindication to use of autotransfusion is the presence of amniotic fluid and/or [[meconium]]. In life saving situations with the consent of the surgeon autotransfusion can be successfully utilized in the presence of the previous stated contraindications i.e. [[sepsis]], bowel contamination and malignancy.

==Collection and processing of blood==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 19</ref>
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 [[cardiotomy]] 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 and size of the centrifuge wash bowl.

When aspirating the blood it is important to utilize the following technique when ever possible:

*Suction blood from pools rather than [[Skimmer (machine)|skimming]].
*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]] of the red cells and will help increase the amount of red cells that will be salvaged.

===Special considerations===
====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 [[collagen]] 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====
[[Cement]] 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.

===Processing===
====Prime phase====
When the "prime" button is pressed, the [[centrifuge]] 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 blood cell|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.

====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 [[antibiotic]]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.

====Reinfuse phase====
When the reinfuse function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of 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. In accordance with Guidelines set by the [[American Association of Blood Banks]] the blood should be reinfused within 6 hours from collection.

==Postoperative autotransfusion==
Postoperative autotransfusion is performed by connecting the double [[lumen]] 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 replacement|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.

==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 [[heparin]]ized [[Saline (medicine)|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. It has been estimated that 90% of the lost red cells can be returned when autotransfusion is performed in conjunction with the soaking of sponges.

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 processing so the exact ratio of Heparin used is not critical. <ref>{{Citation|last=Drago|first=S.S.|title=Banking on your own blood.|journal=Am J Nurs|volume=92|issue=3|year=1992|pages=61–4}}</ref><ref>Langone J, 1988, New methods for saving blood. Researchers are trying to reclaim, recycle and replenish it., Time, 5; 132(23):57, Dec 5, 1988</ref>

==Autotransfusion and religion==
Individuals of the [[Jehovah's Witness]] religion in particular refuse to accept Homologous and [[Autologous]] predonated blood. However some individual members may accept the use of autotransfusion. The process of autotransfusion 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 [[Calcium]] and [[Thrombin]] to create a product similar to [[Fibrin Glue]]. But unlike Fibrin Glue 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. If the fibrin gel procedure is not needed during the procedure the Platelet Rich Plasma can also be reinfused to the patient.

==References==
<references/>

==External links==
*Equipment manufacturers
**[http://www.soringroup-usa.com/ Sorin Group]
**[http://www.haemonetics.com/site/content/ Haemonetics]
**[http://www.fresenius-hemocare.com Fresenius]
**[http://www.davol.com/ Davol]
*Organizations
**[http://www.aabb.org/ American Association of Blood Banks]

==See also==
*[[Bloodless]]

[[Category:Blood]]
[[Category:Transfusion medicine]]
[[Category:Surgical procedures]]

Archive:Autotransfusion

2008-06-12T19:24:06Z

74.137.13.53: /* Disadvantages */

'''Autotransfusion''' <ref>{{Citation|last=Carey|first=J.|title=How to donate to yourself|journal=US News & World Report|volume=102|issue=21|year=1987|pages=59}}</ref> is a [[medicine|medical]] procedure in which the lost [[blood]] of a patient is collected and returned to the same patient. It can be used in circumstances where, for example, the patient has a rare [[blood group]], or there is a risk of infection from an alternative source of blood. The patient's blood can be collected before or during [[surgery]].

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 donor]]s. Later, interest in the procedure returned with new automated machinery being developed for it. Autotransfusion is used in a number of [[orthopedic]], [[Physical trauma|trauma]] and [[cardiac]] cases, amongst others, and it carries advantages, including the reduction of infection risk and the provision of more functional cells. By contrast, a disadvantage of the process is the loss of [[platelet]]s.

==History==
There is some evidence that in 1785 that Philip Physic of Philadelphia transfused a [[post-partum]] patient<ref>{{Citation|last=Schmidt|first=P.J.|title=Transfusion in America in the eighteenth and nineteenth century|journal=N Engl J Med|volume=279|year=1968|pages=1319}}</ref>. However the first documented use of autologous blood transfusion was in 1818 when an Englishman, Blundell salvaged vaginal blood from patient's 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.<ref>{{Citation|last=Blundell|first=J.|title=Experiments on the transfusion of blood by syringe|journal=Medico-Chirurical Journal|volume=9|year=1918|pages=59}}</ref>

