Autologous Tissue Management

Purpose

This document provides guidance for preserving autologous tissue, including cranial bone flaps, parathyroid glands, skin, vessels (eg, veins, arteries), femoral heads, incus, and adipose tissue, in the perioperative setting. Guidance is also provided for team communication related to autologous tissue management; handling, packaging, labeling, storage, disposal, cleaning, transport, and documentation of autologous tissue; and policies and procedures for preservation and delayed replantation or autotransplantation of autologous tissue within the same facility.

Preserving and replanting autologous tissue may improve the patient’s long-term outcomes. Some types of autologous tissue (eg, cranial bone flaps, parathyroid glands) are preserved because the patient’s clinical symptoms (eg, swelling, hormone levels, infection) prevent the tissue from being replanted or autotransplanted during the same procedure in which it was removed. Other types of autologous tissue (eg, veins, skin, adipose tissue) are preserved because the tissue was harvested but was not all used during the original procedure and may be needed for a future procedure (eg, cardiovascular bypass graft, skin graft). In addition, the use of autologous tissue may be preferred over the use of allograft tissue or synthetic tissue implants in certain situations. Following good tissue practices described in 21 Code of Federal Regulations (CFR) Part 1271 Subpart D¹  and evidenced-based guidance for autologous tissue management may

• decrease the patient’s risk for infection;

• decrease the risk for a packaging, labeling, or tissue identification error;

• decrease the risk to perioperative personnel of exposure to blood and other potentially infectious materials; and

• preserve the clinical viability of the tissue.

The following topics are outside the scope of this document:

• autologous tissue that is replanted into the patient during the same procedure in which it was removed (eg, tendons, ligaments, osteochondral grafts, fractional skin grafts, epidermal grafts);

• autologous blood products;

• autologous islet cell or stem cell transplantation;

• autologous cartilage used for staged microtia reconstruction procedures;

• autologous bone that is exposed to cryotherapy, radiation, or thermal therapy for eradication of cancer and replanted during the same procedure in which it was removed;

• tissue-engineered grafts grown from autologous cells;

• allograft organ or tissue transplantation;

• allograft fecal microbiota transplantation; and

• xenogeneic tissue (eg, bovine or porcine implants).

Refer to the AORN Guideline for Specimen Management²  for information regarding surgical specimens and the AORN Guideline for Sterilization Packaging Systems³  for recommendations on packaging systems for sterilization.

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE®, Ovid Embase®, EBSCO CINAHL®, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2014 through October 2018. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until February 2019. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included adipose aspirates, adipose tissue, autograft, bone flap, bone resorption, bone transplantation, cell culture techniques, cranial edema, craniotomy, cryopreservation, decompressive craniectomy, fat grafting, intercranial hypertension (surgery), internal mammary artery, internal mammary artery implantation, internal thoracic artery, mammary arteries, ossiculoplasty, parathyroid glands, pedicle flap, radial artery, renal artery, saphenous vein, skull (microbiology, cytology, surgery), sterilization (methods), sterilization and disinfection (methods), surgical flaps, thoracic arteries, time factors, and transplantation (autologous).

Figure 1

Flow Diagram of Literature Search Results

Adapted from: Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(6):e1000097.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted if there was a disagreement between the lead author and the primary evidence appraiser. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. Embase is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL.