Autologous blood transfusion: The benefits to the patient undergoing abdominal aortic aneurysm repair

The clinical benefits of using intraoperative autologous blood transfusion during abdominal aortic aneurysm bypass surgery become increasingly apparent when use of autologous and homologous blood transfusions is compared. That homologous blood transfusions carry some risk is widely recognized. When autologous blood is used as a sole source of blood transfusion, the risk of transmission of infectious agents and potential immunologic side effects are avoided. A prospective randomized pilot study comparing autologous and homologous blood transfusion in patients undergoing elective infrarenal abdominal aortic aneurysm bypass surgery was undertaken. The purpose of this study was to determine whether autologous blood salvaged intraoperatively may serve as an alternative to homologous blood by comparing the rate of postoperative infection and duration of hospital stay for patients receiving autologous versus homologous blood transfusions. Fifty patients undergoing abdominal aortic aneurysm bypass surgery were prospectively randomly assigned to receive either a homologous or an autologous blood transfusion, with 27 receiving a homologous blood transfusion and 23 receiving an autologous blood transfusion. The data from this study show that the length of hospital stay of patients receiving an autologous blood transfusion intraoperatively was reduced by a mean of 3 days and the risk of postoperative complications, such as a systemic inflammatory response or sepsis, was reduced by more than 50%.     

Simplified enrollment for autologous transfusion: automatic referral of presurgical patients for assessment for autologous blood collections.

We implemented a pilot program at our institution for automatic referral of patients for presurgical assessment for preoperative and intraoperative collection of autologous blood. Although patients and clinicians support the use of autologous transfusion, often a request for collection of autologous blood is not initiated. During 11 months, 269 patients (82%) of three orthopedic surgeons entered the program, and 218 underwent operation and were dismissed from the hospital. A total of 940 units of autologous blood (675 preoperatively and 265 intraoperatively) was collected from these 218 patients, and 84% of the units were transfused. Throughout hospitalization, 86% of the patients received only autologous blood, whereas 14% received various proportions of homologous and autologous blood. In contrast, only 26% of a concomitant control group of 220 consecutive orthopedic surgical patients not participating in the automatic-referral program received only autologous blood. Thus, the automatic-referral program increased the percentage of elective orthopedic surgical patients who received only autologous blood from 26% to 86% (P less than 0.001). This study also showed that the same amount of blood was used for autologous transfusions as was routinely used for homologous transfusions in similar cases. The automatic-referral system was convenient for physicians and patients and offered the benefits of reduction of transfusion-associated risks and amelioration of patient anxieties.     

Intraoperative autologous transfusion: its role in orthotopic liver transplantation

In our orthotopic liver transplantation program, intraoperative autologous transfusion was used in 89 of the first 100 procedures. In these 89 cases, intraoperative autologous transfusion provided a mean of 6.2 erythrocyte units per case or 32% of the total intraoperative erythrocyte requirements. The maximal number of erythrocyte units administered to any patient was 36.6 units (and 51% of the erythrocyte requirements). The most rapid rate of reinfusion of intraoperatively salvaged blood (11.8 units/h) occurred during reperfusion. No coagulopathy, infectious sequelae, or other complications were attributable to intraoperative autologous transfusion. In patients with large volumes of blood loss, intraoperative autologous transfusion is cost-effective, apart from the consideration of its medical benefits. Use of intraoperative autologous transfusion in liver transplantation resulted in conservation of erythrocytes and reduction in exposure to homologous blood and blood components.     

Infection or suspected infection after hip replacement surgery with autologous or homologous blood transfusions

