Autologous Transfusion Flashcards
Talk a little about the history of autologous transfusion
A historic form of transfusion
Cell salvage the only kind of autologous really carried out at the moment but only done in specific hospitals with anaesthetitions trained to do so -> staff often loose their skills in this etc
Where is autologous countries most common?
Third-world countries
What are the four most common categories of autologous transfusion?
Pre-operative or pre-deposit autologous donation
Acute normo-volomaemic haemodilution - before surgery
Perioperative cell salvage
Postoperative blood salvage -> blood taken during infection etc and then given back
What is an autologous transfusion?
Whereby a patient’s own blood is taken and re-transfused back into them
Usually involves some form of processing before re-re-infusion e.g. anti-coagulation, cleannig, microbial testing, concentration etc -> sometimes the only processing will be adding saline
Still a listen product in the IBTS -> listed for rare blood groups but technically it means you could donate a unit and get it back
Why might someone go for an autologous transfusion?
Rare phenotypes or complex antibodies which make blood difficult to get
To prevent all-immunisation
Can be driven by fear e.g. in America where autolgous much more common -> it is considered a premium service in some hospitals -> avoiding infection but still at risk of getting wrong unit etc
What does PAD stand for?
Peri-operative autologous donation
What are the BSH guidelines surrounding PAD?
Only recommended for patients with rare blood groups of mutliple antibodies
Cell salvage interoperatively must not be possible
Optimising Hb/haematinics prior to surgery not possible
Why is PAD often pointless?
PAD is only recommended when no other options are avaialable
The patient must also have a high chance of needing blood
i.e. patient is often really unwell and will generally need a large transfusion therefore the two units taken pre surgery wont be enough anyways and patient ends up needing other blood ayways
The BSH guidelines surrounding autologous transfusion changed this year, what is different
Fear of allogeneic transfusion or in general getting blood was included as a viable reason for getting autologous
What is the main reason cell salvage might not be suitable?
If bacteria present in the site requiring salvage eg. bowel surgery
When would pre-deposit auologous transfusion be recommended, what are some benefits of it?
It reduces the need for allogneic transfusion -> good for rare types
It is most widely used in elective surgery
Evidence shows it is more cost effective than allogeneic and clinical outcome is improved
- no TRIM - especially significant in USA where LD not done on rcc
What is pre-operative or pre-deposit autologous donations (PAD)?
Usually fresh i.e. liquid or occassionally frozen donation
Unit taken before surgery etc
Least commonly used method of autologous
What is acute normovolaemic haemodilution?
Whereby blood is taken just before the surgery, replaced by fluids and returned after the operation
What is perioperative cell salvage?
Blood collected as shed dring surgery, processes at that time and returned to patient while recovering
Involves taking about a litre of blood and relacing it with colloids -> this means the patient is only losing colloids if they bleed during surgery
We usually increase the patients Hb before surgery as well to improve result
we then transfuse the blood back after the surgery
This is actually quite successful
What is postoperative blood salvage?
Drained blood from a wound is processed and returned
This is not widely practiced
Could be done if blood pools etc
In general what are the risks of autologous transfusion
Adverse effects may take a long time to manifest themselves and can post-date lifetime of the recipient
Some potential adverse effects such as IBCT are just as likely to occur wih alogeneic -> commonly dont realise autologous blood in fridge for patient and just given allogeneic
Difficult to balance potential use of autologous blood against fitness of donors to donate -> can be too sick to donate etc
Allogeneic transfusion may lead to an increased risk of postoperative bacterial infections and multi-organ failure e.g. TRIM
Give an example of where autologous blood transfusion was done regularly in Ireland
Kappa hospital
Used to donate 2 units prior to hip surgery
However EU directive stopped them doing this as it would have to make the hospital a blood establishment
-> hospitals in portugal do this
There was no problem with this though as it would still work today and it would probably be cheaper for hospitals -> an mpty pack is a lot cheaper than a full rcc
When was autologous transfusion high, what was its peak
1990s and early 2000
CJD fear increased autologous but very little concern with this nowadays
Peak in 1992 with 8.5% of rccs being autologous
Talk about SHOT reporting of autologous BT
Nowadays SHOT doesnt really get reports for autologous transfusion -> only get reports on cell salvage
Have to go back to 2006 for reports on autologous -> 6 cases in 2006
What three cases of autologous BT did we look at in detail?
