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Autologous Blood Transfusion CURRENT TRENDS, NURSINGIMPLICATIONS Gayle M. Johnson, RN; Robert J. Bowman, MD
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he concept of autologous transfusion has been in existence since 1886.’ Blood salvage devices were used extensively during the Vietnam War and have undergone significant evolution since their introduction in the 1960s.
Current transfusion alternatives include presurgical donation of autologous blood, autologous platelet-rich plasma collection, perioperative autologous transfusion, and postoperative blood collection. Hemodilution and hemoconcentration also are blood conservation techniques. Current transfusion literature supports the use of autologous blood as the most compatible and safest transfusion option for surgical patients.’ There is minimal risk of disease transmission and no alloimmunization, and patients who are unable to meet criteria for autologous presurgical donation still may benefit from intraoperative blood collection. Even if a homologous transfusion becomes necessary,
Gayle M . Johnson, RN. is the coordinator of the intraoperative uutologous transfirsiorr p r o g r u m ut American Red Cross, S t Paul Rcgiorial Blood Services. She earned her us s o c i a te d eg ree in n u 1’s ing at R och ester (Minn)Community College.
Robert J . Bowman, MD, is principal ofJicer and medical director of American Red Cross, St Paul Regiorial Blood Seivices, and an associate professor. Department of Laboratory Medicine and Pathology, UniversiQ of Minnesota, Minneapolis, n,here he earned his medical degree.
variety of transfusion options are available for today’s surgical patient. .Changes in the criteria for transfusion of homologous blood products hzve been driven by the public’s awareness ,,f the risk of transfusion-transmitted diseases. the need to conserve the blood supply, and the availability of autologous transfusion options.
Transfusion Alternatives
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2x2
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The last presurgical donation of blood should be scheduled a minimum of 72 hours before surgery. presurgical donations and intraoperative blood recovery can limit the patient’s exposure to donor blood. Perioperative autologous blood transfusion involves the collection of autologous blood before surgery or the collection, processing, and reinfusion of blood that the patient has lost during or after a surgical procedure. Preoperative collection. To meet the criteria for presurgical autologous donation, the patient must have a hemoglobin level of at least 11 g/dL, and no active infection or bacteremia, and his or her physical condition must be stable enough to permit the d ~ n a t i o n . ~ The scheduling of the donation is important, because the patient must take an iron supplement to stimulate the regeneration of his or her red blood cells between donations. The last presurgical donation of blood should be scheduled a minimum of 72 hours before surgery to ensure the patient’s return to a normovolemic state and some recovery of his or her previous hemoglobin levels. The 72-hour period also provides adequate time for testing, processing, and delivering of the autologous blood. Zntraoperative collection. To meet the criteria for intraoperative salvage of blood, the patient must have a predicted surgical blood loss of at least 800 mL, no infection or malignancy in the operative site, and no enteric contamination of the surgical field.4 In pediatric cases, collection may be warranted in patients with blood losses of less than 800 mL; however, the smallest processing chamber is 125 mL, so this technique is not yet practical for patients with very small blood volumes. Intraoperative collection is used most often on vascular, open heart, and orthopedic procedures.5Nonmalignant urological or gynecological surgeries also may result in blood loss large enough to warrant salvage.6 When blood loss cannot be estimated, the surgical team can set
up the collection reservoir with anticoagulant only. The processing set, which is the most expensive part of the setup, then can be assembled if there is enough blood loss to warrant processing. Postoperative collection. This may include collection and processing only, or it may involve collection and direct reinfusion of blood lost after surgery. Postoperative collection is used during procedures when the majority of blood loss occurs after the surgery is completed (eg, total knee arthr~plasty).~ Thoracic surgery drainage volume may be adequate to reinfuse, and most water-sealed drainage systems have accessory packs for the collection and reinfusion of drainage.
Intruoperutive Salvage Techniques
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he blood processing cycle (Fig 1) begins during surgery as the perioperative team suctions blood from the surgical site and collects it in a sterile reservoir that contains at least a 150 pn filter. Personnel in charge of the autotransfusion equipment should prime the reservoir with 100 to 200 mL of anticoagulant to prevent clotting when the blood first enters the reservoir. This is especially important when rapid blood loss occurs. Anticoagulant must be present as the blood is collected. Autotransfusion personnel may use citrate or heparin according to the equipment manufacturers’ recommendations. Usually, a 1 5 ratio of anticoagulant to blood is delivered.* Improper delivery of anticoagulant may result in clotted blood or an infusion overdose of anticoagulant if the blood is not washed adequately. The surgical team should take care not to suction clotted blood into the reservoir. Clotted blood cannot be salvaged; usually, it will block the exit port of the 283
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Blood Processing Cycle
1
t
components. Microaggregate filter
Transfer pack
Blood is drained into transfer pack, and air is purged from bag.
I
1
.c- Reinfusion bag
v
Washed, packed red blood cells are pumped into reinfusion bag. Plasma, free hemoglobin, and waste products travel to waste bag.
Fig 1. Autologous blood processing cycle. 284
Saline
/LII Normal saline is pumped through bowl to wash cells.
Waste bag
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reservoir and prohibit processing of liquid blood collected above the clots. To reduce the number of red blood cells damaged during the collection process, the circulating nurse should ensure that the suction is regulated at 100 mm Hg. When large volumes of blood are aspirated, higher suction pressures may be necessary; however, rapidly lost, pooled blood is not as susceptible to damage because there is less red blood cell-air interface as the blood is aspirated into the collection r e ~ e r v o i r .Perioperative ~ personnel should understand that attempts to recover blood from surgical sponges is not practical, because there are few viable red blood cells contained in dry sponges, and a basin full of blood-soaked sponges in saline may be a source of contamination.‘* The surgical team should use the suction tip to remove blood from the operative site whenever possible. This practice and the minimal use of sponges will allow maximum recovery of red blood cells.ll Irrigants used in the surgical field also may be incompatible with blood collection. Sterile water, povidone-iodine, peroxide, and alcohol solutions hemolyze red blood cells, making salvage impossible. These solutions are potentially harmful or fatal if injected and should never be used when blood salvage occurs. The surgeon must use antibiotic irrigation with caution as well. Although researchers have documented nontoxic levels of a neomycin-bacitracin rinse after washout, it is thought that parenterally acceptable antibiotics, mixed in saline, are the safest irrigants.12 If a significant volume of irrigant (ie, greater than 200 mL) is used, it is preferable to aspirate the irrigant into a separate suction canister to prevent premature filling of the blood-collection reservoir. Aspirated thrombin preparations and microfibrillar collagen sponges may not be removed completely from the blood during the washing process.13 Manufacturers of some products (eg, Avitene) warn that blood salvage in the area where these products are used is contraindicated, and manufacturers of
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others (eg, Gelfoam powder) state that the products will pass through a 4 0 - p filter. At St Paul Regional Blood Services, we contacted pharmaceutical companies and made a chart listing each product, whether or not it could be used during blood salvage, and a toll-free telephone number to call to verify this information. We distribute this information to each OR we serve. Only normal saline (ie, 0.9%) should be used to wash the bl00d.l~Three-liter bags of saline may be used if they are labeled specifically for “sodium chloride processing,” a generic term for washing the blood. The volume of saline used to wash the blood will vary from 1 to 2 L. Orthopedic procedures have more debris in the surgical field; therefore, recommended wash volumes are usually 1.5 to 2 L of saline per processed unit.I5 Each equipment manufacturer can provide clinical studies documenting anticoagulant and free hemoglobin removal relative to the volume of wash solution used. One study, conducted in 1984, documented heparin levels of 0.1 to 0.2 units of heparin per mL of processed blood when at least 700 mL of saline was used to wash the blood.I6 The end product of intraoperative blood salvage is washed, packed red blood cells suspended in normal saline. Hematocrit levels of the processed blood will vary from 40% to 65%. Smaller processing chambers (ie, 125 mL) yield lower hematocrit levels, as do partially full chambers. Red cells collected during surgery have an optimal ability to deliver oxygen to the tissues because of immediate collection and reinfusion within six hours.” The Standards for Blood Banks and Transfusion Services also states, “Shed blood collected intraoperatively or under postoperative or posttraumatic conditions should be transfused within six hours of initiating the collection.”l* These standards help define the standard of practice, and a copy is available at every hospital blood bank that is a member of the American Association of Blood Banks. The person processing the prepared blood
d) 285
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product should label it and give it to anesthesia personnel for administration. We suggest that labels for perioperatively salvaged blood include patient name and identification number, date and time of collection, expiration date and time, volume in bag, and a label stating “Autologous Use Only.” Proper filtration reduces the chances of fat or particulate embolism during reinfu~ion.’~ The person transfusing the blood should administer the processed red blood cells through a microaggregate filter (eg, 20 to 40 p m ) . ? O A pressure infusion cuff should never be used on the original reinfusion bag, because it may contain air and air embolism may result.?’ The transfusionist should place the blood in a transfer pack with all air purged if rapid infusion is necessary. This also permits processing of successive units of blood without having to wait for the previous unit to be infused. Simultaneous operation of the blood processing machine and pressure reinfusion can have disastrous results if the machine enters the “empty” cycle while an inflated pressure cuff is still on the reinfusion bag. The reinfusion bag cannot withstand the opposing pressures and may detach, resulting in uncontrolled dispersal of blood.
Postoperative Salvage Techniques
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ostoperative blood collection actually begins in the OR when the surgeon places drains in the wound. He or she can attach direct reinfusion devices to the drains for postoperative collection, especially in orthopedic joint replacement procedures where significant blood loss may occur within six hours after the surgery. Direct reinfusion devices are used when 500 to 1,200 m L of drainage is expected from a wound.” The wound must not be contaminated, infected, or contain fluids unsuitable for reinfusion.” The device used should be approved for collection and reinfusion of 288
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blood. A few devices have self-contained suction, but in most cases it will be necessary to provide a suction source. Recommended suction levels usually are 100 mm Hg or less. The suction line may be clamped and disconnected during patient transport to the postanesthesia care unit. The source of the patient’s drainage may determine whether anticoagulant is used. Debate continues about the necessity of anticoagulating postsurgical drainage. If anticoagulant is used, it is usually a small amount of citrate (ie, citrate phosphate dextrose, anticoagulant citrate dextrose). Manufacturers of direct reinfusion devices should offer specific guidelines about anticoagulant use that are backed by clinical studies. If an anticoagulant is used, a minimum amount of drainage (eg, 450 mL) must be collected before reinfusion This ensures that the patient does not receive an overdose of a n t i c o a g ~ l a n t . ~ ~ As an alternative to direct reinfusion devices, the surgeon may attach a collection reservoir to collect the postoperative drainage, wash the blood, and return it to the patient as in intraoperative blood salvage. This is most practical in facilities with perioperative blood programs or services.’j A complete record of blood salvage should be kept on the patient’s chart. A flow sheet for blood salvage, which includes the amount of blood lost, the amount of blood returned to the patient, other blood products given, lot numbers of all supplies, documentation of wash solution and amount, any problems encountered, and the signature of the equipment operator, is recommended.26
Blood Salvage Complications
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any of the complications of perioperative blood salvage can be reduced or eliminated if a few precautions are taken (Table 1). In addition, the following complications are seen. Citrate toxicity. This may occur during massive transfusion in surgery or during
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Table 1
Blood Salvage Complications Complication
Preventive actions
Air embolus
Use individual transfer packs with all air purged. Use a blood pump with an in-line air sensor.
Dilutional coagulopathy
Monitor patient’s clotting factors and hemoglobin. Administer clotting factors (ie, fresh frozen plasma) and blood components as indicated in large blood losses.
Hypervolemia
Carefully monitor fluid administration. Use small bowls (ie, 125 mL) on patients with small blood volumes.
Bacteremia
Do not recover blood from contaminated surgical sites.
Hemoglobinuria
Wash blood with correct amount of normal saline. Verify clear line to waste bag at the end of wash cycle. Keep suction as low as possible. Wash “full bowls” whenever possible.
Anticoagulant overdose
Deliver anticoagulant at recommended rate. Use correct wash volume. Verify correct minimum volume in direct reinfusion devices. Know the symptoms of citrate toxicity and stop transfusion if reaction occurs.
administration of multiple units of postoperatively collected and reinfused drainage. Intraoperatively, the primary symptom of citrate toxicity is increased cardiac irritability. During postoperative reinfusion, the patient’s symptoms may include a tingling sensation in his or her extremities or around the mouth, or muscle tetany. It may be possible to eliminate these symptoms by slowing the reinfusion, but some patients may require that the infu-
sion be temporarily discontinued. Patient reinfusion reactions. Clinical studies on unwashed blood indicate that patient reaction to reinfusion may occur; however, the incidence is low (ie, < 6.3%).27 Patient symptoms include fever, tachycardia, and chills. In large-volume reinfusions (ie, greater than 1,200 mL), coagulopathies may result from infusion of activated clotting factors or the dilution of existing clotting factors 289
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in the patient’s circulation.2xNursing personnel must be aware of this possibility and monitor coagulation profiles in patients who have experienced a large blood loss during or after surgery.19
centers will have different needs than small hospitals.
Cost of Autologous Blood Salvage
hree key components to consider in a quality-assessment program for perioperative autotransfusion are the equipment, the blood product, and most important, the operator of the equipment.32 Equipment manufacturers have recommended maintenance and quality assessment protocols. OR personnel should record the dates of periodic safety checks and quality assessments in an equipment Repairs or corrective actions also should be kept in this log. The personnel operating the blood-recovery equipment periodically should check salvaged blood products to ascertain proper machine function. They also should check the hemoglobin or hematocrit on a washed unit. A false-low hematocrit level will result when the operator initiates the wash cycle unless he or she has filled the bowl to the manufacturer’s preset level on automatic machines or to the level indicated by the manufacturer on manual machines. Some facilities also conduct periodic assays on heparin washout.34 Equipment manufacturers should be able to provide protocols and studies documenting the effectiveness of anticoagulant removal with their equipment. Cultures of the reinfusion bag rarely contain pathogenic bacteria and rarely are linked to clinical infection, but reinfusion bags occasionally will grow surface contaminants such as Staphylococcus epiderrnidi~.~~ To determine the source of this contamination in the event of a patient infection, the autotransfusion personnel would have to culture the reinfusion bag, the surgical site, and the patient’s blood simultaneously. The costs of such cultures could be prohibitive. Determining guidelines for when cultures are indicated may be a more rational, cost-effective approach. Blood-product and equipment quality con-
C
urrent donor selection and testing makes the homologous blood supply safer and the transmission of the human immunodeficiency virus ( H I V ) unlikely. The fear of HIV infection may affect the patient’s ability to assess the risks and benefits of homologous transfusion against the cost of autologous transfusions. Although autologous transfusions have become common for surgical patients, the cost has caused concern. In our experience, presurgical donation is a cost-effective way to replace the loss of 2 to 3 units of blood. Intraoperative autologous blood salvage is cost-effective compared t o homologous transfusion when at least three units of blood can be salvaged. Awareness of the cost and the patient criteria for each option allows the clinician to select a cost-effective means of providing autologous blood to the patient.
