INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)

ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue XI November 2025

Reducing Hospital Stay and Enhancing Wound Healing Through

Intraoperative Cell Salvage in Spine Surgery

Alias Mahmud^1*, Muhammad Affizi Ishak², Abdul Raimi Abd Kadir¹, Azmi Ab Manan¹, Rajesh

Kumar¹

¹Faculty of Technology and Applied Sciences, Open University Malaysia (OUM)

²Sarawak General Hospital, Ministry of Health Malaysia

^*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2025.91100153

Received: 10 November 2025; Accepted: 20 November 2025; Published: 03 December 2025

ABSTRACT

Significant blood loss during spine surgery often necessitates allogeneic blood transfusion (ABT), which poses

clinical and logistical challenges, including immune reactions, infection risks, and supply constraints. This

retrospective cohort study assessed the clinical efficacy of intraoperative cell salvage (ICS) in reducing

dependence on ABT and improving patient outcomes at Malaysia Government General Hospital (GH),

Malaysia. Data from 72 patients who underwent spine surgeries between January 2023 and December 2024

were analysed. Participants were divided into two groups: 36 patients received ICS and 36 received standard

transfusions. Comparative analyses using t-tests and chi-square tests evaluated transfusion requirements,

wound healing, haemoglobin (Hb) trends, recovery time, hospital stay, and cost parameters. The ICS group

demonstrated significantly shorter hospital stays (M = 8.4 days) compared to the non-ICS group (M = 16.9

days; p < .001), as well as faster recovery (M = 6.0 vs. 13.4 days; p = .001) and superior wound-healing

outcomes (p < .001). No significant difference was observed in postoperative Hb levels or intraoperative

packed red blood cell use, suggesting equivalent hematologic recovery between groups. Although the

reduction in transfusion requirement was not statistically significant (p = .108), the trend favoured ICS. These

findings indicate that ICS enhances clinical efficiency by promoting faster recovery, improved wound healing,

and reduced hospital stay without compromising safety or haemoglobin stability. The results support broader

integration of ICS into perioperative blood management in high-blood-loss spine surgeries, particularly in

resource-constrained healthcare systems.

Keywords: Intraoperative cell salvage; Blood transfusion; Spine surgery; Wound healing

INTRODUCTION

Spine surgery frequently involves considerable intraoperative bleeding that necessitates blood transfusion to

maintain hemodynamic stability. Allogeneic blood transfusion (ABT), the administration of donor blood, is

often essential yet poses significant medical, logistical, and ethical concerns. The use of donor blood

introduces risks of transfusion-transmitted infections, immunologic reactions, and prolonged postoperative

recovery (Carson et al., 2021; Raykar et al., 2024). Furthermore, ABT imposes economic and supply

challenges in hospitals where donor blood is limited or rare blood types are difficult to source, as seen in

Sarawak’s indigenous populations (Aubrey, 2021; Banji, 2024). In response, intraoperative cell salvage (ICS)

has emerged as a valuable alternative. ICS is an autologous transfusion technique that collects, processes, and

reinfuses a patient’s shed blood during surgery, thereby minimising dependence on donor blood (Carroll &

Young, 2021). Evidence shows that ICS decreases ABT rates, preserves red cell integrity, and mitigates

infection risk (Cheriyan et al., 2020; Lloyd et al., 2023). However, despite its success in cardiac and

orthopaedic procedures, its use in spine surgery—particularly in Malaysia—remains limited. At Sarawak

General Hospital (SGH), the state’s primary referral center, spine operations are routinely performed twice

weekly. Given the volume and complexity of cases, the hospital blood bank faces recurring pressure to

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INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)

ISSN No. 2454-6186 | DOI: 10.47772/IJRISS | Volume IX Issue XI November 2025

maintain adequate donor supplies. Implementing ICS could reduce ABT dependence, optimise blood resource

utilisation, and enhance surgical outcomes. This study, therefore, evaluates the clinical efficacy of ICS

compared with conventional transfusion methods in spine surgery at SGH, assessing outcomes including

transfusion requirements, haemoglobin stability, wound healing, hospital stay, recovery duration, and cost

implications.

METHODOLOGY

This retrospective cohort study evaluated the clinical efficacy and outcomes of intraoperative cell salvage

(ICS) compared with conventional allogeneic blood transfusion (ABT) among patients undergoing spine

surgery at General Hospital (GH) in Malaysia. The investigation examined whether ICS reduced transfusion

requirements, enhanced postoperative recovery, and optimised hospital resource utilisation in a high-volume

surgical setting. Data were retrieved from the computerised operating theatre documentation system, electronic

medical records, and surgical logs for procedures performed between January 2023 and December 2024.

