POST-OPERATIVE REINFUSION OF SHED BLOOD USING A REINFUSION
DRAINAGE SYSTEM FOR ORTHOPAEDIC JOINT REPLACEMENT/JOINT
SURGERY
Version
5
Name of responsible (ratifying) committee
PORTSMOUTH HOSPITALS NHS TRUST BLOOD
TRANSFUSION COMITTEE
Date ratified
24th October 2014
Document Manager (job title)
Transfusion Practitioner
Date issued
26th November 2014
Review date
25th November 2017
Electronic location
Trust Intranet
Related Procedural Documents
PHT Blood Transfusion Policy
Key Words (to aid with searching)
Reinfusion drain, autologous, blood, homologous
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
5
24/10/2014
Two Yearly Competency & Page 8 Amendment
Kay Heron
CONTENTS
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1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 5
PURPOSE ................................................................................................................................... 5
SCOPE ........................................................................................................................................ 5
DEFINITIONS .............................................................................................................................. 6
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
PROCESS ................................................................................................................................... 7
TRAINING REQUIREMENTS .................................................................................................... 10
REFERENCES AND ASSOCIATED DOCUMENTATION .......................................................... 10
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS ............................................................................................................................ 11
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QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
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Any blood collected in the drain reservoir must be collected for a maximum total of 6 hours
and reinfused within 4 hours
The systems must only be used for a maximum of 1500mls of collected blood for reinfusion,
after which it must revert to a drainage system only
The scrub nurse/ODP must ensure that all clamps are closed and the two-leur lock joints are
tight. Blood must not be allowed to seep into the drain until defibrination has occurred
Theatre team must ensure the recovery team knows the time the drain can be opened. This
should be documented in the nursing notes and on the drainage bag. This is 20 minutes after
closure of the deep cavity. In TKR surgery, if the tourniquet is deflated after the wound is fully
closed, the time should start from the deflation
In recovery the reservoir should be kept upright to ensure the filters stay dry and the drain
should be opened when de-fibrination is complete
Expel any air from the bellows away from the patient
Ensure the clamp directly under the bellows is tightly closed and undo the clamp between the
wound and the reservoir
The time of opening must be documented on the drain and the patient notes to ensure the
salvaged blood has started to re-transfuse within the time limit
Using the bellows system, expel the blood into the reinfusion bag and re-clamp to allow for
more drainage
Once the system has finished collecting and re-infusing autologous blood within the
designated timeframe, the system may still be used as a wound drain. If the patient is
continuing to bleed more than 6 hours post operation, contact the medical team involved
Reinfusion should commence once all clamps are back in place. Reinfusion can continue
whilst collection is still going on
There are 3 main areas involved in the reinfusion of shed blood; theatres, theatre
recovery and ward areas. Each clinical area has specific responsibilities, these are
described below:
Theatre
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There should be a final washout with normal saline prior to closing the wound
The tourniquet release time MUST be recorded by the scrub nurse/ODP in the patient’s notes
The anesthetist will prescribe the autologous re-transfusion on the usual fluid prescription
chart
Recovery
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The recovery nurse/ODP is responsible for completing the patient details onto the
drainage collection chamber and reinfusion blood bag using a permanent marker. This
must include 4 points of patient ID; surname, first name, date of birth and unique
identification number (i.e. NHS, Hospital or District Number) but it must also be dated,
timed and signed
The recovery nurse/ODP must wait 20 minutes after release of the tourniquet before
priming the collection chamber. This allows the body to defibrinate blood and prevents
clotting of reinfused blood (Faris et al 1991). The time the collection begins MUST be
recorded on the device, the nursing notes and the prescription chart
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The collection chamber must be placed below the affected limb and kept upright, once the
clamps have been released
Wards and/or recovery