Equipment Evaluation perating room personnel must weigh several factors including the cost of equipment and disposable supplies, the quality of the training provided by manufacturers. service availability in your area, and the availability of references and clinical studies on equipment function when considering blood-processing equipment .30 The factors that OR personnel must consider in developing a perioperative service or when contracting for that service from an outside source must center around the facility’s equipment budget and its ability to maintain a pool of proficient staff members to operate the Major trauma
Autotmnsfusion Quality Assessment
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trol m a y b e inaccurate if trained, proficient personnel are not used t o operate the equipment.36 Too o f t e n , a d i a g n o s i s o f broken equipment actually is a lack of troubleshooting ability on the part of the operator. All staff members expected to operate blood processing equipment should undergo specific training a n d a preceptorship or certification process. This activity should be documented and repeated annually.37
Summary
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eveloping a quality perioperative autolo g o u s b l o o d r e c o v e r y program is a team effort. M e m b e r s of transfusion committees, hospital blood bank personnel, OR staff members, and the members of the surgery committee are all possible sources of information. Your local blood center also may have literature or services that could be of assistance. Knowledge of current autologous transfusion alternatives will help nurses communicate with patients regarding transfusion therapy and will make nurses more valuable participants in the crucial decisions necessary to deliver optimal patient care in the perioperative period. 0 Notes l.W H Dzik, B Sherbume, “Intraoperative blood sa I v a g e : Me dic al contr o v er s ie s ,” Transfusion Medicine Reviews 3 (July 1990) 208-235. 2. Ibid; American Association of Blood Banks, Guidelines for Blood Salvage and Reinfusion in Surgery and Trauma, I 9 9 0 (Washington, DC: American Association of Blood Banks, 1990) 1. 3. National Blood Resource Education Program’s Nursing Education Working Group, “Choosing blood components and equipment,” American Journal of Nursing 91 (June 1991) 42-46. 4. American Association of Blood Banks, Guidelines for Blond Salvage and Reinfusion in Surgery and Trauma, 1990, 3. 5. R L Tawes, Jr et al, “The Cell Saver and autologous transfusion: An underutilized resource in vascular surgery,” American Journal of Surgery 152 (July 1986) 105; American Association of Blood Banks, Standards For Blood Banks and Transfusion Services, 14th ed (Washington, DC: American Association of Blood Banks, 1990) 106; J M Ray, J C Flynn, A H Bierman, “Erythrocyte survival following intraoperative autotransfusion in spinal
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surgery: An in vivo comparative study and 5-year update,” Spine 11 (November 1986) 879; P E Stanton, Jr et al, “Intraoperative autologous transfusion during major aortic reconstructive procedures,” Southern Medical Journal 80 (March 1987) 3 15; 6. G F Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience,” Transfusion 3 1 (July/August 1991) 509-512. 7. L B Semkiw et al, “Postoperative blood salvage using the Cell Saver after total joint arthroplasty,” Journal of Bone and Joint Surgery 7 (July 1989) 823. 8. K R Williamson, H F Taswell, “Intraoperative blood salvage: A review,” Transfusion 31 (September 1991) 662-675. 9. J C Flynn, C R Metzger, T A Csencsitz, “Intraoperative autotransfusion (IAT) in spinal surgery,” Spine 7 (September/October 1982) 432; M M Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” Annals of Surgery 197 (May 1983) 536. 10. “Recommended practices for basic aseptic technique,” in AORN Standards and Recommended Practices f o r Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1992) m:2-1. 11. Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 12. D Paravicini, J Thys, H Hein, “Rinsing the operative field with neomycin-bacitracin solution with intraoperative autotransfusion in orthopedic surgery,” Arzneimitrel ForshunglDrug Research II 33 (1983) 12. 13. F Robicsek et al, “Inherent dangers of simultaneous application of microfibrillar collagen hemostat and blood-saving devices,” Journal of Thoracic and Cardiovascular Surgery 92 (October 1986) 766. 14. Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 15. D H Yawn, B Bull, “Intraoperative salvage: Quality of products,” in Autologous Blood Transfusion: Current Issues, ed L M Maffei, R L Thurer (Arlington, Va: American Association of Blood Banks, 1988) 43-55. 16. J Ulmas, T P O’Neill, “Heparin removal in an autotransfusor device,” Transfusion 2 1 (January/ February 1981) 70. 17. J Ansell et al, “Survival of autotransfused red blood cells recovered from the surgical field during cardiovascular operations,” Journal of Thoracic and Cardiovascular Surgery 84 (September 1982) 387. 18. American Association of Blood Banks, Guidelines for Blood Salvage and Reinfusion in Surgery and Trauma, 1990, 23; US Food and Drug Administration Division of Blood and Blood Products, Memorandum of March 15,1989 (Bethesda, 291
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Md: US Food and Drug Administration, 1989). 19. Flynn, Metzger, Csencsitz, “Intraoperative autotransfusion (IAT) in spinal surgery,” 432. 20. American Association of Blood Banks, Guidelines f o r Blood Saliage and Reinfirsion in Surgen and Trauma, 1990, 6. 21. Williamson, Taswell. “Intraoperative blood salvage: A review,” 662-675. 22. C R Valeri, “Table 1: Incidence of clinical reactions following transfusion of non-washed intraoperatively or postoperatively shed blood.” i n Postoperarive Blood Salvage (abstract) presented at the Quad-State Blood Bank Meeting, Mayo Clinic, Rochester. Minn, 25 April 1991. 23. Smith + Nephew Richards, Inc, Solcotrans Plus U s e r Manual (Memphis, Tenn: Smith + Nephew Richards, Inc, February 1990) 2 . 24. Ibid. 25. Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience.” 509-5 12: Williamson. Taswell, “Intraoperative blood salvage: A review,” 662-675. 26. American Association of Blood Banks, Guidelines f o r Blood Salvage and Reinfusion in Surge? and Trauma, 1990, 6. 27. J Martin, “Postoperative blood retrieval i n cementless total knee replacement.” (abstract) presented at the New Developments in Total Joint Reconstruction: Sixth Annual DePaul Center International Symposium, St. Louis, 22-24 June 1989; Valeri, “Table 1: Incidence of clinical reactions following transfusion of non-washed intraoperatively or postoperatively shed blood.” 28. L D Griffith et al, “Apparent coagulopathy caused by infusion of shed mediastinal blood and its prevention by washing of the infusate,” Annals of Thoracic Surgery 47 (March 1989) 400. 29. American Association of Blood Banks, Guidelines f o r Blood Salvage and Reinfusion in Surgery and Trauma. 1990, 9; L C Stehling, H L Zauder, W Rogers, “Intraoperative autotransfusion,” Anesthesiology 43 (September 1975) 337. 30. Ibid; Emergency Care Research Institute. “Evaluation: Automated intraoperative processing autotransfusion machines,” Health Devices 17 (August 1988) 219. 3 1. Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience.” 509-5 12. 32. G Johnson, R Bowman. ”Certification criteria for operators of blood salvage equipment,” (abstract) ISBT/AABB 1990 Joint Congress: Book o,f Abstracts: A 128. 33. Emergency Care Research Institute, “Evaluation: Automated intraoperative processing autotransfusion machines.” 219. 34. Williamson, Taswell, “Intraoperative blood salvage: A review,” 662-675. 292
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35. h i d ; Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 36. American Association of Blood Banks, Guidelines ,for Blood Salvage and Reinfusion in Surgery and Trauma, 1990, 1; Williamson, Taswell, “Intraoperative blood salvage: A review,” 662-675; Smith + Nephew Richards, Inc, Solcotrans Plus User Manual (Memphis, Tenn: Smith + Nephew Richards Inc. February 1990) 2. 37. Johnson, Bowman, “Certification criteria for operators of blood salvage equipment,” A 128.