Homologous blood transfusions have been associated in both animals and humans with an increased risk of acute postoperative infectious complications. Eighty-four patients who underwent hip replacement surgery and were transfused with 2 or 3 units of blood were analyzed to determine whether those receiving homologous transfusions had different outcomes than those receiving autologous blood only. Only patients free of other risks for postoperative infection were studied. Those receiving homologous blood had a 32 percent (16/50) rate of proven or suspected infections, which was significantly higher than the 3 percent (1/34) rate in patients receiving autologous blood (p = 0.0029). Wound infections accounted for only a minority (6/17) of the proven or suspected infections, which suggests that nonsurgical factors contributed to these complications. The patients identified as being infected required significantly more antibiotic therapy (mean, 7.6 days) and lengthier hospital stays (mean, 15.5 days) than the patients who remained free of evidence of infection (means: 2.3 days of antibiotics and 12.3 days in the hospital) (p = 0.0001 for each variable). Other potential risk factors for infection, such as duration of surgical procedure, advanced patient age, amount of blood loss, type of anesthesia, surgeon performing the operation, use of a cemented versus porous-coat prosthesis, leukocytopenia, anemia, and underlying medical diagnosis, did not account for the differences in infection rates seen in those receiving homologous and autologous transfusions. These results confirm previous reports of an increased risk of postoperative infection in patients receiving homologous transfusions. Homologous transfusion may contribute to an increased risk of infection by immunologic modulation of the recipient.(ABSTRACT TRUNCATED AT 250 WORDS)     

A controlled trial of intra-operative autologous transfusion in cardiothoracic surgery measuring effect on transfusion requirements and clinical outcome

We carried out a prospective, controlled trial of intra-operative autologous transfusion (IOAT) in cardiac surgery using the Haemonetics Cellsaver 4, to determine the effects on transfusion requirements and early clinical outcome. Intra-operative autologous transfusion in unselected patients resulted in a reduction in the use of red cells in patients undergoing first-time operations (IOAT median 3 units, controls median 4 units, P = 0.0023), with no difference in the use of other blood products. Post-operative haemoglobin was higher in IOAT patients (IOAT 11.6 g/dl +/- 1.1 versus controls 11.2 g/dl +/- 0.98, P < 0.001). There is therefore the potential for a further reduction in homologous blood use in the IOAT group. There was no difference in early clinical outcome in the two groups; in particular the incidence of coagulopathies was not influenced by IOAT. The routine use of IOAT would add substantially to the cost of these operations. The decision to use it must therefore be based on an assessment of the value of the reduction in risk to the patient achieved by a small reduction in homologous donor exposures.     

Costs associated with blood transfusions in Sweden--the societal cost of autologous, allogeneic and perioperative RBC transfusion

Anaemia is characterised by an insufficient number of red blood cells (RBCs) and might occur for different reasons, e.g. surgical procedures are often with associated blood loss. Patients who suffer from anaemia have the option of treatment with blood transfusion or medical treatment. In this study, the societal cost, for the case of Sweden, of RBC transfusion using three different techniques, i.e. allogeneic, autologous and intraoperative transfusion, was estimated. The analysis was based on information from interviews with hospital staff at large Swedish hospitals and from published data. The average cost for a 2 units transfusion was found to be Swedish kronor (SEK) 6330 (702 Euro) for filtered allogeneic RBCs and SEK 5394 (598 Euro) for autologous RBCs for surgery patients. Transfusion reactions accounted for almost 35 per cent of the costs of allogeneic RBC transfusions. The administration cost was found to be much higher for autologous transfusions compared with allogeneic transfusions. The cost of intraoperative erythrocyte salvage was calculated to be SEK 2567 (285 Euro) per transfusion (>4 units).     

Crossover use of donated blood for autologous transfusion: report of the Council on Scientific Affairs, American Medical Association

BACKGROUND: Controversy exists concerning whether the costs and potential risks outweigh the potential benefits of "crossover" use in the general blood supply of unutilized blood that was donated for autologous transfusion. STUDY DESIGN AND METHODS: Published articles and reports were identified through systematic search of MEDLINE and review of references cited in previously identified articles, textbooks, and reports. Consultation was made with experts in blood donation and transfusion. Additional peer review was received from the American Medical Association (AMA) Council on Scientific Affairs RESULTS: Concern over infectious disease transmission has led to increased interest in and support for autologous transfusion for individuals having planned surgeries. Different requirements exist for collection, labeling, and screening of blood to be used for autologous versus allogeneic transfusions; therefore, procedures for diverting autologous blood donations to the general blood supply involve considerable expense. Several cost-effectiveness studies of autologous blood donation and transfusion conclude that currently this "crossover" appears to be an expensive procedure yielding little increased benefit from a societal perspective. CONCLUSIONS: The recommendations in this report were adopted as AMA Policy at the AMA Annual Meeting in June 1997. The AMA does not encourage blood collection programs to "cross over" units donated for autologous use to the allogeneic blood supply. Practice guidelines are needed, and should be utilized to ensure parsimony in the use of autologous blood donations and transfusions.     

