Should intraoperative cell-salvaged blood be used in patients with suspected or known malignancy?

PURPOSE: Intraoperative cell salvage (ICS) is used as an alternative to allogeneic blood transfusion in an attempt to avoid or minimize the risks associated with allogeneic blood. Intraoperative cell salvage is generally avoided in surgeries where malignancy is confirmed or suspected due to concern for potential metastasis or cancer recurrence. The application of post-processing methods for ICS is hypothesized to eliminate this potential risk. The purpose of this narrative review is to examine the in vitro experimental evidence as it pertains to the removal of tumour cells from ICS blood and to review the clinical studies where ICS blood has been used in patients with malignancy. SOURCE: A search of the English literature for relevant articles published from 1973 to 2012 was undertaken using MEDLINE and Cochrane databases. Bibliographies were cross-referenced to locate further studies. PRINCIPAL FINDINGS: Leukoreduction filters are an effective method for removal of malignant cells from ICS blood. Small non-randomized clinical studies to date do not show evidence of an increased rate of metastasis or cancer recurrence. Although a theoretical risk of disease recurrence persists, the decision to use autologous ICS blood must be weighed against the known risks of allogeneic blood transfusion. CONCLUSION: Transfusion of autologous blood harvested via ICS should be considered a viable option for reduction or avoidance of allogeneic product during many oncologic surgeries and may be a lifesaving option for those patients who refuse allogeneic blood products.

Detection of autologous blood transfusions in athletes: a historical perspective.

Autologous blood transfusions (ABTs) has been used by athletes for approximately 4 decades to enhance their performance. Although the method was prohibited by the International Olympic Committee in the mid 1980s, no direct detection method has yet been developed and implemented by the World Anti-Doping Agency (WADA). Several indirect methods have been proposed with the majority relying on changes in erythropoiesis-sensitive blood markers. Compared with the first methods developed in 1987, the sensitivity of subsequent tests has not improved the detection of blood doping. Nevertheless, the use of sophisticated statistical algorithms has assured a higher level of specificity in subsequent detection models, which is a crucial aspect of antidoping testing particularly to avoid "false positives." Today, the testing markers with the best sensitivity/specificity ratio are the Hbmr model (an algorithm based on the total amount of circulating hemoglobin level [hemoglobin level mass] and percentage of reticulocytes, 4.51·ln(Hbmass)-√%ret) and the OFF-hr model (algorithm based on hemoglobin level concentration and percentage of reticulocytes, Hb(g/L)-60·âˆš%ret). Only the OFF-hr model is currently approved by WADA. Recently, alternative indirect strategies for detecting blood doping have been proposed. One method is based upon a transfusion-induced immune-response resulting in specific changes in gene expression related to leukocytes such as T lymphocytes. Another method relies on detecting increased plasticizer metabolite levels in the urine caused by the leakage of plasticizers from the blood bags used during the blood storage. These methods need further development and validation across different types of transfusion regimes before they can be implemented. In addition, several research projects have been funded by WADA in recent years and are now under development including "Detection of Autologous Blood Transfusions Using Activated Red Blood Cells (the red blood cells eNOS system)" and "Detection of Autologous Blood Transfusion by Proteomic: Screening to find Unique Biomarkers, Detecting Blood Manipulation from Total Hemoglobin Mass using 15-nitric Oxide as a Tracer Gas, Storage Contamination as a Potential Diagnostic Test for Autologous Blood Transfusion and Test for Blood Transfusion (Autologous/Homologous) based on Changes of Erythrocyte Membrane Protome" (WADA, WADA Funded Research Projects. http://www.wada-ama.org/en/Science-Medicine/Research/Funded-Research-Projects/. 2010). Although strategies to detect autologous blood transfusion have improved, a highly sensitive test to detect small volumes of transfused autologous blood has not yet been implemented.

[Continuous autotransfusion during liver transplantation]. / Folyamatos autotranszfúzió használata májtranszplantáció során.

The advantages and disadvantages of continuous autotransfusion during liver transplantation are investigated in our study compared with blood saving and traditional cell saving techniques. Patients were divided into three groups in this retrospective study; Group 1 (n = 14): continuous autotransfusion was applied; in Group 2 (n = 14): no blood saving technique used; in Group 3 (n = 14): Haemonetics cell saver was used. In Group 1 the number of Child B patients was significantly higher than Child C patients (p < 0.05). The initial values of haemoglobin were significantly lower in Groups 1 and 3 (89 +/- 19 vs. 103 +/- 17 vs. 90 +/- 16.8 g/l; p < 0.03). During hepatectomy in Group 1 lower haemoglobin values were detected than in the other two groups (96 +/- 7 vs. 104 +/- 16 vs. 106 +/- 16.6 g/l; p < 0.05). The quantity of total blood utilisation (donor + autotransfusion) was significantly higher in Group 3 than Group 2 and in Group 1 than Group 2 (21.06 +/- 11.2 vs. 11.07 +/- 3.8 vs. 30.71 +/- 18 U; p < 0.001). Comparing the values of ACT in each group during operation periods no significant difference was found. Treatment time on the ICU of the patients in Group 3 was significantly longer than in the other two groups (11.08 +/- 7.8 vs. 9.17 +/- 3.5 vs. 26.62 +/- 14.6 days; p < 0.03). We found that applying CATS is advantageous during liver transplantation, as the device reduces donor blood requirement. No significant complication was observed.

