Use of intraoperative cell salvage in neurosurgery

Use of intraoperative cell salvage in neurosurgerytatm_1167 1..7

HELEN ROBERTS* , MBChB , BSc (Hons) & CRAIG CARROLL†, MBChB

*North Manchester General Hospital,Manchester;†Salford Royal Hospitals FoundationTrust, Salford, UK

Correspondence to:Dr H. Roberts, AnaestheticsDepartment, North ManchesterGeneral Hospital, Delaunays Road,Crumpsall, Manchester M8 5RB, UK.E-mail: [email protected]

Publication dataReceived: 29 July 2011Revision received: 2 February 2012Accepted: 16 February 2012

Keywords• Autotransfusion• Cell saver• Neurosurgery

SUMMARY

Intraoperative cell salvage (ICS) is widely used in many surgicalspecialties, but uptake in neurosurgery has been slow. Little directevidence exists to support the use of ICS in neurosurgical procedures;however, studies suggest that ICS may be safe and cost-effective inintracranial surgery and spinal fusion. Nationwide ICS is used in less than50% of neurosurgical centers often without clear local guidance. It ismost commonly used in major spinal surgery and least often surgery forintracranial glioma or metastatic deposits. The major barriers to morewidespread introduction of ICS appear to be concern about tumordissemination in cases of malignancy, lack of trained staff to use themachinery and perceived lack of necessity. Some evidence suggests thatwhen ICS is used in tumor resection surgery, meningioma (benign) cellsare less likely to be detectable in salvaged blood than glioblastoma(malignant) cells but, in contrast to other surgical subspecialties, the useof leukocyte depletion filters to remove tumor cells has not beeninvestigated and the impact of ICS usage on tumor recurrence andlong-term survival rates is unknown. The unpredictable nature of bloodloss in neurosurgery means that many units do not use ICS routinely eventhough hemorrhage is often rapid and substantial when it does occur. Nonationally recognized guidelines currently exist to support the use of ICSspecifically in neurosurgical procedures although the majority of UKneuroanesthetists feel that a standards document would be beneficial.

INTRODUCT ION

The increasing cost and scarcity of allogeneic blood fortransfusion has lead to renewed interest in the use ofintraoperative cell salvage (ICS). Worldwide, concernsrelated to the risks of transfusion-related infection meanthat autologous transfusion may offer a significantsafety benefit over allogeneic blood. While the use of

ICS has become commonplace in many surgicalspecialties, and is supported by recommendations fromprofessional bodies in the UK,1 uptake in neurosurgeryappears to have been slow. This may be due to a lack ofdirect evidence of safety, health benefits and cost-effectiveness in this particular subspecialty and also theperception that neurosurgery does not lend itselfparticularly well to the routine use of this technology.

Transfusion Alternatives in Transfusion Medicine TATM

© 2012 The AuthorsTransfusion Alternatives in Transfusion Medicine © 2012 Medical Education Global Solutionsdoi: 10.1111/j.1778-428X.2012.01167.x

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CL IN ICAL CONSIDERAT IONS

The adverse effects of homologous blood transfusion arewidely known and include immunologic reactions,infection (both transmitted from the donor and frombacterial contamination), coagulopathy and circulatoryoverload. Theoretically ICS should negate the risk ofantigen–antibody immunologic reactions andtransmission of blood-borne disease, while the risk ofother potential complications is unaffected. Theincidence of clinical complications does appear to below: the most recent UK Annual Serious Hazards ofTransfusion (SHOT) Report from 2009 contained detailsof only six adverse events related to the use of ICS, onlythree of which related to clinical outcomes rather thanoperator or machine error and none of which occurredduring neurosurgical procedures.2 All three wereepisodes of profound hypotension occurring duringre-infusion of salvaged cells, common factors appearingto be use of a leukocyte depletion filter and acid citratedextrose as anticoagulant. In each case, the hypotensionwas significant but transient and easily managed, withno long-term sequelae observed.

