Preoperative Autologous Donation Research Articles

A prospective, randomized study of preoperative autologous donation for hip replacement surgery : D.A. Billote, S.N. Glisson, D. Green, et al. J Bone Joint Surg Am 84:1299–1304, 2002

A prospective, randomized study of preoperative autologous donation for hip replacement surgery : D.A. Billote, S.N. Glisson, D. Green, et al. J Bone Joint Surg Am 84:1299–1304, 2002

Con: Preoperative autologous donation has no role in cardiac surgery

THE TRAGEDY OF the 1980s and 1990s caused by viral transmission in blood products has been responsible for efforts to reduce the amount of allogeneic blood products used in both surgical and medical patients. In his final report on the Blood System in Canada, Krever1 recommended appropriate use of, and alternatives to, blood components and blood products. Over the last 2 decades, there have been institutional, regional, and national attempts to prevent allogeneic transfusions. Cardiac surgery is responsible for approximately 20% of allogeneic transfusions; in the last 20 years, the transfusion rate in cardiac surgery has dropped from nearly 100% to 27% to 92% depending on the institution.2 Contributing factors to this decrease include shorter bypass times, improved surgical techniques, bone marrow stimulation, antifibrinolytics, lowering of the transfusion trigger, and the use of autologous blood products. Autologous practices include recovery of shed blood, acute normovolemic hemodilution (ANH), and preoperative autologous donation (PAD). Although some of these techniques have been effective, many, including PAD, remain controversial.

Blood management in revision total knee arthroplasty.

Much attention has been focused on blood management issues in orthopaedic surgery in recent years, but blood management in patients having revision total knee arthroplasty is not well-established. Hematologic values and transfusion records of 100 patients (52 women, 48 men; mean age, 65 years) who had aseptic revision total knee arthroplasty at the authors' institution were evaluated retrospectively. Two- or three-component revisions comprised 66% of the procedures, and 58 patients participated in a preoperative autologous donation program. The mean preoperative hemoglobin level was 12.1 g/dL in the women and 14.1 g/dL in the men, but the men experienced a greater decrease in hemoglobin level (mean largest decrease, 4.2 g/dL versus 3.1 g/dL), possibly caused by the higher allogeneic transfusion rate in women (19.2%) versus men (4.2%). Patient age did not influence hemoglobin level or transfusion rates. Patients who participated in a preoperative autologous donation program had significantly higher hemoglobin levels before donation (14.4 g/dL versus 13.3 g/dL for patients who did not participate in a program) but comparable hemoglobin levels after predonation (12.9 g/dL). Patients with preoperative hemoglobin levels less than 13 g/dL were significantly more likely to have a transfusion. Symptom-based transfusion strategies and blood management approaches such as epoetin alfa that elevate preoperative hemoglobin level therefore may be beneficial in patients having revision total knee arthroplasty.

Audit of Blood Requisition.

Dear Editor, This is with reference to the article titled “Audit of Blood Requisition” MJAFI 2001; 57: 35-8. The authors have pointed out that there were 1697 i.e. 60.71 % demands for single unit blood and the total issues were 1099 i.e.33.34% of the entire demand. Out of this 713 i.e. 64.88% were single issue but unfortunately the authors have missed the fact that utilization of single unit demand is only 42.01% i.e. 713 out of a total demand of 1697, probably indicating the extra cautious nature of surgeons and anesthesiologists to cater for unforseen circumstances during surgery. We would like to inquire from the authors as to the break up of single unit blood demand, department wise and whether the surgeries were elective or emergencies. It is surprising to note that in a Service Zonal Hospital in a time span of 5 years i.e. from 1995 to 1999 only 10 cases of autologous blood transfusion were carried out whereas more than 80 autologous transfusions were done in another Service Zonal Hospital in a span of 2 years [1]. Pre-operative autologous donation and acute normovolemic haemodilution are very safe, viable and practicable alternatives to allogenic transfusions. Single unit transfusion must be avoided. The onus for dissemination of the information and advantages to the patients lies on the medical and para medical staff [2]. This is a small peripheral hospital looking after battle casualties due to militancy trauma. We have transfused 159 bottles of blood to 72 patients during this period out of which 34 i.e.21.38% were single unit and 5 i.e. 3.14% were autologous transfusions. Since we are dealing mainly with trauma cases, the criteria adopted by us for placing demand for blood are: (a) Hb < 8gm/dl after resuscitation (b) If substantial bleeding is anticipated during surgery.

