Cell Salvage in Obstetrics (GL754)

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1 Cell Salvage in Obstetrics (GL754) Approval Approval Group Job Title, Chair of Committee Date Maternity & Children s Services Clinical Governance Committee Chair, Maternity Clinical Governance Committee 7 th November 2014 Change History Version Date Author, job title Reason 1.0 July 2009 Dr R Jones, Consultant Trust requirement 2.0 July 2010 Dr R Jones, Consultant 3.0 Sept 2011 Dr R Jones, Consultant 4.0 Sept 2012 Dr G Jackson, Consultant 4.1 Sept 2014 Dr G Jackson, Consultant Reviewed Reviewed Reviewed Reviewed and minor changes made J Policy Lead: Group Director Urgent Care Version: 4.1 ratified 7 th Nov 2014 This document is valid only on date Last printed 21/11/ :40:00 Page 1 of 7

2 Overview: Autologous blood transfusion can be associated with serious hazards. Cell salvage can provide a useful adjunct to autologous blood transfusion in obstetric haemorrhage. Introduction Cell salvage in obstetrics has not undergone randomised control trials to establish its safety. However, in vitro work has shown that the use of Haemonetics Cell Saver 5 combines with the Pall RS Leucocyte depletion filter will effectively remove all elements of amniotic fluid that have been studied. (1,2.) The last 2 CEMACH Reports have encouraged the use of cell salvage in major haemorrhage and patients refusing blood (3,4), and it was approved by NICE in 2005 (5). It is also suggested as a strategy in the OAA/AAGBI Guidelines for Obstetric Anaesthetic Services (6) There is therefore professional and national support for its use. An OAA survey in 2007 showed that 38% of UK maternity units use cell salvage, and that 28% include its use in their major haemorrhage protocol (7). There have been no reports to the UK regulatory body (MHRA and SHOT via the SABRE reporting system) of any adverse reactions to cell salvage, in maternity or other applications, and its safety has been established by clinical use. Indications for use Cell salvage should be considered for women undergoing caesarean section or postdelivery laparotomy who also have: Haemoglobin less than 8.5 g/dl Placenta praevia Blood disorders including known red cell antibodies Delivery in theatre at full dilatation Other situations where blood loss during caesarean section is unpredictable are : Multiple pregnancies Emergency caesarean section with previous caesarean section Previous classical section/myomectomy This document is valid only on date Last printed 21/11/ :40:00 Page 2 of 7

3 Protocol Prior to use The woman should be counselled as to why cell salvage is recommended. She should be given a copy of the NICE patient information leaflet. Link to NICE website and leaflet: Jehovah s Witnesses should have been seen earlier during their pregnancy. See Blood Product refusal protocol (CG477) In theatre All anaesthetists and obstetricians involved must have knowledge of the indications, contraindications, effects, benefits and risks of cell salvage. ODAs, scrub nurses and other theatre personnel also must be aware of the benefits of the proper use of cell salvage. There is an excellent e-learning module called learn cell salvage on the BTS website at: It would be advisable for anyone involved in cell salvage to have done this module. In addition, ODPs who are operating the equipment should have received suitable training and competency assessment in its use which must be updated every two years. A list of personnel who have been trained is held by Gemma Dix, Clinical Lead Anaesthetic Practitioner in the Anaesthetic Depatment and by the manager of Gynae/Maternity theatres. Only theatre personnel who have completed the trust training programme should use cell salvage in obstetrics. A member of the anaesthetic team should take responsibility for running the machine and make decisions about when blood should be retransfused. It may be used for any situation in which allogenic blood is used, but in practice this has so far been confined to Caesarean sections and uterine-re-exploration/ laparotomy following post partum haemorrhage. The machine is set up and operated in accordance with the standard operating procedures. ACD-A should be used as the anti-coagulant in the suction system. No alterations are to be made to the wash volume. The machine should be placed between the anaesthetic machine and the surgical assistant. If the woman is a Jehovah s Witness an in continuity set up could be use. (This means that the whole circuit is run through with saline and the re-transfusion bag connected to the IV cannula prior to the salvage suction making contact with the shed blood, at which point a continuous circuit is established between the blood lost and the recipient vein.) This document is valid only on date Last printed 21/11/ :40:00 Page 3 of 7