Autologous blood donation and subsequent blood use in patients undergoing total knee arthroplasty

Autologous blood donation is designed to avoid complications from allogeneic blood, leaving units of blood in the general blood supply. It is unclear how efficient these programmes are in accomplishing these goals. It is unclear if autologous donation provokes increased need for any transfusion following surgery and whether it can be avoided in low-risk surgeries. Of 430 patients undergoing unilateral primary knee replacement arthroplasty over 12 months in our hospital, 309 had autologous donations and 121 did not. Of the 121 patients who did not donate, 36% completed surgery without transfusion, whereas only 17% of those who had autologous donations did so (P < 0.05). Age less than 65 years, higher baseline and postoperative haemoglobin levels were associated with lower transfusion rates. Patients who had autologous donations were approximately four times more likely to be transfused. As the number of autologous units donated increased, transfusions following surgery increased. Autologous donation did reduce allogeneic blood transfusions. Therefore, autologous blood donation for unilateral total knee arthroplasty is associated with overall increased transfusion rates, but with reduced need for allogeneic blood, independent of other clinical factors associated with transfusion. Therefore, there is need for reconsideration of these programmes relative to specific surgeries.     

Efficacy of preoperative donation of blood for autologous use in radical prostatectomy

To determine the amount of blood lost, the number of transfusions, and the effectiveness of preoperative autologous blood donation in radical prostatectomy, 163 patients' records from 1987 to 1991 were reviewed at four university hospitals and three community hospitals. Calculated red cell volume lost was 1003 +/− 535 mL (mean +/− SD), which corresponds to 44 +/− 18 percent (mean +/− SD) of total red cell volume. Preoperative donation of blood for autologous use reduced the rate of transfusion of allogeneic blood from 66 to 20 percent (p < 0.001). Of the patients who donated 1 to 2 units, 32 percent received allogeneic blood; 14 percent of those who donated 3 units received allogeneic blood. Donation of 4 units reduced the allogeneic transfusion rate to 11 percent. However, as the number of units donated increased (1-3 units), the units not transfused also increased (0-21%). Ninety-one (56%) of 163 patients donated fewer than 3 units. Autologous blood donation is effective in minimizing the transfusion of allogeneic blood to radical prostatectomy patients, but many patients do not donate enough blood (< 3 units). The donation of 3 units of blood for autologous use is recommended for patients who undergo radical prostatectomy.     

Intraoperative autologous transfusion during major aortic reconstructive procedures

To evaluate the benefits and disadvantages of autologous intraoperative transfusion during major aortic reconstructive procedures, we retrospectively studied 50 patients who had major aortic revascularization procedures without the use of autologous transfusion devices (group 1) and prospectively evaluated a second 50-patient cohort having similar procedures, but with the use of the autologous transfusion device for salvaging and reinfusing lost blood. Both groups were assessed for preoperative risk factors and postoperative complications. We found a somewhat lower morbidity in the autotransfusion group and more complete replacement of blood loss. Autologous transfusion accounted for approximately 75% of all transfused blood in group 2, tremendously reducing blood bank requirements. In addition to reduction of immediate postoperative morbidity, further risks associated with homologous transfusion such as hemolysis, posttransfusion hepatitis, transfusion-related acute lung injury, anaphylaxis, and transfusion-transmitted acquired immunodeficiency syndrome (AIDS) were markedly reduced or eliminated.     

