Preoperative Autologous Blood Donation Research Articles

Preoperative Autologous Blood Donation by Arthritis Patients Is Associated With Preoperative Anemia and Perioperative Transfusion

Preoperative autologous blood donation (PAD) became a common practice in the 1990s in an attempt to reduce the risk of transmission of infectious agents from allogeneic blood. However, a potential risk of PAD is the development of preoperative anemia that may lead, in turn, to an enhanced need for transfusion. Furthermore, the ready availability of autologous blood may predispose to more liberal transfusion peri-/postoperatively. To examine these hypotheses, we retrospectively examined a cohort of knee and hip arthroplasty patients. Charts of patients of 2 orthopedic surgeons from the mid 1980s and 1990s were reviewed for transfusions needed and hematocrits before and after arthroplasties. PAD proved to be a significant risk factor for the development of preoperative anemia and for peri-/postoperative blood transfusion even after adjusting for confounders. These results suggest that PAD may lead to a self-defeating cycle of blood donation followed by blood transfusion. With the improved safety of the allogeneic blood supply, rheumatologists may want to play a more active role in considering PAD in patients in whom elective arthroplasty is planned.

Safety and efficacy of unmodified whole blood vs. buffy coat‐depleted red cell concentrates in autologous transfusion of elective orthopaedic surgery patients

Storing autologous blood as whole blood (WB) has been proposed for increasing the cost-effectiveness of preoperative autologous blood donation programmes. However, experimental data suggest that autologous leucocytes might lead to immunomodulation similar to the effect attributed to allogeneic leucocytes. In a retrospective analysis, the postoperative outcome of 120 patients undergoing elective orthopaedic surgery and having donated up to two units of autologous WB (AWB) was compared with that of a control group of 52 patients, whose autologous donation had been processed into buffy coat-depleted red cell concentrates (RCC). At least one autologous unit, but no allogeneic units, had been transfused in all analysed patients. Donation schemes were equally efficacious in both groups. There was no significant difference in postoperative infection rates between the two groups. Overall rates were 7.7% in the RCC group and 8.3% in the WB group. Surgical, thromboembolic and other recorded complications, length of postoperative hospital stay and days of the use of antibiotics were also not significantly different between the two groups. The results of this study suggest that transfusion of up to two units of unmodified AWB is as efficacious as the transfusion of autologous RCC and does not negatively influence the postoperative outcome in elective orthopaedic surgery.

Product quality in preoperative autologous blood donation--determinants of erythropoiesis

The implementation of alternative blood conservation strategies to their full extent before preoperative autologous blood donation (PABD) is applied might reduce costs and blood donation risks for patients undergoing elective surgery. If PABD has to be performed, it has to be arranged as effective as possible. This includes an optimal time schedule which can be achieved by the preparation of autologous red blood cell (RBC) concentrates or whole blood with an optimal shelf life. Preoperative active immunization against hepatitis A and B should be considered, too. Early screening for iron deficiency including measurement of ferritin and hematocrit values in all patients who have to undergo elective surgery, including those who are not eligible for PABD, should be performed. In the planning of blood conservation strategies, special attention should be paid to patients with low blood volume and low initial hematocrit.

3rd International Symposium "Autologous transfusion--from euphoria to rational: practical handling from the scientific viewpoint" (Part I)

”Your own blood is the safest blood” - this is the statement of the American Association of Blood Banks (AABB) on its official ”Autologous Blood Poster” [1]. It is made for lays in order to promote preoperative autologous blood donation (PABD), and to demonstrate its potential advantages. Autologous transfusion has become an established component of the patient’s blood supply. However, after having done the emotional difficult step ”from euphoria to reason” the next logical step of autologous blood management should be done; namely ”from reason to quality management and quality securing”.