The use of cell salvage (both intra- and postoperative)for minimizing allogeneic transfusion was reviewed bythe Cochrane Collaboration in 2010.3 Meta-analysis of75 randomized trials showed that perioperative use ofcell salvage resulted in an absolute reduction in the riskof exposure to allogeneic blood transfusion of 21%. Theuse of cell salvage did not impact on mortality rates oraffect adverse outcomes such as wound complications,thromboses and non-fatal myocardial infarction,although there was a slight decrease in infection ratesamong ICS patients. However, the majority of trialsreviewed related to orthopedic, cardiac and vascularsurgery and the authors commented on the ‘need . . . forlarge, methodologically rigorous, comparative trials toassess the relative efficacy, safety, and cost-effectivenessof cell salvage in different surgical procedures’. As yet,few such trials have been published in neurosurgery.

One of the largest published to date is a non-randomized, prospective study of the transfusionrequirements of 472 patients having intracranialsurgery.4 A hemoglobin measurement of 8.5 g/dL orbelow was used as transfusion trigger, with ICS bloodre-infused initially unless contra-indicated. Allogeneictransfusion was used when ICS was unavailable or tomake up the shortfall if salvage yielded insufficient

volumes. Patients with malignant tumors or sepsis wereexcluded from receiving autologous blood and technicalproblems meant that three eligible patients were unableto have blood salvaged and received allogeneic cellsinstead. Ninety subjects (19%) required a bloodtransfusion, 61% of these receiving only salvagedautologous blood and the remainder receiving eithersolely allogeneic cells or a mixture of both. Mildprolongation of prothrombin time was noted in patientswho received only autologous ICS blood (up to sevenunits), all of which had returned to within normal limitsby day three post-surgery. Mean prothrombin time wassignificantly longer in the group who had received amixture of autologous and homologous blood, althoughthe three patients in this group who had the mostprolonged times had all received more than 10 units intotal. Activated partial thromboplastin times wereunaffected, and platelet counts decreased in eachcategory but with no difference between groups.

More studies have been conducted in instrumentedspinal fusion, where predicted perioperative blood losstends to be high and consequently ICS has been morewidely utilized. One 2002 study looked at 50 cases ofthoracic and spinal fusion where the mean blood losswas 833 mL.5 ICS was used in all patients but only 66%were judged to require re-infusion of salvaged bloodbased on clinical stability, hematocrit and estimatedblood loss. The mean blood loss in this group wasestimated at 1046 mL. The quantity of salvaged bloodwas sufficient in the majority, with only two patients inthe series requiring additional allogeneic bloodtransfusions. A small elevation in serum bilirubin(below 3 mg/dL) and INR (maximum 1.5) was notedamong the patients receiving salvaged blood at 48 hourspost-transfusion, but there was no evidence of clinicallysignificant hemolysis or bleeding. None of the patientssuffered any of the major reported complications of ICSsuch as sepsis, air embolism and cardiopulmonaryproblems.

Another retrospective analysis of ICS in 188 patientsundergoing instrumented lumbar vertebral fusionshowed no benefit in terms of reduction in allogeneicunits required, although the average estimated bloodloss in the ICS group was almost double that of thenon-ICS recipients (1476 mL vs. 766 mL). This calls intoquestion the possibility of selection bias,6 with clinicianschoosing to utilize ICS in cases where increased bloodloss was expected.