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.<ref>{{Citation|last=Duncan|first=J.|title=On re-infusion of blood in primary and other amputations|journal=Brit M J|volume=1|year=1886|pages=192}}</ref> A German, M.J. Theis, reported the first successful use of intraoperative autotransfusion in 1914, with a ruptured [[ectopic pregnancy]]<ref>{{Citation|last=Thies|first=H.J.|title=Zur Behandlung der Extrauteringraviditar|journal=Zbl Gynaek|volume=38|year=1914|pages=1190}}</ref>. 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.<ref>{{Citation|last=Lockwood|first=C.D.|title=Surgical treatment of bantis disease|journal=Surg Gynec Obstet|volume=25|year=1917|pages=188}}</ref> Interest in unrefined technique of autotransfusion continued through to the early 1940’s, and was applied to various procedures including treatment of ectopic pregnancy<ref>{{Citation|last=Maynard|first=R.L.|title=Case of ruptured extra-uterine pregnancy treated by autotransfusion|journal=JAMA|volume=92|year=1929|pages=1758}}</ref><ref>{{Citation|last=Rumbaugh|first=M.C.|title=Ruptured tubal pregnancy: report of a case in which life was saved by autotransfusion of blood|journal=Penn Med|volume=34|year=1931|pages=710}}</ref> hemothorax<ref>{{Citation|last=Brown|first=A.L.|title=Autotransfusion: use of blood from hemothorax|journal=JAMA|volume=96|year=1931|pages=1223}}</ref>, ruptured spleen<ref>{{Citation|last=Coley|first=B.L.|title=Traumatic rupture of spleen, splenectomy, autotransfusion|journal=Am J Surg|volume=4|year=1928|pages=34}}</ref><ref>{{Citation|last=Downing|first=W.|title=Autotransfusion following rupture of the spleen: case report|journal=J Iowa Med Soc|volume=24|year=1934|pages=246}}</ref>, perforating abdominal injuries<ref>{{Citation|last=Griswald|first=R.A.|title=The use of autotransfusion in surgery of the serous cavities|journal=Surg Gynec & Obstet|volume=77|year=1943|pages=167}}</ref>, and neurosurgical procedures<ref>{{Citation|last=Davis|first=L.E.|title=Experiences with blood replacement during or after major intra-cranial operations|journal=Surg Gynec Obstet|volume=40|year=1925|pages=310}}</ref>.

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 making [[blood 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.<ref>Nicholson E, 1988, Autolgous blood transfusion, Nurs Times, 13-19; 84(2):33-5 Jan 1988</ref> The devices used during the Korean and Vietnam War collected and provided gross filtration of blood before it was reinfused.<ref>Autologous Blood Transfusion Education Program, Training Manual, Shiley Incorporated, Irvine CA, 1992</ref> 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.<ref>{{Citation|last=Klebanoff|first=G.|title=Early Clinical experience with a disposable unit for intraoperative salvage and reinfusion of blood loss (intraoperative autotransfusion)|journal=Am J Surg|volume=120|year=1970|pages=718–722}}</ref> 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 system|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.<ref>{{Citation|last=Wilson|first=J.D.|title=Autotransfusion during transurethral resection of the prostate: Technique and preliminary clinical evaluation|journal=Mayo Clinic Proceedings|volume=44|year=1969|pages=374}}</ref> In 1976, this system was introduced by Haemonetics Corporation and is know commonly as "Cell Saver"<ref>{{Citation|last=Healey|first=T.G.|title=AANA Journal course: New technologies in anesthesia: Update for nurse anesthetists- Intraoperative blood salvage|journal=AANA J|volume=57|issue=5|year=1989|pages=429–34}}</ref>. More recently in 1995 [[Fresenius]] introduced a continuous autotransfusion system.<ref>[http://www.fresenius-hemocare.com] Fresenius</ref>

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 patient's and can greatly reduce the risk of exposure to emergency surgical patient's. Autotransfusion represents a measure of blood conservation and reduction of exposure risk to homologous blood.

==Literature==
Literature relating to autologous blood is extensive - numerous articles and letters have been written. The subject heading of "Blood Transfusion, Autologous" first appeared in 1971 in the [[Cumulated Index Medicus]]. The Cumulative Index to Nursing & Allied Health began the same title in 1983, and also added a new heading of "Blood Salvage" in 1993. The [[Hospital Literature Index]] began the heading "Blood Transfusion, Autologous" in 1985.

The concepts of [[bloodless]] medicine and [[surgery]] have recently been emerging in literature, books and course programs.

