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Uhl L. Patient Blood Management: A 68-Year-Old Woman Contemplating Autologous Blood Donation Before Elective Surgery. JAMA. 2011;306(17):1902–1910. doi:10.1001/jama.2011.1526
Author Affiliations: Dr Uhl is Director, Division of Laboratory and Transfusion Medicine, Beth Israel Deaconess Medical Center and Associate Professor of Pathology, Harvard Medical School, Boston, Massachusetts.
Globally, more than 81 million units of red blood cells are transfused annually. Of the 15 million red blood cell components transfused annually in the United States, approximately 40% are transfused to patients undergoing elective surgical procedures. Because of concerns about limited blood availability as well as risks of transfusion-related adverse events, blood products should be used judiciously. Using the case of Ms C, a 68-year-old woman considering autologous blood donation prior to knee replacement surgery, the concept of patient blood management is discussed. This approach entails a complete evaluation of the patient in the preoperative period to assess for bleeding risks and anemia, with a goal to optimize a patient's condition prior to surgery; use of various strategies in the operative period to mitigate the need for allogeneic blood transfusion; and meticulous postoperative care to again avoid the need for blood transfusion.
DR TESS: Ms C is a 68-year-old woman who presented with progressive right knee pain and swelling. She first developed pain and swelling in her right knee in 2003 and was diagnosed as having osteoarthritis. She underwent arthroscopy and bursectomy in 2006, but in the last few years, she has experienced worsening of her pain as well as significant physical limitations. Joint injections with steroids have resulted in little improvement, and now she is planning to undergo knee replacement surgery in 8 weeks.
Ms C's medical history includes osteoarthritis, hypertension, hyperthyroidism, hypercholesterolemia, and uterine fibroids in addition to the arthroscopy in 2006. Her medications include hydrochlorothiazide, levothyroxine, simvastatin, and aspirin. She has no known drug allergies.
On examination, Ms C is a healthy-appearing woman with normal vital signs. Her physical examination results were normal except for pain on palpation of her medial right knee, an antalgic gait, and difficulty with toe and heel walking due to pain. A routine complete blood cell count revealed a white blood cell count of 7900/μL, hemoglobin level of 15.1 g/dL, mean corpuscular volume of 92 fL, red blood cell (RBC) distribution width of 13.4%, and platelet count of 290 × 103/μL.
Personally, I do not want anyone else's blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That's my concern; I have never had a [serious] infectious disease in my life and at this age, I don't think I want to get one.
I was thinking about donating my own blood for after my surgery so I wouldn't have any worries at all about infection. Did I get hepatitis? Did I get some other kind of disease? I think a doctor should always counsel their patients about the do's and the don’ts of transfusion and explain the risks and options to them.
If I am not able to donate my own blood for my surgery, I would first discuss it with my family and see if they would donate some blood for me. If my family is not able to, then I would have to make the decision about whether to take the blood from the hospital. I would like Dr Uhl to answer the question, “What is my risk if I do not donate my own blood and I have to take the blood from the hospital?”
What is the prevalence of blood transfusion and associated risks and cost in the acute surgical setting? What strategies can be used to minimize the need for blood transfusion for patients facing elective surgery? What options are available for preoperative patient blood management? When should a patient consider preoperative autologous donation? What intraoperative and postoperative measures are available to reduce need for allogeneic transfusion? How should clinicians counsel patients about the risks of transfusion and perioperative blood management? What does the future hold? What is your advice for Ms C?
DR UHL: Ms C, a 68-year-old woman with a long-standing history of knee pain who has undergone numerous nonsurgical interventions without relief, is scheduled for elective total knee replacement, and may need blood transfusion during her recovery period. Because she has concerns about the safety of the blood supply, she is seeking guidance as to whether to donate her own blood for the upcoming surgery. Allogeneic blood transfusion is considered a therapeutic intervention and, as with other medical interventions, requires that a patient provide informed consent.1,2 The physician responsible for prescribing blood component transfusion is also responsible for explaining to the patient the risks and benefits of transfusion. Equally important to the discussion is information on the alternatives to allogeneic transfusion, including preoperative autologous blood donation and intraoperative cell recovery. This discussion should be carried out in an unhurried and unpressured manner with ample opportunity for the patient to ask questions. A careful and thorough description of the transfusion process, including possible adverse effects, improves a patient's understanding of blood transfusion. On conclusion of the informed consent discussion, the mutually agreed-on course of action regarding the approach to transfusion management should be documented in the medical record.1,2 Ms C's desire to understand her options related to transfusion management for her upcoming surgery presents a ripe opportunity for her physicians to embark on the informed consent process.
