intraoperative salvage

[Dr. Pepper]

We have a neurosurgeon who has been lobbying actively for the hospital to buy a cell saver. Right now the OR subcontracts out for intraoperative salvage (an even bigger waste of money). We don't feel, though, that we do the types of bloody surgeries that would make this a good investment. Those of you who use them, how do you do your utilization review? Do you use 1000 ml whole blood salvaged as a break-even cutoff? Any input on the subject and potential pitfalls would be very welcome.

[Lcsmrz]

The benefit of having in-house cell salvage depends on volume. The cost of having trained operators from the blood bank on 24/7/365 call is quite expensive, unless your service level is quite high at a large AHC.

Besides, he contract for a PRN cell saver usually resides on the OR budget ...

[djjohnson]

The benefit for my small hospital to have two cell savers, operated by a tech from lab has far outweighed the cost of allogeneic blood. We mostly do orthopedics/general/obgyn---not hearts/trauma/transplants where you might think that is the only place to use them. And, now with many blood management dictates, and more information about detrimental effects of banked blood....it makes even more sense. We have an in-house program, having gone from the contract situation in the past. You have more control on the education of the operators, quality control of your product, etc. We have had a program for 10 years now, and we have been AABB Periop Accredited for 6 years and will come up for it again next year. The AABB Spring Periop conference has been one of the most educational conferences, and also the SABM (Society for Advancement of Blood Management) conferences. You will see a cell saver (ours is from Sorin/Cobe) lists for about 35-40,000. , but you can get them for about 20,000, and maybe less for a used one. I am the main operator, and coordinator with two others-float pool to back me up. We do about 100 a year average--Spinal surg w. instrumentation/ Total Joints/gen.surg/OBGYN-TAHs.

If I collect 300 cc with patient at normal Hgb,,,I can give back about 150cc each processing pass/batch. We can also use cell saver on Jehovah's Witnesses.

We are not on-call, but could be,,,most surgeries are scheduled. If you have a surgeon who does AAA's, you might want to do an on-call,,,,even most of these are scheduled. I am also looking at making autologous platelet rich plasma. My budget for IAT (intraoperative autologous transfusion), is from BBK/lab. I also am certified by the company to do yearly maintenance, our biotech dept. only does the electrical checks. I would not start an inhouse program without budgeting for two machines---one for backup if something wrong w. the other---however, now, many times there are two ortho docs doing total hip at same time---and this can be done by one operator. Do NOT get ortho pat machines from Haemonetics----unless you plan to have an operator with that machine the whole time. Yes, they are cheaper---the company does NOT fix them--they just send you a new one---so, no machine history,etc--that should tell you something. Also, there is no way to check centrifuge speed with a tachometer (outside calibrated source), as is recommended by AABB.

[Linda0623]

Hello Dr. Pepper--

We too perform cell saver......any chance we get. We are predominently orthopedics, but have some neuro cases as well, and unless the patient is deemed unfit for cellsaver (ie. infection at the surgical site), they are considered for the process if there is any significant EBL anticipated. So far this year, it has been used in ~900 cases! (imagine the cost savings on allogeneic blood....) We used to completely control the whole process, but now the OR "owns" it themselves. They report on it to me for Transfusion Committee review, but all cases where it is used, PM's training, etc. are maintained by the Anesthesia Department Director, with blood bank oversight. We do not currently include this on our AABB accreditation, as the OR has the day to day responsibility, but we do remain the oversight body for stats and reporting purposes. Hemonaetics is the vendor who provides our training, PM's, equipment etc. It has really helped us keep cases moving during blood shortages as well.....

[Dr. Pepper]

Thank you LC, DJ and Linda for your input. A few years ago, we looked at our perioperative blood salvage use for 12 months. (The service was purchased.)

# cases Cell-Saver used #equiv RBC units reinfused total units

41 0 0

5 <1 <5

18 1 18

4 2 8

3 3 9

1 5 5

1 6 6

1 7 7

1 10 10

TOTALS 71 68

So, if you use 2 units or greater as your financial equivalency point to allogenic blood, 64 of 71 cases were a waste of money.

$52,416 cost for the purchased service

$31,801 cost for a cell saver of our own and supplies for 75 cases

$12,274 cost for 68 allogeneic units

It just doesn't seem that we have the case mix to make this practical. I don't have the staff to spare a tech to be on hand for the procedures, scheduled or otherwise. Having the OR own the program, BB oversight or not, is a little frightening. And is allogeneic blood really that bad a product? In terms of infectious risk, the blood supply is safer than it's ever been. Our blood supplier has furnished leukoreduced components for years. Most of the blood we transfusde is 1-2 weeks old.

The hospital is scraping for every penny. This just doesn't make financial sense to me.

Dr. P

[ybunch]

We have a neurosurgeon who has been lobbying actively for the hospital to buy a cell saver. Right now the OR subcontracts out for intraoperative salvage (an even bigger waste of money). We don't feel, though, that we do the types of bloody surgeries that would make this a good investment. Those of you who use them, how do you do your utilization review? Do you use 1000 ml whole blood salvaged as a break-even cutoff? Any input on the subject and potential pitfalls would be very welcome.

In this day and time it is a legal liability not to have cell salvage equipment. When you do a blood consent, you are saying the "risks, benefits and alternatives have been explained". Now, if you do not have an alternative that is widely accepted, you are putting yourself at legal risk. Blood transfusion is also expensive, time consuming and has risks. So, why wouldn't you want to use the patient's own blood? It is a safe and simple alternative. What is your cost to collect blood? A cardiotomy, double lumin, a bag of saline with some heparin. Maybe around $65. Then if you have enough blood to process, bring in your tech or trained nurse. It is very cost effective. Dr. Jonathan Waters has written several articles of this in peer reviewed medical journals. You may find the articles of help. But, I agree with your surgeon--you need a cell salvage machine. Hope this helps.