Intraoperative reinfusion of autoerytocytes using modern devices is one of the most effective methods of blood saving during surgery.
The technique of intraoperative reinfusion of autoerytocytes ensures the collection of lost blood from surgical wound, washing erythrocytes in a centrifuge and returning washed autoerythrocytes to the patient’s vascular bed during myomectomy or hysterectomy.
Indications for intraoperative reinfusion of autoerythrocytes:
The absolute indication for this is blood loss of more than 20% of the blood volume, as well as upcoming surgery due to anemia.
Contraindications to intraoperative reinfusion of autoerythrocytes.
Absolute:
Availability in abdominal cavity purulent contents;
Presence of intestinal contents in the abdominal cavity;
The presence in the shed blood of substances contraindicated for administration into the vascular bed (hydrogen peroxide, distilled water, hemostatic drugs based on collagen, etc.).
Relative:
The patient has a malignant neoplasm.
Until recently, intraoperative reinfusion during operations to remove malignant tumors was considered absolutely contraindicated due to the high risk of hematogenous dissemination of tumor cells. Effective methods for purifying obtained autoerythrocytes from leukocytes and tumor cells are being developed and implemented. One such method is the infusion of washed red blood cells through a leukocyte filter.
Logistics:
A device for autotransfusions, as well as sets of disposable lines for them. These devices can operate in both manual and automatic modes. However, the highest quality of the resulting autoerythrocytes is guaranteed by operation in automatic mode;
Isotonic physiological sodium chloride solution (NaCl solution 0.9%) 200 ml or 400 ml, plastic container 500 ml or 1000 ml;
Anticoagulant - heparin, at the rate of 30 thousand units/liter;
Medical antiplatelet, leukocyte filter.
Technology of using the method.
The principle of the procedure consists of aspiration of spilled blood from the surgical wound, treatment of it in the apparatus and subsequent reinfusion of the resulting autoerythrocytes (Ht 60%) back into the patient’s vascular bed.
Refilling of disposable lines is carried out in the operating room before the operation. The sterile suction is handed over to the operating nurse.
The collection of blood spilled into the wound is carried out by a second assistant. The negative pressure created by the vacuum aspirator should not exceed 100 mmHg.
Blood aspirated from the wound is mixed with an anticoagulant solution, passes through a filter that retains tissue particles and blood clots and is collected in a reservoir. When the volume of collected blood becomes adequate to the volume of the reservoir, the first phase of the device’s operation begins - filling the washing bowl (bell).
This phase consists of several stages:
Acceleration of the centrifuge to 5600 rpm.
Transferring blood from the reservoir to the washing bell using a peristaltic pump, starting the centrifugation process.
Filling of the flushing bell continues until the red blood cells fill the entire volume of the bell (the volume of the bell can be 125 ml, 175 ml, 225 ml). The plasma separated during centrifugation is removed along with the anticoagulant into an appropriate container. After this, the second phase begins in automatic or manual mode - washing of red blood cells in a sterile physiological solution of 0.9% NaCl.
Washing continues until the specified volume of washing solution (1000-1500 ml) is completely passed through the red blood cells. All this time centrifugation occurs.
The final phase of the apparatus is emptying the bell:
The centrifuge stops and the peristaltic pump begins to rotate in the opposite direction.
The washed red blood cells are transferred from the washing bell to the reinfusion bag.
During operation, the device’s display clearly shows all the necessary parameters: centrifuge rotation speed, pump rotation speed, and the amount of solution transferred. After each work cycle, the number of collected and washed red blood cells is displayed.
Reinfusion of washed red blood cells should be carried out within six hours after their receipt, with the mandatory use of a microaggregate or leukocyte filter.
Controlled laboratory parameters: level of hemoglobin, hematocrit, erythrocytes, platelets; hemostasiogram before surgery, during bleeding, in the postoperative period; biochemical parameters: total protein, bilirubin, creatinine, urea, potassium, sodium, chlorine. General urine analysis, hourly diuresis.
Efficiency of using the method:
IRA should only be performed by qualified medical personnel who perform it regularly and have the necessary knowledge and experience. The patient's consent for IRA must be obtained.
