Chapter 228: Autotransfusion

INTRODUCTION

Trauma is the leading cause of death in children and adults under 44 years of age.¹ Exsanguination plays a significant role in as many as half of these deaths, with hemorrhagic shock the most common cause for potentially preventable death.² Hemorrhagic shock is a primary indication for the transfusion of homologous blood products. Transfusions with homologous blood products carry the possibility of associated complications including transfusion reactions, transmission of infectious diseases, and sensitization to antigens.³ Massive transfusions are associated with the additional complications of acidosis, dilutional coagulopathy, and hypothermia. Transfusion of homologous blood products in the trauma patient has been independently associated with an increase in both morbidity and mortality, particularly when transfusing older stored blood products.^4-6 Blood centers have more than doubled the prices of blood products in recent years due to a decline in blood donors, higher skilled labor costs, and increases in the cost of testing and processing blood.⁷ There is evidence that the best replacement for whole blood loss may be fresh whole blood.⁸

Alternative transfusion strategies have been developed for elective surgeries. These include autologous (i.e., acute) normovolemic hemodilution, autologous preoperative donation, autologous priming on bypass initiation during extracorporeal membrane oxygenation (ECMO), and intraoperative cell salvage with autotransfusion.⁹ The first two are not possible in the Emergency Department (ED). Cell salvage with autotransfusion represents a viable alternative to autologous transfusion in the ED but has received limited attention in the trauma patient.

An autotransfusion was first performed in the trauma setting by Elmendorf during the First World War on a soldier with a traumatic hemothorax.¹⁰ It was subsequently used sporadically as a lifesaving procedure.¹¹ A modified autotransfusion for a traumatic hemothorax was described in 1978.¹² This technique was simple, safe, and easy to practice. It was used in approximately 400 patients with a traumatic hemothorax without any noticeable complications. This technique is still applicable to current practice with preliminary studies showing that transfusion of a patient’s own blood is safe.^8,13-15

Many of the patients with a life-threatening hemothorax either die before reaching the ED or experience severe hemodilution that accounts for some deaths in the ED and the Operating Room. Hypovolemic shock secondary to trauma is the most frequent indication for a massive blood transfusion in the ED. It is an indication for an autotransfusion. Much of the controversy surrounding practice paradigms centers on the disagreement as to what constitutes the proverbial “perfect procedure.”

An autotransfusion may occur in the ED, Operating Room, and Surgical Intensive Care Unit with increasing frequency. The shed blood is collected, mixed with an anticoagulant, concentrated, washed or filtered, and then returned through an intravenous (IV) line to the patient. Harmful contaminants (e.g., fat, free hemoglobin, and potassium) are removed from the salvaged blood. This blood is returned through a 40 micron blood filter to collect ...