4 In non-jehovah s Witness patient, it is economical to set up the aspiration and reservoir kit only. The decision to process and re-transfuse can be made when the degree of haemorrhage has become clear (e.g. expected bleeding from placenta praevia) Amniotic fluid may be removed by separate suction prior to starting cell salvage, but recent work suggests this may not be necessary, as clearance of amniotic fluid appears to be independent of the initial load. (8) This means that while it may seem safer to suction the amniotic fluid separately, there is no evidence for this and if the patient is bleeding heavily from the start of the procedure (e.g. placenta accreta), then the cell saver suction can be used throughout. This may also give a higher yield of blood collected, especially when it has been necessary to enter the uterus through the placental site. This has been done in several UK centres with no ill effect. Suction should be via the wide bore sucker in the kit and the surgeon should try to suction blood from pools rather than dabbing tissue surfaces with the sucker which disrupts erythrocytes. Blood from swabs should be gently washed with IV quality isotonic saline solution and salvaged from a sterile bowl into the main reservoir. Suction pressure should be kept as low as practicable (<300 mmhg) to avoid red cell damage, although higher vacuum may be used if necessary. Only isotonic saline for intravenous use may be used for any wash or irrigation associated with cell salvage process. Cell salvage should be temporarily discontinued when substances not licensed for intravenous (IV) use are present within the surgical field and could potentially be aspirated into the collection reservoir. The standard theatre suction should be used to aspirate the surgical field and the wound should be irrigated with copious 0.9% sodium chloride before resuming cell salvage. Injury to bladder/ureters is not a contraindication to cell salvage because cell salvage is widely used in urological surgery. However, the use of cell salvage in the presence of bowel contents is contraindicated by the manufacturers although it has been used in laparotomy for abdominal trauma with no deleterious effects (1,2). Examples of substances that should not be aspirated into the cell salvage system include: o Antibiotics not licensed for IV use o Iodine, chlorhexidene, alcohol or hydrogen peroxide o Topical clotting agents Salvaged blood should always be immediately labelled in theatre with a patient identity sticker and time of the start of collection. This document is valid only on date Last printed 21/11/ :40:00 Page 4 of 7

5 Re-infusion should begin before the patient leaves the operating theatre in order to avoid wrong blood, wrong patient errors. Processed blood must NOT be infused under pressure because of the risk of air embolism. Reinfusion should be completed before patient leaves recovery and within 6 hours of collection. It is generally recommended to use the Pall RS Leukocyte Depletion filter in the retransfusion circuit if there is any risk of amniotic fluid contamination. This has been shown to remove all particulate elements of amniotic fluid in vitro, but will necessarily slow down the rate of re-transfusion. It should be noted that some centres have returned large volumes of cell-saved blood without using this filter with no ill effects, so in extreme clinical circumstances the use of unfiltered blood can be considered. The blood must be prescribed and the time and amount of blood re-infused and should be clearly documented in the patient notes. As with any transfusion, the patient should be carefully monitored, preferably in an obstetric HDU facility for 24 hours. Coagulation tests should be sent post transfusion, and repeated if abnormal or clinically indicated. Post usage The cell saver freely aspirates foetal red cells and cannot distinguish them from maternal red cells. Therefore if the patient is Rhesus negative she will require anti D prophylaxis and should have a Kleihauer test as soon as possible (125 iu Anti-D per ml of foetal blood contamination) A national database of Cell Salvage cases is currently being set up, and units using cell salvage should keep careful local records for audit reporting in due course, and any adverse clinical reaction should be reported through the national web-based SABRE system to MHRA/SHOT. See Appendix 1 below and follow link to form on Stationery References 1. Catling SJ Williams S. Fielding AM. (1999). Int J Obs Anesth; 8; Waters JH. Biscotti C. Potter PS. Phillipson E. (2000) Anaesthesiology; 92; Marion Hall (2004) in Why Mothers Die Report on confidential enquiries into maternal deaths in the United Kingdom (CEMACH), Chapter 4 (Haemorrhage) pp91-92, RCOG Press. Available from: 4. Saving Mothers Lives. The Confidential Enquiry into Maternal and Child Health Royal College of Obstetricans and Gynaecologists, Section 1:80 This document is valid only on date Last printed 21/11/ :40:00 Page 5 of 7

6 aspx. 5. National Institute for Health & Clinical Excellence Guideline IPG144: Intraoperative blood cell salvage in obstetrics (issued November 2005). Available from: 6. OAA / AAGBI Guidelines for Obstetric Anaesthetic Services Teig M, Harkness M, Catling S, Clark V. International Journal of Obstetric Anaesthesia (2007) 1, S30 8. Sullivan I, Faulds J, Ralph C. Contamination of salvaged maternal blood by amniotic fluid and foetal red cells during elective Caesarean section. Br J Anaesth 2008 ;101: ABMU NHS Trust- West Division, Labour Ward Protocol, Cell Salvage 2008, Dr Sue Catling Author: Dr R Jones(July 2009), Reviewed: July 2010, Sept 2011, Sept 2012, September 2014 (Dr G Jackson) Review due: November 2016 This document is valid only on date Last printed 21/11/ :40:00 Page 6 of 7

7 Appendix 1 Cell Salvage Record Form This document is valid only on date Last printed 21/11/ :40:00 Page 7 of 7

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