Evidence of the safety of the use of reinfusion is provided by the results of an assessment of the morphological composition of autoerythrocytes obtained during intraoperative reinfusion and the data of an electron microscopic examination of the resulting erythrocyte suspension: the reinfused liquid is an almost 100% pure suspension of erythrocytes. A study of the lifespan of washed erythrocytes showed that it is equal to ordinary erythrocytes (B-2).
Indicators of the level of free hemoglobin in the reinfusate and calculation of the percentage of hemolysis indicate a high degree of washing of the reinfusate from destroyed red blood cells and the absence of hemolysis in it.
The absence of procoagulant and anticoagulant activity of washed autoerythrocytes confirms the safety of this method in terms of the development of thrombohemorrhagic complications.
The use of IRA in gynecological patients is effective and appropriate; the procedure ensures rapid stabilization of morphometric and electrokinetic indicators of the properties of erythrocytes, helps restore the hemorheological properties of blood and improve general condition patients in the postoperative period.
The use of intraoperative reinfusion of autoerythrocytes is the most effective method of blood conservation, allowing timely and adequate replenishment of globular volume in case of blood loss of any level, minimizing the use of donor blood components and avoiding massive blood transfusion syndrome, as well as significantly improving the course of the postoperative period and reducing the length of stay of patients in the hospital.
Local hemostatic and barrier agents as a method of blood saving.
A key aspect of any success surgery is hemostasis. While sutures and clips are commonly used to control massive bleeding, controlling diffuse bleeding can be challenging. In such cases, to achieve hemostasis during surgery, a number of means have been developed that are used locally, applied to the bleeding site. These hemostatic agents may be natural or synthetic and may include several different components. An ideal hemostatic agent should be characterized by ease of use, high efficiency in achieving hemostasis, and not cause immune reactions, completely absorbable and inexpensive.
One of the newest hemostatic agents is a collagen-based fibrinogen-thrombin patch, indicated for use in adult patients as an additional means to increase hemostasis during surgical operations, to improve tissue ligation and strengthen sutures in vascular surgery, where standard approaches are not sufficiently effective. The patch has a sponge base made of equine collagen and coated on the active side (yellow) with human fibrinogen (5.5 mg/sq. cm) and human thrombin (2.0 IU/sq. cm). Upon contact with fluids (such as blood, lymph, or saline), the coating components are released into the wound surface. This results in a reaction of fibrinogen with thrombin, triggering the last phase of the normal blood clotting process. Fibrinogen is converted into fibrin monomers that can spontaneously polymerize to form a fibrin network, thanks to which the collagen base of the patch adheres more firmly to the surface of the wound, acting as a surgical patch on the tissue and reducing bleeding.
Rapid, effective control of bleeding during surgery is a key aspect during surgery and can reduce the incidence of postoperative complications. The use of hemostatic agents such as fibrinogen-thrombin patch may be useful in combination with traditional methods of achieving hemostasis (including sutures, clips and electrocoagulation). The patch began to be used in digestive tract and hepatobiliary surgery, but its effectiveness was shown in a number of other areas, such as cardiovascular surgery, urological operations, thoracic surgery and neurosurgery.
In a recent retrospective study, the patch was shown to be effective in obstetric and gynecological surgery. The main indications for the use of the patch in obstetrics and gynecology are: C-section, uterine fibroids, ovarian cancer, breast cancer and endometrial cancer.
Another prospective randomized trial aimed to evaluate the use of collagen-fibrin patch after laparoscopic myomectomy. The use of the patch after myomectomy has been found to reduce blood loss during and after surgery. Reducing blood loss is obviously of great importance for the patient's health, and also facilitates the patient's rapid return to normal social life and daily activities. In addition, by reducing postoperative blood loss, the risk of blood clot formation and pelvic adhesions is reduced, increasing the likelihood of maintaining reproductive functions. Although assessing reproductive health after laparoscopic myomectomy was not the primary objective of this study, there was a nonsignificant trend toward an increased likelihood of conception when fibrinogen-thrombin patch was used when compared with patients who did not use a hemostatic agent.
Finally, in this study The patch was shown to be easy to install, as indicated by the lack of significant differences in operative time between the two groups. The very short time required to install the patch confirms the ease of installation of the patch.