Utilization of preoperative autologous blood donation in elective surgery.

The aim of the present paper was to review the pattern of collection and transfusion of autologous red cells for elective surgical procedures Data on requests for preoperative autologous donation of blood were obtained from the Australian Red Cross Blood Service, Victoria and the Royal Melbourne Hospital for the calendar year 1998. The following information was collected: patient age, sex, surgery type, number of autologous units requested and collected and, if relevant, reasons for not achieving the requested collection. Transfusion of autologous units and any additional homologous units was confirmed from records at the blood banks of the Royal Melbourne Hospital and Melbourne Pathology (the pathology provider performing cross-matching for the majority of autologous units collected by Australian Red Cross Blood Service, Victoria). Over 12 months, 2803 units of autologous blood were requested and 2282 units collected from 1301 patients. The most common reason for failure to collect the number of units requested was insufficient time between referral and surgery. Of the autologous units collected, 73% were transfused giving a collection to transfusion ratio of 1.4. Sixty-eight per cent of patients received their autologous units only, 10% received both autologous and homologous units, while 22% were not transfused. For the majority of procedures, patients using preoperative autologous donation of blood had higher transfusion rates than those who did not use this. Ninety per cent of patients undergoing preoperative autologous donation of blood successfully avoided homologous blood exposure. However, preoperative autologous donation of blood is both wasteful and increases the incidence of transfusion in surgical procedures.

Prophylactic pinning of the contralateral hip in slipped capital femoral epiphysis : evaluation of long-term outcome for the contralateral hip with use of decision analysis.

The risk of a contralateral slip in patients who are first seen with a unilateral slipped capital femoral epiphysis has been reported to be 2335 times higher than the risk of an initial slip. The overall prevalence of bilaterality varies widely throughout the literature, with some reports indicating rates as high as 80%. This finding has led many authors to recommend prophylactic pinning of the contralateral asymptomatic hip in patients presenting with a unilateral slipped capital femoral epiphysis. A decision analysis model with probabilities for the occurrence of contralateral slip and for the severity of slip at different intervals of follow-up was used in the present study. These probabilities were compared with those for various outcomes when the contralateral hip is prophylactically pinned. Scores representing long-term outcome, according to the Iowa hip-rating system, were used in the model as a measure of utility. The probabilities of contralateral slip and the rates of slip severity were taken from large retrospective series. All meaningful clinical scenarios with regard to long-term outcome for the hip were considered in the model. Variables of uncertainty were subjected to sensitivity analyses in order to explore the effect on outcome over the range of plausible values for variables of interest. The results showed a benefit in the long-term outcome for patients who had prophylactic pinning of the contralateral hip. The threshold level at which a benefit is obtained with prophylactic pinning is expressed according to the rates of sequential slip, rates of slips overlooked at follow-up, and complications associated with prophylactic pinning of the contralateral hip. The decision model shows that, when pooled data are used to predict probabilities of sequential slip, treatment of the contralateral hip with prophylactic pinning is beneficial to the long-term outcome for that hip. When considering prophylactic pinning of the contralateral hip, the clinician should use sound clinical judgment with respect to the age, sex, and endocrine status of the patient. Long-term follow-up studies are needed to establish the efficacy of prophylactic pinning, but the predictions in the present study, which are based on findings in the literature, support the safety of this procedure.

