Download Cell Salvage Using an Intra-Operative Cell Salvage Machine

Cell Salvage using an intra-operative cell salvage machine
Version
4.1
Name of responsible (ratifying) committee
Hospital Transfusion Committee
Date ratified
26/10/2012
Document Manager (job title)
Transfusion Practitioner
Date issued
27/11/2012
Review date
01/10/2017
Electronic location
Clinical Policies
Related Procedural Documents
Blood Transfusion Policy
Key Words (to aid with searching)
Cell Salvage
Blood
Transfusion
Reinfusion
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
4.1
14/10/2016
Extension to review date agreed
HTC
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
Page 1 of 8
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE ...................................................................................................... 3
INTRODUCTION ......................................................................................................................... 5
PURPOSE ................................................................................................................................... 6
SCOPE ........................................................................................................................................ 6
DEFINITIONS .............................................................................................................................. 6
DUTIES AND RESPONSIBILITIES.............................................................................................. 7
PROCESS ................................................................................................................................... 7
TRAINING REQUIREMENTS ...................................................................................................... 8
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 8
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS.............................................................................................................................. 8
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
Page 2 of 8
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy
1. Set up and operation of the equipment
 Plug in equipment and allow time for self test
 Disposables needed for collect only include: a 4 litre reservoir, an aspiration and anticoagulation line, ACDA
citrate and a yankeur sucker
 Disposables needed for processing and reinfusion include: a suitably sized bowl processing pack
2. Collect only
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Hang anticoagulant solution on equipment stand
Place the reservoir in the holder, ensuring the clamp is closed
Hand the sterile aspiration line to the scrub nurse and receive the end with the spike back
Insert spike into anticoagulant bag (with the roller clamp off) and attach to the suction port of the reservoir
Connect external suction to the reservoir and turn on. Vacuum should be set at 100mmHg to start but could
be increased to between 120 – 140mmHg if brisk blood flow
Open the roller clamp on the aspiration line and put 150mls approx into the reservoir, set the drip rate
following this at approximately 1 drip per second
3. Setting up the processing pack
 Open the processing pack and load the bowl into the centrifuge and close the centrifuge support arm. Spin
the bowl to ensure it moves freely
 Fix the tubing into the manifold and sensor lines and ensure locking gates and covers are closed
NB the machine will not operate unless all of the above has been completed
 Color connect the lines accordingly
 The wash solution is 1000mls Normal Saline (NaCl 0.9%)
 Ensure that the clamp to the reinfusion bag is open and the retransfusion port clamps are shut
 The clamp from the reservoir is open
 The wash solution clamps are open
 The waste bag is hung on the hooks
 The equipment is set to automatic, press start at anytime to override this or at the end of the operation to
ensure all cells that are available can be processed
4. Processing the salvaged blood for reinfusion
 Cell washing is automatic when the centrifuge detects a full bowl
 Once wash cycle is completed the centrifuge will stop, re-suspending the red cells. The pump will reverse
and pass the cells to the reinfusion bag along the blue colored line
 Once complete further blood can be processed
5. Reinfusion of processed blood
 The reinfusion bag must be labeled with the full patient details e.g. surname, first name, date of birth and
hospital number
 The time and date of collection must be put onto the bag
 DO NOT USE A PRESSURE CUFF! The bags are not designed for pressure infusion
 Be aware there will be some residual air in the bags from the system, this air can be removed prior to
reinfusion by inverting the bag and opening the clamps to expel the air
 There is no need to disconnect the bag from the equipment once reinfusion starts, processing can continue
 Once the operation is completed and no further blood will be salvaged, disconnect the large blue line from
the processing pack and use the blue stopper to plug the hole (to avoid drips)
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
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The blood can continue with the patient to recovery and/or clinical area
Autologous blood must NOT, UNDER ANY CIRCUMSTANCES, be removed
from the patient, stored in a clinical area, ward fridge or blood fridge
6. Decontamination of the equipment
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Once the procedure is completed the disposables can be removed
Ensure all clamps are closed and end caps are replaced
Disposal of the waste products can be directly into the sluice, taking care to avoid ‘splashing’
All disposables must be placed inside 2 yellow disposal bags and sealed
Damp cloth the outside of the equipment to ensure any dirt, dust or spilt blood are removed in between
each use
7. Setting up the equipment for Jehovah Witness patients
 See appendix 1
 NB – please note that consultation with patient prior to procedure will establish if complete set up is needed.
Most Witnesses will accept cell salvage but do not need to see equipment set up
8. Recording of blood loss and reinfusion totals
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The approximate blood loss can be calculated using the total processed figure minus the amount of ACDA
The amount of unprocessed blood in the reservoir can be worked out by the deducting the approximate
amount of ACDA that has been used
These 2 figures added together will give you the approximate blood loss
9.
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Prescriber Role and Responsibilities
The prescription of the blood is the responsibility of the Clinician
Prescribe on designated prescription sheets using 4 points of patient identification
Duration and infusion rate
The blood must be identified as ‘AUTOLOGOUS’ blood
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10. Identity band
 All patients, including unconscious patients, must have surname, first name, date of birth, a patient
identification number and the gender of the patient recorded on the identity band
11. Observations and administration
 Cell salvaged blood can be given immediately the processing is finished and can be given stat. Completion
of the transfusion must be within 4 hours as per hospital policy for administration
 Observations should be recorded in line with current hospital policy
12. Documentation (All patients)
 The patient notes must contain the volume re-transfused and any adverse effects. A follow up note to
record the clinical response should also be recorded
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
Page 4 of 8
INTRODUCTION
Since the publication of the NHS Executive, Health Service Circular entitled Better Blood
Transfusion, published in 1998; attention has focused on blood transfusion for many reasons:

