To the Editor:
Sloan et al.1 described readministration of salvaged blood to two different patients who subsequently experienced hemoglobinuria and coagulation abnormalities. The authors concluded that this problem is unstudied. I would disagree. Either this event resulted from severe hemolysis from high suction pressures being applied2 or the gross hemolysis was the result of washing with sterile water.3
The two major complications associated with intraoperative blood recovery and readministration (commonly called cell saving) are fatal air embolism and the hemolysis scenario depicted in this case report. The AABB (formerly known as the American Association of Blood Banks) has long recognized that intraoperative blood processing is fraught with errors. For this reason, they have created standards and an accreditation process to establish quality systems that may have prevented the cases presented in this case report.
The AABB standards outline the need for some form of quality assessment of the final blood product before readministration. This typically requires assessing clarity and color of the processed blood. If used in these cases, the blood would have been noted to be transparent and purplish in color. Within the case report, the authors note that, retrospectively upon review of the empty bag, there was evidence of gross hemolysis.
In addition to visual assessment, processing of the blood should be monitored for clarity of the effluent wash solution. When the effluent wash solution achieves the same clarity as the normal saline wash, the bowl of blood is adequately washed. If the effluent is grossly red upon termination of the wash cycle, then the blood has either been inadequately washed and needs further washing, or the wrong wash solution has been used.
As with administration of any blood product, personnel processing the shed blood should have adequate training and knowledge to produce a safe product. Taking a manufacturer’s course on how to install disposables and operate the equipment may not provide a comprehensive understanding of this technology. Like the AABB, the American Society of Extracorporeal Technology has recognized the lack of adequate knowledge of many users of this equipment. As a result, the American Society of Extracorporeal Technology has implemented a certification process to assess knowledge of blood salvage equipment. Although not a guarantee of proficiency, this process does assure a greater level of competency than is frequently accepted.
In summary, the problems described in this case report offer an opportunity to reevaluate the complacency with which we use blood salvage equipment. I would strongly encourage adoption of the AABB perioperative standards.
Jonathan H. Waters, MD
Department of Anesthesiology
Magee Women’s Hospital of University of Pittsburgh Medical Center
1. Sloan TB, Myers G, Janik DJ, Burger EM, Patel VV, Jameson LC. Intraoperative autologous transfusion of hemolyzed blood. Anesth Analg 2009;109:38–42
2. Gregoretti S. Suction-induced hemolysis at various vacuum pressures: implications for intraoperative blood salvage. Transfusion 1996;36:57–60
3. Waters JH, Sprung J. Errors during intraoperative cell salvage because of inappropriate wash solutions. Anesth Analg 2001;93:1483–5
4. Perioperative blood recovery and readministration standards. 4th ed. Bethesda, MD: AABB Press, 2009