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Profound hypotension in the absence of hypovolemia during cell salvage use in obstetrics.
Abstract Number: F-40
Abstract Type: Case Report/Case Series
Clinical experience of cell salvage in obstetric surgery is increasing and has been endorsed by several professional bodies. Leucocyte depletion filters (LDF) are advocated to improve safety by reducing the concentration of leucocytes, lipid particles and fetal squames in reinfused blood. We describe a case of significant hypotension during administration of LDF processed cell salvage blood.
A 28 year old female with a myometrial arteriovenous malformation at the anterior lower uterine segment underwent elective cesarean section under regional anesthesia, with radiologically placed intra-arterial balloon catheters as there was concern about significant uncontrollable hemorrhage at delivery. Cell salvage was used intra-operatively with a LDF (LeukoGuard RS, Pall Medical, New York, USA). Brisk blood loss was encountered at uterine incision, and total volume collected was 1474mls, with 350mls processed blood returned to the patient near the end of the procedure. 24 minutes after commencing blood reinfusion the patient reported significant nausea and dyspnea, coinciding with a precipitous fall in blood pressure, requiring several Phenylephrine boluses followed by reinstitution of a Phenylephrine infusion (5mg/hr). Concealed blood loss and hypovolemia were excluded. Blood gas analysis demonstrated a mild metabolic acidosis (base deficit: -4.6) and normal lactate (0.8). Serial thromboelastography failed to demonstrate coagulopathy, and sequential plasma tryptases were normal. Over a period of 30 minutes following discontinuation of cell salvaged blood, hemodynamic stability improved and vasopressors were weaned. Tentatively, the remainder of the salvaged blood was reinfused and no further significant compromise was noted. Transthoracic echocardiography performed at the end of surgery demonstrated normal left and right ventricular size and function, normal pulmonary arterial pressure and normal valves. Recovery was otherwise uneventful and the patient was discharged 4 days later.
Reaction to the negatively charged LDFs has been previously reported and is putatively related to the generation of bradykinin and complement causing an anaphylactoid reaction. This may be most evident when blood is administered via LDF under pressure, at 37°C or with concurrent ACE inhibitor use. Hypotension related to cell salvage use in obstetrics may be attributed to a number of causes, including amniotic fluid embolus, but we felt that in view of normal investigations and temporal relation to reinfusion of processed blood to her relatively transient hypotension, an LDF reaction may have been responsible.
1) Intraoperative blood cell salvage in obstetrics (2005) National Institute for Health and Clinical Excellence TPG144, Manchester, UK
2) Iwama H. Bradykinin-associated reactions in white cell-reduction filter Journal of Critical Care (2001) 16: 2; 74-81