Transfusión sanguínea autóloga en cirugía plástica: técnica e indicaciones / Autologous blood transfusion in plastic surgery: technique and indications

La tendencia actual en cirugía plástica a realizar procedimientos quirúrgicos combinados o de gran porte, en un solo tiempo quirúrgico y bajo una única anestesia general, asociado al surgimiento del síndrome de inmunodeficiencia adquirida, han propiciado la difusión de la transfusión sanguínea autóloga. Las diferentes modalidades, sus ventajas, así como la técnica e indicaciones en cirugía plástica son discutidas

Transfusión sanguínea autóloga en cirugía plástica: técnica e indicaciones / Autologous blood transfusion in plastic surgery: technique and indications

La tendencia actual en cirugía plástica a realizar procedimientos quirúrgicos combinados o de gran porte, en un solo tiempo quirúrgico y bajo una única anestesia general, asociado al surgimiento del síndrome de inmunodeficiencia adquirida, han propiciado la difusión de la transfusión sanguínea autóloga. Las diferentes modalidades, sus ventajas, así como la técnica e indicaciones en cirugía plástica son discutidas

Transfusión autóloga. Sistema de Baylor / Baylor system autologous transfusions

Se efectúa un recorrido histórico hasta llegar al momento en que comienza a utilizarse la propia sangre para transfundir. Se analizan los diferentes tipos de transfusión autóloga, para pasar a detallar específicamente el sistema de transfusión autóloga rápida de Baylor. Se describen sus aplicaciones clínicas y las ventajas que presenta en cuanto a recuperación intraoperatoria, en disminución de riesgos de transmisión de infecciones y la mejor aceptación del paciente (AU)

[History of autologous blood transfusion in neurosurgical operations].

The first report on predeposit autologous blood transfusion was made in 1921 by F.C. Grant, neurosurgeon in the University Hospital of Pennsylvania. The patient was a 42-year-old man with cerebellar tumor, having a rare blood type for which no donor had been listed up. 500 ml of autologous blood was obtained, kept in 0.2% sodium citrate solution in a refrigerator and retransfused following a suboccipital exploration. Clinically, no reaction was noted and there was a favorable postoperative course, and 'autotransfusion' was evaluated as a life-saving procedure. In 1925, L.E. Davis and H. Cushing reported the first case of intraoperative autotransfusion (intraoperative blood salvage). The patient was a 42-year-old man with left occipital meningioma which, due to massive bleeding, could not be removed even by two-stage operations. In a 3rd stage operation, they could remove the tumor of 120 g totally by the aid of intraoperative replacement using 600 ml autologous blood collected with a home-made suction apparatus. No adverse side-effect was noted. This procedure was performed for 23 cases and it revealed beneficial effects except in one case. In ten of the cases, the procedure was estimated as a life-saving treatment. At the present time, the appropriate use of the patients' blood for transfusion therapy is recommended due to a shortage of donors. The use of autologous blood could play a key role, not only in saving the homologous blood supply, but also in avoiding complications encountered in conventional transfusion treatments. The methods of 'Autotransfusion' originated from operations in the neurosurgical area. On that account, it is desirable that neurosurgeons should be concerned with this subject even now.

[History of autologous blood transfusion in the 19th century]. / Zur Geschichte der autologen Bluttransfusion im 19. Jahrhundert.

Autologous blood transfusion in animal experiments was performed already in the first half of the 19th century. These experiments, however, were not conducted to explore the feasibility of autologous blood transfusion in man, but provided only the experimental design for physiological investigations on the defibrination of blood. Blood withdrawn from the animals by phlebotomy in these experiments was retransfused either with or without defibrination. The idea of retransfusing the patient's own blood was mentioned for the first time by Eulenburg and Landois, when in 1866 they proposed to treat gas poisonings with a type of exchange transfusion (transfusion with simultaneous depletory bleeding). They suggested that the blood that would be withdrawn could be retransfused after the poisonous gases had been eliminated. The first who demonstrably considered the possibility of autologous blood transfusion in operative medicine was the Halle surgeon Richard von Volkmann in 1868. The first originally sourced autologous blood transfusion, however, was performed by the Kiel surgeon Friedrich von Esmarch who, in a case of exarticulation of the thigh at the hip joint, collected the blood that had been shed during the operation in a washbowl, defibrinated it, and reinjected it into the severed femoral vein. However, despite some further cases of autologous blood transfusion performed for various indications and in different countries, the method was unable to gain a foothold in the treatment of acute blood loss, and fell into oblivion until the Leipzig gynaecologist Johannes Thies revived interest in it in 1914. The authors surmise that the advantages of autologous blood transfusion had not been recognised in the 19th century.

