1. Autologous Blood
Donation and
transfusion
1

2. What does ‘Autologous Transfusion’ mean?
Autologous transfusion is
where the donor and recipient
are the same person.
There are different types of
autologous transfusion including:
•Preoperative autologous
donation (PAD)
•Intra-operative cell salvage
•Post-operative cell salvage
•Acute normovolaemic
haemodilution
•Directed donation
2

3. Aims:
To demonstrate an awareness of the different techniques
available as alternatives to allogeneic blood transfusion
and an awareness of their appropriate use.
Objectives:
•To develop an awareness of better transfusion
practice.
•Discuss different autologous transfusion techniques
available.
•Identify alternative care strategies to avoid the use of
allogeneic blood.
•To promote the appropriate and timely use of
transfusion alternatives.
3

4. Although the risks of blood transfusion
have been considerably minimised, the
incidents highlighted in the Serious
Hazards of Transfusion (SHOT) reports
show the importance of continuing
education in the appropriate use of
blood.
TRANSFUSE ONLY WHEN THE
BENEFITS OUTWEIGH THE RISKS
4

5. Good Transfusion Practice - General Considerations
Minimise amount
of phlebotomy for
lab samples
Base practice on
transfusion triggers,
targets set by local
guidelines, and individual
patient assessment
Establish target
haemoglobin
tolerable to the
individual patient
5

6. Reducing transfusion requirements
Pre-operative procedures include:
Pre-operative surgical assessment
units: blood tests should be performed Discuss treatment options with
and reviewed in a timely manner for patient: this is of particular importance if
diagnosis and treatment of anaemia e.g. the patient has any strong beliefs or
iron deficiency anaemia. Assessment of thoughts about blood transfusion (not just
patient’s previous clinical history e.g Jehovah’s Witness patients) - allow plenty
bleeding disorders. of time to plan for any specific
Assessment of patient’s current medication alternatives to transfusion to be
- where possible plan to stop medications organised.
pre-operatively e.g. anti-coagulant / anti-
platelet drugs
Maximum Surgical Blood Ordering Plan for possible cell salvage:
Schedule: this is a guidance schedule many hospitals now provide peri or
developed following agreement with post operative cell salvage - these
surgeons and anaesthetists - it should be techniques can be used in a variety of
used as a guide/tool to indicate how many surgical procedures - individual
units to order for different surgical patients should be assessed for
procedures - hospital blood banks may suitability pre-operatively and options
question clinicians if a request differs from discussed with the patient.
6
the MSBOS.

7. Module 4: Alternatives to Allogeneic Blood
Transfusion
Reducing transfusion requirements
Intra-operative procedures include:
Careful positioning Appropriate
of the patient during use of surgical
Use of intra-
surgery - may help dissecting instruments -
operative cell
reduce blood loss by some instruments help to
salvage
minimising venous reduce blood loss
congestion in the e.g. diathermy knives,
operating field. lasers, ultrasonic
scalpel.
Maintain
Preventing hypertension normothermia
Use of fibrin seals /
(controlled hypotension) (unless hypothermia is
haemostatic agents /
- hypertension may lead indicated) -
drugs to help reduce
to excessive bleeding coagulation factors
surgical bleeding
NOTE: this is a specialist may be less effective
anaesthetic technique. at lower temperatures,
increasing the risk of
blood loss.
7

8. Advantages
1 Prevent transfusion TTDs
2 Prevent red cell Allo - immunization
3 Supplements the blood supply in BTS
4 Provide compatible blood for patient with
Allo-antibodies
5 Prevent adverse transfusion reactions
6 Provide reassurance to patients concerned
about blood risk
7 reduce postoperative risk of bacterial
infection
8 reduce risk of cancer recurrence because
the fewer effect of Immuno modulation 8

9. 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 prone to perioperative
anemia & increase likelihood of transfusion
and side effect of iron supplementation
7 same risk of clerical error
8 anxiety to some patient
9

10. TYPES OF AUTOLOGOUS
TRANSFUSION
 Preoperative autologous blood donation
(PABD)
 Acute normovolemic hemodilution (ANH)
 Intra operative and post operative blood
recovery (blood salvage)
10

