In this video, we demonstrate how to perform autotransfusion.
Video coming soon!
Accumulating blood in the pleural, peritoneal or pericardial space resulting from ongoing hemorrhage can be collected and administered back to the patient using a technique called autotransfusion (click here to learn how to perform autotransfusion).
This is a great, life-saving technique to learn if you are in a place that has limited access to blood products or referral centers.
Autotransfusion can be used to maintain patient stability, while waiting for a clot to form, for the hemorrhage to resolve, or for the site of hemorrhage to be addressed surgically. I think of ongoing hemorrhage like a fish tank with a hole in it. If all the water drains out, all of the fish will die. Autotransfusion is like collecting the water coming out of the hole, and pouring it back into the tank, so that the water level in the tank remains stable. Obviously, if the hole doesn’t get patched (if the bleeding doesn’t stop), then you will be there all day.
In the anemic and actively hemorrhaging patient, it is wise to check blood clotting times. If these are significantly prolonged, fresh frozen plasma will likely be needed to restore clotting factors. Many patients with significant ongoing hemorrhage will develop a consumptive coagulopathy, where clotting factors are consumed so that the blood can no longer clot effectively. With active hemorrhage and prolonged clotting times, the bleeding will probably not stop until the coagulopathy has been addressed.
Autotransfusion can only be performed for pure internal hemorrhage. You must confirm that an effusion is hemorrhagic. This is done by comparing the PCV of the effusion to the peripheral blood; with a hemorrhagic effusion, the PCV of the fluid will be HIGHER than that of the peripheral blood.
How to Perform Autotransfusion : Step by Step
Prepare your supplies:
Start by getting all of your supplies out and ready to go. Remember to label any syringes containing drugs and medications.
Assemble the 3-way stopcock and ensure that your assistant understands how to use it (click here to learn how to operate a 3-way stopcock).
Select Site, Clip Fur, and Infuse Local Anesthetic:
Start by selecting your optimal centesis site using ultrasound. This may be on the left side or the right side, depending on the patient, and whether they have been in prolonged lateral recumbency. Theoretically, the right side should have a larger window between the lungs, but often the left side of the chest provides better access. It just depends on the patient.
Clip the selected side generously.
I like to circle my optimal centesis site (identified by ultrasound) with a sharpie, and then infiltrate local anesthetic into that area, making sure that I go deep enough into underlying musculature to minimize discomfort as I pass the catheter through the chest wall.
Scrub Site and Fenestrate Catheter:
Your assistant can then aseptically scrub the site while you put your sterile gloves on and begin to “fenestrate” the catheter. If your black circle starts to disappear, have your assistant re-mark it before a final scrub.
Fenestrate the catheter ((fenestra means window in Latin).
You will only fenestrate the distal ¼ to 1/3 of the catheter. When you fenestrate the catheter, leave the stylet in the catheter and make small apertures or windows in the catheter so that there will be less resistance to flow. Make sure that your holes are evenly spaced and small, and that you are not leaving any burs in the catheter or compromising its integrity. You would not want any pieces of the catheter to break off inside of the patient.
Introducing The Catheter:
For hemoabdomen, it is generally preferred to position the patient in dorsal recumbency. Sternal recumbency is often more comfortable for patients and also can used in most situations.
At the selected centesis site, make a small stab incision into the skin using your scalpel blade, so that there will be less drag on the catheter as you pass it through the body wall.
Grab your catheter, and remember that this is just like a gigantic IV catheter. If you look at the tip, you will notice that the metal style protrudes a couple of millimeters beyond where the actual Teflon catheter starts. You can begin to slowly advance the catheter and stylet together through the skin. Closely watch the length of your catheter to you gauge your depth as you are advancing the catheter into the body.
When your catheter encounters the effusion, you will see a flash in the hub of your catheter. At this point, you will advance your stylet and catheter together a couple more millimeters, and then, holding the stylet still, feed the catheter off the stylet (while holding the stylet still), the same way you would if you were feeding a catheter into a vein. It may help to twist/rotate the catheter between your fingers as you slide it off the stylet. Remove the stylet, and temporarily occlude the hub of the catheter while you attach the extension set. Your assistant can begin to aspirate the fluid by drawing back on the syringe.
Administer the blood back to the patient intravenously:
Blood collected into a syringe can be administered back to the patient intravenously through a hemonate blood filter. You do not need to mix the blood suctioned from a body cavity with an anticoagulant such as CPDA.
When a significant volume of hemorrhagic effusion (>200 ml) is retrieved and active hemorrhage is suspected, it is more efficient to transfer blood retrieved directly into a blood collection/blood administration bag, so that it can be administered back to the patient through a filtered blood administration set.
When you are done, remove the catheter and place a biocclusive over the site, For the next 1-2 hours, continue to monitor the site intermittently with ultrasound for recurrence of pericardial effusion, and continue to monitor the patient’s vital parameters (heart rate, blood pressure, EKG) continuously if possible.