BACKGROUND: Cell salvage (CS) techniques are used to reduce exposure to allogeneic packed red blood cell (pRBC) transfusion in patients undergoing cardiac surgery. However, some studies suggest that inappropriate use of these techniques is associated with increased incidences of thrombocytopenia, excessive bleeding, and transfusion of non-red blood cell blood products, including fresh frozen plasma (FFP), cryoprecipitate, and platelets. Pediatric patients undergoing cardiac surgery are at higher risk for increased perioperative bleeding and blood product transfusion requirement. To date, limited evidence supports the use of CS to reduce pRBC transfusion in neonates and children undergoing cardiac surgery. OBJECTIVES: This study analyzed the efficacy of systematic use of CS in neonates and children undergoing cardiac surgery with cardiopulmonary bypass (CPB) compared to a historic cohort of children in whom CS was not used. Our primary endpoints included the incidences of pRBC, cryoprecipitate, and platelets transfusion occurring within 48 hours after CPB. METHODS: We performed a retrospective medical chart review to study all neonates and children who underwent cardiac surgery with CPB between January 2013 and December 2014 at Boston Children’s Hospital (BCH). Considering that CS has been systematically applied at BCH since January 2014, children were separated into a control group (before January 2014) and a CS group (after January 2014). Children treated with CS before January 2014 were excluded. We used uni- and multivariable logistic regression analysis to assess the effect of CS on the odds of blood products transfusion. RESULTS: Among 1228 patients included in the analysis, 730 were included in the CS group and 498 in the control group. The results of our multivariate logistic regression analysis showed that age < 12 months (odds ratio (OR): 2.95, 95% confidence interval (CI): 2.26-3.84), American Society of Anesthesiologists Physical Status Classification (ASA) > 3 (OR: 2.95, 95% CI: 2.26-3.84), Risk Adjustment for Congenital Heart Surgery score (RACHS) > 3 (OR: 1.78, 95% CI: 1.28-2.49), and the use of CS (OR: 0.57, 95% CI: 0.44-0.73) were good predictors for perioperative transfusion. Using univariable analysis, the use of CS was associated with a significant reduction in pRBC transfusion (OR: 0.76, 95% CI: 0.61-0.96, p = 0.021), but a significant increase in cryoprecipitate (OR: 1.37, 95% CI: 1.08-1.76, p = 0.009) and platelets transfusions (OR: 1.37 95% CI: 1.08- 1.76, p = 0.004). However, after adjustment for age < 12 months, ASA > 3, and RACHS > 3, the use of CS significantly reduced pRBC transfusion (OR: 0.57, 95% CI: 0.44-0.73, p < 0.001), with no effect on cryoprecipitate (OR: 1.08, 95% CI: 0.83-1.41, p = 0.543) and platelets transfusions (OR: 1.05, 95% CI: 0.81-1.36, p = 0.694). CONCLUSION: The use of CS in neonates and children undergoing cardiac surgery with CPB significantly reduced the incidence of pRBC transfusion. Although the systematic use of CS in adults has been associated with an increased incidence of non-pRBC transfusions, the use of CS in a high risk pediatric population (age < 12 months, ASA > 3, RACHS > 3) was associated with a 43% reduction of pRBC transfusion without any increases in cryoprecipitate and platelets transfusions.