A novel method of preoperative autologous blood donation with a large volume of plasma for surgery in gynecologic malignancies

The objective of this study was to establish a novel method of preoperative autologous blood donation (PAD) for surgery of gynecologic malignancies, which requires considerable amounts of plasma relative to the red blood cell component. To collect a double volume of plasma over the amount obtained from whole blood without using an aphaeresis system, we first collected 500 ml of whole blood (2.5 units), and centrifuged it. We gave back the resultant red cell component alone, and retained the plasma component. We further collected an additional 500 ml of whole blood, and centrifuged it. The red cell component (2.5 units) was stored in the refrigerator (as a concentrated red cell, CRC). The resultant plasma together with the plasma collected first (5 units) was frozen and stored in the freezer (fresh frozen plasma, FFP), We repeated this procedure at most three times at intervals of 1 week. Erythropoietin was injected once a week and iron tablets were prescribed. Ninety-nine patients undergoing surgery for a gynecological malignancy were subjected to this method and 86 patients without PAD served as a control. We conducted the procedure for PAD without any noticeable side effects. The amount of actual use of allogeneic CRC and FFP were significantly reduced in the PAD group compared with the control group. In particular, 93.6% of the PAD cases who gave 10 or less units of FFP could go without allogeneic FFP. Postoperative serum albumin levels were higher in the PAD group compared with the control. We have established a novel PAD method which can yield a greater volume of FFP relative to CRC, thus meeting requirements for surgery for gynecological malignancies.

Predeposit autologous donation in spinal surgery: a multicentre study.

Allogeneic blood transfusions (ABT) are often necessary in elective spine surgery because of perioperative blood loss. Preoperative autologous blood donation (PABD) has emerged as the principal means to avoid or reduce the need for ABT. Consequently, a multicentre study was conducted to determine the yield and efficacy of PABD in spine surgery and the possible role of recombinant human erythropoietin (EPO) in facilitating PABD. We retrospectively reviewed the hospital charts and blood bank records from all consecutive spine surgery patients who were referred for PABD. Data were obtained from two A-category hospital blood banks and one general hospital. Although we collected data from 1994, the analytic study period was from the last quarter of 1995 to December 2003. Fifty-four (7%) out of 763 patients referred for PABD were rejected, and medical records were available for 680 patients who were grouped into spinal fusion (556; 82%) and scoliosis surgery (124;18%). EPO was administered to 120 patients (17.6%). From 1999 to 2003, PABD steadily increased from 60 to 209 patients per year. Overall, 92% of the patients were able to complete PABD, 71% were transfused, and almost 80% avoided ABT. PABD was more effective in fusions (86%) than in scoliosis (47%). Blood wastage was 38%, ranging from 18% for scoliosis to 42% for fusions. EPO allowed the results in the anaemic patients to be improved. Therefore, despite the limitations of this retrospective study, we feel that PABD is an excellent alternative to ABT in spine surgery. However, the effectiveness of PABD may be enhanced if associated with other blood-saving techniques.

Preoperative erythropoietin in spine surgery.

Spine surgery may be associated with profuse intraoperative bleeding that often requires blood transfusions. In recent years several techniques have been developed to avoid allogenic transfusions and their potential complications to surgical patients. In this study we review and analyse the role of preoperative recombinant human erythropoietin (rHuEPO) administration in spine surgery as a blood conservation strategy. Between 1998 and 2002, a total of 250 patients scheduled for spine surgery were included in our blood-sparing program: 114 patients (group 1), operated on before rHuEPO approval (2000), underwent preoperative autologous blood donation (ABD) alone, and 136 patients operated on after rHuEPO approval (groups 2 and 3) received rHuEPO while undergoing ABD. Adding rHuEPO to ABD resulted in higher haemoglobin and haematocrit values the day of surgery, more ABD units retrieved per patient and, consequently, reduced allogenic transfusion requirements. The effectiveness of rHuEPO as the only preoperative blood conservation technique was evaluated in ten patients with a predicted blood loss of less than 30% of their total volume, scheduled for lumbar surgery. Data from these patients were matched with those from a similar group of patients who had undergone ABD. Patients receiving rHuEPO alone had higher haemoglobin levels the day of surgery than did patients in the ABD program. Neither group required allogenic transfusions. preoperative rHuEPO is useful for reducing allogenic blood requirements in elective spine surgery. In patients with an expected blood loss of around 50% of blood volume, rHuEPO improves ABD, minimising preoperative anaemia and increasing the number of ABD units collected. In patients with expected blood loss below 30% of total volume, rHuEPO administration may replace ABD.

Transfusion of post-operative shed blood: laboratory characteristics and clinical utility.

