Anaesthesia 2019
14667
Editorial
To salvage (routinely) or not to salvage: that is the question
C. A. Wong1 and P. Toledo2
1 Professor, Chair, and Department Executive Officer, University of Iowa Carver College of Medicine, Iowa City, IA, USA
2 Assistant Professor, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
............................................................................................................................................................................................................................................................................................................
Correspondence to: C. A. Wong
Email: cynthia-wong@uiowa.edu
Accepted: 20 March 2019
Keywords: blood conservation; blood management; obstetric haemorrhage; transfusion
This editorial accompanies an article by Sullivan and Ralph, Anaesthesia 2019; https://doi.org/10.1111/anae.14630.
Twitter: @CynthiaAWongMD
To salvage – it means to save – from a shipwreck, a fire, a
wrecking ball or other forms of permanent destruction or
loss. The act of salvaging implies repurposing, putting to
use somewhere else. It makes perfect sense in a world that
throws away and loses a lot of things. Cell salvage also
makes perfect sense: collect the patient’s own blood from
the operative field, wash away the impurities and re-infuse it
to the patient; thus, avoiding the risks, and costs, of
allogeneic transfusion. But a lot of things in medicine that
appear to make perfect sense do not actually work as
expected. For example, the practice of bloodletting to rid
the body of bad humours made perfect sense to our
medical colleagues practicing in previous centuries, but it
does not work and may cause harm. Similarly, we need to
ask, does cell salvage use actually result in lower allogeneic
transfusion rates and its associated risks? Specifically, in the
obstetric population, does the benefit of routine use of cell
salvage outweigh the risks?
Postpartum haemorrhage
Postpartum haemorrhage is the leading cause of maternal
mortality worldwide. The incidence is increasing, and the
incidence of postpartum haemorrhage requiring blood
transfusion in the US nearly quadrupled between 1993 and
2014 [1]. In 2014, 0.4% of all deliveries required a blood
transfusion. Importantly, experts estimate that between 70%
and 90% of postpartum haemorrhage-related deaths are
preventable [2, 3]. The morbidity
haemorrhage often reflects the quality of the clinical
response; early recognition and prompt management of
haemorrhage are critical to improving maternal outcomes.
Recommendations to improve care include: identification
© 2019 Association of Anaesthetists
doi:10.1111/anae.
of women at high risk for haemorrhage; improved
recognition of haemorrhage; and timely management. Yet,
identifying at-risk women is challenging; many women who
experience postpartum haemorrhage do not have
identifiable risk factors [4]. Therefore, strategies such as the
routine use of cell salvage during caesarean section might
improve the timeliness of clinical response and improve
outcomes. But does this strategy actually work, and is it safe
and cost effective?
In this issue of Anaesthesia, Sullivan and Ralph report
the results of a retrospective observational study of one UK
centre’s experience with cell salvage in 6352 obstetric
patients [5]. Between 2008 and 2017, cell salvage was used
routinely for 98% of caesarean deliveries. Salvaged blood
was re-infused in 1170 women (18.4%), and only 44 women
(3%) required an allogeneic blood transfusion in addition to
salvaged blood. In a subset of patients, the investigators
assessed the ‘quality’ of the salvaged blood; fetal blood
cells were found in all samples; however, the rate of allo-
immunisation was very low. Of note, the authors used a
single suction catheter to aspirate blood from the surgical
field; washed all surgical swabs; and, in the latter years of
the study period, did not use a leucocyte depletion filter.
They reported no major safety events. The authors
concluded that “it is possible to use cell salvage at
caesarean section both safely and economically” without the
need for additional staff, using one suction device and no
of postpartum leucocyte depletion filter.
