Balancing the Blood Component Transfusion Ratio for High- and Ultra High–Dose Cell Salvage Cases

Objective: To assess the ratio of non-red blood cell to red blood cell components required to avoid coagulopathy when transfusing large amounts of salvaged blood using laboratory test–guided therapy. Design: Retrospective cohort study. Setting: Single-center, academic hospital. Participants: Thoracoabdominal and abdominal open aortic surgery patients. Measurement and Main Results: Thirty-eight patients in whom at least 1,000 mL of salvaged red blood cells were transfused were identified and divided into the following 2 cohorts: 1,000-to-2,000 mL of salvaged red blood cells (high dose) (n = 20) and >2,000 mL of salvaged red blood cells (ultra-high dose) (n = 18). Compared with the high-dose cohort, the ultra high-dose cohort received ∼4 times more salvaged red blood cells (1,240 ± 279 mL v 5,550 ± 3,801 mL). With transfusion therapy guided by intraoperative coagulation tests and thromboelastography, the adjusted ratio of non-red blood cell to red blood cell components (plasma + platelets + cryoprecipitate:allogeneic + salvaged red blood cells) was 0.59 ± 0.66 in the high-dose and 0.93 ± 0.27 in the ultra high-dose cohorts. Multiple coagulation parameters were normal and similar between cohorts at the end of surgery, as determined by the mean, median, and 95% confidence intervals. Conclusions: When transfusing large volumes of salvaged blood, it is important to balance the ratio between non-red blood cell and red blood cell components. Through a laboratory test–guided approach, coagulopathy was not detected when transfusing blood in ratios of approximately 1:2 for patients receiving 1,000-to-2,000 mL of salvaged blood and 1:1 for patients receiving >2,000 mL of salvaged blood.