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When the collection chamber has 250 – 500mls of blood in it OR the 6 hours allowed for
collection is almost elapsed, the blood must be transferred into the blood transfusion bag
After 6 hours the drain can be used as a normal wound drainage system but the contents
must not be re-infused
Transferring collected shed blood into the reinfusion bag
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The device is a closed unit and blood is collected from the drainage chamber to the
transfusion bag by the method detailed in section 8
All autologous shed blood must be transfused through a blood giving set at a rate of
200mls/hr
Once shed blood has been collected into a transfusion bag, it must be administered
immediately. IT MUST NOT UNDER ANY CIRCUMSTANCES be removed from the patient’s
bedside, stored on the ward, in a ward fridge or blood fridge
One qualified staff member must check the details on the blood bag against the prescription
chart and the patient identity band, in accordance with Trust Blood Transfusion Policy
Patient monitoring and observations in line with the Trust Transfusion Policy, should be
performed
Empty blood bags must be kept in accordance with Trust policy and then disposed of in the
clinical waste
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1. INTRODUCTION
Practice in autologous blood transfusion has increased in response to several initiatives and reports:
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Recommendations from the Serious Hazards of Transfusion (SHOT 2004) enquiry, regarding
safety of patients receiving transfusion
Department of Health (2007) Better Blood Transfusion 3 circular, which identifies those
alternatives to donor blood, and the appropriate use of autologous blood transfusion, should
be pursued. This includes postoperative cell salvage
Department of Health (1998) White Paper, The New NHS – Modern and Dependable, which
suggests that autologous blood transfusion is seen as a valuable advance in improving
clinical practice
Potentially lower risks of infection or febrile episodes following autologous blood transfusion
in comparison to bank blood (Newman et al, 1997, Gleason and Leone, 1997, Murphy et al,
1991, Tartter, 1988)
European Blood Directive 2005, suggests alternative strategies must be considered for
effective use of blood
Indications for use
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Post operative autologous blood collection for reinfusion after orthopaedic surgery e.g.
any joint surgery
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Patients will need to receive information regarding options for autologous transfusion
during the pre assessment process
Contraindications
Do not use this type of reinfusion device if any of the following are present or are suspected:
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Infected wound
Bacteraemia or Septic contamination of the autologous blood
Malignant lesions in the area of blood collection
Presence in collected blood of a substance not suitable for reinfusion e.g. adrenaline or
peroxide (NB See page 8 for further clarification)
2. PURPOSE
The purpose of this policy is to:
 Provide a clear framework and guidance for safe reinfusion of a patient’s own blood,
throughout Portsmouth Hospitals NHS Trust
 To ensure a consistent approach to the storage, prescribing, handling and administration of
the patient’s own blood throughout the Trust
 To ensure that all members of staff involved in any stage of the process of transfusing
patient’s own blood are aware of their role and the legal aspects of this practice
3. SCOPE
Only Registered Nurses (RN) or Operating Department Practitioners (ODP) who have been trained in
the use of the Post Operative Autologous blood transfusion system, are allowed to collect and
reinfuse blood using this system.
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Ward / Department managers must satisfy themselves that the RNs / ODP’s who undertake this
practice have achieved the level of education and competence required.
The appropriate manager should keep a record of staff achieving competence.
All staff involved in the administration of autologous blood transfusion must be familiar with the Trusts
Administration of Blood Components Policy and have completed the Administration of Blood
Components competency.
This policy should be read and applied in conjunction with the Trust Blood
Transfusion Policy, which is located on the Trust Intranet
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Homologous
Autologous
Reinfusion
–
–
–
ODP
RN
–
–
Donated blood from an unknown donor
The patients own blood
Giving back patients own shed blood using a post-operative
reinfusion device
Operating Department Practitioner
Registered Nurse
5. DUTIES AND RESPONSIBILITIES
The Hospital Transfusion Committee
The Committee is comprised of members of the Hospital Transfusion Team and
representatives from all clinical areas were a blood component/product is administered. It has
responsibility for ensuring that transfusion practice throughout PHT adheres to local policies.
