Methods

Concealment of treatment allocation was by use of sealed envelopes. Method of generating allocation sequences was not described.

Participants

90 patients undergoing primary total knee arthroplasty were randomised to 1 of 3 groups:
1) Group 1 (No drain group): n=30; M/F=11/13; mean age (95% CI) = 70 (67‐74) years.
2) Group 2 (Autotransfusion group): n=30; M/F=4/20; mean age (95% CI) = 71 (69‐74) years.
3) Group 3 (Control group): n=30; M/F=9/16; mean age (95% CI) = 72 (69‐75) years.

Interventions

(1) Group 1: No drain was used.
(2) Group 2: Solcotrans autotransfusion system collected blood for 6 hours or until the unit was full. Acid citrate dextrose‐anticoagulant (ACD‐A) was not added to the collection unit. Continuous suction was applied at 20cm H2O. Drains were maintained for 24 hours post‐operatively.
(3) Group 3: A standard disposable closed suction drainage system (Redon) was used with two standard drains maintained for 24 hours post‐operatively.

Outcomes

Number of patients transfused allogeneic blood.
Blood loss.
Hospital length of stay.
Hb & Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

32 patients undergoing cardiac surgery requiring cardiopulmonary bypass were randomised to 1 of 2 groups:
(1) Group 1 (Washed shed mediastinal blood group): n=16; mean age (+/‐sd) = 60+/‐8 years.
(2) Group 2 (Control group): n=16; mean age (+/‐sd) = 61+/‐8 years.

Interventions

(1) Group 1: received the volume of mediastinal shed blood that had been collected up to the point of transfusion.
(2) Group 2: received 1 unit of packed red blood cells (PRBC).
NB: The decision to transfuse a patient post‐operatively was made by the clinician who was responsible for the patient's post‐operative care, and who was not involved in the study. The clinical criteria used to determine the need for transfusion consisted of the following: systolic BP less than 80mmHg; mean arterial pressure less than 50mmHg; central venous pressure (CVP) less than 5mmHg; pulmonary capillary wedge pressure (PCWP) less than 5mmHg; cardiac index (CI) less than 2.0L/min/m2; evidence of inadequate end‐organ perfusion (ie: urine output less than 20ml/hr), or anaemia (Hct less than 25%). Any patient who bled more than 400ml in the first 4 hours post‐operatively and who met any of these criteria underwent transfusion.

Outcomes

Amount of allogeneic blood transfused.
Amount of autologous blood transfused.
Number of patients transfused autologous and/or allogeneic blood.
Complications.
Bleeding times.
Plasma protein variables.
Post transfusion febrile reactions.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomly assigned on the basis of hospital number. The method of generating allocation sequences was not described.

Participants

232 patients undergoing total hip arthroplasties were randomly assigned to 1 of 2 groups:
(1) Group 1 (Autovac Post‐operative Orthopaedic Autotransfusion Canister system group): n=103.
(2) Group 2 (Control group): n=129.
NB: Demographic data not reported.

Interventions

(1) Group 1 (Autovac Post‐operative Orthopaedic Autotransfusion Canister group): blood was collected for 4 hours post‐operatively. The canister was injected with 40mls of acid‐citrate‐dextrose anticoagulant (ACD‐A) before activation. The canister was connected to wall suction with use of an Autovac Autotranfusion Regulator that limited maximum collection pressure to 100mmHg. If at least 300mls of blood was collected within 4 hours, the unwashed blood was reinfused through a microaggregate filter; if less than 300mls of blood was collected, the blood was discarded. Any blood that had not been reinfused within 6 hours after the beginning of collection was discarded.
(2) Group 2: closed suction drainage system (Hemovac system) was used.

Outcomes

Number of patients transfused allogeneic and./or autologous blood.
Blood loss.
Hb levels.

Notes

Transfusion protocol not reported.
All revision patients were exposed to cell salvage intra‐operatively.
85% of Group 1 patients predeposited blood pre‐operatively (PAD).
77% of Group 2 patients predeposited blood pre‐operatively (PAD).

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

75 consecutive patients undergoing coronary artery bypass graft surgery were randomised into 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=42; mean age (+/‐sd) = 60+/‐7 years.
(2) Group 2 (Control group): n=33; mean age (+/‐sd) = 59+/‐8 years.

Interventions

(1) Group1 (Autotransfusion group): received autotransfusion of shed mediastinal blood using the cardiotomy reservoir, after the completion of the coronary artery bypass grafting (CABG). As soon as the chest was closed, the mediastinal tubes were attached to the inlet port of the cardiotomy reservoir, which allows the chest tube drainage to pass through a 20 micron filter. The filtered blood was collected in the bottom of the cardiotomy reservoir, ready for reinfusion. The vacuum port was attached to wall suction apparatus and negative pressure was instituted at 20cm H2O. The chest drains were milked every 30 minutes. The collected blood was reinfused using a standard infusion pump. The hourly volume of mediastinal drainage was measured and the infusion pump adjusted to deliver this amount of blood over the next hour. Reinfusion was continued until the drainage was less than or equal to 50ml per hour for two consecutive hours.
(2) Group 2: was treated with standard chest drainage.
NB: Allogeneic packed cells were transfused intra‐operatively or post‐operatively when the haematocrit fell below 30%.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Wound infection.
Re‐operation for bleeding.
Hospital length of stay.
Fever.
Mortality.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

A stratified block design was used to pre‐operatively assign patients to intervention or control groups. Concealment of treatment allocation was by sealed envelopes.

Participants

100 patients undergoing aortic surgery were randomly allocated to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=50; M/F= 41/9; mean age (+/‐sd) = 63+/‐11 years.
(2) Group 2 (Control group): n=50; M/F=43/7; mean age (+/‐sd) = 65+/‐9 years.

Interventions

(1) Group1: Intra‐operative autotransfusion with Cell Saver device.
(2) Group 2: Did not receive autotransfusion.

Outcomes

Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Estimated blood loss.
Hospital length of stay.
ICU length of stay.
Adverse events.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

112 patients undergoing cardiac surgery were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=56; M/F=36/20; mean age (+/‐sd) = 67.4+/‐9.0 years.
(2) Group 2 (Control group): n=56; M/F=41/15; mean age (+/‐sd) = 65.3+/‐10.5 years.

Interventions

(1) Group 1: Autotransfusion group, transfused with washed post‐operative drainage fluid with a Fresenius Continuous Autotransfusion System.
(2) Group 2: Control group received usual care management without autotransfusion.

Outcomes

Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Mortality.
Reoperation for bleeding.
Blood loss.
Coagulopathy.
Hb levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

50 patients undergoing aortic surgery were randomly allocated to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=25; M/F=21/4; mean age (+/‐sd) = 68+/‐8 years.
(2) Group 2 (No intraoperative salvage group): n=25; M/F=22/3; mean age (+/‐sd) = 70+/‐8 years.

Interventions

(1) Group 1: blood was salvaged using the Sorenson autotransfusion system. Blood lost from the surgical site was suctioned into the Sorenson receptal device and this blood was retransfused into the patient at the time of surgery. Additional bood loss which was not able to be collected was replaced according to haematocrit levels, 3.5% polygeline being given if the haematocrit was above 30% and allogeneic blood if the haematocrit was below 30%. The collected blood was anticoagulated with an acid citrate dextrose solution and administered via a burette at a rate of 70ml for every 430ml of autologous blood collected. The scavenged blood was collected in a 1900ml sterile disposable Sorenson receptal ATS trauma liner contained within the rigid reusable receptal canister. When approximately 1 litre of autologous blood had been scavenged the liner was removed and this blood then administered to the patients after being filtered through a Pall 40 micron filter.
(2) Group 2: intraoperative blood loss was replaced with either 3.5% polygeline or allogeneic blood according to the measured Hct. If the Hct was above 30% then polygeline was used; if the Hct was below 30% then allogeneic blood was administered.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Mortality.
Reoperation for bleeding.
Haemodialysis.
Blood loss.
Coagulopathy.
Hb levels.
Organisms cultured from autologous vs allogeneic blood.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

100 patients undergoing myocardial revascularisation were randomly assigned to 1 of 4 groups:
(1) Group 1: n=25; mean age (+/‐sd) = 56.0+/‐6.6 years.
(2) Group 2: n=25; mean age (+/‐sd) = 54.1+/‐6.8 years.
(3) Group 3: n=25; mean age (+/‐sd) = 55.0+/‐9.4 years (4) Group 4: n=25; mean age (+/‐sd) = 55.7+/‐6.3 years.