Thus, an analysis of the available literature and our own experience show that the use of a fibrinogen-thrombin patch does not cause technical difficulties even during laparoscopic operations, and this product effectively reduces blood loss during and after surgery (B-2).
Appendix No. 1
CLASSIFICATION
Table No. 2
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Levels of Evidence |
Description |
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Meta-analyses High Quality, systematic reviews of randomized controlled trials (RCTs), or RCTs with very low risk of bias |
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Meta-analyses, systematic, or RCTs with high risk systematic errors |
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High-quality systematic reviews of case-control or cohort studies. High-quality reviews of case-control or cohort studies with very low risk of confounding effects or bias and moderate probability of causality |
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Well-conducted case-control or cohort studies with moderate risk of confounding effects or bias and moderate probability of causality Case-control or cohort studies with a high risk of confounding effects or bias and a moderate probability of causation |
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Non-analytical studies (for example: case reports, case series |
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Expert opinion |
Appendix No. 2
PROTOCOL
INTRAOPERATIVE BLOOD REINFUSION
Last name, I., O. women ___________________________________________________
N source illness, childbirth __________________ Date of surgery ____________________
Clinical diagnosis _______________________________________________________
Surgical diagnosis _____________________________________________________
Blood loss during surgery _________ Total blood loss _________________
Name of the reinfusion device _________________________________________________
Volume of saline consumed __________________________
Volume of collected red blood cells _____________ Of these, _________________ were transfused
Reaction to reinfusion ______________________________________________________________
Blood transfusion from donor era. mass _____________________________________________
Transfusion of donor plasma ________________________________________________
Homeostasis indicators: before surgery / 1st day / 3rd day
HB ____/____/____ g/l Ht ____/____/____ l/l Er. ____/____/____
Total protein ____/____/____ g/l Total bilirubin ____/____/____ µmol/l
ITP thromboelastogram ____/____/____ a.u.
Doctor's signature
who performed the reinfusion _____________________________________________________
This system offers an alternative to conventional surgical use donated blood.
Can be used in the following areas of medicine:
- Cardiovascular surgery;
- Orthopedics;
- Pediatric surgery (blood loss from 100 ml);
- Emergency surgery;
- Traumatology;
- Transplantology.
The weight of the device is 30 kg, which ensures mobility and ease of intrahospital transportation. The device has a display that continuously displays process parameters. Thanks to the design of the device, the operator has the opportunity to visually monitor the bell and the progress of the washing procedure.
Can be used in the following areas of medicine:
- Cardiovascular surgery;
- Orthopedics;
- Pediatric surgery (blood loss from 100 ml);
- Emergency surgery;
- Traumatology;
- Transplantology.
Autotransfusion
Autotransfusion of blood is used for heavy blood loss during surgery. The blood lost during surgery is collected by suction, then mixed with an anticoagulant and entered into a reservoir, where small pieces of tissue, blood clots and other macrostructures are filtered out. From the reservoir, blood flows into a rotating bell using a peristaltic pump. The red blood cells are bound in the centrifuge by centrifugal forces, while the plasma is carried out of the bell, washing away free hemoglobin, anticoagulant, activated clotting factor (ACT), and activated platelets. As soon as the blood hematocrit contained in the bell reaches 55%, saline solution begins to flow there, washing the red blood cells. The washing efficiency is more than 95%, the number of red blood cells is more than 98% of the collected ones. At the end of the flushing cycle, a concentrated suspension of red blood cells in saline solution is released into the reinfusion bag. The device has a high operating speed. For example: the time of one cycle using typical pump speeds with 1200 ml of collected blood in a reservoir with Ht = 10-20% is 3 minutes. The result is 225 ml of a suspension of red blood cells in saline solution, which contains 137 ml of pure red blood cells. The pump speed is adjustable from 0 ml/min to 1000 ml/min. Maximum centrifuge speed: not less than 5600 rpm. There are no restrictions on the volume of blood processed. The device also allows for preoperative sequestration of the patient's blood into erythromass and platelet-rich plasma in a semi-automatic mode. The system is very easy to operate and allows you to start the procedure almost instantly, which makes it indispensable during surgical operations. It is also possible to switch to manual control, which, increasing the flexibility of the system, expands its scope of application.