The Reduction of Preoperative Autologous Blood Donation for Primary Total Hip or Knee Arthroplasty: The Effect on Subsequent Transfusion Rates

We conducted this quality assurance observational study to examine the effects of a change in policy regarding preoperative autologous blood donation (PABD) and indications for perioperative blood transfusion in patients undergoing primary total hip or knee arthroplasty. Two successive time periods, each including 182 successive patients treated by the same medical team and with standardized anesthesia, were compared. The first study had the following standard transfusion policy: 3 U of PABD collected (n = 119) and liberal autologous transfusion (AT). The second study introduced a specific indication for PABD, on the basis of estimated red blood cell reserve and a life expectancy of more than 10 years; 2 U of PABD was collected (n = 81), and criteria were identical for AT and allogeneic transfusion. We mainly compared the incidence of AT; allogeneic and overall transfusions; the inclusion, admission, and discharge hematocrit values; and the wastage of PABD units. This novel policy increased the number of untransfused patients by a factor of 10 (5.5% vs 56.6%) (P < 0.0001), decreased the number of PABD patients by 30% with a 2.4-fold reduction in AT (30% vs 80%) (P < 0.0001), and did not change allogeneic requirements (13% vs 15%). Although fewer autologous units were collected (172 vs 426), the wastage was higher in Study 2 (46% vs 12%) (P < 0.0001). We conclude that incorporation of patients' individual factors improves the efficiency of transfusion for total hip and total knee arthroplasty surgeries. We compared two transfusion policies for primary total hip or knee arthroplasties: first, a standard preoperative autologous donation with a liberal autologous transfusion policy; and second, a more restrictive indication for autologous donation that was based on patients' individual factors, with identical criteria for autologous and allogeneic transfusion. We found that this change of policy reduced autologous donation and transfusion with no increase in allogeneic transfusion.

High or low hematocrits during cardiopulmonary bypass for patients undergoing coronary artery bypass graft surgery? An evidence-based approach to the question

We have observed an inverse relationship between a CPB Hct <20% and the need for cardiac support and hospital mortality. These data call for an aggressive and concerted effort to avoid a CPB Hct of <20%. The focus should be directed at women and small men since this subset of patients are most likely to experience low CPB Hct. A comprehensive, multimodality blood-conservation plan that involves the use of erythropoietin, aprotinin, preoperative autologous donation, shed blood reinfusion, and minimal phlebotomy for blood testing was proposed by Rosengart and colleagues based on their experience in caring for 50 Jehovah's Witness patients. Efforts to conserve blood and ensure hemostasis should cover the entire spectrum of care, including preoperative phlebotomy (for blood tests), diagnostic and interventional procedures, and intraoperative and postoperative care. Further work is needed to understand the mechanism for the relationship between low Hct and adverse outcomes. Each open-heart center should consider the Hct question carefully, examining both the published literature and their own results related to CPB Hct and patient outcomes.

The use of the orthopaedic perioperative autotransfusion (OrthoPAT) system in total joint replacement surgery.

Management of blood loss in orthopaedic surgery has evolved over the years. New approaches to making blood safer for patients has involved the use of preoperative autologous donation, the use of epoetin alfa administered preoperatively, intraoperative salvage, and perioperative salvage and infusion devices. A new alternative to salvage and infusion devices is the OrthoPAT. This article is meant to introduce the device to the orthopaedic nurse who works in the OR, PACU, and orthopaedic or medical-surgical unit, and who cares for orthopaedic patients who experience significant blood loss in total joint replacement surgery.

Autotransfusion in cardiac surgery.

There are a number of problems with allogeneic blood transfusion. Some of these problems are defined and can be quantified, such as the problem of rising cost or the risk of viral infection, but some of the problems are not well defined and it is only outcome data that point to allogeneic blood transfusion contributing to patient mortality and morbidity. Autotransfusion includes any technique in which the patient's own blood is collected, processed and stored, followed by reinfusion when circumstances dictate. In the perioperative period of cardiac surgery, a number of techniques are recognized as useful in this context. Preoperative autologous donation, with or without erythropoietin supplementation, intraoperative acute normovolaemic haemodilution, intraoperative cell salvage, postoperative cell salvage (reinfusion of shed mediastinal blood) and platelet rich plasmapheresis are all techniques which are used with more or less enthusiasm to reduce the need for an allogeneic blood transfusion. Modification of the priming technique of the cardiopulmonary bypass circuit using an autologous blood prime is included in this review even though it does not fall strictly within the definition of autotransfusion. Although autotransfusion is not the answer to every problem, there is no doubt that it should play a significant part in the strategy of blood conservation.

