Autologous Transfusion & Blood sparing strategies

Dr PV Sulochana Blood Transfusion Officer

Dept of Transfusion Medicine
Sree Chitra Tirunal Institute for Medical Sciences & Technology Thiruvananthapuram 11

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History
AT attempted by James Blundell in 1818 Highmore W in 1874 Duncan J in 1886 Revived in 1960 by Dyer RH, Klebanoff G, Wilson D & Taswell HL.
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Decades of clinical application demonstrate that it is quite feasible to auto transfuse blood that has been collected and stored for an interval up to 6 weeks in standard storage media and 3 standard collection volumes(approx 500ml) can be collected from normal sized adults (50kg)-British committee for standards in hematology,Tx
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 AT indicate that donor and recipient are identical. Was very much under utilized Recent growth due to the emergence of HIV Used as part of a comprehensive strategy of blood conservation
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Advantages
Eliminate viral & parasitic transmission Prevent - immune mediated reactions -alloimmunization -potential immune modulatory effects Supplement blood supply Reassurance for donor patient Source of blood for pts with multiple alloantibodies Stimulate erythropoiesis
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Disadvantages
Donor reaction Increased cost and complexity of service Outdating of units if surgery is postponed
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Different types
Pre op donation-blood drawn prior to anticipated need Intra op hemodilution-blood collected at the start of surgery and reinfused during/at the end of surgery. Intra operative blood collection-blood recovered from surgical bleed and reinfused Post operative blood salvage-shed blood from surgical drain collected and reinfused
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Indication
Patients undergoing only elective surgery. Type & Screen cases not to be considered. Consider delay in surgery,time interval available,expected blood loss,patients fitness to undergo several blood donations.
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Patient eligibility
Should be free from cardiovascular, cerebrovascular & respiratory diseases. Hb level >11g/dL & Hct 34%. No specific age limit. Must have good venous access & can comprehend and willing to cooperate.
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Contraindications
Unconfirmed or unreliable surgical date Anemia Poor venous access Active infection Ischaemic heart disease Stenotic valvular disease Uncontrolled hypertension
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Contraindications-cont
Respiratory disease: restrictive or obstructive lung disease CNS: Cerebral tumor,Epilepsy, h/o stroke or Transient Ischaemic Attack. Pregnancy: impaired placental flow, IUGR, pregnancy related hypertension, pre eclampsia, cardiac disease, respiratory disease, renal disease, insulin dependent diabetes. Patients with virological markers Adverse reaction to phlebotomy
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General guidelines
Written information. Informed consent.Explain risks & merits. Request from treating physician in writing should be kept by the collecting facility. Request include name, number, number of units, kind of component, anticipated surgical date & surgical procedure. www.similima.com
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Donation schedule
Governed by operation date & shelf life of blood. Once enrolled give oral iron supplemtn. Weekly schedule is used Last donation occurs 72 hrs prior to surgery. Check Hb before each collection.
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Pre donation check by phlebotomist

Donors identity checked Health history.donor should not be thirsty or hungry. Temperature. Pulse. Hb.
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Volume collected
Patients weighing >50 kg,collect standard unit <50kg proportional reduction in volume. Volume should not exceed 15% of donors blood volume. Skin preparation-surgical cleanliness for maximum product safety.
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Lab testing
ABO & Rh group Testing for TTD? Culture for asymptomatic bacteremia. Compatibility?
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Labeling
Label should contain For autologous use only, not suitable for other patients Special label in addition to blood group and product, patient ID. Date of collection.
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Storage
Physically separated from homologous blood stock. Store at 4-60C.

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Records
All consent forms, donation records and transfusion records must be handled as for homologous transfusion.

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Acute normovolemic hemodilution

Patients who are not anemic can have about one quarter of their blood volume withdrawn (not exceeding 20ml/kg)

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ANH is simpler,less expensive and available to patients undergoing surgery at short notice.

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Indication
Patients who can tolerate rapid withdrawal of one or several units of blood (not exceeding 20ml/kg) before the period of blood loss
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Benefits
Lowering blood viscosity improves tissue perfusion and oxygenation. Reduce red cell loss at intraoperative hemorrhage. Provide fresh whole blood with coagulation factors and functional platelets. Reduce the need for allogenic blood, there by avoiding TTD.& immune mediated reactions.
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Patient eligibility
Attending anesthetist should determine the patients suitability to undergo ANH. Patient should have near normal O2 transport capacity. Free from cardiovascular, respiratory and cerebrovascular diseases. Hb level >11g/dl
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Exclusion criteria
Hb<11g/dl IHD, critical stenotic heart valve disease, symptomatic AS Uncontrolled HT(BP >180/100) or hypotension. Patient on blockers/calcium channel blockers. Restrictive/obstructive lung disease
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Exclusion criteria-cont
Impaired renal function Coagulation disorders. Potential or active bacterial infection. Hypovolaemia.
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Consent: Should obtain valid consent Protection against contamination Blood should be withdrawn through arterial/venous catheter

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Volume withdrawn
Formula to estimate the possible volume to be withdrawn Volume withdrawn=EBV x(Hct0-Hct1)/Hctav EBV-estimated blood volume Hct0-Hct before hemodilution Hct1-desired Hct after hemodilution Hctav- average of Hct before & after
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Volume replacement
Crystalloid/ colloid should be given simultaneously as blood is withdrawn. Monitoring continuous monitoring of hemodynamic variables

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Labeling & storage

With proper identification and message For autologous use only. Keep the blood in the same operating room as the patient to preserve the platelet function. If it is anticipated that more than 6hrs will elapse before transfusion store at 2-60C.
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Documentation
Written protocol describing policies & procedure, approved by transfusion committee. Anaesthetist must note on the anaesthesia record ,the amount of blood withdrawn,the amount and type of fluid infused ,amount of blood returned, along with patients vital signs.
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Intra operative blood collection

Collection & return of blood recovered from operative sites or from associated extra corporeal blood circuits. Technique has been widely used in cardiac, vascular and orthopedic surgery. In addition to decreasing allogenic donor exposure, IBC provide an important source of red cell mass during massive transfusion.
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Indication
Most suitable in anticipated blood loss >20% Conditions-surgical field free of tumor cells, sterile & with out hemolysis.

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Contraindications
Malignancy. Infection. Contamination hemolysis, procoagulants, FDP, fat particles, amniotic fluid.
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Postoperative Blood Collection

Collection of blood from surgical drains and reinfusion with or without processing. Used after cardiac & orthopedic surgeries. Shed blood collected and reinfused through microaggregate filter.
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Other blood sparing strategies

Iron supplementation. Improve surgical procedures. Blood auditing.

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Pharmacological alternatives
Recombinant growth factors: - Erythropoietin. - GM -CSF, G-CSF. - Red Cell substitutes. - DDAVP. - Vit K. - Fibrinolytic inhibitors.
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References
Technichal Manual AABB The Hongkong Association of Blood Transfusion and Hematology. Autologous and Directed Blood Programs-AABB British Committee for Standards in Haematology,Transfusion-Guidelines for alternatives to allogenic transfusion
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Thank you
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