Increased awareness of the potential hazards of allogenic blood transfusion, such as incompatibility reactions, metabolic and immunologic disorders, or transmission of viral diseases, has led to an emphasis on allogeneic blood alternatives. For orthopaedic surgery, several autologous transfusion modalities have emerged as alternatives to allogeneic blood transfusion, avoiding its immunomodulatory effects. Among them, transfusion or return of post-operative salvaged shed blood has become popular in major orthopaedic procedures. However, although the effectiveness of this blood-saving method is well documented, several authors have questioned its safety and recommended the use of washed blood. Therefore, this review analyses the haematologic characteristics of unwashed filtered shed blood, including metabolic status and survival of red blood cells, the components of the haemostatic system, the content of fat particles, bacterial and tumour cells and the possibility of their removal, the content of inflammatory mediators, and the effects on the patient's immune system. From data reviewed in this paper, it can be concluded that post-operative salvage of blood seems to be an excellent source of functional and viable red cells without many of the transfusion-related risks and with some immuno-stimulatory effects. In addition, from our experience, post-operative re-infusion of unwashed shed blood after major spine procedures has proved to reduce post-operative homologous transfusion requirements and to complement pre-operative autologous blood donation, without any clinically relevant complication.

Letters to the Editor: Blood Management after Bilateral Total Knee Arthroplasties

Reply: We thank Dr. Slappendel and Dr. Dirksen for their interest in our study.2 As mentioned in the manuscript a pneumatic tourniquet was used routinely in all patients having bilateral total knee replacements (TKRs). The tourniquet was inflated on the more symptomatic knee before the skin incision and was released after cementing the implant. After thorough assessment of the patient, the tourniquet was inflated on the other side and a separate team started the second procedure. Releasing the first tourniquet and starting the second TKR before closing the incision of the first knee reduces the overall operation time and offers the possibility to take care of any bleeding vessels before inserting the drains and closing the knee. However, this protocol accounts for a small amount of intraoperative blood loss.2 The average intraoperative blood loss (367.7 mL) in the patients2 is similar to data presented in the literature.7,8 Based on our experience with 461 patients having simultaneous bilateral TKRs, we do not think that predonation of autologous blood is unnecessary and that it is easy to calculate the need for blood transfusions in patients having simultaneous bilateral TKRs. Although there are some protocols to decrease the need for allogenic blood transfusions to almost zero in patients with unilateral TKRs,1,6 blood management in bilateral TKRs seems to be more complex.2,4,5,7,8 The total blood loss after simultaneous bilateral TKRs seems to be as much as 50% greater than the sum of both surgeries in staged bilateral TKRs.3,7 Bould et al3 addressed the issue of blood loss in bilateral TKRs as not simply being double that of a unilateral TKRs. In their study the blood loss in the second knee was increased significantly by what might be explained by a decrease in clotting factors, by effects of the tourniquet, and tissue trauma.3 In a study by Lane et al,8 patients with simultaneous bilateral TKRs had an approximately 17 times greater need for banked blood than patients having unilateral TKRs despite the use of a cell saver and a twofold greater preoperative autologous blood donation in the patients having simultaneous bilateral TKRs. Fick et al5 reviewed 44 patients having bilateral TKRs. Although 95% of the patients received an average of 1059 mL of filtered wound drainage blood and 44% additionally received an average of approximately 1 unit of predonated autologous blood (593 mL), 57% of the patients required allogenic blood transfusions.5 Breakwell et al4 randomized 33 patients having bilateral TKRs to either allogenic blood transfusions alone or the additional use of a postoperative cell saver. Using a postoperative cell saver decreased the need for allogenic blood by 2.5 units, however, these patients still required an average of 3.8 units of allogenic blood.4 Therefore it seems unlikely that using a postoperative cell saver alone will solve the issue of the increased need for allogenic blood transfusions in patients having simultaneous bilateral TKRs. In the Materials and Methods section we stated that: “It was assumed that patients with a postoperative hemoglobin greater than 10.5 mg/dL between postoperative Days 4 to 7 had received too many blood transfusions if they had no medical conditions justifying increased transfusion requirements, such as preexisting coronary artery disease or a history of myocardial infarction,” to reduce the risk of overestimating the transfusion requirements. In the study we focused on reducing the need for allogenic blood transfusions and therefore recommended predonation of 2 units of autologous blood in combination with a postoperative cell saver, knowing that other protocols that rely on allogenic blood transfusions are less expensive. We agree that not mentioning the mean body weight is a weakness of the paper. Friedrich Bottner, MD Hospital for Special Surgery, New York, NY;, and the Department of Orthopaedics,, University Hospital of Muenster,, Muenster, Germany Thomas P. Sculco, MD Hospital for Special Surgery,, New York, NY

Blood management for patients with hemoglobin level lower than 130 g/l in total knee arthroplasty.