High volume of salvaged blood re-infused
Hypotensive reacction using cellsaver
Febrile reaction to postoperatively salvaged blood
Talk in detail about the case where a High volume of salvaged blood re-infused
Post operative
58yr old female underwent bilateral knee replacement
Blood was salvaged bilaterally from a drain postoperatively in HDU
Hospital and manufacturer policy stated that a maximum of 1000mL could be reinfused but the HDU nurses reinfused 2280mL of the salvaged blood as they were unfamiliar with the process
There was no adverse reaction
Talk in detail about the case where of hypotensive reaction using cellsaver machine
82 yr old male underwent intraoperative cell salvage using cellsaver whilst he underwent vascular surgery
First unit was salvaged with no adverse reaction
Second unit was slightly under filled and when the patient was reinfused with it they became hypotensive, transfusion was stopped and vasoconstrictors were given, transfusion was restarted with same effects
Upon investigation of unit, CoNS grew- thought to be contaminants
Concluded that under-collection of units may have led to incorrect washing
Resolveed by amending policies and retraining staff accordingly
Talk in detail about the case of a febrile reaction to reinfused postoperatively salvaged blood
Minor febrile reaction to blood salvaged postoperatively
64 yrs old male who had been previously transfused on two occasions
600mls of blood collected via a Bellovac drain after knee replacement
Blood was reinfused over 4 hours and 30 minutes
patient developed an isolated febrile reaction but no investigations were performed
What are some criteria for suitability of pre-doposit autologous donation (PAD)
Patient selection -> not everyone is suitable
Nature of surgery - must require nlood
Hb not <11g/dl
Hct not <33%
No age limit
No strict weight limit
If patient is anaemic it can increase bleeding time
There is a much lower threshold for transfusion of pre-deopsited blood -> want to use if as it cannot be put back into normal stock -> unnecessary risk associated with this - pack could be contaminated etc
Who is not suitable for pre-deposit
If active infection
If heart condiiton e.g. angina
If HIV + -> wont risk having a HIV+/ve unit in the fridge
What are the indications for PAD?
Major orthopedic surgeries e.g. hip and knee replacement surgeries
Cardiovascular surgeries e.g. valve surgery
obstetric surgeries such as hysterectomy
Radical prostectomy or mastectomy
Gastro-surgery e.g. gall bladder, splenectomy etc
Pregnancy
NB: surgery must require 2 units according to MESBOS -> no point doing PAD if less needed ->no point if more will be needed
Talk about PAD for pregnancy
Done for rare blood types
Can give blood in advance of delivery
Units will be ready if theyre ever needed
Probably the only time we would use this in ireland
What are some issues with PAD
Cannot be done if active bacterial infection
A US study suggested that the risk of hospital admission was 10 times more with PAD -> potentially not enough blood? think about patient cohort though
Wastage - up to 50% of blood is wasted as it cannot be used for others
If surgery is cancelled etc then it can mean waste
- units have to be taken 4 weeks apart from each other
- delay in surgery can mean first unit is out of date as only 35 days
EU Directive imply need for blood bank establishment if PAD is carried out in hospital etc
Patient history NB -> medications can be problematic and cardiac problems
Units must be clearly labelled for patients - biohazard stickers might be needed
Talk through the process of autologous donation (PAD)
Informed consent collected from the patient
Agreement on disposal of wasted units
Possibility of extra homologous blood as required
Booked appointments 5 weeks and 72 hours
Iron supplements - oral not intravenous
Erythropoietin -> expensive
Talk about the leapfrog method of PAD
Method used to collect up to 4 or 5 units
Day 0: unit A withdrawn
Day 7: units B and C are withdrawn whilst A transfused
Day 14: units D and E are withdrawn whilst B transfused
Day 21: units F and G are withdrawn, whilst unit C transfused
Day 28: units D and E (2 weeks), units F and G (one week) are available for transfusion
Folate and iron supplements given to increase Hb
Erythropoietin can be given to increase red cell production by 50%
Talk about erythropoietin for PAD
Aggressive PAD to increase blood cell production
UK task force uses this
Use in clinical circumstances are exceptional and not recommended due to its prothrombotic effects - clots are reported
Talk about how units are prepared for PAD
Collected either in a hospital or transfusion centre -> hosp in portugal
Used to have autologous labels but no hospitals in Ireland have labelling systems now
Units prepared would have to be sent to the IBTS to look for contaminants etc as you cant have an infected unit sitting in the fridge
Storage - used to have a seperate box in the fridge etc -> difficult to do as couldnt inform all staff - reliance on computer systems
Only real scenario is in maternity nowadays
Any unused units have to be disposed of as they cant be used for anyone else
What was the issue with autologous labels?
