autologous blood donation and transfusion

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Autologous Autologous Blood Donation Blood Donation and transfusionand transfusion

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What does ‘Autologous Transfusion’ mean?

Autologous transfusion is where the donor and recipient

are the same person.

There are different types of autologous transfusion including:•Preoperative autologous donation (PAD)•Intra-operative cell salvage•Post-operative cell salvage•Acute normovolaemic haemodilution•Directed donation

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Aims:To demonstrate an awareness of the different techniques available as alternatives to allogeneic blood transfusion and an awareness of their appropriate use.

Objectives:•To develop an awareness of better transfusion

practice.

•Discuss different autologous transfusion techniques available.

•Identify alternative care strategies to avoid the use of allogeneic blood.

•To promote the appropriate and timely use of transfusion alternatives.

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Although the risks of blood transfusion have been considerably minimised, the

incidents highlighted in the Serious Hazards of Transfusion (SHOT) reports

show the importance of continuing education in the appropriate use of

blood.

TRANSFUSE ONLY WHEN THE BENEFITS OUTWEIGH THE RISKS

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Good Transfusion Practice - General Considerations

Base practice on transfusion triggers, targets set by local

guidelines, and individual patient assessment

Minimise amount of phlebotomy for

lab samples

Establish target haemoglobin

tolerable to the individual patient

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Reducing transfusion requirements

Pre-operative procedures include:

Pre-operative surgical assessment units: blood tests should be performed

and reviewed in a timely manner for diagnosis and treatment of anaemia e.g. iron deficiency anaemia. Assessment of

patient’s previous clinical history e.g bleeding disorders.

Assessment of patient’s current medication - where possible plan to stop medications pre-operatively e.g. anti-coagulant / anti-

platelet drugs

Discuss treatment options with patient: this is of particular importance if

the patient has any strong beliefs or thoughts about blood transfusion (not just Jehovah’s Witness patients) - allow plenty

of time to plan for any specific alternatives to transfusion to be

organised.

Maximum Surgical Blood Ordering Schedule: this is a guidance schedule

developed following agreement with surgeons and anaesthetists - it should be

used as a guide/tool to indicate how many units to order for different surgical

procedures - hospital blood banks may question clinicians if a request differs from

the MSBOS.

Plan for possible cell salvage: many hospitals now provide peri or post operative cell salvage - these

techniques can be used in a variety of surgical procedures - individual patients should be assessed for

suitability pre-operatively and options discussed with the patient.

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Reducing transfusion requirements

Module 4: Alternatives to Allogeneic Blood Transfusion

West Midlands

Intra-operative procedures include:

Careful positioning of the patient during surgery - may help

reduce blood loss by minimising venous congestion in the operating field.

Use of intra-operative cell

salvage

Maintain normothermia

(unless hypothermia is indicated) -

coagulation factors may be less effective

at lower temperatures, increasing the risk of

blood loss.

Preventing hypertension (controlled hypotension) - hypertension may lead to excessive bleeding

NOTE: this is a specialist anaesthetic technique.

Use of fibrin seals / haemostatic agents / drugs to help reduce

surgical bleeding

Appropriate use of surgical

dissecting instruments - some instruments help to

reduce blood loss e.g. diathermy knives,

lasers, ultrasonic scalpel.

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Advantages1 Prevent transfusion TTDs2 Prevent red cell Allo - immunization3 Supplements the blood supply in BTS4 Provide compatible blood for patient with

Allo-antibodies5 Prevent adverse transfusion reactions6 Provide reassurance to patients concerned

about blood risk7 reduce postoperative risk of bacterial

infection8 reduce risk of cancer recurrence because

the fewer effect of Immuno modulation

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Disadvantages1 Same risk of bacterial contamination2 Same risk of ABO incompatibility error3 Costlier than allogenic blood 4 Wastage of blood, if not switched over. 5 Chances of unnecessary transfusion 6 Subjects patient prone to perioperative

anemia & increase likelihood of transfusion and side effect of iron supplementation

7 same risk of clerical error8 anxiety to some patient

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TYPES OF AUTOLOGOUS TRANSFUSION

Preoperative autologous blood donation (PABD)

Acute normovolemic hemodilution (ANH) Intra operative and post operative blood

recovery (blood salvage)

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Preop. Autologous donation

Inclusion: Stable patients scheduled for surgical procedure in which blood transfusion is likely. Donor Pt. should qualify criteria for blood donation in surgery that bleeding is more than 1000cc.