National Health Insurance: A Money Saver? A national health care insurance plan similar to the one currently used in Canada could save the United States more than $1 trillion during the next decade. According to study results reported in the Winter 1992 issue of Advances, the newsletter of the Robert Wood Johnson Foundation, if the United States reduced its health care spending to Canadian levels (ie, from 12.8% to 8.7% of the gross domestic product), savings would amount to $241 billion the first year and more than $4.2 trillion by the year 2000. The study was the first of its kind to use computer simulation techniques to project the financial impact of different national health care plans on the US economy. Other results show that by extending health coverage to all of the estimated 33 million people currently uninsured and holding health care spending growth to the growth of the economy would save $1.3 trillion. Businesses would save at least $1 trillion over a 10-year period. According to the article, shifting the responsibility for financing health care from the private to the public sector would result in a tax increase, with overall savings to the economy and business by the year 2000. The article also states, however, that although a national health care plan would give all Americans access to basic medical care, tight controls on spending could affect the future development and availability of medical technology.
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AORN JOURNAL
bxamination AUTOLOGOUS BLOODTRANSFUSION
1. Autologous blood is obtained from a. a close relative b. a blood donor c. the person receiving the transfusion d. a person of the same sex 2. Advantages to autologous blood include: a. minimal risk of disease transmission b. no alloimmunization c. decreased exposure to donor blood d. all of the above 3. The patient who is a candidate for blood salvage must have an anticipated surgical blood loss of mL. a. 100 b. 250 c. 400 d. 800 4. Patients who are candidates for presurgical autologous blood donation must have 1. a physical condition stable enough to permit the donation 2. a hemoglobin level of at least 1lgm/dL 3. no active infection, malignancy, or bacteremia 4. no aversion to large needles a. 1 and4 b. 2 a n d 3 c. 1, 2, and 3 d. 3 and 4 5. List the components of processed, salvaged blood. 1. packed red blood cells 2. clotting factors 3. plasma 4. albumin a. 1 and2 b. 3 only
c. 3 and4 d. 1 only 6. When can autologous blood be collected? a. at least 72 hours before surgery b. during surgical procedures c. from postsurgical drainage d. all of the above 7. Why is there a minimum recommended time of 7 2 hours between presurgical autologous donation and surgery? a. Scheduling appointments to donate blood is difficult. b. This time allows the patient to rebuild adequate volume and hemoglobin/ hematocrit levels. c. The collected blood is only good for 72 hours. d. The patients are available to donate at that time. 8. Intraoperative blood salvage is used most often on what types of procedures? a. vascular, open heart, orthopedic b. general, vascular, orthopedic c. pediatric, vascular, general d. neurosurgery, orthopedic, general 9. Postoperative autologous blood salvage is the collection and processing or the collection and direct reinfusion of blood lost after a surgical procedure. a. true b. false 10. The expiration time for processed blood is -hours. a. 6 b. 12 c. 24 d. 48
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1 1. Potential complications of intraoperative blood salvage include 1. air embolus 2. dilutional coagulopathy 3. hypervolemia 4. anticoagulant overdose a. l a n d 2 b. 1 and 4 c. 2,3, and 4 d. 1,2, 3, and 4 12. Damage can occur to the red blood cells recovered from the operative site. What are some ways that this can occur? a. suction used at settings higher than 100 mm Hg b. use of solutions on the field that hemolyze red blood cells c. attempts to wring blood out of laparotomy sponges d. all of the above 13. How does anticoagulant overdose occur? 1. Unsuspected coagulopathies convert normal doses of anticoagulants into overdoses. 2. An improper delivery of anticoagulant to the salvage system occurs. 3. Salvaged blood is not washed adequately. 4. Long cases can result in the overuse of anticoagulants. a 1 and2 b. 2 a n d 3 c. 2 a n d 4 d. 3 and 4 14. Pressure infusion cuffs should never be used on an original reinfusion bag. Why? a. Red cell damage can occur with pressure reinfusion. b. With pressure reinfusion, blood is transfused too rapidly. c. The bag may contain air, and pressure reinfusion could result in an air emboli. d. There is too little airblood interface. IS. It is important to wash salvaged blood to remove potentially harmful substances (eg, excess anticoagulant, antibiotic irrigants). What is the proper washing solution? a. normal saline (ie, 0.9 %) 296
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b. Ringer’s lactate C . DgW d. glycine 16. In patients who have had large blood losses during or after surgery and are receiving large-volume reinfusions, the nurse should assess for by monitoring patients’ a. anemiahemoglobin level. b. coagulopathies/coagulationprofile c. shock/bIood pressure d. oxygenationloxygen saturation 17. To determine the source of contamination of an intraoperatively processed unit of blood, cultures should be performed on a. the patient’s blood b. the reinfusion bag c. the surgical site d. all of the above 18. The nurse should ensure that intraoperatively salvaged blood is properly filtered when administered by using a a. leukopor depletion filter b. standard blood administration set (ie, 180 elm) c. microaggregate filter (ie, 20 to 40 pn) d. an HEPA or ULPA filter 19. The scrub nurse should not be concerned about the use of microfibrillar sponges during procedures using blood recovery techniques, because this type of particulate matter is removed during the washing phase of blood processing. a. true b. false 20. The perioperative nurse is aware that the following solutions should never be collected with shed blood. 1. povidone iodine 2. alcohol 3. sterile water 4. peroxide a. 2 and3 b. 1,2,and3 c. 2 , 3, and 4 d. 1, 2, 3, and 4
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Answer Sheet AUTOLOGOUS BLOODTRANSFUSION
P
lease fill out the application and answer forni below and the evaluation on the back of this page. Tear out the page from the Journul or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 8023 1
Event # 935001
Mark only one answer per question 1
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Program offered August 1992 The deadline for this program is Feb 28, 1993.
1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
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AORN (ID) # If nonmember, please provide Social Security
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Address City
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RN license and state Florida license # (Required for Flonda CE credit)
Phone number
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Fee enclosed or bill the credit card indicated
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5.
1. Objectives. To what extent were the following objectives of this home study p r o m achieved? ( 1 ) Discuss autologous blood salvage. ( 2 ) Describe how autologous blood can be salvaged. ( 3 ) List the complications of perioperative blood salvage. (4) Describe the role of the perioperative nurse in blood salvage.
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2. Content. ( I ) Did this article increase your knowledge of the subject matter'? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives?
3. Test questionslanswers. ( I ) Were they reflective of the content? (2) Were they easy to understand? ( 3 ) Did they addresc important points?
4. What other topics would you like to see addressed in a future home study program? Would you be intcrested or do you know someone who would be interested in writing an article on this topic?
Author names and addresses:
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Autologous Blood Transfusion CURRENT TRENDS, NURSINGIMPLICATIONS Gayle M. Johnson, RN; Robert J. Bowman, MD
A
he concept of autologous transfusion has been in existence since 1886.’ Blood salvage devices were used extensively during the Vietnam War and have undergone significant evolution since their introduction in the 1960s.
