Presentation on theme: "AUTOLOGOUS (pre-operative), DIRECTED & DESIGNATED DONATIONS Blood Centre Perspective Transfusion Medicine Resident Topic Teaching October 11, 2011 D.K."— Presentation transcript:
1AUTOLOGOUS (pre-operative), DIRECTED & DESIGNATED DONATIONS Blood Centre Perspective Transfusion Medicine Resident Topic Teaching October 11, 2011D.K. Towns, MD, FRCPC (Anesthesia)Medical Director - CalgaryCanadian Blood Services
2Autologous DonationAutologous donor: an individual who donates blood for the purpose of transfusion back to him/herself at a later time. At Canadian Blood Services, autologous donors must meet Donor Selection Acceptance Criteria, modified from the Whole Blood Programme for allogeneic donors.This is most commonly requested in preparation for upcoming, scheduled elective surgeryConsent is requiredNo age limitsMust be requested by a physician (usually the surgeon, or, the family physician)If outside of CBS criteria, may consider collection at the hospital
3Autologous Donation (con’t) Minimum weight of 55 lb- If less than 110 lb, a formula-driven reduced collection is performedMinimum hemoglobin/hematocrit at first donation: 110 g/l/.33- Subsequent donations: 105/.32Red cell shelf life is 42 days- Therefore, usually a maximum of 4 units, 1 week apart, and no more than 72 hours prior to surgeryConsider oral iron replacement- ?erythropoietinCollected in CPD with added SAGM- Red blood cells and plasma produced- Plasma discarded unless specifically requested - then issued as FPWhole blood no longer available
4IndicationsConsider only if the chance of requiring a transfusion is > 10%How many and when to collect?The same number as would be ordered for an allogeneic crossmatch using M-BOS (or a case-by-case assessment)Common surgical indications:major vascular surgery, including cardiacradical prostatectomymajor orthopedic, including hip and knee (particularly re-do), scoliosisliver resection“at risk” obstetrics
5Many Canadian hospitals have autologous donation programs Patients deemed high risk at Canadian Blood Services may be considered for in-hospital donationPAD programs are available at most Canadian Blood Services permanent donor clinics
6Acceptance criteria differs from allogeneic donation (hemoglobin, hematocrit, collection intervals)The donor questionnaire is significantly abbreviated, focusing primarily on risks of the donation process to the donor or risks of bacterial contaminationOther areas differing from allogeneic donation:Can donate if:received blood/blood products recentlycancersome cardiac conditionsrecent invasive procedures (example, tattoos, piercings)medication use (which does not increase risk to the donation process)pregnancysyphilis positive
7Contraindications Evidence of infection/risk of bacteremia IHSS (idiopathic hypertrophic subaortic stenosis)Aortic stenosisLeft main coronary artery diseaseUnstable anginaCardiac failureMI in previous 6 weeksA-V blockUncontrolled hypertensionCyanotic heart diseaseActive seizure disorder
8Each unit in every series is tested for the same infectious disease markers as for allogeneic donationsTD positive units (except for syphilis) must be discardedTD markers repeat reactive for infectious diseases but confirmatory negative or indeterminate can be released but have a biohazard labelAnti-HBcore positive units with or without a positive anti-HBs can be similarly releasedNote: Hospital-collected autologous units "should be" tested for transmissible diseases, but if positive - do not have to be discarded; a policy shall simply be in place as to how to deal with them
9AdvantagesMajor impetus - particularly in the past - was patient and physician desire to eliminate the risk of transfusion-transmitted viral diseases (particularly HIV and Hepatitis)Autologous transfusion minimizes exposure to allogeneic red cells and leukocyte antigens which could lead to future transfusion compatibility difficultiesThere is some evidence that allogeneic transfusion can lead to modulation of the recipients immune systemAutologous donation theoretically can enhance the available allogeneic supplyProvides compatible blood for patients with alloantibodies/rare bloodDecreases risk of some adverse transfusion reactions (febrile reactions, TRALI reactions, allergic reactions, delayed hemolytic reactions)
10Disadvantages Higher costs High wastage (approximately 50%) Logistic issues- The blood must be at the right place in the right condition at the right time- Must be specially labelled- Must be a system in place at both the hospital and blood centre- The hospital blood bank must know the blood is available, and how many units are available, so that autologous blood is used before allogeneicHigh wastage (approximately 50%)Surgical delay may result in outdating and discard of unitsUnits cannot be crossed over into the allogeneic pool (differing acceptance criteria)Subjects patients to perioperative anemia, in general.