These tags could have fallen and this did happen
What are the advantages of pre-deposit autologous donation?
Virtually eliminates the risk of viral transmission and immunologically mediated haemolytic, febrile, or allergic reactions
It may decrease the risk of postoperative infection and recurrence of cancer because immunomodulation as a result of transfusion, TRIM is avoided
What is the frequency of HIV contamination
1 in 1,000,000
What is the risk of febrile reaction
0.5%
What are the disadvantages of PAD
Up to 50% of blood is wasted
The amount of blood drawn off needs to exceed the MESBOS medium usually to avoid need for additional allogeneic transfusion
Leftover blood cannot be used for others - thus wastage costs are higher than allogeneic
Other risks remain - WBCT etc
Blood establishment requirment by EU directive
What is acute normovolaemic haemodilution?
Taking blood immediately before surgery
Takes about 20-25 minutes
Whole blood removed into standard bags
Blood replaced with crystalloids such as saline, colloids or haemacell
Blood must stay with the patient as no microbiology done
Blood re-infused at end of surgery
When is acute normovolaemic haemodilution recommended?
Advised when expected blood loss is greater than 20% e.g. 1L or more
In ANH what is used to replace blood volume, what are the effects associated?
Crystalloids such as saline, colloids or haemacell
Colloids provide some osmotic pressure unlike saline
Crystalloids can cause leakage of water into tissues post transfusion
In NHA why must blood stay with the patient?
It undergoes no microbiology investigation and it has not been typed or screened etc
Why is NHA rarely carried out
It has to be carried out in theatre prior to surgery
It takes 20-25 mins and clinicans dont like keeping patients in theatre for longer then absolutely necessary
What are the advantages of ANH?
Can be used before any procedure
Systemic infection does not preclude its use - no incubation time for bacteria
Reduced stress on patient - patient asleep during transfusion
Blood is stored at rt for short time so deterioration of clotting factors and cells is minimal
Lower cost as micro and cross matching not required
Minimal waste as most or all blood is transfused - as patient nearly always needs 1L blood
Blood is maintained at POC therefore little or no administrative cost
Risk of ABO incompatibility further minimised
What are the disadvantages to ANH?
The circulating red cell mass is lowered appreciably and acutely -> Hct lowered thus increasing clotting time, Hb is lowered but unit taken will be high in Hb (as high Hb requirement for NHA) -> advantageous over an allogeneic unit as Hb could be much lower etc
Risk of allergic reactions of haemostatic abnormality from the use of colloids
Additionally expense of and inconvenience to anaesthetist - patient constantly monitored etc
Additional training and experience for anaesthetist
What have studies revealed about ANH?
No studies have been carried out to investigate the morbidity or mortality from acute anaemia brought on by ANH
Meta-analysis has shown that this method is very safe and good -> dont understand why not carriied out more widely
What is Intraoperative Blood Cell Salvage, how is it carried out?
Blood is collected by cell saver, anti-coagulated, processed and re-infused
Blood is vaccuumed up at site of bleeding and processed at the bedside
Blood is resuspended in saline and reinfused
When can Intraoperative cell salvage be used?
Most common autologous transfusion in ireland
Open heart surgery
Liver transplants
Ruptured ectopic pregnancies
Post-partum bleeding/C-sections (most common use)
To satisfy religious scruples of Jehovis’ witnesses
When can cell salvage not be used?
On sites likely to be infected or contain commensal bacteria e.g skin or gut flora
Thus ‘messy/dirty/ wounds such as car crash or stab wounds are not suitable for cell salvage
What patients are not suitable for cell salvage?
Cell salvage is available to all patients regardless of their fitness to donate
But it is no indicated where procoagulants are used in surgery
Talk about the blood product produced from cell salvage
RBC survival and O2 carrying capacity is the same as allogeneic blood
40um filters are used to get rid of any tissue debris such as blood clots or bone fragments
Even though infection is rare blood cultures are sometimes positive (commensals etc)
Expense is not a major issue as can salvage up to 12 litres of blood, which is equivalent to 24 units therefore cost effective
What is the main complication seen post cell salvage, why is this though to be
Between 25 and 30 patients a year present with hypotension after cell salvage
Cell salvage syndrome
Not understood why this is but it is though that to be caused by the saline used -> rbcs are washed and concentrated in saline to produce a pack with a hct of 50-60%
What are the three different methods of cell salvage?
Fixed volume bowl system
Variable volume disk system- rbcs pushed to the sides - used in the Rotunda
Separation of red blood cells ina fixed volume bowl
- plasma pushed out the top
What are the different stages in intra-operative cell salvage
Collection/anticoagulation
Separation
Washing
Reinfusion
What is the end product of cell salvage?