Interventions

(1) Group 1: patients received unprocessed oxygenator blood after the termination of extracorporeal circulation (ECC).
(2) Group 2: the blood remaining in the oxygenator after ECC was processed to packed cells with a cell separator (Haemonetics Cell Saver) and retransfused until the end of the operation.
(3) Group 3: after the induction of anaesthesia and before the start of the operation, isovolumetric hemodilution (harvesting of 10ml/kg autologous blood) was performed under electrocardiographic and haemodynamic control. The blood loss was replaced with hydroxyethyl starch. After termination of ECC, the blood remaining in the oxygenator was processed by a cell separator. The preoperatively drawn blood and the packed cells were retransfused before the end of the operation.
(4) Group 4: patients in Group 4 were managed as in Group 3. In addition, the shed mediastinal blood was retransfused in the Intensive Care Unit (ICU). The cardiotomy reservoir of the heart lung machine was used to collect this blood. The drained blood was retransfused intermittently according to the circulatory state of the patient and when at least 250ml of blood had been collected in the reservoir. The last retransfusion was performed 6 hours postoperatively.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Mortality.
ICU length of stay.
Blood loss.
Reexploration for bleeding.
Operation time.
Haematological variables.
Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

45 patients undergoing total hip arthroplasty were randomly allocated to 1 of 3 groups;
(1) Group 1 (Control group): n=15.
(2) Group 2 (Autotransfusion ‐ Cell Saver group): n=15.
(3) Group 3 (Autologous predonation + Cell Saver group): n=15.
NB: Demographic data not reported.

Interventions

(1) Group 1 (Control group): blood loss was replaced with heterologous erythrocyte concentrate (SAGM‐ERC) and 3% dextran 60 in a ratio of 1:1. If necessary, additional SAGM‐ERC was transfused to correct erythrocyte volume fraction (EVF)>27%.
(2) Group 2 (Autotransfusion ‐ Cell Saver group): blood loss was replaced with 3% dextran and by autotransfusion of washed and haemconcentrated blood salvaged by intraoperative suction and from wound drains up to 4 hours postoperatively. As in Group 1, additional SAGM‐ERC was transfused to correct erythrocyte volume fraction (EVF)>27%.
(3) Group 3 (Autologous predonation + Cell Saver group): blood loss was replaced with 3% dextran and by autotransfusion of washed and haemconcentrated blood salvaged by intraoperative suction and from wound drains up to 4 hours postoperatively. Predonated autologous SAGM‐ERC was used instead of heterologous blood to maintain erythrocyte volume fraction (EVF)>27%. In 2‐3 sessions within 6 weeks prior to the operation, 2 to 3 units of SAGM‐ERC had been withdrawn. If necessary, heterologous SAGM‐ERC was used if transfusion of all predonated autologous blood failed to maintain EVF>27%.
Autotransfusion technique ‐ Haemonetic Cell Saver 4, Althin model AT 1000, or Shiley/Dideco STAT were used. Blood was retrieved from the operation site by suction through a double lumen catheter and was then anticoagulated with heparin (30,000 IU heparin in 1000ml of physiological saline). The blood was collected into a reservoir where a macrofilter removed debris. Thereafter, the blood was pumped into a spinning centrifuge bowl (125ml of blood) and washed with 1500ml of physiological saline. The erythrocytes were concentrated to an EVF of about 50‐60% and pumped into an infusion bag. The effluent containing platelets, free haemoglobin and anticoagulants was disposed.

Outcomes

Amount of allogeneic blood transfused.
Amount of autologous blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Swollen legs.
Minor stroke.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Concealment of treament allocation was by use of sealed envelopes. Method of generating allocation sequences was not described.

Participants

40 patients undergoing primary total hip arthroplasty were randomly allocated to 1 of 2 groups:
(1) Group 1 (IAT group): n=20; M/F=9/11; mean age = 68 years (range 59‐89 years).
(2) Group 2 (Control group): n=20; M/F=8/12; mean age = 74 years (range 48‐89 years).

Interventions

(1) Group 1 (Intra‐operative autotransfusion ‐ IAT group): received autologous blood using the cell saver. Intraoperative blood salvage was performed using the Electromedic Autotrans AT1000 autotransfusion system. Blood was retrieved from the operative field with a double lumen suction catheter. The blood was immediately anticoagulated with sodium citrate. Larger debris was removed by a 240 micron filter in the cardiotomy reservoir. The filtered blood was pumped into a bowl centrifuge and washed with 1500ml saline. The supernatant was discarded. The erythrocyte concentrate was pumped into a reinfusion bag and then reinfused into the patient.
(2) Group 2: received allogeneic blood.
NB: Thromboprophylaxis was given to all patients using dextran 70, 6% in saline (Macrodex) 500ml during the operation, another 500ml during the remainder of the operation day, and 500ml on postoperative days 1,3 and 5. A transfusion was given if the haemoglobin was less than 8.5g/dL or if there were symptoms of anaemia.

Outcomes

Amount of allogeneic units transfused.
Number of patients receiving allogeneic blood.
Complications.
Blood loss.
Haematological variables.

Notes

Tranfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

40 patients (33 males and 7 females) undergoing elective coronary artery bypass surgery were randomised into 1 of 2 groups:
(1) Group 1 (Autologous blood transfusion group): n=20.
(2) Group 2 (Control group): n=20.
Mean age for both groups = 55.75 years (range 33‐69 years).

Interventions

(1) Group 1: received postoperative autologous blood transfusion (AT) using the Shiley hardshell venous reservoir. At the end of the operation in theatre, the chest drains were connected to the Shiley hardshell venous reservoir using the Shiley drainage set. After the system was primed and specimens obtained for haematological, biochemical, and bacteriological analyses, transfusion of the shed blood was commenced, the rate depending on the amount of drainage, reinfusing the previous hours blood loss over the subsequent hour. At the end of 6 hours the AT was discontinued and further specimens were obtained.
(2) Group 2: patients were managed in the same manner without the use of autologous blood transfusion.
NB: Blood was used only when the haematocrit fell below 25%, haemoglobin below 9.0g/dL or the blood loss exceeded 500ml in the first 4 hours.

Outcomes

Amount of blood re‐transfused from the cell save.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Hospital length of stay.
Mortality.
Blood loss.
Haematological variables.
Wound infection.
Sternal wound discharge.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described [Italian article].

Participants

82 patients undergoing myocardial revascularisation were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=41; M/F=37/4; mean age (+/‐sd) = 60.2+/‐9.3 years.
(2) Group 2 (No Autotransfusion group): n=41; M/F=33/8; mean age (+/‐sd) = 62.7+/‐8.9 years.

Interventions

(1) Group 1: Autotransfusion was used.
(2) Group 2: Autotransfusion was not used.

Outcomes

Amount of blood collected by the cell saver.
Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Blood loss.
Mortality.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

A computer‐generated random number list was used to pre‐operatively assign patients to intervention or control groups. Method of allocation concealment was not described.

Participants

239 consecutive patients undergoing total knee replacement procedures were randomly assigned to 1 of 2 groups:
(1) Group 1 (Solcotrans system): n=124; M/F=59/65; mean age = 65 years.
(2) Group 2 (Control group): n=115; M/F=46/69; mean age = 69 years.

Interventions

(1) Group 1: the wounds of patients in the study group were drained into Solcotrans (Solco Basle) postoperative blood salvage cannisters. There was a 6 hour total time limit for collection and reinfusion of blood. Because 40ml of citrate ACD‐A was entered in each Solcotrans canister prior to use, a minimum of 320ml of blood and citrate volume was necessary before reinfusion to prevent citrate toxicity. If wound drainage was slow and an adequate volume had not been collected before the 6‐hour time limit, the canister and blood were discarded, and a standard collection canister was attached to the drainage tube for the duration. If wound drainage was rapid, the canister was allowed to fill completely (500ml volume). The blood was then infused at an appropraite rate as long as the 6‐hour pre‐canister limit was not exceeded. Another Solcotrans canister could then be attached, beginning a new 6‐hour time interval.
(2) Group 2: the wounds of patients in the control group were drained into standard 400ml suction cannisters.

Outcomes

Amount of blood re‐transfused from the cell saver.
Number of patients transfused allogeneic blood.
Complications.
Transfusion reactions.
Fat embolism.
Respiratory distress syndrome.
Sepsis.
Intravascular coagulopathy.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

128 patients undergoing total hip arthroplasty, total knee arthroplasty, or spine fusion were randomly allocated to 1 of 3 groups:
(1) Group 1 (Orth‐Evac group): n=44; M/F=18/26; mean age = 67.9 years (range 41‐82 years).
(2) Group 2 (Solcotrans group: n=40); M/F=20/20; mean age = 66.3 years (range 54‐82 years).
(3) Group 3 (Control group): n=44; M/F=23/21; mean age = 62.5 years.

