Errors During Intraoperative Cell Salvage Because of
Inappropriate Wash Solutions
Jonathan H. Waters, MD, and Juraj Sprung, MD, PhD*
Department of General Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio; and *Mayo Clinic, Mayo Medical
School, Rochester, Minnesota
fusion (1). Likewise, a growing awareness of errors in
medicine has attracted attention because of a recent In-
stitute of Medicine (IOM) report on errors (2). This IOM
report documents that from 44,000 to 98,000 deaths a
year result from a broad range of medical errors. The
conclusion of the IOM report was that most medical
errors result from the basic organization of the health
care system. In this case report, a description of two
reported. In the first case, absence of a quality assurance
system and lack of an organized cell salvage program
contributed to a patient receiving a cell salvaged unit of
blood that was contaminated with glycine. In the second
case report, changes instituted as a result of a quality
improvement process prevented a similar occurrence.
nterest in blood conservation techniques is growing
in the United States. This interest stems from a
shortage of blood components available for trans-
A 73-yr-old male was undergoing the repair of an 11-cm
Type IV thoracoabdominal aneurysm. Cell salvage was re-
quested for the surgical procedure. Cell salvage was initi-
ated with a Hemonetics Cell Saver 4 (Hemonetics Corp.,
Braintree, MA) managed by the operating room (OR) circu-
lating nurse. Shed blood was heparinized and scavenged
into a standard 120-?m cardiotomy reservoir. Blood pro-
cessing used a 225-mL Latham bowl with 0.9% saline solu-
tion as the wash solution. Immediately after release of the
aortic cross-clamp, vigorous blood loss required 6 U of
blood to be processed rapidly. Besides managing the cell
salvage equipment, the circulating nurse was performing
other operating room tasks. These duties included obtaining
supplies for the operating room technician, computer entry
for supply charges, answering pages for the surgeons, main-
taining OR paperwork, and assisting the anesthesia provider
as needed. During this period of heavy blood loss, the bag of
wash solution was changed. Instead of 0.9% saline solution,
the nurse connected 1.5% glycine solution, which is a solu-
tion normally reserved for bladder irrigation during the
performance of transurethral resection of the prostate
(TURP). One unit of blood was processed and administered
to the patient. On processing of the second unit, the anes-
thesiologist managing the patient noticed the solution error.
Cell salvage was discontinued and the surgery was com-
pleted without other complications. Glycine and ammonia
levels were sent immediately after discovery of the error but
were found to be within normal limits. After the surgery, the
patient was transported to the intensive care unit, where he
had an uneventful recovery.
A 74-yr-old patient was undergoing an 8-cm type IV thora-
coabdominal aneurysm repair. Cell salvage was requested
for the surgical procedure. Cell salvage was initiated using a
Medtronic Sequestra (Medtronic, Inc., Minneapolis, MN)
which was managed by a technician dedicated to the cell
salvage equipment. Shed blood was heparinized and scav-
enged into a standard 120-?m cardiotomy reservoir. Blood
processing used a 225-mL Latham bowl with 0.9% saline
solution as the wash solution. After the processing of five
bowls of blood, the technician noticed that the effluent su-
pernatant line did not clear of its red coloration and that the
color of the blood did not appear to have a normal color (Fig.
1). A routine hemoglobin check of the processed blood was
found to be 9 gm/dL, well below expected values. On
noticing these three events, the technician noticed that in-
stead of using 0.9% saline as a wash solution, he had used
sterile water. The processed blood was discarded, the sys-
tem was changed, and the case proceeded uneventfully,
with the patient ultimately losing 21,000 mL of blood with
5045 mL being processed and returned from cell salvage.
As anesthesiologists become more interested in blood
conservation, an understanding of the complications
related to cell salvage and how to prevent complica-
tions related to cell salvage is important. These two
cases illustrate how similar labeling of three irrigation
solutions often used in an OR can lead to errors during
Accepted for publication August 1, 2001.
Address correspondence and reprint requests to Jonathan H.
Waters, MD, Department of General Anesthesiology, Cleveland
Clinic Foundation, 9500 Euclid Ave., E31, Cleveland, OH 44195.
Address e-mail to firstname.lastname@example.org.
©2001 by the International Anesthesia Research Society
0003-2999/01Anesth Analg 2001;93:1483–5
cell salvage. It also demonstrates the need for a quality
assurance system to help prevent errors during cell
In the first case, the cell salvage equipment was
managed by a circulating nurse who was responsible
for multiple OR tasks in addition to managing the cell
salvage equipment. In this system, cell salvage pro-
cessing generally occurred at the convenience of the
nurse because of the multiple tasks that were assigned
to her. As a result, shortcuts have been taken that
included processing of incomplete bowls, which can
lead to inadequate wash quality (3), a failure to ade-
quately anticoagulate the salvaged blood, which can
lead to poor red cell recovery, and occasional errors in
processing as described here. The error described in
the first case occurred at a time when the nurse was
trying to respond to multiple demands during a crit-
ical period of the surgery when acute blood loss was
After this case, a cell salvage program was estab-
lished that complied with the recommendations of the
American Association of Blood Banks (AABB) which
proposes “Standards for perioperative collection and
Transfusion” (Table 1) (4). In these proposed stan-
dards is guidance for product testing. For cell salvage,
the recommendations are for inspection of the effluent
supernatant color, a measure of the product hemato-
crit, measurement of the weight of the product, and
visual inspection of the final blood product. In addi-
tion, these guidelines recommend that a dedicated
technician who has undergone training and periodic
continuing education, rather than an individual who
has multiple OR job responsibilities, be in charge of
the cell salvage process. In our program, technicians
with a minimum educational background of an asso-
ciate’s degree were hired and trained via the cell sal-
vage equipment manufacturer’s training program.
