Transcript Slide 1

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
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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
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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
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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.”
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Preop Auto Blood--Other
Issues
Preop Auto Blood Donations Before Elective
Hyster-ectomy. M.H. Kanter et al. JAMA. 1996; 276: 798801.
• Design: Retrospective; compared 140 elective hysterectomy 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
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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
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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.
Marshall Hospital/BloodSource
TJR Surgery Blood Use Study
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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)
Marshall Hospital/BloodSource TJR
Surgery Blood Use Study
• 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.
Marshall Hospital/BloodSource TJR
Surgery Blood Use Study
Summary of hematocrit data for the
“autologous donor/patients” (n = 24)
Average
Median
Range
Hct Prior to
1st Donation
41.5%
42%
34-46%
Hct Prior to
2nd Donation
38.0%
37%
33-45%
Hct Immediately
Prior to Surgery
36.5%
35.5%
30.1-45.2%
– Summary of hematocrit data for the “nonautologous donor/patients,” immediately
prior to surgery (n = 19)
• Ave. Hct = 42.2% (35.6-to-49.6%)
Marshall Hospital/BloodSource TJR
Surgery Blood Use Study
• 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
a. Average = 315 mL
b. Median = 250 mL
c. Range = 0-to-1000 mL
For Non-Auto
Donor/Patients
a. Average = 263 mL
b. Median = 250 mL
c. Range = 100-400 mL
Marshall Hospital/BloodSource TJR
Surgery Blood Use Study
• 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).
Marshall Hospital/BloodSource TJR
Surgery Blood Use Study
• 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
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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 donating 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
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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
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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 association 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, significant 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 nondirected homologous blood from volunteers.”
Paul Gann Blood Safety Act
• 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
Paul Gann Blood Safety 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
Available 24/7
Fully tested
Autologous
Your own blood
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
Infection
Immune reactions
Circulatory overload,
citrate toxicity, etc.
Autologous
Infection (? Less risk)
Remote risk of incompatibility or
allergic/anaphylactic (if wrong unit
or synthetic allergen introduced)
Same
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