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Waters JH, Tuohy MJ, Hobson DF, Procop G.
Bacterial reduction by cell salvage washing and leukocyte
depletion filtration. Anesthesiology. 2003 Sep;99(3):652-5.
BACKGROUND: Blood conservation techniques are being increasingly
used because of the increased cost and lack of availability of allogeneic blood.
Cell salvage offers great blood savings opportunities but is thought to be
contraindicated in a number of areas (e.g.,
blood contaminated with bacteria).
Several outcome studies have suggested the safety of this technique in trauma
and colorectal surgery, but many practitioners are still hesitant to apply cell
salvage in the face of frank bacterial contamination. This study was undertaken
to assess the efficacy of bacterial removal when cell salvage was combined with
leukocyte depletion filtration. METHODS: Expired packed erythrocytes were
obtained and inoculated with a fixed amount of a stock bacteria (Escherichia
coli American Type Culture Collections [ATCC] 25922, Pseudomonas aeruginosa ATCC
27853, Staphylococcus aureus ATCC 29213, or Bacteroides fragilis ATCC 25285) in
amounts ranging from 2,000 to 4,000 colony forming units/ml. The blood was
processed via a cell salvage machine. The washed blood was then filtered using a
leukocyte reduction filter. The results for blood taken during each step of
processing were compared using a repeated-measures design. RESULTS: Fifteen
units of blood were contaminated with each of the stock bacteria. From the
prewash sample to the postfiltration sample, 99.0%, 99.6%, 100%, and 97.6% of E.
coli, S. aureus, P. aeruginosa, and B. fragilis were removed, respectively.
DISCUSSION: Significant but not complete removal of contaminating bacteria was
seen. An increased level of patient safety may be added to cell salvage by
including a leukocyte depletion filter when salvaging blood that might be
grossly contaminated with bacteria.
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Valbonesi M, Bruni R, Lercari G, Florio G, Carlier P, Morelli F.
Autoapheresis and intraoperative blood
salvage in oncologic surgery. Transfus Sci. 1999 Oct;21(2):129-39.
Transfusion of predeposit or salvaged autologous blood has
continued to grow since the 1980s. Issues such as the indications for use and
cost effectiveness as well as the safety of autologous
blood salvaged during cancer surgery
have emerged and should be addressed. The concern for possible contamination of
autologous RBC with cancer cells responsible for metastasis has limited the use
of autologous salvaged blood in cancer patients. Nevertheless, clinical
experience has been gained on the use of salvaged blood in patients with
colorectal, gastric, renal, hepatic, breast, bladder and lung cancer. No
evidence has been reported showing an increase in metastasis or a decrease in
patient survival, in spite of the obvious demonstration that salvaged blood is
contaminated with viable tumor cells which are not washed out of the RBC layer
during intraoperative blood salvage (IOBS). However, a number of limitations
have hampered the widespread use of IOBS in these patients and the technique is
not well established. Increasing knowledge of the deleterious effects of
allogeneic blood transfusion both in terms of the increased number of viral or
bacterial infections and the down-regulation of the patient's immune system have
recalled attention to IOBS and to the techniques such as filtration, which might
reduce the risk of reinfusion of cancer cells, or totally eliminate the risks
such as irradiation has been proposed by Hansen's group. This paper reviews the
topic with some emphasis on our personal experience with gamma and X-ray
irradiation of salvaged blood in a large reference hospital, where IOBS and
filtration of salvaged blood were established for use in cancer patients in 1993
and 1996.
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Waters JH, Biscotti C, Potter PS, Phillipson E.
Amniotic fluid removal during cell salvage in
the cesarean section patient.
