Autologus3+++

Autologous Autologous Blood Donation Blood Donation and transfusionand transfusion

Dr. J.A. OlaniyiDepatment of Haematology

UCH, Ibadan

Contents Introduction Categories Advantages and Disadvantages Indications and contraindications Preoperative Blood collection Acute Normovolemic Hemodilution Intra and Post-operative Blood

collection New Program

Definition

Blood collected from patient for re-transfusion at later time into the same individual is called autologous blood transfusion.– The Donor is the Recipient.– Infusion of patients own blood.

Synonyms

Autologous transfusion Autologous blood transfusion Autotransfusion Auto blood transfusion Auto hemofusion

History Neither a new concept nor a new technology Benefits and advantages had been known and has been in use for over 100years [ in

view of life saving effect of the procedure] First autologous transfusions were done at the time when allogeneic transfusion was

cumbersome, if not impossible. It was stimulated in the early years of blood banking by the involvement of patients in

donor recruitment and hence made autologous donation a convenient alternative. Limitations then include shelf life of 7-10 days and the need for post donation

recovery time. In the 1960s and 1970s however, its wide spread acess and use suffer a slow growing

process when public and Physicians interest diminished It acquired inordinate importance in the 1980s after blood transfusion is realized to

be the vehicle for the for HIV 1, HTLV-1, NANB-hepatitis & other viral and parasitic diseases

It has now become a routine measure of standard care It is now highly desirable and recommended

Types of Autologous Transfusion

Pre operative donation,

Acute normo-volumic hemodilution,

Intra-operative salvage,

Post operative salvage

(Leap frog technique)

Advantages1 Prevent transfusion TTDs2 Prevent red cell allo-immunization3 Supplements the blood supply in BTS4 Provide solution to patients with allo-

antibodies5 Prevent adverse transfusion reactions6 Provide solution to religious belief

(Jehovah's witness)

Disadvantages1. Same risk of bacterial contamination2.Same risk of ABO incompatibility error

{Clerical error}3.Costlier than allogenic blood 4.Wastage of blood, if not switched over. 5. There are Chances of unnecessary

transfusion 6. Subjects patient to peri-operative

anemia & increase likelihood of transfusion.

Preop. Autologous donation (1)

Donation that sets aside patients own blood in anticipation of surgery so that it can be re-infused, if needed, as an autologous transfusion during peri-opoerative period

Preop. Autologous donation (1)

Indicated in Stable patients scheduled for surgical procedure in which blood transfusion is likely.

Donor patient should meet the standard criteria for blood donation

Necessity:a. Close liaison between clinician & blood bank (BB)b. Donor suitability by Blood Bank physicianc. Oral Fe one week before & many weeks afterd. Hb% should not drop below 10 gm%.

Indications POAD

POAD is indicated in anticipation of any surgical procedure with a reasonable probability for transfusion and for which there is sufficient time to obtain 1 U or more with minimal risk and without creating a significant haemoglobin deficit.

Autologous donation should be considered only if the patient has an haemoglobin level >11g/dl.

Idealy donation interval should be one week but clearly never less than 72hrs and never within 72hrs of the anticipated use to allow time for volume restoration.

Pre-op. Autologous donation (2)

Indications: Major Orthopedic surgeries:

(Hip & Knee replacement surgeries) Cardiovascular surgeries: (Valve surgery & ? CP bypass surgery) Obstetric surgeries (hysterectomy, ovarian

tumour etc.) Radical prostectomy, mastectomy, Gatro-surgery (Gall bladder, Gastrectomy,

OLT, splenectomy)

Study Outcome

Orthopaedic 40% Plastic surgery 25% Cardiovascular surgery 6% General Surgery 5% O&G 3%

Pre-op Autologous Donation (3)

Contraindications:1 Evidence of infection and risk of bacteremia2 Scheduled surgery to correct aortic stenosis3 Unstable angina4 Active seizure disorder5 Myocardial infarction or CV accidents6 Significant cardiac or pulmonary disease7 Cyanotic heart disease8 Uncontrolled hypertension9 Malignant diseases

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 is placed on oral supplemental iron 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


Procedure


Procedure A sufficient number of units should be drawn

to avoid exposure to allogenic blood

Two units collection via an automated red cell aphaeresis system may also be an option

Difference between two collections, >72 hours

The last collection should be >72 hours before surgery.

Pre-op Autologous Donation (6) 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.

Liquid storage is feasible for 6 weeks. For longer duration, the red cell have to be frozen.

Special Autologous label may be used with numbering to ensure that oldest units are issued first.

Acute Normovolemic/isovolumic

Hemodilution[ANH] (1)Definition:It is the removal of whole blood from a Patient and its simultaneous replacement

with an appropriate volume of acellular fluid just before the surgery and the blood is returned as indicated by the intra-operative blood loss immediately after the surgery.

It is also known as ‘preoperative hemodilution’.

ANH -Procedure

The degree of haemodilution is defined by the final desired haematocrit

Limited Normovolumic Haemodilution:- The term used for reduction of Hct to approx 20-25%

Acute Extreme Haemodilution:- designates reduction of Hct to <20%. Reserved for relatively young and healthy.

ANH (2)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.

Blood units are re-infused in reverse order of collection.– 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.

ANH (3) Procedure

ANH (4) 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.

ANH (5) 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

Advantages of Haemodilution

Povides the only source of fresh whole blood for transfusion [no biochemical alterations associated with blood storage].

Platelet function is preserved bcos of storage at room temp.

Hypothermia associated with refrigerated blood is avoided.

Blood is free of TTIs, haemolytic, allergic and immunomodulatory complications of BTxn

Ever present clerical error is avoided

Advantages contd

Using the technique red cell loss is decreased. Eg

Hct40%1000mls loss40% RBC loss Hct 25%1000mls loss25% RBC loss Decrease in the use of allogeneic blood to the

tune of 20-90% Can be employed in urgent and emergency cases Simpler and less expensive to collect 2-4 U by

haemodilution than by POAD

May represent the only alternative with patients with potential bacteraemia from eg indwelling catheter or ostemyelitis

Not contraindicated in the presence of malignancy.

Intra-operative Blood Collection (1)

Definition:Whenever there is blood loss and collected inside the body cavity, it

is collected and transfused back to the patient.


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


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


Two types of procedures are available One is simpler canisters type in which

salvaged blood is anticoagulated and aspired, using vacuum supply into a liner bag (capacity 1900ml) contained in reusable canister and integral filter

Other is more automated, based on centrifuge assisted, semi-continuous flow technology. Process results in 225 ml unit of saline suspended red cells with Hct 50-60%

Postoperative Blood Collection (1)

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

Postoperative Blood Collection (2)

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

New Program (1) Defining Indications: Cardiothorasic,

Vascular, Orthopedic & Obstetric Special screening and Phlebotomy: No

age bar, Hb-11gm%, many variations as compared to homologous donations

Scheduling: 72 hours or once a week duration; documentations

Policies: Largely Whole bloodNo cross-over (?)No to TTD positive bloodCross-match, to avoid last minute check

New Program (2) SOPs at each step 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

Conditions Excluding Autologous Donors

Hypertension [Diastolic>100] Hypotension [Systolic<100] Active Asthma/pulmonary disease History of siezures Arrythmias/bradycardias [PR<60/min] Major surgery [<2 months] Tooth extraction [<72hrs] Known AIDS

Leapfrog Technique

Starts 3 wks before surgery and could provide at least 3U of blood, and assuming normal erythropoiesis, only 1g/dl haemoglobin deficit at the time of operation.

The advent of blood freezing, permitting longer storage of blood obviated the need for leap frog and allow development of more extensive programme

Autologus3+++

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