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Lipid / Leucocyte Reinfusion Filter for Salvaged Blood Questions & Answers Booklet

Lipid / Leucocyte

Reinfusion Filter for Salvaged Blood

Questions & Answers Booklet

GENERAL

Q1.

What are the clinical problems associated with contaminants in salvaged blood?

Impaired lung function and reperfusion injury

Adult Respiratory Distress Syndrome (ARDS)

Brain Injury and Fat Embolic Syndrome (FES) - Lipid

Lung dysfunction - Microaggregates and surgical debris

Q2.

Do you have any clinical data to support reinfusion of post-operative shed blood?

A review of 87 papers by Munoz Gomez et al 1 concluded that “…salvaged filtered blood is a source of red blood cells of sufficient quality to be safely reinfused and that their reinfusion contributes significantly to reduce the need for homologous blood.”

The American Association of Blood Banks (AABB) state that “The collected blood can be processed with or without cell washing, but must be filtered before reinfusion”. 2,3

Q3.

Are all filters the same?

There is a wide variation in filter types. The choice will depend on the particular application and the level of protection desired. Advice should be sought from the manufacturer. Ideally for salvaged blood a filter with enhanced lipid and leucocyte removal capabilities is required to minimise subsequent clinical sequelae.

Q4.

How does the Lipid/Leucocyte filter differ from a standard screen filter?

The Lipid/Leucocyte incorporates a clinically proven 40 µm screen filter for reduction of microaggregates and debris. However, it also has additional media which typically removes 84% of lipids and 71% of leucocytes.

PRACTICAL ISSUES

Q5.

What is the filter volume?

Approximately 20 ml

Q6.

Why do we need to remove air in the bag when priming the Lipid/Leucocyte filter? Can't you just hang the bag up and run it through?

By removing as much air as possible this ensures that the maximum filtration area is being used to reduce the contaminants in the blood.

Q7.

Does air affect the Lipid/Leucocyte filter i.e. the air you need to remove from the bag, before priming the filter?

If

too much air is contained in the Lipid/Leucocyte filter

this can result in a reduced flow-rate or even blockage of the device.

Q8.

Does it matter if the entire Lipid/Leucocyte filter is not quite primed when starting reinfusion?

A

small volume (e.g. 1-2 ml) of air at the top of the

Lipid/Leucocyte filter housing should not cause any problems. It is essential, however, to ensure that the media is completely wetted as this gives optimal air removal and filtration performance.

Q9.

Does the line need priming with saline? If you prime with saline how do you prime the Lipid/Leucocyte filter?

The line does not need to be primed with saline, but if this is your preferred practice then just replace the saline bag with the blood bag ensuring as little air as possible is transferred into the Lipid/Leucocyte filter.

Q10. If the Lipid/Leucocyte filter is washed out with saline at the end of use can you use it again? What are the hazards of doing this?

The filter should not be re-used after indicated use. Also, we do not recommend flushing the Lipid/Leucocyte filter with saline as this may affect the binding capability of the additional media in the filter. This could potentially result in flushing retained contaminants from the filter.

Q11. How do I achieve a good prime?

The best way to prime the filter is to invert it after spiking the blood unit. Loosen the administration set cap (unless it is vented) and maintain an even pressure on the bag before opening any clamps downstream of the filter. Pressure should be evenly maintained until the administration set is primed and the downstream clamps closed. The blood unit can now be positioned on the drip stand and the filter should be completely primed.

LEUCOCYTES

Q12. What is a neutrophil?

This is the most abundant phagocytic leucocyte i.e. it engulfs foreign debris and cells and can be very aggressive.

Q13. What happens when a neutrophil is activated?

Cell salvaged blood contains numerous leucocytes of which the neutrophils are in an activated state 4 .

They release reactive oxygen species, proteolytic enzyme and lipid mediators. This can cause reperfusion injury.

LIPID

Q14. Where does the lipid in salvaged blood come from?

Subcutaneous fat released from connective tissue when cutting the skin

Bone marrow 6 from when bones are cut or reamed 7

Blood i.e. diet related

Q15. What symptoms are seen with Fat Embolic Syndrome?

The patient must display 2 out of 3 major symptoms 9,10 .