Current transfusion alternatives include presurgical donation of autologous blood, autologous platelet-rich plasma collection, perioperative autologous transfusion, and postoperative blood collection. Hemodilution and hemoconcentration also are blood conservation techniques. Current transfusion literature supports the use of autologous blood as the most compatible and safest transfusion option for surgical patients.’ There is minimal risk of disease transmission and no alloimmunization, and patients who are unable to meet criteria for autologous presurgical donation still may benefit from intraoperative blood collection. Even if a homologous transfusion becomes necessary,
Gayle M . Johnson, RN. is the coordinator of the intraoperative uutologous transfirsiorr p r o g r u m ut American Red Cross, S t Paul Rcgiorial Blood Services. She earned her us s o c i a te d eg ree in n u 1’s ing at R och ester (Minn)Community College.
Robert J . Bowman, MD, is principal ofJicer and medical director of American Red Cross, St Paul Regiorial Blood Seivices, and an associate professor. Department of Laboratory Medicine and Pathology, UniversiQ of Minnesota, Minneapolis, n,here he earned his medical degree.
variety of transfusion options are available for today’s surgical patient. .Changes in the criteria for transfusion of homologous blood products hzve been driven by the public’s awareness ,,f the risk of transfusion-transmitted diseases. the need to conserve the blood supply, and the availability of autologous transfusion options.
Transfusion Alternatives
T
2x2
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The last presurgical donation of blood should be scheduled a minimum of 72 hours before surgery. presurgical donations and intraoperative blood recovery can limit the patient’s exposure to donor blood. Perioperative autologous blood transfusion involves the collection of autologous blood before surgery or the collection, processing, and reinfusion of blood that the patient has lost during or after a surgical procedure. Preoperative collection. To meet the criteria for presurgical autologous donation, the patient must have a hemoglobin level of at least 11 g/dL, and no active infection or bacteremia, and his or her physical condition must be stable enough to permit the d ~ n a t i o n . ~ The scheduling of the donation is important, because the patient must take an iron supplement to stimulate the regeneration of his or her red blood cells between donations. The last presurgical donation of blood should be scheduled a minimum of 72 hours before surgery to ensure the patient’s return to a normovolemic state and some recovery of his or her previous hemoglobin levels. The 72-hour period also provides adequate time for testing, processing, and delivering of the autologous blood. Zntraoperative collection. To meet the criteria for intraoperative salvage of blood, the patient must have a predicted surgical blood loss of at least 800 mL, no infection or malignancy in the operative site, and no enteric contamination of the surgical field.4 In pediatric cases, collection may be warranted in patients with blood losses of less than 800 mL; however, the smallest processing chamber is 125 mL, so this technique is not yet practical for patients with very small blood volumes. Intraoperative collection is used most often on vascular, open heart, and orthopedic procedures.5Nonmalignant urological or gynecological surgeries also may result in blood loss large enough to warrant salvage.6 When blood loss cannot be estimated, the surgical team can set
up the collection reservoir with anticoagulant only. The processing set, which is the most expensive part of the setup, then can be assembled if there is enough blood loss to warrant processing. Postoperative collection. This may include collection and processing only, or it may involve collection and direct reinfusion of blood lost after surgery. Postoperative collection is used during procedures when the majority of blood loss occurs after the surgery is completed (eg, total knee arthr~plasty).~ Thoracic surgery drainage volume may be adequate to reinfuse, and most water-sealed drainage systems have accessory packs for the collection and reinfusion of drainage.
Intruoperutive Salvage Techniques
T
he blood processing cycle (Fig 1) begins during surgery as the perioperative team suctions blood from the surgical site and collects it in a sterile reservoir that contains at least a 150 pn filter. Personnel in charge of the autotransfusion equipment should prime the reservoir with 100 to 200 mL of anticoagulant to prevent clotting when the blood first enters the reservoir. This is especially important when rapid blood loss occurs. Anticoagulant must be present as the blood is collected. Autotransfusion personnel may use citrate or heparin according to the equipment manufacturers’ recommendations. Usually, a 1 5 ratio of anticoagulant to blood is delivered.* Improper delivery of anticoagulant may result in clotted blood or an infusion overdose of anticoagulant if the blood is not washed adequately. The surgical team should take care not to suction clotted blood into the reservoir. Clotted blood cannot be salvaged; usually, it will block the exit port of the 283
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Blood Processing Cycle
1
t
components. Microaggregate filter
Transfer pack
Blood is drained into transfer pack, and air is purged from bag.
I
1
.c- Reinfusion bag
v
Washed, packed red blood cells are pumped into reinfusion bag. Plasma, free hemoglobin, and waste products travel to waste bag.
Fig 1. Autologous blood processing cycle. 284
Saline
/LII Normal saline is pumped through bowl to wash cells.
Waste bag
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reservoir and prohibit processing of liquid blood collected above the clots. To reduce the number of red blood cells damaged during the collection process, the circulating nurse should ensure that the suction is regulated at 100 mm Hg. When large volumes of blood are aspirated, higher suction pressures may be necessary; however, rapidly lost, pooled blood is not as susceptible to damage because there is less red blood cell-air interface as the blood is aspirated into the collection r e ~ e r v o i r .Perioperative ~ personnel should understand that attempts to recover blood from surgical sponges is not practical, because there are few viable red blood cells contained in dry sponges, and a basin full of blood-soaked sponges in saline may be a source of contamination.‘* The surgical team should use the suction tip to remove blood from the operative site whenever possible. This practice and the minimal use of sponges will allow maximum recovery of red blood cells.ll Irrigants used in the surgical field also may be incompatible with blood collection. Sterile water, povidone-iodine, peroxide, and alcohol solutions hemolyze red blood cells, making salvage impossible. These solutions are potentially harmful or fatal if injected and should never be used when blood salvage occurs. The surgeon must use antibiotic irrigation with caution as well. Although researchers have documented nontoxic levels of a neomycin-bacitracin rinse after washout, it is thought that parenterally acceptable antibiotics, mixed in saline, are the safest irrigants.12 If a significant volume of irrigant (ie, greater than 200 mL) is used, it is preferable to aspirate the irrigant into a separate suction canister to prevent premature filling of the blood-collection reservoir. Aspirated thrombin preparations and microfibrillar collagen sponges may not be removed completely from the blood during the washing process.13 Manufacturers of some products (eg, Avitene) warn that blood salvage in the area where these products are used is contraindicated, and manufacturers of
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others (eg, Gelfoam powder) state that the products will pass through a 4 0 - p filter. At St Paul Regional Blood Services, we contacted pharmaceutical companies and made a chart listing each product, whether or not it could be used during blood salvage, and a toll-free telephone number to call to verify this information. We distribute this information to each OR we serve. Only normal saline (ie, 0.9%) should be used to wash the bl00d.l~Three-liter bags of saline may be used if they are labeled specifically for “sodium chloride processing,” a generic term for washing the blood. The volume of saline used to wash the blood will vary from 1 to 2 L. Orthopedic procedures have more debris in the surgical field; therefore, recommended wash volumes are usually 1.5 to 2 L of saline per processed unit.I5 Each equipment manufacturer can provide clinical studies documenting anticoagulant and free hemoglobin removal relative to the volume of wash solution used. One study, conducted in 1984, documented heparin levels of 0.1 to 0.2 units of heparin per mL of processed blood when at least 700 mL of saline was used to wash the blood.I6 The end product of intraoperative blood salvage is washed, packed red blood cells suspended in normal saline. Hematocrit levels of the processed blood will vary from 40% to 65%. Smaller processing chambers (ie, 125 mL) yield lower hematocrit levels, as do partially full chambers. Red cells collected during surgery have an optimal ability to deliver oxygen to the tissues because of immediate collection and reinfusion within six hours.” The Standards for Blood Banks and Transfusion Services also states, “Shed blood collected intraoperatively or under postoperative or posttraumatic conditions should be transfused within six hours of initiating the collection.”l* These standards help define the standard of practice, and a copy is available at every hospital blood bank that is a member of the American Association of Blood Banks. The person processing the prepared blood
d) 285
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product should label it and give it to anesthesia personnel for administration. We suggest that labels for perioperatively salvaged blood include patient name and identification number, date and time of collection, expiration date and time, volume in bag, and a label stating “Autologous Use Only.” Proper filtration reduces the chances of fat or particulate embolism during reinfu~ion.’~ The person transfusing the blood should administer the processed red blood cells through a microaggregate filter (eg, 20 to 40 p m ) . ? O A pressure infusion cuff should never be used on the original reinfusion bag, because it may contain air and air embolism may result.?’ The transfusionist should place the blood in a transfer pack with all air purged if rapid infusion is necessary. This also permits processing of successive units of blood without having to wait for the previous unit to be infused. Simultaneous operation of the blood processing machine and pressure reinfusion can have disastrous results if the machine enters the “empty” cycle while an inflated pressure cuff is still on the reinfusion bag. The reinfusion bag cannot withstand the opposing pressures and may detach, resulting in uncontrolled dispersal of blood.