Red blood cells are a scarce resource whose demand often exceeds its supply. Intraoperative red cell salvage has proven to be a highly effective blood conservation strategy, as it can reduce the need for allogeneic blood transfusion. However, the use of cell saver alone is not sufficient. Without specific blood ordering guidelines, the amount of allogeneic blood product requested and cross&ndash;matched is often much greater than the real level of consumption. Efficient blood ordering guidelines have been developed in the past, and have succeeded in providing a more accurate prediction of actual need for intraoperative blood transfusion and minimizing waste. Few studies attempted to examine the blood ordering and utilization pattern with an emphasis on surgical cases that involve the use of intraoperative cell salvage. With the use of intraoperative cell salvage devices to reduce the amount of blood bank products required during surgery, considerable change in the practice of ordering cross&ndash;matched blood should be made. We retrospectively assessed the effectiveness of one Standardized Clinical Assessment and Management Plan (SCAMP) in improving the efficiency of blood utilization and reducing waste. This SCAMP was introduced at our Boston Children's Hospital in July 2012 as a blood ordering guideline for all pediatric orthopedic patients who are scheduled for intraoperative cell salvage. We retrospectively compared demographic variables, clinical characteristics, and blood utilization patterns of patients who underwent orthopedic procedure and received cell saver blood during the 17 months prior to the introduction of SCAMP (n = 455) and those who underwent similar procedures during the 15 months after the introduction of SCAMP (n = 487). Results suggested that demographic variables including age, weight, and sex were similar between the pre&ndash;SCAMP and post&ndash;SCAMP groups. It also demonstrated that after the introduction of SCAMP, the mean percentage utilization of blood (number of units used/number of units ordered x 100%) increased by 24.4% (p < 0.001), while the difference between the number of units ordered and number of units used reduced by 0.5 units (p < 0.001). In conclusion, the introduction of a SCAMP for blood product ordering has led to an increase in the efficiency of blood utilization and a reduction in blood waste. However, further evaluation and modification of the SCAMP need to be made in order to better predict actual level of utilization of blood products.

Submitted in fulfillment for the degree of Master of Technology, Clinical Technology: Cardiovascular Perfusion, Durban University of Technology, Durban, South Africa, 2016. / Introduction: A large volume of residual haemodilute blood remains in the cardiopulmonary bypass (CPB) circuit after termination of the bypass. It is common practice in many centres to process residual pump blood with an autologus cell salvage system (ACSS), thereby producing a re-suspended red blood cell (RBC) concentrate and attenuating the need for donor blood RBC concentrate. It has also become standard practice to wash donor pack red blood cells (PRBC) before adding it to neonate cardiopulmonary circuits (Swindell et al., 2007). Manufactures of ACSS recommend 0.9% sodium chloride (NaCl) as a wash solution for processing salvaged blood. Previous studies have demonstrated that washing PRBC with normal saline results in acid-base (Huber et al., 2013) and electrolyte derangements (Varghese et al., 2007). Infusion of normal saline in healthy volunteers also results in significant changes in osmolality (Williams et al., 1999). The use of normal saline as a wash solution in processing residual CPB blood requires investigation. Aims and Objectives: This was a prospective, quantitative in vitro investigation to analyze and compare the quality of residual pump blood post CPB that had been washed with either an unbalanced electrolyte solution (0.9% normal saline) or a balanced electrolyte solution (Balsol®). Both are crystalloid solutions. The primary objective of the present study was to measure and compare the pH, electrolytes, metabolites, osmolality and strong ion difference (SID) of residual pump blood to the pH, electrolytes, metabolites, osmolality and SID of processed cell saver blood, which was washed with either 0.9% normal saline or Balsol® solution. The secondary objective was to measure and compare protein levels (albumin and total protein) in residual pump blood to protein levels in processed cell saver blood, that is washed with either 0.9% normal saline or Balsol® solution. The final objective was to determine the volume, haematocrit and haemoglobin yield post cell saver processing, from the input volume of residual pump blood