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Autologous Blood Transfusion9. Autologous Blood TransfusionAutologous blood transfusion is a unique approach of providing the patient with his own blood. In other words, autologous blood transfusion (ABT) refers to the procedure of transfusing blood or blood components that have been donated by the intended recipient. ABT in all its forms has now gained a prominent role in transfusion medicine and modern medical practice.Although the practice of autologous blood transfusion was introduced long back, it has gained a renewed interest due to the threat of transfusion transmitted AIDS. Types of ABT 4 categories of ABT have been described 1. Preperative deposit 2. Perioperative haemodilution 3. lntraoperative blood salvage 4. Post operative ART 1. Preoperative autologous deposit Collection of blood prior to surgery can meet the transfusion requirements of a significant number of patients and reduce the need for homologous blood. Patients undergoing elective surgery (general, plastic or orthopaedic surgery) are capable of donating blood prior to surgery. This is especially effective in centres having difficulty in maintaining homologous blood stock. The hospital transfusion centre must plan its autologous blood transfusion programme in such a manner that it collects blood from patients undergoing only those surgical procedures for which blood is required routinely. If properly planned upto 4-5 units of blood can be collected during the pre-operative period and stored for 35 days shelf life in CPDA-1. The autologous red cells can also be frozen until required. 2.Criteria of donor selection The criteria for selection of donor for ABT are not as strict as for homologous donors. 1. Age There is no upper age limit for autologous donation.. Patients under the age of 18 years may also be included provided they are cooperative and have no cardiac or respiratory problem. Blood bags with smaller gauge needles and less volume of anticoagulant should be made available for collection of blood. Upto 250 ml (3Sml - CPD-A-1) of blood can be collected from children weighing between 28 and 50 kg. 2. Weight There are no specific weight requirements. The amount of blood to be collected is calculated as weight (kg)/50 x 350 Amount of anticoagulant = Volume of donation (ml) x 49 /350 The excess anticoagulant may be transferred into a satellite bag. 3. Patients on medication, pregnant women with a risk of bleeding during delivery, patients with mild cardiac disease or recent surgery may also be accepted as donors for ABT. Patients with moderate to severe cardiovascular disease can be infused with saline during blood collection. 4. Haemoglobin/haematocrit The haemoglobin concentration prior to each donation should be lig/dI or greater and the haematocrit greater than or equal to 34%. 5. Frequency of donation Careful planning must be done for the probable date of surgery and blood collection should be based on the number of blood units required. Blood should be collected at interval of 7 days and the last phlebotomy should preferrably be 1 week before surgery, however a minimum period of 72 hours is a must prior to surgery. Tests on collected blood The same tests should be done on autologous blood units as for homologous blood. This is to: i. Avoid any identification error ii. Know the baseline status for various markers of infection i.e. HBsAg, anti-HIV, syphilis, etc. Contraindications for pre-deposlt ABT 1. Bacteraemia or septicaemia 2. Significant cardiovascular disease such as cardiac failure, unstable angina and hypetension. 3. Cerebrovascular disease. 4. Pregnancy with anaemia, hypovolemia, pre-eclamptic toxemia or foetal growth retardation. Iron supplementation When several units of autologous blood are to be collected, oral iron therapy should be given. Ferrous sulphate 300 mg three times a day is recommended. This should begin one week prior to the first phlebotomy and continue few months after the last donation. If adequate iron supplementation has been given, upto 4 units can be collected. IdentificatIon and issue of blood Blood for ABT must be labelled as ‘For Autologous use’, and if possible stored in a seperate blood storage refrigerator at 4° - 6°C for a period of 35 days (CPDA-1). The patient’s identification number, date of donation and expiry and blood group must be mentioned on the label. The collected unit should be issued after crossmatching, in the same manner as homologous units and the patient must be identified before starting the infusion. Using autologous blood for homologous use Unused autologous blood can be put into homologous stock if the donor meets all the criteria for homologous donors. This will help supplement the hospital/community blood supply. If it is not suitable for routine use, the unit must be discarded. However, there is some controversy regarding the use of autologous blood for other purpose and most of the institutions use autologous blood for the indicated recipient only. Promotion of ABT Autologous blood transfusion has not gained popularity due to the lack of interest by transfusion specialists and physicians. There is also a lack of awarenesss about the criteria of donor selection and the clinical conditions in which autologous blood can be collected. The blood transfusion officer should effectively collaborate with the clinicians and make all efforts to actively promote ABT. Education by leaflets or talks with particular stress on: * Advantages of ABT * Patients for whom it is useful * Selection criteria may be provided to propagate the programme. The decision to introduce an autologous transfusion programme requires the cooperation of haematologists, blood transfusion specialists, blood transfusion centre staff, surgeons and anaesthetists. Perioperative haemodilution This is a procedure wherein red cells and fibrinogen in the circulation are replaced by a crystalloid or colloid solution. This result in a decrease in whole blood viscosity and also the peripheral resistance which causes an increase in cardiac output. The end effect is an increase tissue oxygenation. Procedure The procedure can be performed just before surgery in the operation theatre. One to three units of blood are collected from the internal jugular vein into CPDA-1 bags. The patient is monitored after the first unit is collected for arterial and venous pressures. During collection of second and third units, crystalloids/ colloids may be administered through the peripheral vein. Adequate labelling of the blood bag must be done. The autologous whole blood collected is reinfused immediately after the surgical procedure. Operative procedures with blood loss of upto 50% of total volume can be supported without homologous blood using this technique. 3. Intraoperative blood salvage (IBS) This refers to the retrieval of blood shed from operating site. It has the advantage of providing blood rapidly and immediately. The operative site must be clean and free from bacteria, bowel contents and tumour cells. The blood aspiration technique must avoid haemolysis from excessive suction turbulance and frothing. Two forms of blood salvage procedures can be used: i. Manual system which involves collection, filteration and infusion of blood. ii. Automated blood salvage which involves collection, filteration; washing and reinfusion of the red cells. In the automated system, blood from the operative site is sucked by a roller pump into a reservoir. A tubing allows anticoagulant to mix with the blood. Blood is pumped from the reservoir into the centrifuge bowl and red cells are separated by centrifugation. The red cells are washed, resuspended and pumped into a plastic bag for transfusion. The process may be fully automated or require operator control at every step. The personnel involved in operating lBS equipment must therefore be well- trained. Cell salvage machines are very useful when operative loos is unexpectedly high and it cause a heavy drain on blood stocks in the blood transfusion centre. High capacity cell saver machines are capable of processing about 1 unit of packed cells every 3 minutes. Indications 1. Cardiovascular surgery 2. Vascular surgery 3. Liver transplantation 4. Trauma and emergency surgery 5. Orthopaedic surgery Contraindications 1. Infection at the operation site 2. When bleeding is anticipated to be minimal. 3. When there is a malignancy in the potential operative field 4. Faecal contamination at operative site. Advantages lBS has a prominent role in transfusion medicine. The main advantages are 1. It conserves red cells. 2. It provides blood ready for infusion quickly. Complications 1. Air embolism 2. Sepsis from contaminated salvaged blood. 3. Dilutional coagulopathy since salvaged blood is deficient in coagulation factors and platelets. Post-operative blood salvage Salvage and reinfusion of mediastinal blood shed during cardiac surgery is referred to as postoperative blood salvage. Advantages 1. The procedure is cost-effective. 2. It is easy to use and readily acceptible. 3. Since the system is closed the risk of infection is minimal. 4. The filter provides filtration of mediastinal blood.
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