Role of Autologous Blood Donation

Peter Lewkonia, M.D., FRCSC
Vancouver, BC

Zhi Wang, M.D., FRCSC
Saint-Jerôme, QC

Several techniques have been developed to limit the use of allogeneic blood by perioperative re-infusion of the patient's own red cells. These technologies include cell salvage, acute normovolemic dilution, and preoperative autologous blood donation (PABD)1,2. The popularity of all three techniques grew in the 1980s as public fear over HIV and hepatitis B/C transmission rose3. In PABD, patients donate one or more units of blood within 40-45 days of the planned procedure on a pre-determined schedule. This blood is then processed and retained specifically for that patient at the time of surgery4. The use of PABD has decreased over the last decade in North America because of concerns regarding safety, cost-effectiveness, wastage, and overall patient benefit3.

 

Patient and procedure selection for PABD remains controversial. Certain patient characteristics are absolute contraindications including risk of bacteremia, significant cardiac or pulmonary disease, and seizure disorders5. Age (either paediatric or geriatric) is no longer considered a contraindication and PABD is safe in these groups6,7. Anaemia is a relative contraindication, and a preoperative haemoglobin of 110g/L with a hematocrit of at least 30-33% is considered a minimum baseline requirement for donation1,4,8,9. Mathematical models and clinical data strongly suggest that anaemia below this level does not allow for adequate reconstitution of a safe preoperative blood oxygen carrying capacity9-11. Reconstitution can take as long as 30-35 days for each unit of donated blood10,12. Considering the shelf life of donated red cells (42-49 days5), it becomes clear that post-donation, preoperative haemoglobin may be decreased even in healthy patients. Avoidance of anaemia due to PABD is assisted by the use of daily oral iron supplementation (150-300 mg Bid) and Erythropoetin injection5,13,14. The use of PABD should be restricted to procedures with significant expected blood loss. Preoperative donation is recommended for procedures with a transfusion rate greater than 10%1,4,11,15 such as complex lumbar spine surgery and total joint arthroplasty6,11,16-19.

A number of benefits are associated with the appropriate use of PABD. Of course, the primary benefit is the decreased need for allogeneic blood transfusion. In complex orthopaedic operations, allogeneic transfusion rates may drop by as much as 68%8,14,16-22. Decreased rates of viral infection transmission such as HIV and hepatitis remain a major benefit, although fears of this devastating complication have lessened as the risks of contaminated blood have decreased in the Canadian blood supply23. The use of autologous blood has also been shown to avoid the increased systemic bacterial infection risk associated with allogeneic blood transfusion in procedures such as large total joint replacement17,21,24. Furthermore, in orthopaedic procedures, total hospital length of stay has also been shown to be decreased in patients who participated in PABD programs17,25.

More recently, attention has been turned to the risks and effectiveness of PABD. For example, despite the lower risk of receiving allogeneic blood after PABD, it has been shown that the relative risk of transfusion of any kind (including autologous) is moderately increased14,21. In clinical studies of elective orthopaedic and spine surgery, wasted units account for between 10-90% of all donations6-8,11,16,17,19,20,24,25. This wide variability can be attributed to changes in transfusion practice over time and location, as well as differences in the amount of pre-donated blood and the transfusion risk for each procedure type. Depending on the transfusion triggers, some studies have shown that discharge hematocrit values can be lower in patients who have participated in PADB programs. This finding suggests that some patients who donate do not gain a net benefit due to wastage of their donated blood or the inability to reconstitute their haemoglobin preoperatively8,18. Finally, cost-effectiveness studies have failed to demonstrate significant benefit. Donation of autologous blood has an incremental cost-effectiveness measure of up to US $235,000 per Quality-Adjusted Life Year (QALY), which is considered a poor investment by most measures26.

PABD remains a useful choice for select patients. In healthy, non-anaemic patients undergoing procedures such as revision hip replacement or mulitilevel lumbar fusion, it likely reduces the chance of exposure to allogeneic blood and its associated risks27. Patient factors such as preoperative haemoglobin, weight, and age should be considered4,8. Finally, the expected blood loss from surgery should be carefully balanced against the patient's overall ability to donate and reconstitute that volume of red cells.

References

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  2. Lemos M.J., Healy W.L. Blood transfusion in orthopaedic operations. J Bone Joint Surg Am. 1996 Aug;78(8):1260-70.
  3. Brecher M.E., Goodnough L.T. The rise and fall of preoperative autologous blood donation. Transfusion. [Comment Editorial]. 2001 Dec;41(12):1459-62.
  4. Goodnough L.T. Autologous blood donation. Anesthesiol Clin North America. 2005 Jun;23(2):263-70, vi.
  5. American Association of Blood Banks. Technical manual : 50th anniversary AABB edition 1953-2003. 14th ed. Bethesda, Md.: American Association of Blood Banks; 2002.
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  7. Silvergleid A.J. Safety and effectiveness of predeposit autologous transfusions in preteen and adolescent children. Jama. 1987 Jun 26;257(24):3403-4.
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  14. Henry D.A., Carless P.A., Moxey A.J., O'Connell D., Forgie M.A., Wells P.S., et al. Pre-operative autologous donation for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2002(2):CD003602.
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  17. Bierbaum B.E., Callaghan J.J., Galante J.O., Rubash H.E., Tooms R.E., Welch R.B. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999 Jan;81(1):2-10.
  18. Cha C.W., Deible C., Muzzonigro T., Lopez-Plaza I., Vogt M., Kang J.D. Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries. Spine (Phila Pa 1976). 2002 Jan 1;27(1):99-104.
  19. Garcia-Erce J.A., Munoz M., Bisbe E., Saez M., Solano V.M., Beltran S., et al. Predeposit autologous donation in spinal surgery: a multicentre study. Eur Spine J. 2004 Oct;13 Suppl 1:S34-9.
  20. Billote D.B., Glisson S.N., Green D., Wixson R.L. Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement. J Clin Anesth. 2000 Nov;12(7):537-42.
  21. Carless P., Moxey A., O'Connell D., Henry D. Autologous transfusion techniques: a systematic review of their efficacy. Transfusion medicine. [Meta-Analysis Research Support, Non-U.S. Gov't Review]. 2004 Apr;14(2):123-44.
  22. Goodnough L.T., Marcus R.E. Effect of autologous blood donation in patients undergoing elective spine surgery. Spine (Phila Pa 1976). 1992 Feb;17(2):172-5.
  23. Kleinman S., Chan P., Robillard P. Risks associated with transfusion of cellular blood components in Canada. Transfus Med Rev. [Research Support, Non-U.S. Gov't Review]. 2003 Apr;17(2):120-62.
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  25. Regis D., Corallo F., Franchini M., Rosa R., Ricci M., Bartolozzi P. Preoperative autologous blood donation in primary total knee arthroplasty: critical review of current indications. Chir Organi Mov. 2008 Jan;91(1):41-4.
  26. Etchason J., Petz L., Keeler E., Calhoun L., Kleinman S., Snider C., et al. The cost effectiveness of preoperative autologous blood donations. N Engl J Med. 1995 Mar 16;332(11):719-24.
  27. Faught C., Wells P., Fergusson D., Laupacis A. Adverse effects of methods for minimizing perioperative allogeneic transfusion: a critical review of the literature. Transfus Med Rev. 1998 Jul;12(3):206-25.

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