Effect of blood conservation efforts in cardiac operations at the Mayo Clinic

In a retrospective study of 388 patients who had undergone cardiac operations at our institution during two time periods-before (1982) and after (1984) introduction of autologous transfusion-we analyzed the effect of blood conservation efforts and autologous transfusion on blood usage, postoperative complications, and duration of hospitalization. Cell salvage techniques resulted in a significant reduction (P less than 0.0001) in use of not only homologous blood (from a mean of 9.6 units per patient in 1982 to 3.2 units in 1984) but also fresh-frozen plasma and platelet concentrates. We found no significant difference in morbidity or mortality for the two study periods. Although the mean duration of hospitalization decreased from 11.7 days in 1982 to 9.6 days in 1984, this change was probably related to factors other than the introduction of blood conservation efforts. Thus, techniques used to decrease the amount of blood replacement needed for cardiac surgical procedures are beneficial.     

Blood use in elective surgery: the Austrian benchmark study

BACKGROUND: Benchmarking transfusion activity may help to eliminate inappropriate use of blood products. The goal of this study was to measure and to compare the current transfusion practice and to identify predictors of transfusion in public hospitals to develop strategies to optimize transfusion practices. STUDY DESIGN AND METHODS: This was a prospective observational study in 18 randomly selected public hospitals from April 2004 to February 2005. Primary outcome measures were the amount of intra- and postoperative blood components transfused and intercenter variability of transfusion rate. Secondary outcome measures were prevalence of preoperative anemia, calculated perioperative blood loss, and lowest measured perioperative hemoglobin (Hb) level. RESULTS: Adult patients undergoing primary unilateral total hip replacement (THR, n = 1401), primary unilateral knee replacement (TKR, n = 1296), hemicolectomy (HECOC, n = 148), and coronary artery bypass graft (CABG) surgery (n = 777) were enrolled. Due to the small number, data of HECOC patients were not fully analyzed. In the remaining procedures, there was a large intercenter variability in the percentage of patients who received transfusions: THR 16 to 85 percent, TKR 12 to 87 percent, and CABG 37 to 63 percent. In the patients who received transfusions, the number of red blood cells (RBC) units transfused varied significantly. There was also a considerable intercenter variability in RBC loss. The prevalence of preoperative anemia was 19 percent and identical in both sexes. The incidence of preoperative anemia was three times higher in patients who received transfusions compared to those who did not. CONCLUSION: This study demonstrates a high intercenter variability in RBC transfusions and RBC loss in standard surgical procedures. Whereas the variability in blood loss remains largely unexplained, the main predictors for allogeneic RBC transfusions are preoperative and nadir Hb and surgical RBC loss.     

Intraoperative autologous transfusion

Intraoperative autologous transfusion is a technique that was first used almost 2 centuries ago but that has realized its potential only in the past 5 years. A growing national awareness of transfusion-related morbidity, of the need for alternative blood sources, and of improved methods for red blood cell recovery has led to an increased frequency of use of autologous transfusion. Most hospital programs use semicontinuous flow centrifugation or canister technology for the intraoperative salvage and reinfusion of shed blood. This technique is particularly valuable for cardiovascular surgical procedures but has been useful in many other types of surgical procedures as well. Deleterious effects formerly attributed to this technique have been eliminated by methodologic improvements. Concerns about use of autologous transfusion in patients who have an infection or a malignant lesion persist. Most hematologic aberrations are related to massive transfusions and should not be considered a contraindication to the general use of autologous blood.     

A randomized trial of perioperative hemodilution versus transfusion of preoperatively deposited autologous blood in elective surgery

Hemodilution, one of several methods proposed to decrease homologous blood transfusion in elective surgery, has not been studied in a prospective controlled trial to determine if it is successful. A prospective, randomized controlled study was conducted to determine if hemodilution can serve as an alternative to preoperative autologous blood donation. Fifty patients were randomized to preoperatively deposit 3 units of autologous blood or to undergo hemodilution immediately before elective radical retropubic prostatectomy. All patients were treated under a standard protocol, including surgery performed by a single surgeon. The preoperative deposit groups received a mean of 2.44 +/− 1.0 units of blood; 2 of 25 patients required homologous blood transfusion for blood loss of 2600 mL and 1700 mL. The hemodilution group received a mean of 2.88 +/− 0.4 units of autologous blood: no hemodilution patient received homologous blood. At discharge, the mean hematocrit for the preoperative deposit group was 35.5 +/− 4.9 (0.35 +/− 0.05), and that for the hemodilution group was 31.8 +/− 4.7 (0.32 +/− 0.05) (p less than 0.001). There were no differences in perioperative morbidity in the treatment groups. The best predictor of discharge hematocrit was the initial hematocrit of the patient. It can be concluded that hemodilution can safely replace or at least augment preoperative autologous donations as a means of decreasing homologous blood transfusion in study patients. These results can be applied to any elective surgery procedure in which a 1000-mL blood loss is anticipated. Other advantages of hemodilution, including convenience, lower cost, and better preservation of all components of autologous blood, suggest that this practice deserves wider application.     