Globally, more than 81 million units of RBCs are transfused annually.3 According to the 2009 US National Blood Collection and Utilization Survey, approximately 15 million RBCs were transfused in 2008 in the United States, 40% of which were transfused to surgical patients.4 The possible deleterious effects of blood transfusion and the associated costs of transfusion require that both primary care physicians and surgeons look for opportunities to improve the preoperative status of patients, in particular hemoglobin concentration, to attempt to reduce the need for blood transfusion.5-7 The risks of transfusion include transfusion-associated infections and noninfectious complications and occur at different rates (Table 1).8-11Quiz Ref IDFortunately, in the United States and other developed countries, the risk of transfusion-associated infectious disease has dramatically declined during the last 20 years because of improved donor screening and laboratory testing as well as decreased prevalence of transmissible diseases (eg, hepatitis C).10 Currently in the United States, all whole blood donations are screened for human immunodeficiency virus (HIV) types 1 and 2, hepatitis B and C virus, human T-cell lymphotrophic virus types 1 and 2, West Nile virus, Chagas disease, and syphilis.8,11 Epidemiological studies carried out by major US blood suppliers demonstrate the current risk of HIV and hepatitis C virus to be approximately 1 in 1.5 million whole blood units transfused and for hepatitis B virus, 1 in 280 000 to 357 000 whole blood units.8 Despite these reduced risks, however, the potential persists for new and emerging infectious agents to affect the safety of the blood supply. By comparison, transfusion-related noninfectious complications occur with much higher frequency (Table 1).9
Determining the cost of blood transfusion is complex and requires consideration of not only the direct acquisition cost of an RBC unit but also the costs associated with regulatory management of donor services, transfusion services, patient laboratory testing and preparation for transfusion (eg, type and screen and cross-match), administration and patient monitoring during transfusion, and evaluation of any adverse events related to the transfusion event.12 Through the use of a carefully constructed model that took into consideration critically important variables related to blood transfusion and applied them to 4 different institutions (2 US and 2 European), Shander et al13 estimated the total cost per RBC unit to be $760.82 ± $293.74. The total cost of transfusions for surgical patients at participating institutions ranged from $1.61 million (at a center with 451 surgical patients receiving transfusions) to $6.03 million (at a center with 2237 surgical patients receiving transfusions) during the period evaluated. These costs are driven by the proportion of surgical patients receiving transfusions as well as the number of units transfused per patient.
The concept of patient blood management, recently embraced by surgeons and anesthesiologists, is broad in scope, is multifaceted, and includes interventions that are used in the prehospitalization period, the intraoperative period and the postoperative period (Box).14,15 More recently, the concept of patient blood management has caught the attention of organizations responsible for patient quality and safety initiatives, including the Joint Commission,16 which has set forth performance measures directed at preoperative patient assessment for anemia and clinical decisions regarding blood component transfusion.
Clinical assessment for anemia and bleeding risk
Preoperative autologous blood donation
Acute normovolemic hemodilution
Intraoperative blood recovery
Use of topical/systemic hemostatic agents
Restrictive use of transfusion
Restrictive use of phlebotomy
Judicious use of anticoagulants and platelet inhibitors
aSee text for evidence and caveats regarding interventions.
Patients undergoing elective surgical procedures for which there is a high likelihood of significant intraoperative blood loss represent the target population for patient blood management programs.7,17 Patients who because of religious preferences are not accepting of allogeneic blood transfusion or patients who have complex RBC alloantibodies and therefore present difficulties in finding appropriately matched RBCs also represent ideal candidates for patient blood management programs.
