In Reply:-I appreciate Dr. Zauder's comments, and I am aware of the AABB/NHLBI guidelines; however, I do not agree with them. I taken them at their face value; only as guidelines and more importantly, not standards. “Guidelines are recommendations (italics added) for patient management that may identify a particular management strategy or a range of management strategies … Variances from practice parameters may be acceptable based on the judgment of the responsible anesthesiologist.” All guidelines should be interpreted within the context of total patient care.
When I manage the cell-salvage machine, whether I medically supervise a CRNA or perform the anesthetic myself, I believe I provide better care to the patient. I have a heightened awareness of the blood loss, blood volume, and hemodynamic status of the patient. Further, after almost 2 years of involvement in cell salvage and after speaking with numerous OR/anesthesia technicians, OR nurses, perfusionists, and autotransfusionists throughout the country, I believe these guidelines are widely ignored. Perhaps these guidelines are widely ignored because they are based on older machines that are less automated or viewed as too restrictive and unrealistic in today's economic climate and therefore are irrelevant. As half of our anesthesia group is now trained and certified on the autotransfusion machine, our surgical colleagues have the convenience in an emergency to arrange for cell salvage on short notice (15 min) without having to contact a local perfusion or autotransfusion contract group and hoping that somebody will be available within a reasonable amount of time. It is for these reasons that I propose that the anesthesiology service consider assuming this intraoperative service.
When stating, “it is possible in certain cases, to perform the anesthetic and operate the autotransfusion machine simultaneously,” I was specifically referring to those cases in which blood loss is slow but constant. I do not think it is safe to simultaneously perform the anesthetic and run the machine in cases where large blood loss can occur acutely such, as in major vascular cases. With the advanced technology and full automation of the newest machines, I still believe in certain, select cases the anesthesiologist can perform the anesthetic and operate the machine. Our colleagues in Europe and South America and in countries such as Sweden, France, and Chile are directly responsible for the cell-salvage equipment and personally manage the machine in slow blood loss cases. Like in our group, they will use a dedicated operator in cases where in large blood loss can occur acutely.
When considering the financial aspects of assuming responsibility for a cell-saving operation, I again disagree with Dr. Zauder. In our small hospital, we were able to save $15,000–20,000 in the first year of service. I see no reason why such savings cannot extend to other situations than the military. That cost savings could be split between the anesthesia group and the originating cost center paying for the service. The relative savings will vary depending on the practice situation. It would be up to the anesthesia group at that hospital to determine the financial feasibility of establishing a cell-salvage division. Although it may be true that most large institutions already use perfusionists who are trained to operate the autotransfusion machines, there is still a significant number of hospitals that pay a premium price for a contract perfusion or autotransfusion group to operate the machines Bottom line: If somebody is being paid to perform this function, why can't it be a properly trained and certified member of the anesthesia team?
In considering the “potential of increased exposure to liability claims,” let the anesthesia group determine its medicolegal tolerance to assuming such a service. With properly trained and certified personnel, as you receive from the aforementioned cell salvage and autotransfusion course, I believe this risk is very small because I can attest to a perfect 2-yr safety record at our institution.
In conclusion, our group is functioning as perioperative physicians. We are available on a consultative basis to recommend and perform blood sparing techniques such as 3-component separation, platelet pheresis, platelet gel, intraoperative hemodilution, and cell salvage to our surgical colleagues for challenging patients in ways a technician would never dream of.*
David M. Green, M.D., Major, U.S.A.F., M.C.
Director, Perioperative Autologous Transfusion Service; Department of Surgery; Anesthesia Service/SGOSA; David Grant Medical Center; Travis AFB, California 94535
(Accepted for publication April 25, 1997.)
*The views expressed in this material are those of the author and do not reflect the official policy or position of the U.S. Government, the Department of Defense, or the Department of the Air Force.