The weight of the device is 30 kg, which ensures mobility and ease of intrahospital transportation. The device has a display that continuously displays process parameters. Thanks to the design of the device, the operator has the opportunity to visually monitor the bell and the progress of the washing procedure.
Product quality control is carried out using:
- Multi-beam optical sensor for monitoring the concentration of erythromass hematocrit;
- Free hemoglobin detector;
- Optical sensor for the presence of red blood cells in the washing solution.
The device also monitors the pressure in the line and automatically adjusts the volume of the washing solution to obtain required level washing red blood cells.
The patient safety system includes:
- Automatic self-diagnosis mode when the device is turned on and locking in case of malfunction;
- Possibility of operator intervention in the process when operating in automatic mode;
- Centrifuge speed limiter;
- Protection against over/under pressure;
- Depressurization sensor of the bell in the centrifuge;
- Monitoring the compliance of the pump operating mode (direction of rotation and speed) in accordance with the operating mode of the device;
- If an error occurs in the operation of the device, its code is recorded in the error log. Software can be updated regularly.
Electrical characteristics: 220-240 V, 50 Hz. The device has a certificate of conformity of the State Standard of Russia and registration certificate Ministry of Health of the Russian Federation. The device comes with the necessary connectors, cables, software, and documentation in Russian. Warranty service (12 months from the date of installation), installation and commissioning are carried out by specialists authorized by the manufacturer. On-the-job training is also provided for staff.
Set of consumables for the Cell Saver 5+ device:
- Autotransfusion line (high-speed line with a 225 ml bell, a 1000 ml reinfusion bag and a 10,000 ml drain bag) (cat. No. 263);
- Autotransfusion line (high-speed line with 125 ml bell, 1000 ml reinfusion bag and 10,000 ml drain bag) (cat. no. 261);
- Autotransfusion line (high-speed line with a 70 ml bell, a 1000 ml reinfusion bag and a 10,000 ml drain bag) (cat. no. 291E);
- Cardiotomy reservoir (3000 ml blood collection reservoir with 150 µm filter) (cat. no. 205);
- Line for aspiration and anticoagulation of blood (cat. No. 208);
- 40 micron filter with transfusion system for removing microaggregates from blood components and reinfusion;
- Catheter for suction (disposable), medium size;
- Oil-free electronic vacuum suction device (30 l/min);
* Autotransfusion - transfusion of blood to a patient, which was taken from him during a surgical operation.
Cell Saver 5 represents the fifth generation of autologous blood systems, the product of twenty years of testing, combining previously achieved advantages with the latest developments in microprocessor and sensor technology.
System information
Cell Saver 5 is designed to restore blood usually lost during surgery. The main advantages of the procedure are that there is no risk of disease transmission, there are no reactions during transfusion, and there is no need for tests. Additional benefits are the removal of free hemoglobin, anticoagulant, extracellular potassium, breakdown products, lipids. Can be used in the intensive care unit for drainage. Eliminates the need to use hemoconcentrators. There is a set for preoperative receipt of platelet concentrate for the purpose of further transfusion and/or obtaining fibrin gel to ensure hemostasis.
The blood is collected, mixed with an anticoagulant, filtered and placed in a sterile reservoir. When a sufficient volume is reached, a processing cycle is automatically started, including the processes of hemoconcentration and washing of blood cells with a sterile saline solution. At the end of the cycles, the washed red blood cells are pumped into a plastic bag for reinfusion.
Indications for use: operations on open heart and blood vessels, aneurysm, operations on the joints and spine, operations on the liver and spleen, ruptured ectopic pregnancy and some neurosurgical procedures.
Special properties
Automatic operation
- automatic start of the process when a sufficient amount of liquid is reached in the tank;
- automatic selection of optimal parameters for processing;
- the built-in microprocessor controls the operation of the device using data received from many sensors.
- automatic product quality control.
- possibility of switching to manual control.
Simplicity and ease of use
- installation of the system according to the microprocessor prompts;
- the control panel is simple and convenient, there is a well-informative display;
- the design of the tube system does not allow for the possibility of erroneous installation;
- The apheresis bell is accessible for visual inspection.
