The staff member responsible for cell salvage should have completed the appropriate training and be competent in process of cell salvage. The operative surgeon and anaesthetist should have understanding and appreciation of the risks and benefits of IOCS.
Intraoperative Cell Salvage, Maternity (555)
Warning
Objectives
This guideline aims to cover the benefits, risks and indications for intraoperative cell salvage use in the maternity department. It brings the procedure recommendations in line with current available evidence.
Scope
Greater Glasgow and Clyde Maternity Theatres
Intra-operative cell salvage (IOCS) is a useful technique for blood replacement and its practice is well established in other areas of medicine; indeed, it used routinely in some areas of surgical practice. There is a strong case for its widespread use in maternity surgery to avoid the well recognised risks and costs of blood transfusion.
Theoretical risks have slowed the introduction of the use of IOCS in maternity settings but NICE reviewed the evidence in 2005 and supported its use subject to1:
- Data collection
- Reporting of complications to the Medicine and Healthcare Products Regulatory Agency
- Women should be fully informed ‘whenever possible’ of the potential complications
- Performed by a multidisciplinary team who develop regular experience of intraoperative blood cell salvage
The use of IOCS in maternity has also been endorsed by the RCOG2, The Confidential Enquiry into Maternal and Child Health3 and the Association of Anaesthetists Guidelines4.
- To avoid the risks associated with conventional homologous or allogenic/donor blood transfusion:
- Infection (viruses, bacteria, prions)
- Acute incompatibility or reactions
- Hypothermia
- Transfusion related lung injury
- Transfusion related immunomodulation
- Cost
- Increasing scarcity of blood products
- To enhance the safety of caesarean section for women who decline blood products from donors.
- Amniotic Fluid Embolism (AFE)
There have been no reported cases to date of AFE associated with the use of IOCS in maternity. AFE is now considered to be a type of anaphylactic reaction rather than an embolic disease. In addition, the washing and filter processes used in cell salvage have now been shown to effectively remove amniotic fluid contaminants, fetal squames and other debris. - Sensitisation to Fetal Red Cells
The cell salvage machine is unable to distinguish between maternal and fetal red cells. Therefore, in cases where blood is transfused back to the mother, the fetal red cell concentration may be higher than in the maternal circulation (and higher than that normally occurs naturally at delivery). Maternal sensitization to fetal red cell antigens may then occur. Rh (D) incompatibility is relatively common but sensitization can be prevented with adequate anti-D administration after delivery.
However, the development of antibodies to other antigens can occur and these may pose a risk of fetal anaemia and haemolytic disease of the newborn in future pregnancies. With modern management, good outcomes are usually achieved in such cases but treatment is invasive and poses risks to the mother and baby. Studies have shown fetal red cells still present in cell-salvaged blood during caesarean section5,6. - Systemic spread of malignant cells or infected material
Suctioned cancer cells could in theory seed to distant sites and cause metastases. Infected material could lead to systemic sepsis.
The use of IOCS is at the discretion of the operative surgeon and anaesthetist. The following may be considered:
- Placenta praevia
- Placenta Accreta Spectrum
- Maternal bleeding disorders
- Anticipated difficulty with cross-matching due to antibodies
- Lower uterine segment fibroids or classical incision
- Women on anticoagulants
- Past history of significant uterine atony
- Significant anaemia
- Placental abruption
- Laparotomy following post-partum haemorrhage
- Full dilatation caesarean with deeply impacted head
- Maternal refusal of blood products
Contra-indications for IOCS include:
- Contamination of the surgical field with bowel contents
- Use of substances not licensed for IV use (temporary contraindication)
Likely agents include haemostatic agents such as floseal, perclot, tachosil and bone cement. Cell salvage should be paused and separate suction used while these are in the surgical field, the surgical field can be irrigated with saline and cell salvage resumed following this if required. - Malignancy (relative contraindication, balance of risk needs to be considered)
- Overt infection
- Sickle cell disease (discuss with Haematology including Sickle cell trait)7
Only staff appropriately trained and competent should set up and use maternity IOCS. Women should receive information about the risks and benefits of the IOCS preoperatively8.
Collection-only set up should be the standard in the majority of cases.
The use of a single suction set up is now recommended to reduce inadvertent suction of maternal blood into the waste suction. The filter and washing process effectively removes amniotic cells and single suction has not been shown result in amniotic fluid embolism.
Standard theatre suction should be available to be deployed in the event of incompatible fluid in the surgical field e.g. haemostatic agents, pus, faecal contamination.
Leucocyte depletion filters are no longer routinely recommended due to concerns about hypotension on reinfusion. A leucocyte depletion filter could be considered during cancer surgery.
The washing of swabs has been shown to increase the quantity of blood reinfused by 70%.8
- The blood-soaked swabs are soaked in 1000ml normal saline using sterile technique.
- The saline should be licensed for IV infusion, not irrigation.
- Gently squeeze the swabs to minimise red cell trauma.
- The vessel in which the swabs are soaked should be positioned within the clean air area to minimise airborne contamination.
- Swabs contaminated with Betadine or other substances contraindicated in cell salvage should not be washed.
- In long procedures the swab wash should be evacuated every 2 hours.
- At the end of the procedure the swab wash should be aspirated into the collection reservoir.
The re-infusion bag should not be pressurised to reduce risk of air embolism and damage to red cells. Reinfusion with the Belmont Rapid Infuser is safe and appropriate.
The salvaged blood bag should be labelled with a patient identification label containing:
- Full name
- DOB
- CHI number
- Collection start date and time
Expiry date and time
Re-transfusion should be completed within four hours after completion of processing of salvaged blood.
The Intra-Operative Cell Salvage Monitoring Sheet (Appendix 1) should be completed at the end of the procedure.
In any Rhesus negative woman with a Rhesus positive fetus, there is a danger of Rhesus iso-immunisation if the maternal circulation is exposed to fetal red cells. Administration of 1500iu Anti-D should occur immediately upon confirmation of a Rh positive baby (and certainly within 48-72 hours of delivery) in any woman receiving retransfusion of autologous IOCS blood.
A sample for Kleihauer testing should also be sent to ensure adequate quantities of Anti-D have been given at least 45 minutes following completion of transfusion.2