Interventions

(1) Group 1 received autologous shed blood reinfusion collected from wound drainage by an Orth‐evac device.
(2) Group 2 received autologous shed blood reinfusion collected from wound drainage by a Solcotrans device.
(3) Group 3 received either autologous predonated blood or allogeneic banked blood.
NB: Patients randomised to the autologous shed blood groups (Group 1 and Group 2) were randomly assigned to one of two infusion filters (Pall 40 micron screen filter or Pall RC100 polyester filter) for the transfusion phase of the study. In patients who were not reinfused with postoperative shed blood, a standard wound drainage system (Hemovac) was used, and these patients received liquid‐preserved autologous predonated blood or allogeneic blood filtered with a standard 170 micron screen filter. With the Solcotrans drainage system, 40ml acid citrate detrose (ACD) was used. No anticoagulant was added with the Ortho‐evac drainage system.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from cell saver.
Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Complications.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

81 patients undergoing elective knee arthroplasty were randomly assigned to 1 of 2 groups:
(1) Group 1 (Solcotrans group): n=39; M/F=14/25; mean age (+/‐sd) = 69.3+/‐6.9 years.
(2) Group 2 (Control group): n=40; M/F=14/26; mean age (+/‐sd) = 71.0+/‐9.0 years.

Interventions

(1) Group 1: patients underwent drainage and autotransfusion transfusion using a Solcotrans system. The autologous blood collected into the drainage and transfusion device was transfused if specific transfusion guidelines were met. Patients were transfused the initial unit of Solcotrans blood if 350ml or more had been collected within 3 hours of the patients entry to the recovery room. The 3‐hour collection time provided for collection and transfusion of the blood within the maximum interval of 6 hours. After successful collection and transfusion of the first autologous blood unit, a second autologous blood collection device was attached. For this and subsequent collections, autologous blood was transfused if 150ml or more was collected within 3 hours. When the rate of drainage was less than 250ml of blood within a 3 hour period, a subsequent drainage and transfusion device was not attached. The first Solcotrans device attached to the drain contained 40ml of ACD‐A.
(2) Group 2: the drained blood was collected by a Davol suction unit and discarded. The Davol unit was the current standard practice in the two study centres. Patients assigned to the Davol suction group received 1 unit of allogeneic red cells if more than 500ml of blood drained from the surgical site within a 2 hour period. Subsequently, whenever drainage exceeded 500ml within a 2 hour period, 1 unit of allogeneic blood was transfused.
Nb: On postoperative Days 2 through 5, the criteria for allogeneic red cell transfusions were identical for both groups. Patients were given one unit of red cell concentrate if their haemoglobin was within the range of 80 to 89g/L, two units when the value was from 70 to 79g/L, three units when the value was from 60 to 69g/L, and four units if the value was from 50 to 59g/L.

Outcomes

Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Transfusion reactions.
Blood loss.
Coagulation variables.
Venogram results.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomised on an alternating basis to either intervention or control. Method of randomisation was not described.

Participants

36 patients undergoing aortobifemoral or aortobi‐iliac bypass for occlusive disease were randomised to 1 of 2 groups:
(1) Group 1 (Cell Saver Autotransfusion Device ‐ Haemonetics): n=18.
(2) Group 2 (Control group): n=18.
NB: Demographic data not reported.

Interventions

(1) Group 1: Cell Saver Autotransfusion Device (Haemonetics) was monitored and operated by a technician‐member of the perfusion team.
(2) Group 2: No Cell‐Saver system was used.
NB: After operation allogeneic red cell transfusions were not given to patients who were haemodynamically stable, and had haemoglobin values greater than 8.0g/dL.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Complications.
Hospital length of stay.
Blood loss.
Hb levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Each patient was allocated on an alternating basis to one of two groups. The method of randomisation was not described.

Participants

40 patients undergoing elective coronary artery bypass graft surgery (CABG) were randomised to 1 of 2 groups:
(1) Group 1 (Cell Saver III‐plus ‐ Haemonetics group): n=20; M/F=14/3; mean age (+/‐sd) = 64+/‐7 years.
(2) Group 2 (Control group): n=20; M/F=17/3; mean age (+/‐sd) = 62+/‐10 years.

Interventions

(1) Group 1: Cell‐Saver group all received peri‐operative autotransfusion of blood processed by means of the Cell‐Saver III‐plus with a 225ml bowl. Additionally, allogeneic packed cells were transfused to maintain an Hct at 30%.
(2) Group 2: Control group received allogeneic packed cells only to maintain a Hct at 30%. No cell saver was used.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell save.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Blood loss.
Hb & Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Each patient was allocated on an alternating basis to one of two groups. The method of randomisation was not described.

Participants

60 patients undergoing total hip arthroplasty or dorsal lumbo‐sacral fusion surgery were randomised to 1 of 2 groups:
(1) Group 1 (Haemonetic Haemolite‐2 Cell Saver group): n=30; M/F=6/23; mean age (+/‐sd) = 51+/‐18 years.
(2) Group 2 (Control group): n=30; M/F=7/23; mean age (+/‐sd) = 53+/‐18 years.

Interventions

(1) Group 1: all patients received peri‐operative autotransfusion by means of the Haemonetics Haemolite‐2 with a 200ml bowl. Allogeneic packed cells were transfused to maintain the patients Hct at 30%. The blood shed intra‐operaively and during the first six post‐operative hours was collected and heparinised. The blood was processed in the Haemolite‐2 by personnel of the Intensive Care Unit. The erythrocyte suspension thus produced was transfused to the patient within 4 hours after collection through a 40 micron blood filter. Blood cultures were taken before retransfusion to the patient.
(2) Group 2: received only allogeneic transfusions to maintain a Hct at 30%.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Blood loss.
Hb & Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Patients were randomised by coded instruction packets which specified the processing and administration of the patient's salvaged intra‐operative blood. Sealed instruction packets were randomised using a shuffle deck procedure, serially numbered, and assigned sequentially to patients in order of enrollment. The sealed instruction packets were sent with the patients to the operating room.

Participants

50 patients undergoing primary coronary revascularisation were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=19; M/F=15/4; mean age (+/‐sd) = 65.0+/‐10.5 years.
(2) Group 2 (Control group): n=19; M/F=14/5; mean age (+/‐sd) = 64.4+/‐9.2 years.

Interventions

(1) Group 1: blood was scavenged from the surgical field in all cases using an autologous blood scavenging system (Cell Saver 4, Haemonetics). The shed blood collected from the operative field and the pump blood were washed and then reinfused.
(2) Group 2: blood was scavenged from the surgical field in all cases using an autologous blood scavenging system (Cell Saver 4, Haemonetics). The shed blood collected from the operative field was discarded. Only the pump blood was reinfused.
NB: Packed red blood cell transfusions were given if the patients haemoglobin was less than 7.0g/dL or if the patient was haemodynamically unstable due to volume loss.

Outcomes

Amount of blood re‐transfused from the cell saver.
Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Amount of any blood product transfused.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

135 patients undergoing cardiac surgery were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=67; M/F=52/15; mean age (+/‐sd) = 60+/‐12 years.
(2) Group 2 (Control group): n=68; M/F=51/17; mean age (+/‐sd) = 61+/‐10 years.

Interventions

(1) Group 1: after use in extracorporeal circulation, the cardiotomy reservoir (Dideco 742) was reconfigured to serve as a receptacle for post‐operative mediastinal drainage. One of the inlet ports was connected to the tubes draining the mediastinum. In this way the drainage from the chest passed through the 20 micron filter of the cardiotomy reservoir. The cardiotomy outlet tubing was replaced with an adapter connecting with standard intravenous tubing. A standard infusion pump was used to reinfuse the collected blood.The filtered blood collecting in the reservoir was reinfused at hourly intervals. No blood was reinfused after the 6th post‐operative hour. Thereafter the reservoir served only as a receptable for shed mediastinal blood. Reservoir blood was sampled at 6 hours for bacteriologic study.
(2) Group 2: received no reinfused blood, but in other respects was managed the same as the autotransfusion group.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Mortality.
Blood loss.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not clear [German article].

Participants

64 patients scheduled for total hip arthroplasty were randomly divided into 1 of 4 groups:
(1) Group 1 (Preoperative autologous donation group): n=16.
(2) Group 2 (Preoperative haemodilution group): n=16.
(3) Group 3 (Intraoperative + Postoperative autotransfusion group): n=16.
(4) Group 4 (Control group): n=15.