Utilization of technologies to reduce allogeneic blood transfusion in the United States.

Concern over safety of the blood supply has led to the use of technologies to reduce allogeneic blood transfusion. The objective of this research was to determine the utilization of these technologies in the United States. We evaluated the following techniques: preoperative autologous donation (PAD), cell salvage (CS) and acute normovolemic haemodilution (ANH); and the following pharmaceuticals: aprotinin (APR), epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), desmopressin (DDAVP) and recombinant human erythropoietin (EPO). In 1997, we conducted a cross-sectional mail survey of service chiefs at 1000 US hospitals randomly selected and stratified by status as a provider of open-heart surgery, geographical location and hospital bed size. Sixty-nine per cent (690) of hospitals responded to at least one of the four surveys sent to each hospital. Hospitals reported use of techniques more than pharmaceuticals (P < 0.001); PAD (83%, n = 206) and CS (82% n = 420) were used most frequently. Lack of familiarity was the most common reason cited for infrequent use of pharmaceuticals. Organizational characteristics (e.g. provision of open-heart surgery, size, geographical location, teaching status and type of hospital) were differentially associated with technology use. There is greater use of techniques than pharmaceuticals in US hospitals to reduce the need for allogeneic blood in the peri-operative setting. Providing open-heart surgery is strongly associated with the utilization of these technologies.

Unchanging attitudes to autologous transfusion in the UK.

Our aim was to assess changes in attitudes to autologous transfusion amongst surgeons over a 10-year period in response to scientific evidence, public awareness, published guidelines, management and the increasing cost of blood products. Surgeons across the north-west of England completed questionnaires on knowledge, experience and attitude towards autologous transfusion in 1990, 1994 and 1999. Main outcome measures were changes in knowledge, experience and utilization of autologous transfusion; perceived advantages of autologous transfusion, obstacles to its implementation in surgical practice and preferences for specific techniques (preoperative autologous donation, acute normovolaemic haemodilution, intraoperative and postoperative cell salvage). There has been little change in practice over 10 years. Many more surgeons were keen to employ autologous transfusion than were using it. Autologous transfusion was only used in general, orthopaedic and cardiothoracic surgery. Safety and patient preference were the main arguments for implementation and logistics the main obstacles. Autologous transfusion was used sporadically in surgical practice. Clinical trials are needed to guide clinicians in the choice of transfusion techniques.

Autologous blood transfusions.

Due to enormous risks of transfusion-transmitted diseases in allogenic blood transfusions, including dreaded AIDS, there has been constant endeavour to look for a safer alternative. Autologous transfusion which is transfusion of blood/component donated by intended recipient, has proved to be a safe and viable alternative. Initially tried in 1874 in the form of blood salvage, the process has become popular since 1971 with better PVC containers and storage facilities. Due to ignorance and lack of interest the procedure in still unpopular in India. It is very useful for preventing complications of allogenic transfusion and in rare blood group or patients for whom it is difficult to find compatible blood. Since 1980s the procedure is being widely used. Maximally used category is preoperative donation. Strict protocols regarding selection, storage and labelling are essential. There has been tenfold increase in the preoperative autologous donations in many centres. Isovolemic hemodilution and blood salvage are also being used. The procedure has also been used for preteenage and paediatric ages successfully. 1 to 5 units can be collected from single donor. Now the popularity of the procedure has increased due to awareness and interest.

IS PREOPERATIVE DONATION OF AUTOLOGOUS BLOOD RATIONAL FOR RADICAL RETROPUBIC PROSTATECTOMY?

