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Autologous Blood Donation and transfusion anaemia

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					In The Name Of God



Shiraz Blood Transfusion
       Organization



                           1
Autologous Blood
  Donation and
   transfusion



                   2
      What does ‘Autologous Transfusion’ mean?


                                      Autologous transfusion is
                                    where the donor and recipient
                                       are the same person.

There are different types of
autologous transfusion including:
•Preoperative autologous
donation (PAD)
•Intra-operative cell salvage
•Post-operative cell salvage
•Acute normovolaemic
haemodilution
•Directed donation




                                                                    3
Aims:
To demonstrate an awareness of the different techniques
available as alternatives to allogeneic blood transfusion
and an awareness of their appropriate use.
   Objectives:
• To develop an awareness of better transfusion
practice.

• Discuss different autologous transfusion techniques
available.

• Identify alternative care strategies to avoid the use of
allogeneic blood.

• To promote the appropriate and timely use of
transfusion alternatives.
                                                             4
Although the risks of blood transfusion
have been considerably minimised, the
  incidents highlighted in the Serious
Hazards of Transfusion (SHOT) reports
   show the importance of continuing
  education in the appropriate use of
                 blood.



     TRANSFUSE ONLY WHEN THE
    BENEFITS OUTWEIGH THE RISKS



                                          5
Good Transfusion Practice - General Considerations



                               Minimise amount
                               of phlebotomy for
                                  lab samples

      Base practice on
    transfusion triggers,
     targets set by local
  guidelines, and individual
     patient assessment
                                 Establish target
                                  haemoglobin
                                 tolerable to the
                                individual patient


                                                     6
                 Reducing transfusion requirements
Pre-operative procedures include:
Pre-operative surgical assessment
 units: blood tests should be performed          Discuss treatment options with
     and reviewed in a timely manner for        patient: this is of particular importance if
  diagnosis and treatment of anaemia e.g.           the patient has any strong beliefs or
  iron deficiency anaemia. Assessment of        thoughts about blood transfusion (not just
    patient’s previous clinical history e.g     Jehovah’s Witness patients) - allow plenty
             bleeding disorders.                of time to plan for any specific alternatives
Assessment of patient’s current medication             to transfusion to be organised.
 - where possible plan to stop medications
  pre-operatively e.g. anti-coagulant / anti-
                platelet drugs

Maximum Surgical Blood Ordering                    Plan for possible cell salvage:
 Schedule: this is a guidance schedule              many hospitals now provide peri or
   developed following agreement with               post operative cell salvage - these
 surgeons and anaesthetists - it should be        techniques can be used in a variety of
used as a guide/tool to indicate how many             surgical procedures - individual
    units to order for different surgical             patients should be assessed for
  procedures - hospital blood banks may            suitability pre-operatively and options
question clinicians if a request differs from           discussed with the patient.
                                                                                                7
                the MSBOS.
Module 4: Alternatives to Allogeneic Blood                                                  West Midlands
               Transfusion




                                         Reducing transfusion requirements
                 Intra-operative procedures include:



                                                Careful positioning              Appropriate
                                                of the patient during         use of surgical
                Use of intra-
                                                 surgery - may help      dissecting instruments -
               operative cell
                                                reduce blood loss by     some instruments help to
                  salvage
                                                 minimising venous           reduce blood loss
                                                  congestion in the        e.g. diathermy knives,
                                                   operating field.          lasers, ultrasonic
                                                                                   scalpel.

                                                     Maintain
       Preventing hypertension                    normothermia
                                                                         Use of fibrin seals /
      (controlled hypotension)               (unless hypothermia is
                                                                        haemostatic agents /
       - hypertension may lead                     indicated) -
                                                                        drugs to help reduce
         to excessive bleeding                 coagulation factors
                                                                          surgical bleeding
       NOTE: this is a specialist             may be less effective
        anaesthetic technique.               at lower temperatures,
                                              increasing the risk of
                                                    blood loss.
                                                                                                            8
               Advantages
1   Prevent transfusion TTDs
2   Prevent red cell Allo - immunization
3   Supplements the blood supply in BTS
4   Provide compatible blood for patient with
    Allo-antibodies
5   Prevent adverse transfusion reactions
6   Provide reassurance to patients concerned
    about blood risk
7   reduce postoperative risk of bacterial
    infection
8   reduce risk of cancer recurrence because the
    fewer effect of Immuno modulation              9
         Disadvantages
1 Same risk of bacterial contamination
2 Same risk of ABO incompatibility error
3 Costlier than allogenic blood
4 Wastage of blood, if not switched over.
5 Chances of unnecessary transfusion
6 Subjects patient prone to perioperative
    anemia & increase likelihood of transfusion
    and side effect of iron supplementation
7 same risk of clerical error
8 anxiety to some patient
                                                  10
TYPES OF AUTOLOGOUS
    TRANSFUSION