Técnicas de autotransfusäo para reduzir o emprego de sangue homólogo em cirurgia / Auto-transfusion techniques to reduce use of homologous blood transfusion in surgery

A reduçäo no emprego de sangue homólogo em cirurgia é uma crescente preocupaçäo tendo em vista os riscos inerentes, custo e disponibilidade. Entre as técnicas de autotransfusäo utilizadas com este objetivo podem ser descritas a pré-doaçäo autóloga, a autodoaçäo intra-operatória, a hemodiluiçäo combinada com hemoconcentraçäo e a reinfusäo de sangue aspirado do campo cirúrgico ou coletado de drenos após filtraçäo simples ou processamento. A seleçäo da técnica a ser empregada depende de fatores diversos, tais como características do paciente, tipo de cirurgia, facilidades, recursos disponíveis e habilidade da equipe envolvida no tratamento. A utlizaçäo isolada ou associaçäo das técnicas descritas vem possiblitando uma diminuiçäo no emprego de sangue homólogo e deve ser encorajada

Maternal blood donation for intrauterine transfusion.

Pregnancy affected by erythrocyte alloimmunization often requires intrauterine transfusion for fetal survival. Because blood donated by a random donor has been associated with an increased risk of disease transmission, maternal blood donation has been advocated as an alternative blood source for intrauterine transfusion. Collaboration between medical, nursing, laboratory, and nutrition personnel optimizes the safety and success of the procedure. This article describes the collaborative care of the woman participating in maternal blood donation for intrauterine transfusion.

Intraoperative and postoperative red blood cell salvage.

The risks associated with homologous blood transfusions include hepatitis, transfusion reactions, and AIDS. Intraoperative and postoperative red blood cell salvage and reinfusion are techniques available to decrease the need for homologous transfusions. In this article the techniques of red blood cell salvage are described and the benefits and potential risks of these methods are discussed.

Intraoperative blood salvage.

Interest in and use of IBS have increased recently. This form of haemotherapy involves the retrieval of blood shed perioperatively. IBS, together with other forms of ABT, has gained a prominent role in transfusion medicine, largely due to an increased awareness of the risks associated with transfusion of homologous blood. In addition to conserving erythrocytes, IBS prevents disease transmission, other adverse transfusion reactions, and alloimmunization to antigens in blood cells and plasma which may result from homologous blood use. An array of IBS devices is presently available, ranging from disposable canisters to complete processing systems. The devices are capable of recovering, filtering, washing and reinfusing shed erythrocytes. They can be divided into slow-flow and rapid-flow systems based on the rapidity of blood processing. Most systems use a dual channel aspiration cannula through which shed blood is aspirated and mixed with anticoagulant solution. The salvage procedure requires operator control at every step, even for the highly automated instruments. Various health care personnel have been trained to operate IBS equipment; a transfusion service nurse with blood bank expertise has proved to be a highly reliable operator in our practice. Extensive clinical observation has shown that salvaged erythrocytes function and survive normally. IBS has been applied in many surgical fields; it has two relative contraindications: its use in areas affected by infection or malignancy. Operative procedures characterized by large blood losses provide a cost-efficient application of IBS, including cardiac surgery, orthopaedic procedures, trauma, vascular surgery, and liver transplantation. New, highly efficient technology is emerging that is capable of recovering other blood components. Consequently, what presently amounts to erythrocyte recovery will be expanded shortly to include platelets and plasma, with its many constituents.

Blood salvage for cardiovascular surgery.

Intraoperative blood salvage produces safe and clinically effective red cells. Intraoperative salvage for cardiovascular surgery procedures can be expected to cause a substantial reduction in the use of homologous red cells in patients requiring redo operations, and repair of complex aortic aneurysms. The procedure per se will have very little impact on the use of other blood components such as platelets or plasma. For carefully selected patients, autologous perioperative or intraoperative collection of these components should also be considered. The primary risks of intraoperative blood transfusion include washout of clotting proteins and platelets, infusion of undesirable constituents (such as antibiotics and haemostatic agents added during the surgical procedure) and air embolism. Intraoperative autologous transfusion is only one part of an effective programme to minimize homologous transfusion. Equally important is the use of preoperatively donated blood, the use of effective and safe pharmacological agents to enhance haemostasis and haematopoiesis, a conservative approach that allows only the transfusion of blood components absolutely necessary, and, when possible, the elimination of anticoagulant and antiplatelet therapy several days prior to the cardiovascular surgical procedure.