2 ROBERTS & CARROLL | USE OF INTRAOPERATIVE CELL SALVAGE IN NEUROSURGERY

© 2012 The AuthorsTransfusion Alternatives in Transfusion Medicine © 2012 Medical Education Global Solutions • ••, ••–••

COST ANALYS IS

In addition to health benefits, routine introduction ofnew technologies relies on evidence of cost-effectiveness. Transfusion of homologous donated bloodcontinues to become more expensive as it is subjectedto more extensive and sophisticated safety checksand processes such as leukodepletion. Investigatorshave highlighted the huge financial burden relatedto reducing the incidence of transfusion-relatedtransmission of infection. For instance, the cost ofreducing cases of hepatitis C and HIV using nucleic acidtesting for viral detection is over 90 times higher thanaccepted cost-effectiveness benchmarks ($50,000 perquality-adjusted life year gained).7

Tighter restrictions on those eligible to donate havebeen introduced to reduce risks but have also lead toever-scarcer resources. In contrast, an aging populationand advances in the surgical management of manypathologies previously considered inoperable haveresulted in an inexorable increase in demand for bloodproducts.

However, the unit price of packed cells is only oneelement of the total cost of allogeneic transfusion to ahospital. The Society for Advancement of BloodManagement has sought to estimate the additional costsof red cell transfusion through its cost-of-bloodconsensus conferences. Although it could be argued thatsome of the costs included would be incurred whether ornot a transfusion was carried out or even considered(routine full blood count testing, physician reviewingblood results, preparation of discharge documentation),the process cost analysis technique highlights manyareas which could easily be overlooked when comparingthe price of allogeneic transfusion with the moreimmediate and transparent process of intraoperativesalvage.8 An analysis of blood transfusions in surgicalpatients in two American and two European hospitalspublished in 2010 found that product acquisition priceaccounts for only 21–32% of transfusion-relatedexpenditure and derived a mean unit cost for packed redcells of 761 US dollars (around £490), far exceedingprevious estimates.9

In 2006, the UK National Institute for Health Researchevaluated the relative cost of transfusion strategiesincluding cell-salvage, preoperative autologousdonation and acute normovolemic hemodilution.10 Cellsalvage resulted in a relative risk of exposure to

allogeneic blood of 0.59 (confidence interval 0.48–0.73)and had lower costs and slightly higher quality-adjusted life years than all other strategies apart fromacute normovolemic hemodilution. It is difficult toquantify the cost savings achieved by use of ICS, withrespect to decreased postoperative infection orreduction in other complications of allogeneictransfusion. ICS for malignancy surgery may actuallyincur additional costs where irradiation of the salvageproduct is employed in order to effectively eliminate there-infusion of viable malignant cells. Advocates of thistechnique would suggest that ICS in malignancysurgery should not be considered unless productirradiation is performed.11

Reviews of the cost-effectiveness of ICS in differentsurgical subspecialties tend not to mentionneurosurgery as large-scale financial analyses have notbeen undertaken;3,12 however, some cost information isavailable. The Cataldi et al. prospective study of ICS in472 patients undergoing intracranial surgery (primarilyfor meningiomas and aneurysms) found that during thestudy period, the average cost of a unit of re-infusedsalvaged blood was 48% of the price of a unit ofallogeneic packed cells.4 In their series of patientsundergoing spinal fusion, Chanda et al. estimated thatthe costs of autotransfusion were statisticallycomparable to those of allogeneic transfusion wheremore than 500 mL of packed cells would have beenrequired, although substantially higher when smallervolumes were re-infused.5

CURRENT USAGE IN NEUROSURGERY

In order to estimate the usage of ICS in UK neurosurgery,links to an online survey were emailed to members ofthe Neuroanesthesia Society of Great Britain and Ireland(NASGBI) in January 2011,13 inviting consultantneuroanesthetists to complete a questionnaire relatingto use of ICS in their neurosurgical practice. A total of115 society members working at 33 UK neurosurgicalcenters responded.

While staff at 27 of these centers report use of ICS inother surgical specialties when predicted blood lossexceeds 20% of blood volume, in only 15 of these unitswas ICS ever used for neurosurgical procedures. Of the17 institutions that offer pediatric neurosurgery, threeroutinely use ICS in pediatric cases.

