Intra Operative cell salvage (ICS)
We would also encourage you to use the Handbook for Transfusion Medicine
Blood and blood products are an increasingly limited resource and in the future may be even more so. In view of this, the Medical Director of the NHS Executive issued a Health Service Circular in 1998 entitled Better Blood Transfusion (HSC 1998/224). In this he recommended that "by March 2000 all NHS Trusts, where blood is transfused should have explored the feasibility of autologous blood transfusion... in particular they should have considered the introduction of perioperative cell salvage". A second Health Service Circular - Better Blood Transfusion 2 (HSC 2002/009) subsequently reiterated the need to examine the option of autologous blood transfusion including ICS, and to use it where appropriate.
ICS has been introduced into many Trusts since this time and there are numerous publications confirming its effectiveness and safety as an alternative to donor blood transfusion.
In ICS, blood lost during surgery is collected, anticoagulated, filtered, centrifuged to separate the red blood cells and washed with saline. The final product, red blood cells suspended in saline, is pumped to a reinfusion bag ready to return to the patient. ICS is used frequently in cardiac, vascular and major orthopaedic surgery. Its use in procedures including radical hysterectomy, prostatectomy and cystectomy is increasing. NICE have published advice regarding the use of cell salvage in obstetric procedures.
'A Manual for Blood Conservation', ISBN 1 903378 24 9
Edited by DW Thomas, Consultant Anesthetist, Morriston Hospital, Swansea, UK, JF Thompson Consultant Surgeon and Dr BMF Ridler Clinical Blood Conservation Co-ordinator, Royal Devon and Exeter Hospitals, Exeter, UK.
Provided the term is taken as applying only to centrifugal techniques that return packed washed red blood cells, this is the only autologous technique for which there is a substantial body of favourable evidence on efficacy and safety.
In the past this technique was often ignored because it was considered to be too expensive, however the fact that it provides red blood cells in proportion to the rate at which the patient is bleeding has always given it a degree of efficiency not available with the other autologous techniques. The unit cost of the service is reduced if the technique is used often, and the quality and safety associated with the technique rises.
ICS is used routinely in many hospitals and is operated by a range of staff including Perfusionists, Operating Department Practitioners, Anaesthetic and Scrub Nurses and Anaesthetists.
ICS is just one more technique that can be employed in a relatively technical environment, along with ventilators, balloon pumps, haemofiltration machines etc. Modern ICS machines are among the easier devices to set up and use in this relatively well staffed environment. The graph below shows the net annual cost of the service at Liverpool. Costs depend on how many units of allogeneic blood are saved, and the comparative allogeneic unit cost.
ICS should be considered in all surgical procedures where there are no associated contra-indications and where the anticipated blood loss is greater than 1000mls or where it is likely the patient will require a transfusion e.g. low preoperative haemoglobin, risk factors for bleeding etc, or declines transfusion with allogeneic blood. The use of irrigants in the surgical field, such as hydrogen peroxide or chlorhexidie, is not a contra-indication, however, aspiration of substances unsuitable for intravenous use into the ICS system should be avoided and copious saline irrigation of the wound should be performed prior to resuming ICS. A separate suction system should be employed to remove contaminated irrigation fluid. Infected operating fields or the presence in the field of malignant cells are said to be contraindications to cell salvage, but there is no real evidence to support this contention and insufficient evidence to refute it. Infected or malignant operating fields are relative contraindications only.
Graph of cost of cell salvage service:
In hospitals that require the use of ICS in a smaller number of patients, it may be difficult to generate and maintain the same level of familiarity with the machine. Each hospital should establish how ICS will be managed and in some cases this may involve buying the service in, either from a neighbouring hospital or from a commercial organisation.
The following are the basic requirements for an intraoperative cell salvage service.
- All those operating the machines should be trained and familiar with their use
- The machines should be operated and serviced in accordance with the manufacturer's instructions
- Once set up, the machine should remain with the patient until processing has finished
- At set up the patients identification details (Name, Unique Identifier and Date of Birth) should be placed on the re-infusion bag. This bag should be kept with the patient at all times.
When managed in this way the risk of clerical error resulting in patients being given the wrong blood is minimal.
Issues to consider when setting up an ICS service:
- Roles and Responsibilities
- Training and Accreditation
- Policies, Toolkits and Guidelines
- Quality Assurance
- Industry Providers
- Key References
UK Cell Salvage Action Group
A UK Cell Salvage Action Group was established in 2006 to help support the wider implementation of ICS as an alternative to donor blood, and to facilitate a UK approach to its use. The Action Group reports to the Appropriate Use of Blood Group in England and the equivalent groups in the devolved countries. The group consists of UK leaders in Cell Salvage and will make recommendations considered to be best practice. The outputs of the group will be available to all ICS users through the Toolkit
Intraoperative Cell Salvage competency workbook
Intraoperative Cell Salvage competency workbook
A reviewed version of the UK Intraoperative Cell Salvage Competency Assessment Workbook is now available as a training framework for cell salvage operators. The review of the workbook was undertaken by the UK Cell Salvage Action Group. The workbook was originally produced to address training concerns and specifically the lack of competency assessments for this specialist area of practice.
The content of the competency assessment workbook is linked to the National Occupational Standards for Intraoperative Cell Salvage (PCS19, PCS20, PCS21 and PCS22), which can be downloaded form the Skills for Health website
This workbook has been endorsed by the Association for Perioperative Practice (AfPP), The Association of Anaesthetists of Great Britain and Ireland, British Blood Transfusion Society and the College of Operating Department Practitioners.
The document is available for download as a PDF below:
Intraoperative Cell Salvage Competency Assessment Workbook (pdf)
Postoperative Cell Salvage competency workbook
To complement the Intraoperative Cell Salvage Competency Assessment Workbook, the UK Cell Salvage Action Group has developed a Postoperative Cell Salvage Competency Assessment Workbook. This workbook has been produced to address training concerns and specifically the lack of competency assessments for this specialist area of practice.
We are currently seeking endorsement for this work from the relevant professional bodies.
The document is available for download as a PDF. Additional copies of certificates, reflective practice, case logs etc. can be downloaded separately (in WORD format) from the links below:
Postoperative Cell Salvage Competency Assessment Workbook (pdf)
POCS Case Log (doc)
Accumulative Postoperative Log (doc)
Certificate of Competence - Theatre (doc)
Certificate of Competence - Recovery and Wards (doc)
POCS Reflective Learning Record (doc)
This page was last reviewed on 06/08/2010