BACKGROUND: Cell salvage has been used in obstetrics to a limited
degree because of a fear of amniotic
fluid embolism. In this study, cell salvage was combined with blood
filtration using a leukocyte depletion filter. A comparison of this washed,
filtered product was then made with maternal central venous blood. METHODS: The
squamous cell concentration, lamellar body count, quantitative bacterial
colonization, potassium level, and fetal hemoglobin concentration were measured
in four sequential blood samples collected from 15 women undergoing elective
cesarean section. The blood samples collected included (1) unwashed blood from
the surgical field (prewash), (2) washed blood (postwash), (3) washed and
filtered blood (postfiltration), and (4) maternal central venous blood drawn
from a femoral catheter at the time of placental separation. RESULTS:
Significant reductions in the following parameters were seen when the
postfiltration samples were compared to the prewash samples (median [25th-75th
percentile]): squamous cell concentration (0.0 [0.0-0.1 counts/high-powered
field (HPF)] vs. 8.3 counts/HPF [4. 0-10.5 counts/HPF], P < 0.05); bacterial
contamination (0.1 [0.0-0. 2] vs. 3.0 [0.6-7.7] colony-forming units (CFU)/ml, P
< 0.01); and lamellar body concentration (0.0 [0.0-1.0] vs. 22.0 [18.5-29.5]
thousands/microl, P < 0.01). No significant differences existed between the
postfiltration and maternal samples for each of these parameters. Fetal
hemoglobin was in higher concentrations in the postfiltration sample when
compared with maternal blood (1.9 [1.1-2. 5] vs. 0.5% [0.3-0.7] ). Potassium
levels were significantly less in the postfiltration sample when compared with
maternal (1.4 [1.0-1.5] vs. 3.8 mEq/l [3.7-4.0]). CONCLUSIONS: Leukocyte
depletion filtering of cell-salvaged blood obtained from cesarean section
significantly reduces particulate contaminants to a concentration equivalent to
maternal venous blood.
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Smith LA, Barker DE, Burns RP:
Autotransfusion utilization in abdominal trauma. Am Surg 1997
Jan;63(1):47-49 Summary: The use of salvaged autologous blood
comprised 45 per cent of total blood transfused. On a case-by-case basis, 75 per
cent of cases were cost-effective compared to blood bank costs for an equivalent
transfusion. Transfusion of intraoperatively salvaged autologous blood (autotransfusion)
is a cost-effective, efficient way to provide blood products to operative
trauma patients.
*****
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Gray CL, Amling CL, Polston GR, Powell CR, Kane CJ.
Intraoperative cell salvage in radical
retropubic prostatectomy. Urology. 2001 Nov;58(5):740-5.
OBJECTIVES: To investigate the efficacy and
safety of intraoperative cell salvage with autotransfusion using leukocyte
reduction filters in patients undergoing radical retropubic prostatectomy (RRP).
METHODS: Between September 1996 and March 1999, 62 patients (age range 48 to 70
years) with clinically localized prostate cancer underwent RRP with
intraoperative cell salvage as the sole blood management technique. Salvaged
blood was passed through a leukocyte reduction filter before autotransfusion.
The 62 cell salvage patients were compared with a cohort who predonated 1 to 3 U
autologous blood (n = 101). The estimated blood loss, preoperative and
postoperative hematocrit, need for homologous transfusion, and biochemical
recurrence rates were compared between the two groups. The progression-free
survival rates were compared using the Kaplan-Meier method. RESULTS: No
difference was found in preoperative prostate-specific antigen level, pathologic
stage, or estimated blood loss between the cell salvage and autologous
predonation groups. The preoperative and postoperative hematocrit levels were
higher in the cell salvage group (42.7% versus 39.6% and 31.3% versus 27.9%,
respectively; P <0.001 for each). The homologous transfusion rates were lower in
the cell salvage group (3% versus 14%, P = 0.04). The incidence of
progression-free survival (prostate-specific antigen level 0.4 ng/mL or greater)
was no different between the groups (P = 0.41). CONCLUSIONS: Intraoperative cell
salvage with autotransfusion using leukocyte reduction filters in RRP results in
higher perioperative hematocrit levels and low homologous transfusion rates and
eliminates the need for autologous predonation. Cell salvage does not appear to
be associated with an increased risk of early biochemical progression after RRP.
- Elias D, Lapierre V, Billard V.
Perioperative autotransfusion with salvage blood in cancer
surgery. Ann Fr Anesth Reanim. 2000 Dec;19(10):739-44. Review.