ROBERTS & CARROLL | USE OF INTRAOPERATIVE CELL SALVAGE IN NEUROSURGERY 3


When the service is offered it is usually available ona 24-hour basis, although a number of respondentscommented that the particular staff members presentrather than the time of day was more important indetermining service availability. In the vast majority ofcases, the ICS is operated by an anesthetic nurse oroperating department assistant, with only one report ofa specialist ICS technician and six anesthetists who runthe cell salvage equipment themselves. Seventy-fourpercent of respondents felt the decision to utilize ICS ismade jointly between surgeon and anesthetist, while theremainder felt they were left to make the decision ontheir own.

Local policies intended to guide the use of ICS inneurosurgery are often not available or perhaps notwidely appreciated: multiple respondents from a singleunit frequently disagreed about whether or not therewas a protocol for the use of ICS in neurosurgicalpatients at their hospital. It appears that eight hospitalshave a formal protocol identifying neurosurgical casesin which ICS should be utilized.

ICS is currently most widely used in major spinalsurgery, with 43% of units utilizing ICS routinely forspinal procedures. It is rarely employed in evacuation ofintracranial hematomas and at least two-thirds of theanesthetists who responded avoid using ICS in surgeryfor glioma or metastatic deposits entirely. Intermediatelevels of usage were reported in aneurysm surgery andresection of large meningiomas.

The overall findings from the 2011 survey mirror thosefrom a similar survey carried out in 2005, which foundthat although ICS was widely employed in spinalprocedures including surgery for deformity, fracturesand vertebral fusion, it was not routinely used in anyintracranial surgery and rarely in spinal metastaticdisease.14 Occasional use was reported in arteriovenousmalformation and meningioma surgery, although onlyone centre had used cell salvage in other central nervoussystem (CNS) tumors.

In our own unit, ICS has been used an average of 3.5times a month over the last 2 years, predominantly inmajor spinal surgery. It yields sufficient salvage forprocessing and re-infusion 68% of the time and therehas been a gradual increase in the volume of bloodre-infused during this period. ICS blood is mostcommonly re-infused during scoliosis correctionsurgery, although other corrective surgeries and spinalfixations also frequently receive salvaged blood. By

contrast, ICS set up for spinal decompression surgeryonly yields enough blood to make processingworthwhile 14% of the time.

NEOPLAST IC D ISEASE

When ICS was first introduced, theoretical concernsabout hematologic dissemination meant that malignantdisease was considered to be an absolutecontraindication to its use.15 As appreciation of itspotential benefits increased, ICS was graduallyintroduced into cancer surgery, initially only followingindividualized risk–benefit analysis and a fulldiscussion with the patient, with informed consentrecorded.16 Such a discussion, however, is oftenomitted when a transfusion of stored allogeneic bloodis considered, although this has been shown to resultin immunosuppression and to increase the risk of localand distant recurrence in bowel cancer, an effectwhich increases with the length of storage and volumetransfused. Large series of patients receiving ICSduring cancer surgery now exist, particularly forurologic malignancy, and long-term survival ratesfollowing radical cystectomy appear to be unaffectedby ICS usage.17 Cancer is no longer generallyconsidered to be an absolute contraindication to theuse of ICS and autotransfusion;12 however, repeatedsurveys of neuroanesthetists confirm that fear ofdissemination of neoplastic disease is a major barrierto the widespread introduction of the technology inneurosurgery. Forty-nine percent of those questionedin 2011 voiced this as a concern and, as in 2005, itwas the major reason why ICS is avoided even forneurosurgical procedures in which blood loss exceedsa liter. Cell salvage has been used most frequently insurgery for meningiomas, the vast majority of whichare benign and non-invasive and 78% of thosequestioned had used ICS at least occasionally in thisgroup of patients. More caution has traditionally beenexercised in surgery for glioma and metastatic brainlesions, where only 28% employ ICS occasionally anda further 67% of anesthetists say that they never useit. One small scale study of cytologic contamination ofre-infused blood following ICS in neurosurgery foundtumor cells in the blood from five out of nineglioblastoma patients but only one out of 13meningioma patients. The authors concluded that ICSshould not be used in glioblastoma patients but is safe