Ms C is facing an elective surgical procedure that is often associated with a need for blood transfusion during the postoperative period.18,19 As such, she is an ideal candidate for careful consideration of blood management to mitigate the need for allogeneic transfusion.
Quiz Ref IDAny patient facing an elective surgical procedure associated with a high likelihood of major blood loss should be fully evaluated to assess for factors predictive of preoperative and postoperative anemia and the need for transfusion. These include comorbidities associated with high likelihood of postoperative transfusion (eg, renal insufficiency, adult-onset type 1 diabetes, peripheral vascular disease)20,21; personal or family history of bleeding problems that could contribute to blood loss during the surgical procedures (eg, a history of von Willebrand disease or specific clotting factor deficiency [eg, factor XI deficiency]); history of use of drugs that interfere with either primary or secondary hemostasis (eg, aspirin, antiplatelet agents, anticoagulants); or evidence of anemia either by history or by laboratory assessment.22
Administration of iron and erythropoietin are 2 preoperative blood management approaches that have been evaluated. Preoperative anemia is common in the elective surgical patient population,23 with a reported prevalence of 34% to 76% among various surgical patient populations.24 Studies demonstrate that the clinical consequences of preoperative anemia include a higher likelihood of allogeneic blood transfusion5,6,25 and increased incidence of postoperative infection and longer lengths of stay.26 The presence of anemia in any patient should prompt a thorough evaluation to determine its cause. In some patients, it may be the result of an occult colon cancer; in others, it may reflect poor nutritional status.
Iron deficiency is the underlying cause in approximately 30% of preoperative anemia cases. Fortunately, preoperative anemia due to iron deficiency, particularly in elective orthopedic surgical patients, appears to be readily reversible with preoperative iron supplementation.26-28 For example, Theusinger et al24 demonstrated a clear benefit of preoperative iron supplementation in patients scheduled for major elective orthopedic surgery who were anemic (men with hemoglobin concentrations of 10.0-13.0 g/dL and women with hemoglobin concentrations of 10.0-12.0 g/dL) and having marginal iron stores based on an absolute ferritin concentration of less than 100 μg/L or ranging between 100 and 300 μg/L with iron saturation of less than 20%. In that study, patients meeting inclusion criteria were administered intravenous infusions of iron sucrose for 10 days prior to scheduled surgical procedures. Mean hemoglobin concentration increased significantly (P < .001) from baseline (1.0 [SD, 0.6] g/dL; 95% CI, 0.8-1.3 g/dL). Iron stores as assessed by ferritin also increased significantly (P < .001) from baseline values (median increase, 638%; 95% CI, 523%-958%).
Erythropoietin, a key regulator of erythropoiesis, is a hormone that promotes cellular differentiation and maturation of erythroid precursors in bone marrow, leading to enhanced hemoglobin synthesis and release of reticulocytes into the systemic circulation.29 Erythropoietic response to acute blood-loss anemia is modest,30 but because exogenous erythropoietin (recombinant erythropoietin) improves compensatory hematopoiesis, the role of erythropoietin therapy in patient populations undergoing surgical procedures associated with significant blood loss (eg, major orthopedic, cardiovascular, and urological surgical procedures) has been studied.31-37 As summarized in Table 2, clinical trials in the orthopedic patient population, using a variety of dosing regimens, demonstrated increased preoperative hemoglobin concentrations and reduced allogeneic transfusions.31-34,38,39 Patients with preoperative hemoglobin concentrations ranging between 10 and 13 g/dL appeared to benefit the most from preoperative administration of erythropoietin.33 Erythropoietin therapy was approved in 1996 for perioperative use in patients scheduled for elective noncardiovascular surgical procedures. Quiz Ref IDMore recent trials in orthopedic patient populations have confirmed that erythropoietin administration can reduce allogeneic RBC transfusion, particularly when coupled with iron repletion and restricted use of preoperative autologous blood donation.27,40,41 However, erythropoietin has not been widely used for preoperative blood management because of the inconvenience of self-administration; restrictive reimbursement by insurance companies; concern about thrombosis, particularly in the cardiovascular surgical patient population42; and lack of demonstrable cost-effectiveness with respect to patient morbidity and mortality.43 Studies of cost-effectiveness have found high marginal cost.44,45 In a model of cost-effectiveness of erythropoietin use in young patients undergoing extensive spine surgery for scoliosis repair, Vitale et al44 reported a cost-effectiveness ratio of more than $1.5 million per quality-adjusted life-year.