Necessity:a. Close relation between clinician & blood bank (BB)b. Donor suitability by BB physicianc. Oral Fe one week before & many weeks after

e. at least Hb before operation is 11 * No limit of weight or aheage

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CANDIDATES FOR P.A.B.D

Stable patients M.S.O.B.S (surgical procedure with blood loss) Major orthopedic procedure Patients with alloantibodies Vascular surgery Thoracic or cardiac surgery Total joint replacement

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Pre-op Autologous Donation

Contraindications:1 Evidence of infection and risk of bacteremia2 Scheduled surgery to correct aortic stenosis3 Unstable angina4 Active seizure disorder5 Myocardial infarction or CVA accidents in 6 mounth6 Significant cardiac or pulmonary disease7 Cyanotic heart disease8 Uncontrolled hypertension9 Malignant diseases10 high grade main coronary artery disease 11 diarrhea12 dental operation13 skin ulcer14 Antibiotic use

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Each blood centre or hospital that decides to conduct an autologous blood collection program must have its own policies, processes and procedures

Patient’s physician initiates the request for autologous services, which then is approved by Transfusion Medicine physician after physical evaluation

Patient advised oral supplemental iron from one week before operation

Request by physician should include the patient name, unique identifying number, number of units and kind of component required, date of scheduled surgery, nature of surgical procedure

Pre-op Autologous Donation Procedure

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A sufficient number of units should be drawn to avoid exposure to allogenic blood

In lower than 50 kg (weight*450cc/50)

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It usually begins 3-5 weeks before scheduled surgery. usually 2-4 units on each occasion ,approximately 500 ml of blood are collected .patient with more than 50 kg body weight usually donate 500 ml of blood in one session .patient with less than 50 kg body weight donate smaller volumes. The volume collected shouldn’t be more than 10% of the patient’s estimated blood volume .

One donation per week is usually scheduled, although more aggressive donation schedules are possible . In theory , donation every 3 days are feasible . The last donation takes place not later than 48-72 hour before surgery . This is to allow for the equilibration of blood volume.

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New Program

SOPs at each step Testing Protocol: Once in 30 days Separate inventory to avoid mix-ups Separate tags/ green labels to ensure

that the right unit goes to right patient X-match & Issue Discarding unused unit and not used as

allogenic because of different criteria and chances of clerical error

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ABO and Rh typing on labeled samples of patient. Units should have ‘green label’ with patient name

& number & marked ‘FOR AUTOLOGOUS USE ONLY’

Longest possible shelf life for collected units increases flexibility for the patient and allows time for restoration of red cell mass, between collection and surgery.

Special Autologous label may be used with numbering to ensure that oldest units are issued first.

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PAD Complications

Anemia and hypovolemia vasovagal reaction Venous access Pediatrics- low volume challenges Donor adverse reactions Clerical errors leading to the use of regular

donors before autologous units Over transfusion

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RISKS OF P.A.B.D

1-Mistake of transfusion 1-Mistake of transfusion 2-Human error (ABO incompatibility) 2-Human error (ABO incompatibility) 3-Bacterial contamination3-Bacterial contamination

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PABPD CONTRAINDICATION

1-Anemia1-Anemia2-Serious cardiac disease 2-Serious cardiac disease 3-Predisposing to bacteremia 3-Predisposing to bacteremia (e.g. urinary (e.g. urinary catheter or device)catheter or device)4-HBV, HCV, HIV positive4-HBV, HCV, HIV positive