in surgery for meningioma.18 While there is littlerobust evidence available to assess the safety of usingICS in neurosurgical procedures for malignant disease(including metastatic deposits within the CNS), muchmore work has been carried out in other fields. The UKNational Institute for Health and Clinical Excellence(NICE) refused to investigate the overall use of red cellsalvage in malignancy or sepsis in 2007 because it wasfelt to be ‘considered standard clinical practice with anefficacy and safety profile that is sufficiently wellknown’; however, it did publish interventionalprocedure guidance on the use of intraoperative redblood cell salvage during radical prostatectomy orradical cystectomy in 2008.19 ICS was found to beefficacious and safe, even when re-infusion ofcancerous cells leading to distant metastases wasspecifically considered as a theoretical adverse event.The committee found no evidence that this actuallyoccurred, although it did comment on the use ofleukocyte depletion filters, which are thought tominimize the risk of re-infusion of malignant cells thatmay be present in the aspirate. Although studies ingynecologic and hepatic malignancies suggest that theuse of a leukocyte depletion filter significantly reducesthe number of intact malignant cells detectable inprocessed salvaged blood,20,21 no such evidence existsspecifically for neurologic malignancies.

There is a body of opinion that strongly opposes thereinfusion of salvage product that may still containmalignant cells, however few, and some centers haveemployed irradiation of salvaged blood as a strategy toeliminate this risk. Work performed by Hansen et al. hasdemonstrated the presence of tumor cells in salvaged/processed blood during cancer surgery. This groupsuggests that even with the use of leukocyte depletionfilters, tumor cells are still evident in the re-infusionproduct and has shown that these cells have thepotential to survive and undergo mitosis.22 Hansen et al.have also demonstrated that a radiation dose of 50 Gydelivered to blood mixtures with high numbers of cellsfrom solid tumors or cell lines left no cancer cellsremaining that were capable of proliferation or DNAmetabolism. Red blood cell integrity, viability and 2,3-diphosphoglycerate levels were unaffected.23 However,data regarding primary CNS tumors (including lowgrade malignancy and benign tumors) and the risk ofdistant metastasis following ICS is lacking. Opinion isdivided and on current evidence there is no universally

accepted decision as to the safety of ICS in CNSoncologic surgery. The practice of irradiation of salvageproduct is not widespread.

Avoiding transfusion altogether is the only certainway to avoid potentially increasing the risk ofrecurrence in patients with neurologic malignancy. Theuse of allogeneic transfusion is known to have a dose-dependent effect on reducing immune integrity inpatients, this effect being compounded by use of bloodapproaching its expiry date. However, where blood lossis rapid, hemoglobin levels drop below recognizedtransfusion thresholds and outcomes have been shownto be worse, ICS may have a vital role in managing theimmediate effects of significant hemorrhage andreducing the incidence of complications of massiveallogeneic transfusion and should still be considered.Insistence on irradiating salvaged blood in an attempt toreduce an unknown risk of tumor seeding may result inavoidance of salvage altogether in such circumstances,thereby denying patients its benefits.

OTHER BARRIERS TO USAGE

Cell salvage has probably not been embraced byneuroanesthetists and neurosurgeons because theoverall requirement for any kind of blood transfusion issmall, meaning that setting up the salvage equipmentis often viewed as an unnecessary expense. Perceivedlack of necessity was also found to be a barrier toroutine introduction in 2005. Many respondents alsocite the unexpected nature of major hemorrhage inneurosurgery as a problem, with massive blood lossfrequently difficult to predict from either details of theplanned surgical procedure or clinical assessment of thepatient.