We investigated differences in the rate of homologous blood transfusion and the degree of anemia to determine whether it is rational to have patients donate autologous blood before radical prostatectomy. We retrospectively reviewed the charts of 221 consecutive men who underwent radical retropubic prostatectomy performed by 1 surgeon in a 14-month period. About half of the patients donated autologous blood preoperatively. We evaluated perioperative hemoglobin, and the rate of autologous and homologous transfusion. The groups did not significantly differ in terms of demographic data, co-morbid conditions, clinical variables or hospitalization. Preoperatively mean hemoglobin plus or minus standard deviation was 13.4 +/- 1 and 14.7 +/- 1 gm./dl. in patients who did and did not donate blood, while homologous transfusion was required in 1 (1%) and 4 (3.5%), respectively (p = 0. 18). At hospital discharge anemia was more prevalent in nondonors. Of the men who did versus did not donate blood hemoglobin was less than 10 and less than 9 gm./dl. in 8.4% versus 34% (p <0.0001), and 12.5% versus 0% (p <0.0004), respectively. Our retrospective review of a cohort of patients who underwent radical retropubic prostatectomy showed no difference in homologous blood transfusion based on preoperative autologous donation status. Autologous donors had lower hemoglobin preoperatively, a higher rate of transfused units and higher hemoglobin at hospital discharge. Preoperative donation of autologous blood may not decrease the need for homologous transfusion in healthy patients undergoing radical retropubic prostatectomy.

Radiological findings in angiofibroma.

Surgery after pre-operative embolization has become the main treatment modality in angiofibroma therapy. As surgical planning is based on precise preoperative tumour evaluation, knowledge of the characteristic growth patterns is of great interest. Analysis of tumour extension and blood supply, as well as methods of controlling intra-operative bleeding, help in determining the appropriate surgical approach. Though benign, angiofibroma demonstrates a locally aggressive nature. This fibrovascular tumour is characterised by typical radiological findings and by predictable growth patterns. The tumour extension and blood supply can be accurately determined by CT, MR imaging and angiography. With classic radiological findings, no pre-operative biopsy is necessary in most angiofibromas. Advances in radiological imaging have contributed to improved surgical planning and tumour resection. The surgeon is able to select the least traumatic approach with secure haemostatic control, which is also critical for avoiding the disturbance of facial skeletal growth in this group of young patients. Embolization, pre-operative autologous donation and the cell saver system for immediate retransfusion of the collected blood after filtration, are important tools for dealing with blood loss in angiofibroma surgery as they minimize homologous blood transfusion.

Red Blood Cell Apheresis is a cost-effective procedure to avoid Allogeneic Transfusion

SUMMARY In the last decade, clinical investigators have focused attention on interventions to decrease the use of allogeneic blood products in surgical patients, especially in orthopedic joint surgery. Repeated Preoperative Autologous Donation (PAD) of whole blood is now widely accepted as an alter native to allogeneic transfusion1. The most import ant criticisms of this procedure deal with its cost-effectiveness2–4, the moderate anemia induced by the technique and the organizational difficulties of the method. Red Blood Cell apheresis(RBC apheresis) is also a preoperative autologous blood donation, as it is performed three weeks prior to surgery, but 3 RBC units can be collected by apheresis on one occasion. The quality of apheresis packed red eells collected 30 days prior to surgery is similar to RBC from manual whole blood collection5.

Preoperative autologous donation of blood for a simple cardiac anomaly: Analysis of children weighing under twenty kilograms

Objective: Preoperative autologous donation of blood has been expanded to cardiac operations in children. However, because of problems such as lack of cooperation and hemodilution during cardiopulmonary bypass, its efficacy in small children is unclear. This study clarifies the clinical significance of preoperative autologous donation of blood in small children. Methods: Thirty-seven patients weighing under 20 kg (age range, 3-9 years; weight range, 13-20 kg) underwent preoperative autologous donation and cardiac operations to treat a simple anomaly. Twenty-five age- and weight-matched patients who were not cooperative or refused preoperative autologous donation served as control subjects. Autologous blood was collected by the simple or leapfrog method and stored as blood components. Each collecting volume was 5 to 10 mL/kg. Results: The donation was performed 6 ± 2 times during 50 ± 16 days, and the whole storage volume was 48 ± 17 mL/kg. There was no serious complication. The minimum hematocrit level negatively correlated with the priming volume of cardiopulmonary bypass (preoperative donation patients: P < .01, r2 = 0.4; control subjects: P = .5, r2 = 0.03). Blood loss did not significantly differ between preoperative donation patients and control subjects, and the transfused blood volumes were 43 ± 13 mL/kg and 29 ± 22 mL/kg, respectively. All of the autologous blood products but fresh frozen plasma were reinfused. Use of homologous blood was significantly less in preoperative donation patients than in control subjects (0% vs 80%, P < .01). In preoperative donation patients postoperative recovery in hemoglobin level was significantly better, which is concurrent with a higher reticulocyte level. Conclusion: Preoperative autologous donation can be performed safely with clinical efficacy, even in children under 20 kg. This can be improved further through coupling with another procedure. (J Thorac Cardiovasc Surg 2000;120:783-9)