Randomised vs. observational studies
Although these results are promising, they contrast with the
results of the cell salvage in obstetrics (SALVO) trial, a
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pragmatic, multicentre (26 UK units), randomised
controlled trial [6]. In the trial, 3028 women at risk for
haemorrhage and undergoing a scheduled or intrapartum
caesarean section were randomly allocated to receive cell
salvage in addition to standard care (experimental group) or
standard care alone (control group). The rate of allogeneic
transfusion was 2.5% in the cell salvage group and 3.5% in
the standard care group, a difference that was not
statistically different (adjusted risk difference 1.03, [95%
CI: 2.13 to 0.06]) [6]. On average, 1 in every 100 women
who received routine cell salvage avoided an allogeneic
transfusion. Similar to the study by Sullivan and Ralph [5],
the SALVO trial investigators concluded that use of cell
salvage in obstetric patients was safe [6]. Finally, the SALVO
investigators used their data to perform a cost effectiveness
analysis from the perspective of the NHS, and concluded
that cell salvage was more expensive than standard care;
the incremental cost effectiveness ratio was £8110 (€9711;
$10,303) per transfusion avoided [6].
How can we bridge the gap between the Sullivan and
Ralph study and the SALVO trial [5, 6]? The studies differed
methodologically. In the hierarchy of evidence, the findings
of randomised controlled trials are normally considered
superior to observational studies. The SALVO trial was a
large, well-conducted, randomised controlled trial in
women at increased risk for haemorrhage [6]. The primary
outcome was the rate of women receiving allogeneic blood
transfusion to manage haemorrhage; secondary outcomes
included safety and cost. In contrast, the Sullivan and Ralph
study was a retrospective observational trial [5]. All women
undergoing caesarean section were included. Although
outcomes were not defined a priori, the authors reported
allogeneic transfusion rates over the 10-year study period,
as well as safety data.
Treatment costs
Although Sullivan and Ralph did not report cost as an
outcome of their study, they emphasised key differences
between their own practice and that described in the
SALVO study [5, 6]. Specifically, in the SALVO study, a full
setup for both collection and processing of salvaged blood
was mandated as part of the study protocol [6]. In contrast,
in the Sullivan and Ralph study, the cell salvage machine was
initially setup for collection only, and the processing kit was
opened only if a sufficient amount of blood had collected in
the reservoir [5]. By protocol, all surgical swabs were
washed and a single suction device was used to aspirate
blood from the surgical field, rather than using one suction
before delivery of the placenta, and a second one
afterwards (the use of two suction catheters has been
2 © 2019 Association of Anaesthetists
Editorial
recommended to reduce the volume of amniotic fluid
collected into the cell salvage reservoir [7]). Leucocyte
depletion filters were not used after 2015, and perhaps
most importantly, no additional staff were required to
operate the cell salvage machine. Operating department
practitioners, who are routinely available to assist the
anaesthetist, were trained in cell salvage operation and
were available 24 h a day, 7 days a week. In contrast, in the
SALVO trial, many centres required additional personnel to
operate the cell salvage machine, and just over half of the
centres used a leucocyte depletion filter, washed swabs and
used one suction, rather than two [6]. Thus, personnel costs
and routine use of the processing kit were likely to have
been significant costs in the SALVO trial.
Importantly, the cost-saving measures used by Sullivan
and Ralph did not appear to reduce the quality of the
salvaged blood, or result in any identifiable patient harm,
although both studies were underpowered for safety
outcomes [5, 6]. Although it was once thought that a
leucocyte depletion filter was necessary to reduce amniotic
fluid contaminants in the salvaged blood [7], many centres,
including nearly half of the centres in the SALVO trial [6],
have abandoned their use due to reports of acute
hypotensive events, as well as slower infusion rates [8].
Indeed, 16 out of 18 adverse events reported in the SALVO
trial were thought to be related to the leucocyte depletion
filter [6].
An additional safety concern is maternal allo-
immunisation. Among the subset of 647 women in the
Sullivan and Ralph study who had subsequent allo-
immunisation testing, only two women developed new
antibodies [5]. Additionally, the authors reported that, in the
past 3 years, they observed no increase in the dose of
Rho(D) immune globulin administered to Rh-negative
women with Rh-positive fetuses, indirect evidence that
abandoning the use of leucocyte depletion filters does not
increase the risk of fetomaternal haemorrhage [5]. In
contrast, the SALVO investigators reported a greater
incidence of fetomaternal haemorrhage, defined as ≥ 2 ml,
in women who received cell salvage compared with those
who did not [6]. Although the Sullivan and Ralph study was
not powered to investigate this safety outcome, the results
add reassurance that leucocyte depletion filters may not be
necessary for routine cell salvage [5]. More studies are
needed to fully understand the impact of cell salvage
reinfusion on the risk of allo-immunisation.
