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Intraoperative Cell Salvage

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Presentation on theme: "Intraoperative Cell Salvage"— Presentation transcript:

1 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Education Workbook Slides

2 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Training Pathway

3 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

4 Learning Outcomes Describe the main functions of blood
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes Describe the main functions of blood Identify the main components of blood and describe their individual functions Describe basic coagulation List the allogeneic (donor) blood components available for clinical use

5 Blood separated into its constituent parts
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood separated into its constituent parts

6 The coagulation cascade
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK The coagulation cascade Anticoagulants Citrate binds free calcium (Ca++), preventing activation of clotting factors Heparin is an antithrombin agent which inactivates thrombin, preventing conversion of fibrinogen to fibrin

7 Allogeneic (Donor) Blood Components
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Allogeneic (Donor) Blood Components Blood and blood components must always be stored under controlled storage conditions in designated fridges, freezers etc.

8 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

9 Learning Outcomes Identify the principles of blood conservation
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes Identify the principles of blood conservation Identify the areas where blood conservation can be undertaken in surgical patients Describe the main strategies of blood conversation

10 Blood Conservation Allogeneic (Donor) Blood Limited Resource
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Conservation Allogeneic (Donor) Blood Limited Resource Donor Restrictions e.g. age, previous transfusion, lifestyle Risks e.g. Wrong Blood Incidents Transfusion Transmitted Infections Transfusion reactions Costs

11 Blood Conservation Patient Blood Management
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Conservation Patient Blood Management a multidisciplinary, evidence-based approach to optimising the care of patients who might need a blood transfusion Recommendations published by the National Blood Transfusion Committee (2014) Emergency Plans for Blood Shortages To ensure the availability of blood where critical in the event of a blood shortage Autologous blood transfusion is one of many blood conservation strategies which should be considered when addressing Patient Blood Management.

12 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Blood Conservation

13 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

14 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes Demonstrate an understanding of the principles of haemovigilance Identify the risks associated with administration of allogeneic (donor) blood

15 Haemovigilance Serious Hazards of Transfusion (SHOT)
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Haemovigilance Serious Hazards of Transfusion (SHOT) Serious Adverse Blood Reactions and Events (SABRE)

16 Reporting cell salvage incidents to SHOT
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Reporting cell salvage incidents to SHOT

17 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

18 Learning Outcomes Identify the three main stages of ICS
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes Identify the three main stages of ICS Identify the different ICS systems that exist Describe the end product of ICS

19 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage

20 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Collection Blood is aspirated and mixed with anticoagulant through an aspiration and anticoagulation (A&A) line, into a collection reservoir. The collection reservoir contains a filter that removes clots and other gross particulate matter.

21 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Separation The reservoir contents are pumped/drawn into a spinning centrifuge system. The RBC component is retained within the bowl while the lighter components are forced out into a waste line. As the reservoir contents continue to enter the system and separate, the HCT within the system increases.

22 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Washing IV normal saline (0.9% NaCl) is pumped into the spinning centrifuge system, passing through the heavier RBC component and out into the waste line displacing the remaining waste products

23 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Most systems have a minimum wash volume recommended by the manufacturer. It is not advisable to decrease the wash volume below this level. It is advisable to increase the wash volume for procedures where there is a high risk of contamination of salvaged blood, e.g. obstetrics and orthopaedics.

24 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage Reinfusion The end product of washed, packed RBCs suspended in IV normal saline (0.9% NaCl) is pumped to a bag ready for reinfusion.

25 Principles of Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Principles of Intraoperative Cell Salvage ICS can reduce and sometimes eliminate the need to transfuse allogeneic (donor) RBCs. In cases where large blood loss occurs, patients receiving ICS may still become depleted of clotting factors and platelets. In such cases transfusion of allogeneic (donor) components such as fresh frozen plasma (FFP), platelets or cryoprecipitate may be required.

