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Intraoperative Cell Salvage

UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK. Intraoperative Cell Salvage. Education Workbook Slides. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK. Training Pathway. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK. Intraoperative Cell Salvage. Basic Blood Facts Blood Conservation

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Intraoperative Cell Salvage

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  1. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Education Workbook Slides

  2. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Training Pathway

  3. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  4. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • Describe the main functions of blood • Identify the main components of blood and describe their individual functions • Describe basic coagulation • List the allogeneic (donor) blood components available for clinical use

  5. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood separated into its constituent parts

  6. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK The coagulation cascade Anticoagulants Citrate binds free calcium (Ca++), preventing activation of clotting factors Heparin is an antithrombin agent which inactivates thrombin, preventing conversion of fibrinogen to fibrin

  7. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Allogeneic (Donor) Blood Components Blood and blood components must always be stored under controlled storage conditions in designated fridges, freezers etc.

  8. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  9. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • Identify the principles of blood conservation • Identify the areas where blood conservation can be undertaken in surgical patients • Describe the main strategies of blood conversation

  10. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Conservation • Allogeneic (Donor) Blood • Limited Resource • Donor Restrictions e.g. age, previous transfusion, lifestyle • Risks e.g. • Wrong Blood Incidents • Transfusion Transmitted Infections • Transfusion reactions • Costs

  11. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Conservation • Patient Blood Management • a multidisciplinary, evidence-based approach to optimising the care of patients who might need a blood transfusion • Recommendations published by the National Blood Transfusion Committee (2014) • Emergency Plans for Blood Shortages • To ensure the availability of blood where critical in the event of a blood shortage Autologous blood transfusion is one of many blood conservation strategies which should be considered when addressing Patient Blood Management.

  12. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Conservation

  13. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  14. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • Demonstrate an understanding of the principles of haemovigilance • Identify the risks associated with administration of allogeneic (donor) blood

  15. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Haemovigilance • Serious Hazards of Transfusion (SHOT) • Serious Adverse Blood Reactions and Events (SABRE)

  16. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Reporting cell salvage incidents to SHOT

  17. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  18. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • Identify the three main stages of ICS • Identify the different ICS systems that exist • Describe the end product of ICS

  19. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage

  20. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Collection • Blood is aspirated and mixed with anticoagulant through an aspiration and anticoagulation (A&A) line, into a collection reservoir. • The collection reservoir contains a filter that removes clots and other gross particulate matter.

  21. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Separation • The reservoir contents are pumped/drawn into a spinning centrifuge system. • The RBC component is retained within the bowl while the lighter components are forced out into a waste line. • As the reservoir contents continue to enter the system and separate, the HCT within the system increases.

  22. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Washing • IV normal saline (0.9% NaCl) is pumped into the spinning centrifuge system, passing through the heavier RBC component and out into the waste line displacing the remaining waste products

  23. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Most systems have a minimum wash volume recommended by the manufacturer. It is not advisable to decrease the wash volume below this level. It is advisable to increase the wash volume for procedures where there is a high risk of contamination of salvaged blood, e.g. obstetrics and orthopaedics.

  24. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Reinfusion • The end product of washed, packed RBCs suspended in IV normal saline (0.9% NaCl) is pumped to a bag ready for reinfusion.

  25. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage ICS can reduce and sometimes eliminate the need to transfuse allogeneic (donor) RBCs. In cases where large blood loss occurs, patients receiving ICS may still become depleted of clotting factors and platelets. In such cases transfusion of allogeneic (donor) components such as fresh frozen plasma (FFP), platelets or cryoprecipitate may be required.

  26. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  27. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • To identify the indications for ICS • To identify the relative contraindications for ICS • To outline when the risks/benefits of using/not using ICS change

  28. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications • Indications and patient selection • Elective and emergency surgical procedures • Clinical decision (surgeon and/or anaesthetist) • Estimated blood loss >20% of patient’s estimated blood volume • Patient factors • Risk factors for bleeding • Low preoperative Hb • Rare blood group / multiple antibodies • Unwilling to receive allogeneic blood on religious or other grounds

  29. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications • Relative Contraindications • Bowel contents in the surgical field • Infected surgical fields • Sickle cell disease • Heparin induced thrombocytopenia (if heparin is the only available anticoagulant for ICS)