Preoperative autologous blood donation (PAD), in which a patient donates 1 or more units of his or her own blood preoperatively, has traditionally been advocated for patients who are undergoing elective surgical procedures that are associated with significant blood loss procedures associated with greater than 90% likelihood of requiring blood transfusion.46 In contrast, PAD is of limited medical value for patients scheduled for procedures with little or no anticipated blood loss; for example, vaginal hysterectomies.47 PAD has been widely used in the management of patients undergoing elective major orthopedic procedures including total knee arthroplasty.18,19,41,48,49
The success of PAD is dependent on a patient's underlying nutritional status, clinical status, and timing of preoperative autologous donation.46 For patients with baseline anemia, PAD may not be possible because the patient does not meet donation eligibility requirements; moreover, PAD may exacerbate anemia since the erythropoietic response replaces only a small amount of blood from the time of donation to surgery. Consequently, PAD may not reduce allogeneic blood transfusion in the perioperative period. Patients with significant underlying cardiac disease (eg, aortic stenosis), for whom acute blood loss by phlebotomy of 500 mL of whole blood could exacerbate underlying medical conditions, or underlying infections (eg, infected prosthesis), which risks the collection of a contaminated blood component, are not appropriate candidates for PAD and should not be referred for autologous donation.
Concern about the safety of the blood supply appears to be the primary motivation for Ms C's consideration of autologous blood donation in advance of her surgical procedure. This concern was also prevalent 25 years ago, when the threat of transfusion-transmitted disease, in particular HIV, spawned the implementation of hospital-based autologous whole blood donation programs. These programs continued into the 1990s, but more recently the number of units collected nationally for autologous transfusion declined 26.9% from 2004 to 2006 and 24.5% from 2006 to 2008.4,50Quiz Ref IDA number of factors are thought to have contributed to this downward trend,51 including the decline in the risk of transfusion-associated disease, the lowering of clinical transfusion thresholds over the last 10 to 15 years, and the realization that PAD may actually increase the likelihood of transfusion. The latter point is supported by a systematic review by Henry et al52 of randomized controlled trials evaluating the efficacy of PAD with respect to mitigation of allogeneic blood exposure and overall transfusion exposure. They found that although PAD is associated with a reduction in allogeneic blood exposure, patients participating in PAD had a higher likelihood of transfusion (allogeneic and autologous blood) compared with patients who did not participate in PAD. Reasons for this include lower preoperative hemoglobin concentrations resulting in increased probability of intraoperative and/or postoperative blood transfusion and, possibly, more liberal use of autologous blood transfusion based on the knowledge of availability and perceived safety (compared with allogeneic blood). The results of Billote et al53 in particular demonstrated PAD's limited reduction of allogeneic blood exposure in patients undergoing unilateral primary total hip replacement. In this study, patients were randomized to PAD that was completed 2 weeks prior to the elective surgical procedure vs no PAD. Intraoperative and postoperative transfusion, applied to both treatment groups, was guided by a standard transfusion protocol. This study found that no patient required allogeneic blood transfusion, only patients randomized to the PAD group required any transfusion (with their autologous blood), and PAD contributed to significant wastage of blood components (41% of the collected autologous units were discarded). More pertinent to Ms C is the prospective observational study by Bierbaum et al18 examining transfusion requirements in patients undergoing major total joint arthroplasty (hip and knee). In this study, only 18% of patients who had primary unilateral knee replacement surgeries and who did not participate in PAD required allogeneic transfusion.
