Autologous Blood Donation and transfusion

1. Autologous Blood Donation and transfusion Dr. N. Choudhury Prathama Blood Centre, Ahmedabad www.prathama.org Only Indian blood center accredited as per ISO:15189

3. Contents • Introduction • Categories • Advantages and Disadvantages • Indications and contraindications • Preoperative Blood collection • Acute Normovolemic Hemodilution • Intra and Post-operative Blood collection • Initiating a new program

4. Definition • Blood collected from patient for retransfusion at later time into the same individual is called autologous blood transfusion.

5. Types of Autologous Transfusion • Pre operative donation, • Acute normo-volumic hemodilution, • Intra-operative salvage, • Post operative salvage • (Leap frog technique)

6. Advantages 1 Prevent transfusion TTDs 2 Prevent red cell allo-immunization 3 Supplements the blood supply in BTS 4 Provide soln. to patients with allo-antibodies 5 Prevent adverse transfusion reactions 6 Provide soln. to religious belief (Jehovah's witness)

7. 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 to perioperative anemia & increase likelihood of transfusion

8. Prathama’s Reception Area

9. Preop. Autologous donation (1) Inclusion: Stable patients scheduled for surgical procedure in which blood transfusion is likely. Donor Pt. should qualify criteria for blood donation • Necessity: a. Close liaison between clinician & blood bank (BB) b. Donor suitability by BB physician c. Oral Fe one week before & many weeks after d. Hb% should drop below 10 gm%.

10. 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, Gastectomy, OLT, splenectomy)

11. Pre-op Autologous Donation (3) 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 CV accidents 6 Significant cardiac or pulmonary disease 7 Cyanotic heart disease 8 Uncontrolled hypertension 9 Malignant diseases

12. Pre-op Autologous Donation (4)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 • 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

13. Pre-op Autologous Donation (5)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

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

15. Autologous Sticker

16. Acute Normovolemic Hemodilution (1) 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’.

17. Acute Normovolemic Hemodilution (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.

18. Acute Normovolemic Hemodilution (3)Procedure • 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.

19. Acute Normovolemic Hemodilution (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.

20. Acute Normovolemic Hemodilution (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

21. Intra-operative Blood Collection (1) Definition: Whenever there is blood loss and collected inside the body cavity, it is transfused back to the patient.

22. Intra-operative Blood Collection (2) • 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

23. Intra-operative Blood Collection (3) • 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

24. Intra-operative Blood Collection (4) 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 integal filter • Other is more automated, based on centrifuge assisted, semi-continuous flow technology • Process result in 225 ml unit of saline suspended red cells with Hct 50-60%

25. Component Room

26. 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

27. 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

28. 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 blood No cross-over (?) No to TTD positive blood Cross-match, to avoid last minute check

29. New Program (2) • 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