Is It Appropriate to Use Cell Savers to Collect and Re-Infuse Blood During a C-section?

Steve Howarth, MD; Katherine W. Arendt, MD

Q Is It Appropriate to Use Cell Savers to Collect and Re-Infuse Blood During a C-section?

Dear Q&A,

Is it appropriate to use cell savers to collect and re-infuse blood during a C-section (i.e., are squamous cells and vernix removed safely)?

I have an OB doctor who insists it is.

Regards,
Steve Howarth, MD

A Dear Dr. Howarth,

What a great question! This has been hotly debated over the past 13 years with experts now leaning toward the safety of the use of cell salvage during cesarean delivery.

An excellent and thorough review on this topic1 states that no harm has yet been reported from the use of red cell salvage during cesarean delivery or ectopic pregnancy surgery—no increased rate of infection or DIC, and no reported cases of amniotic fluid embolism. You are likely getting the information that it is safe to use from your obstetric colleagues because the ACOG has recently endorsed its use in obstetric hemorrhage associated with placenta accreta with the statement, “Autologous blood salvage devices have proved safe, and the use of these devices may be a valuable adjunct during the surgery.”2 Further, United Kingdom organizations have also endorsed its use in maternal hemorrhage since 2005.3

c-section

You will note, however, that one very important piece of data is missing from all the work that has been done—large enough case series to prove that cell salvage in obstetrics is safer than or even as safe as allogeneic blood transfusions. The largest series of cell salvage use during a birth includes only 46 patients.4 I know that larger series are in the works in the UK. Until those are completed, since I practice conservatively, and my institution has an excellent blood bank, I therefore do not routinely use cell salvage for postpartum hemorrhage, placenta previa, or even placenta accreta cases.

However, if one is practicing with a limited blood supply, or if rare maternal blood antibodies exist and massive blood transfusion is needed, I would definitely consider its use. As another example, last year I set up cell saver for a cesarean delivery for a Jehovah’s Witness with a placenta accreta (she simply asked that the tubing be contiguous from her to the cell salvage machine and back to her).

There are a number of important caveats to consider when using this technology in the obstetric population:

  1. In the case of Rh negative mothers with Rh positive babies, some still question as to whether the use of cell saver will increase maternal antibody production as fetal blood will likely get suctioned into the cell salvage. Because during any CS it is believed that there is exposure of fetal to maternal blood, other experts do not consider this a concern.
  2. It is also important to note the filter on the cell salvage device. The “LeukoGuard RS filter (Pall Medical)” is what has been involved in many of the contamination studies and is what is recommended in the above-referenced review.1
  3. The obstetricians are to avoid directly sucking up the amniotic fluid. When we used the device, the surgeons had 2 separate suctions and only after the amniotic fluid appeared to be grossly out of the surgical field did they begin to use the cell salvage suction.

In conclusion, it is my opinion that the routine use of cell salvage during cesarean delivery for postpartum hemorrhage, previa, or accreta is debatable until large series are published demonstrating that the safety of its use nears that of allogeneic blood transfusion. I feel that in cases in which allogeneic blood transfusions are limited by supply, limited in safety, or are limited by maternal request, cell salvage is an option for the obstetric anesthesiology team.

Respectfully,
Dr. Katherine Arendt

Katherine W. Arendt, MD
Consultant, Department of Anesthesiology
Assistant Professor of Anesthesiology
College of Medicine
Mayo Clinic
Rochester, MN



The APSF Committee on Technology

Numerous questions to the Committee on Technology are individually and quickly answered each quarter by knowledgeable committee members. Many of those responses would be of value to the general readership, but are not suitable for the Dear SIRS column. Therefore, we have created this simple column to address the needs of our readership.

The information provided is for safety-related educational purposes only, and does not constitute medical or legal advice. Individual or group responses are only commentary, provided for purposes of education or discussion, and are neither statements of advice nor the opinions of the APSF. It is not the intention of the APSF to provide specific medical or legal advice or to endorse any specific views or recommendations in response to the inquiries posted. In no event shall the APSF be responsible or liable, directly or indirectly, for any damage or loss caused or alleged to be caused by or in connection with the reliance on any such information.