Transfusion of red cells after autologous bone marrow harvest in patients with acute leukemia and malignant lymphoma

Bone marrow was harvested for the purpose of autologous bone marrow transplantation (ABMT) in 21 patients previously treated with chemotherapy and in complete remission from acute leukemia or non-Hodgkin's lymphoma. The volume required to obtain 2 x 10(8) nucleated cells per kg was less than 15 mL per kg in 13 patients and more than 15 mL per kg in 8 patients. The blood admixture was proportional to the aspirated volume (p less than 0.0001). The number of granulocyte-macrophage colony-forming units (CFU-GM) harvested in the groups was 8.4 +/- 2.2 and 3.4 +/- 1.4 x 10(4) per kg, respectively (p less than 0.0001). Autologous red cells were transfused into 16 of 21 patients, who did not require further homologous transfusions. The mean drop in hemoglobin from the preoperative level was 1.0 +/- 0.2 g per dL. No adverse effects were noted. It is concluded that large single-volume bone marrow harvests are possible and may reduce the need for a second harvest, and that, through the transfusion of autologous red cells obtained during marrow harvest, homologous blood transfusion can be avoided in most patients.     

Identifying elective orthopedic surgical patients transfused with amounts of blood in excess of need: the transfusion trigger revisited

The discharge hematocrit has been analyzed as a clinical indicator of the transfusion trigger by which to identify patients undergoing elective orthopedic surgery who were transfused with blood in excess of need. The volume of red cells lost by each patient during surgical hospitalization was compared to the volume of red cells transfused. Three clinical indicator levels were considered. Red cell losses of 10, 20, and 30 percent of each patient's baseline red cell volume at admission were considered to be appropriate before subsequent blood transfusion replacement, representing generous, intermediate, or strict clinical indicator levels, respectively. With Level I as a generous clinical indicator, 110 (25%) of 525 patients were transfused in excess of blood needs; by Level II (intermediate) and Level III (strict) criteria, 221 (42%) and 314 (60%) of 525 patients, respectively, were transfused in excess of blood needs. Significant differences were found for transfused patients analyzed by gender (26% of women vs. 13% of men; Level I, p less than 0.001) and preoperative autologous blood donation (25% of autologous blood donors vs. 11% of those who did not donate autologous blood; Level I, p less than 0.001). It can be concluded that the discharge hematocrit and amount of blood lost during hospitalization can be used as clinical indicators with which to identify patients receiving transfusions in excess of needs in the elective surgical setting. With this method, it was found that the transfusion trigger is different for women and for men as well as for autologous blood donors and those who did not donate autologous blood undergoing elective orthopedic surgery [corrected].     