 Preoperative autologous blood donation
  (PABD)
 Acute normovolemic hemodilution (ANH)
 Intra operative and post operative blood
  recovery (blood salvage)
                                             11
        Preop. Autologous
            donation
Inclusion: Stable patients scheduled for surgical
  procedure in which blood transfusion is likely. Donor
  Pt. should qualify criteria for blood donation in
  surgery that bleeding is more than 1000cc.
 Necessity:
  a. Close relation between clinician & blood bank
  (BB)
  b. Donor suitability by BB physician
  c. Oral Fe one week before & many weeks after
  e. at least Hb before operation is 11
   * No limit of weight or aheage
                                                          12
    CANDIDATES FOR P.A.B.D

   Stable patients
   M.S.O.B.S (surgical procedure with blood loss)
   Major orthopedic procedure
   Patients with alloantibodies
   Vascular surgery
   Thoracic or cardiac surgery
   Total joint replacement

                                                     13
        Pre-op Autologous
            Donation
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 CVA accidents in 6 mounth
6 Significant cardiac or pulmonary disease
7 Cyanotic heart disease
8 Uncontrolled hypertension
9 Malignant diseases
10 high grade main coronary artery disease
11 diarrhea
12 dental operation
13 skin ulcer
14 Antibiotic use
                                                       14
      Pre-op Autologous
          Donation
           Procedure
 Each blood centre or hospital that decides to
  conduct an autologous blood collection program
  must have its own policies, processes and
  procedures
 Patient’s physician initiates the request for
  autologous services, which then is approved by
  Transfusion Medicine physician after physical
  evaluation
 Patient advised oral supplemental iron from one
  week before operation
 Request by physician should include the patient
  name, unique identifying number, number of units
  and kind of component required, date of scheduled
  surgery, nature of surgical procedure
                                                  15
      Pre-op Autologous
          Donation
           Procedure

 A sufficient number of units should be
  drawn to avoid exposure to allogenic
  blood
 In lower than 50 kg (weight*450cc/50)




                                           16
 It usually begins 3-5 weeks before scheduled surgery.
  usually 2-4 units on each occasion ,approximately 500 ml
  of blood are collected .patient with more than 50 kg body
  weight usually donate 500 ml of blood in one session
  .patient with less than 50 kg body weight donate smaller
  volumes. The volume collected shouldn’t be more than
  10% of the patient’s estimated blood volume .
 One donation per week is usually scheduled, although
  more aggressive donation schedules are possible . In
  theory , donation every 3 days are feasible . The last
  donation takes place not later than 48-72 hour before
  surgery . This is to allow for the equilibration of blood
  volume.

                                                           17
           New Program
 SOPs at each step
 Testing Protocol: Once in 30 days
 Separate inventory to avoid mix-ups
 Separate tags/ green labels to ensure that
  the right unit goes to right patient
 X-match & Issue
 Discarding unused unit and not used as
  allogenic because of different criteria and
  chances of clerical error
                                                18
  Pre-op Autologous Donation
                     Procedure

 ABO and Rh typing on labeled samples of patient.
 Units should have ‘green label’ with patient name &
  number & marked ‘FOR AUTOLOGOUS USE ONLY’
 Longest possible shelf life for collected units increases
  flexibility for the patient and allows time for
  restoration of red cell mass, between collection and
  surgery.
 Special Autologous label may be used with numbering
  to ensure that oldest units are issued first.