Hospital Transfusion Practitioner
The Practitioner is responsible for:

Acting as the main point of contact for staff requiring information / guidance on the use
of autologous drains.
Prescribing Clinicians
Prescribing Clinicians are responsible for:
 Obtaining and documenting consent or inability to provide consent
 Where practical - informing patients of the reasons for transfusion, their right to refuse
transfusion and of the risks and benefits
 Providing information about alternatives to blood transfusion where appropriate
All Ward/Line Managers
All managers have a responsibility:
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To be aware of this policy and associated guidelines
Releasing staff for training
Integrating compliance into the Knowledge and Skills Framework and appraisals for all
staff
Ensuring appropriate evidence of compliance is gained during the appraisal process
Ensure their staff are aware of and understand this policy and comply with its content
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All staff involved in the processes associated with reinfusion of blood
All staff members involved have a responsibility to:
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Attend training relevant to their role in the process
Comply with this policy at a level commensurate with their involvement
Report all adverse incidents and near misses
6. PROCESS
Principles of Autologous Blood Collection and reinfusion systems
Any blood collected in the drain reservoir must be collected within 6 hours of opening the drain in
accordance with manufacturer’s guidelines and reinfused within 4 hours.
The systems must only be used for a maximum of 1500mls of collected blood for reinfusion, after
which it must revert to a drainage system only.
The scrub nurse/ODP must ensure that all clamps are closed and the two-leur lock joints are tight.
Blood must not be allowed to seep into the drain until defibrination has occurred.
Theatre team must ensure the recovery team knows the time the drain can be opened. This should
be documented in the nursing notes and on the drainage bag. This is 20 minutes after closure of
the deep cavity. In TKR surgery, if the tourniquet is deflated after the wound is fully closed, the time
should start from the deflation.
In recovery the reservoir should be kept upright to ensure the filters stay dry and the drain should
be opened when de-fibrination is complete.
Expel any air from the bellows away from the patient.
Ensure the clamp directly under the bellows is tightly closed and undo the clamp between the
wound and the reservoir.
The time of opening must be documented on the drain and the patient notes to ensure the
salvaged blood has started to re-transfuse within the time limit.
Using the bellows system, expel the blood into the reinfusion bag and re-clamp to allow for more
drainage.
Once the system has finished collecting and re-infusing autologous blood within the designated
timeframe, the system may still be used as a wound drain. If the patient is continuing to bleed more
than 6 hours post operation, contact the medical team involved.
Reinfusion should commence once all clamps are back in place. Reinfusion can
continue whilst collection is still going on.
CLINICAL AREAS INVOLVED IN THE REINFUSION PROCESS
There are 3 main areas involved in the reinfusion of shed blood; theatres, theatre
recovery and ward areas. Each clinical area has specific responsibilities, these are
described overleaf:
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Theatre
Drugs such as lignocaine, bupivacaine, adrenaline, peroxide or any other drug not licensed for
intra-venous use or contra-indicated for reinfusion, should NOT be left in the wound. Antiseptic
solutions should also be washed away using sodium chloride 0.9% irrigation (normal saline). There
should be a final washout with normal saline prior to closing the wound.
Local anaesthetic and/or adrenaline can be injected into the soft tissues during surgery, and in
these cases shed blood can safely be reinfused (Reference – Wallace et al 2012). The
administration of these drugs should be documented in the notes, specifying they were injected into
the tissues not the cavity.
The tourniquet release time MUST be recorded by the scrub nurse/ODP in the patient’s notes.
The anaesthetist will prescribe the autologous re-transfusion on the usual fluid prescription chart.
The prescription must state ‘reinfusion of shed blood must be completed within 4 hours at a rate of
200mls/hr’ (Newman 1997).