Augmented autologous transfusions in major reconstructive spine surgery

Intraoperative autologous transfusion during major reconstructive spine surgery decreased allogeneic red blood cell transfusions, but patients were exposed to significant numbers of allogeneic blood products. This study reports a prospective study of 160 randomized patients undergoing major reconstructive spine surgery. Without delaying start of surgery, 80 patients underwent hemapheresis with coincidental normovolemic hemodilution in the operating room to sequester autologous blood components. A therapeutic dose plateletpheresis product and an average of 2 U each of freshly collected autologous red cells and fresh plasma were prepared prior to surgical incision. The same supplies and equipment were used subsequently to carry out intraoperative autologous transfusion (IAT). Autologous plasma and platelets were transfused to Sequestration patients, contributing to a significant decrease of total allogeneic donor exposures. One or more autologous red blood cell unit equivalents were cost effectively salvaged and retransfused to 78% of the Sequestration patients. Altogether, autologous red cells comprised 87% of the total red cells transfused. During the same time period, 80 age-, sex-, and weight-matched controls, who received IAT only, were accrued for comparison with Sequestration patients. Of all red cells transfused to control patients, autologous units comprised 47%. Both patient groups received the same total perioperative red blood cell support. The per patient cost for IAT, with or without sequestration, was competitive with supplying one unit of cross-matched allogeneic red cells. IAT only patients had greater allogeneic blood donor exposures than Sequestration patients, in whom the numbers of allogeneic red cells, plasma and platelet transfusions were decreased. Compared with IAT alone, the hospital post-operative stay of Sequestration patients was 23% less than IAT only patients. J. Clin. Apheresis 13:62–68, 1998. © 1998 Wiley-Liss, Inc.     

预存自体输血在脊柱侧弯矫正术的应用

目的：探讨预存自体输血在脊柱侧弯矫正术中的应用价值。方法：18例行脊柱侧弯后路矫正术病人分为两组。均在全麻后行手术，A组术中输库存血，作为对照组。B组术中使用预存自体输血，作为研究组。结果：两组脊柱侧弯后路矫正术病人术中皆输入库存血，但输入的库存血量相差大，术中预存自体输血及输库存血皆未出现输血并发症。结论：在脊柱侧弯后路矫正术中应用预存自体血液回输措施可有效减少输入库存血，降低住院费用，可安全应用于临床。     

Effects of the Sangvia blood collection system on patients undergoing elective hip surgery

We have conducted a randomized controlled study where 164 patients were randomized to receive autologous salvaged blood collected by Sangvia? Blood Salvage System or allogeneic red cell concentrates if transfusion was indicated by clinical judgement. The study was powered to detect if transfusion of autologous blood reduced the occurrence of postoperative infections. We found no statistical significant difference in postoperative infection rate between the groups, but this may be due to the fact that postoperative infections were diagnosed in only five patients. Increased C-reactive protein concentrations slightly above level of significance indicate that autologous blood transfusions stimulate the patient's immune system. However, there was no indication of increased transfusion reaction rate, including febrile reactions, in the autologous group. Transfusion of autologous blood did not reduce the use of allogeneic red cell concentrates. The mean use of allogeneic red cell concentrates was 0.93 units (both groups combined), indicating that the transfusion policy may have been too liberal. There was a highly significant inverse correlation between pre-operative haemoglobin concentration and transfusion of allogeneic blood. In a patient population with a low frequency of postoperative infection, a larger study is needed to clarify if autologous salvaged blood protects against postoperative infections.     

Hypotensive transfusion reactions can occur with blood products that are leukoreduced before storage

BACKGROUND: Leukoreduction before storage, rather than bedside white blood cell filtration, is recommended to prevent hypotensive transfusion reactions. STUDY DESIGN AND METHODS: Investigation of hypotensive transfusion reactions during radical prostatectomy in two patients on angiotensin-converting enzyme inhibitors. In Patient A, hypotension occurred during the transfusion of each of the following blood products: 2 units of autologous blood deposited and leukoreduced (LR) before storage; 3 units of allogeneic red cells LR before storage; and 2 units of non-LR acute normovolemic hemodilution (ANH) whole blood. When each of the transfusions was stopped, the blood pressure recovered. In Patient B, hypotension occurred during the transfusion of non-LR ANH whole blood. All implicated units were administered rapidly using a blood infuser at 37 degrees C. Bradykinin (BK) and des-Arg9-BK formation and degradation and the activity of kinin-degrading metallopeptidases were measured in plasma samples from both patients. RESULTS: Degradation of des-Arg9-BK was severely impaired and the activity of aminopeptidase P severely reduced in Patient A, but not in Patient B. BK degradation was mildly impaired in both patients. CONCLUSION: Hypotensive reactions can occur with blood products that are LR before storage and non-LR ANH. An inherent defect in the metabolism of kinins may be a risk factor for the development of hypotensive transfusion reactions.