Although significant bleeding in neurosurgery isinfrequent, it can often be torrential when it does occurand there is a perception that cell salvage suctionapparatus is unable to cope with the scale of blood loss.Teams that do not use ICS systems regularly maystruggle to prepare the equipment quickly enough incases of sudden unexpected massive hemorrhage. Theother most frequently cited reasons for avoidance of ICSin neurosurgery are lack of available trained staff,logistical barriers (such as training, audit anddeveloping standard operating procedures), concernsregarding cost and the risk of infection or othercontamination.



Occasional technical problems with blood collectionpersist, and the equipment itself has occasionally provedunpopular among neurosurgeons as the double-lumensuction required (one lumen for instillation ofanticoagulant, the other for suction) is inevitably largerand more unwieldy than traditional suction apparatus.When bleeding is less rapid, red blood cells can becomemore damaged by turbulent flow and the resultanthemolysis means that there are concerns that freehemoglobin in the re-infused blood may cause healthproblems such as acute tubular necrosis or the salvageyield will be unacceptably low. To minimize hemolysis awide bore suction catheter (minimum 4 mm) should beused, with the level of suction as low as practicable.When bleeding in neurosurgical procedures isuncontrolled, a common strategy is to introduce topicalhaemostatic material into the wound; however, suchmaterial has been proposed as a contraindication tocontinued use of cell salvage.24

ENCOURAGING USE OF ICS

Guidelines relating to transfusion management in theintraoperative period have recently been published bythe Italian Society of Transfusion Medicine andImmunohematology25 and include a grade 2Crecommendation that ICS should be used in vertebralcolumn fusion operations and intracranial surgery forgiant aneurysms of the basilar artery in the contextof local protocols. These protocols should take intoaccount the individual patient’s characteristics and the

experience of the surgical and anesthetic teams, with theultimate aim of minimizing allogeneic transfusion andoptimizing cost-efficiency.

There are currently no national guidelines in the UKcovering the use of ICS in neurosurgery specifically,although its use is recommended in the Association ofAnaesthetists of Great Britain and Ireland (AAGBI)guidelines for management of massive hemorrhagewhere blood loss exceeds 20% of estimated bloodvolume or 1000 mL.1 However, it is being used regularlyby some in the field, and when questioned directly 86%of UK neuroanesthetists felt it would be useful to have ajointly produced standards document guiding the use ofICS in neurosurgical procedures. Of anesthetists whohave never used ICS, around one-third stated that theyhad no intention of introducing it into their practice,meaning that two-thirds would consider doing so –recommendations from a joint working party includingperhaps the AAGBI, NASGBI and Society of BritishNeurologic Surgeons could be a key factor inencouraging them.

Although rare, massive and rapid blood loss does occurin neurosurgery and the use of ICS in these circumstancesmay be extremely beneficial to the patient and possiblyalso cost-effective. Neurosurgical units need to developfamiliarity and expertise with the technique if they are tobe expected to provide emergency salvage in instances ofunexpected massive hemorrhage. An opportunity existsto promote ICS and deal with issues regarding patientselection, technical concerns and other perceived barriersto its widespread introduction.

REFERENCES

1 Thomas D, Wee M, Clyburn P, et al. Bloodtransfusion and the anaesthetist:Management of massive haemorrhage.Anaesthesia 2010; 65: 1153–61.

2 Taylor C, Cohen H, Mold D, et al. Onbehalf of the serious hazards oftransfusion (SHOT) steering group. The2009 Annual SHOT Report. 2010.

3 Carless PA, Henry DA, Moxey AJ, et al.Cell salvage for minimising peri-operative allogeneic blood transfusion.Cochrane Database Syst Rev 2010; (4):CD001888.

4 Cataldi S, Bruder N, Dufour H, et al.Intraoperative autologous blood

transfusion in intracranial surgery.Neurosurgery 1997; 40: 765–71.

5 Chanda A, Smith DR, Nanda A.Autotransfusion by cell saver techniquein surgery of lumbar and thoracic spinalfusion with instrumentation. J Neurosurg2002; 96: 298–303.