==Indications for autotransfusion==
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 group]]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. <ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

==Common cases==
===Orthopedic===
Spinal Instrumentation, Spinal Fusion, [[Discectomy]], [[Laminectomy]], Total [[shoulder replacement]], Total hip replacement, Total knee replacement, Femur Fractures, Open Reduction Internal Fixation Pelvic Fractures, IM Rodding

===Trauma===
Subdural [[Hematoma]], Chest Injuries, Liver Fractures, Kidney Fractures, Major Vessel Lacerations, [[Aneurysm]]s, Gun Shot Wounds, Stab Wounds, Extremity Reimplantations, Splenectomy, Blunt [[Physical trauma|Trauma]] (Thoracic or Abdominal)

[[===Cardiac===
Cardiothoracic, Coronary Artery Bypass, Cardiac Valvular Repair / Replacement, Aortic Arch Aneurysms, Thoracic Trauma, Cardiac Transplantation
]]

===Other===
Ectopic Pregnancy, Liver Resection (Non-Malignant), Porto-Caval Shunts, Liver [[Organ transplant|Transplant]],
Nephrectomy (Non-Malignant), Speno-Renal Shunts, Abdominal Aortic Aneurysm, Aorto-Femoral Reconstruction, Major Vessel Resection, [[Hysterectomy]] (Non-Malignant), Cerebral Aneurysms, Craniotomy (Non-Malignant), Thoracotomy (Non-Malignant)

==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 sole disadvantage of autotransfusion is the depletion of [[Blood plasma|plasma]] and [[platelet]]s. The washed autotransfusion system removes the plasma and platelets, to eliminate activated [[clotting factor]]s 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 reaches half of the blood volume of the patient.

==Contraindications==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 3</ref>

The use of blood recovered from the operative field is contraindicated in the presence of [[bacteria]]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.

===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 [[cancer]] cells from the surgical site. There are two possible exceptions to this contraindication:

*The surgeon feels complete removal of an encapsulated [[tumor]] 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.

Autotransfusion should not be used in [[C-Section]]s, because the possibility of an [[amniotic fluid]] [[embolism]] exists. The amniotic fluid may not be washed away during the wash phase of autotransfusion process.

The absolute contraindication to use of autotransfusion is the presence of amniotic fluid and/or [[meconium]]. In life saving situations with the consent of the surgeon autotransfusion can be successfully utilized in the presence of the previous stated contraindications i.e. [[sepsis]], bowel contamination and malignancy.

==Collection and processing of blood==
<ref>Dideco Shiley BT795/AA Machine Operation Manual, Shiley Incorporated, Irvine CA, 1988, page 19</ref>
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 [[cardiotomy]] 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 and size of the centrifuge wash bowl.

When aspirating the blood it is important to utilize the following technique when ever possible:

*Suction blood from pools rather than [[Skimmer (machine)|skimming]].
*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]] of the red cells and will help increase the amount of red cells that will be salvaged.

===Special considerations===
====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 [[collagen]] 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====
[[Cement]] 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.

===Processing===
====Prime phase====
When the "prime" button is pressed, the [[centrifuge]] 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 blood cell|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.

====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 [[antibiotic]]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.

====Reinfuse phase====
When the reinfuse function is selected, the centrifuge braking begins. The clamps change positions, enabling the transfer of 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. In accordance with Guidelines set by the [[American Association of Blood Banks]] the blood should be reinfused within 6 hours from collection.

==Postoperative autotransfusion==
Postoperative autotransfusion is performed by connecting the double [[lumen]] 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 replacement|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.

==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 [[heparin]]ized [[Saline (medicine)|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. It has been estimated that 90% of the lost red cells can be returned when autotransfusion is performed in conjunction with the soaking of sponges.

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 processing so the exact ratio of Heparin used is not critical. <ref>{{Citation|last=Drago|first=S.S.|title=Banking on your own blood.|journal=Am J Nurs|volume=92|issue=3|year=1992|pages=61–4}}</ref><ref>Langone J, 1988, New methods for saving blood. Researchers are trying to reclaim, recycle and replenish it., Time, 5; 132(23):57, Dec 5, 1988</ref>

==Autotransfusion and religion==
Individuals of the [[Jehovah's Witness]] religion in particular refuse to accept Homologous and [[Autologous]] predonated blood. However some individual members may accept the use of autotransfusion. The process of autotransfusion 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 [[Calcium]] and [[Thrombin]] to create a product similar to [[Fibrin Glue]]. But unlike Fibrin Glue 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. If the fibrin gel procedure is not needed during the procedure the Platelet Rich Plasma can also be reinfused to the patient.

==References==
<references/>

==External links==
*Equipment manufacturers
**[http://www.soringroup-usa.com/ Sorin Group]
**[http://www.haemonetics.com/site/content/ Haemonetics]
**[http://www.fresenius-hemocare.com Fresenius]
**[http://www.davol.com/ Davol]
*Organizations
**[http://www.aabb.org/ American Association of Blood Banks]

==See also==
*[[Bloodless]]

[[Category:Blood]]
[[Category:Transfusion medicine]]
[[Category:Surgical procedures]]