Cost effectiveness of epoetin-alpha to augment preoperative autologous blood donation in elective cardiac surgery.

The objective of this study was to assess the cost effectiveness of using epoetin-alpha (erythropoietin) to augment preoperative autologous donation (PAD) of blood prior to elective cardiac surgery. We designed a decision-analytic model incorporating the risk of receiving allogeneic blood, the costs of blood products, the likelihood of developing transfusion-related diseases, the costs of transfusion-related diseases and their impact on life expectancy, and the effect of epoetin-alpha on the probability of transfusion. The efficacy of epoetin-alpha was derived from data from a meta-analysis of published randomised trials comparing the use of epoetin-alpha to augment PAD with the use of PAD alone. Estimates for the other parameters were obtained by a systematic review of the literature. The use of epoetin-alpha reduced the proportion of patients receiving allogeneic transfusions by 60% (from 31.6 to 12.7%). However, this led to only a modest benefit of 0.000035 life years gained per patient and an incremental cost per life year gained of $Can44.6 million (1998 Canadian dollars). A detailed sensitivity analysis confirmed that the cost-effectiveness ratio was larger than that which is generally considered acceptable. Our study indicates that the use of epoetin-alpha to reduce perioperative allogeneic transfusions in cardiac surgery is not cost effective.

Blood conservation in patients undergoing non-cardiac surgery

Concerns about the safety, inventory, and cost of allogeneic blood have led to a renewed interest in blood conservation. Autologous blood collection techniques, including preoperative autologous donation, acute normovolemic hemodilution, and perioperative blood recovery are routinely used as alternatives to allogeneic transfusion. In the future, these techniques may be combined with pharmacological strategies, such as presurgical erythropoietin therapy or red cell substitutes, to reduce further the need for allogeneic blood.

Use of interventions to minimise perioperative allogeneic blood transfusion in Australia. A survey by the International Study of Perioperative Transfusion (ISPOT) Study Group.

To investigate use of interventions to minimise need for perioperative transfusion of allogeneic blood in surgical units in Australia. Two questionnaire-based surveys of practice. All hospitals in Australia, 1996-1997. Survey 1: all Australian hospitals that have at least 50 beds and undertake surgery; Survey 2: surgical units identified as using the interventions. Reported rates of use of the various interventions (preoperative autologous donation, acute normovolaemic haemodilution [ANH], cell salvage, and drugs); use of guidelines; and perceptions about the appropriateness of current levels of use. Survey 1 was returned by 349 of 400 hospitals (87%) and Survey 2 by 324 of 578 surgical units (56%). Preoperative autologous donation was most widely used (70% of hospitals), most commonly in units performing orthopaedic or vascular surgery (65% and 37%, respectively). Cell salvage and ANH were used by 27% and 24% of hospitals, respectively, most often in units performing cardiothoracic (40% and 44%, respectively) and vascular surgery (29% and 15%, respectively). These three interventions were used significantly more in private than in public hospitals (P < 0.05). Use of printed guidelines was uncommon. Respondents considered that autologous transfusion techniques should be used more widely because of their perceived efficacy and concerns about safety of allogeneic blood. Perceived barriers to greater use included lack of surgeon or physician interest, uncertain scheduling of surgery in public hospitals and cost (cell salvage). Drugs to minimise blood loss were used by fewer than 10% of hospitals. Interventions to minimise the need for perioperative allogeneic blood transfusion (apart from drugs) are widely used in Australia. However, enthusiasm for intraoperative techniques of re-infusing autologous blood needs to be assessed against the evidence of their efficacy and cost-effectiveness.