The risk of requiring allogeneic blood transfusion after total knee arthroplasty has been recently decreased with several methods such as blood donation, blood salvage, and hematinic. For patients with a low baseline hemoglobin level, however, the rate of allogeneic transfusion is still high, and an effective method for avoiding allogeneic blood transfusion has not been established. We introduced intra- and postoperative blood salvage with the Cell Saver for patients with a baseline hemoglobin level lower than 130 g/l and analyzed the frequency of allogeneic blood transfusion. From 1993 to 1997, 218 consecutive total knee arthroplasties were performed, and 155 knees with baseline hemoglobin lower than 130 g/l were included in this study. Baseline hemoglobin ranged from 62 to 129 g/l, with a mean of 110 g/l. All patients were managed with intra- and postoperative blood salvage with the Cell Saver. Preoperative autologous blood donation and/or use of hematinic was performed for 129 knees (group 1) and was not performed for 26 knees (group 2). There were no significant differences between the two groups with regard to preoperative factors. To examine the role of perioperative factors (age, sex, baseline hemoglobin level, revision procedure, preoperative blood donation, and use of hematinic) in determining the requirements for allogeneic transfusion, backward elimination logistic regression analysis was used. Seven knees (4.5%) required allogeneic transfusion. Group 1 (2.3%) exhibited a lower rate of allogeneic blood transfusion than group 2 (15.4%) (p=0.016). Hemoglobin levels on the day (p=0.016), 1 week (p=0.0001), and 2 weeks (p=0.007) after surgery were lower in group 1 than in group 2. Backward elimination logistic regression analysis showed that preoperative blood donation (p=0.048) and use of hematinic (p=0.040) were significantly associated with a requirement for allogeneic blood transfusion. Preoperative blood donation and use of hematinic were associated with a low incidence of allogeneic blood transfusion after total knee arthloplasty with intra- and postoperative blood salvage, even for patients with a baseline hemoglobin level below 130 g/l.

Do we need autologous blood donation?

The aim of preoperative autologous blood donation (ABD) was to reduce both the risk of transfusion transmitted disease and the need of blood from donors. Since ABD has been developed, the conditions of surgery and the criteria of choice have been modified thus leading to actualise the evaluation of this therapy. The first theoretical advantage of ABD is prevention of transfusion-transmitted disease namely viral infections such as HIV or hepatitis virus or emerging virus. Actually, the very low residual risk that remains from allogeneic transfusion after appropriate selection of donors, leukoreduction and nuclear acid testing does not argue for ABD. On the other hand, the risk of bacterial contamination must be taken in account for both ABD and homologous transfusion. A meta-analysis showed that ABD reduces the exposure to homologous transfusion (OR: 0.17). Clinical studies showed that patients who predonated autologous blood were more likely to receive any blood transfusions (autologous and/or allogeneic) than those who did not (OR: 3.31). More, the reduction of exposure to allogeneic transfusion may be questioned in view of prescription bias. Additionally, ABD is poorly cost-effective. It leads to significant blood wastage as in most of the studies about half of the units are discarded. In conclusion the interest of ABD has not been sufficiently evaluated. The interest of this therapy remains to be demonstrated.

The Pharmacoeconomics of Alternatives to Allogeneic Blood Transfusion

SUMMARY Background and Objectives: Pharmacoeconomics provides a standardized methodology for valid comparisons of interventions in different fields of healthcare. The role of pharmacoeconomics in the safety of blood, blood products and alternatives has however been very limited up to today. This paper discusses the pharmacoeconomic evaluations of alternatives to blood transfusion that have been published in the scientific literature. Methods: We reviewed pharmacoeconomic methodology with special reference to cost‐effectiveness and cost‐utility analysis. We searched the literature for such cost‐effectiveness analyses related to alternatives to blood transfusion. Results: Net costs per quality‐adjusted life year (QALY) gained varied from cost‐saving for reduction of blood transfusions by antifibrinolytics and for analyses which included assumed complications caused by transfusion‐related immunomodulation to more than a hundred millions of US$ per QALY gained for preoperative autologous donation by transurethral prostatectomy patients and epoetin augmentation of preoperative autologous donation. Conclusions: Currently preoperative autologous blood donation with or without epoetin augmentation and epoetin in the absence of autologous transfusion cannot be regarded as cost‐effective healthcare interventions for the general population. Perioperative use of antifibrinolytics may be cost‐saving, but at present evidence is scarce. Cost‐effectiveness of alternatives to blood transfusion may improve if the impact of adverse effects of allogeneic transfusion, such as immunomodulation, bacterial infection and TRALI, can be further substantiated, if the costs of allogeneic blood transfusion continue to rise due to the introduction of (more) safety measures or if donor blood becomes scarce.

