Principles of Autotransfusion, Preparing for the PBMT Exam Region 7 ASATT Meeting Honolulu, Hawaii John Rivera, BS, MA October 4, 2015

Perioperative Blood Management Technologists Exam PBMT - Perioperative Blood Management Technologist Created and maintained by IBBM (International Board of Blood Management) via American Society of Extracorporeal Technology (AmSECT) Available quarterly for proctored on-line testing Examines operator competencies Recognized by aaBB Will most likely be mandated in the future by liability insurers Annual recertification is already a regulatory requirement per aaBB, CAP, CLIA, FDA, Joint Commission and state departments of health Covers all autotransfusion devices in the perioperative setting Includes platelet rich plasma sequestration and platelet gel practices

Blood Components Plasma Formed Elements Water Proteins Electrolytes Lipids Formed Elements RBC White Cells Platelets

Principles of Autotransfusion Density of Blood Components: Plasma 1.025 - 1.029 gm/cc Leukocytes 1.065 - 1.09 gm/cc Erythrocytes 1.089 - 1.097 gm/cc

Principles of Autotransfusion Centrifugal force separates these components relative to their respective densities. The higher density components will move farther from the axis of rotation than those of lower density

Principles of Autotransfusion Before commencing to salvage blood: Prime autotransfusion circuit with 100 - 200 ml of anticoagulant 30,000 units of heparin per 1000ml Saline (0.9% Normal) or citrate based anticoagulant (ACD-A) Suction should be maintained at approximately 80 - 120 mm/Hg. (No more than 200 mm/Hg is recommended under normal circumstances)

“Maximizing Effectiveness” Appropriate suction levels, 80 to 120 torr, which can be temporarily increased “in the event of massive blood loss” Suction tip style and technique, appropriate size and immersion in pools of blood to minimize air aspiration Timely sponge rinsing with appropriate isotonic solutions AABB Guidelines 2010, pp. 2-4

Anticoagulation Heparinized saline - 30,000 units of heparin per 1000 ml 0.9% Normal saline or 15,000 units of heparin per 500 ml Normal saline. Higher initial dose with the new heparin?? Heparin complexes with Antithrombin III (ATIII) Heparin should not be used on ATIII deficient patients or patients prone to Heparin Induced Thrombocytopenia (HIT) ACD-A inhibits the early steps in the clotting cascade by chelating (binding) Calcium Do not use ACD-A on patients with impaired liver function ACD-A comes pre-mixed in bags Do not aspirate blood mixed with Ringers Lactate irrigation solutions when using citrate based anticoagulants due to excess calcium

Principles of Autotransfusion Whenever you empty the collection reservoir, always re-prime it with at least 100 ml of anticoagulant During collection keep the anticoagulant running at 13 -15 ml per 100 ml of collected blood

Autotransfusion System Components Suction tip Suction/Anticoagulant line Anticoagulant solution Filtered collection reservoir Centrifuge bowl and disposable tubing set (tubing, bowl, holding bag and waste bag) Saline wash solution bags – 500 ml, 1000 ml and sometimes 3000 ml Blood transfer bag (300 ml, 600 ml and 1000 ml)

Principles of Autotransfusion with Latham and Baylor Bowl Devices Once sufficient volume has been collected in the blood collection reservoir, select FILL on the device to commence filling the bowl with blood. Some devices can start automatically When the red blood cells approach the middle of the bowl shoulder on the 225 or 250 ml bowl, the level sensor will detect a full bowl and enter the WASH mode Use the appropriate wash program based upon the urgency to return volume to the patient

Principles of Autotransfusion with Latham and Baylor Bowl Devices Automatic: the machine will automatically go into the Wash cycle Semi-automatic: the machine will go into Standby mode and you will have to select Wash. Once Wash is complete, you must select Empty Continue: the machine will automatically Fill, Wash and Empty four (4) bowls at a time. Insure that the waste bag and holding bag are empty Manual: the operator must initiate the Wash cycle

Principles of Autotransfusion with the autoLog Device There are two initial level detects The first Fill rate is 600 ml/min If the blood volume required to initiate the first level detect is less than 225 ml, the second Fill rate will be 600 ml/min If the first blood volume is greater than 225 ml, the second Fill rate will be 250 ml/min The autoLog selects the appropriate blood processing program by itself

Principles of Autotransfusion with the Latham and Baylor Bowl Devices Once a minimum of 3 - 4 times the bowl volume in wash solution has been used for cardiac or vascular surgery or 7 to 10 times the bowl volume for orthopedic surgery and the line to the waste bag appears to be clear The washed red blood cells are then pumped to the holding bag. Drain the red blood cells into a transfer bag (if available) for later patient reinfusion and remove all remaining air

Principles of Autotransfusion with Latham and Baylor Bowl Devices Factors affecting the quality of the product: Fill Rate Always select the rate with the patient need in mind (i.e., a trauma patient in need of fluid volume) Always completely fill a bowl; if a bowl is not full, select Return or Concentrate modes

Principles of Autotransfusion with Latham and Baylor Bowl Devices Wash rate Choose wash rates based upon the urgency of returning blood to the patient The wash solution must be isotonic – 0.9% Normal saline is the best choice (NO Ringers if using citrate anticoagulant) Always wash with a minimum of 3 - 4 times the bowl size (i.e. 750 ml for a 225 or 250 ml bowl) in “clean” cases; 7 -10 times for orthopedic cases.

