autologous transfusions: when to use ‘em & when to lose ‘em christopher j. gresens, md...

Autologous Transfusions: When to Use ‘em & When to

Lose ‘em

Christopher J. Gresens, MD

Associate Medical Director

BloodSource

Preview

• Types of Autologous Donations/Transfusions– Preoperative– Perioperative (e.g., intra- and postoperative)– Acute Normovolemic Hemodilution

• Gann Act• Marshall-BloodSource Experience• Pros/Cons of Autologous Blood• Wrap up

Overview of Autologous Options

• Before Surgery– Preoperative collection

• During Surgery– Intraoperative blood salvage

• After Surgery– Postoperative blood salvage

• Acute Normovolemic Hemodilution

Preoperative Autologous Collection

• Donated before surgery• “Target” usually is RBCs• Eligibility criteria relaxed• Minimum Hct 33%• No absolute minimum age• No weight limits• Increased donation frequency

Preop Auto Blood--Contraindications

• Significant cardiac abnormalities (e.g., aortic stenosis, severe CAD or CHF)

• Very recent MI or CVA • Potential bacteremia• Hematocrit < 33%• Surgery <72 hours from time of

donation

Preop Auto Blood--Risks

• Development of anemia due to donation process (see Kanter et al)

• Small risk of septic & several other transfusion reactions

• Remote risk of wrong unit being transfused

• Blood may not be immediately available in an emergency

Preop Auto Blood--Other Issues

• Venous access• Iron supplementation• Special handling• Fees• Unused autologous

units destroyed

Preop Auto Blood--Other Issues• Crossover to allogeneic supply—Virtually never done• Frozen autologous blood—To be discouraged, except

when strong clinical indication exists• Transfusion criteria for autologous blood are sometimes

debated (should they be same as/different from allo?)• Local hospitals have varying policies regarding the use of

confirmed HBV- and HIV-infected units (ADA Act)• Certain patient populations (e.g., elective hysterectomy

patients) generally should not give autologous blood • Cost-effectiveness—May never by cost-effective, per

traditionally utilized criteria.

Preop Auto Blood--Other Issues• The ADA, HIV, & Autologous Blood Donations• Supreme Court’s Bragdon vs. Abbott Decision: HIV+

patient (A) successfully sued dentist (B) for refusing to fill his cavity anywhere other than in a hospital.

• “Extrapolated” Opinion of AABB’s Lawyers: “Bragdon may render unlawful those policies that deny HIV-infected patients the opportunity to use their own blood. Blood centers and hospitals that have such policies or procedures should, with the assistance of counsel, consider carefully whether they can defend their actions successfully given the sweep of the Bragdon decision and the ADA’s prohibitions.”

Preop Auto Blood--Other Issues

• Preop Auto Blood Donations Before Elective Hyster-ectomy. M.H. Kanter et al. JAMA. 1996; 276: 798-801.

• Design: Retrospective; compared 140 elective hyster-ectomy patients who gave auto blood with 123 who didn’t.

• Results: 25 of 140 auto donors were transfused (3 with allo RBCs); 1 of the other 123 was transfused (p < 0.001).

• Conclusion: “For hysterectomy patients, donation of autologous blood causes anemia and is associated with a more liberal transfusion policy. Elimination of preoperative autologous donation for these patients should not result in frequent exposure to allogeneic blood”

Autologous Blood Transfusions in Total Joint Replacement

Surgery:The Marshall

Hospital/BloodSource Experience

C. Gresens et al. Transfusion 2002; 42 (Suppl): 18S-19S.

Marshall Hospital/BloodSource Total Joint Replacement Surgery

Blood Use Study

• Background: Many orthopedic surgeons advise their TJR surgery patients to consider making preoperative autologous blood donations (PABDs) to reduce the need for perioperative allogeneic transfusions.

• We recently examined the blood transfusion use of such patients to understand better the impact of PABDs on perioperative transfusion requirements.