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SAMPLE OF PROTOCOLS

Select of patient Select of patient Detection of number unitsDetection of number unitsRecommendation to interval collectingRecommendation to interval collectingUse of iron supplementsUse of iron supplementsTransport of unitsTransport of unitsReview of criteria autologousReview of criteria autologousManage of reactionManage of reactionPolicies programPolicies programAdditional informationAdditional information

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IRON SUPPLEMNTS

Prescription of ironPrescription of ironSuitable dose for decrease GI side effectsSuitable dose for decrease GI side effectsMaybe can not store of ironMaybe can not store of iron

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Autologous Sticker

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Acute Normovolemic Hemodilution

Definition:It is the removal whole blood from a patient just before the surgery and transfused immediately after the surgery. It is also known as

‘preoperative hemodilution’.

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PHYSIOLOGIC CONSIDERATION

Reduction of RBC losses Increase of perfusion’s tissues Improved oxygenation Decrease blood viscosity (The best oxygen delivery Hct 30-35%) Preservation of hemostasis

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Properly labeled units are stored at RT for up to 8 hours, unused units must be stored within 8 hours at 1-6 C, outdates in 24h

Re infuse units in reverse order to provide maximum hemostatic functions

ANH is equivalent to PAD in radical prostatectomy, knee and hip replacement

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CLINICAL STUDIES OF A.N.H

1-A.N.H equivalent to PAD1-A.N.H equivalent to PAD2-Minimized cost2-Minimized cost3-Elimination waste of units3-Elimination waste of units4-No inventory or testing4-No inventory or testing5-Never leaves the patient’s room 5-Never leaves the patient’s room (minimize clerical error &ABO (minimize clerical error &ABO incompatible)incompatible)

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CRITERIA FOR SELECTION OF A.N.H

1-Likliehood of transfusion exceeds1-Likliehood of transfusion exceeds2-Preoperative Hb at least 12 g/dl2-Preoperative Hb at least 12 g/dl3-Absence of coronary, pulmonary, renal or 3-Absence of coronary, pulmonary, renal or liver diseaseliver disease4-Absence of sever hypertension 4-Absence of sever hypertension 5-Absence of infection & bacteremia5-Absence of infection & bacteremia

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INDICATIONS FOR A.N.H

Hct>34%Hct>34%Intraoperative blood loss>1 litIntraoperative blood loss>1 litAny type of surgery with significant blood lossAny type of surgery with significant blood lossWhen the blood can be drawn after When the blood can be drawn after aneasthesia and transfusedaneasthesia and transfused

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CONTRAINDICATION FOR ANH

1-Anemia1-Anemia2-Impaired renal function2-Impaired renal function3-C.A.D, A.S, (no compensatory 3-C.A.D, A.S, (no compensatory mechanism)mechanism)4-Limitation of cardiac or pulmonary 4-Limitation of cardiac or pulmonary functionfunction5-Untreated hypertention5-Untreated hypertention6-Coagulation disorder6-Coagulation disorder

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PRACTICAL CONSIDERATION

1-ANH related to procedure & volume of 1-ANH related to procedure & volume of blood & target Hct blood & target Hct 2-Documented the manner 2-Documented the manner 3-Exact monitoring 3-Exact monitoring 4-Aseptic collection 4-Aseptic collection 5-Labelling 5-Labelling 6-Storage 6-Storage (room temperature=8h & (room temperature=8h & refrigirator=24h) refrigirator=24h) 7-Increase time staying in the operating 7-Increase time staying in the operating roomroom

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TYPES OF ANH PROCEDURES

Cardiovascular Vascular Orthopedic Organ transplant Neuro Others

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WHO IS A CANDIDATE FOR ANH?

Every one Loose >500 ml of the blood Unpredictable blood loss Need for homologous transfusion

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WHAT ARE CONTRAINDICATIONS FOR

A.N.H? (RELATIVE)

Anemia Hct<28% Hb<10 Impaired renal function Limitation of cardiac, pulmonary function Untreated hypertension Impossible compensatory C.O. Coagulation disorder

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WHAT ARE THE POST-OP CONCERNS FOLLOWING A.N.H?

