We are having some disagreement in our Blood Transfusion committee about the use of the Cell Saver autotransfuser in massive bleeding with intestinal injuries.

The McSwain group has 2 articles supporting the use of the Cell Saver even with intestinal contamination. The AAB (or whatever the Blood Bank national regulatory or advisory committee is called) apparently forbids it.

What do you do?

Do you have guidelines for use, such as massive life-threatening bleeding, okay to use Cell Saver even with intestinal contamination?

Gail Waldby, MD
Huron Clinic SD

Your transfusion committee should not be getting into the area of dictating clinical management, especially of conditions that those bureaucrats know nothing about--you are right that compellingt evidence exists as to the safety of transfusing this blood--if I remember correctly, thru a micropore filter or after washing--with antibiotics on board. Any who challenge this must show hard evidence to refute your evidence--the burden is now on THEM to prove their point.

Eric Frykberg, M.D.
Jacksonville, Fl

We use cell saver in all trauma patients that require massive transfusion for their abdominal or thoracic injuries, regardless of the spillage. We have no problems that we have identified or suspected from its use in these patients. Occasional anesthesia resident staff objects but since they dont run for the blood (our interns do) they usually give in. OUr cell saver is generally set up and run by our own anesthesiologists or their staff not the blood bank.

Lisa Dresner
Trauma Surgeon
Kings County Hospital Center
Brooklyn New York

Pam, I've asked Drs. Spackman & DeLoughery (from Transfusion Medicine) and Dr. Steve Fiamengo (Anesthesia, member of Transfusion Committee, and Medical Director of the Intraoperative Blood Collection Program at OHSU) to comment as well. You may hear from them. The American Association of Blood Banks (AABB referred to by Dr. Waldby below) has no specific written requirement that forbids collection of blood intraoperatively when there are intestinal injuries. In its accreditation document, it asks the question "Do the written instructions ensure safe, aseptic collection & reinfusion, as well as accurate identification ..... ". I suspect this might be where some disagreement is occuring. The technical manual of the same organization states "use of intraoperative blood collection is most suitable when the surigcal field is sterile ...., in which blood may be aspirated without excessive hemolysis, and in which anticipated blood loss is 20% or more of the patient's estimated blood volume". "Relative contraindications to intraop blood collection include malignancy, infection, and contaminants in the field." "Studies document that washing [commonly performed on salvaged blood before reinfusion to reduce hemolysis, activated clotting factors, etc.] does not remove bacterial contamination, it is generally recommended that shed blood not be reinfused if the field has bacterial soilage."

Having quoted all of that, and risking a difference from other OHSU staff I referred this to, I think that it is an individual decision by the physician and anesthesiologist. If there is adequate blood available from the bank, the additional risk to the patient must be considered. If there is life-threatening bleeding, and inadequate blood available, educated physicians should be allowed to accept that risk. What I would like not to see would be a carte blanche acceptance outside of the latter case. I know this is framing a cool, conscious decision in the midst of a hectic scenario, but it seems the most prudent course to me. I also believe that the patient's medical record must contain documentation of the event.

Thanks for a great response. It feels great to read something in the internet that has real time meaning to me as a surgeon.

Jose A. Acosta, CDR, MC,USNR
USNH Keflavik, Iceland