11. Preop. Autologous
donation
Inclusion: Stable patients scheduled for surgical
procedure in which blood transfusion is likely. Donor
Pt. should qualify criteria for blood donation in
surgery that bleeding is more than 1000cc.
 Necessity:
a. Close relation between clinician & blood bank
(BB)
b. Donor suitability by BB physician
c. Oral Fe one week before & many weeks after
e. at least Hb before operation is 11
* No limit of weight or aheage
11

12. CANDIDATES FOR P.A.B.D
 Stable patients
 M.S.O.B.S (surgical procedure with blood loss)
 Major orthopedic procedure
 Patients with alloantibodies
 Vascular surgery
 Thoracic or cardiac surgery
 Total joint replacement
12

13. Pre-op Autologous
Donation
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 CVA accidents in 6 mounth
6 Significant cardiac or pulmonary disease
7 Cyanotic heart disease
8 Uncontrolled hypertension
9 Malignant diseases
10 high grade main coronary artery disease
11 diarrhea
12 dental operation
13 skin ulcer
14 Antibiotic use
13

14. Pre-op Autologous
Donation
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 from one
week before operation
 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
14

15. Pre-op Autologous
Donation
Procedure
 A sufficient number of units should be
drawn to avoid exposure to allogenic
blood
 In lower than 50 kg (weight*450cc/50)
15

16.  It usually begins 3-5 weeks before scheduled surgery.
usually 2-4 units on each occasion ,approximately 500 ml
of blood are collected .patient with more than 50 kg body
weight usually donate 500 ml of blood in one session
.patient with less than 50 kg body weight donate smaller
volumes. The volume collected shouldn’t be more than
10% of the patient’s estimated blood volume .
 One donation per week is usually scheduled, although
more aggressive donation schedules are possible . In
theory , donation every 3 days are feasible . The last
donation takes place not later than 48-72 hour before
surgery . This is to allow for the equilibration of blood
volume.
16

17. New Program
 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
17

18. Pre-op Autologous Donation
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.
 Special Autologous label may be used with numbering
to ensure that oldest units are issued first.
18

19. PAD Complications
 Anemia and hypovolemia
 vasovagal reaction
 Venous access
 Pediatrics- low volume challenges
 Donor adverse reactions
 Clerical errors leading to the use of regular
donors before autologous units
 Over transfusion
19

20. RISKS OF P.A.B.D
1-Mistake of transfusion
2-Human error (ABO incompatibility)
3-Bacterial contamination
20

21. PABPD CONTRAINDICATION
1-Anemia
2-Serious cardiac disease
3-Predisposing to bacteremia (e.g. urinar
catheter or device)
4-HBV, HCV, HIV positive
21

22. SAMPLE OF PROTOCOLS
Select of patient
Detection of number units
Recommendation to interval collecting
Use of iron supplements
Transport of units
Review of criteria autologous
Manage of reaction
Policies program
Additional information
22

23. IRON SUPPLEMNTS
Prescription of iron
Suitable dose for decrease GI side effects
Maybe can not store of iron
23

24. Autologous Sticker
24

25. Acute Normovolemic
Hemodilution
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’.
25

26. PHYSIOLOGIC
CONSIDERATION
 Reduction of RBC losses
 Increase of perfusion’s tissues
 Improved oxygenation
 Decrease blood viscosity
 (The best oxygen delivery Hct 30-35%)
 Preservation of hemostasis
26

27. Acute Normovolemic
Hemodilution
 Properly labeled units are stored at RT for
up to 8 hours, unused units must be stored
within 8 hours at 1-6 C, outdates in 24h
 Re infuse units in reverse order to provide
maximum hemostatic functions
 ANH is equivalent to PAD in radical
prostatectomy, knee and hip replacement
27

28. CLINICAL STUDIES OF A.N.H
1-A.N.H equivalent to PAD
2-Minimized cost
3-Elimination waste of units
4-No inventory or testing
5-Never leaves the patient’s room
(minimize clerical error &ABO
incompatible)
28