1-Fluid overload1-Fluid overload2-High blood loss procedure2-High blood loss procedure3-Excessive hemodilution (diuretics)3-Excessive hemodilution (diuretics)

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WHAT IS NEEDED FOR A SUCCESSFUL A.N.H PRGRAM?

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Acute Normovolemic Hemodilution Procedure

Blood collected in ordinary blood bags with 2 phlebotomies & minimum of 2 units are collected

The blood is then stored at room temp. and re-infused in operating room after major blood loss.

Carried out usually by anesthetists in consultation with surgeons.

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Theme behind: Patient losses diluted blood during surgery and replaced later with autologous blood.

Withdrawal of whole blood and replacement of with crystalloid/ colloid solution decreases arterial O2 content but compensatory hemo-dynamic mechanisms and existence of surplus O2 delivery capacity mechanism make ANH safe.


Procedure

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Procedure Drop in red cell number lowers blood

viscosity, decreasing peripheral resistance and increasing cardiac output.

Administrative costs are minimized and there is no inventory or testing cost

This also eliminates the possibility of administrative or clerical error

Usually employed for procedures with an anticipated blood loss is one liter or more than 20% of blood volume.

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Procedure

Decision about ANH should be based on surgical procedure, preoperative blood volume and hematocrit, target hemodilution hematocrit, physiologic variables

Careful monitoring of patient’s circulating volume and perfusion status

Blood must be collected in an aseptic manner

Units must be properly labeled and stored

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procedure

For first litre compensate with 1 litre colloid after that blood must be compensated with 3 crystalloid.

For every litre of blood we must give 3 litre crystalloid.

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Before you start you have to calculate how much blood you can safely remove from your patient you may want to use the following equation to calculate the tolerable blood loss.

ABV=EBV * (H0-HT)

(H0+HT)/2Where ABV is the autologous blood volume

to be withdrawn; H0 is the prehemodilution hematocrit(zero time);

HT is the target hemoglobin and EBV is estimated blood volume of patient.

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AGENTS AFFECT ON WEIGHT

BODY FLUID ADULT MALE

(ml/kg)ADULT FEMALE

(ml/kg)

MUSCULAR 75 70

AVERAGE 70 65

THIN 65 60

OBESE 60 55

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It is a matter of knowledge and experience to define a

reasonable target hemoglobin : mild (hematiocrit 20-24%) , and profound/server/extreme (hematocrit<20%) .

Some consider a target hematocrit less than 20%, in the absence of hypothermia and cardiopulmonary bypass,too risky, since it is considered to impair oxygen delivery.

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WHAT ARE THE COMPENSATORY

MECHANISMS WHEN DILUTING THE PATIENT

Increase total & local flow rate Increase extraction of 02

Right shift of 02 diassociative curve

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Intra-operative Blood Collection

Definition:Whenever there is blood loss and collected inside the body cavity, it

is transfused back to the patient.

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SAMPLE PROTOCOL Phlebotomy (agreement

with surgeon The units of blood with Storage at room or

refrigerator 1 ml blood 3ml crystalloid

1ml blood 1ml colloid Salvage Transfusion Blood loss-fluid

replacements-U/O

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Oxygen transport properties of recovered red cell are equivalent to stored allogenic red cells

Contraindicated when pro-coagulant materials are applied.

Micro aggregate filter(40 micron) are used as recovered blood contain tissue debris, blood clots, bone fragments

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Hemolysis of red cells can occur during suctioning from surface (vacuum not more than 150 torr is recommended)

Indications: Blood collected in thoracic or abdominal cavity due to organ rupture or surgical procedures.

Contraindications: Malignant neoplasm, infection and contaminants in operative field.

