Autologous Transfusion

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Why use blood-sparing strategies?
Worlds Most Precious Liquid
Indications
Patient request
Difficulty in finding suitable blood
Availability/Economic considerations
Complications relating to blood
transfusion


Complications of blood transfusion

Infection
Hepatitis B and C, HIV, CMV, vCJD
Immunological
Early: anaphylaxis, acute lung injury,
alloimmunization, urticaria, acute
haemolysis
Delayed: delayed haemolysis,
immunosuppression

Complications of blood transfusion
Metabolic
Hyperkalaemia, hypocalcaemia, acid
base disturbance, coagulopathy
Physical
Hypothermia, microemboli, air embolus,
circulatory overload
Allogeneic blood-sparing strategies
Pharmacological
Preoperative
- Erythropoietin
- Ferrous sulphate, vitamin B12, folate
- Discontinue drugs that may impair
haemostasis
Perioperative
- Aprotinin
- DDAVP
- Tranexamic acid
- Topical haemostatic agents
Erythropoietin
Daily s/c inj for at least 10 days before
surgery.
Disadvantages of erythropoietin
Expensive
Labour intensive
Side effects - thrombosis / hypertension.
Unsuitable for emergency surgery.
Restricted to patients aged less than 70 years
Studies support use cardiac/ orthopaedic
surgery
Optimization of haemostatic function
Discontinue NSAIDs, anticoagulants
Haematology advice cong. coagulopathy
Haemophilia - factor VIII conc.
Liver-associated coagulopathy - vitamin K
CRF - preoperative dialysis improves
platelet function
Pharmacological manipulation- Periop.
Evidence supporting use from studies in cardiac surgery
Aprotinin - non-specific protease inhibitor /inhibits plasmin-
reducing fibrinolysis
- Reduces blood loss in cardiac surgery
- May be associated with graft failure
- Use in valve surgery is proven
- Hypersensitivity reactions
Tranexamic acid - synthetic antifibrinolytic drug
- Minimal side effects
- Effective in cardiac surgery.
Desmopressin acetate (DDAVP) - analogue of vasopressin
- Increases conc. of factor VIII/ von Willebrand factor
- Indicated in haemophilia or vonWillebrands
- No evidence to support use in patients without congenital
bleeding disorders.
Allogeneic blood-sparing strategies
Non-pharmacological
Anaesthetic technique
- Regional anaesthesia
- Careful positioning
- Controlled hypotension
- Avoidance of hypertension/hypothermia
Surgical technique
- Planning of procedure
- Minimally invasive choices
- Dissecting instruments
- Use of tourniquets

Surgical techniques

Staging of complicated procedures or sequencing a
procedure harvesting a vein by one member of a team
whilst another member prepares the receiving site.
Use of minimally invasive surgical techniques e.g.
laparoscopic surgery or interventional radiology for
embolization of aneurysms
Dissecting instruments spare blood vessels / provide
haemostasis e.g monopolar diathermy knife, laser,
harmonic scalpel
Topical agents e.g thrombin-based sealants, fibrin-
based sealants and calcium alginate
- Role in reducing allogeneic transfusion is unclear
Tourniquets - clearer surgical field / unlikely to
contribute to blood-sparing
Allogeneic blood-sparing strategies
Transfusion protocols
Autologous transfusion
- Preoperative donation
- Acute normovolaemic haemodilution
- Cell salvage
Preoperative autologous blood donation
(PABD)
Criteria for autologous donors (American Association of
BloodBanks (AABB) Standards for Blood Banks and
Transfusion Services)
Candidates for preoperative collection - stable patients
for surgery in which blood transfusion is likely such as
orthopedic, vascular, cardiac, thoracic and radical
prostatectomy
Hb not less than 11 g/dL or Hct 33%
No age or weight limits
May donate 10.5 mL/kg
Donations may be scheduled more than once a week, but
the last should occur no less than 72 hours before
surgery
Autologous blood with positive viral markers commonly
precluded
Contraindications