Pulmonary distress

Mental disturbances

Petechial rash

MICROAGGREGATE DEBRIS

Q16. What are microaggregates?

The clotting and coagulation cascades are stimulated during the loss of blood at the wound site during collection and handling of salvaged blood. This induces the formation of microaggregates composed of activated platelets, leucocytes and fibrin. Additionally bone fragments, skin, cement and other debris may be present in salvaged blood.

Q17. What are the clinical implications of these contaminants?

If the blood is not adequately filtered then these debris are capable of blocking capillaries thus affecting organ function. The arterioles in the lungs are the body’s natural filters and if these become blocked then this can result in Adult Respiratory Distress Syndrome.

Q18. What is Adult Respiratory Distress Syndrome (ARDS)?

This is a condition of diffuse pulmonary infiltrates, refractory hypoxaemia and respiratory distress 15,16 . The patient requires ventilation and X-rays show characteristic changes. In summary, the lung is unable to function properly to oxygenate the blood before passing to the heart.

11.

Blevins FT, Shaw B, Valeri CR, Kasser J, Hall J. Reinfusion of shed blood after orthopaedic procedures in children and adolescents. J Bone Joint Surg Am. 1993; 75(3):363-71.

12. Clements A, Mulholland J, Pope N. Scanning electron microscopy of a lipid filter after use with washed salvaged blood. Therapeutic Filtration and Extracorporeal Circulation Conference (TFECC) 2003.

13. Fox MA. Filtration of shed mediastinal blood. Perfusion. 1993; 8:331-6.

14. Chapman, MJ. Adult respiratory distress syndrome - an update [Web Page]. Available at http://www.nda.ox.ac.

uk/wfsa/dl/html/reviews/rev003.htm.

(Accessed 13 November 2003).

15. Petty TL, Ashbaugh DG. The adult respiratory distress syndrome. Chest. 1971; 60(3):233-9.

REFERENCES

1. Munoz Gomez M, Garcia Vallejo J, Lopez-Andrade Jurado A, Gomez Luque A, Ruiz Romero De La Cruz M, Maldonado Eloy-Garcia J. Autotransfusion after orthopedic surgery. Analysis of quality, safety and efficacy of salvaged shed blood. Rev Esp Anestesiol Reanim. 2001; 48(3 ):131-40.

2. American Association of Blood Banks (AABB). Blood Transfusion Therapy: A Physicians's Handbook. 7th edition. American Association of Blood Banks (AABB), 2002. (Triulzi D ).

3. Standards for perioperative autologous blood collection and administration. 1st edition. Bethesda, M.D.:American Association of Blood Banks, 2001. (Santrach PJ ).

4. Pertilla J, Leino L, Poyhonen M, Salo M. Leucocyte content in blood processed by autotransfusion devices during open-heart surgery. Acta Anesth Scand. 1995; 39:443-8.

5. Henn-Beilharz A KC . Retransfusion in bone surgery: what happens to the fat? Anasthesiol Intensivmed Notfallmed Schmerzther. 1991; 26(4):224-5.

6. Henn-Beilharz A, Hoffmann R, Hempel V, Brautigam KH.

The origin of non-emulsified fat during autotransfusions

in elective hip surgery. Anaesthesist.

1990; 39(2):88-95.

7. Brooker RF, Brown WR, Moody DM et al. Cardiotomy suction: A major source of brain lipid emboli during cardiopulmonary bypass. Ann Thorac Surg. 1998;

65:1651-5

8. Johnson MJ, Lucas GL. Fat embolism syndrome. Orthopedics. 1996; 19(1):41-8.

9. Gossling HR, Donohue TA. The fat embolism syndrome. JAMA. 1979; 241(25):2740-2.

10. Barnett M. The origins, clinical significance and visual perception of particulate matter. American Society for Parenteral and Enteral Nutrition (ASPEN) 20th Clinical Congress. 178-82.

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Phone: +45 48 16 70 00 Telefax: +45 48 10 30 00 www.unomedical.com

The information provided in this literature was reviewed for accuracy at the time of publication. Product data may be subject to change without notice. For current information consult your local Pall distributor or contact Pall directly. Part numbers quoted above are protected by the Copyright of Pall Europe Ltd.

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