Blood is defibrinated but it does not coagulate

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SIDE EFFECTS OF INTRAOPERATIVE RECOVERY

Air embolous Hemolysis Higher plasma free hemoglobin Positive bacterial culture (clinical infection is rare)

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PRACTICAL CONSIDERATION FOR INTRAOPERATIVE CELL

RECOVERY

Sterile operating field A device for intraoperative blood collection with

0.9% saline Storage (room temperature 4 h after terminating

collection) Transfusion begins 6h of initiating the collection Labeling Stored in the blood bank

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Intra-Operative Cell Salvage (ICS)

Disadvantages Restricted to operations with high blood loss (>20 % of total blood volume). Cannot be used where wound site has an infection. Not normally used where cancer cells are in the operative field. Not suitable for patients with sickle cell disease. Requires capital outlay and trained operators - needs sufficient suitable operations to be cost effective. Only red cells are returned without platelets or plasma.

Advantages Reduction in allogeneic blood usage. Can be used regardless of patient’s medical fitness. Life saving where there is uncontrolled bleeding. System accepted by some Jehovah’s Witnesses.

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Intraoperative Blood Collection

Complications are rare but have been reported- DIC, hemolysis due to high pressure suction and mechanical compression in roller pumps

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Postoperative Blood Collection

Recovery of blood from surgical drain followed by re-infusion with or without processing

Shed blood is collected into sterile canister and re-infused through a micro-aggregate filter

Recovered blood is diluted, partially hemolysed and de-fibrinated and may contain high concentrate of cytokines

Upper limit on the volume(1400 ml) of unprocessed blood can re-infused

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RECOVERED BLOOD

Dilute Partially hemolyzed Defibrinated High cytokines

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HARMFUL MATERIAL IN RECOVERED BLOOD

Free Hb RBC Stroma Marrow fat Toxic irritant Tissue or debris Fibrin degradation product Activated coagulation factors Complement

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Postoperative Blood Collection

Transfusion should be within 6 hours of initiating collection

Infusion of potentially harmful material in recovered blood, free Hb, red cell stroma, marrow, fat, toxic irrigant, tissue debris, fibrin degradation activated coagulation factors and complement

Most common in orthopedic procedures such as hip or knee replacement.

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Transfusion Algorithm

Avoid Transfusion : medical and surgical Alternatives

replacement fluids: crystalloids and non plasma colloids over plasma

pharmacologic agents to reduce bleeding Autologous donation Minimize exposure to allogeneic transfusion

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It is possible to avoid transfusion ? Medical: Treat underlying cause of asymptomatic

anemias: Nutritional deficiencies-supplements Chronic GI bleeds-medications Renal failure- erythropoietin

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Transfusion Algorithm Is it possible to avoid transfusion? Surgical: Excellent surgical skill (Factor XIV!=avoid tissue trauma, attention to hemostasis, utilize avascular plane etc) Use of topical hemostatic agents in OR Eg. Fibrin Glue- Fibrin sealant :Tisseel Collagen- platelet adhesion

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When transfusion is deemed necessary, a physician must obtain informed consent from patient.

“Informed Consent to the administration of blood and blood products involves the following: an explanation by the physician in language the patient will understand of the risks and benefits of, and options to, an allogeneic blood transfusion

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Informed Consent- patient decides

Information provided by physician: 1. product description.

2. Benefit and potential risks. 3. Alternatives if available-including risks and benefits. 4.Risks of refusing transfusion Opportunity for questions and clarification Patient’s documentation of consent or

refusal

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Strategies to minimize exposure to allogeneic transfusion

1. replacement fluids- crystalloids and non plasma colloids

2. pharmacologic agents to reduce bleeding

3. Autologous Transfusion

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Strategies to minimize exposure to allogeneic transfusion

1. replacement fluids- crystalloids and non plasma colloids2. pharmacologic agents to reduce bleeding3. Autologous Transfusion4. Minimize allogeneic donor exposure in

neonatal transfusion

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Red Cell Transfusion- Is a clinical decision!!!

Tissue oxygenation does NOT depend on hemoglobin concentration alone!

Cardiac performance Pulmonary function O2 Binding Coefficient Demand of Tissue (physical activity)

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THANKS FOR YOUR ATTENTION