Recovery
To ensure correct patient identification – right product to right patient –
The recovery nurse/ODP is responsible for completing the patient details onto the drainage
collection chamber and reinfusion blood bag using a permanent marker. This must include 4 points
of patient ID; surname, first name, date of birth and hospital number but it must also be dated,
timed and signed.
The recovery nurse/ODP must wait 20 minutes after release of the tourniquet before priming the
collection chamber. This allows the body to defibrinate blood and prevents clotting of reinfused
blood (Faris et al 1991). The time the collection begins MUST be recorded on the device, the
nursing notes and the prescription chart.
The collection chamber must be placed below the affected limb and kept upright, once the clamps
have been released.
Ensure the anesthetist has correctly prescribed the autologous blood
If 250 – 500mls has drained and transfusion is necessary, follow the details in the next section
Wards and/or recovery
When the collection chamber has 250 – 500mls of blood in it OR the 6 hours allowed for collection
is almost elapsed, the blood must be transferred into the blood transfusion bag.
After 6 hours the drain can be used as a normal wound drainage system but the contents must not
be re-infused.
Transferring collected shed blood into the reinfusion bag
The device is a closed unit and blood is collected from the drainage chamber to the transfusion
bag.
All autologous shed blood must be transfused through a blood giving set at a rate of 200mls/hr.
Once shed blood has been collected into a transfusion bag, it must be administered immediately.
IT MUST NOT UNDER ANY CIRCUMSTANCES be removed from the patient’s bedside, stored on
the ward, in a ward fridge or blood fridge.
One qualified staff member must check the details on the blood bag against the prescription chart
and the patient identity band, in accordance with Trust Blood Transfusion Policy.
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Patient monitoring and observations in line with the Trust Transfusion Policy, should be performed.
Empty blood bags must be kept in accordance with Trust policy and then disposed of in the clinical
waste.
PATIENT INFORMATION
Inform the patient about the intended transfusion therapy and giving them a full explanation, giving
them the opportunity to discuss and raise any concerns they may have. The risks and benefits of
transfusion must be explained and documented.
Prescriber responsibility
The prescription of blood products is the responsibility of a Clinician / designated Nurse
Practitioner.
The Prescription
Prescribe on designated prescription sheets, stating:

4 points of patient identification, duration and infusion rate.
Identity Band
All patients, including unconscious patients, must have surname, first name, date of birth, and a
patient identification number, recorded on their identity band.
Observations and administration
Prior to the start of the reinfusion:
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Record temperature, pulse and blood pressure and respirations
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Check pulse, blood pressure, respirations and temperature 15 minutes after starting the
reinfusion
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Observe the patient throughout the transfusion
Deteriorating Patients.
Consider a transfusion reaction if the patient’s condition deteriorates within the first
15 minutes of a transfusion
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Immediately stop the transfusion and inform the medical team responsible for the patient
Report to Bloodbank on ext 6539
Complete a Transfusion Reaction Form, available from blood bank, if a reaction is
suspected
Transfusions should be given in clinical areas where frequent visual and verbal contact can take
place.
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Documentation (All patients)
Medical record
The patient’s notes should contain the volume re-transfused and any adverse effects. A follow up
note to record the clinical response should be recorded in the patient notes.
Awareness
All medical staff must be aware of the beliefs and individual wishes of the Jehovah’s Witness
patient in relation to receiving any blood component.
7. TRAINING REQUIREMENTS
The additional education and skills training required for RNs/Practitioners and ODP’s to undertake
this practice will be provided in the Trust by an expert in practice.
Assessment of practice will be undertaken in the usual practice environment of the RN or ODP and
will be competency based and updated annually.
Assessors must be competent to undertake this practice and must hold a recognised qualification in
assessing (i.e. 998, City and Guilds D32/33 or 730).
The RN or ODP is responsible for their decision to transfuse blood using this device. If the
practitioner is unsure of any aspect of the system they should seek advice from their clinical lead.
Assessment of competency must be completed prior to undertaking any post-operative reinfusion.