Autologous blood donation

Although preoperative autologous blood donation is employed in elective surgery, this is declining because of the increasingly safe allogeneic blood supply. However, it continues to be used because of the public's perception of allogeneic blood risks and increasing blood shortages. Patients may donate a unit of blood (450 ± 45 ml) as often as twice weekly, up to 72 hours before surgery. Preoperative autologous blood is most beneficial in procedures that cause significant blood loss. It has been determined that preoperative autologous blood donation is poorly cost-effective; the use of this procedure must be based on evidence that it is safe and of value for the patient.

Intraoperative blood salvage in vascular surgery – worth the effort?

Intraoperative autologous transfusions have been used for many years to avoid transmission of infections, especially in vascular surgery, where blood usage is considerable. Several autotransfusion devices exist, but these devices are often associated with negative outcomes such as cost, contamination, and removal of essential blood components (e.g. platelets). Preoperative autologous blood donation is another blood preservation method to avoid possible transfusion-related infections. Several vascular surgery groups have compared the use of these techniques, and their results are discussed in this review. Cell saver techniques often do not prevent the need for transfusions, nor are they very cost-effective; therefore, their use should be considered on a case-by-case basis.

Preoperative recombinant human erythropoietin in anemic surgical patients

Preoperative anemia in a surgical patient predisposes to poor outcomes and allogeneic blood transfusions. As an alternative to transfusions, pharmacologic management of preoperative anemia with recombinant human erythropoietin (rHuEPO) has been well studied in many different types of surgery. rHuEPO, when used alone or in combination with preoperative autologous blood donation before elective surgery, stimulates erythropoiesis and helps to avoid or reduce the need for allogeneic blood transfusions. The clinical evidence on preoperative use of rHuEPO in orthopedic, cardiac, and cancer surgery, as well as in bloodless surgery, is reviewed.

Outcome Quality in Terms of Product Safety in Preoperative Autologous Blood Donation

Objective: The most common form of autologous blood transfusion is where blood is donated in anticipation of elective surgery. The aim of this study is to critically evaluate the product safety of autologous blood units. Material and Methods: The results are based on an analysis of the documented data and records of 22,630 cases with 21,553 patients and 49,650 autologous blood donations, blood processing and testing protocols, and reported transfusion reactions following autologous transfusions. Results: Autologous blood components are prepared individually, and an established system of quality assurance with controls of processes and products is particularly important to meet quality standards. The red cell content of autologous units cannot be standardized as in allogeneic components. Due to the differences between the laboratory screening programs for patients and donors, the risk of transmission of virus infections is different from that of allogeneic blood components. The quality of stored autologous red cells is comparable to that of allogeneic products. Conclusion: Results of systematic sterility monitoring lead to the conclusion that under the conditions practiced the risk of transfusion-associated sepsis is not higher than that associated with allogeneic products. Soluble biological response modifiers which accumulate during storage are assumed to be the cause of transfusion reactions that occur in 1 of 4,500 autologous transfusions. Incorrect allocation and handling errors continue to be a serious problem in autologous transfusions.

Autologous blood donation before elective off-pump coronary artery bypass grafting.