Autologous donation carries no more risk than allogeneic donation in patients who qualify for donation (eg, patients who pass the basic eligibility physical for heart rate, blood pressure, and hemoglobin concentration; have no significant medical comorbidities; and have no signs or symptoms of active infection). In both populations, the risk of adverse reactions related to donation is approximately 2% to 5%54 and includes vasovagal reactions, hematoma at the phlebotomy site, and nerve damage. Similar to allogeneic donation, the occurrence of donor reactions is associated with female sex, first-time donation, and increasing age.55 An individual's familiarity with blood donation as well as adequate hydration has been shown to mitigate risk of adverse reactions.56
The cost-effectiveness ratio for PAD is high; several studies published in the mid-1990s found that PAD had a cost ranging from $235 000 to more than $23 million per quality-adjusted life-year saved, depending on the surgical procedure and associated blood transfusion requirements as well as the number of autologous units collected.57-60 More specifically, cost-effectiveness analyses for major orthopedic procedures showed a cost of $1.4 million per quality-adjusted life-year saved in the patient population undergoing primary unilateral knee replacement.60 The primary contributors to these high costs were the expense of autologous donation compared with allogeneic donation; the discard rate of autologous blood units; and the low risk of the adverse outcomes associated with allogeneic transfusion included in the analyses (eg, risk of transfusion-transmitted HIV and hepatitis C and B viruses). Given the progressive decline in risk of transfusion-transmitted viral disease and more restrictive use of allogeneic transfusion, the current cost-effectiveness ratios for both PAD and erythropoietin are likely even higher than studies have shown to date. In the United States, insurance carriers cover costs related to PAD or erythropoietin provided a patient meets certain clinical and laboratory requirements (eg, hemoglobin level <12.5 g/dL). The requirements for coverage of either PAD or preoperative erythropoietin therapy vary among insurance providers, so patients and physicians are encouraged to seek guidance prior to embarking on a course of action.61,62
Strategies to reduce risk of allogeneic transfusion in the perioperative period include acute normovolemic hemodilution (ANH) and RBC recovery techniques. In addition, agents that reduce surgical blood loss (eg, antifibrinolytic drugs and fibrin sealants) can reduce the need for allogeneic transfusion.
Quiz Ref IDAcute normovolemic hemodilution refers to the process whereby blood is removed from a patient, usually during induction of anesthesia, and replaced with either crystalloid or colloid to maintain circulating blood volume, and the collected and reserved whole blood units are typically transfused back at the conclusion of the surgical procedure. Although considered a relatively safe procedure, reports on the clinical efficacy of ANH are mixed and its use in orthopedic surgery is limited.15,63
In contrast, perioperative cell recovery has been applied in a variety of surgical settings, including orthopedic, cardiothoracic, vascular, and urological surgery, as well as obstetrics.64 It involves the collection of shed blood during the surgical procedure or from the surgical site during the postoperative period. Intraoperative techniques involve direct suctioning of shed blood, which is collected into canisters, as well as the recovery of blood from surgical sponges. The accumulated shed blood is then prepared for transfusion by 1 of 2 methods. In the first method, hemofiltration, shed blood is drawn into an autotransfusion device equipped with an integral filtration device. The collected product is then simply filtered (ie, without washing the product) and reinfused to the patient.65 The second, RBC wash systems, involves collecting shed blood and processing via automated devices that wash the shed blood free of cellular debris and other contaminants, as well as concentrating the recovered RBCs.65,66 When the practice of cell recovery was originally introduced, it was recommended for surgical procedures in which estimated blood loss was anticipated to be more than 20% of a patient's blood volume or for procedures for which more than 10% of patients require transfusion (and the mean transfusion requirement is >1 unit).67 These recommendations were largely derived from cost comparisons between cell recovery and the cost of allogeneic blood. Given the cost escalation of allogeneic blood, proponents of cell recovery suggest that its use, from a financial perspective, may be appropriate in settings of much smaller blood loss.65
Whether general use of cell recovery processes contributes to a meaningful reduction in allogeneic blood exposure remains an open question. A review of 75 studies spanning 1979 to 2008 suggests that part of the difficulty in assessing efficacy relates to the methodological problems in this area of investigation, including small numbers of patients studied, heterogeneity in transfusion practice (protocol-driven vs transfusion at the investigators' discretion), and either no reference to whether the study was blinded or the study was definitely unblinded.68 Despite these limitations, the reviewers, having applied strict review criteria, concluded that use of RBC recovery and reinfusion reduced the relative risk of perioperative allogeneic RBC transfusion exposure by a relative 38% (relative risk, 0.62; 95% CI, 0.55-0.70). Moreover, they observed the most pronounced reduction in the orthopedic surgical population (relative risk reduction of 54% vs 23% in the cardiac surgical population).68
Potential complications of RBC recovery techniques include air embolus, nonimmune hemolysis secondary to traumatic RBC injury during cell collection by suction devices, coagulopathy, and transfusion of recovered blood contaminated with drugs, bacteria, or tumor cells. However, these appear to be rare events.64 A retrospective review by Domen69 performed at the Cleveland Clinic showed the incidence of adverse events associated with reinfusion of salvaged blood to be 0.027%. Thus, when appropriately performed, including the participation of trained operators, cell recovery systems are fairly safe.