Interventions

(1) Group 1: preoperative autologous donations were stored in CPDA‐1 buffer. Three units of 450ml were requested. A predonation haemoglobin (Hb) concentration of 11g/dL was required. Surgery was carried out in the 5th week after the first donation.
(2) Group 2: preoperative haemodilution to Hb 9.0g/dL was carried out after the induction of anaesthesia and initial circulatory stabilisation.
(3) Group 3: a cell separator was used for intraoperative and post‐operative autotransfusion. Post‐operative autotransfusion of drainage blood was continued until 6 hours after the beginning of the operation. Autologous blood collected with the cell separator was retransfused at the end of the operation and after the autotransfusion period irrespective of the actual Hb concentration.
(4) Control group: received standard care.
NB: Polygeline was used for volume resuscitation. If the Hb concentration fell below 9.0g/dL in the operating room and the intensive care unit (ICU) or below 10.0g/dL in the general ward, autologous or allogeneic packed red cells were transfused.

Outcomes

Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Blood loss.

Notes

Transfusion protocol use.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomised using a computer‐generated randomisation table. Method of allocation concealment was not described.

Participants

99 patients undergoing elective primary total knee replacement surgery were randomly allocated to one of two groups:
(1) Group 1 (Cell‐Saver Electromedics BT‐795 group): n=44.
(2) Group 2 (Control group): n=55.
NB: Demographic data not reported.

Interventions

(1) Group 1: blood salvage was performed using a semi‐automated autotransfuser (Electromedics BT‐795) according to the manufacturer's instructions. Intra‐operative blood salvage was performed by a nurse in conjunction with an anaesthetist. Post‐operative blood salvage was a continuation of the intra‐operative salvage for a duration not exceeding 6 hours after the tourniquet was released. On completion of salvage, the wound drains were connected to two vacuum‐charged Redivac bottles and the drains were removed at 48 hours post operation. The average volume of blood salvaged in each patient was calculated after adjusting the haematocrit to 40%. Transfusions were used intra/post‐operatively to maintain a safe blood volume and the haemoglobin level around 100g/L.
(2) Group 2: no cell saver system was used.
NB: In total knee replacement patients, standard surgical technique using a midline incision and medial parapatellar approach under tourniquet control was followed, and lateral release of the quadriceps expansion was not routinely performed.

Outcomes

Number of patients transfused allogeneic blood.
Blood loss.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

40 patients undergoing primary unilateral total knee arthroplasty were randomised to 1 of 2 groups:
(1) Group 1 (Solcotrans groups): n=20; M/F=6/14; mean age = 71.3 years.
(2) Group 2 (Control group): n=20; M/F=6/14; mean age = 70.3 years.

Interventions

(1) Group 1: the two deep intra‐articular drains were connected to a Solcotrans reservoir and a suction pressure of 80mmHg applied for an initial period of 10 minutes, after which the wound was allowed to drain by gravity alone. Two Solcotrans reservoirs were attached sequentially to each patient regardless of the volume drained. Blood was reinfused if a sufficient volume had been collected. Drains were removed at 48 hours.
(2) Group 2: all drains were attached to Redivac bottles.
NB: Allogeneic blood was given to patients if the haemoglobin fell below 9.5g/dL or if indicated haemodynamically.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Complications.
Deep vein thrombosis.
Wound complications.
Haematological variables.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

198 patients undergoing coronary arery bypass grafting (CABG) or valvular surgery were randomised to 1 of 2 groups:
1) Group 1 (Autotransfusion group): n=98; M/F= 75/23; mean age (+/‐sd) = 62+/‐2 years.
(2) Group 2 (Control group): n=100; M/F=70/30; mean age (+/‐sd) = 66+/‐2 years.

Interventions

(1) Group 1: were treated with an autotransfusion system (Atrium Medical Corporation) consisting of 28F thoracic tubes connected to a 3 chamber system. All collected blood is filtered through a filter and autotransfused until no drainage was present or for a maximum period of 12 hours. Transfusion began 1 hour after the patient arrived in ICU.
(2) Group 2: post‐operative mediastinal drainage was achieved by a 24F double‐lumen soft pump drain under high pressure wall suction, from which the collected blood was discarded.

Outcomes

Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Blood loss.
Adverse events.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Randomisation was performed using a random numbers table. Allocation concealment was not described.

Participants

111 patients undergoing elective primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) were randomly assigned to 1 of 2 groups:
(1) Group 1 (CBC‐Consta Vac reinfusion system): n=57.
(2) Group 2 (Consta Vac collection unit): n=54.
Mean age of TKA patients was 68 years (range 39‐88 years). Mean age of THA patients was 62 years (range 27‐85 years).

Interventions

(1) Group 1: were treated with a blood collection system, CBC Consta Vac, a battery‐operated suction unit set at 62mmHg, with a 800ml collection canister. The CBC Consta Vac system has an umbrella valve that ensures that the top 100ml of fluid containing serum fat, and bone debris does not leave the reservoir. Post‐operative drainage was collected, and the unwashed red blood cells were reinfused within a 6‐hour period. The blood was reinfused through a 20um macroaggregate filter.
(2) Group 2: were treated with a standard post‐operative collection system, the Consta Vac, a battery‐operated suction unit set at 62mmHg, with a 400ml collection canister.
NB: All patients were encouraged to donate two units of autologous blood prior to both THA and TKA. Intra‐operative blood transfusion was left to the discretion of the operating surgeon.

Outcomes

Number of patients transfused allogeneic or autologous blood Post‐operative drainage.
Hb levels.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patient allocations were generated from random number tables by an independent observer and concealed in sealed opaque envelopes.

Participants

256 patients undergoing elective coronary artery bypass surgery were randomly allocated to 1 of 3 groups:
(1) Group 1 (Intra‐operative cell salvage group): n=84; M/F=75/9; mean (+/‐sd) age = 63.8+/‐7.8 years.
(2) group 2 (Combined treatment group): n=84; M/F=74/10; mean (+/‐sd) age = 63.1+/‐8.2 years.
(3) Group 3 (Control group): n=84; M/F=74/10; mean (+/‐sd) age = 63.4+/‐9.1 years.

Interventions

(1) Group 1: during surgery blood from the operation site was collected in a storage system. At the termination of cardiopulmonary bypass, blood remaining in the bypass circuit was added to the storage system. This blood was then centrifuged using a cell salvage system (Dideco Compact cell saver) leaving a concentrated solution of red blood cells with a haematocrit of 50‐60%. This autologous blood was then re‐transfused to the patient during the intra‐operative period.
(2) Group 2: were treated with cell salvage and acute normovolaemic haemodilution (ANH). After induction of anaesthesia 10ml/kg of blood was removed from a central venous line while being replaced at the same time with an equivalent volume of modified gelatin (Gelofusine). The Harvest Blood Stream Recovery System, an autologous recovery system, was used to remove blood. The recovered blood was stored at room temperature.
(3) Group 3: were treated without the use of cell salvage or acute normovolaemic haemodilution (ANH).
NB: Allogeneic red blood cells were transfused in all groups when the haemoglobin level fell below 9.0g/dL.

Outcomes

Number of patients transfused allogeneic blood.
Number of patients receiving any blood product.
Amount of allogeneic blood transfused.
Blood loss.
Re‐operation for bleeding.
Hospital length of stay.
Infection.
Stroke.
Renal failure.
Myocardial infarction.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described [German article].

Participants

42 patients undergoing total hip surgery and predonor plasmapheresis (Abbott Autotrans) were randomised into 1 of 3 groups:
(1) Group 1 (Control group): n=12; mean age (+/‐sd) = 66.7+/‐12.7 years.
(2) Group 2 (Autotransfusion group): n=14; mean age (+/‐sd) = 55.9+/‐18.2 years.
(3) Group 3 (Autotransfusion + FFP group): n=16; mean age (+/‐sd) = 70.6+/‐7.0 years.

Interventions

(1) Group 1: for the substitution of blood loss, patients received, in addition to crystalloids and colloids, only allogeneic red blood cells (erythrocyte concentrate). Cell salvage was not used.
(2) Group 2: for the substitution of blood loss, patients received, in addition to crystalloids and colloids, only autologous packed red blood cells (erythrocyte concentrate) (collected via Autotrans BT 795 P, Dideco, intra‐operatively) post‐operatively.
(3) Group 3: received additionally, intra‐operative and post‐operative autologous fresh frozen plasma (FFP).
NB: Study investigated the influence of two different methods of autotransfusion on the intravascular haemostatic system.

Outcomes

Amount of blood re‐transfused from the cell saver.
Number of patients transfused allogeneic blood.
Blood loss.
Hb & Hct levels.
Clotting status (PT/TT/PTT/ATIII).
Immunological methods.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation was not reported and allocation concealment was unclear. Baseline comparability was unclear. However the study reported that, "no significant difference between groups were detected at any stage of the study." Participants were not blind to treatment allocation and blinding of the outcome assessor was unclear [Russian article].