Packed RBCs suspended in IV normal saline (0.9% NaCL solution)
What reactions relating to cell salvage must be reported to SHOT, what is the definition?
Any adverse events or reactions associated with cell salvage (autologous) transfusion methods, including intraoperative cell salvage (ICS) and postoperative cell salvage (PCS) washed or unwashed
Give a breakdown of the SHOT Cell Salvage 2023 reprot
26 total reports
21 adverse events, 11 attributatble to avoidable errors, 10 machine/disposable failures and 5 adverse reactions all of which were hypotension not related to hypovalaemia
What are the three SHOT key messages on cell salvage
It is a safe and effective alternative to allogeneic blood when used correctly and appropriate resources are available
The risks are low but need to be considered and managed appropriately
Most incidents reported to SHOT are avoidable however unforseen reactions can occur and vigilance is necessary
What are the three main learning points from SHOT report on cell salvage
Safe practice relies on staff involved in the process having adequate knowledge and understanding of their role, vigilance, communication and situational awareness is required
Individuals must be either fully trained or supported by someone who is, to use the equipment safely
In the abscence of manufacturors guidance, a risk assessment should eb performed when considering the use of infusion devices with salvaged red cells
What was the SHOT 2021 SAR post ICS case study we looked at
A case of hypotension on reinfusion of salvaged red cells
Elective C-section in a woman in her 20s experiences intraoperative haemorrhage post deliver of 4L
three units of allogeneic blood transfused
800mls collected through cell salvage and reinfused
Patient became hypotensive and tachycardic immediately
Cell salvage reinfusion was stopped immediately and patient received vasopressors and fluids - recovered quickly
200ml CS reinfusion recommenced slowly without incidence
At end of transfusion the remainder of blood within bag was drawn into a 30mL via a 3-way tap downstream of the filter and infused, this bolus resulted in a second hypotensive event with tachycardia
Patient was resuscitated with vasopressors and fluids and made a full recovery
What is posteroperative blood salvage
Used on wound drains post operative
Cleans cells and reinfuses them - hence peri-operatove
Equipment available to wash salvaged blood while on the ward
When is postoperative blood salvage carried out?
Its not as common nowadays
It is still done in low income countries without blood systems and with high TTI risk
What is the shelf life of postoperative blood salvage blood, why is this
Only 6 hours storage as bacteria can grow in it etc
What are the advantages of cell salvage?
Safe and efficacious alternative to allogeneic but little data
These techniques offer same advantages of haemodilution without infusion of crystalloids or colloids
Many litres of blood can be salvafe - up to 12 L per hour - thus cost effective
What are the disadvantages of cfell salvage
Blood is not haemostatically intact compared with blood derived by haemodilution
Coagulation in the ound can lead to consumption of coagulation factors and platelets
Salvaged blood is not washed and thus contains raised concentration of various tissue materials
Contamination either by bacteria or malignant cells you didnt know were there as well as chemokines and cytokines
Salvaged blood syndrome
Disturbances to pH and electrolytes due to large amounts of saline
Expensive to train staff
Evidence based medicine still missing, research ongoing etc
What is salvaged blood syndrome?
Multiorgan failure and consumption coagulopathy
Dont really know whats happening here
Unexplained coagulopathy
possibly too much saline
When is cell salvage contraindicated?
Bacterial infection or malignant cells in the operative field
Use of microfibrillar collagen or other foreign material at operative site e.g. used in liver surgeries
Restricted to procedures resulting in substantial blood loss >12 Litres due to expensive autologous techniques
Talk about autologous platelet transfusion
High-yield perioperative autologous plateletpheresis and reinfusion
Collection though an automated plateletpheresis device
Platelets can be taken prior to surgery and then adminstered post surgery - success associated with this especially if difficult to get suitable platelets etc
Reduces reliance on allogeneic PLTs especially for complex cardiothoracic surgery
What are the 6 advantages of autologous blood donation?
Prevents transfusion-transmitted disease
Prevents red cell alloimmunisation
Supplements the blood supply
Provides compatible blood for patients with alloantibodies
Prevents some adverse transfusion reactions such as TRIM
Provides reassurance to patients concerned about blood risks
What are the 6 disadvantages of autologous blood donation?
Does Not affect risk of bacterial contamination
Does not affect risk of ABO incompatibility
Is more costly
Results in more waste
Increased risk of volume overload after transfusion
Subjects patients to perioperative anaemia and increase likelihood of transfusion