French
OBJECTIVES: Intraoperative blood cells salvage using a Cell Saver
technique is controversial in oncologic surgery because tumor cells could be
aspirated and reinfused to the patient. The goal of this review was to discuss
the risk associated with this technique, and the way to minimize it. DATA
SOURCES: A review of the literature has been made by questioning PubMed site
(http://nbci.nlm.nih.gov) on the period of 1968 to 2000. The key words were:
intraoperative blood salvage, blood transfusion, autologous, cancer. Cases
reports have been excluded. STUDY SELECTION: Tumor cells aspirated and reinfused
have been numbered in both experimental and clinical studies. In clinical
studies, the outcome after intraoperative cells salvage/reinfusion has been
compared to published data or historical groups of allogeneic transfusion, all
in non randomized studies. DATA SYNTHESIS: Both experimental and clinical
studies confirmed the presence of cancer cells in the blood either aspirated or
reinfused. However, six clinical studies with limited number of patients did not
show metastatic spread associated with Cell Saver. The addition of leukocyte
filters reduces greatly this quantity of cancer cells. Irradiation of the pack
did not destroy tumor cells but blocked their proliferative capacity. In the
other hand, some infiltrative tumors were shown to have permanent cancer cells
seeding, quantitatively superior to the seeding observed when a Cell Saver is
used. CONCLUSION: It seems reasonable to use the Cell Saver in oncologic surgery,
if possible with a leukocyte filter, not only in case of unexpected major
bleeding (consensus), but also in programmed cases with high risk of huge
hemorrhage.
- Mirhashemi R, Averette HE, Deepika K, Estape R, Angioli R, Martin J,
Rodriguez M, Penalver MA.
The impact of intraoperative autologous
blood transfusion during type III radical hysterectomy for early-stage cervical
cancer. Am J Obstet Gynecol. 1999 Dec;181(6):1310-5;
discussion 1315-6.
OBJECTIVE: The aim of this study was to determine the effects on
transfusion rates, perioperative complications, and survival of using
intraoperative autologous blood transfusions for patients undergoing type III
radical hysterectomy and lymphadenectomy. STUDY DESIGN: A retrospective analysis
was conducted on 156 patients treated with type III radical hysterectomy and
lymphadenectomy at the University of Miami School of Medicine from 1990 to 1997.
One group of patients (n = 50) had intraoperative autologous blood transfusions
and the other (n = 106) did not. RESULTS: The group that received intraoperative
autologous blood transfusion had a significant reduction in homologous blood
transfusions (12% vs 30%; P =.02). Patient demographic data, histologic
parameters, and operative factors were similar between the 2 groups. There was a
higher percentage of patients with positive pelvic lymph nodes in the group that
did not receive intraoperative autologous blood transfusion (10% vs 30%; P
=.02). Seven patients in the intraoperative autologous blood transfusion group
(14%) died with disease present and all the recurrences in this group were local.
CONCLUSION: The use of intraoperative autologous blood transfusions during type
III radical hysterectomy and lymphadenectomy appears to be safe and effective
without compromising rates and patterns of recurrence.
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Kongsgaard UE, Wang MY, Kvalheim G.
Leucocyte depletion filter removes cancer cells in human
blood. Acta Anaesthesiol Scand. 1996 Jan;40(1):118-20.
BACKGROUND: Autologous blood transfusion has been avoided in
cancer surgery because of the metastatic potential of reinfused tumour cells.
METHODS: This study evaluated the efficacy of a blood transfusion filter in
removing tumour cells from blood. Whole human blood was admixed with two
different malignant cell lines (breast cancer PM1 and MCF7). The blood was
filtered through a RC400TE leucocyte depletion filter. Unfiltered blood was used
as a control. Detection of malignant cells was performed with immunomagnetic
beads and clonogenic assays. RESULTS: No viable tumour cells were found after
filtration with the leucocyte depletion filter. CONCLUSION: These findings
suggest that the use of a leucocyte filter after intra-operative blood salvage
may make autotransfusion safe even in tumour surgery.
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Muller M, Kuhn DF, Hinrichs B, Schindler E, Dreyer T, Hirsch C, Schaffer R,
Hempelmann G.
