Intra-operative autologous blood management

The evolution of cardiac surgery has been accompanied by a wide variety of techniques and equipment available for blood conservation. It has also given us data that allows identification of preoperative risk factors for transfusion needs in other surgical specialties. There is however great diversity of opinion as to how this technology should be applied. Examples can be found in the literature of discrepancies between countries but also individual institutions . The authors encounter differences in opinion between practitioners regularly. The authors believe that the variance in opinion may be based on the experiences of single techniques and that a broader depth of practice is required to achieve best practices for intra-operative transfusion management. The most performed procedure in our experience is red cell salvage and processing with a cell-washing device (CS). There are two primary issues related to CS, cost and reduction in allogenic blood exposure. A recent meta-analysis has shown that cell salvage in orthopedic surgery decreases the proportion of patients requiring allogeneic blood transfusion peri-operatively, but post-operative cell salvage is only marginally effective in cardiac surgery. There are close analogies to be drawn from issues surrounding the whole picture of transfusion. Medical practice guidelines are frequently promoted as a way to improve the cost-effectiveness of healthcare. But non-compliance with guidelines is still a major issue. Guiding the decision to transfuse or autotransfuse can improve transfusion practices, but effective processes must first identify problem(s) in transfusion practice and then include the attending medical practitioner as an educational target. Process improvements that have been shown to be effective include, briefly meeting one-on-one with physicians, teaching at scheduled conferences, making daily clinical rounds of patients who receive transfusion, concurrently reviewing orders for transfusion before issue of the blood product, and installing algorithms and guidelines in the operating room. Transfusion practices improved with these process improvements. The success of a change of practice patterns relies on hospital administration, education and feedback, written and immediately available guidelines, employment of specially trained personnel, and establishing long-standing actions. It is the authors' observation that the success of an intra-operation blood management program is twofold, early identification of patients and a multi-team approach of Surgeon, Haematologist, Transfusion services, Anaesthetist and Perfusionist. This team approach offers far greater depth for management of intra-operative blood conservation and transfusion practice. Interventions must be patient specific and targeted toward the best possible patients outcome.