6 Gause PR, Siska PA, Westrick ER, et al.Efficacy of intraoperative cell saverin decreasing postoperative bloodtransfusions in instrumented posteriorlumbar fusion patients. Spine (Phila Pa1976) 2008; 33: 571–5.

7 Jackson BR, Busch MP, Stramer SL,AuBuchon JP. The cost-effectiveness of

NAT for HIV, HCV, and HBV in whole-blood donations. Transfusion 2003; 43:721–9.

8 Shander A, Hofmann A, Gombotz H,Theusinger OM, Spahn DR. Estimatingthe cost of blood: Past, present, andfuture directions. Best Pract Res ClinAnaesthesiol 2007; 21: 271–89.

9 Shander A, Hofmann A, Ozawa S, et al.Activity-based costs of bloodtransfusions in surgical patients at fourhospitals. Transfusion 2010; 50: 753–65.

10 Davies L, Brown TJ, Haynes S, et al.Cost-Effectiveness of cell salvageand alternative methods of minimising



perioperative allogeneic bloodtransfusion: a systematic review andeconomic model. Health Technol Assess2006; 10: iii–iv, ix–x, 1–210.

11 Hansen E, Bechmann V, Altmeppen J.Intraoperative blood salvage in cancersurgery: Safe and effective? TransfusApher Sci 2002; 27: 153–7.

12 Ashworth A, Klein AA. Cell salvage aspart of a blood conservation strategy inanaesthesia. Br J Anaesth 2010; 105:401–16.

13 Bishop M, Krassnitzer S, Oliver C.Annual scientific meeting of theNeuroanaesthesia Society of GreatBritain and Ireland, Newcastle, UnitedKingdom, May 5-6th, 2011. J NeurosurgAnesthesiol 2011; 23: 278–87.

14 Ingram KL, Nathanson MH, Lamb J.National survey of the use ofintraoperative cell salvage inneurosurgery and spinal surgery. JNeurosurg Anesthesiol 2005; 17: 157.

15 Hendee WR. Autologous bloodtransfusions. JAMA 1986; 256: 2378–80.

16 Thompson JF, Riddler B. A cell salvageupdate. Blood and Transplant Matters2011; 33: 4–6.

17 Nieder AM, Manoharan M, Yang Y,Soloway MS. Intraoperative cell salvageduring radical cystectomy does not affectlong-term survival. Urology 2007; 69:881–4.

18 Kudo H, Fujita H, Hanada Y, et al.Cytological and bacteriological studiesof intraoperative autologous blood inneurosurgery. Surg Neurol 2004; 62:195–9.

19 National Institute for Health and ClinicalExcellence. Intraoperative red blood cellsalvage during radical prostatectomy orradical cystectomy. April 2008.

20 Catling S, Williams S, Freites O, et al. Useof a leucocyte filter to remove tumourcells from intra-operative cell salvageblood. Anaesthesia 2008; 63: 1332–8.

21 Liang TB, Li DL, Liang L, et al.Intraoperative blood salvage duringliver transplantation in patients with

hepatocellular carcinoma: Efficiency ofleukocyte depletion filters in the removalof tumor cells. Transplantation 2008; 85:863–9.

22 Hansen E, Wolff N, Knuechel R, et al.Tumor cells in blood shed from thesurgical field. Arch Surg 1995; 130: 387–93.

23 Hansen E, Altmeppen J, Marienhagen J,Taeger K. Quality of blood salvaged andirradiated during cancer surgery.Transfusion 1999; 39: 58S.

24 Waters JH. Indications andcontraindications of cell salvage.Transfusion 2004; 44(12 Suppl.): 40S–44S.

25 Liumbruno GM, Bennardello F, LattanzioA, Piccoli P, Rossetti G.Recommendations for the transfusionmanagement of patients in the peri-operative period. II. The intra-operativeperiod. Blood Transfus 2011; 9: 189–217.



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Use of intraoperative cell salvage in neurosurgery