Autologous Transfusion

Question 1

Talk a little about the history of autologous transfusion

Answer 1

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

Question 2

Where is autologous countries most common?

Answer 2

Third-world countries

Question 3

What are the four most common categories of autologous transfusion?

Answer 3

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

Question 4

What is an autologous transfusion?

Answer 4

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

Question 5

Why might someone go for an autologous transfusion?

Answer 5

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

Question 6

What does PAD stand for?

Answer 6

Peri-operative autologous donation

Question 7

What are the BSH guidelines surrounding PAD?

Answer 7

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

Question 8

Why is PAD often pointless?

Answer 8

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

Question 9

The BSH guidelines surrounding autologous transfusion changed this year, what is different

Answer 9

Fear of allogeneic transfusion or in general getting blood was included as a viable reason for getting autologous

Question 10

What is the main reason cell salvage might not be suitable?

Answer 10

If bacteria present in the site requiring salvage eg. bowel surgery

Question 11

When would pre-deposit auologous transfusion be recommended, what are some benefits of it?

Answer 11

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

Question 12

What is pre-operative or pre-deposit autologous donations (PAD)?

Answer 12

Usually fresh i.e. liquid or occassionally frozen donation

Unit taken before surgery etc

Least commonly used method of autologous

Question 13

What is acute normovolaemic haemodilution?

Answer 13

Whereby blood is taken just before the surgery, replaced by fluids and returned after the operation

Question 14

What is perioperative cell salvage?

Answer 14

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

Question 15

What is postoperative blood salvage?

Answer 15

Drained blood from a wound is processed and returned

This is not widely practiced

Could be done if blood pools etc

Question 16

In general what are the risks of autologous transfusion

Answer 16

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

Question 17

Give an example of where autologous blood transfusion was done regularly in Ireland

Answer 17

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

Question 18

When was autologous transfusion high, what was its peak

Answer 18

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

Question 19

Talk about SHOT reporting of autologous BT

Answer 19

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

Question 20

What three cases of autologous BT did we look at in detail?

Answer 20

High volume of salvaged blood re-infused

Hypotensive reacction using cellsaver

Febrile reaction to postoperatively salvaged blood

Question 21

Talk in detail about the case where a High volume of salvaged blood re-infused

Answer 21

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

Question 22

Talk in detail about the case where of hypotensive reaction using cellsaver machine

Answer 22

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

Question 23

Talk in detail about the case of a febrile reaction to reinfused postoperatively salvaged blood

Answer 23

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

Question 24

What are some criteria for suitability of pre-doposit autologous donation (PAD)

Answer 24

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

Question 25

Who is suitable for pre-deposit

Answer 25

If active infection
If heart condiiton e.g. angina
If HIV + -> wont risk having a HIV+/ve unit in the fridge

Question 26

What are the indications for PAD?

Answer 26

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

Question 27

Talk about PAD for pregnancy

Answer 27

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

Question 28

What are some issues with PAD

Answer 28

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

Question 29

Talk through the process of autologous donation (PAD)

Answer 29

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