Competency can be found on the Trust Learning and Development website
To be read in conjunction with the Trust Blood Transfusion Policy available on the intranet.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
Guidelines for blood recovery and reinfusion in surgery and trauma: American Association of
Blood Banks, 1993.
DIRECTIVE 2002 /98/EC OF THE EUROPEAN PARLIAMENT. Official Journal of the European
Union, 27th January 2003.
Better Blood Transfusion Appropriate use of blood. DOH. 2002.
DOH (1998) The New NHS – Modern and Dependable.
Faris, P.M. et al (1991) Unwashed and filtered shed blood collected after knee and hip
arthroplasty. The Journal of Bone and Joint Surgery 73(8) 1169 –1178.
Gleason DH, Leone BJ. Cost effectiveness of blood transfusions; the risks and the benefits,
1997.
Guidelines for the Clinical Use of Red Cell Transfusions: British Committee for Standards in
Haematology, Blood Transfusion Task Force in collaboration with the Royal College of Nursing
and the Royal College of Surgeons of England. British Journal of Haematology 2001; 113, p2431.
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Statutory Instrument 2005 No. 50, The Blood Safety and Quality Regulations 2005:
Handbook of Transfusion Medicine (2001), D.B.L. McClelland, Third Edition. The Stationery
Office Norwich
Newman JH, Bowers M, Murphy J. The clinical advantages of autologous. The Journal of Bone
and Joint Surgery, 1997: 79(4) 630 – 633.
Murphy P, Heal JM, Blomberg N. Infection or suspected infection after hip replacement surgery
with autologous or homologous blood transfusions. Transfusion, 1991: 31, p 212 – 217.
SHOT steering group: Annual Report, 2002.
Tartter PI. Blood Transfusion and Infectious Complications Following Colorectal Cancer
Surgery. British Journal of Surgery, 1988: 75, p 789 – 792.
An Organisation-Wide Policy for the Development and Management of Procedural Documents:
NHSLA, May 2007. www.nhsla.com/Publications/
Wallace DF, Emmett SR, Kang KK, Chahal GS, Hiskens R, Balasubramanian S, McGuinness
K, Parsons H, Achten J, Costa ML (2012) The safety of peri-articular local anaesthetic injection
for patients undergoing total knee replacement with autologous blood transfusion. The Journal
of Bone and Joint Surgery 94-B No 12 16323 - 1636
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
Assessment of competency must be completed prior to undertaking any post-operative reinfusion.
Competency can be found on the Trust Learning and Development website.
To be read in conjunction with the Transfusion Policy, available on the intranet
Only staff aware of their legal, ethical and professional responsibilities, should be involved with the
transfusion process – Assessment to Level 2 of the Trust Competency for Blood Administration
Only staff who have completed biannual updates and competency assessment, can participate in the
clinical process – Competency available on the learning and development site.
Patients are monitored according to hospital policy and any untoward events (including suspected
transfusion reactions) are immediately clinically managed and promptly reported to the Hospital
Transfusion Committee (HTC) – monitored by annual local audit and spot checks of data recording
and bedside checks and participation in national audit initiatives.
Serious Adverse and Events and Near Miss incidents are reported to the Trust Clinical Incident
reporting system in accordance with local protocols.
Reports of serious adverse events or reactions and near miss incidents are submitted to the Serious
Adverse Blood Reactions and Events (SABRE) and the Serious Hazards of Transfusion (SHOT)
initiative by the relevant staff.
1. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
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This policy has been assessed accordingly.
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
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1. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to
be monitored
Lead
All staff involved in care of
post-op
drains
to
be
competency assessed
Theatre/ ward
managers
Tool
Competency
records
Frequency of Report
of Compliance
2 yearly
Reporting arrangements
Policy audit report to:

Lead(s) for acting on
Recommendations
HTC
HTC
Policy audit report to:

Policy audit report to:

This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
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