A California blood banker reports that salvaged red cells collected from patients undergoing surgery in their hospital are collected in bags and then re-infused through an appropriate filter but without washing the collected blood. The blood is usually collected from trauma patients, abdominal aortic aneurysm patients, or those undergoing back surgery. In addition to the blood salvage scheme outlined above, their current practice is to ALSO transfuse 3 units of FFP and 1 unit of plateletpheresis for every 4 units of salvaged blood that are reinfused. The inquiring blood banker is wondering if the described "cookbook" approach is justified according to any published evidence or expert experience.

In response to the above, the following replies were submitted. Clearly, this is a contentious topic, and the e-Network Forum Editor & Moderator has attempted to keep the discussion collegial.

1. One blood banker suggested that the e-Network read the information about ultrasound to filter fat from blood just published at Nature (Science Update).

2. An anesthesiologist in San Francisco commented that, in his opinion, the use of non-washed salvaged "blood" from surgical wounds has been addressed, in part, in the review by Stowell DP, Giordano GF, Renner SW, Thurer RL, and Weiskopf RB - An annotated bibliography on autologous transfusion second edition. Transfusion 88:400-409, 1998. According to the anesthesiologist, many experienced clinicians would be of the opinion that the amount of non-washed material being infused at the inquiring institution is greater than recommended. He continues by suggesting that washed salvaged material is preferred. In addition, as far as he is aware, there is no support for the formula described. All practice parameters/ guidelines of which he is aware (e.g. American Society of Anesthesiologists Task Force on Blood Component Therapy Practice guidelines for blood component therapy. Anesthesiology 84:732-747, 1996 and the CAP publication) state specific well-known criteria for the administration of FFP or platelets and advise against any specific formula. Furthermore, the anesthesiologist believes that one would not expect a coagulopathy based on dilution of coagulation factors or platelets until much greater blood loss and transfusion than is represented by 4 units (in a normal sized adult), even though such collected material is generally defibrinated.

3. A transfusion medicine physician in Chicago says that to his knowledge there is no published evidence to support the approach used at the inquiring blood banker's institution. To quote "If compelling data existed, it would be the standard of care. Most published guidelines, in fact, recommend avoiding use of such cookbook approaches. With regard to not washing salvaged blood, there are data and published experience to indicate that not washing salvaged blood is problematic. These RBC's contain anticoagulant (usually heparin) and other naturally occurring degradation products of in situ clotting, such as activated plasminogen, fibrin degradation products, etc., other middle molecules that may be either anticoagulant or prothrombotic in nature." He adds that he does not know of reports analyzing the supernatant materials of un-washed salvaged RBC specifically for D-dimers, but he would bet that they contain D-dimers, too.

The Chicago physician offers the following summary (edited) of his opinions:

• Published guidelines warn against such approaches because doing so is based on little or no evidentiary validity.
• From a blood conservation approach, the reported practice is not indicated (i.e., risks and costs outweigh benefits) and a waste of blood.
• At the Chicago physician's institution they salvage (and wash) 25-40 cases per month (typically the heavy bleeders, such as re-do orthopedic joint surgeries, scoliosis surgeries, triple-A's and CABG-valve replacements, chiefly). In the last 12 years of their experience, they have never provided such replacement on a cookbook basis. And although they haven't studied it scientifically, they are not in the midst of an on-going and progressive deluge of post-operative coagulopathy cases either.
• Such institutionally invented approaches set a false standard of care.

4. The Director of an Intraoperative Autotransfusion Service in Ohio believes that the transfusion of platelets and plasma at the inquiring blood banker's institution is compensating for the DIC which is being caused by the readministration of unwashed product. In the responding individual's opinion, unwashed cell salvage should be used in very, very limited quantities, if at all. In Ohio, they perform transfusion of post-operative unwashed cell salvage with devices such as the Gish and Stryker drains because they generally only retransfuse a few hundred mls. The respondent believes that the human body has the ability to compensate for limited amounts of such material being readministered. Even with these devices where minimal quantities of readministered blood are given, there have been reports of DIC occurring.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator