Categories
Advantages and Disadvantages
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Indications and contraindications
Preoperative Blood col ection
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Acute Normovolemic HemodilutionIntra and Post-operative Blood col ection
Our Experience
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Autologous Blood DonationDefinition
Blood collected from patient for re-transfusion
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at later time into the same individual is calledautologous blood transfusion.
Why autologous donation?
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Safest blood.
Shortage of blood.
As a part of blood sparing strategy.
Individuals with rare blood groups/ irregular
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antibodies.
Patient's apprehensions.
Jehova's witnesses( JW).
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Currently, there are more than 7.5 mil ion JW global y and around
37,913 in India, and their number is rapidly increasing.[3,4]
Advantages
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Prevents transfusion-transmitted disease.
Prevents red cell allo-immunization.
Supplements the blood supply.
Prevents some adverse transfusion reactions.
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Provides compatible blood for patients withallo-antibodies.
Provides reassurance to patients concerned
about blood risks.
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CONCERNSDoes NOT eliminate risk of bacterial
contamination.
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Does NOT eliminate risk of ABO incompatibility
error.
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May results in wastage of blood.May subjects patients to peri-operative anemia
and increased likelihood of transfusion.
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Is more costly in case of intra-operative and postoperative col ection.
Types of Autologous Transfusion
Preoperative col ection
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Blood is collected and stored prior to anticipated
need.
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Peri-operative col ection and administrationAcute normovolemic hemodilution: Blood is
collected at the start of surgery and then infused
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during or after the procedure
Intraoperative col ection: Shed blood is recovered
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from the surgical field or circulatory device theninfused.
Postoperative col ection: Blood is collected from
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the drainage devices and reinfused to the patient.
Pre-operative Autologous
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DonationBlood is drawn and stored before anticipated
need.
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Two or more units blood are drawn and stored
prior to anticipated need.
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Should be stable patients who are scheduledfor a surgical procedure in which blood
transfusion is probable.
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Indications of Pre-operativeAutologous donation
Major Orthopedic surgeries: Most common
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(Hip & Knee replacement surgeries)
Cardiovascular surgeries:
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(Valve surgery & ? CP bypass surgery)Obstetric surgeries (hysterectomy, ovarian tumour
etc.)
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Radical prostectomy, mastectomyGatro-surgery (Gall bladder, Gastectomy, OLT,
splenectomy
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Contraindications / Exclusion
criteria
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? Hb < 11 gm%.? IHD, Scheduled surgery to correct aortic stenosis
? Uncontrolled hypertension ( BP > 180/100).
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? Myocardial infarction or cerebrovascular accident within
6 months of donation.
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? Restrictive/obstructive lung disease.? Impaired renal function.
? Coagulation disorders, Hypovolemia.
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? Active bacterial infection.
? Uncontrolled Seizure Disorder
Autologous blood should not be col ected for procedures
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that seldom (less than 10% of cases) require transfusion,
such as cholecystectomy, herniorrhaphy, vaginal
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hysterectomy, and uncomplicated obstetric delivery.Pre-requisites for Pre-operative
Autologous Blood Donation.
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Request from attending Physician
Written request from the Clinician is required and kept by
the col ecting facility.
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Request includes :-
Patient's name,
No. of units and kind of component requested i.e. whole
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blood, packed cel s etc.,Anticipated surgical date & surgical procedure,
Clinician's comment on patient's ailment and clearance
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that blood donation would not affect his physicalcondition & physician's signature.
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Information to the DonorGeneral information about blood donation and
regarding any special fee charged for the procedure
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etc.
Donor Selection Criteria
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Age ? No age limits exist.Weight ? Donors weighing 60 kg or more can donate
450 ml of blood and donors weighing less than 60 kg
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may donate proportionately smaller volume of bloodbut no more than 8-9 ml/kg body weight.
Note: In pediatric patient of 8 years of age the weight should
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be 27 kg and no more than 10% of the patients blood volume
should be drawn at each phlebotomy.
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Hemoglobin and hematocrit ? Hemoglobin shouldnot be less than 11.0 gm/dl and hematocrit not
less than 33%.
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Blood Tests:ABO & Rh testing
Test for Transfusion Transmitted Disease
Frequency of donation:
A sufficient number of units should be drawn to
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avoid exposure to al ogenic blood
Difference between two col ections, >72 hours
The last col ection should be >72 hours before
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surgery
Iron Therapy
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Oral iron may be prescribed to accelerate therestoration of hemoglobin to predonation levels.
Erythropoietins along with iron can also be prescribed
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to these patients but it is expensive.
Labeling of Blood Unit
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Units should be clearly labeled with:-
a) Donor's name.
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b) Identifying numbers, i.e. donor number.c) Collection & Expiration date.
d) Patient's signature.
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The units should be clearly marked "FOR AUTOLOGOUS USE ONLY". It
should also be labeled as Autologous Donor Blood.
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A biohazard label must be applied if the donor tests positive for HCV,
HBsAg, Hepatitis B core antibodies, HIV I & II & VDRL.
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In no circumstance the blood should be used for another patient (CrossOver).
Autologous Sticker
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Leap frog techniqueWEEK OF
UNIT
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RE INFUSION
COLLECTION
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OF UNIT1st
A
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None
2nd
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BNone
3rd
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C
None
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4thD+E
A
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5th
F+G
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BAcute Normovolemic
Hemodilution
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Definition:
It is the removal whole blood from a patient
just before the surgery and transfused
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immediately after the surgery. It is also known
as `preoperative hemodilution'.
Acute normovolemic hemodilution
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Patients who are not anemic can have about
one quarter of their blood volume withdrawn
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(not exceeding 20ml/kg)ANH is simpler, less expensive and available to
patients undergoing surgery at short notice.
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Indication
Patients who can tolerate rapid withdrawal of
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one or several units of blood (not exceeding
20ml/kg) before the period of blood loss.
Benefits
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Lowering blood viscosity improves tissue perfusion
and oxygenation.
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Reduce red cell loss at intraoperative hemorrhage.Provide fresh whole blood with coagulation factors
and functional platelets.
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Reduce the need for allogenic blood, there byavoiding Transfusion Transmitted Diseases & immune
mediated reactions.
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Patient eligibility
Attending anesthetist should determine the
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patient's suitability to undergo ANH.
Patient should have near normal O2 transport
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capacity.Free from cardiovascular, respiratory and
cerebrovascular diseases.
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Hb level >11g/dl
Should obtain valid consent
Volume withdrawn
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Formula to estimate the possible volume to bewithdrawn
Volume withdrawn=EBV x(Hct0-Hct1)/Hctav
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EBV-estimated blood volumeHct0-Hct before hemodilution
Hct1-desired Hct after hemodilution
Hctav- average of Hct before & after
hemodilution
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Volume replacement
Crystalloid,3ml for every 1ml and colloid,1ml
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for every 1ml should be given simultaneouslyas blood is withdrawn.
Monitoring ?continuous monitoring of
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hemodynamic variables
Labeling & Storage
With proper identification and message "For
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autologous use only".
Keep the blood in the same operating room as
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the patient to preserve the platelet function.If it is anticipated that more than 6hrs will
elapse before transfusion store at 2-6 degree C.
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Documentation
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Written protocol describing policies &procedure, approved by transfusion
committee.
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Anaesthetist must note on the anaesthesia
record ,the amount of blood withdrawn, the
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amount and type of fluid infused ,amount ofblood returned, along with patient's vital signs
Procedure
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Blood collected in ordinary blood bags with 2phlebotomies & minimum of 2 units are
collected
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The blood is then stored at room temp. and re-
infused in operating room after major blood
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loss.Carried out usually by anesthetists in
consultation with surgeons
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Blood units are re-infused in reverse order of
collection.
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Theme behind: Patient losses diluted blood duringsurgery and replaced later with autologous blood.
Withdrawal of whole blood and replacement of with
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crystalloid/ colloid solution decreases arterial O2
content but compensatory hemo-dynamic
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mechanisms and existence of surplus O2 deliverycapacity mechanism make ANH safe
Drop in red cell number lowers blood viscosity,
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decreasing peripheral resistance and increasingcardiac output.
Administrative costs are minimized and there is no
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inventory or testing cost
This also eliminates the possibility of administrative
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or clerical errorUsually employed for procedures with an anticipated
blood loss is one liter or more than 20% of blood
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volume.
Decision about ANH should be based on
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surgical procedure, preoperative blood volumeand hematocrit, target hemodilution
hematocrit, physiologic variables
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Careful monitoring of patient's circulating
volume and perfusion status
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Blood must be collected in an aseptic mannerUnits must be properly labeled and stored
Intra-operative Blood Col ection
Definition:
Whenever there is blood loss and collected
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inside the body cavity, it is transfused back to
the patient.
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Oxygen transport properties of recovered redcell are equivalent to stored allogenic red cells
Contraindicated when pro-coagulant materials
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are applied.
Micro aggregate filter(40 micron) are used as
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recovered blood contain tissue debris, bloodclots, bone fragments
Hemolysis of red cells can occur during suctioning
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from surface (vacuum not more than 150 torr isrecommended)
Indications: Blood col ected in thoracic or abdominal
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cavity due to organ rupture or surgical procedures.
Contraindications: Malignant neoplasm, infection and
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contaminants in operative field.Blood is defibrinated but it does not coagulate
Two types of procedures are available
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One is simpler canisters type in which salvagedblood is anticoagulated and aspired, using
vacuum supply into a liner bag (capacity 1900ml)
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contained in reusable canister and integal filter
Other is more automated, based on centrifuge
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assisted, semi-continuous flow technologyProcess result in 225 ml unit of saline suspended
red cel s with Hct 50-60%
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Postoperative Blood Col ectionRecovery of blood from surgical drain followed
by re-infusion with or without processing.
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Shed blood is collected into sterile canister andre-infused through a micro-aggregate filter.
Recovered blood is diluted, partially
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hemolysed and de-fibrinated and may contain
high concentrate of cytokines
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Upper limit on the volume(1400 ml) of unprocessedblood can re-infused
Transfusion should be within 6 hours of initiating
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collection.
Infusion of potentially harmful material in recovered
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blood, free Hb, red cell stroma, marrow, fat, toxicirrigant, tissue debris, fibrin degradation activated
coagulation factors and complement.
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Cel SaverContraindications
? Malignancy
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? Perforated viscera resulting in contaminationof blood with fecal matter, urine, bile etc.
? When the rate of blood loss is less than 50ml
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per hour
Pharmacological alternatives
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Recombinant growth factors:- Erythropoietin.
- GM -CSF, G-CSF.
Red Cell substitutes.
Desmopressin.
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Vit K.Fibrinolytic inhibitors.
Summary
Each type of autologous transfusion has
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potential risks and benefits.
However, when feasible, the patient
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should have the option to use his or herown blood.
SOPs at each step.
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Separate inventory to avoid mix-ups.Summary cont.
Separate tags/ green labels to ensure that
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the right unit goes to right patient.
X-match & Issue.
Discarding unused unit and not used as
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allogenic because of different criteria and
chances of clerical error.
References
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1. Technical Manual, AABB. 18th edition.
2. R.K Saran. Transfusion Medicine Technical Manual. 2nd
Edition 2003
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3. Chua R, Tham KF. Wil "no blood" kil Jehovah
Witnesses? Singapore Med J. 2006;47:994 1001.
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4. Jehovah's Witness Statistics. 2013. Available from:http://www.jwfacts.com/images/2013-publisher-
report.pdf.
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Thank You