Participants

66 patients undergoing elective coronary artery bypass surgery (CABG) were randomly allocated to 1 of 2 groups:
(1) Group 1 (Control group): n=33.
(2) Group 2 (Autotransfusion): n=33.
NB: Demographic data not reported.
Inclusion criteria: patients with an uneventful postoperative period (discharge of less than 800ml through draining tubes during first 8 hours post operation).

Interventions

Group 1: no retransfusion of drainage discharge.
Group 2: drainage discharge collected for 8 hours post‐operatively and reinfused using a BRAT‐2 Cell Saver. Drainage discharge collected for 8 hours post‐operatively and erythrocytes reinfused post‐operatively after washing. The volume of autologous blood collected was up to 800mls.

Outcomes

Number of patients transfused allogeneic blood.

Notes

Transfusion protocol not reported.
Russian study.
English abstract only.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

D ‐ Not used

Methods

Randomisation was by random‐number tables. Method of allocation concealment was not described.

Participants

70 consecutive patients undergoing unilateral total knee replacement with a cruciate‐sparing Kinemax Plus prosthesis were randomly allocated to 1 of 2 groups:
(1) Group 1 (Autologous blood group ‐ Dideco 797): n=35.
(2) Group 2 (Standard Haemovac system group): n=35.
Mean age of patients enrolled in study was 72 years. NB: Demographic data not reported.

Interventions

(1) Group 1: deep and superficial drains were inserted before skin closure and connected to the Dideco 797 reinfusion system which maintains a constant suction of ‐25mmHg. The drainage collected was mixed with citrate in a ratio of 12:1, filtered during collection and again during reinfusion through a 40um filter. No washing took place. Drainage was collected for 6 hours or until 500 ml had accumulated, at which point reinfusion of the unwashed salvaged blood took place.
(2) Group 2: deep and superficial drains were inserted before skin closure and connected to a standard Haemovac system which maintains a constant suction of ‐25mmHg. Autotransfusion was not available to this group.

Outcomes

Amount of blood re‐transfused from cell saver.
Amount of allogenic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Hospital length of stay.
Urinary tract infections.
Chest infections.
Antibiotic usage.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

100 consecutive patients undergoing elective coronary artery or valvular operations were randomly allocated to 1 of 2 groups:
(1) Group 1 (Control group): n=51; M/F=38/14; mean age (+/‐sd) = 56.9+/‐9.4 years.
(2) Group 2 (Cell salvage group): n=48; M/F=38/11; mean age (+/‐sd) = 58.3+/‐8.9 years.

Interventions

(1) Group 1 ‐ a Polystan soft‐shell cardiotomy reservoir (Polystan A/S Walgerholm 8) was used during bypass. Blood was drained into conventional drainage bottles with an applied suction of 25cmH2O.
(2) Group 2 ‐ a Bentley Catr hard‐shell cardiotomy reservoir (Bentley‐Edwards CVS Division) was used during bypass. Both drains were connected to the top of the cardiotomy reservoir, previously used during bypass, and suction of 50cmH2O was applied. Patients had their shed mediastinal blood reinfused for up to 18 hours post‐operatively.
Nb: After bypass, any residual blood left in the perfusion circuit was saved and infused through a peripheral vein. Both groups of patients had pericardial and mediastinal drains (Axiom). A variety of both membrane and bubble oxygenators were used in both groups. Allogeneic blood or hetastarch was infused to maintain cardiovascular stability and a haematocrit of 30%.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Re‐exploration for bleeding.
Blood borne infection.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

66 patients undergoing aortocoronary bypass surgery were randomly assigned to 1 of 3 groups:
(1) Group 1: n=22; mean age = 61 years.
(2) Group 2: n=22; mean age = 60 years.
(3) Group 3: n=22; mean age = 55 years.

Interventions

(1) Group 1: patients received allogeneic blood transfusions if their haematocrit fell below 20% during bypass, 28% at the end of the procedure, 30% within 24 hours, or if their haemoglobin level was less than 10g/dL while on the cardiac surgery ward (8 to 10 days).
(2) Group 2: received intra‐operative autologous blood. Intra‐operative autologous blood consisted of the blood contents of the oxygenator after concentration but without any washing, by the Haemonetics Cell Saver III autologous transfusion system.
(3) Group 3: received intra‐operative and post‐operative autologous blood. Post‐operative autologous blood consisted of the mediastinal blood shed during the first 6 hours, into a heparinised drainage system (PLEUR‐EVACA 4005) which was concentrated and washed by a Haemonetics Haemolite system.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Mortality.
Blood loss.
Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

A random number table was used to assign patients in equal numbers to the two groups. Method of allocation concealment was not described.

Participants

50 patients undergoing elective spinal surgery were randomly assigned to 1 of 2 groups:
(1) Group 1 (Solcotrans group): n=25; M/F=7/18; mean age (+/‐sd) = 52+/‐16 years.
(2) Group 2 (Control group): n=25; M/F=12/13; mean age (+/‐sd) = 52+/‐17 years.

Interventions

(1) Group 1: post‐operatively drained blood was collected into a Solcotrans Orthopedic Plus system. The salvaged blood was considered for re‐infusion.
(2) Group 2: post‐operatively drained blood was collected into a Solcotrans Orthopedic Plus system but the salvaged blood was not considered for re‐infusion.
NB: No anticoagulation was added to the Solcotrans system. The duration of drainage was limited to the first 5‐hours of the post‐operative period. At the end of this period, patients from the Solcotrans group whose drained blood volume was greater than 200ml had this blood re‐infused. In the control group the salvaged blood was not re‐infused. Blood transfusion (allogeneic and/or autologous) was decided if haematocrit was below 25% during the peri‐operative period.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomised by month of birth into four groups.

Participants

153 patients undergoing primary total hip arthroplasty were randomised to 1 of 4 groups:
(1) Group 1 (Haemonetics group): n=35; M/F=19/16; mean age = 68 years (range 50‐86 years)
(2) Group 2 (Solcotrans drainage infusion system group): n=40; M/F=24/16; mean age = 68 years (range 28‐87)
(3) Group 3 (Closed system Hemovac drain group): n=38; M/F=20/20; mean age = 64 years (range 39‐85 years)
(4) Group 4 (No drain group): n=38; M/F=20/18; mean age = 61 years (range 38‐86).

Interventions

(1) Group 1: the intra‐operative salvage of red blood cells was performed with the Haemonetics Cell‐Saver. A paediatric bowl was used for the processing of salvaged, shed blood. This collection was continued after surgery through two medium drains while the patient remained in the recovery room. A closed‐suction standard Hemovac drain was placed when salvage was discontinued.
(2) Group 2: were treated with a Solcotrans drainage infusion system at the completion of surgery. This system consists of a 500ml collection canister with 260 micron pre‐transfusion filter for collection and a 40 micron filter for transfusion. A minimum of 300 ml of blood had to be collected within a 4 hour period. Total collection / infusion time could not exceed 6 hours. A maximum of 2 units could be reinfused. After the completion of the transfusions, the Solcotrans unit was discarded and replaced with a closed‐suction drain.
(3) Group 3: were treated with a standard 400ml Hemovac closed‐suction drain.
(4) Group 4: did not receive drains at the completion of surgery.

Outcomes

Amount of allogeneic and/or autologous blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Hb & Hct levels.
Thigh circumference measures.
Wound drainage.

Notes

Patients were able to donate at least 2 units of autologous blood pre‐operatively were included in the study.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Patients were randomised by month of birth into four groups.

Participants

153 patients undergoing primary total hip arthroplasty were randomised to 1 of 4 groups:
(1) Group 1 (Haemonetics group): n=35; M/F=19/16; mean age = 68 years (range 50‐86 years)
(2) Group 2 (Solcotrans drainage infusion system group): n=40; M/F=24/16; mean age = 68 years (range 28‐87)
(3) Group 3 (Closed system Hemovac drain group): n=38; M/F=20/20; mean age = 64 years (range 39‐85 years)
(4) Group 4 (No drain group): n=38; M/F=20/18; mean age = 61 years (range 38‐86).

Interventions

(1) Group 1: the intra‐operative salvage of red blood cells was performed with the Haemonetics Cell‐Saver. A paediatric bowl was used for the processing of salvaged, shed blood. This collection was continued after surgery through two medium drains while the patient remained in the recovery room. A closed‐suction standard Hemovac drain was placed when salvage was discontinued.
(2) Group 2: were treated with a Solcotrans drainage infusion system at the completion of surgery. This system consists of a 500ml collection canister with 260 micron pre‐transfusion filter for collection and a 40 micron filter for transfusion. A minimum of 300 ml of blood had to be collected within a 4 hour period. Total collection / infusion time could not exceed 6 hours. A maximum of 2 units could be reinfused. After the completion of the transfusions, the Solcotrans unit was discarded and replaced with a closed‐suction drain.
(3) Group 3: were treated with a standard 400ml Hemovac closed‐suction drain.
(4) Group 4: did not receive drains at the completion of surgery.

