JBJS | Erythrocyte Viability in Blood Salvaged During Total Joint Arthroplasty with Cement

The Journal of Bone & Joint Surgery, Volume 84, Issue 1

Scientific Article | January 01, 2002

Erythrocyte Viability in Blood Salvaged During Total Joint Arthroplasty with Cement

Clifford W. ColwellJr., MD; Ernest Beutler, MD; Carol West; Mary E. Hardwick, RN, MSN; Beverly A. Morris, RN, CNP

Investigation performed at the Scripps Clinic, La Jolla, California

Clifford W. Colwell Jr., MD
Ernest Beutler, MD
Carol West
Mary E. Hardwick, RN, MSN
Beverly A. Morris, RN, CNP
Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037. E-mail address for C.W. Colwell Jr.: colwell@scripps.edu

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Funds were received in total or partial support of the research or clinical study presented in this article. The funding source was The Scholl Foundation.

The Journal of Bone & Joint Surgery. 2002; 84:23-25

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Abstract

Background: Erythrocyte salvage, the collection of a patient’s blood shed from the surgical wound, is one aspect of blood management. Previous investigators have examined salvaged blood for content; however, to our knowledge, none have examined the viability of erythrocytes after exposure to the chemical and thermal reactions produced by motorized instruments and polymethylmethacrylate during surgery. The purpose of this study was to determine the viability of salvaged erythrocytes from patients undergoing primary total joint arthroplasty with cement.

Methods: Erythrocyte viability studies were performed on specimens from three subjects with use of a double isotope-labeling technique employing chromium-51 and technetium-99m. With use of a fresh blood specimen obtained prior to surgery and a specimen of salvaged blood that had been recycled, washed, and filtered with use of the Cell Saver, the viability of the Cell-Saver-processed erythrocytes, labeled with chromium-51, was calculated on the basis of the technetium-99m-labeled red blood-cell mass.

Results: The mean erythrocyte viability (and standard deviation) in blood salvaged with use of the Cell Saver was 88.0% ± 3.8%. The standard of the American Association of Blood Banks for minimum erythrocyte viability in adequately cross-matched allogeneic blood or predeposited autologous blood is 70%.

Conclusions: The high rate of viability of the erythrocytes in this study shows that the Cell Saver is a valuable adjunct to other blood management techniques for patients having total joint arthroplasty. We believe that the very high mean rate of erythrocyte viability and the extremely small standard deviation in our three subjects, as compared with the standards of the American Association of Blood Banks, made additional study subjects unnecessary.

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Introduction

The concept of autologous transfusion of blood shed during surgery was first proposed in the 1800s but did not become feasible until the mid-1970s. Blood salvage techniques are utilized during both elective orthopaedic operations and those for traumatic injury. Techniques have been developed to use salvaged, reinfused erythrocytes after cell washing and filtering or after filtering alone^1-7.

The survival and/or viability of erythrocytes has been reported by various authors. Ansell et al., using a double isotope-labeling technique, stated that there was no difference between the erythrocyte survival in nonprocessed venous blood and that in venous blood processed with use of the Cell Saver (Haemonetics, Braintree, Massachusetts) during cardiovascular surgery⁸. Jones et al. used a single isotope-labeling technique and reported a half-life of 22.4 days for erythrocytes in undefined orthopaedic procedures⁹. Erythrocyte survival of twenty-four days in blood salvaged during spinal surgery was reported by Ray et al.¹⁰. In 1993, Umlas et al. reported a twenty-four-hour survival rate of 82.8% and a half-life of nineteen days for erythrocytes in shed, unwashed salvaged blood from seven patients undergoing hip or knee arthroplasty¹¹. Gronborg et al. reported a half-life of twenty-one days for erythrocytes in shed, unwashed blood salvaged with use of a filtering system after cementless total knee arthroplasty¹².

With total hip and knee arthroplasty, there is concern that erythrocytes may be damaged from exposure to motorized instruments or polymethylmethacrylate and the high temperatures that they create. This study was undertaken to determine the viability of erythrocytes exposed to the trauma associated with total joint arthroplasty and then washed and filtered with use of a salvaging system.

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Fig. 1:: Estimated blood loss and red blood-cell (RBC) volume for the three subjects at twenty-four hours after surgery.

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Fig. 2:: Erythrocyte viability for the three subjects at twenty-four hours after surgery.