Postoperative management can also reduce allogeneic blood transfusion exposure. Restricted phlebotomy for laboratory testing avoids iatrogenic RBC loss, and the use of topical and systemic hemostatic agents combined with meticulous wound care reduces blood loss. Decisions regarding use of allogeneic blood transfusion should take into account the physiologic condition of the patient and risk of end organ ischemia balanced against the risks associated with RBC transfusion. Although reliance on a numeric “transfusion trigger” should be avoided, particularly because there are few high-quality studies in the surgical patient population to support this practice, transfusion is generally considered reasonable for hemoglobin concentrations of less than 7 g/dL.70-72
Despite improved surgical management and operative techniques, for many patients undergoing elective surgical procedures, notably cardiac, orthopedic, or complex gynecological/urological surgeries, blood transfusion continues to be a routine part of patient care. Several factors relate to the likelihood of blood transfusion, including sex, age, and preoperative hemoglobin concentration.17,73 Clinicians responsible for the care and referral of patients in need of elective surgical interventions should recognize the associated risk factors for perioperative transfusion needs and, when indicated, offer medical intervention to mitigate those needs (eg, iron replacement therapy).22 Furthermore, clinicians should actively involve their patients in an informed discussion on existing options for patient blood management, including PAD and the available alternatives to PAD (eg, use of perioperative cell recovery and ANH). Careful consideration of a patient's underlying health status (eg, potential risk of PAD-associated anemia), assessment of likelihood of transfusion based on type of elective surgical procedure, and thorough understanding of a patient's wish for PAD are important factors in a patient-physician discussion of the appropriateness of PAD. Primary care physicians should also know the current risks of transfusion, particularly the risks of transfusion-transmitted infection, as this is often patients' primary concern related to blood transfusion. Finally, clinicians should be aware of current literature on evidence-based transfusion practice as well as the indications for transfusion.15,52,68,71,72,74
National and international blood utilization studies demonstrate that blood component therapy continues to be a regular practice in surgical patient management. Because of recognized complications related to transfusion and observations tying blood transfusion to increased morbidity and mortality, increasing emphasis is being placed on managing predisposing risk factors for transfusion.22 Implementation of patient blood management programs serves to bring multiple caregivers together to assess the opportunities and implement treatment plans that potentially mitigate the need for blood transfusion.75
The transfusion medicine community has made great strides in reducing the risk of transfusion-transmitted disease, largely through improved donor screening and testing.10 However, the risk of noninfectious transfusion complications has remained largely unchanged, and for some complications there is significant risk of morbidity and mortality (eg, transfusion-associated circulatory overload and transfusion-related acute lung injury).9 Basic science research and prospective data collection initiatives (eg, national biovigilance programs76) are ongoing, with the intent to garner a better understanding of the pathophysiology and the prevalence of these complications as well as potential risk reduction strategies.77-80 Endeavors such as these serve to inform the transfusion medicine and medical communities at large of opportunities to further improve the quality and safety of transfusion practice.