Postoperative Salvage Techniques
P
ostoperative blood collection actually begins in the OR when the surgeon places drains in the wound. He or she can attach direct reinfusion devices to the drains for postoperative collection, especially in orthopedic joint replacement procedures where significant blood loss may occur within six hours after the surgery. Direct reinfusion devices are used when 500 to 1,200 m L of drainage is expected from a wound.” The wound must not be contaminated, infected, or contain fluids unsuitable for reinfusion.” The device used should be approved for collection and reinfusion of 288
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blood. A few devices have self-contained suction, but in most cases it will be necessary to provide a suction source. Recommended suction levels usually are 100 mm Hg or less. The suction line may be clamped and disconnected during patient transport to the postanesthesia care unit. The source of the patient’s drainage may determine whether anticoagulant is used. Debate continues about the necessity of anticoagulating postsurgical drainage. If anticoagulant is used, it is usually a small amount of citrate (ie, citrate phosphate dextrose, anticoagulant citrate dextrose). Manufacturers of direct reinfusion devices should offer specific guidelines about anticoagulant use that are backed by clinical studies. If an anticoagulant is used, a minimum amount of drainage (eg, 450 mL) must be collected before reinfusion This ensures that the patient does not receive an overdose of a n t i c o a g ~ l a n t . ~ ~ As an alternative to direct reinfusion devices, the surgeon may attach a collection reservoir to collect the postoperative drainage, wash the blood, and return it to the patient as in intraoperative blood salvage. This is most practical in facilities with perioperative blood programs or services.’j A complete record of blood salvage should be kept on the patient’s chart. A flow sheet for blood salvage, which includes the amount of blood lost, the amount of blood returned to the patient, other blood products given, lot numbers of all supplies, documentation of wash solution and amount, any problems encountered, and the signature of the equipment operator, is recommended.26
Blood Salvage Complications
M
any of the complications of perioperative blood salvage can be reduced or eliminated if a few precautions are taken (Table 1). In addition, the following complications are seen. Citrate toxicity. This may occur during massive transfusion in surgery or during
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Table 1
Blood Salvage Complications Complication
Preventive actions
Air embolus
Use individual transfer packs with all air purged. Use a blood pump with an in-line air sensor.
Dilutional coagulopathy
Monitor patient’s clotting factors and hemoglobin. Administer clotting factors (ie, fresh frozen plasma) and blood components as indicated in large blood losses.
Hypervolemia
Carefully monitor fluid administration. Use small bowls (ie, 125 mL) on patients with small blood volumes.
Bacteremia
Do not recover blood from contaminated surgical sites.
Hemoglobinuria
Wash blood with correct amount of normal saline. Verify clear line to waste bag at the end of wash cycle. Keep suction as low as possible. Wash “full bowls” whenever possible.
Anticoagulant overdose
Deliver anticoagulant at recommended rate. Use correct wash volume. Verify correct minimum volume in direct reinfusion devices. Know the symptoms of citrate toxicity and stop transfusion if reaction occurs.
administration of multiple units of postoperatively collected and reinfused drainage. Intraoperatively, the primary symptom of citrate toxicity is increased cardiac irritability. During postoperative reinfusion, the patient’s symptoms may include a tingling sensation in his or her extremities or around the mouth, or muscle tetany. It may be possible to eliminate these symptoms by slowing the reinfusion, but some patients may require that the infu-
sion be temporarily discontinued. Patient reinfusion reactions. Clinical studies on unwashed blood indicate that patient reaction to reinfusion may occur; however, the incidence is low (ie, < 6.3%).27 Patient symptoms include fever, tachycardia, and chills. In large-volume reinfusions (ie, greater than 1,200 mL), coagulopathies may result from infusion of activated clotting factors or the dilution of existing clotting factors 289
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in the patient’s circulation.2xNursing personnel must be aware of this possibility and monitor coagulation profiles in patients who have experienced a large blood loss during or after surgery.19
centers will have different needs than small hospitals.
Cost of Autologous Blood Salvage
hree key components to consider in a quality-assessment program for perioperative autotransfusion are the equipment, the blood product, and most important, the operator of the equipment.32 Equipment manufacturers have recommended maintenance and quality assessment protocols. OR personnel should record the dates of periodic safety checks and quality assessments in an equipment Repairs or corrective actions also should be kept in this log. The personnel operating the blood-recovery equipment periodically should check salvaged blood products to ascertain proper machine function. They also should check the hemoglobin or hematocrit on a washed unit. A false-low hematocrit level will result when the operator initiates the wash cycle unless he or she has filled the bowl to the manufacturer’s preset level on automatic machines or to the level indicated by the manufacturer on manual machines. Some facilities also conduct periodic assays on heparin washout.34 Equipment manufacturers should be able to provide protocols and studies documenting the effectiveness of anticoagulant removal with their equipment. Cultures of the reinfusion bag rarely contain pathogenic bacteria and rarely are linked to clinical infection, but reinfusion bags occasionally will grow surface contaminants such as Staphylococcus epiderrnidi~.~~ To determine the source of this contamination in the event of a patient infection, the autotransfusion personnel would have to culture the reinfusion bag, the surgical site, and the patient’s blood simultaneously. The costs of such cultures could be prohibitive. Determining guidelines for when cultures are indicated may be a more rational, cost-effective approach. Blood-product and equipment quality con-
C
urrent donor selection and testing makes the homologous blood supply safer and the transmission of the human immunodeficiency virus ( H I V ) unlikely. The fear of HIV infection may affect the patient’s ability to assess the risks and benefits of homologous transfusion against the cost of autologous transfusions. Although autologous transfusions have become common for surgical patients, the cost has caused concern. In our experience, presurgical donation is a cost-effective way to replace the loss of 2 to 3 units of blood. Intraoperative autologous blood salvage is cost-effective compared t o homologous transfusion when at least three units of blood can be salvaged. Awareness of the cost and the patient criteria for each option allows the clinician to select a cost-effective means of providing autologous blood to the patient.
