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An evaluation of intraoperative cell salvage in obstetrics

Thursday, 22 May, 2014 - 11:30
Board 5

Poster Presenter: David Lesliedavidleslie83@googlemail.com
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Service Evaluation

An Evaluation of Intraoperative Cell Salvage in Obstetrics
D Leslie, S Morris, G Lilley
University Hospital of Wales, Cardiff, UK
In the most recent CMACE report1, haemorrhage was responsible for the death of nine women. Blood loss in obstetrics is notoriously difficult to predict, but occurs frequently. Allogeneic blood is increasing in cost as the donor pool decreases.
Intraoperative cell salvage (ICS) has been shown to be both safe and clinically effective in obstetrics. There is now even some evidence to suggest that ICS used in all but the lowest risk patients is cost-effective2.
ICS is recommended by NICE3, RCOG4 and AAGBI5 but all guidelines are quite non-specific. As a result, there is considerable variation in its use between obstetric units in the UK. We attempted to identify risk factors associated with blood loss of >1000 mL at lower segment Caesarian section (CS) in order to establish departmental guidelines for the use of ICS in obstetrics. We also assessed our current use of ICS.
Data were collected retrospectively from April to December 2012. Patients with measured blood loss (MBL) >1000 mL were identified using the Obstetric Bleeding Study 1 (OBS1)5 database, and denominator data obtained from the departmental database.
Between April and December 2012, 1069 CS were performed. The percentage of patients with MBL >1000 mL was significantly greater in patients undergoing second stage CS (Table 1). For emergency CS, median MBL in Syntocinon-augmented patients was greater than in those not receiving Syntocinon (Table 2). ICS was used in 41 patients, with blood being returned to just seven, equating to a return rate of 17%. The primary causes for PPH, taken from the OBS1 database, were numerous (Table 3), but vascular lower segment and uterine atony were identified as leading causes.
Our data highlights that use of ICS is sub-optimal. ICS was not used in many patients in whom it would have been beneficial, and when used, return rate was poor. For cost effectiveness, our return rate must increase from 17% to approximately 25%. Second stage CS has been identified as a clear risk factor for PPH, with 36% of patients bleeding >1000 mL. Syntocinon augmentation was also shown to increase severity of PPH. We suggest that ICS should be used for all second stage CS, and that its use should be strongly considered for all patients undergoing CS after receiving Syntocinon augmentation.
Setting up ICS at the time of second stage CS is clearly not practical, due to time and personnel constraints. To overcome this, we propose having an ICS collection system prepared and ready to use at all times. ICS can then be used for any appropriate case in theatre, and if sufficient blood is collected, it can then be processed and returned to the patient.
Our recommendations seem reasonable based on our dataset. We are aware, however, that our numbers are relatively small, and there is therefore potential for error in our conclusions. The ongoing multi centre randomised controlled SALVO trial is likely to provide more robust evidence, in relation to when ICS should be used in obstetrics.
Centre for Maternal and Child Enquiries. Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006-8.The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118(Suppl 1):1-203
C Brearton, A Bhalla, S Mallaiah, P Barclay. The economic benefits of cell salvage in obstetric haemorrhage. Int J Obstet Anesth 2012; 21: 329-333
National Institute for Health and Clinical Excellence. Intraoperative blood cell salvage in obstetrics. http://www.nice.org.uk/nicemedia/live/11038/30690/30690.pdf; 2005 [accessed February 2013]
Royal College of Obstetrics and Gynaecology. Green top guide
The Association of Anaesthetists of Great Britain and Ireland, safety guideline: blood transfusion and the anaesthetist. Intra-operative cell salvage. http://www.aagbi.org/sites/default/files/cell%20_salvage_2009_amended.pdf; 2009 [accessed February 2013]
GJ Lilley, DA Burkett-St.Laurent, PW Collins, RE Collis. A prospective study to evaluate early Clauss fibrinogenand Fibtem as predictors for major obstetric haemorrhage. Int J Obstet Anesth 2013; 22: S7