Emergency mode
- allows for high-speed blood processing (800 ml/min) in automatic mode during procedures where a lot of blood is lost.
Maneuverability and portability
Possibility of sequestration
- a special protocol carries out preoperative sequestration of plasma and platelets.
Reverse transfusion the victim's own blood, poured out as a result of wounding of blood vessels into the serous cavities, returning its own cellular elements and immune bodies, is the most physiological method of replenishing blood loss.
Benefits of blood reinfusion are as follows:
autologous blood is an absolutely compatible transfusion medium, ready for immediate use;
there is no need to determine group and individual compatibility;
no risk of intolerance or transfer reactions viral diseases;
autologous red blood cells circulate in the vascular bed 1.5-2 times longer than donor red blood cells and are immediately included in the bloodstream, unlike donor red blood cells, which are characterized by deposition;
the use of blood reinfusion, being clinically effective, provides a significant economic effect.
At the same time for blood, collected from serous cavities, typically complete absence fibrinogen against the background of high fibrinolytic and thromboplastic activity, increased content of free hemoglobin and potassium ions, which with reinfusion of three or more liters of blood can affect the hemostasis of circulating blood and the usefulness of glomerular filtration, especially with unstable hemodynamics [Abakumov M.M. and etc.].
In 1988, our employee N. V. Lebedev was completed scientific work, which studied the effect of massive reinfusion on the hemostatic system in victims with chest and abdominal trauma. It was found that blood poured into the serous cavities during injury internal organs and being there for various periods of time, undergoes some changes. Blood samples from 82 victims with chest and abdominal trauma were studied.
In this blood, the number of erythrocytes was reduced to 3.9+0.77 x 10 12 /l, platelets to 181+42.4x10 9 /l, the content of free hemoglobin was increased (1.7±0.5 g/l) due to partial destruction shaped elements. Noteworthy was the complete absence of fibrinogen in the blood poured into the cavity, as well as an increase in its fibrinolytic activity to 27.2±4.7 minutes in case of chest injury and 54+10 minutes in case of abdominal injury. The plasminogen level was 1.9±0.1 KU/ml, and the plasmin content was 0.31±0.13 KU/ml.
Thus, blood from the abdominal cavity does not differ from blood from the chest cavity, with the exception of the amount of fibrinolytic activity of plasma.
The effect of massive (more than 1 liter) on the state of the hemostasis system of circulating blood was studied in 44 victims with trauma to the chest and abdomen. Analysis of the hemostatic system of circulating blood in victims with intracavitary bleeding (before reinfusion) revealed pronounced hypocoagulation changes. At the same time, the temporary indicators of the thromboelastogram (P and K) were lengthened by 25% and 1.5 times, respectively, and the maximum amplitude (MA) was reduced by 20-25%. The fibrinogen content was at the lower limit of normal, and the plasma recalcification time was extended by 30-35% (averaging 175+21.5 s for abdominal trauma and 210+21.0 s for chest trauma).
Fibrinolytic activity of blood was increased by 11-22% compared to the average level, but did not go beyond physiological norm. At the same time, a more pronounced activation of fibrinolysis was noted in the group of patients with chest wounds, and hypocoagulative changes were more pronounced in patients with abdominal wounds.
In patients before reinfusion, an increase in proteolytic circulating blood activity, which is probably due to the entry of proteolytic enzymes into the bloodstream from damaged tissues. At the same time, the antiproteinase potential, which was assessed by the content of the main proteolysis inhibitors α1-AT and α2-MG, was 25-150% higher than normal. The platelet count during this period was reduced slightly - to (220-235) x 109/l (at normal (250-350) x 109 l).
Transfusion to victims 1 liter or more blood, removed from the chest or abdominal cavities, led to a short-term worsening of hypocoagulative changes. In the first hours after massive reinfusion, the R and K values of the thromboelastogram increased by 1.5-2 times, and the amplitude of the MA decreased by 5-10% compared to baseline, and the fibrinogen value reached 1.6-1.8 g/l. The recalcification time extended to 196+20.9 s after reinfusion of blood from the abdominal cavity and to 231+21.4 s after chest injury. Fibrinolytic activity changed slightly and was within normal limits.
