Title: Section 58-2.25 - Intraoperative and postoperative blood recovery and normovolemic hemodilution

Effective Date

10/23/2007

58-2.25 Intraoperative and postoperative blood recovery and normovolemic hemodilution.

(a) Blood recovered intraoperatively or postoperatively from a person or collected for normovolemic hemodilution shall not be transfused into another person.

(b) Methods for intraoperative or postoperative recovery of blood and for normovolemic hemodilution shall be safe and aseptic and shall ensure accurate identification of all blood collected. The equipment used shall be operated according to the manufacturer's instructions, shall be pyrogen-free, shall include a filter capable of retaining particles potentially harmful to the recipient, and shall prevent air embolism. If the blood is warmed prior to reinfusion, the warming system shall be equipped with a visible thermometer and an alarm to ensure that the blood is not warmed above the temperature specified in a written protocol, in conformance with the system manufacturer’s instructions.

(c) A complete written protocol for collection and processing of recovered blood and for normovolemic hemodilution, approved by the director of transfusion services, shall be maintained and followed. The protocol shall include criteria for selection of suitable patients and determination of dosage of ancillary agents used, as well as procedures for prevention and management of adverse reactions.

(d) If recovered blood or blood collected for normovolemic hemodilution is removed from the immediate premises for processing or storage, identification procedures shall be in place to ensure its transfusion into the intended recipient.

(e) If not immediately transfused, recovered blood shall be stored under one of the following conditions:

(1) at one to 24 degrees Celsius for up to six hours after initiating the collection; or

(2) at one to six degrees Celsius under monitored conditions for up to 24 hours, provided storage at one to six degrees Celsius is begun within six hours of initiating the collection and the blood is washed under sterile conditions.

(f) Blood collected for normovolemic hemodilution shall be stored under one of the following conditions prior to initiation of transfusion:

(1) at one to 24 degrees Celsius for up to eight hours after initiating the collection; or

(2) at one to six degrees Celsius under monitored conditions for up to 24 hours, provided that storage at one to six degrees Celsius is begun within eight hours of initiating the collection.

(g) Untested recovered blood and blood collected for normovolemic hemodilution which are kept in the blood bank shall be stored in a specially designated area separate from other units and prominently labeled with the patient's name and a label "Caution: Untested Blood" or similar wording.

(h) Transfusion of blood recovered postoperatively or from post-traumatic patients shall commence within six hours of the initiation of the collection, or if not, the blood shall be discarded.

(i) All records of transfusions of blood recovered intraoperatively or postoperatively shall be available to the department for inspection for at least seven years after each transfusion. Summary records, listing the patient's name, the medical record number and procedures performed, shall be kept of all such procedures, separate from the patient's chart.
 

Volume

VOLUME A-1 (Title 10)

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