Principles of Autotransfusion with All Bowl Devices Do Not Try to Wash Partially Filled Bowls Poor wash quality (poor cellular removal) Additional hemolysis is created by excessive saline volumes Clinically insignificant red cell mass is involved Use Return and Concentrate functions Per AABB November 2010 Guidelines for Blood Recovery and Reinfusion in Surgery and Trauma

“Partially Filled Bowls” “Low hematocrit (usually <15%) in the final product” Cellular debris in “higher concentrations than…following a normal wash” “Transfusion of a clinically insignificant red cell mass” versus complications, there is limited evidence supporting this practice Alternatives include Return or Concentrate functions AABB Guidelines 2010, pp. 5-6

Principles of Autotransfusion Other factors affecting processing time: Bowl filling volume Hematocrit of the salvaged blood Wash volume required Flow rate at which bowl is emptied

Principles of Autotransfusion Contaminants such as betadine, alcohol, bleach, hydrogen peroxide, water, bone cement (both application and removal), gastric fluids, etc., should not be collected into the reservoir and should be removed to the wall suction, these agents will cause red blood cell hemolysis

Principles of Autotransfusion Collagen based hemostatic agents should not be aspirated into the autotransfusion system (i.e. Avitene and Instat) Although cellulose based hemostatic agents, such as Surgicel, may be aspirated into the reservoir, large amounts of those materials should be aspirated to the wall suction The product insert of the hemostatic agent should have specific statements regarding use during autotransfusion Always increase anticoagulation volumes on all devices and Wash volumes on Latham and Baylor bowl devices

“Unwashed Systems for Postoperative Recovery” Specifically designed for postoperative use Blood is collected and filtered and anticoagulant is not always used “When adequate amounts of blood are collected, the device is typically flipped over and the blood runs through a filter” and these are frequently called “flip-n-drip” systems Suction levels below 100 mmHg and citrate anticoagulant is preferred AABB Guidelines 2010, pp. 8-10

Potential Complications of Reinfusion of Unwashed, Shed Blood Contaminants such as “tissue fragments; activated clotting factors; complement proteins; lymphokines; and exogenous materials, such as antibiotics and topical clotting agents” Recommendations to limit the amount of unwashed blood being reinfused Febrile reactions – “4% to 12%” and potential for hypotension Washing this blood is a simple solution, but that involves the availability of trained operators and potentially costly disposables AABB Guidelines 2010, pg. 9

“Complications of Intraoperative Blood Recovery” Air embolism - use a “secondary reinfusion bag” (Transfer Bag), remove air and disconnect and replace with another bag Air embolism is a potential cause of injury and death during autotransfusion procedures “Under no circumstances should a pressure cuff be used on the primary reinfusion bag when blood is being directly reinfused into the patient” Avoid inadvertent mixing of the recovered blood with inappropriate solutions The final product is washed red blood cells with a small amount of 0.9% saline solution AABB Guidelines 2010, pp. 7 - 8

Prevention of Air Embolism The safest mechanism is to use a Blood Transfer Bag, remove air and disconnect the bag Primary cause of injury and death is air embolism via direct infusion from the holding bag Recovered product must be inspected prior to release for clots, discoloration, fat, particulate, hemolysis or fluid interface Do not use a pressure cuff on the main holding bag! Per AABB 5th Edition of Standards for Perioperative Autologous Blood Collection and Administration

Quality Control Issues PRP With the product Platelets: count and volume if performing sequestration and/or platelet gels (platelet function if that testing is available) Bacterial testing will generally yield skin flora Cellular removal of activated platelets and white cells

Expiration Times Hemodilution - 8 hours at room temperature Intraoperative autotransfusion with blood processing at room temperature – 4 hours from completion of processing Intraoperative autotransfusion with processing, 1 – 6 degrees C, 24 hours total if refrigerated within 4 hours of processing Intraoperative autotransfusion without processing – 6 hours from the start of collection Postoperative autotransfusion with or without processing – 6 hours from start of collection “Single-patient use materials intended to produce a postoperative product shall be used for no more than 24 hours after coming into contact with a patient’s blood at room temperature.” 5th Edition, AABB Standards for Perioperative Autologous Blood Collection and Administration, Reference Standard 5.1.8A, pp. 22-23

Estimating Blood Loss (EBL) 1). Start with the total fluid volume that arrived to the Collection Reservoir 2). Subtract the amount of anticoagulant solution delivered to the reservoir 3). Ask the scrub nurse how much irrigation solution was used and subtract that number from the corrected fluid volume from step 2 Under normal circumstances red blood cell mass recovery rates should fall into the 60 to 80% range Carefully monitor EBL – at 50% of a patient’s blood volume lost, coagulation factor testing is warranted and Fresh Frozen Plasma (FFP) may be required. At 100% or greater of a patient’s blood volume lost, coagulation factor testing and a CBC and/or platelet function testing are warranted and platelet transfusion may be required. ASA 2007 Transfusion Guidelines, autoLog Policies and Procedures Manual

Conclusion The Perioperative Blood Management Technologist exam is being offered on a quarterly basis It is a proctored exam The next exam is in November 2015 Go to amsect.org, then the IBBM tab and then the PBMT exam All operators of autotransfusion devices must be trained and certified in some manner on an annual basis 40 actual autotransfusion procedures must be completed to qualify for this exam In the near future, PBMT certification will be required to obtain liability insurance Contact perfusion regarding autotransfusion activities