29. CRITERIA FOR SELECTION OF
A.N.H
1-Likliehood of transfusion exceeds
2-Preoperative Hb at least 12 g/dl
3-Absence of coronary, pulmonary, renal or
liver disease
4-Absence of sever hypertension
5-Absence of infection & bacteremia
29

30. INDICATIONS FOR A.N.H
Hct>34%
Intraoperative blood loss>1 lit
Any type of surgery with significant blood loss
When the blood can be drawn after
aneasthesia and transfused
30

31. CONTRAINDICATION
FOR ANH
1-Anemia
2-Impaired renal function
3-C.A.D, A.S, (no compensatory
mechanism)
4-Limitation of cardiac or pulmonary
function
5-Untreated hypertention
6-Coagulation disorder 31

32. PRACTICAL CONSIDERATION
1-ANH related to procedure & volume of
blood & target Hct
2-Documented the manner
3-Exact monitoring
4-Aseptic collection
5-Labelling
6-Storage (room temperature=8h &
refrigirator=24h)
7-Increase time staying in the operating
32
room

33. TYPES OF ANH
PROCEDURES
 Cardiovascular
 Vascular
 Orthopedic
 Organ transplant
 Neuro
 Others 33

34. WHO IS A CANDIDATE FOR
ANH?
 Every one
 Loose >500 ml of the blood
 Unpredictable blood loss
 Need for homologous transfusion
34

35. WHAT ARE
CONTRAINDICATIONS FOR
A.N.H? (RELATIVE)
 Anemia Hct<28% Hb<10
 Impaired renal function
 Limitation of cardiac, pulmonary function
 Untreated hypertension
 Impossible compensatory C.O.
 Coagulation disorder
35

36. WHAT ARE THE POST-OP
CONCERNS FOLLOWING A.N.H?
1-Fluid overload
2-High blood loss procedure
3-Excessive hemodilution (diuretics)
36

37. WHAT IS NEEDED FOR A
SUCCESSFUL A.N.H PRGRAM?
37

38. Acute Normovolemic
Hemodilution
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.
38

39. Acute Normovolemic
Hemodilution
Procedure
 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.
39

40. Acute Normovolemic
Hemodilution
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.
40

41. Acute Normovolemic
Hemodilution
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
41

42. procedure
 For first litre compensate with 1 litre
colloid after that blood must be
compensated with 3 crystalloid.
 For every litre of blood we must give 3
litre crystalloid.
42

43.  Before you start you have to calculate how
much blood you can safely remove from
your patient you may want to use the
following equation to calculate the
tolerable blood loss.
 ABV=EBV * (H0-HT)
(H0+HT)/2
Where ABV is the autologous blood volume
to be withdrawn; H0 is the prehemodilution
hematocrit(zero time);
HT is the target hemoglobin and EBV is
estimated blood volume of patient.
43

44. AGENTS AFFECT ON WEIGHT
ADULT MALE ADULT FEMALE
BODY FLUID
(ml/kg) (ml/kg)
MUSCULAR 75 70
AVERAGE 70 65
THIN 65 60
OBESE 60 55
44

45.  It is a matter of knowledge and experience to define
a
reasonable target hemoglobin : mild (hematiocrit 20-
24%) , and profound/server/extreme
(hematocrit<20%) .
Some consider a target hematocrit less than 20%, in the
absence of hypothermia and cardiopulmonary
bypass,too risky, since it is considered to impair
oxygen delivery.
45

46. WHAT ARE THE
COMPENSATORY
MECHANISMS WHEN
DILUTING THE PATIENT
 Increase total & local flow rate
 Increase extraction of 02
 Right shift of 02 diassociative curve
46

47. Intra-operative Blood
Collection
Definition:
Whenever there is blood loss and
collected inside the body cavity, it is
transfused back to the patient.
47

48. SAMPLE PROTOCOL
 Phlebotomy (agreement
with surgeon
 The units of blood with
 Storage at room or
refrigerator
 1 ml blood 3ml crystalloid
1ml blood 1ml colloid
 Salvage
 Transfusion
 Blood loss-fluid
replacements-U/O
48

49. Intra-operative Blood
Collection
 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
49

50. Intra-operative Blood
Collection
 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
50

51. SIDE EFFECTS OF
INTRAOPERATIVE RECOVERY
 Air embolous
 Hemolysis
 Higher plasma free hemoglobin
 Positive bacterial culture
 (clinical infection is rare)
51