Equipment Evaluation perating room personnel must weigh several factors including the cost of equipment and disposable supplies, the quality of the training provided by manufacturers. service availability in your area, and the availability of references and clinical studies on equipment function when considering blood-processing equipment .30 The factors that OR personnel must consider in developing a perioperative service or when contracting for that service from an outside source must center around the facility’s equipment budget and its ability to maintain a pool of proficient staff members to operate the Major trauma
Autotmnsfusion Quality Assessment
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trol m a y b e inaccurate if trained, proficient personnel are not used t o operate the equipment.36 Too o f t e n , a d i a g n o s i s o f broken equipment actually is a lack of troubleshooting ability on the part of the operator. All staff members expected to operate blood processing equipment should undergo specific training a n d a preceptorship or certification process. This activity should be documented and repeated annually.37
Summary
D
eveloping a quality perioperative autolo g o u s b l o o d r e c o v e r y program is a team effort. M e m b e r s of transfusion committees, hospital blood bank personnel, OR staff members, and the members of the surgery committee are all possible sources of information. Your local blood center also may have literature or services that could be of assistance. Knowledge of current autologous transfusion alternatives will help nurses communicate with patients regarding transfusion therapy and will make nurses more valuable participants in the crucial decisions necessary to deliver optimal patient care in the perioperative period. 0 Notes l.W H Dzik, B Sherbume, “Intraoperative blood sa I v a g e : Me dic al contr o v er s ie s ,” Transfusion Medicine Reviews 3 (July 1990) 208-235. 2. Ibid; American Association of Blood Banks, Guidelines for Blood Salvage and Reinfusion in Surgery and Trauma, I 9 9 0 (Washington, DC: American Association of Blood Banks, 1990) 1. 3. National Blood Resource Education Program’s Nursing Education Working Group, “Choosing blood components and equipment,” American Journal of Nursing 91 (June 1991) 42-46. 4. American Association of Blood Banks, Guidelines for Blond Salvage and Reinfusion in Surgery and Trauma, 1990, 3. 5. R L Tawes, Jr et al, “The Cell Saver and autologous transfusion: An underutilized resource in vascular surgery,” American Journal of Surgery 152 (July 1986) 105; American Association of Blood Banks, Standards For Blood Banks and Transfusion Services, 14th ed (Washington, DC: American Association of Blood Banks, 1990) 106; J M Ray, J C Flynn, A H Bierman, “Erythrocyte survival following intraoperative autotransfusion in spinal
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surgery: An in vivo comparative study and 5-year update,” Spine 11 (November 1986) 879; P E Stanton, Jr et al, “Intraoperative autologous transfusion during major aortic reconstructive procedures,” Southern Medical Journal 80 (March 1987) 3 15; 6. G F Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience,” Transfusion 3 1 (July/August 1991) 509-512. 7. L B Semkiw et al, “Postoperative blood salvage using the Cell Saver after total joint arthroplasty,” Journal of Bone and Joint Surgery 7 (July 1989) 823. 8. K R Williamson, H F Taswell, “Intraoperative blood salvage: A review,” Transfusion 31 (September 1991) 662-675. 9. J C Flynn, C R Metzger, T A Csencsitz, “Intraoperative autotransfusion (IAT) in spinal surgery,” Spine 7 (September/October 1982) 432; M M Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” Annals of Surgery 197 (May 1983) 536. 10. “Recommended practices for basic aseptic technique,” in AORN Standards and Recommended Practices f o r Perioperative Nursing (Denver: Association of Operating Room Nurses, Inc, 1992) m:2-1. 11. Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 12. D Paravicini, J Thys, H Hein, “Rinsing the operative field with neomycin-bacitracin solution with intraoperative autotransfusion in orthopedic surgery,” Arzneimitrel ForshunglDrug Research II 33 (1983) 12. 13. F Robicsek et al, “Inherent dangers of simultaneous application of microfibrillar collagen hemostat and blood-saving devices,” Journal of Thoracic and Cardiovascular Surgery 92 (October 1986) 766. 14. Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 15. D H Yawn, B Bull, “Intraoperative salvage: Quality of products,” in Autologous Blood Transfusion: Current Issues, ed L M Maffei, R L Thurer (Arlington, Va: American Association of Blood Banks, 1988) 43-55. 16. J Ulmas, T P O’Neill, “Heparin removal in an autotransfusor device,” Transfusion 2 1 (January/ February 1981) 70. 17. J Ansell et al, “Survival of autotransfused red blood cells recovered from the surgical field during cardiovascular operations,” Journal of Thoracic and Cardiovascular Surgery 84 (September 1982) 387. 18. American Association of Blood Banks, Guidelines for Blood Salvage and Reinfusion in Surgery and Trauma, 1990, 23; US Food and Drug Administration Division of Blood and Blood Products, Memorandum of March 15,1989 (Bethesda, 291
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Md: US Food and Drug Administration, 1989). 19. Flynn, Metzger, Csencsitz, “Intraoperative autotransfusion (IAT) in spinal surgery,” 432. 20. American Association of Blood Banks, Guidelines f o r Blood Saliage and Reinfirsion in Surgen and Trauma, 1990, 6. 21. Williamson, Taswell. “Intraoperative blood salvage: A review,” 662-675. 22. C R Valeri, “Table 1: Incidence of clinical reactions following transfusion of non-washed intraoperatively or postoperatively shed blood.” i n Postoperarive Blood Salvage (abstract) presented at the Quad-State Blood Bank Meeting, Mayo Clinic, Rochester. Minn, 25 April 1991. 23. Smith + Nephew Richards, Inc, Solcotrans Plus U s e r Manual (Memphis, Tenn: Smith + Nephew Richards, Inc, February 1990) 2 . 24. Ibid. 25. Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience.” 509-5 12: Williamson. Taswell, “Intraoperative blood salvage: A review,” 662-675. 26. American Association of Blood Banks, Guidelines f o r Blood Salvage and Reinfusion in Surge? and Trauma, 1990, 6. 27. J Martin, “Postoperative blood retrieval i n cementless total knee replacement.” (abstract) presented at the New Developments in Total Joint Reconstruction: Sixth Annual DePaul Center International Symposium, St. Louis, 22-24 June 1989; Valeri, “Table 1: Incidence of clinical reactions following transfusion of non-washed intraoperatively or postoperatively shed blood.” 28. L D Griffith et al, “Apparent coagulopathy caused by infusion of shed mediastinal blood and its prevention by washing of the infusate,” Annals of Thoracic Surgery 47 (March 1989) 400. 29. American Association of Blood Banks, Guidelines f o r Blood Salvage and Reinfusion in Surgery and Trauma. 1990, 9; L C Stehling, H L Zauder, W Rogers, “Intraoperative autotransfusion,” Anesthesiology 43 (September 1975) 337. 30. Ibid; Emergency Care Research Institute. “Evaluation: Automated intraoperative processing autotransfusion machines,” Health Devices 17 (August 1988) 219. 3 1. Giordano et al, “An autologous blood program coordinated by a regional blood center: A five-year experience.” 509-5 12. 32. G Johnson, R Bowman. ”Certification criteria for operators of blood salvage equipment,” (abstract) ISBT/AABB 1990 Joint Congress: Book o,f Abstracts: A 128. 33. Emergency Care Research Institute, “Evaluation: Automated intraoperative processing autotransfusion machines.” 219. 34. Williamson, Taswell, “Intraoperative blood salvage: A review,” 662-675. 292
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35. h i d ; Keeling et al, “Intraoperative autotransfusion: Experience in 725 consecutive cases,” 536. 36. American Association of Blood Banks, Guidelines ,for Blood Salvage and Reinfusion in Surgery and Trauma, 1990, 1; Williamson, Taswell, “Intraoperative blood salvage: A review,” 662-675; Smith + Nephew Richards, Inc, Solcotrans Plus User Manual (Memphis, Tenn: Smith + Nephew Richards Inc. February 1990) 2. 37. Johnson, Bowman, “Certification criteria for operators of blood salvage equipment,” A 128.