Additionally, weekly educational meetings are held to
discuss cell salvage management and program prob-
lems. Because the educational background of these
individuals is not extensive, minimal increases in the
cost of producing a cell salvage product have occurred
from implementation of the AABB standards. The
value of these quality checks and a dedicated techni-
cian is illustrated in the second case. Here, a similar
wash solution identification error was made but, un-
like the first case, the error was recognized before
administration of the blood.
The similar labeling of the 0.9% saline, glycine, and
sterile water infusion bags led to these errors. (Fig. 2)
When we inspected how this could have happened,
we noticed that in our central core storage area all
types of irrigation fluid (0.9% saline, sterile water, and
1.5% glycine) are kept in close proximity. Further-
more, we found several bags of glycine stored with
0.9% saline. In 1981, Wang and Turndorf (5) noted that
up to 12% of drugs administered in hospitals were in
error. This lead to an effort to standardize and en-
hance the labeling of drugs and prefilled syringes (6).
This case would suggest that the same effort should be
applied to the labeling of these irrigation fluids.
No injury resulted from either of these mistakes;
however, in the second case, the consequences may
have beensignificant. Administration
washed with sterile water has not been previously
reported but a similar problem has been described
with albumin dilution. From 1994 to present there
have been ten reports of 25% albumin being diluted
with sterile water and being administered to patients
(7,8). In these albumin cases, the red cell hemolysis
which resulted from the hypotonic solution caused
renal insufficiency and failure, decreases in hemato-
crit, increases in serum lactate dehydrogenase, in-
creases in total serum bilirubin concentration, dissem-
inated intravascular coagulation, and, in two patients,
death. Thus, it is extremely important to recognize this
error to prevent serious patient injury.
The consequences of the glycine infusion may be
less significant to patient outcome because of the
isoosmotic character of the fluid, though the glycine
administration may have caused transient blindness
as may occur during the TURP syndrome. Glycine has
a distribution similar to that of ?-aminobutyric acid,
an inhibitory transmitter in the brain, and is believed
to act as an inhibitory transmitter also at the spinal
cord level, brainstem, and retina. In addition, absorp-
tion of glycine may result in central nervous system
toxicity based on its oxidative biotransformation to
ammonia. Subsequent analysis of the patient’s blood
glycine and ammonia levels, and a finding that these
levels were within normal range, suggested that the
Figure 1. The unit of processed blood on the left was washed with
sterile water and is compared to a unit of blood that was washed
with 0.9% saline on the right. It is important to note that the unit of
blood processed with sterile water was hemolyzed, resulting in a
darker, transparent coloration. Hemoglobin measurement was per-
formed with conversion to hematocrit and is written on the bag.
CASE REPORTSANESTH ANALG
patient received small amounts of glycine with the
unit of glycine-washed blood. This conclusion would
be supported by the volume of glycine that was in the
administered unit of washed cells. In general the av-
erage unit of cell salvage blood has a hematocrit of
60% with a standard volume of 225 mL. This means
that approximately 90 mL of the unit was glycine
In conclusion, these cases highlight the need to be
vigilant when performing cell salvage. This report is
also illustrative of the importance of adopting the
AABB standards for perioperative cell salvage. In ad-
dition, it demonstrates that product labeling can be
important in areas other than drug labels.
1. Wallace EL, Churchill WH, Surgenor DM, et al. Collection and
transfusion of blood and blood components in the United States,
2. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human:
building a safer health system. Washington, DC: National Acad-
emy Press, 2000.
3. Szpisjak DF. Debris elimination from partially filled cell salvage
bowls. Anesth Analg 2001;92:1137–8.
4. Standards for perioperative collection and transfusion, 1st Edi-
5. Wang BC, Turndorf H. Prevention of medication error. N Y State
J Med 1981;81:395–402.
6. Rendell-Baker L. Better labels will cut drug errors. Anesthesia
Patient Safety Foundation Newsletter 1987;2:29–40.
7. Pierce LR, Gaines A, Varricchio F, Epstein J. Hemolysis and renal
failure associated with use of sterile water for injection to dilute
25% human albumin solution. Am J Health Syst Pharm 1998;55:
8. Centers for Disease Control and Prevention. Hemolysis associ-
ated with 25% human albumin diluted with sterile water–United
States, 1994–1998;JAMA 1999:281:1076–7.
Table 1. Outline of Standards for Perioperative Collection and Transfusion as Proposed by the American Association of
Create a management structure for the program.
Create a mechanism to ensure that adequate resources are
available to run the program.
Create an equipment maintenance program.
To ensure that equipment suppliers are qualified.
Create a process which assures that a quality product is
Assures that policies and procedures are established for the
program and that a method of record keeping is
established for management of the program.
Establishes a program to capture adverse events, and to
respond and fix any problem that might have caused an
Periodic external and internal reviews of the program
should be established.
To establish a process for corrective and preventive action.
4.0: Supplier and Customer Issues
5.0: Process control
6.0: Documents and Records
7.0: Incidents, Errors, and Accidents; Nonconforming
Blood or Components and Services, and
8.0: Assessments-Internal and External
9.0: Process Improvement through corrective and
10.0: Facilities and Safety Guarantee that the program provides a safe workplace for
Figure 2. This figure shows the similar product labeling for the three
solutions. The wording is identically colored in a red/orange color
on all three bags.