Ms C's interest in preoperative autologous donation stems from her concerns about transfusion-associated disease. She is certainly not unusual; many patients facing the possibility of requiring blood transfusion are concerned about the safety of the blood supply.81 In light of her concerns, I would discuss with her the blood management plan for her upcoming surgery. This would include providing a realistic assessment of anticipated blood loss related to the surgical procedure; ways the effects of the anticipated blood loss could be assessed (eg, complete blood count); a review of alternatives to allogeneic transfusion including PAD, cell recovery, and ANH and their risks and benefits; and a discussion of the risks and benefits of allogeneic blood transfusion. Based on the information provided in the clinical presentation, Ms C meets the eligibility requirements for PAD and has adequate time before her surgery to donate and still avoid donation-associated preoperative anemia. Thus, she could reasonably be referred for donation if it were indicated based on her likelihood of needing a transfusion.41 However, given that she may not complete the donation process (eg, if she has poor venous access or experiences an adverse event during the donation), the current infectious disease risks related to blood transfusion should be clearly communicated to Ms C with the goal of allaying her concerns regarding the safety of the blood supply. Additionally, I would advise her that family-directed donations may be no safer than that supplied by voluntary donors82; in fact, published data suggest that directed donations may carry a higher risk of transfusion-associated disease.83 Finally, I would assure her that allogeneic blood would be used only when needed and when benefit is expected and outweighs the possible risks.
QUESTION: How does the diagnosis of malignancy affect the strategies you presented?
DR UHL: A diagnosis of malignancy raises questions about whether intraoperative blood recovery can be used during surgical procedures, given the concern about tumor cell contamination of the recovered blood product and consequent theoretical risk of metastatic disease following transfusion. The literature examining this issue, which is limited to retrospective cohort studies and small prospective studies and thus is potentially insensitive, suggests that the reluctance to use cell recovery for this reason is not well-founded.64 In a retrospective review of 408 of 769 medical records of patients who had undergone radical retropubic prostatectomy and met study inclusion criteria, Davis et al84 found no differences in tumor recurrence rates in patients who were transfused autologous products derived from intraoperative blood recovery techniques [n = 87] as compared to patients who either received transfusions of autologous products collected preoperatively (PAD; n = 264) or received no transfusion (n = 57). More recently, Liang et al85 demonstrated that the use of leukodepletion filters during the processing of recovered shed blood efficiently removed contaminating tumor cells in patients with hepatocellular carcinoma undergoing orthotopic liver transplantation, supporting the consideration that intraoperative blood recovery techniques in conjunction with postcollection leukodepletion can be used safely in patients with significant transfusion requirements.
QUESTION: Why are unused units of autologous blood donations discarded instead of being put in circulation?
DR UHL: Blood donations that enter the general blood supply are collected from donors who meet donor eligibility criteria set forth by the Code of Federal Regulations86 and the AABB Standards for Blood Banks and Transfusion Services.87 In general, the donor criteria used to assess autologous donor eligibility for donation are less rigid than those used for allogeneic donor eligibility. For example, the hemoglobin threshold for an autologous donor is 11 g/dL compared with 12.5 g/dL for an allogeneic donor.87 In addition, autologous donors are generally not required to take the rigorous donor history questionnaire that is used to assess suitability of allogeneic donors.88 For these reasons, unused autologous units are not entered into the general blood bank inventory.
QUESTION: Does PAD decrease the rate of noninfectious complications of transfusion?
DR UHL: There are no specific data to support or refute risk reduction of noninfectious complications of transfusion with the use of autologous blood except for alloimmunization.89 However, it is generally understood that autologous transfusion carries the same risk as allogeneic transfusion of transfusion-associated circulatory overload, misadministration, and untoward effects related to RBC storage.88 Thus, there should always be a clear indication for transfusion, irrespective of the source of the blood component.
Corresponding Author: Lynne Uhl, MD, Beth Israel Deaconess Medical Center, Yamins 309, 330 Brookline Ave, Boston, MA 02215 (firstname.lastname@example.org).
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank the patient for sharing her story and for providing permission to publish it.
The conference on which this article is based took place at the Surgery Grand Rounds at Beth Israel Deaconess Medical Center, Boston, Massachusetts, on February 24, 2010.
Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Risa B. Burns, MD, series editor; Tom Delbanco, MD, Howard Libman, MD, Eileen E. Reynolds, MD, Marc Schermerhorn, MD, Amy N. Ship, MD, and Anjala V. Tess, MD.
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