Ethical approval was obtained from the institutional Research Ethics Committee, and all data were anonymised

prior to analysis. The study population comprised patients who underwent elective spine surgery within the

specified period. Purposive sampling identified cases meeting the inclusion criteria: availability of complete

medical records; documentation of intraoperative blood management (ICS or standard practice); and absence

of conditions that could confound transfusion requirements. Patients were excluded if records were incomplete,

surgery was performed emergently, or pre-existing coagulopathies were documented. A priori power analysis,

with α = 0.05 and 80% power, indicated a minimum of 36 participants per arm to detect an absolute 30%

difference in transfusion rates; thus, 72 patients were enrolled, with 36 per arm. Variables extracted included

age, sex, body mass index (BMI), comorbidities, estimated blood loss (EBL), haemoglobin (Hb) levels

preoperatively and on postoperative days one and three, units of packed red blood cells (PRBC) transfused

intraoperatively, wound-healing grade, length of stay, recovery time (days from surgery to discharge), and total

hospital costs. Data were captured using structured case report forms to standardise abstraction and then

analysed in IBM SPSS Statistics (Version 28). Descriptive statistics summarised cohort characteristics.

Independent-samples t-tests compared continuous outcomes (e.g., EBL, Hb, length of stay), and chi-square

tests examined categorical variables (e.g., wound-healing grade, comorbidities). Effect sizes (Cohen’s d,

Hedges’ g) quantified the magnitude of between-group differences. Data integrity procedures included record

cross-checking and outlier review to mitigate errors caused by documentation inconsistencies. Because the

design was retrospective, causal inference is limited; however, methodological rigour and standardised

protocols were applied to provide credible real-world evidence on the utility of ICS in this setting.

RESULTS

A total of 72 patients met the inclusion criteria, consisting of 45.8% males and 54.2% females. The mean age

was 30.4 years (SD = 20.4), with the ICS group representing a younger cohort (M = 17.4, SD = 3.9) compared

to the non-ICS group (M = 43.4, SD = 21.9). The body mass index (BMI) was significantly lower in the ICS

group (M = 18.9 kg/m², SD = 3.4) than in the non-ICS group (M = 24.2 kg/m², SD = 5.9; t(70) = –4.68, p <

.001). Table 1 presents the comparison of key intraoperative and postoperative variables between groups.

Although estimated blood loss (EBL) was higher among ICS patients (M = 908 mL) than non-ICS patients (M

= 664 mL; p = .005), 72.2% of ICS cases required no packed red blood cell (PRBC) transfusion, compared to

63.9% in the non-ICS group (p = .108). Haemoglobin (Hb) levels were comparable between groups

preoperatively (ICS: M = 12.99 g/dL; non-ICS: M = 12.69 g/dL) and on postoperative days one and three (p >

.05).

Notably, postoperative recovery indicators improved substantially among ICS patients. The mean length of

hospital stay was significantly shorter (M = 8.4 days, SD = 5.9) than for the non-ICS group (M = 16.9 days,

SD = 12.6; p < .001), while the mean recovery time from surgery to discharge was also reduced (M = 6.0 vs.

13.4 days; p = .001). Wound-healing outcomes were markedly better in the ICS group, with 94.4% achieving

Grade 1 healing compared with 50.0% in the non-ICS cohort (χ² = 18.52, p < .001).

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INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)

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Table 1: Comparison of Clinical and Haematologic Outcomes Between ICS and Non-ICS Groups (N = 72)

Non-ICS Group (n

= 36)

Variable

ICS Group (n = 36)

17.4 ± 3.9

p Value

< .001

Interpretation

Age (years), M ±

43.4 ± 21.9

The ICS group is significantly younger

Significant difference in body composition

BMI (kg/m²), M ±

18.9 ± 3.4

24.2 ± 5.9

664 ± 376

Estimated blood loss

(mL), M ± SD

908 ± 347

.005

.465

Higher blood loss in ICS surgeries

No significant difference

Pre-operative Hb

(g/dL),

12.99 ± 1.48

12.69 ± 1.93

M ± SD

Post-operative Hb

Day 1 (g/dL)

11.11 ± 1.40

10.50 ± 1.35

10.98 ± 2.13

10.54 ± 2.20

.768

.930

Comparable Hb after surgery

Comparable Hb recovery

Post-operative Hb

Day 3 (g/dL)

PRBC transfusion

required (% of

cases)

