Abstract
The British Association of Anaesthetists 2018 peri-operative blood conservation guidelines state, ‘The use of cell salvage is recommended when it can be expected to reduce the likelihood of allogeneic (donor) red cell transfusion and/or severe postoperative anaemia.’ 1 The guidelines further support and encourage an increase in the use of cell salvage, recommending it be available in any hospital undertaking surgery where blood loss is a recognised complication (italics added). The Australian National Blood Authority’s Patient Blood Management (PBM) Guideline makes similar recommendations. 2
Cell salvage technology has advanced significantly since it was first introduced. Cell salvage units are now smaller, more automated, with simple fill, wash and empty cycles and affordable consumables. This, combined with the guidelines above, suggests cell salvage technology should be available in any sized hospital performing major surgery. By way of confirming the applicability and success of cell salvage in small hospitals we conducted an audit of intraoperative cell salvage in 100 consecutive mixed orthopaedic patients (63 spinal procedures, 29 hip arthroplasties, eight knee arthroplasties), in a small regional private hospital, achieving a 6% allogeneic transfusion rate. Eighty-six patients had blood returned with a mean (standard deviation) return volume of 148 (88) ml. Returned volumes ranged from 0 to 470 ml, median 283 ml. Returned salvage blood typically has a haematocrit of 50%–70% 3 (comparable to packed cells). The cell saver employed was a Medtronic Autolog (Medtronic Australasia Pty Ltd, Macquarie Park, NSW, Australia) operated by one of two appropriately trained nurse technicians. At the time of publication, a training course run by the Australian and New Zealand College of Perfusionists costs AUD$300 for non-members (free for members). 4
Allogeneic blood transfusion is well known to be associated with increased operative risk and adverse patient outcome. Best practice PBM can be achieved by ensuring: that preoperative anaemia is treated, that there is good surgical technique, appropriate use of tranexamic acid, and the use of intraoperative cell salvage. Allogeneic blood should be a last resort. At the time of writing a unit of red blood cells costs approximately AUD$400.5,6 This makes no allowance for the indirect costs of blood sampling, cross matching, transport, storage, wastage or clinical incidents; including these costs puts the estimate close to AUD$750 per unit. The consumables with the Medtronic cost approximately AUD$300 per patient. There is the capital cost of the unit, but if used regularly, this can be depreciated and spread over many patients. Business case guidance on this issue is available from the National Blood Authority. 7 Once a cell salvage unit is available its applications in theatre will expand. Given the clinical and economic benefit, the simplicity of use and recommendation as a standard of care, cell salvage should not be withheld from patients simply because of their location or the size of the hospital in which they have their procedure. Cell salvage units should not be viewed as an overly complex addition to surgical/anaesthetic practice. We have successfully demonstrated the safe and effective use of cell salvage in a small regional private hospital. We would encourage other small hospitals to likewise adopt and employ cell salvage technology.