Plasmin content after reinfusion decreased to 2.4 KE/ml (with a norm of 3.8-4.2 KE/ml). During this period, there was a tendency towards normalization of proteolytic activity and proteolysis inhibitors.
Reinfusion also had an effect on the platelet component of hemostasis: the number of platelets in venous blood decreased to (140-180)x10 9 /l, and their aggregation ability decreased 1.5 times compared to the norm.
State of expressed hypocoagulation persisted after reinfusion for 24 hours. However, starting from the second day, there was a tendency towards normalization of the parameters of the plasma component of the circulating blood hemostasis system. Thus, by the end of the first day after surgery and reinfusion, the level of fibrinogen reached its physiological parameters, the time of plasma recalcification decreased to 218 + 24 s, the time indicators R and K of the thromboelastogram were reduced, the maximum amplitude extended to 21 ± 2.9 mm for abdominal wounds and up to 35.9+2.0 mm for chest wounds. The plasminogen content remained reduced by the end of the day to 2.55+0.24 KU/ml for abdominal wounds and 2.97+0.34 KU/ml for chest wounds.
Subsequently, there was a gradual normalization of indicators thromboelastograms, plasma recalcification time. Within 6-11 days after reinfusion in a state of hemostasis, patients noted changes characteristic of inflammatory and reparative processes accompanying post-traumatic and postoperative periods: fibrinogen content increased sharply (up to 5-7 g/l), proteolytic and antiproteinase activities of the blood increased. The content of plasminogen by 7-8 days after reinfusion approached the physiological level, reaching 3.4-3.5 KU/ml.
Thromboelastogram data indicated normalization of blood coagulation properties. The number and aggregation ability of platelets by the end of observations were within normal limits. In the examined victims there were no clinical manifestation DIC syndrome in the form various types hemorrhage or thrombotic complications.
Thus, the data obtained from the study hemostasis systems in victims with injuries to the thoracic and abdominal organs, suggests that the direct effect of reinfusion on the state of hemostasis is felt only in the first day. Subsequently, changes in the hemostatic system develop that are generally characteristic of pathological conditions, flowing with inflammatory reactions. Reinfusion of blood against the background of hypocoagulation does not lead to stable pathological changes in the hemostatic system that would require specific correction.
Currently, all countries recognize the high effectiveness of this method of replenishing blood loss. Reinfusion with the Cell Saver device is most widespread. It should be noted that back in 1986, N.V. Lebedev, together with the engineer of the All-Union Scientific Research Institute of Medical Instrumentation, I.N. Shvyrkov, was created and applied in clinical practice 42 victims with chest wounds had the first blood reinfusion device in the USSR ARPC-1. However, due to historical events Due to its non-medical nature, this device was safely forgotten after its demonstration at VDNKh. (The cost of the Cell Saver device in 2010 prices ranges from 30 to 50 thousand euros.)
Using Cell Saver blood device, removed from the serous cavity, enters a centrifuge system that allows red blood cells to be separated from the plasma and washed. Blood is passed first through a macrofilter with a pore size of 180-200 microns, and then through a microfilter with a pore size of 20-40 microns. Washed red blood cells suspended in an isotonic sodium chloride solution are pumped into a container for reinfusion. The use of Cell Saver devices allows you to quickly collect blood from serous cavities, process it within 5-10 minutes and begin reinfusion of the cellular component.
The technology of this process comes down to collecting blood into a sterile container through filters, its stabilization, instrumental fragmentation into components (plasma and cells), washing of cells, repeated fragmentation and concentration of the cellular component.
Blood collection is carried out by the surgeon using a double-lumen tube, onto the tip of which an anticoagulant solution is supplied through a microchannel at a speed of 40-60 drops per minute and through the main channel with a vacuum of 100-150 mmHg. Art. the blood flows into a sterile reservoir. A standard sodium citrate solution (SCA) is usually used as a stabilizer in a ratio of 15 ml of citrate per 100 ml of blood.