National Health Insurance: A Money Saver? A national health care insurance plan similar to the one currently used in Canada could save the United States more than $1 trillion during the next decade. According to study results reported in the Winter 1992 issue of Advances, the newsletter of the Robert Wood Johnson Foundation, if the United States reduced its health care spending to Canadian levels (ie, from 12.8% to 8.7% of the gross domestic product), savings would amount to $241 billion the first year and more than $4.2 trillion by the year 2000. The study was the first of its kind to use computer simulation techniques to project the financial impact of different national health care plans on the US economy. Other results show that by extending health coverage to all of the estimated 33 million people currently uninsured and holding health care spending growth to the growth of the economy would save $1.3 trillion. Businesses would save at least $1 trillion over a 10-year period. According to the article, shifting the responsibility for financing health care from the private to the public sector would result in a tax increase, with overall savings to the economy and business by the year 2000. The article also states, however, that although a national health care plan would give all Americans access to basic medical care, tight controls on spending could affect the future development and availability of medical technology.
AUGUST 1992, VOL 56, NO 2
AORN JOURNAL
bxamination AUTOLOGOUS BLOODTRANSFUSION
1. Autologous blood is obtained from a. a close relative b. a blood donor c. the person receiving the transfusion d. a person of the same sex 2. Advantages to autologous blood include: a. minimal risk of disease transmission b. no alloimmunization c. decreased exposure to donor blood d. all of the above 3. The patient who is a candidate for blood salvage must have an anticipated surgical blood loss of mL. a. 100 b. 250 c. 400 d. 800 4. Patients who are candidates for presurgical autologous blood donation must have 1. a physical condition stable enough to permit the donation 2. a hemoglobin level of at least 1lgm/dL 3. no active infection, malignancy, or bacteremia 4. no aversion to large needles a. 1 and4 b. 2 a n d 3 c. 1, 2, and 3 d. 3 and 4 5. List the components of processed, salvaged blood. 1. packed red blood cells 2. clotting factors 3. plasma 4. albumin a. 1 and2 b. 3 only
c. 3 and4 d. 1 only 6. When can autologous blood be collected? a. at least 72 hours before surgery b. during surgical procedures c. from postsurgical drainage d. all of the above 7. Why is there a minimum recommended time of 7 2 hours between presurgical autologous donation and surgery? a. Scheduling appointments to donate blood is difficult. b. This time allows the patient to rebuild adequate volume and hemoglobin/ hematocrit levels. c. The collected blood is only good for 72 hours. d. The patients are available to donate at that time. 8. Intraoperative blood salvage is used most often on what types of procedures? a. vascular, open heart, orthopedic b. general, vascular, orthopedic c. pediatric, vascular, general d. neurosurgery, orthopedic, general 9. Postoperative autologous blood salvage is the collection and processing or the collection and direct reinfusion of blood lost after a surgical procedure. a. true b. false 10. The expiration time for processed blood is -hours. a. 6 b. 12 c. 24 d. 48
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1 1. Potential complications of intraoperative blood salvage include 1. air embolus 2. dilutional coagulopathy 3. hypervolemia 4. anticoagulant overdose a. l a n d 2 b. 1 and 4 c. 2,3, and 4 d. 1,2, 3, and 4 12. Damage can occur to the red blood cells recovered from the operative site. What are some ways that this can occur? a. suction used at settings higher than 100 mm Hg b. use of solutions on the field that hemolyze red blood cells c. attempts to wring blood out of laparotomy sponges d. all of the above 13. How does anticoagulant overdose occur? 1. Unsuspected coagulopathies convert normal doses of anticoagulants into overdoses. 2. An improper delivery of anticoagulant to the salvage system occurs. 3. Salvaged blood is not washed adequately. 4. Long cases can result in the overuse of anticoagulants. a 1 and2 b. 2 a n d 3 c. 2 a n d 4 d. 3 and 4 14. Pressure infusion cuffs should never be used on an original reinfusion bag. Why? a. Red cell damage can occur with pressure reinfusion. b. With pressure reinfusion, blood is transfused too rapidly. c. The bag may contain air, and pressure reinfusion could result in an air emboli. d. There is too little airblood interface. IS. It is important to wash salvaged blood to remove potentially harmful substances (eg, excess anticoagulant, antibiotic irrigants). What is the proper washing solution? a. normal saline (ie, 0.9 %) 296
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b. Ringer’s lactate C . DgW d. glycine 16. In patients who have had large blood losses during or after surgery and are receiving large-volume reinfusions, the nurse should assess for by monitoring patients’ a. anemiahemoglobin level. b. coagulopathies/coagulationprofile c. shock/bIood pressure d. oxygenationloxygen saturation 17. To determine the source of contamination of an intraoperatively processed unit of blood, cultures should be performed on a. the patient’s blood b. the reinfusion bag c. the surgical site d. all of the above 18. The nurse should ensure that intraoperatively salvaged blood is properly filtered when administered by using a a. leukopor depletion filter b. standard blood administration set (ie, 180 elm) c. microaggregate filter (ie, 20 to 40 pn) d. an HEPA or ULPA filter 19. The scrub nurse should not be concerned about the use of microfibrillar sponges during procedures using blood recovery techniques, because this type of particulate matter is removed during the washing phase of blood processing. a. true b. false 20. The perioperative nurse is aware that the following solutions should never be collected with shed blood. 1. povidone iodine 2. alcohol 3. sterile water 4. peroxide a. 2 and3 b. 1,2,and3 c. 2 , 3, and 4 d. 1, 2, 3, and 4
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Answer Sheet AUTOLOGOUS BLOODTRANSFUSION
P
lease fill out the application and answer forni below and the evaluation on the back of this page. Tear out the page from the Journul or make photocopies and mail to: AORN Accounting Department c/o Home Study Program 10170 E Mississippi Ave Denver, CO 8023 1
Event # 935001
Mark only one answer per question 1
2 3
Session #%I7
Program offered August 1992 The deadline for this program is Feb 28, 1993.
1. Record your identification number in the appropriate section below. 2. Completely darken the space that indicates your answer to the examination starting with question one. 3. A score of 70% correct is required for credit. 4. Record the time required to complete the program 5. Enclose fee: Members $7; Nonmembers $14.
4
5 6
7 8
9 10
AORN (ID) # If nonmember, please provide Social Security
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#
12
Name
13
Address City
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State
Zip
15
RN license and state Florida license # (Required for Flonda CE credit)
Phone number
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Fee enclosed or bill the credit card indicated
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(Turn Over) 291
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Learner Evaluation The following evaluation is used to determine the extent to which this home study program met your learning needs. Rate the following items on a scale of 1 to 5.
1. Objectives. To what extent were the following objectives of this home study p r o m achieved? ( 1 ) Discuss autologous blood salvage. ( 2 ) Describe how autologous blood can be salvaged. ( 3 ) List the complications of perioperative blood salvage. (4) Describe the role of the perioperative nurse in blood salvage.
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2. Content. ( I ) Did this article increase your knowledge of the subject matter'? (2) Was the content clear and organized? (3) Did this article facilitate learning? (4) Were your individual objectives met? ( 5 ) Was the content of the article relevant to the objectives?
3. Test questionslanswers. ( I ) Were they reflective of the content? (2) Were they easy to understand? ( 3 ) Did they addresc important points?
4. What other topics would you like to see addressed in a future home study program? Would you be intcrested or do you know someone who would be interested in writing an article on this topic?
Author names and addresses:
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