Increased demand for blood compared to the decrease in donations

Recommendations from the Serious Hazards of Transfusion (SHOT) enquiry, on how the safety of
patients receiving blood could be improved

Theoretical risk of new-variant CJD
Autologous blood transfusion (transfusion of a patient’s own blood) is seen as a valuable advance in
improving clinical practice (Department of Health, 2005). There are systems available to collect and re-infuse
post-operative patients’ own blood, these are called cell salvage machines
In addition to the general benefits of autologous transfusion, cell salvage:
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Is generally accepted by Jehovah’s Witnesses
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Allows rapid return of the patient’s own washed red blood cells
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Can be used in obstetrics
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Can be used in malignancies
Practice in autologous blood transfusion has increased in response to several initiatives and reports;
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Recommendations from the Serious Hazards of Transfusion (SHOT 2005) enquiry, regarding safety of
patients receiving transfusion
Department of Health (2002) Better Blood Transfusion 2 circular, which identifies those alternatives to
donor blood, and the appropriate use of autologous blood transfusion, should be pursued. This includes
intra-operative cell salvage
Department of Health (1998) White Paper, The New NHS – Modern and Dependable, which suggests
that autologous blood transfusion is seen as a valuable advance in improving clinical practice
Potentially lower risks of infection or febrile episodes following autologous blood transfusion in
comparison to bank blood (Newman et al, 1997, Gleason and Leone, 1997, Murphy et al, 1991, Tartter,
1988)
European Blood Directive 2005, suggests alternative strategies must be considered for effective use of
blood
Indications for use
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Any surgery where a blood loss is expected which may result in a post-operative
homologous transfusion
Any patient who refuses a blood product transfusion for religious or personal beliefs
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
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Contraindications for use
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Surgery involving contamination from bowel contents – although this is contraindicated due to the integrity
of the cells, in life threatening situations for people with religious or personal beliefs, cell salvage must
continue with care being taken to avoid contamination of the cells
Infected wound
Bacteraemia or Septic contamination of the autologous blood
Presence in collected blood of a substance not suitable for reinfusion e.g. adrenaline or
peroxide
1. PURPOSE
The purpose of this policy is to:
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Reduce the risk associated with homologous product transfusion by utilising patients own cells
Provide a clear framework and guidance for safe collection and reinfusion of intra-operative cell salvaged
blood using a cell salvage machine, throughout Portsmouth Hospitals NHS Trust
To ensure a consistent approach to the collection, processing, storage, prescribing, handling and
administration of the patient’s own blood throughout the Trust
To ensure that all members of staff involved in any stage of the process of transfusing patient’s own blood
are aware of their role and the Legal aspects of this Practice
To ensure staff competencies are maintained
2. SCOPE
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Unregistered practitioners can be responsible for assembling the equipment needed but are not allowed to
process or administer the shed blood
Only Registered Nurses (RN) or Registered Operating Department Practitioners (RODP) who have been
trained in the use of the Intra-operative cell salvage machine and have completed the Trust competency,
will be allowed to collect, process and reinfuse blood using this system
Department managers must satisfy themselves that the RNs/RODP’s who undertake this practice have
achieved the level of education and competence required
The appropriate manager should keep a record of staff achieving competence and provide copies to the
Transfusion Practitioner
All staff involved in the administration of autologous blood transfusion must be familiar with the Trusts Blood
Transfusion Guidelines and have completed the administration of blood products competency
This policy should be read and applied in conjunction with the
Trust Blood Transfusion Policy, which is located on the Trust Intranet
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that
it may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety’
3. DEFINITIONS
Homologous – Donated blood from an unknown donor
Autologous – The patients own blood
Reinfusion – Giving back a patients own shed blood using an intra-operative cell salvage machine
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
Page 6 of 8
RODP – Registered Operating Department Practitioner
RN – Registered Nurse
Unregistered Practitioner – staff member who does not hold a professional qualification
Autotransfusion – reinfusion of patient shed cells
4. DUTIES AND RESPONSIBILITIES
The Operational Manager & Professional Lead for Theatres is responsible for all staff; ensuring training is completed in
a timely and logical manner
The Theatre Training Manager is responsible for providing the training ensuring staff complete their competency prior
to carrying out intra-operative cell salvage unsupervised
The Transfusion Practitioner is responsible for supporting the Training Manager, assisting where possible with the
development of the cell salvage programme. Maintaining records of trained staff, policy updates, quality control and
incident reporting
Registered Nurses/RODP’s are responsible for identifying their own training needs and operating the machine in
accordance to Trust policy
5. PROCESS
Rationale
This document has been written as a direct result of increased focus on the transfusion process
by the publication of the NHS Executive, Health Service Circular entitled Better Blood
Transfusion, republished in 2005 and is due to an:

Increased demand for blood compared to the decrease in donations

Recommendations from the Serious Hazards of Transfusion (SHOT) enquiry, on how the safety of
patients receiving blood could be improved

Theoretical risk of new-variant CJD
Autologous blood transfusion (transfusion of a patient’s own blood) is seen as a valuable advance in
improving clinical practice (Department of Health, 2005). There are systems available to collect and re-infuse
post-operative patients’ own blood, these are called cell salvage machines
A review of the available documentation, has provided a baseline for the policy and resources
used include:
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NPSA Safer Practice Notice 14 – Right Patient Right Blood
BCSH Guidelines for Transfusion
Handbook of Transfusion Medicine
Clinical Networks
Department of Health
Stakeholders
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PHT Hospital Transfusion Committee
PHT Theatre Departments
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
Page 7 of 8
6. TRAINING REQUIREMENTS
Qualified Staff
The training will consist of three levels. Level One involves an out of theatre demonstration and principles of
cell salvage, allowing time to demonstrate patient selection, assembly of the machine, collection and
subsequent re-infusion of bled blood and the safe disposal of and cleaning of the machine and parts therein,
according to hospital infection control policy. This will allow for questions and practical demonstration of the
running of the machine
All members of staff will receive training manual and a training record form supplied by PHT and must
complete the competency prior to undertaking any unsupervised cell salvage. No one will be allowed to
operate the machine unsupervised in any way unless they have first attended a training session and
completed the competencies
Level Two will allow time for the operator to develop their own skills whilst undergoing supervision
Level 3 will be an established practitioner with additional training responsibilities
Unregistered Practitioners
Unregistered Practitioners must be aware of their responsibilities and limitations of their role in the assembly
and dismantling of the equipment. Under no circumstances must an Unregistered Practitioner operate the cell
salvage machine or reinfuse blood to a patient
7. REFERENCES AND ASSOCIATED DOCUMENTATION
NHS Executive (2002) Better Blood Transfusion. Health service Circular, DoH
Contreras, M (2002) 3rd Edition, ABC of Blood Transfusion. BMI, Rugby
National Blood Service (2005) Serious Hazards of Transfusion. SHOT Office, Manchester
Farmer, S. Webb, D (2000) Your Body, Your Choice. Media Masters Pte Ltd, Singapore
Tawes, R.L (1997) Autotransfusion – Therapeutic Principles and Trends. Gregory Appleton, Detroit
Murphy, M. Pamphilon, D. (2001) Practical Transfusion Medicine. Blackwell Science Ltd, London
Gleason, D.H, Leone, B.J (1997) Cost effectiveness of blood transfusions; the risks and the benefits
Guidelines for the Clinical Use of Red Cell Transfusions, British Committee for Standards in Haematology, Blood
Transfusion Task Force in collaboration with the Royal College of Nursing and the Royal College of Surgeons of
England. British Journal of Haematology 2001; 113, 24-31
Statutory Instrument 2005 No. 50, The Blood Safety and Quality Regulations 2005
Handbook of Transfusion Medicine (2007), D.B.L. McClelland, 4th Edition. The Stationery Office Norwich
European Blood Directive 2005
8. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS
Compliance with this policy will be monitored through several key performance indicators:
 Annual staff updates to ensure compliance with the policy through the APDR
 Monitoring responses to incidents whilst using the intra-operative system
 Success / failure to use the system and incidents where the system was not used due to
lack of competent staff
The results of these indicators will also be reported to the Hospital Transfusion Committee, where
any recommendations / required actions will be discussed. These reports will enable the
effectiveness of the Policy to be evaluated and presented to the Theatre Training Manager,
Theatre Operational Manager and the Hospital Transfusion Committee
Policy for the Development and Management of Procedural Documents: Template for Procedural Documents
Version 4. Issued: 26th October 2012 (review date October 2017)
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