52. PRACTICAL CONSIDERATION FOR
INTRAOPERATIVE CELL
RECOVERY
 Sterile operating field
 A device for intraoperative blood collection with
0.9% saline
 Storage (room temperature 4 h after terminating
collection)
 Transfusion begins 6h of initiating the collection
 Labeling
 Stored in the blood bank
52

53. Intra-Operative Cell Salvage (ICS)
Advantages
 Reduction in allogeneic blood usage.
 Can be used regardless of patient’s medical fitness.
 Life saving where there is uncontrolled bleeding.
 System accepted by some Jehovah’s Witnesses.
Disadvantages
 Restricted to operations with high blood loss (>20 % of total blood volume).
 Cannot be used where wound site has an infection.
 Not normally used where cancer cells are in the operative field.
 Not suitable for patients with sickle cell disease.
 Requires capital outlay and trained operators - needs sufficient suitable operations to be
cost effective.
 Only red cells are returned without platelets or plasma.
53

54. Intraoperative Blood Collection
 Complications are rare but have been
reported- DIC, hemolysis due to high
pressure suction and mechanical
compression in roller pumps
54

55. Postoperative Blood
Collection
 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 55

56. RECOVERED BLOOD
 Dilute
 Partially hemolyzed
 Defibrinated
 High cytokines
56

57. HARMFUL MATERIAL IN
RECOVERED BLOOD
 Free Hb
 RBC Stroma
 Marrow fat
 Toxic irritant
 Tissue or debris
 Fibrin degradation product
 Activated coagulation factors
 Complement
57

58. Postoperative Blood
Collection
 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
 Most common in orthopedic
procedures such as hip or knee
replacement.
58

59. Transfusion Algorithm
 Avoid Transfusion : medical and surgical
 Alternatives
replacement fluids: crystalloids and non
plasma colloids over plasma
pharmacologic agents to reduce bleeding
 Autologous donation
 Minimize exposure to allogeneic
transfusion 59

60. Transfusion Algorithm
It is possible to avoid transfusion ?
Medical:
Treat underlying cause of asymptomatic
anemias:
Nutritional deficiencies-supplements
Chronic GI bleeds-medications
Renal failure- erythropoietin
60

61. Transfusion Algorithm
Is it possible to avoid transfusion?
Surgical:
Excellent surgical skill (Factor XIV!=avoid
tissue trauma, attention to hemostasis, utilize
avascular plane etc)
Use of topical hemostatic agents in OR
Eg. Fibrin Glue- Fibrin sealant :Tisseel
Collagen- platelet adhesion
61

62. Transfusion Algorithm
 When transfusion is deemed necessary, a
physician must obtain informed consent from
patient.
 “Informed Consent to the administration of blood
and blood products involves the following: an
explanation by the physician in language the
patient will understand of the risks and benefits
of, and options to, an allogeneic blood
transfusion
62

63. Informed Consent- patient decides
 Information provided by physician:
1. product description.
 2. Benefit and potential risks.
 3. Alternatives if available-including risks
and benefits.
 4.Risks of refusing transfusion
 Opportunity for questions and clarification
 Patient’s documentation of consent or
refusal
63

64. Transfusion Algorithm
Strategies to minimize exposure to
allogeneic transfusion
1. replacement fluids- crystalloids and
non plasma colloids
2. pharmacologic agents to reduce bleeding
3. Autologous Transfusion
64

65. Transfusion Algorithm
Strategies to minimize exposure to
allogeneic transfusion
1. replacement fluids- crystalloids and non
plasma colloids
2. pharmacologic agents to reduce
bleeding
3. Autologous Transfusion
4. Minimize allogeneic donor exposure in
neonatal transfusion 65

66. Red Cell Transfusion- Is a clinical
decision!!!
 Tissue oxygenation does NOT depend on
hemoglobin concentration alone!
 Cardiac performance
 Pulmonary function
 O2 Binding Coefficient
 Demand of Tissue (physical activity)
66

67. THANKS FOR YOUR
ATTENTION
67