when washed with either 0.9% normal saline or Balsol® solution. This was the first study of this nature done in the South African population group. Methodology: In this investigation in a series of forty patients (n=40) undergoing elective cardiac surgery with CPB, the first twenty patients were allocated to the NaCl control group (n=20) and the second twenty patients were allocated to the Balsol® interventional group (n=20). The extracorporeal circuit consisted of a standard integral hollow fibre membrane oxygenator and tubing that was primed with 1500-1800 millilitres of balanced crystalloid solution (Balsol®), for both the control group and the interventional group, and addition of 5000 iu heparin. The balanced crystalloid solution (Balsol®) is the approved standard CPB priming solution for all cardiac procedures at Inkosi Albert Luthuli Central Hospital. This setup was used with the Stockert S5 roller pump heart lung machine. The operations were performed as per protocol with standard non-pulsatile CPB and hypothermia was maintained at 28 – 32 ºC (core) and haemodilution (haematocrit 20 % to 30 %). A standard flow rate of 2.4 L/min/m² was used. Cardio protection consisted of either cold Blood Cardioplegia using the Buckberg 4:1 ratio, being four parts blood to one part cardioplegia (with the 35ml of 20 % Dextrose + 1 gram Magnesium Sulphate added per 500ml), or 20ml/kg cold St Thomas II cardioplegia (with addition of 10ml of 8.5% NaHCO3 + 100mg lignocain per litre). Topical cooling was achieved with ice cold 0.9 % saline. Maintenance fluid used during CPB was Balsol® for both the control and the interventional groups. Calcium, potassium and sodium bicarbonate was administered as required during CPB to correct deficits for both groups. Weaning of CPB was performed after re-warming to a rectal temperature of at least 35 ºC for both study groups. Immediately on termination of CPB a blood sample was taken from the sampling manifold of the CPB circuit for pre wash analysis. Residual pump blood was then flushed out with one litre of Balsol® solution for both groups and collected into the Medtronic autolog cell saver reservoir to be processed. In the control study group 0.9% NaCl was used as the wash solution and in the interventional study group Balsol® solution was used as the wash solution. After processing of the salvaged blood is complete, a blood sample was taken for post wash analysis. Clinical data recorded for pre and post wash samples included: pH, pCO2, pO2, [K+], [Na+], [Cl-], [Ca2+], lactate, glucose, [HCO3-], TCO2, haematocrit, haemoglobin (GEM 4000® premier™ blood gas analyser) blood volume (Medtronic autolog) and SID (calculated as per equation). Inorganic phosphate, total magnesium, albumin, total protein (Siemens Advia 1800 blood gas analyser) and osmolality (Gonotech osmometer) were also measured. Results: There was a highly significant decrease (p < 0.05) within the NaCl group after washing with pCO2 (28.3 ± 2.9 vs. <6.0 ± 0.0), [K+] (4.5 ± 0.5 vs. 1.0 ± 0.7), total magnesium (1.7 ± 0.7 vs. 0.29 ± 0), ionized calcium (1.0 ± 0.09 vs. 0.1 ± 0.03), inorganic phosphate (0.9 ± 0.4 vs. 0.09 ± 0.04) and SID (27.1 ± 2.1 vs. 18.4 ± 2.2). There was a highly significant increase (p < 0.05) within the NaCl group after washing with pH (7.5 ± 0.1 vs. 7.7 ± 0.1), [Na+] (132.9 ± 3.2 vs. 146.3 ± 1.9), [Cl-] (107.8 ± 3.1 vs. 127.4 ± 2.1) and osmolaltity (256.9 ± 38.4 vs. 296.2 ± 57.5). There were highly significant decrease (p < 0.05) within the Balsol® group after washing with pCO2 (30.15 ± 6.0 vs. 18.9 ± 4.9), [Na+] (134.7 ± 2.2 vs. 125.6 ± 1), [Cl-] (108.8 ± 2.7 vs. 100.2 ± 1.4), ionized calcium (0.9 ± 0.1 vs. 0.02 ± 0.04), inorganic phosphate (0.8 ± 0.2 vs. 0.1 ± 0.024) and osmolality (288.8 ± 20.6 vs. 272.8 ± 19.9). There were highly significant increase (p < 0.05) within the Balsol® group after washing with pH (7.5 ± 0.1 vs. 7.7 ± 0.1), [K+] (4.2 ± 0.4 vs 4.6 ± 0.3). Total magnesium and SID were similar after washing within the Balsol® group. Albumin and total protein revealed similar significant decreases within both groups after washing. There was a highly significant difference (p < 0.05) in the change between groups after washing in all the variables measured, except for pH, inorganic phosphate, lactate, glucose, albumin, total protein, haematocrit, haemoglobin, and blood volume. Total carbon dioxide and [HCO3-] were not compared because they were incalculable by blood gas analyser in the NaCl group. Conclusion: This investigation concluded that the balanced electrolyte solution Balsol® used for washing residual CPB blood results in a re-suspended RBC concentrate, with an osmolality and electrolyte profile that is superior compared to washing residual CPB blood with 0.9% NaCl solution. / M