27.8 %

36.1 %

.108

Trend toward reduced transfusion in ICS

Significantly shorter with ICS

Faster recovery in ICS

Length of hospital

stay (days),

8.4 ± 5.9

16.9 ± 12.6

13.4 ± 12.3

< .001

.001

M ± SD

Recovery time to

discharge (days), M 6.0 ± 5.3

± SD

Grade 1 wound

94.4 %

50.0 %

< .001

.153

Significantly better wound healing

Lower trend, not significant

healing (% of cases)

Hospital cost (RM),

193.9 ± 225.3

645.4 ± 1 860.2

M ± SD

Note. Hb = haemoglobin; PRBC = packed red blood cells; ICS = intra-operative cell salvage; M = mean; SD =

standard deviation. Statistical significance set at p < .05.

Seventy-two patients met the inclusion criteria (45.8% male; 54.2% female). The overall mean age was 30.4

years (range 12–77), with a younger ICS cohort (M = 17.4 years) compared with the non-ICS group (M = 43.4

years). BMI differed significantly between groups (ICS M = 18.9 kg/m² vs. non-ICS M = 24.2 kg/m²; p <

.001). Mean intraoperative estimated blood loss was greater in ICS (M = 908 mL) than in non-ICS (M = 664

mL; p = .005), reflecting selective ICS use in higher-risk procedures. Despite higher blood loss, 72.2% of ICS

patients avoided intraoperative PRBC transfusion, compared with 63.9% of non-ICS patients; differences in

units transfused were not statistically significant (p = .631). Haemoglobin trajectories were comparable:

preoperative Hb averaged 12.99 g/dL (ICS) and 12.69 g/dL (non-ICS; p = .465); postoperative day one values

were 11.11 and 10.98 g/dL, respectively; by day three, both groups averaged around 10.5 g/dL (all p > .05).

Wound-healing outcomes differed markedly: 94.4% of ICS patients achieved Grade 1 healing versus 50.0% in

non-ICS (χ² = 18.52, p < .001), with higher grades of complications concentrated in the non-ICS cohort.

Length of stay was significantly shorter with ICS (M = 8.4 vs. 16.9 days; p < .001), as was recovery time from

surgery to discharge (M = 6.0 vs. 13.4 days; p = .001). Comorbidities were more prevalent in the non-ICS

group (55.6% with at least one condition) than in ICS (19.4%; χ² = 10.02, p = .002). Although total

hospitalisation costs trended lower in ICS (RM194 vs. RM645; p = 0.153), government subsidies and

procurement models limited standardisation for formal cost-effectiveness analysis.

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INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)

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DISCUSSION

This study adds context-specific evidence from a Malaysian tertiary centre to the international literature on

intraoperative cell salvage. In a cohort of spine surgery patients, ICS was associated with significantly shorter

hospital stays, faster recovery, and superior wound-healing outcomes, while maintaining haemoglobin

trajectories comparable to those with conventional allogeneic transfusion. Although intraoperative PRBC

usage did not differ significantly, 72% of ICS patients avoided intraoperative transfusion despite higher blood

loss, suggesting that ICS enabled autologous red cell reinfusion sufficient to preserve haematologic stability.

These results align with and extend prior syntheses showing ICS reduces exposure to donor blood. The

Cochrane review by Lloyd et al. (2023) reported a 56% relative reduction in transfusion in spinal surgery with

ICS, whereas Cheriyan et al. (2020) demonstrated an average reduction of 0.81 allogeneic units across spine

procedures. Our non-significant difference in PRBC units may reflect sample size constraints and case-mix:

ICS was preferentially deployed in higher EBL cases, diluting the detectable between-group contrast.

Importantly, haemoglobin trends were comparable by postoperative day three, mirroring Liu et al. (2017) who

observed early postoperative Hb benefits with ICS that converged by discharge. Collectively, the pattern

supports ICS as a safe conservation strategy that does not compromise haematologic recovery.

A key, underreported finding is the strong association between ICS and improved wound healing. Transfusion-

related immunomodulation (TRIM) is a well-established concern associated with ABT, encompassing cytokine

shifts, impaired cellular immunity, and microchimerism that can impact infection and tissue repair (Carson et

al., 2021). Our observation that 94% of ICS patients achieved Grade 1 healing, compared to 50% in non-ICS

patients, is consistent with the hypothesis that limiting donor exposures mitigates TRIM and downstream

complications. While we cannot definitively attribute causality, the magnitude and direction of effect,

alongside the absence of Hb disadvantages in ICS, argue that autologous strategies may favour tissue recovery.