  30. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications • Warnings • Contaminating substances* e.g. • Non-intravenous substances • e.g. antibiotics not licensed for IV use; Iodine; topical clotting agents; orthopaedic cememt • Non-intravenous bodily fluids • e.g. gastric/pancreatic secretions; pleural effusions; metal fragments from implants *Action when contaminating substances present: • Avoid aspirating (discontinue ICS) • Irrigate with 0.9% Sodium Chloride (NaCl) • Resume ICS

  31. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications • Cautions • Hartmann’s can inhibit the action of ACD-A anticoagulant if used as an irrigant or wash solution • Air will be present in the reinfusion bag (risk of air embolus) • Automatic mode is recommended

  32. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications • Areas for further consideration • Infected fields • Malignancy • Obstetrics The decision to use blood that is potentially contaminated with bacteria, malignant cells or amniotic fluid should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

  33. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  34. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • To identify the equipment used for blood collection and describe the function of each component • To name the two main types of anticoagulant used in ICS, describe their functions and mechanism of action • To describe methods of maximizing blood collection • To identify potential problems areas during blood collection

  35. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Aspiration of blood from surgical field • Anticoagulation • Filtering • Storage prior to processing

  36. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Decision to collect blood • Anticipated blood loss • Patient risk factors for bleeding • Low Preoperative Haemoglobin • Patient objections to receiving allogeneic (donor) blood

  37. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Collect only setup Where adequate blood loss for processing cannot be predicated

  38. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Anticoagulants* • Heparin saline • 25-30, 000 IU heparin/1000mls IV normal saline (0.9% NaCl) • Ratio 1:5 e.g. 20ml to 100ml blood • Antithrombin III Ineffective if the patient suffers an antithrombin III deficiency • ACD-A • Pre-prepared • Ratio 1:7 e.g. 15ml to 100ml blood • Binds Calcium Calcium containing fluids may block the action of ACD-A e.g. Hartmann’s Solution *Recommended minimum flow rate – 1 drip per second

  39. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Wide bore suction tip • e.g. Yankauer • Low vacuum level • to minimise RBC Haemolysis

  40. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • During collection • Regulate vacuum • Regulate anticoagulant flow (↑ with ↑ blood loss) • Monitor volume of blood loss Only IV grade fluids should be aspirated into the system

  41. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Maximising blood collection • Maintain a low vacuum level • Suction technique (aspirate from pools of blood) • Wide bore suction tip • Swab washing

  42. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Swab washing • Blood normally lost to swabs is salvaged • Sterile bowl • 1000mls IV normal Saline (0.9%NaCl) • Swabs placed in bowl for ~ 5 mins then gently squeezed out • Swab wash aspirated in to ICS machine and processed Ensure the swab wash bowl is maintained within the sterile field. Ensure no substances not intended for IV use enter the swab wash bowl e.g. Betadine soaked swabs.

  43. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection • Troubleshooting • Loss of suction • Clotting in reservoir • Contamination with non-IV substances* *The decision to use blood that is potentially contaminated with bacteria, amniotic fluid or malignant cells should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

  44. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage • Basic Blood Facts • Blood Conservation • Haemovigilance • Principles of Intraoperative Cell Salvage • Indications and Contraindications • Practicalities – Blood Collection • Practicalities – Blood Processing • Practicalities – Blood Reinfusion • Information and Best Practice • Unloading and Discarding

  45. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes • To identify the steps taken in making the decision to process • To list the equipment used for blood processing and describe the function of each component • To describe the steps required in preparing for and commencing blood processing • To describe the risks of overriding the automatic functions of the machine • To identify the steps necessary to complete the blood processing phase

  46. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing* • Separation of RBCs from waste products • Concentration of RBCs • Washing of RBCs with 0.9% sodium chloride (NaCl) • Transfer of RBCs to reinfusion bag *Blood collection can continue during the processing phase

  47. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing • Decision to process • Adequate blood loss in collection reservoir • Anticipated adequate blood loss in collection reservoir due to rapid bleeding • Patient factors • Low Hb • Anticipated postoperative benefit

  48. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing • Full processing setup

  49. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing • Automatic mode • It is highly recommended that ICS machines are run in automatic mode* *Running the machine in manual mode could result in residual contaminants in the RBCs, which could be potentially harmful to the patient

  50. UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing • Wash volume • Always use the minimum wash volume as outlined by the manufacturer • DO NOT decrease wash volumes - this could result in potentially harmful contaminants being reinfused to the patient • Wash volumes may be increased where there are some types of contaminants e.g. fat in orthopaedic procedures

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