Outcomes

Amount of allogeneic and/or autologous blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Hb & Hct levels.
Thigh circumference measures.
Wound drainage.

Notes

Patients able to donate at least 2 units of autologous blood were included in the study.
NB: Data from Rollo 1995 has been used to formulate Rollo 1995/a which represents a comparison of Haemonetics Cell‐Saver group vs No drainage group (Control).

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Patients were randomised by month of birth into four groups.

Participants

153 patients undergoing primary total hip arthroplasty were randomised to 1 of 4 groups:
(1) Group 1 (Haemonetics group): n=35; M/F=19/16; mean age = 68 years (range 50‐86 years).
(2) Group 2 (Solcotrans drainage infusion system group): n=40; M/F=24/16; mean age = 68 years (range 28‐87).
(3) Group 3 (Closed system Hemovac drain group): n=38; M/F=20/20; mean age = 64 years (range 39‐85 years).
(4) Group 4 (No drain group): n=38; M/F=20/18; mean age = 61 years (range 38‐86).

Interventions

(1) Group 1: the intra‐operative salvage of red blood cells was performed with the Haemonetics Cell‐Saver. A paediatric bowl was used for the processing of salvaged, shed blood. This collection was continued after surgery through two medium drains while the patient remained in the recovery room. A closed‐suction standard Hemovac drain was placed when salvage was discontinued.
(2) Group 2: patients were treated with a Solcotrans drainage infusion system at the completion of surgery. This system consists of a 500ml collection canister with 260 micron pre‐transfusion filter for collection and a 40 micron filter for transfusion. A minimum of 300 ml of blood had to be collected within a 4 hour period. Total collection / infusion time could not exceed 6 hours. A maximum of 2 units could be reinfused. After the completion of the transfusions, the Solcotrans unit was discarded and replaced with a closed‐suction drain.
(3) Group 3: patients were treated with a standard 400ml Hemovac closed‐suction drain.
(4) Group 4: patients did not receive drains at the completion of surgery.

Outcomes

Amount of allogeneic and/or autologous blood transfused.
Number of patients receiving allogeneic blood.
Complications.
Hb & Hct levels.
Thigh circumference measures.
Wound drainage.

Notes

Patients able to donate at least 2 units of autologous blood were included in the study.
NB: Data from Rollo 1995 has been used to formulate Rollo 1995/b which represents a comparison of the Solcotrans group vs No drainage group (Control).

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described. [French article]

Participants

30 patients undergoing total knee arthroplasty were randomised to 1 of 3 groups:
(1) Group 1 (Ortho‐evac group): n=10; mean age (+/‐sd) = 68+/‐10 years.
(2) Group 2 (Solcotrans group): n=10; mean age (+/‐sd) = 70+/‐10 years.
(3) Group 3 (Control group): n=10; mean age (+/‐sd) = 68+/‐15 years.

Interventions

(1) Group 1: an Ortho‐evac system (not containing an anticoagulant) was connected to the deep suction drains in the operating room, after skin closure and before tourniquet removal. The salvaged blood was reinfused in the subsequent six hours via a 40 micron filter. The volume of collected blood was measured and allogeneic blood was added as required, to maintain a haematocrit of 30%. A blood sample was obtained before surgery, before reinfusion, two hours later, one day later, and from the collecting device before reinfusion. The Ortho‐evac system had a 1000ml capacity.
(2) Group 2: a Solcotrans system (not containing an anticoagulant) was connected to the deep suction drains in the operating room, after skin closure and before tourniquet removal. The salvaged blood was reinfused in the subsequent six hours via a 40 micron filter. The volume of collected blood was measured and allogeneic blood was added as required, to maintain a haematocrit of 30%. A blood sample was obtained before surgery, before reinfusion, two hours later, one day later, and from the collecting device before reinfusion. The Solcotrans system had a 500ml capacity.
(3) Group 3: cell salvage was not performed.

Outcomes

Amount of blood collected by the cell saver.
Number of patients transfused allogeneic blood.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

120 patients undergoing total knee arthroplasty randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=60.
(2) Group 2 (Control group): n=60.
NB: Demographic data not reported.

Interventions

(1) Group 1: autotransfusion was used. Methods used to perform cell salvage were not described.
(2) Group 2: cell salvage not performed.

Outcomes

Number of patients transfused allogeneic blood.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomised by odd or even history numbers to either intervention or control groups.

Participants

114 patients undergoing cardiac surgery were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=63; M/F=41/22; mean age (+/‐sd) = 53.6+/‐10.3 years.
(2) Group 2 (Control group): n=51; M/F=32/19; mean age (+/‐sd) = 53.4+/‐10.0 years.

Interventions

(1) Group 1: patients were treated with a Sorenson autotransfusion system (ATS) for the collection of shed mediastinal blood. Blood collected in the ATS bags was considered suitable for autotransfusion only if 400mls or more was collected within 4 hours. If the rate of mediastinal bleeding was slow and 4 hours passed without 400ml volume being collected, this blood was not reinfused. If Hct values were below 35% and left ventricular filling was judged to be adequate, whole blood and/or packed red blood cells were infused to restore intravascular volume. With higher haematocrit and with low left ventricular filling pressures, patients received an infusion of colloid solution or crystalloid solution (Ringer's lactate). Shed mediastinal blood was given in preference to stored bank blood when volume replacement was necessary.
(2) Group 2: received only transfusions of stored bank blood. Cell salvage was not performed.

Outcomes

Amount of allogeneic blood transfused.
Total blood and blood component replacement.
Mediastinal blood loss.
Haematological variables.
Complications.

Notes

Transfusion protocol not reported.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation was not described. Allocation concealment was by means of sealed envelopes.

Participants

120 adult patients undergoing primary elective coronary artery bypass grafting were randomly allocated to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=53; M/F=46/7; mean age (+/‐sd) = 58.5+/‐7.4 years (range 38‐69 years).
(2) Group 2 (Control group): n=56; M/F=51/5; mean age (+/‐sd) = 57.5+/‐8.9 years (range 31‐72 years).

Interventions

(1) Group 1: at the end of the operation, the mediastinal and pleural tubes were attached to the inlet port of the Bard cardiotomy / autotransfusion reservoir. Shed mediastinal blood from the cardiotomy reservoir was transfused every hour for the first 18 postoperative hours if more than 20ml of blood had accumulated. Prior to transfusion the shed mediastinal blood was filtered through a 40micron filter in the cardiotomy reservoir.
(2) Group 2: the cardiotomy reservoir was used for mediastinal drainage only.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Sternal infections.
Myocardial infarctions.
Sepsis.
Mortality.
Blood loss.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

40 patients undergoing elective primary unilateral internal mammary (IMA) artery bypass grafting were randomly assigned to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=20; M/F=15/5; mean age (+/‐sd) = 64+/‐10.7 years.
(2) Group 2 ‐ No autotransfusion group (Control group): n=20; M/F=15/5; mean age (+/‐sd) = 63+/‐6.3 years.

Interventions

(1) Group 1: patients underwent internal mammary artery (IMA) surgery with pre‐bypass removal of autologous blood, reinfusion of the remaining volume in the extracorporeal circuit (ECC) after aortic decannulation, administration of 200ml aprotinin containing 280mg of aprotinin (2 million kallikrein inactivator units) added to the pump prime, acceptance of normovolemic anaemia (Hct greater than or equal to 25%) and autotransfusion of the shed blood post‐operatively.
(2) Group 2: patients underwent IMA surgery under the same conditions as Group 1 with the exclusion of autotransfusion (AT).
NB: Allogeneic packed red cells were transfused when the post‐operative Hct fell below 25%.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Re‐exploration for bleeding.
Blood loss.
Perioperative infarction.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were allocated to groups according to a computer generated randomisation schedule. Method of allocation concealment was not described.

Participants

100 consecutive patients undergoing total knee replacement were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=50; M/F=21/29; mean age males = 70.4 years (range 47‐78 years); mean age females = 69.3 years (range 52‐81 years).
(2) Group 2 (Allogeneic blood group): n=50; M/F=24/26; mean age males = 67.9 years (range 51‐82 years); mean age females = 70.8 years (range 46‐88).

