Comments invited from members on the draft AAGBI guideline Cell salvage for peri-operative blood conservation

Comments invited from members on the draft AAGBI guideline Cell salvage for peri-operative blood conservation
A draft guideline on cell salvage for peri-operative blood conservation is in its final draft stage and comments are invited from members. Please read the draft and submit any comments to workingparties@aagbi.org. All comments submitted will be considered before a final version is brought before the AAGBI Board for approval. The closing date for comment submission is 5pm on Friday 12 January 2018.

 

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Comments

comments invited on cell salvage guideline

7. Cell salvage is not recommended for routine use during CS....... is a statement which I, and  many colleagues disagree. The working group appear to have made this recommendation without due consideration of the evidence that supports the use if intra-operative Cell Salvage (ICS) as an intergral part of many obsetric PBM strategies. References are predominantly made to SALVO which has been misinterpreted and conclusions  drawn which contradict current practice . Whilst SALVO did not find a statistically significant difference in blood transfusion rates between women who had and did not have ICS , they only randomised women considered at risk of bleeding and did not employ ICS routinely during caeserean section (CS) 1.It is stated the SALVO trial did not demonstrate benefit in women who had ICS and underwent CS due to malplacentation . SALVO did not show no benefit.

SALVO secondary outcomes looked at fetal maternal haemorrhage (FMH)>2mls in RhD negative women 10.5% (n=9) control and 25.5% (n=21) who had ICS . Concluding there was an association with increased exposure to fetal blood >2mls in women with RhD neg blood who gave birth to RhD positive babies. The guideline then states SALVO found the risk of FMH was significantly increased by use of cell salvage . This is not what it found. SALVO  only studied RhD negative women and measured differences in maternal contamination to fetal rbc in a small subgroup (n=30). The significance of fetal rbc contamination is if they produce an antibody response and for RhD negative women this can be effectively treated . SALVO clearly state they are unable to comment on antibody sensitisation . No conclusion can be drawn relating to FMH, fetal rbc contamination, or sensitisation . There has been no follow up of the 761 women who received ICS blood to assess antibody formation and no comparison  of fetal rbc contamination of women who are not RhD negative or have had a vaginal delivery.There is published work showing there is no difference in the levels of fetal rbc contamination of the maternal circulation in women who have delivered with, or without, cell salvage 2.

The working group have recommended the use of 2 suction devices to aspirate amniotic fluid first, but there is no evidence to support this practice . 58.1% of the centres recruiting to SALVO used one suction (41.9% used 2). There is evidence to support using one suction 3.

There is no mention of the use of swab washing to improve blood collection and the recommendation regarding the use of the LDF is confusing and contradictory . Areas of uncertainty have not been addressed , such as use of partial bowls and double washing obstetric collections . 

My suggestion is to remove the guidance in this document relating to obstetric ICS .

Catherine Ralph 

SHOT expert adviser for ICS 

1. Ralph CJ, Sullivan I, Faulds J. IOCS blood as part of a blood conservation strategy in CS: is fetal red cell contamination important? BJA 2011:107:404-408

2. Endean E, Pooley S, Ralph CJ ........Routine use of IOCS for CS and its affect on Ab formation and ABT rates. Transfusion medicine 2017; 27 : S2:P51 (In press - accepted for publication)

3. Sullivan I, Faulds J, Ralph C.Contamination of salvaged amternal blood by AF and fetal RBC during elective CS. BJA 2008 :101 (2); 225-9 

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Leucodepletion filters

Hi,

I have read the draft guidelines and thank you for your hard work. 

I am working on the cell salvage service in Swindon. In the south west it seems common to not use LDFs. This is mainly due to it slowing transfusions.  I am concerned that this decision is not evidence based. However, I can see that in severe rapid blood loss the speed of reinfusion should take priority. 

In the draft guidelines it says LDFs should be used but later says that LDF use 'should be considered' and the evidence for there effectiveness is mixed. 

Would it be possible to clarify the position on LDFs otherwise I feel to not use them would be indefensible. 

Many thanks 

Edward Bick

Cons anaesthetist swindon

E.bick@nhs.net

07815097744