                                                          19
         PAD Complications
 Anemia and hypovolemia
 vasovagal reaction
 Venous access
 Pediatrics- low volume challenges
 Donor adverse reactions
 Clerical errors leading to the use of regular
  donors before autologous units
 Over transfusion
                                                  20
    RISKS OF P.A.B.D

1-Mistake of transfusion
2-Human error (ABO incompatibility)
3-Bacterial contamination



                                      21
PABPD CONTRAINDICATION
 1-Anemia
 2-Serious cardiac disease
 3-Predisposing to bacteremia (e.g. urinar
 catheter or device)
 4-HBV, HCV, HIV positive

                                        22
SAMPLE OF PROTOCOLS
Select of patient
Detection of number units
Recommendation to interval collecting
Use of iron supplements
Transport of units
Review of criteria autologous
Manage of reaction
Policies program
Additional information
                                         23
    IRON SUPPLEMNTS

Prescription of iron
Suitable dose for decrease GI side effects
Maybe can not store of iron




                                              24
Autologous Sticker




                     25
  Acute Normovolemic
     Hemodilution

Definition:
It is the removal whole blood from a
patient just before the surgery and
transfused immediately after the
surgery. It is also known as ‘preoperative
hemodilution’.

                                             26
            PHYSIOLOGIC
           CONSIDERATION

   Reduction of RBC losses
   Increase of perfusion’s tissues
   Improved oxygenation
   Decrease blood viscosity
   (The best oxygen delivery Hct 30-35%)
   Preservation of hemostasis

                                            27
         Acute Normovolemic
            Hemodilution

 Properly labeled units are stored at RT for
  up to 8 hours, unused units must be stored
  within 8 hours at 1-6 C, outdates in 24h
 Re infuse units in reverse order to provide
  maximum hemostatic functions
 ANH is equivalent to PAD in radical
  prostatectomy, knee and hip replacement
                                                28
CLINICAL STUDIES OF A.N.H
 1-A.N.H equivalent to PAD
 2-Minimized cost
 3-Elimination waste of units
 4-No inventory or testing
 5-Never leaves the patient’s room
 (minimize clerical error &ABO
 incompatible)
                                     29
CRITERIA FOR SELECTION OF
          A.N.H
  1-Likliehood of transfusion exceeds
  2-Preoperative Hb at least 12 g/dl
  3-Absence of coronary, pulmonary, renal or
  liver disease
  4-Absence of sever hypertension
  5-Absence of infection & bacteremia
                                          30
INDICATIONS FOR A.N.H

Hct>34%
Intraoperative blood loss>1 lit
Any type of surgery with significant blood loss
When the blood can be drawn after
aneasthesia and transfused



                                                   31
       CONTRAINDICATION
           FOR ANH
1-Anemia
2-Impaired renal function
3-C.A.D, A.S, (no compensatory
mechanism)
4-Limitation of cardiac or pulmonary
function
5-Untreated hypertention
6-Coagulation disorder                 32
PRACTICAL CONSIDERATION
 1-ANH related to procedure & volume of
 blood & target Hct
 2-Documented the manner
 3-Exact monitoring
 4-Aseptic collection
 5-Labelling
 6-Storage (room temperature=8h &
      refrigirator=24h)
 7-Increase time staying in the operating
                                            33
 room
      TYPES OF ANH
      PROCEDURES
 Cardiovascular
 Vascular
 Orthopedic
 Organ transplant
 Neuro
 Others
                     34
WHO IS A CANDIDATE FOR
          ANH?

  Every one
  Loose >500 ml of the blood
  Unpredictable blood loss
  Need for homologous transfusion

                                     35
        WHAT ARE
  CONTRAINDICATIONS FOR
      A.N.H? (RELATIVE)
 Anemia Hct<28% Hb<10
 Impaired renal function
 Limitation of cardiac, pulmonary function
 Untreated hypertension
 Impossible compensatory C.O.
 Coagulation disorder
                                              36
  WHAT ARE THE POST-OP
CONCRNS FOLLOWING A.N.H?

1-Fluid overload
2-High blood loss procedure
3-Excessive hemodilution (diuretics)



                                       37
  WHAT IS NEEDED FOR A
SUCCESSFUL A.N.H PRGRAM?




                           38
   Acute Normovolemic
      Hemodilution
           Procedure
 Blood collected in ordinary blood bags with 2
  phlebotomies & minimum of 2 units are
  collected
 The blood is then stored at room temp. and
  re-infused in operating room after major
  blood loss.
 Carried out usually by anesthetists in
  consultation with surgeons.
                                                  39
   Acute Normovolemic
      Hemodilution
            Procedure
 Theme behind: Patient losses diluted blood
  during surgery and replaced later with
  autologous blood.
 Withdrawal of whole blood and replacement
  of with crystalloid/ colloid solution
  decreases arterial O2 content but
  compensatory hemo-dynamic mechanisms
  and existence of surplus O2 delivery
  capacity mechanism make ANH safe.

                                               40
   Acute Normovolemic
      Hemodilution
             Procedure
 Drop in red cell number lowers blood
  viscosity, decreasing peripheral resistance
  and increasing cardiac output.
 Administrative costs are minimized and
  there is no inventory or testing cost
 This also eliminates the possibility of
  administrative or clerical error
 Usually employed for procedures with an
  anticipated blood loss is one liter or more
  than 20% of blood volume.
                                                41
  Acute Normovolemic
     Hemodilution
           Procedure
 Decision about ANH should be based on
  surgical procedure, preoperative blood
  volume and hematocrit, target hemodilution
  hematocrit, physiologic variables
 Careful monitoring of patient’s circulating
  volume and perfusion status
 Blood must be collected in an aseptic manner
 Units must be properly labeled and stored
                                             42
               procedure
 For first litter compensate with 1 litter
  colloid after that blood must be
  compensated with 3 crystalloid.
 For every litter of blood we must give 3
  litter crystalloid.



                                              43
 Before you start you have to calculate how
  much blood you can safety remove from
  your patient you may want to use the
  following equation to calculate the
  tolerable blood loss.
 ABV=EBV * (H0-HT)
           (H0+HT)/2
Where ABV is the autologous blood volume
  to be withdrawn; H0 is the prehemodilusion
  hematocrit(zero time);
HT is the target hemoglobin and EBV is
  estimated blood volume of patient.
                                           44
AGENTS AFFECT ON WEIGHT
             ADULT MALE   ADULT FEMALE
BODY FLUID
               (ml/kg)       (ml/kg)
MUCULAR          75            70

 AVERAGE         70            65

   THIN          65            60

  OBESE          60            55
                                         45
 It is a matter of knowledge and experience to define a
  reasonable target hemoglobin : mild (hematiocrit 20-
  24%) , and profound/server/extreme
  (hematocrit<20%) .
Some consider a target hematocrit less than 20%, in the
  absence of hypothermia and cardiopulmonary
  bypass,too risky, since it is considered to impair
  oxygen delivery.



                                                       46
     WHAT ARE THE
    COMPENSATORY
  MECHANISMS WHEN
 DILUTING THE PATIENT

 Increase total & local flow rate
 Increase extraction of 02
 Right shift of 02 diassociative curve

                                          47
     Intra-operative Blood
           Collection

Definition:
Whenever there is blood loss and
collected inside the body cavity, it is
transfused back to the patient.



                                          48
   SAMPLE PROTOCOL
 Phlebotomy (agreement
  with surgeon
 The units of blood with
 Storage at room or
  refrigerator
 1 ml blood 3ml crystalloid
  1ml blood 1ml colloid
 Salvage
 Transfusion
 Blood loss-fluid
  replacements-U/O

                               49
    Intra-operative Blood
          Collection
 Oxygen transport properties of
  recovered red cell are equivalent to
  stored allogenic red cells
 Contraindicated when pro-coagulant
  materials are applied.
 Micro aggregate filter(40 micron) are
  used as recovered blood contain tissue
  debris, blood clots, bone fragments

                                           50
      Intra-operative Blood
            Collection
 Hemolysis of red cells can occur during suctioning
  from surface (vacuum not more than 150 torr is
  recommended)

 Indications: Blood collected in thoracic or abdominal
  cavity due to organ rupture or surgical procedures.

 Contraindications: Malignant neoplasm, infection and
  contaminants in operative field.

 Blood is defibrinated but it does not coagulate
                                                          51
      SIDE EFFECTS OF
 INTRAOPERATIVE RECOVERY

 Air embolous
 Hemolysis
 Higher plasma free hemoglobin
 Positive bacterial culture
 (clinical infection is rare)

                                  52
PRACTICAL CONSIDERATION FOR
    INTRAOPERATIVE CELL
         RECOVERY
   Sterile operating field
   A device for intraoperative blood collection with
    0.9% saline
   Storage (room temperature 4 h after terminating
    collection)
   Transfusion begins 6h of initiating the collection
   Labeling
   Stored in the blood bank
                                                         53
                  Intra-Operative Cell Salvage (ICS)

Advantages
 Reduction in allogeneic blood usage.
 Can be used regardless of patient’s medical fitness.
 Life saving where there is uncontrolled bleeding.
 System accepted by some Jehovah’s Witnesses.