Marshall Hospital/BloodSource TJR Surgery Blood Use Study

• Methods: Retrospective review of primary, one-joint TJR surgery patient charts (at Marshall Hospital) and autologous donor charts (at BloodSource).

• Blood volume estimated as: Patient mass (kg) x 0.069 L/kg (male) or 0.065 L/kg (female).

• Autologous blood was transfused as pRBCs.• Perioperative blood salvage was not used.• Criteria for transfusion of autologous and allogeneic blood

were identical.


• Results• Date Range: July 2000-March, 2001• N = 43 (19 male; 24 female)• Surgical Procedures: Primary, unilateral joint

replacement surgeries:– Knee--29 (67%); Hip--14 (33%)

• Ages of Patients: Mean = 67.1 (45-86 years)


• Twenty-four patients (57%) made PABDs:– 17 (71%) were knee surgery patients– 7 (29%) were hip surgery patients

• PABD Profile– Mean # of PABDs = 1.9 (1-2) units– In total, 45 PABDs were made by these 24 patients.


– Summary of hematocrit data for the “non-autologous donor/patients,” immediately prior to surgery (n = 19)

• Ave. Hct = 42.2% (35.6-to-49.6%)

Summary of hematocrit data for the “autologous donor/patients” (n = 24)

Hct Prior to

1st Donation Hct Prior to 2nd Donation

Hct Immediately Prior to Surgery

Average 41.5% 38.0% 36.5% Median 42% 37% 35.5% Range 34-46% 33-45% 30.1-45.2%


• Mean Estimated Blood Volumes– Autologous Donor/Patients: 5.8 L– Non-Autologous Donor/Patients: 5.5 L (p > 0.05)

Estimated perioperative blood loss

For Autologous Donor/Patients

For Non-Auto Donor/Patients

a. Average = 315 mL b. Median = 250 mL c. Range = 0-to-1000 mL

a. Average = 263 mL b. Median = 250 mL c. Range = 100-400 mL


• Nine of the 24 autologous donor/patients (39%) required perioperative autologous RBC transfusions– Mean = 1.9; Median = 2; Range = 1-2 units;– Five (56%) were knee and 4 (44%) were hip;– 17 total auto units transfused.

• Only one of the 19 non-auto donor/patients (5%) required a single allogeneic RBC transfusion (p < 0.05).


• Conclusions:• PABDs prior to TJR surgery were associated with:

– A moderate reduction in patient hematocrits;– A large increase in perioperative transfusions;– 62% of PABDs not transfused.

• PABDs no longer are routinely recommended for primary, one-joint TJR surgery patients at Marshall Hospital.

Preop Auto Blood--Other Issues• The Cost Effectiveness of Preoperative

Autologous Blood Donations. J Etchason, L Petz, et al. NEJM. 1995; 332: 719-724.

• Design: Decision-analysis model for cost effectiveness assessment (based upon 1992, UCLA data); looked at THR, CABG, abdom. hysterectomy, & TURP patients.

• Results: “The cost-effectiveness values ranged from $235,000 to over $23 million per quality-adjusted year of life saved.”

• Conclusion: “The increased protection afforded by donat-ing autologous blood … may not justify the increased cost.

Intraoperative Blood Salvage• Collection and re-infusion of

blood lost during surgery• Alternative to pre-operative

collection• Can be especially useful for

massively bleeding patients• Semi-automated systems

are available for this purpose

Intraop Blood--Considerations• Washed vs. unwashed• Guaranteed blood

compatibility• Up to 50% of RBCs

(sometimes more) are lost

• May be acceptable to Jehovah’s Witnesses (particularly if the collection/reinfusion circuit is circular)

Intraop Blood--Contraindications

• Infection/contamination of surgical field

• Cancer involving surgical field

Post-operative Blood Salvage

• Cardiac & Orthopedic surgical patients

• Blood collected from drainage devices

• Defibrinogenated• Unwashed• Can only be stored for

up to 6 hours at room temperature

Post-operative Blood Salvage• Red Cell Loss Following Orthopedic Surgery:

The Case Against Postoperative Blood Salvage. J. Umlas et al. Transfusion. 1994; 34: 402-406.