Interventions

(1) Group 1: a Haemonetics cell saver 3 machine was used for post‐operative cell salvage. Blood was collected via the wound drains following the release of the tourniquet. The collected blood was anticoagulated with heparinised saline. The machine aspirate the wound drainage into the centrifuge bowl via roller pumps. The blood underwent accelerated sedimentation, being spun at 5600 revs/per/minute. The supernatant was discarded and the resulting red cells washed and resuspended in normal saline. The machines produced a product with a haematocrit of over 55% and a volume of 250 ml. When the post‐operative haemoglobin fell below 9.0g/dL they were transfused with allogeneic transfusion.
(2) Group 2: patients were given allogeneic blood in the post‐operative period when the haemoglobin fell below 9.0g/dL.
NB: Routine procedure of crossmatching two units of packed cells was performed for all patients in the study.

Outcomes

Amount of blood collected by the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Hospital length of stay.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

40 patient undergoing first time coronary artery bypass graft sugery were randomly divided into 1 of 2 groups. The 2 groups were further subdivided according to whether the patients received aspirin preoperatively or not:
(1) Group 1 (Control group + aspirin): n=12.
(2) Group 2 (Control group ‐ no aspirin): n=9.
(3) Group 3 (Autotransfusion group + aspirin): n=10.
(4) Group 4 (Autotransfusion group ‐ no aspirin): n=11.
Nb: Demographic data not reported.

Interventions

(1) Group 1: patients were transfused post‐operatively with allogeneic blood. Patients from this group received 75mg of aspirin daily pre‐operatively.
(2) Group 2: patients were transfused post‐operatively with allogeneic blood. Patients from this group did not receive 75mg of aspirin daily pre‐operatively.
(3) Group 3: patients were autotransfused using an IMED 960 Volumetric Infusion Pump but donor blood was also available if needed. Patients from this group received 75mg of aspirin daily pre‐operatively.
(4) Group 4: patients were autotransfused using an IMED 960 Volumetric Infusion Pump but donor blood was also available if needed. Patients from this group did not receive 75mg of aspirin daily pre‐operatively.
NB: The indication for transfusion was the maintenance of a haematocrit (Hct) level of 30 to 35%.

Outcomes

Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Re‐operation for bleeding.
Blood loss.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

24 patients undergoing elective total joint arthroplasty were randomly assigned to 1 of 2 groups:
(1) Group 1 (Solcotrans system): n=12; M/F=5/7; mean age = 64.7 years (range 53‐76 years).
(2) Group 2 (Control group): n=12; M/F=5/7; mean age = 59.6 years (range 41‐76 years).

Interventions

(1) Group 1: a Solcotrans drain was inserted in the operating room and connected to the collection unit and placed under continuous suction (‐20cmH2O) once wound closure was complete. Collection continued for 6‐hours or until the unit was full. At that time, the amount of drainage was noted. If greater than 350ml, the drainage was reinfused and a new Solcotrans unit connected. ACD‐A (citrate‐based anticoagulant) was used in each unit (40mls). If the drainage was greater than 150ml but less than 350ml, the drainage was reinfused and a standard, spring loaded, closed intermittent suction canister was connected. If the drainage was less than 150ml, the drainage was not reinfused and collection continued, either in the Solcotrans canister or a closed suction drain.
(2) Group 2: had drains inserted in the operating room that was connected to a standard, closed system, spring loaded, intermittent suction device.
NB: Drains for both patient groups were discontinued once drainage was less than 40ml per 8‐hour shift.

Outcomes

Amount of blood collected by the cell saver.
Average collection times.
Blood loss.
Hb & Hct levels.
Coagulation variables.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

109 patients undergoing total hip or knee arthroplasty were randomly assigned to 1 of 2 groups:
(1) Group 1 (Hemolite cell saver group): n=51.
(2) Group 2 (Control group): n=51.

Interventions

(1) Group 1: a Hemolite cell saver was used. The wound drainage tubes were connected in the operating room to a sterile reservoir which contained 200ml of a heparin saline solution.The reservoir was connected to wall suction (120mmHg) in the operating suite. Collection was continued in the post‐anaesthetic care unit and the surgical ward. At the end of the 4 hour period the collected wound drainage was processed. Under sterile conditions the blood was washed with 2 litres of saline and processed in the Hemolite cell washer to remove heparin, cellular debris, platelets and clotting factors. After processing, the wound drainage consisted of concentrated red blood cells suspended in saline. This product was transfused back to the patient. After wound drainage collection was completed, the drains were attached to standard Hemovac suction and output was monitored at 8 hour intervals until the drains were disconnected at 48 hours.
(2) Group 2: a Hemovac standard drainage system was used. At the termination of the operative procedure the control group underwent Hemovac wound drainage only. Autotransfusion was not performed.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Coagulopathy.
Blood loss.
Transfusion reactions.

Notes

Transfusion protocol not reported.
Patients who were transfused only one unit of blood received only pre‐banked autologous blood.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation not described. Allocation concealment was by sealed envelopes.

Participants

50 patients undergoing elective infrarenal abdominal aortic aneurysm surgery were randomised to 1 of 2 groups:
(1) Group 1 (Autologous group): n=23; M/F=19/4; median age = 71 years (interquartile range 54‐78 years).
(2) Group 2 (Control group): n=27; M/F=20/7; median age = 68 years (interquartile range 54‐82 years).

Interventions

(1) Group 1: patients received autologous blood via intra‐operative autotransfusion (IAT). A COBE Baylor rapid autologous transfusion system was employed for intraoperative cell salvage. Blood was retrieved from the operative site by suctioning into a double lumen catheter at less than 150mmHg, to minimise haemolysis. Blood was anticoagulated with heparin (30,000 Units / 1litre 0.9% saline). The salvaged blood was then collected in a reservoir where a macrofilter of 150 microns removed larger particles of debris. When 500 ml of blood was collected, it was pumped to a spinning centrifuge bowl. The red cells were washed with 0.9% saline, and concentrated to a Hct above 50%. The effluent containing plasma fractions, platelets, leukocytes, free haemoglobin, anticoagulant and saline was discarded. The washed red cells, suspended in saline were pumped from the centrifuge to the patient through a microfilter of either 20 or 40 microns.
(2) Group 2: patients were transfused allogeneic blood if the Hct fell below 25%. Cell salvage was not performed.

Outcomes

Amount of allogeneic blood transfused.
Number of patients tranfused allogeneic blood.
Complications.
Hospital length of stay.
Blood loss.
Mortality.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

High risk

C ‐ Inadequate

Methods

Method of randomisation and allocation concealment was not described.

Participants

150 consecutive patients undergoing elective valve surgery using cardiopulmonary bypass were randomly allocated to 1 of 2 groups:
(1) Group 1 (Cell salvage + ANH group): n=50; M/F=35, females n=15; mean age (+/‐SD) 29.1+/‐11.8 years.
(2) Group 2 (ANH group): n=50; males n=25, females n=25; mean age (+/‐SD) 28.1+/‐9.2 years.
(3) Group 3 (Control group): n=50; males n=15, females n=35; mean age (+/‐SD) 26.1+/‐9.3 years.

Interventions

(1) Group 1: received autologous fresh blood donated before bypass, and both cell saver and membrane oxygenator were used. Autologous blood was removed by a central venous catheter after induction of anaesthesia and collected in citrate phosphate preservative at room temperature for subsequent transfusion. Blood volume was maintained with a simultaneous infusion of Ringer's lactate solution. A Dideco, Shiley cell saver system was used to collect all blood at the operation site. This system heparinises, washes, and centrifuges the blood to produce a red cell concentrate for transfusion. At the conclusion of CPB, all the blood remaining in the oxygenator was also processed by the cell saver in preparation for subsequent transfusion. A "Maxima" membrane oxygenator was used for this group.
(2) Group 2: were reinfused with autologous blood only. Blood was withdrawn as in Group 1 patients and was stored for subsequent transfusion.
(3) Group 3: underwent routine management, using a Bentley bubble oxygenator without specific blood conservation techniques.
NB: In Groups 2 and 3, the blood remaining in the oxygenator at the termination of CPB was returned to the patient before decannulation, or collected in a bag for immediate use to provide optimum filling presures and haemodynamic stability in the post‐bypass period. Bank blood (whole blood) was subsequently used in all groups if the haematocrit was less than 25%.

Outcomes

Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Re‐exploration for bleeding.
Chest drainage.
Hct levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

60 patients undergoing cardiac valve surgery were randomised to 1 of 3 groups:
1) Group 1 (Cell salvage group): n=20; M/F=14/6; mean age (+/‐sd) = 27.7+/‐10.1 years
(2) Group 2 (Aprotinin group): n=20; M/F=12/8; mean age (+/‐sd) = 25.9+/‐11.1 years
(3) Group 3 (Control group): n=20; M/F=12/8; mean age (+/‐sd) = 26.6+/‐7.35 years.

