Cell Salvage in Cardiac Surgery: Recommendation
Cell salvage should be used at minimum in 'collect only' mode for all cardiac surgery, with processing and reinfusion when collected blood exceeds 500 ml, as this approach reduces allogeneic red blood cell transfusion by 40% without increasing mortality or complications. 1
Evidence-Based Recommendation
Primary Benefit: Reduction in Allogeneic Transfusion
Meta-analysis of 31 randomized trials demonstrates that routine cell salvage during cardiac surgery reduces red blood cell transfusion by 40%, making it a widely accepted blood conservation strategy. 1
Cell salvage reduces both the rate of exposure to allogeneic blood products (OR 0.63,95% CI: 0.43-0.94) and specifically red blood cells (OR 0.60,95% CI: 0.39-0.92), while decreasing mean transfusion volume by 256 mL per patient. 2
Practical Implementation Algorithm
Pre-Bypass Period:
- Use cell salvage to collect blood lost before heparinization, as this blood would otherwise be wasted. 1
During Bypass:
- Do NOT use cell salvage during cardiopulmonary bypass—use standard cardiotomy suckers instead, as cell salvage during bypass depletes clotting factors and platelets. 1, 3
Post-Bypass Period:
- Resume cell salvage immediately after bypass for any ongoing blood loss. 1
- Process residual bypass pump blood (500-1000 ml remaining in circuit) through cell salvage to concentrate red cells and increase hematocrit before reinfusion, which reduces allogeneic blood requirements. 1
- Alternatively, centrifugation of residual bypass pump blood is reasonable if cell salvage is not already in progress. 1
Off-Pump Surgery:
- Cell salvage is specifically recommended for all cardiac surgery performed without bypass ('off-pump'), as there is no cardiotomy reservoir available. 1
Processing Threshold
- If collected blood volume is >500 ml, process and return to the patient; if less, maintain in 'collect only' mode. 1
Safety Profile
No increase in mortality (OR 0.65,95% CI: 0.25-1.68), stroke/TIA (OR 0.59), atrial fibrillation (OR 0.92), renal dysfunction (OR 0.86), or infection (OR 1.25) with cell salvage use. 2
Cell salvage devices used in cardiac surgery do not cause the same level of blood cell damage as previously thought, making them safe and effective. 3
Cost-Effectiveness Considerations
When Cell Salvage is Most Beneficial:
Complex cardiac procedures with anticipated high blood loss clearly benefit from cell salvage. 4
Patients at higher risk of bleeding derive the greatest benefit. 5
When Benefits Are Less Clear:
Low-risk surgery (primary coronary bypass or single valve surgery, EuroSCORE <10%) shows conflicting cost-effectiveness evidence. 1, 5
In low-risk patients with preoperative hemoglobin >13.3 g/dL and body surface area >1.74 m², cell salvage may not reduce transfusion rates. 5
Studies show that in routine first-time cardiac surgery with rigorous blood conservation protocols (including tranexamic acid), cell salvage may not reduce the proportion of patients exposed to allogeneic blood, though it does reduce the number of units transfused in those who receive blood. 6
In institutions where <7% of cases generate sufficient blood volume for processing, routine use may not be cost-effective. 7
Critical Pitfalls to Avoid
Never use cell salvage during cardiopulmonary bypass—this depletes clotting factors and platelets, worsening coagulopathy. 1, 3
Do not rely solely on cell salvage—it must be part of a comprehensive blood management program including tranexamic acid and rigorous transfusion protocols. 6
Processing cardiotomy suction blood with cell salvage only during bypass has no significant benefit and may increase fresh frozen plasma requirements. 2
Avoid using other blood concentrating devices for residual bypass pump blood—they have not been shown effective. 1
Optimal Strategy
The most effective approach is using cell salvage for shed blood and/or residual bypass pump blood, or throughout the entire operative period (excluding the bypass phase itself), rather than limiting use to only the bypass period. 2