• Design: The volume of salvaged RBCs was measured for the 1st 6 hours postop & compared to total RBC loss and volume of allogeneic RBCs transfused.

• Results: Mean postop RBC losses in 31 THR & 20 TKR patients were 55 + 29 and 121 + 50 mL, respectively.

• Conclusion: “The relatively small red cell loss in the postoperative period in most arthroplasty patients does not appear to justify the routine use of this technique.”

Perioperative Blood Salvage Risks

• Coagulopathy• Hemolysis• Air embolism (Linden

et al)

Perioperative Blood Salvage Risks• Fatal Air Embolism Due to Perioperative Blood

Recovery. J.V. Linden et al. Anesth Analg. 1997; 84: 422-426.

• Design: Retrospective review of 127,586 periop blood salvage procedures (PBSPs) and 8,955,619 conventional transfusions(CTs); 1990-1995.

• Results: 4 fatal air embolism cases occurred in associ-ation with PBSPs (1 in 30,000-38,000); none with CTs.

• Conclusion: Even when considering all the other risks associated with CTs, the risk for a fatal complication during PBSP is far higher than that for CTs.

Acute Normovolemic Hemodilution• ANH involves collecting blood from a

patient in the OR at the start of surgery, for re-infusion later in the surgery or during the immediate postoperative period.

• > 4 units may be removed (with simultaneous 3:1 crystalloid or 1:1 albumin replacement).

• In properly selected and monitored patients, a target Hct of 20-25% may be acceptable.

ANH--Considerations

• Lowers blood viscosity• Reduces RBC loss during

surgery• No testing required• Ideal candidate has good

preop Hct & will lose > 1 L intraoperatively

• Exclusion criteria include anemia, renal failure, signifi-cant CAD, CVD, and others

ANH--Risks

• Critical organ ischemia• Dilutes circulating

coagulation factors

Paul Gann Blood Safety Act

California Health and Safety Code, Section 1645

“Whenever there is a reasonable possibility, as determined by a physician and surgeon, that a blood

transfusion may be necessary as a result of medical or surgical procedure, the physician and surgeon, by means of a standardized written summary … shall

inform the patient of the positive and negative aspects of receiving autologous blood and directed and non-

directed homologous blood from volunteers.”


• What constitutes a “reasonable possibility” (“that a blood transfusion may be necessary”)?

– T + C (i.e., Type + Cross) equals Gann Act– T + S (i.e., Type + Screen) does not equal Gann Act


• The Gann Act does not apply “when medical contraindications or a life-threatening emergency exists.”

Pros and Cons for Auto/Allo Blood Benefits

Allogeneic Autologous

Available 24/7 Your own blood

Fully tested Fully tested (sometimes we even identify

heretofore unknown infections)

Completely compatible (if correct unit is used)

Pros and Cons for Auto/Allo Blood Risks

Allogeneic Autologous

Infection Infection (? Less risk)

Immune reactions Remote risk of incompatibility or allergic/anaphylactic (if wrong

unit or synthetic allergen introduced)

Circulatory overload, Same

citrate toxicity, etc.

Mild anemia

Not often available for emergency

Pros and Cons for Auto/Allo Blood

• One more “risk” of autologous blood:

» Cost

Conclusion• Types of Autologous

Donations/Transfusions– Preoperative– Perioperative– Acute Normovolemic

Hemodilution• Gann Act• Marshall-BloodSource

Experience• Pros/Cons of Autologous Blood

autologous transfusions: when to use ‘em & when to lose ‘em christopher j. gresens, md...

Documents

intraop blood

preop auto blood

donat ing autologous

reinfusion of blood

autologous transfusions

purpose slide

circular slide

surgery target