Interventions

(1) Group1: patients were treated with cell salvage using a Dideco system before heparin and after protamine administration.
(2) Group 2: patients were treated with aprotinin at the dose of 30 000KIU/kg was added to the prime with a further 15 000 KIU/kg added at the end of each hour of CPB.
(3) Group 3: patients underwent routine management which included the collection of autologous blood during the pre‐CPB period.
NB: Groups 1 and 3 had blood remaining in the oxygenator at the conclusion of CPB returned before decannulation or collected in a bag for immediate use to provide optimal filling pressures and hemodynamic stability in the post‐CPB period.

Outcomes

Amount of allogeneic blood transfused.
Re‐exploration for bleeding.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

231 patients undergoing elective total knee replacement surgery were randomly allocated to 1 of 2 groups:
(1) Group 1 (Cell salvage group): n=115; M/F=44/71; mean age of males = 67.4 years; mean age of females = 70.5 years.
(2) Group 2 (Control group): n=116; M/F=55/61; mean age of males = 69.7 years; mean age of females = 70.2 years.

Interventions

(1) Group 1: patients received autotransfusion of wound drainage if the volume of blood collected was greater than 125 ml post‐operatively. The collected blood was washed and re‐suspended in saline before re‐infusion using a centrifugal cell washing machine (Cell Saver 5 ‐ Haemonetics). Patients in the cell salvage group were transfused allogeneic red blood cells if their haemoglobin fell below a haemoglobin level of 9.0 g/dL after autotransfusion was completed.
(2) Group 2: were treated without the use of cell salvage (autotransfusion). All drainage blood was discarded. Patients in the control group were transfused allogeneic red blood cells if their haemoglobin fell below a haemoglobin level of 9.0 g/dL.

Outcomes

Number of patients transfused allogeneic blood.
Amount of allogeneic blood transfused.
Complications.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

113 consecutive adult patients undergoing cardiac surgical procedures requiring cardiopulmonary bypass were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=54; M/F=48/6; mean age = 55.9 years (range 24‐72 years).
(2) Group 2 (Control group): n=59; M/F=55/4; mean age = 54.8 years (range 38‐73 years).

Interventions

(1) Group 1: shed mediastinal blood was collected post‐operatively by an autotransfusion system (Sorenson). Suction was applied (‐20cmH2O), allowing shed blood to flow into the upper bag of the system and then through two 170 micron filters into a lower 800ml collection bag. The lower bag was then disconnected from the system and its contents infused, the collected blood being transfused through an in‐line 40 micron filter. No blood was allowed to remain in the system longer than 4 hours. Shed blood that was not utilised during this time period was discarded. When notable bleeding ceased (4‐8 hours) retransfusion was no longer employed.
(2) Group 2: received usual care without the use of cell salvage.
NB: Intra‐operative and post‐operative haemodilution was performed in all patients but not equally distributed between groups.

Outcomes

Amount of blood collected by the cell saver.
Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Complications.
Myocardial infarction.
Mortality.
Post‐operative infections.
Renal function impariment.
Fluid replacement.
Blood loss.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Patients were randomised on the day before surgery using a computer randomisation programme. Method of allocation concealment was not described.

Participants

105 patients undergoing primary elective coronary artery bypass graft surgery were randomised to 1 of 3 groups:
(1) Group 1 (Control group): n=34; M/F=30/4; median age = 63 years (range 58‐67 years).
(2) Group 2 (Uncoated Autotransfusion group): n=36; M/F=30/6; median age = 64 years (range 58‐67 years).
(3) Group 3 (Heparin Coated Autotransfusion group): n=35; M/F=31/4; median age = 62 years (range 55‐67 years).

Interventions

(1) Group 1: chest drains were connected to underwater sealed drainage bottles with suction applied at 10Kpa. Cell salvage was not performed.
(2) Group 2: chest drains were connected to a cardiotomy reservoir (CATR 3500) to which suction at 10Kpa was applied. This reservoir contained a 20 micron filter which removed debris and clot from the drained blood. From there blood was carried via an infusion pump which incorporated an air‐in‐line detector to a peripheral line. Autotransfusion commenced when there was more than 100ml in the cardiotomy reservoir and continued thereafter for 10 hours. Infusion was in hourly pulses according to the previous hours drainage.
(3) Group 3: the autotransfusion circuit was bonded with heparin (heparin coated circuit). The heparin‐bonded circuit comprised an identical system of drains and tubes except that all surfaces, including the cardiotomy reservoir and connector but excluding the piston chamber of the infusion pump and the intravenous cannula, were coated with heparin by the Duraflow II methodology.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients receiving allogeneic blood.
Complications.
Re‐exploration for bleeding.
Blood loss.
Mortality.
Haematological variables.
Coagulation variables.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment was not described.

Participants

35 consecutive male patients undergoing elective myocardial revascularisation or valve replacement were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group):
n=18; mean age (+/‐sd) 64+/‐8.5 years.
(2) Group 2 (Control group): n=17; mean age (+/‐sd) 63+/‐8.2 years.

Interventions

(1) Group 1: patients received autotransfusions with mediastinal shed blood for the first 12 hours post‐operatively. Autotransfusion involved reinfusion within 4 hours, a minimum of 100ml of chest drainage in the reservoir before initiation of autotransfusion, and discontinuation of autotransfusion for core temperatures greater than 39.5 degrees celsius. A two‐filter system was employed to minimise emboli.
(2) Group 2: were treated with standard chest drainage and fluid replacement.
NB: Mediastinal chest drainage tubes were placed in all patients and connected to an in‐line autotransfusion system. The chest drainage system was placed on suction (20cm H20), and the tubes were milked every 15 minutes. Haemodilution was tolerated to a haemoglobin level of 8.0g/dL/.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Number of patients transfused allogeneic blood.
Complications.
Re‐operation for bleeding.
Chest tube drainage.
Mortality.
Myocardial infarction.
Wound infection.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Methods of randomisation and allocation concealment was not described.

Participants

42 patients undergoing cardiac operations were randomised to 1 of 2 groups:
(1) Group 1 (Autotransfusion group): n=22; mean (+/‐sd) age = 49+/‐11 years.
(2) Group 2 (Control group): n=20; mean (+/‐sd) age = 45+/‐12 years.

Interventions

(1) Group 1: patients received non‐washed shed mediasinal blood during the post‐operative period.
(2) Group 2: received banked blood only. No autotransfusion was performed.

Outcomes

Amount of blood re‐transfused from the cell saver.
Amount of allogeneic blood transfused.
Blood loss.
Hb levels.

Notes

Transfusion protocol not reported.
English abstract only.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear

Methods

Method of randomisation and allocation concealment were unclear. Participants were not blind to treatment allocation and blinding of the outcome assessor was unclear.

Participants

60 patients undergoing elective primary coronary artery bypass graft surgery were randomly allocated to 1 of 2 groups:
(1) Group 1 (Autologous transfusion group): n=30; M/F=26/4; mean (+/‐ sd) age = 59.5+/‐8.0 years.
(2) Group 2 (Control group): n=30; M/F=27/3; mean (+/‐sd) age = 59.2+/‐8.2 years.
Exclusion criteria: bleeding time more than 10 minutes due to anti‐coagulant use; pre‐operative Left Ventricular Ejection Fraction (LVEF) less than 0.40; diabetes; pulmonary or renal disease.

Interventions

(1) Group 1: patients received non‐washed shed mediastinal blood retransfused postoperatively after CABG using a cell saver device (Beijing PerMed Biomedical Engineering Company) up to 18 hours post‐surgery. Shed blood not returned within 4 hours was discarded and a new bag attached. When more than 200mls shed mediastinal blood collected within 4 hours the patients received autologous blood if volume replacement was considered necessary. Extracorporeal blood was routinely returned to patients after CABG. Length of cardiopulmonary bypass (CPB) = 121+/‐26 minutes. Aortic cross‐clamp time 74+/‐15 minutes.
(2) Group 2: received banked allogeneic blood only. Cell salvage (autotransfusion) was not used. Extracorporeal blood was routinely returned to patients after CABG. Length of cardiopulmonary bypass (CPB) = 121+/‐58 minutes. Aortic cross‐clamp time 76+/‐33 minutes.

Volume of autologous blood collected/retransfusion.

Outcomes

Number of patients transfused allogeneic blood; volume of allogeneic blood transfused (mls).
Number of patients trasnfused autologous blood.
Volume of autologous blood transfused (mls).
Post‐operative blood loss (median and range).
Pre‐operative Hb levels.

Notes

Transfusion protocol used.

Risk of bias

Bias

Authors' judgement

Support for judgement

Allocation concealment?

Unclear risk

B ‐ Unclear