This aligns with broader perioperative blood management guidance, which recommends a multimodal

approach utilising TXA, meticulous haemostasis, hypotensive anaesthesia, and salvage to reduce

complications (Mikhail et al., 2020; Lenet et al., 2023).

From a systems perspective, ICS supports the sustainability and resilience of the blood supply. Malaysia’s

reliance on volunteer donors can lead to periodic shortages, and East Malaysia faces unique compatibility

challenges due to rare phenotypes (Aubrey, 2021; Banji, 2024). ICS provides an on-demand autologous source

that reduces pressure on blood banks, shortens hospital stay, and potentially lowers expenditure through fewer

transfusion-associated events and faster throughput. Although we did not perform a formal cost-effectiveness

analysis—owing to subsidy structures and non-itemised procurement the direction of the results aligns with

international assessments that associate ICS adoption with downstream savings in high-blood-loss contexts

(Brandão et al., 2023). Future Malaysian cost studies should incorporate micro-costing of disposables,

amortised device costs, staff time, and savings from reduced length of stay and complications to inform

procurement policy.

Ethically, ICS enhances respect for patient values and autonomy. Jehovah’s Witnesses may decline ABT

entirely, and ICS—with appropriate consent—offers a clinically acceptable alternative (Klein et al., 2018).

Likewise, for patients with rare antigen profiles, ICS reduces the risk of haemolytic reactions from mismatched

donor units. Institutionalising ICS within perioperative pathways, therefore, advances patient-centred care

while safeguarding safety.

A critical appraisal of our findings must account for selection bias and confounding. The ICS cohort was

younger with lower BMI and fewer comorbidities—factors themselves associated with better wound healing

and faster recovery (Briguglio et al., 2022; Myles, 2020). While statistical testing identified significant group

differences, residual confounding remains a plausible concern in any retrospective design. Moreover, greater

EBL in ICS cases reflects clinical triage toward salvage in higher-risk surgeries; paradoxically, the superior

outcomes in ICS despite this disadvantage strengthen the signal in favour of ICS but also complicate causal

inference. Future research should use prospective allocation or randomised designs, standardise transfusion

thresholds, and stratify by procedure complexity to isolate ICS effects more clearly. Pragmatic trials embedded

within theatre lists at SGH could leverage existing documentation systems to minimise incremental cost.

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INTERNATIONAL JOURNAL OF RESEARCH AND INNOVATION IN SOCIAL SCIENCE (IJRISS)

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Generalizability is enhanced by focusing on routine practice in a government hospital serving diverse

populations; however, implementation fidelity matters. ICS benefits depend on timely setup, adequate

suctioning of shed blood, appropriate anticoagulation and washing parameters, and staff proficiency (Carroll &

Young, 2021). Investment in training Assistant Medical Officers and anaesthetic teams, along with 24/7

availability of devices and disposables, is essential. Parallel adoption of evidence-based adjuncts, such as TXA

(Mikhail et al., 2020), topical haemostats (Huec et al., 2022), and strict haemostasis, can maximise salvage

yield and consistency.

Finally, our findings fit within a broader movement toward patient blood management (PBM) to reduce

unnecessary transfusions and improve outcomes across surgical specialities (Kiyatkin et al., 2023). PBM

emphasises preoperative anaemia optimisation, minimally invasive techniques, restrained transfusion

thresholds, and autologous strategies. In this PBM framework, ICS is not a standalone solution but a pivotal

intraoperative pillar. For SGH, an ICS-first algorithm for anticipated high-EBL spine procedures—coupled

with standard TXA, haemostatic techniques, and postoperative surveillance could serve as the basis for local

guidelines and MQA-aligned quality indicators for training and audit.

CONCLUSION

In spine surgery at Malaysia General Hospital, intraoperative cell salvage was associated with a shorter length

of stay, faster recovery, and superior wound-healing outcomes, while maintaining haemoglobin recovery

comparable to that of conventional transfusion. Although intraoperative PRBC use was not significantly

different, a favourable trend toward transfusion avoidance was observed despite higher blood loss in the ICS

group. These findings support ICS as a safe and valuable component of perioperative blood management in

high-blood-loss spine procedures, particularly in resource-constrained settings and populations with rare blood

phenotypes or transfusion objections. Prospective studies and context-specific economic evaluations are

warranted to confirm effect sizes and inform hospital-wide policy and procurement.

ACKNOWLEDGEMENT

The authors gratefully acknowledge the Faculty of Technology and Applied Sciences, Open University

Malaysia and Sarawak General Hospital, Ministry of Health Malaysia, for the institutional support and

academic guidance that significantly contributed to the successful completion of this work.

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