1. Evidence of infection and risk of bacteremia
2. Scheduled surgery to correct aortic stenosis
3. Unstable angina
4. Active seizure disorder.
5. Myocardial infarction or cerebrovascular accident
within 6 months of donation
6. Patients with significant cardiac or pulmonary disease
who have not yet been cleared for surgery by their
treating physician
7. High-grade left main coronary artery disease
8. Cyanotic heart disease
9. Uncontrolled hypertension
Standards no longer permits allogeneic
transfusion of unused autologous units
("crossover") because autologous donors
are not volunteer donors
PABD
Efficacy of PABD depends on the
degree of patient's erythropoiesis
Compensatory erythropoiesis suboptimal
under "standard" conditions [expansion
in RBC volume of 11% (with no oral iron
supplementation) to 19% (with oral iron
supplementation) ]
Not sufficient to prevent anemia
PABD results in perioperative anemia
and an increased likelihood of any blood
transfusion
PABD
Aggressive autologous blood
phlebotomy (twice weekly for 3 weeks,
beginning 25 to 35 days before surgery)
endogenous erythropoietin levels
increase with RBC volume expansion of
19% to 26%
Exogenous erythropoietin therapy
stimulates erythropoiesis (Expansion up
to 50% RBC volume)
PABD
Transfusion Trigger
- Hb/Hct level at which autologous
blood should be given
- Trials indicate that even critical care
patients can tolerate substantial
anemia ( Hb ranges of 7 to 9 g/dL)
with no apparent benefit from more
aggressive transfusion
PABD
Disadvantages of PABD
Labour intensive-identification of suitable
patients, organizing appropriately timed blood
donation, storing the blood
Storage life of blood (5 weeks) limits number
of units that can be donated / reduces
flexibility in the postponement of surgery
Not suitable for emergency surgery.
Clerical errors can occur at any stage of the
process
Not suitable for anaemic patients / ischaemic
heart disease
Acute normovolaemic haemodilution
(ANH)
Principle
Removal of whole blood from a patient, while restoring the
circulating blood volume with an acellular fluid shortly
before an anticipated significant surgical blood loss
Blood collected in standard blood bags containing
anticoagulant
Stored at room temperature
Reinfused during surgery after major blood loss has
ceased, or sooner
Simultaneous inf. of crystalloid (3: 1 ) or colloid (1:1)
Blood reinfused in the reverse order of collection
Augmented hemodilution (replacement of ANH collected in
part by synthetic oxygen carriers)
V = EBV . Hi Hf / Hav

Physiological consequences
- Increased cardiac output
- Decreased viscosity
Criteria for selection
High likelihood of transfusion
Hb > 12
No significant ds.
Absence of severe
hypertension
Absence of infection

ANH
Advantages of ANH
Reduction in the RBC mass lost for a given blood loss
Perceived lower relative cost compared with PABD or
allogeneic blood transfusion
Almost negligible potential for clerical error because
blood is kept in the operating theatre until transfusion
Infectious and immunological complications associated
with allogeneic blood are avoided
Platelet function and coagulation factors are preserved
Theoretically improved tissue oxygen delivery due to
right shift of oxygen dissociation curve and reduced
viscosity.
Acute normovolaemic haemodilution
(ANH)
Disadvantages of ANH
Greater haemodynamic instability
Hypovolaemia is more likely
Potential complications of administration of
large volumes ofcrystalloid.
Useful only in healthy adults having surgery
with substantial anticipated blood loss, who
have a high preoperative haemoglobin and who
can tolerate low intraoperative haemoglobin
Intraoperative cell salvage
Physics of cell saver
Technique based on centrifugation, separating red
blood cells (RBC) from the lighter components and
fluids, including plasma, saline and buffy coat
System filled with 100-200 ml heparinized saline
(priming)
Blood released at the wound site aspirated via a
double-lumen suction catheter (80-100 mmHg)
Anticoagulated
stored in a reservoir with a filter
pumped into a rotating separation chamber
washed with 1000-1500 ml saline and concentrated
Intraoperative cell salvage
Optimising red cell return
- Suction
- Rinsing of sponges
- Anticoagulant
- Collection reservoir
Intraoperative cell salvage
Calculation of blood loss during cell
salvage
[Hs/Hp] . Vb. Nb / SE
Intraoperative cell salvage
Advantages of cell salvage
Suitable for elective and emergency surgery.
Reduced risk of administration of incorrect blood
Reduced use of allogeneic blood

Disadvantages of cell salvage
No preservation of clotting factors or platelets necessary.
Initial financial outlay to buy the machine and train staff (but
the cost of the disposables is less than the cost of one unit of
blood)
Use in malignancy is controversial
Blood salvaged from contaminated fields is unsuitable for re-
infusion.
Factor VIIa
central role in initiating the process of coagulation
Active after forming complex with tissue factor
Activates factors IX and X
Induction of thrombin burst on surface of activated
platelets
Formation of fibrin clots at the site of vascular injury
Fibrin clots are stable / resistant to premature lysis
The use of for treatment of intractable life-
threatening haemorrhage is
Recombinant factor VIIa (rFVIIa)
FDA-approved
- Hemophiliacs with factor VIII or IX inhibitors
- Factor VII deficiency
Novel therapy for the treatment of acquired
coagulopathies
- severe trauma
- intractable bleeding after pelvic surgery
- life-threatening post-partum haemorrhage
- pulmonary haemorrhage
- correction of coagulopathy in neurosurgical patients
- Jehovah's Witness after cardiac surgery
Other uses of rFVIIa
- severe thrombocytopenia
- platelet function disorders
- impaired liver function
rFVIIa
Bolus dose - 90120 mg kg1
used with caution in
- patients with known hypercoagulability
- DIC or other states of generalized
activation of the hemostatic system
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