Is the elimination of osteosarcoma
cells with intraoperative "mesh autotransfusion" and leukocyte depletion filters
possible?[Article in German] Anaesthesist. 1996 Sep;45(9):834-8.
Intraoperative autotransfusion is contraindicated in cancer
surgery because of the possible risk of systemic tumor spread. The aim of the
present study was to investigate whether a cell saver in combination with a
white blood cell depletion filter can remove osteosarcoma cells. METHODS: A
defined number of osteosarcoma cells from an established cell line were added to
red cell concentrates and Ringer solution. The tumor cell concentration was
1000/ ml in the first five experiments, 7111/ml in test no. 6, 1667/ml in test
no. 7 and 167/ml in test no. 8. Following thorough mixing, each unit was
processed separately by a cell saver (DIDECO BT 795/P) in its normal operation
mode to produce a red cell concentrate. This red cell concentrate was filtered
using a leukocyte depletion filter (PALL BPF 4). Samples were taken before and
after processing with the autotransfuser and after filtration with the white
cell depletion filter. Cytospin specimens from all samples were examined for
osteosarcoma cells by three different methods (Papanicolaou stain, Vimentin
antibodies, DNA analysis). RESULTS: After processing with the autotransfuser,
tumor cells were identified in the red cell concentrate. No osteosarcoma cells
were evident after the combined use of cell saver and leukocyte depletion filter.
CONCLUSION: The sole use of the autotransfuser DIDECO BT 795/P during
osteosarcoma surgery is not recommended because of the potential danger of
retransfusion of malignant cells. In combination with the leukocyte depletion
filter PALL BPF 4, no osteosarcoma cells were identified in the red cell
concentrate. Since the adhesiveness of tumor cells from established cell lines
may be different from that of tumor cells in the intraoperative salvaged blood,
further studies with blood from the surgical field are necessary to determine
the efficacy of white cell depletion filters to eliminate osteosarcoma cells.
- Hansen E, Bechmann V, Altmeppen J.
Intraoperative blood salvage in cancer surgery: safe and
effective? Transfus Apheresis Sci. 2002 Oct;27(2):153-7.
To support blood supply in the growing field of cancer surgery
and to avoid transfusion induced immunomodulation caused by the allogeneic
barrier and by blood storage leasions we use intraoperative blood salvage with
blood irradiation. This method is safe as it provides efficient elimination of
contaminating cancer cells, and as it does not compromise the quality of RBC.
According to our experience with more than 700 procedures the combination of
blood salvage with blood irradiation also is very effective in saving blood
resources. With this autologous, fresh, washed RBC a blood product of excellent
quality is available for optimal hemotherapy in cancer patients.
- Park KI, Kojima O, Tomoyoshi T: Assessment of availability
of intraoperative autotransfusion in urological operations. J Urol
1997; 157:1777-1780 1. Summary: Our results suggest that intraoperative
autotransfusion is safe for urological operations in which bacteria and
tumor cells are not present in the operative field. Our data also indicate
that intraoperative autotransfusion may be safe for urological cancer operations
if it is combined with leukocyte removal filters to prevent unexpected
reinfusion of tumor cells.
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Collin GR, Bianchi Jd: Laparoscopic Examination of fhe
Traumatized Spleen with Blood Salvage for Autotransfusion Am Surg 1997
Jun; 63:478-480. Summary: The management of splenic trauma presents
a dilemma to the surgeon, who must weigh the risks of operative versus
nonoperative management. Laparoscopy has been used increasingly for trauma
cases to decrease the morbidity associated with standard laparotomy. Autotransfusion
of the patient's shed blood has also become widespread to decrease
the risks associated with transfusion. The Authors describe the case of
a 15-year-old male with blunt splenic trauma, in which laparoscopy was
used to examine the spleen to ascertain the need for operative treatment,
to look for other intra.abdominal injuries, and to salvage intraperitoneal
blood for autotransfusion. In this case, laparoscopy determined that laparotomy
would be nontherapeutic, and that autotransfusion could obviate the need
for banked.blood transfusion.
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