Materials and Methods

Consecutive patients, without a history of coronary artery disease or cerebrovascular disease, who were scheduled for elective total hip or knee arthroplasty with cement were approached to participate in this study, originally designed for eight subjects.

Four patients agreed to participate and signed a consent form approved by the Scripps Human Subjects Committee, but one subject could not be included in the study because we could not obtain venous access in the contralateral arm to draw post-labeling specimens. Two patients having a total hip arthroplasty and one patient having a total knee arthroplasty completed the study.

A fresh blood specimen was obtained prior to surgery. During surgery, blood and debris were aspirated by low-pressure suction (£180 cm H2O) from the surgical site into the Cell Saver Reservoir. After closure of the wound, the patient was moved to the Post-Anesthesia Care Unit and drainage was aspirated by low-wall suction (23 mm Hg), through a drain that had been placed in the wound, and was collected in the reservoir. When 400 to 600 mL of drainage had accumulated in the reservoir, the blood and drainage was washed with normal saline solution and centrifuged before reinfusion into the patient.

Viability studies of erythrocytes collected with use of the Cell Saver were performed with a double isotope-labeling technique using chromium-51 and technetium-99m¹³ (see Appendix). The red blood-cell viability was corrected for the change in the red blood-cell mass due to bleeding between the time of surgery and the first postoperative day.

Results

The total amount of salvaged blood transfused was 660 mL. Twenty-four hours postoperatively, the mean total red blood-cell volume was 1657 mL and the mean estimated blood loss was 1117 mL (Fig. 1). The twenty-four-hour mean erythrocyte viability of blood salvaged perioperatively with use of the Cell Saver was 88.0% ± 3.8% (Fig. 2). This value is well above the standard of the American Association of Blood Banks for minimum erythrocyte viability.

Discussion

The minimum blood bank requirement for erythrocyte viability in homologous or predeposited autologous blood is 70%¹⁴. In this study, the erythrocyte viability of 88.0% ± 3.8% in blood salvaged with use of the Cell Saver was much higher than that value. The viability of the salvaged cells that had been exposed to the trauma associated with motorized instruments and polymethylmethacrylate as well as the suction and solutions involved in the blood salvage process in this study was similar to that in venous blood (mean, 83.7%; range, 69% to 93%), reported by Umlas et al. in their study of six patients, two of whom had a hip arthroplasty and four, a knee arthroplasty¹¹.

The hematological and coagulation factors of perioperative salvaged blood have been examined in clinical studies. According to Dalen et al., erythrocyte, leukocyte, and platelet counts were significantly (p < 0.001) decreased in unwashed salvaged blood compared with those counts in venous blood at two hours after surgery; however, by six to eight hours after surgery, the erythrocyte count in salvaged blood was similar to that in venous blood, while the leukocyte and platelet counts continued to decline^15,16. Another study indicated that unwashed blood allowed initiation of clot formation in normal plasma and contained more fibrin degradation products, including D-dimer, than did washed blood¹⁷. Although the use of salvaged blood in total joint arthroplasty has been promoted¹⁸, some have discouraged its use from an economic standpoint¹⁹. However, the use of salvaged blood is still recommended if >1000 mL of blood loss, which may occur in hip revision and trauma^20,21, is anticipated. Perioperative transfusion of salvaged autologous blood has been demonstrated to be an effective adjunct to hemodilution and the use of predeposited autologous blood in blood management^22,23.

In the design of this study, we had planned to enroll eight subjects and anticipated a small standard deviation. After we completed the study of only three subjects, the mean erythrocyte viability was quite high (88.0%) and the standard deviation was extremely low (3.8%), with a coefficient of variation of 4.3%. Given this initial data, the expected conditional power of rejecting the null hypothesis that erythrocyte viability would be 70% was calculated. If the additional five patients had been enrolled, the probability of the mean viability being significantly greater than 70% would have been in excess of 0.95²⁴. Hence, we sought no further enrollment of subjects.

The erythrocyte viability that was shown in this study confirms that the use of salvaged, reinfused autologous blood is an excellent adjunct to other methods of blood management for patients undergoing total joint arthroplasty.

Appendix

The specific technique of the erythrocyte viability studies is presented in detail in the electronic versions of this article, on our web site at www.jbjs.org (go to the article citation and click on "Supplementary Material"), and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

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