Surely the vigour with which some of my anaesthetic colleagues give patients blood couldn't be related to the fee that come with the item number could it?

Thanks Nolan

in tumour surgery, the blood is irradiated prior to infusion

it seems that the relative apathy regards cell savers is really a state of mind - not being fully attuned to their use. I also have disappointments, like the other day we used one for a big fusion in a Jehova's witness but didnt collect enough to return to her. We were religious in using the cell saver sucker and not the wall sucker. Perhaps the surgeon's mind is more focussed and less blood is spilt!

I have no idea about anti-fibrinolytics, didnt even know that they existed

Does anyone use antifibrinolytics in major joint surgery eg redo hips or multilevel spines ?

 Hi Ralph, I can't answer all of your questions and have to declare that most of my interest in cell salvage is based in obstetric anaesthesia (the only orthopaedics I do these days are healthy primary hips and knees), but can help with some of your questions.

The disposable costs for cell salvage depend slightly on the machine chosen, but as an example for the machine we utilise the cost of a full setup (collection system/washing bowl/leukocyte depletion filter) is $330 (Australian) per patient. You can increase the cost effectiveness by collecting initially, then only using the other disposable's if you have enough blood to process.

They certainly do have a role in avoiding allogeneic transfusions, which has been shown in the literature on a number of occasions.

In terms of why are they not used? Its difficult for me to answer in an orthopaedic setting but the general reasons which I would suggest would be relevant would be the issues of needing dedicated/trained staff to run the machine; the lack of clear benefits other than a decrease in allogeneic transfusion (not saying there are not other benefits, just we don't always have the evidence to show these benefits); the cost of purchasing the equipment and the lack of a culture among OR staff of blood conservation techniques. 

If the ooze that you refer to can be suctioned effectively then it should be able to be salvaged, you can also rinse the swabs in saline to increase red cell capture. The salvaged blood is anti-coagulated within the suction tubing (depending on the system you use) so you do have considerable time for processing.

Its interesting to see you are using it in tumour surgery. It was once a relative contraindication because of the theoretical risk of transfusing tumour cells back into the body but opinion seems to have changed somewhat, although once again it will be very difficult to get evidence to support this.

Hope this helps. 

what role do the experts see for intra-operative cell-savers/blood salvagers?

and why arent they used more?

is the value of their use restricted by the expected rate of blood loss? ie. in a long case with 'steady ooze' might not produce blood quickly enough for cell-saving but the losses could still be considerable.

what is the cost of a cell-saver for a case?

should i push to use cell-savers more often? i usually only do so when doing major tumour surgery.

I agree with Richard's comments about a lot of tradition. His appraoch I think is excellent and is really much more science that tradition but his approach is not generally reflected. I believe that there is a very signifiocant placebo affect with a blood transfusion that applies to many practitioners as well as patients and it is this which I suspect is the single strongest factor in changing practice.

I can not speak for my colleagues but my thoughts are -

Traditionally (there is a lot of tradition when it comes to transfusions) the old 10/30 rule was taught i.e. a patient should have an Hb of 10g/dl or an haemocrit of 0.3 prior to surgery.  This is now regarded as sub optimal practice, rather the haemoglobin should be at a level that will allow sufficient oxygen delivery (DO₂) to the tissues.  What this level is in an individual patient is the tricky bit.  It will depend on the type of surgery, the physiological reserve and co-morbidities of the patient. 

O₂ consumption can be measured using cardiopulmonary exercise testing (CPX).  Individualised predictions of outcome can be made based on when aerobic DO₂ is insufficent for oxygen demand (exercise level), at this point anaerobic metabolism is initiated the so called anaerobic threshold or AT.  However CPX is not available to most of us and so we use or clinical judgement/experience and what evidence we can find..

Oxygen consumption is increased post operatively due to the stress response to surgery - initiated by, and proportional to, tissue damage.  During anaesthesia this response is blunted and basal oxygen requirements are low due to immobility, however blood loss and hypovolaemia will reduce DO₂ (DO₂ = Hb x O₂ sat x cardiac output + dissolved O₂).  If hypovolaemia is avoided moderate anaemia is usually well tolerated - see Bruce Spiess' comments in the inappropriate transfusion section.

In elective surgery the pre-operative Hb level and type of surgery are the most predictive variables as to need to transfusion assuming haemostasis is used!  Therefore pre operative anaemia should be investigated and treated.

I can think of no reason to transfuse someone with a normal Hb at the beginning of surgery and plenty of reasons not to, I hope this comment was a bit of hyperbole!  if not perhaps the Anaesthetists should be directed to this web site to make their case.

Or is it because the blood is sitting there in theatre that it just gets used anyway?? So like Dr Courtenay I too am curious about why patients are being transfused at the begining of the operative procedure.

As an orthopaedic surgeon I am always curious about anaesthetic thresholds about when to start a transfusion. In particular there is a very common practice among some colleagues to automatically commence a transfusion almost at the time of the initial incision even when the haemoglobin is normal preoperatively. 

To me it can only be due to 2 reasons. Firstly the surgeon hasn't even heard of the word haemostasis or the anaesthetist lack faith in the surgeon.

Does anyone have any thoughts or comments.