Disadvantages
 Restricted to operations with high blood loss (>20 % of total blood volume).
 Cannot be used where wound site has an infection.
 Not normally used where cancer cells are in the operative field.
 Not suitable for patients with sickle cell disease.
 Requires capital outlay and trained operators - needs sufficient suitable operations to be
cost effective.
 Only red cells are returned without platelets or plasma.




                                                                                               54
Intraoperative Blood Collection
 Complications are rare but have been
  reported- DIC, hemolysis due to high
  pressure suction and mechanical
  compression in roller pumps




                                         55
       Postoperative Blood
            Collection
 Recovery of blood from surgical drain
  followed by re-infusion with or without
  processing
 Shed blood is collected into sterile canister
  and re-infused through a micro-aggregate
  filter
 Recovered blood is diluted, partially
  hemolysed and de-fibrinated and may
  contain high concentrate of cytokines
 Upper limit on the volume(1400 ml) of
  unprocessed blood can re-infused                56
  RECOVERED BLOOD

 Dilute
 Partially hemolyzed
 Defibrinated
 High cytokines

                        57
HARMFUL MATERIAL IN
 RECOVERED BLOOD

   Free Hb
   RBC Stroma
   Marrow fat
   Toxic irritant
   Tissue or debris
   Fibrin degradation product
   Activated coagulation factors
   Complement
                                    58
        Postoperative Blood
             Collection
 Transfusion should be within 6
  hours of initiating collection
 Infusion of potentially harmful
  material in recovered blood, free
  Hb, red cell stroma, marrow, fat,
  toxic irrigant, tissue debris, fibrin
  degradation activated coagulation
  factors and complement
 Most common in orthopedic
  procedures such as hip or knee
  replacement.
                                          59
      Transfusion Algorithm
 Avoid Transfusion : medical and surgical
 Alternatives
  replacement fluids: crystalloids and non
  plasma colloids over plasma
  pharmacologic agents to reduce bleeding
 Autologous donation
 Minimize exposure to allogeneic
  transfusion                                60
     Transfusion Algorithm
It is possible to avoid transfusion ?

Medical:
Treat underlying cause of asymptomatic
anemias:
Nutritional deficiencies-supplements
Chronic GI bleeds-medications
Renal failure- erythropoietin
                                         61
        Transfusion Algorithm
Is it possible to avoid transfusion?

Surgical:
Excellent surgical skill (Factor XIV!=avoid
tissue trauma, attention to hemostasis, utilize
avascular plane etc)
Use of topical hemostatic agents in OR
Eg. Fibrin Glue- Fibrin sealant :Tisseel
    Collagen- platelet adhesion

                                                  62
       Transfusion Algorithm
 When transfusion is deemed necessary, a
  physician must obtain informed consent from
  patient.

 “Informed Consent to the administration of blood
  and blood products involves the following: an
  explanation by the physician in language the
  patient will understand of the risks and benefits
  of, and options to, an allogeneic blood
  transfusion
                                                      63
 Informed Consent- patient decides

 Information provided by physician:
  1. product description.
 2. Benefit and potential risks.
 3. Alternatives if available-including risks
     and benefits.
 4.Risks of refusing transfusion
 Opportunity for questions and clarification
 Patient’s documentation of consent or
  refusal
                                                 64
      Transfusion Algorithm
   Strategies to minimize exposure to
    allogeneic transfusion
1. replacement fluids- crystalloids and
    non plasma colloids
2. pharmacologic agents to reduce bleeding
3. Autologous Transfusion


                                             65
        Transfusion Algorithm
     Strategies to minimize exposure to
      allogeneic transfusion
1.    replacement fluids- crystalloids and non
     plasma colloids
2.   pharmacologic agents to reduce
      bleeding
3.    Autologous Transfusion
4.   Minimize allogeneic donor exposure in
      neonatal transfusion                       66
 Red Cell Transfusion- Is a clinical
            decision!!!
 Tissue oxygenation does NOT depend on
  hemoglobin concentration alone!

 Cardiac performance
 Pulmonary function
 O2 Binding Coefficient
 Demand of Tissue (physical activity)
                                          67
THANKS FOR YOUR
   ATTENTION




                  68