Collected blood enters the separator, where the main part of the plasma fraction is separated by the centrifugal method, and the remaining cellular part of the blood is diluted with an isotonic solution of sodium chloride, which ensures a more complete washing of unchanged cells from their fragments and the remaining part of the plasma. The remaining cellular component is a concentrate of cells in an isotonic solution, in which there is practically no plasma (with a concentration total protein no more than 1.7 g/l). The hematocrit level in this cell concentrate is about 70%, the hemoglobin level is about 200 g/l.
Removing 97-98% of plasma proteins, technique Cell Saver ensures the release of the cellular component of the blood from plasminogen activators, plasmin, fibrin breakdown products and other biological active substances affecting the hemostasis system. The absence of fibrinolytic activity in blood components returned to the patient avoids such undesirable consequences, as the development of DIC syndrome in cases of reinfusion of blood volumes exceeding the bcc.
At the same time, application hardware blood reinfusion is associated with a number of difficulties. Firstly, the method requires a complete replacement of plasma components by infusion of not only crystalloid and colloidal solutions, how many large volumes of fresh frozen plasma.
Secondly, if present in serous cavities large number of blood clots sampling volume liquid blood decreases sharply, and in such cases the globular volume has to be replenished by transfusion of donor blood.
If massive bleeding continues, thrombosis of all sterile lines of the Cell Saver device may occur, which requires their urgent replacement.
Sharp decrease volume of returned cellular component(compared to the volume of blood withdrawn) is observed when attempting to reinfuse hemolyzed “old” blood. In such cases, during the separation process, all defective and fragmented red blood cells are removed and no more than 20-25% of the cellular component is returned.
Finally, and with hardware reinfusion there is a problem of microbial contamination. In case of injuries to the hollow organs of the abdominal cavity (to a lesser extent - the bronchi) and with massive blood loss (more than 3.5 liters), vital indications for reinfusion appear, for example, in victims with rare group blood or in the absence of donor blood (erythromass). As the experience of the Research Institute of SP has shown. I.V. Sklifosovsky, in such cases, repeated washing of contaminated blood makes it possible to reduce the level of contamination of microorganisms in the cellular component by 10-12 times, the reinfusion of which does not lead to bacteremia [Kobzeva E.N.]. In order to prevent purulent-septic complications, these patients are given antibacterial and immune therapy.
Thus, effectiveness of hardware blood reinfusion with wounds of the neck, chest, abdomen, and even more so with combined wounds, there is no doubt. But this method is quite expensive. In addition, his wide application requires the creation of a special transfusiology service, the introduction of a specialist transfusiologist to the duty team. Therefore, in many hospitals in the country, reinfusion is carried out without devices.
Usually blood is collected from the cavities with a special scoop into a sterile vessel with a capacity of 1000 ml, containing 150 ml of 4% sodium citrate solution (at the rate of 15 ml of stabilizing solution per 100 ml of blood). After stabilization, the blood is transferred into a bottle for intravenous infusion through a homemade filter (8 layers of gauze). However, this technique is imperfect: the evacuation of blood occurs too slowly, which makes it difficult to find the source of bleeding; open transfusion from a scoop into a bottle and from a bottle with a preservative into a reservoir for reinfusion increases the risk of blood contamination.
Therefore the majority surgeons closed aspiration systems are used. The most simple system is as follows. The stopper of a sterile 500 ml vial containing 75 ml of 4% sodium citrate solution is treated antiseptic solution and pierced with two needles for blood transfusion: to a long needle, the end of which is lowered to the bottom of the bottle, a tube with a tip wrapped in several layers of gauze is attached and takes blood from the serous cavity, and to a short needle is a hose from an electric suction. After filling the bottle, it is turned over with the stopper down and placed in a stand for blood transfusion.
To prevent destruction of red blood cells the vacuum value should not exceed 100-140 ml Hg. Art. The tube connecting the suction tip to the bottle should be made of siliconized rubber and should be solid, without separate sections with adapters, which increases blood turbulence and damage during aspiration.
At massive reinfusion(more than 1.5-2 l) to neutralize the hypocoagulation effect, it is recommended to simultaneously administer fibrinogen and a solution of aminocaproic acid. To prevent unwanted side effect large doses of sodium citrate during reinfusion of every 500 ml of autologous blood, a 10% solution of calcium chloride or gluconate should be administered intravenously.