26 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

27 Learning Outcomes To identify the indications for ICS
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Learning Outcomes To identify the indications for ICS To identify the relative contraindications for ICS To outline when the risks/benefits of using/not using ICS change

28 Indications and Contraindications
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications Indications and patient selection Elective and emergency surgical procedures Clinical decision (surgeon and/or anaesthetist) Estimated blood loss >20% of patient’s estimated blood volume Patient factors Risk factors for bleeding Low preoperative Hb Rare blood group / multiple antibodies Unwilling to receive allogeneic blood on religious or other grounds

29 Indications and Contraindications
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications Relative Contraindications Bowel contents in the surgical field Infected surgical fields Sickle cell disease Heparin induced thrombocytopenia (if heparin is the only available anticoagulant for ICS)

30 Indications and Contraindications
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications Warnings Contaminating substances* e.g. Non-intravenous substances e.g. antibiotics not licensed for IV use; Iodine; topical clotting agents; orthopaedic cememt Non-intravenous bodily fluids e.g. gastric/pancreatic secretions; pleural effusions; metal fragments from implants *Action when contaminating substances present: Avoid aspirating (discontinue ICS) Irrigate with 0.9% Sodium Chloride (NaCl) Resume ICS

31 Indications and Contraindications
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications Cautions Hartmann’s can inhibit the action of ACD-A anticoagulant if used as an irrigant or wash solution Air will be present in the reinfusion bag (risk of air embolus) Automatic mode is recommended

32 Indications and Contraindications
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Indications and Contraindications Areas for further consideration Infected fields Malignancy Obstetrics The decision to use blood that is potentially contaminated with bacteria, malignant cells or amniotic fluid should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

33 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

34 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes To identify the equipment used for blood collection and describe the function of each component To name the two main types of anticoagulant used in ICS, describe their functions and mechanism of action To describe methods of maximizing blood collection To identify potential problems areas during blood collection

35 Blood Collection Aspiration of blood from surgical field
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Aspiration of blood from surgical field Anticoagulation Filtering Storage prior to processing

36 Blood Collection Decision to collect blood Anticipated blood loss
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Decision to collect blood Anticipated blood loss Patient risk factors for bleeding Low Preoperative Haemoglobin Patient objections to receiving allogeneic (donor) blood

37 Blood Collection Collect only setup
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Collect only setup Where adequate blood loss for processing cannot be predicated

38 Blood Collection Anticoagulants* Heparin saline ACD-A
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Anticoagulants* Heparin saline 25-30, 000 IU heparin/1000mls IV normal saline (0.9% NaCl) Ratio 1:5 e.g. 20ml to 100ml blood Antithrombin III Ineffective if the patient suffers an antithrombin III deficiency ACD-A Pre-prepared Ratio 1:7 e.g. 15ml to 100ml blood Binds Calcium Calcium containing fluids may block the action of ACD-A e.g. Hartmann’s Solution *Recommended minimum flow rate – 1 drip per second

39 Blood Collection Wide bore suction tip Low vacuum level e.g. Yankauer
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Wide bore suction tip e.g. Yankauer Low vacuum level to minimise RBC Haemolysis

40 Blood Collection During collection
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection During collection Regulate vacuum Regulate anticoagulant flow (↑ with ↑ blood loss) Monitor volume of blood loss Only IV grade fluids should be aspirated into the system

41 Blood Collection Maximising blood collection
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Maximising blood collection Maintain a low vacuum level Suction technique (aspirate from pools of blood) Wide bore suction tip Swab washing

42 Blood Collection Swab washing Blood normally lost to swabs is salvaged
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Swab washing Blood normally lost to swabs is salvaged Sterile bowl 1000mls IV normal Saline (0.9%NaCl) Swabs placed in bowl for ~ 5 mins then gently squeezed out Swab wash aspirated in to ICS machine and processed Ensure the swab wash bowl is maintained within the sterile field. Ensure no substances not intended for IV use enter the swab wash bowl e.g. Betadine soaked swabs.