Preoperative autologous blood donation reduces exposure to homologous blood transfusions in cardiac surgery. The purpose of this study was to ascertain the volume of predonated autologous blood needed to avoid homologous blood transfusion in scheduled off-pump coronary artery bypass grafting (off-pump CABG). Fifty-six patients underwent scheduled off-pump CABG between January 1999 and December 2000. These patients all donated either 400 ml (group 1, n = 33) or 800 ml (group 2, n = 23) of autologous blood before operation. These patients donated at a rate of 400 ml per week. All patients were given an equal volume of saline solution at the time of autologous donation. There were no significant differences in the mean age, mean body weight, mean preoperative hematocrit values, mean graft number, or mean volume of intraoperative blood loss between groups 1 and 2. There was a significant difference in the mean postoperative day-7 hematocrit value (33.6% +/- 1.3% vs 39.3% +/- 1.3%, P << 0.05). The rates of avoiding homologous blood transfusion were 63.6% in group 1 and 100% in group 2 ( P << 0.05). Autologous blood transfusion is effective for reducing the homologous blood requirement. We believe that an 800-ml predonation is sufficient to avoid homologous blood transfusion in scheduled off-pump CABG; furthermore, patients with cardiovascular disease, including severe coronary artery disease, should be administered saline along with the blood donation.

Validation of a transfusion prediction model in head and neck cancer surgery.

Allogeneic transfusions are necessary in 14% to 80% of patients undergoing major head and neck cancer surgery. Defining the risk for receiving allogeneic transfusion allows for informed decisions regarding appropriateness of type and crossmatch, preoperative autologous blood donation, and priming with erythropoietin. Based on logistic regression analysis of transfusion risk factors in 438 patients, we developed a transfusion prediction risk assessment (TPRA) model to determine the need for transfusion based on the preoperative hemoglobin value, tumor stage, and need for flap reconstruction. To examine the utility of this TPRA model in clinical practice by assessing the performance of the model in a validation set of patients. Between 1996 and 1999, 125 consecutive patients entered into a clinical care pathway underwent major surgical procedures. The ability of the model to discriminate between patients requiring and those not requiring transfusion was assessed using the area under the receiver operating characteristic curve. The agreement between actual and predicted risks was tested using the chi2 goodness-of-fit statistic. The overall transfusion rate was 25%. A 1-U transfusion was required in 7 patients, and multiple units were necessary for 24 patients. Flap reconstruction was required in 63 patients, 44 patients had preoperative anemia by normative values, and 64 had T3/T4 tumors. Among the low-risk non-T3/T4 patients whose preoperative hemoglobin level was normal, the actual/predicted transfusion rate without flap reconstruction was 10%/2%. For high-risk patients with T3/T4 tumors, anemia, and flap reconstruction, the actual/predicted transfusion rate was 43%/65%. The area under the receiver operating characteristic curve was 0.72. The goodness-of-fit statistic indicated lack of fit of the original model, but a recalibrated model fit the observed data well. In general, the TPRA model identifies patients at low or high risk for allogeneic transfusion and provides guidelines for preoperative counseling regarding the risk of receiving a transfusion. Knowledge of a patient's risk can help direct cost-effective utilization of type and crossmatch, preoperative autologous blood donation, and preoperative priming with erythropoietin.

Proportion of autologous blood used in maxillofacial surgery in California: a 7-year retrospective analysis of 900 patients

Specific Aim: To assess whether the current policy of preoperative autologous blood donation is clinically appropriate.

Post-operative course of coronary artery bypass surgery patients who pre-donate autologous blood

Background: Pre-operative autologous blood donation is used to reduce the need of allogeneic blood in patients undergoing coronary bypass surgery operations, but it is not clear what impact the blood donation has on the post-operative course of these patients. Methods: We studied the post-operative course of 210 patients who pre-donated autologous blood before their coronary bypass operation (donors) and of 67 patients who were eligible to pre-donate but did not (controls). Results: The clinical variables and the technical operative parameters of the patients in the two groups were similar. There was no significant difference between the duration of assisted ventilation post-operatively (756±197 vs. 802±395 min; P=0.54) or length of stay in the intensive care unit (1.8±1.1 vs. 1.7±0.9 days; P=0.52) of the two groups. The number of autologous units of packed red cells and of fresh frozen plasma (FFP) received by the donors was significantly higher than the number of units of allogeneic packed red cells (1.5±0.9 vs. 0.3±0.9; P=0.001) and the units of homologous FFP received by the controls (2.3±0.8 vs. 0.6±1; P=0.001). Conclusions: We found no evidence that autologous blood donation exerted a negative influence on the post-operative course of patients undergoing coronary bypass surgery. Patients who pre-donated blood received no allogeneic blood products, but the number of autologous blood products received by donors was higher than the number of blood products received by patients who did not pre-donate.