Risk vs. benefit
When making the decision to use any medical intervention,
the benefits must be weighed against the risks, including
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cost. Arguably, the primary benefit of cell salvage is a
reduction in allogeneic blood transfusion. The SALVO study
found no benefit in terms of reduced allogeneic blood
transfusion when cell salvage was used routinely for high-
risk patients undergoing caesarean section, although in a
planned sub-group analysis in women undergoing
emergency caesarean section, the allogenic transfusion rate
was lower in the cell salvage group at 3.0% vs. 4.6% in the
standard care group [6]. Although Sullivan and Ralph
reported an inverse relationship between cell salvage use
and allogenic transfusion over the 10-year study period, the
causality of this association must be viewed with scepticism
[5]. As noted by the authors, other blood conservation
strategies were also implemented during the study period
that were likely to have contributed to the observed
decrease in the allogeneic transfusion rate.
However, before we totally dismiss the routine use of
cell salvage for obstetric patients, we should consider other
possible benefits of its use. These include improved ability
to rescue, a reduction in maternal near-miss events and
death due to haemorrhage, a leading, but usually
preventable cause of maternal mortality. Perhaps, the rate of
allogeneic blood transfusion is not the outcome we should
be assessing, but rather other important outcomes, such as
failure to rescue. As confirmed in the current study as well as
in others, the risks of cell salvage are low and the costs could
be lower if modelled on the setup described by the authors
in their institution [5]. The SALVO study cost analysis only
considered direct costs from the provider perspective – it
did not consider the costs, to both the provider and to
society, of serious adverse outcomes such as failure to
rescue. The death of a mother due to haemorrhage is a
tragedy, all the more so because it is almost always
preventable with appropriate and timely management.
In the US, the National Partnership for Maternal
Safety, an organisation formed with the goal of reducing
maternal mortality, published an obstetric haemorrhage
safety bundle in 2015 [9]. A key element of the bundle is
readiness. It is possible that using cell salvage in all
patients improves the team’s preparedness to manage
cell salvage, the quality of the salvaged blood and
perhaps other components of preventing and treating
postpartum haemorrhage. The routine use of cell salvage
would certainly improve our ability to initiate treatment
early in haemorrhage. It would provide the ‘regular
experience’ required by the National Institute for Health
and Care Excellence (NICE) guidelines for its use [10].
Furthermore, its use might serve as a trigger to focus the
team on postpartum haemorrhage diagnosis and
treatment, leading to improved outcomes.
© 2019 Association of Anaesthetists
Anaesthesia 2019
What about guidelines?
Many organisations, including the Royal College of
Obstetricians and Gynaecologists, the National Institute
of Health and Care Excellence (NICE), the American
College of Obstetricians and Gynecologists and the
American Society of Anesthesiologists, recommend that
cell salvage be considered in selected situations, such as
when large blood loss is expected (> 20% of blood
volume), when patients refuse allogeneic blood or during
intractable haemorrhage when banked blood is not
available [10–13]. These guidelines imply, although they
do not directly state, that the routine use of cell salvage
in all obstetric patients is not indicated. Indeed, in the
first updated guideline published since the SALVO trial,
the Association of Anaesthetists state that cell salvage “is
not used routinely for caesarean section based on the
current evidence, be it elective, urgent or emergency”
[14].
We suggest that further research is necessary before
completely condemning the routine use of cell salvage.
The sub-group analysis in emergency caesarean section
patients in the SALVO study suggests that the technique
may have benefit in this patient group [6]. We suggest a
randomised controlled trial of the routine use of cell
salvage in emergency caesarean section patients,
incorporating the paradigm suggested by Sullivan and
Ralph, and powered to assess outcomes such as near
misses or a composite outcome of adverse outcomes, is
a rational next step for further defining the role of cell
salvage in obstetric care.
Acknowledgements
No external funding or competing interests declared.
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