43 Blood Collection Troubleshooting Loss of suction Clotting in reservoir
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Collection Troubleshooting Loss of suction Clotting in reservoir Contamination with non-IV substances* *The decision to use blood that is potentially contaminated with bacteria, amniotic fluid or malignant cells should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

44 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

45 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes To identify the steps taken in making the decision to process To list the equipment used for blood processing and describe the function of each component To describe the steps required in preparing for and commencing blood processing To describe the risks of overriding the automatic functions of the machine To identify the steps necessary to complete the blood processing phase

46 Blood Processing* Separation of RBCs from waste products
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing* Separation of RBCs from waste products Concentration of RBCs Washing of RBCs with 0.9% sodium chloride (NaCl) Transfer of RBCs to reinfusion bag *Blood collection can continue during the processing phase

47 Blood Processing Decision to process
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Decision to process Adequate blood loss in collection reservoir Anticipated adequate blood loss in collection reservoir due to rapid bleeding Patient factors Low Hb Anticipated postoperative benefit

48 Blood Processing Full processing setup UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Blood Processing Full processing setup

49 Blood Processing Automatic mode
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Automatic mode It is highly recommended that ICS machines are run in automatic mode* *Running the machine in manual mode could result in residual contaminants in the RBCs, which could be potentially harmful to the patient

50 Blood Processing Wash volume
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Wash volume Always use the minimum wash volume as outlined by the manufacturer DO NOT decrease wash volumes - this could result in potentially harmful contaminants being reinfused to the patient Wash volumes may be increased where there are some types of contaminants e.g. fat in orthopaedic procedures

51 Blood Processing During processing Replace wash solution as necessary
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing During processing Replace wash solution as necessary Change reinfusion bag if necessary Empty the waste bag as needed

52 Blood Processing Incomplete bowls
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Incomplete bowls Inadequate RBCs to fill the bowl and complete processing (fixed volume systems) Processing incomplete bowls manually is NOT recommended* Wait for more blood loss in the collection reservoir Concentrate function – uses already processed RBCs from the reinfusion bag to fill the bowl and complete the processing *Processing incomplete bowls may result in potentially harmful contaminants being reinfused to the patient

53 Blood Processing Completing processing Empty reinfusion line
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Completing processing Empty reinfusion line Remove air from reinfusion bag Disconnect reinfusion bag

54 Blood Processing Troubleshooting Incomplete bowls
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Troubleshooting Incomplete bowls Machine Alarms (on screen instructions)

55 Wet – Dry weight of swabs
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Processing Blood loss calculations n.b. Irrigation relates to irrigation used within the surgical field and aspirated into the system and not to the volume of IV normal saline (0.9% NaCl) wash solution used during processing Calculation = Example = Fluid in Irrigation fluid Anticoagulant used Swab wash Theatre suction Wet – Dry weight of swabs Approx. blood loss 2,500ml 200ml 400ml 1,000ml 150ml 1,250ml

56 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

57 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes To identify the equipment used for reinfusion and describe the function of each component To describe the composition of the final product for reinfusion To identify the conditions for reinfusion

58 Blood Reinfusion ICS end product RBCs in IV normal saline (0.9% NaCl)
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion ICS end product RBCs in IV normal saline (0.9% NaCl) Haematocrit ~ 50-70%

59 Blood Reinfusion ICS end product
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion ICS end product The decision to use blood that is potentially contaminated with bacteria, amniotic fluid or malignant cells should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

60 Blood Reinfusion ICS end product
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion ICS end product In cases of massive haemorrhage, it is likely that the patient will require allogeneic (donor) blood components e.g. Platelets, Fresh Frozen Plasma, Cryoprecipitate and RBCs

61 Blood Reinfusion Prescribing ICS Blood
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion Prescribing ICS Blood The reinfusion of ICS blood should be prescribed by the responsible clinician on the documentation approved within your hospital.

