Transfusion Medicine

In this section, you will find:

1) Guideline for the use of Intraoperative Cell Salvage in patients with known/suspected malignancy

2) Phlebotomy/Acute Normovolemic Hemodilution (ANH) Kit Instructions

3) Transfusion Dashboard (In house link)

4) Transfusion Medicine PPO Links (In house link)

5) Guideline for the Management of Isolated PTT

6) Ordering Blood Products / G&S in CST

7) FiiRST-2 Trial Info and Instructions for Charting in SA Anesthesia

8) How to Set Up and Run ATG for Renal Transplant

ICS

Guidelines for the use of intraoperative cell salvage (ICS) in patients with known or suspected malignancy

1. Based on the best available data, it is reasonable to use intraoperative cell salvage (ICS) in operative cases with suspected or known malignancy*(1,2)

2. The additional step of filtering the cell salvaged product through a leukoreduction filter (LeukoGuard RS Leukocyte Removal Filter for salvaged blood, Pall Corp.) prevents malignant cells from being re-infused into a patient. The addition of a leukoreduction filter is recommended, but should not be considered mandatory.

3. A discussion should occur preoperatively between the patient and the anesthesiologist and surgeon that outlines the risks and benefits of both allogeneic blood and autologous cell-salvaged blood. This discussion should be documented in the medical record. ICS with leukofiltration should be considered if expected losses are likely to cause significant morbidity secondary to anemia and transfusion.

4. In the event of tumour rupture intraoperatively, direct suctioning of tumour contents should be avoided, and a second in-line leukoreduction filter should be considered.†

5. Administration of cell-salvaged product that has been leukofiltered has an increased risk of causing hypotensive transfusion reactions (3) that are particularly apparent and potentially severe in the presence of angiotensin converting enzyme inhibitors (ACEi) (4) . All leukofiltered product should be administered slowly, especially at first, to gauge patient reaction. In the event of a severe hypotensive reaction, the infusion should be slowed or discontinued. It is reasonable to consider restarting the infusion without the leukoreduction filter, and reassessing.

*The literature does not support the notion that patients undergoing oncologic surgery are at an increased risk of tumour recurrence or metastases after having received blood from ICS; particularly given the real possibility of immunomodulation contributing to increased risk of tumour recurrence with allogeneic blood transfusion in cancer surgery. Unfortunately, due to the complex nature of the problem, a proper RCT comparing allogeneic blood transfusion with leukofiltered ICS autologous transfusion is unlikely.

†There is evidence to suggest that a leukoreduction filter can become overwhelmed with resultant decrease in filtering efficacy in the event of tumour rupture (i.e. a large burden of tumour cells).

References:

1. Waters JH, Yazer M, Chen Y, Kloke J. Blood salvage and cancer surgery: a meta-analysis of available studies. Transfusion 2012; 52:2167-2173.

2. Trudeau JD, Waters T, Chipperfield K. Should intraoperative cell-salvaged blood be used in patients with suspected or known malignancy? Can J Anesth 2012; 59:1058-1070.

3. Arnold DM et al. Hypotensive transfusion reactions can occur with blood products that are leukoreduced before storage. Transfusion 2004; 44:1361-1366.

4. Quillen K. Hypotensive transfusion reactions in patients taking angiotensin-converting-enzyme inhibitors. NEJM letter. Nov 9, 2000.

Last updated: Mar 9th, 2018 by Dr. J Trudeau