Indications for reinfusion is the presence of 500 ml or more of liquid blood in the pleural or abdominal cavities. The constant readiness of the duty teams to carry out reinfusion allows it to be used in every bleeding victim.
Absolute contraindications for blood reinfusion V emergency surgery Hardly ever. It is believed that reinfusion is contraindicated in cases of damage to the hollow organs of the abdominal cavity or large bronchi, with prolonged (over a day) presence of blood in the serous cavity and with severe hemolysis.
1. Injuries of hollow organs. It is clear that with moderate blood loss and a stable condition of the victim, reinfusion of contaminated blood is absolutely contraindicated. It is also contraindicated in case of massive blood loss, if there is a sufficient number of donor blood components available. But what to do if there is a blood loss of 3-4 liters and a lack of donor blood or the absence of blood of a suitable type?
By now in literature About 400 observations of reinfusion of contaminated blood have been published. All these observations can be divided into unintentional and intentional.
Reinfusion contaminated blood is unintentional when the surgeon collected a large amount of blood and decided to begin reinfusion before completing a thorough examination of the organs. As a rule, this occurs in conditions of shortage of donor blood and critical condition the victim. By the time damage to a hollow abdominal organ is detected, 1000 ml of blood can be reinfused.
On purpose reinfusion surgeons went to hopeless situation, when the patient practically died, and there was not enough donor blood (or no blood at all).
According to domestic and foreign data authors- E. A. Wagner et al.; S.D. Popova et al.; I.I. Deryabina et al.; R.N. Smith et al.; J.W. Hauer et al., in all these observations there was a rapidly passing bacteremia, which disappeared under the influence of antibacterial therapy within 3-5 days. In none of the surviving patients did sepsis develop. But at the same time, many authors warn about the danger of developing fatal endotoxic shock if antibiotics are added directly to a container of contaminated blood.
IN Research Institute of SP named after. N.V. Sklifosovsky reinfusion of blood in case of organ damage gastrointestinal tract performed on 22 victims. In five victims, reinfusion was carried out before inspection of the abdominal organs and detection of intestinal damage, in 17 - due to the severe or terminal condition of the victim caused by shock and blood loss and insufficient amount of donor blood.
Total volume transfused autologous blood when the gastrointestinal tract was injured, it was 21,050 ml (an average of 1 liter of blood per victim). In no case were deaths or complications associated with blood reinfusion.
Conducted clinical analysis allowed us to conclude that with large blood loss, threatening fatal, and in the absence of a sufficient amount of donor blood, the presence of damage to hollow organs can be neglected and reinfusion can be performed. In such cases, reverse transfusion of blood that has spilled into the cavity can play a decisive role in saving the life of the victim.
2. Long-term exposure of blood in serous cavities. At present, there is no reason to believe that blood that has been in the pleural or abdominal cavity without damaging the hollow organs for 24 hours is unsuitable for reinfusion. The blood remains sterile for 2-3 days, and the level of free hemoglobin does not exceed 500 mg% (310 µmol/l). By vital signs reinfusion should also be used after 48 hours: our experience has shown that such blood remains sterile, and the concentration of free hemoglobin does not reach 200 mg% (124 µmol/l). Of course, than longer blood is outside vascular bed, the less its biological value; the number of red blood cells and platelets decreases and the degree of hemolysis increases.
3. Hemolysis. The pathological effect of hemolysis depends on the degree of its severity in the entire volume of circulating blood, i.e. on the concentration of free hemoglobin in the reinfused blood and on the volume of reinfusion.
For example, when reinfusion 2 liters of blood with a free hemoglobin content of 800 mg% (596 µmol/l), its concentration in the patient’s circulating blood in the first hours will reach a level of only 30-40 mg% (18.6-24.8 µmol/l). A day later, the concentration of free hemoglobin in the circulating blood, regardless of the degree of its increase immediately after reinfusion, does not differ from the physiological norm.
Appearance of intense pink coloration plasma after centrifugation of blood means that the level of free hemoglobin is more than 800 mg%, which serves as a relative contraindication for reinfusion of more than 2 liters of such blood.