62 Blood Reinfusion Filters Obstetrics & malignancy
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion Filters Type of filter Medium Removes Standard blood administration set µm screen Blood component and non-blood component particulate matter. Microaggregate blood filter 40µm screen Blood component microaggregates and non-blood component particulate matter. Lipid depleting microaggregate filter Microaggregates, lipids, C3a, some leucocytes. Leucodepletion filter Affinity filter Leucocytes, lipids, microaggregates, some bacteria Obstetrics & malignancy

63 Blood Reinfusion Reinfusion “Storage” Time limits
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion Reinfusion “Storage” Time limits Reinfusion can occur: While reinfusion bag is still attached to ICS disposable The reinfusion line from the processing set must remain open for this set up. Once it has been disconnected The reinfusion bag should not be disconnected while the machine is processing.

64 Blood Reinfusion Administration of ICS blood Pre-transfusion checks
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion Administration of ICS blood Pre-transfusion checks Standard blood transfusion practice Baseline observations Patient ID Expiry time / damage or abnormality of blood Administration of blood Appropriate filter Observations Documentation

65 Blood Reinfusion Transfusion reactions
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Blood Reinfusion Transfusion reactions If a transfusion reaction is suspected, STOP the reinfusion and see immediate advice from the lead surgeon and/or anaesthetist. Incident reporting (according to local policy)

66 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Information and Best Practice Unloading and Discarding

67 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes To outline the operator’s responsibilities for labelling ICS blood To discuss the factors to be considered when dealing with patient specific religious requirements To outline the responsibilities of the operator during the procedure To describe the operators responsibilities with regards to dealing with procedural problems

68 Information and Best Practice
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Information and Best Practice Labelling Handwrite an autologous transfusion label at the start of blood collection at patient’s side from information on patient’s identification band Securely attach the label to the collection reservoir (collect only) Transfer the label to the reinfusion bag as soon as the processing set is loaded

69 Information and Best Practice
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Information and Best Practice Patients with religious requirements Set up of equipment may differ Requirements should be discussed with the patient prior to use All relevant staff should be made aware of these requirements

70 Information and Best Practice
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Information and Best Practice Monitoring the system The operator is responsible for the machine throughout the procedure The operator should be working within the vicinity of the machine to allow them to monitor the system and respond to alarms The operator should ensure that necessary procedures are carried out e.g. emptying the waste bag

71 Information and Best Practice
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Information and Best Practice Potential Contamination The decision to use blood that is potentially contaminated with bacteria, amniotic fluid or malignant cells should be made by the clinicians caring for the patients, taking into account the latest evidence and considering the risks and benefits for the individual patient.

72 Information and Best Practice
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Information and Best Practice Procedural problems The responsible clinician should be made aware of any problems that have occurred during the process e.g. contamination of the collection reservoir with non-IV substances, so that the decision to reinfuse under these circumstances can be made based on the relative risks and benefits

73 Intraoperative Cell Salvage
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Intraoperative Cell Salvage Basic Blood Facts Blood Conservation Haemovigilance Principles of Intraoperative Cell Salvage Indications and Contraindications Practicalities – Blood Collection Practicalities – Blood Processing Practicalities – Blood Reinfusion Unloading and Discarding

74 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK Learning Outcomes Identify when unloading of ICS machine and disposables is appropriate Determine the risks associated with the unloading phase Describe the appropriate procedure for safely discarding waste products and disposables that is compliant with your hospital policy

75 Unloading and Discarding
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Unloading and Discarding Establish end of blood collection / completion of processing Detach the reinfusion bag (if there is blood in the bag for reinfusion) Follow manufacturer’s guidance for unloading Follow local policy for disposal of biohazardous waste Observe standard precautions

76 Further information www.transfusionguidelines.org.uk
UK CELL SALVAGE ACTION GROUP EDUCATION WORKBOOK Further information Better Blood Transfusion Toolkit Appropriate Use UK Cell Salvage Action Group ICS Education Workbook ICS Competency Assessment Workbook

77 UK CELL SALVAGE ACTION GROUP
EDUCATION WORKBOOK UK CELL SALVAGE ACTION GROUP

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