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Impact of Cell Saver on Allogenic Transfusion Rates at Cesarean Delivery in Women with Abnormal Invasive Placentation
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Impact of Cell Saver on Allogenic Transfusion Rates at Cesarean Hysterectomy in Women with Abnormal Invasive Placentation

Background

- Abnormally invasive placenta previa (AIP) carries significant risk of maternal morbidity and mortality, the most common being massive blood loss at Caesarean hysterectomy.
- Several perioperative strategies have been proposed to decrease blood loss and the requirement for allogenic blood transfusion.
- Multidisciplinary management of women with AIP was recently documented to reduce maternal morbidity.1
- Data on cell salvage in obstetrics is limited. Its use in this population has been controversial due to the theoretical risk of amniotic fluid embolism and heparin anticoagulation from recycled blood.
- Previous studies evaluating the use of intraoperative cell salvage specifically in the context of AIP are limited by small sample sizes.2,3 In heterogenous groups of patients, cell salvage has been reported to reduce allogenic blood use.3,4
 
Purpose
 
- To describe the utility of introducing cell salvage in 2014 for the surgical management of AIP and its impact of maternal outcomes.
 
Methods
 
- Single-centre retrospective review of all cases of surgically confirmed AIP between 2012 to 2016, cell saver was introduced in 2014. Cohorts are those with and without cell saver.
- Women with AIP who did not receive any of the blood conservation techniques due to an unscheduled surgery were excluded.
- Categorical variables are expressed as percentages and continuous variables are expressed as a mean  or median ± standard deviation.
- Student’s t-test, Chi square test, Fisher’s exact test, and Wilcoxon rank test were used as appropriate. A p value of < 0.05 was significant.
 
Results
 
- 54% of cases utilized the cell saver (27/50).
- 92% (46/50) of cases had a hysterectomy (89% with cell saver vs. 96% without cell saver).
- Comprehensive protocol changes that evolved along with introduction of the cell saver resulted in several significant differences between the cohorts (use of tranexamic acid, use of general anaesthesia, gestational age at delivery)
- Autologous blood was transfused in 16/27 (59%) (median 250 ml, range 125-3044 ml).
- 52% of women in the cell saver group received allogenic blood transfusions compared to 57% of those without (p=0.74), the median units were 1 (0-7) compared to 2 (0-12), respectively (p=0.94).
- Briefing that allogenic blood transfusions would not be instituted until after discussion with surgical team was introduced April 2016. Transfusion rates pre- and post-briefing in the cell saver cohort were 13/18 (72%) vs. 1/9 (11%) (p=0.003).
 
Conclusions and Implications
 
- Introduction of cell saver alone, is insufficient to decrease the number of women receiving allogenic transfusion nor the mean number of units transfused.
- Use of a cell saver in women with AIP resulted in no significant transfusion complications.
- Increased stringency of the use of transfusion guidelines, including team consensus on the use of allogenic transfusion in the setting of cell salvage, may reduce the rate of allogenic blood transfusions. 
 
References

1. Walker MG, Allen L, Windrim RC, Kachura J, Pollard L, Pantazi S et al. Multidisciplinary management of invasive placenta previa. J Obstet Gynaecol Can. 2013 May;35(5):417-25.

2. Elagamy A, Abdelaziz A, Ellaithy M. The use of cell salvage in women undergoing cesarean hysterectomy for abnormal placentation. Int J Obstet Anesth. 2013 Nov;22(4):289-93.

3. King M, Wrench I, Galimberti A, Spray R. Introduction of cell salvage to a large obstetric unit: the first six months. Int J Obstet Anesth. 2009 Apr;18(2):111-7.

4. McDonnell NJ, Kennedy D, Long LJ, Gallagher-Swann MC, Paech MJ. The development and implementation of an obstetric cell salvage service. Anaesth Intensive Care. 2010 May;38(3):492-9.

5. Aitken K, Allen L, Pantazi S, Kingdom J, Keating S, Pollard L et al. MRI Significantly Improves Disease Staging to Direct Surgical Planning for Abnormal Invasive Placentation: A Single Centre Experience. J Obstet Gynaecol Can. 2016 Mar;38(3):246-251.e1.

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