11Risks which are NOT decreased Bacterial contaminationRisk of driving to and from donationClerical error leading to wrong unit being transfused (1:50,000)Receiving allogeneic blood before, or instead of autologous bloodAutologous donors have approximately 12x higher risk of reaction than allogeneic donors at the time of donation. (Usually in young patients, underweight, previous reaction, or first time donation.)**Never transfuse autologous blood simply because it’s there
14Krever Recommendations – Interim Report Using The Patient’s Own Blood (articles 18-25) The programs for autologous blood be made available throughout Canada to patients who are scheduled for elective surgeryThat Departments of Public Health determine in which public hospitals it would be feasible to create autologous programsThat programs be ‘inclusive’That hospitals, surgeons, physicians inform patients of the existence of autologous programsThat written information be provided well in advance of elective surgery
15Krever Recommendations – Interim Report Recommendations to the Blood Service The blood service should:Examine ways in which it can extend its PAD to a greater number of patients over a wider geographic areaEnsure that its PAD Program is available to patients about to undergo surgery outside their province of residenceTake active measures to publicize its PAD service
16The Cochrane database of Systematic Reviews Volume 2, 2002 Pre-operative autologous donation reduced the risk of receiving allogeneic blood transfusion by a relative 63%The risk of receiving any blood transfusion was 43.8%.Billote, et al. J Bone Joint Surg 2002prospective randomized controlled trial:patients undergoing total hip arthroplasty - hemoglobin ≥ 120 g/Lhalf donated autologous blood, half did not*pre-determined transfusion trigger was definedneither received allogeneic bloodof the autologous donors, 69% received an autologous transfusion41% of the autologous units were wasted
17Vamvakas in 2002 and 2007 (Vox Sang) critical reappraisal of clinical trials on the immunomodulatory effect of allogeneic blood transfusiondid not unequivocally identify an association between allogeneic erythrocyte concentrate transfusion and postoperative infection, or short term mortality
18Utilization CBS data Calgary-specific data Gail Rock (Transfusion Medicine, 2006; A review of nearly two decades in an autologous blood programme...)other ...All show < 50% utilization rates of autologous blood
19PAD not recommended unless the clinical circumstances are exceptional Guidelines for policies on alternatives to allogeneic blood transfusion PAD and transfusion. Transfusion Medicine, 2007PAD not recommended unless the clinical circumstances are exceptionalrare blood groupschildren with scoliosispatients at serious psychiatric riskpatients who refuse to consent to allogeneic transfusion
20Caspari - letter to the editor (Transfusion Medicine 2007) autologous donation may be indicated for patients with rare blood groups and/or blood group antibodiesfor patients in highly developed countries - where safety and supply is not an issueit is difficult to demonstrate a net benefit of autologous over allogeneic blood transfusion
21Case Study #163 year old female undergoing bilateral mandibular osteotomyfamily physician takes responsibility for ordering 2 units RBCdonation takes place at CBSnegative past historyfirst unit anti-HCV positive*surgeon cancels surgery altogether
22Case Study #2 45 year old male undergoing total hip arthroplasty 2 units RBC ordered1st unit anti-HIV positivea) donation takes place at CBS- what do you do with the unit?b) donation takes place at hospital... and now?what are the issues?
23Dedicated Donations: 1) Directed Donations an allogeneic donation where the patient who requires a blood transfusion selects an individual or individuals (usually friends or relatives) to provide the necessary blood products (usually RBCs). For patients who are not yet of legal age, the selection of the donor(s) is done by the parents.2) Designateddonations selected from a specific donor for a specific recipient, for medically indicated reasons.
25Directed Donations have been available in the U. S Directed Donations have been available in the U.S. (and Europe, Australia . . .) for many yearsUntil 1996, not permitted by the CRCS - BTS (unless medically indicated, now termed "designated")In January 1996, Dr. Francine Décary convened an advisory group of experts:concluded that DD should be made available but not actively promotedAt the same time, a court order obliged the CRCS in Montreal to provide DD to a child undergoing heart surgery from his two parents
26The CRCS program started soon after Héma-Québec - which now became the blood operator in Quebec, also started a DD programCRCS (and now CBS) provided DD from parent (biological or adoptive) to a minor aged child, as does CBS currentlyHéma-Québec's program is open to any compatible donor/recipient pair irrespective of recipient age or donor and recipient relationship
27Dr. Goldman's 1998 article in the CSTM Bulletin summarizes the first 2 years of Héma-Québec's experience:it was a small programthe utilization rates were poorit decreased donor exposure in only 20% of recipients
28CBS procedure:The transfusing physician must fill out a requisition after determining the selected donor's blood is compatible with the recipient.If CMV seronegativity is required, this must be determined and ensured by the physician prior to the request.The donor must fulfill the same criteria as an allogeneic donor (a few exceptions)Bled into a "B-2" pack (capability to make RBC and FP)shelf life 42 days BUT will likely be irradiated, therefore 28 days* Note, FP is only issued if specifically requested* Note also, RBC may be compatible but FP might notlast donation must be at least 72 hours prior to transfusion
29What about safety?possibility of graft vs. host disease (risk mitigated by appropriate gamma irradiation)transmissible disease risk:Dr. Nadine Shehata analyzed CBS TD data:Directed Donors in Canada had slightly higher rates of positivity for Hepatitis B, C, and syphilis than regular allogeneic doors
30Other risks: Same as allogeneic transfusion, but in addition: In newborn - maternal antibodies against paternally inherited antigens (therefore don't use plasma; TRALI risk reduction measures have since prevented maternal plasma transfusion)In newborn - father's red cells may be incompatible with maternally derived antibodies still presentIf any adverse event related to the blood transfusion were to occur - ? guilt/blame
31Case Presentation #18 year old child undergoing craniotomy and tumor removalMom is a family physicianDad is selected as compatible RBC donor2 units requestedFirst unit successfully donated24 hours later, dad called with post donation information . . .What are the issues?What would you do with this unit?What about the next planned donation?
32Designated Donations: Some of the medically indicated reasons for designateddonations include:patients with rare blood groups and antibodiesinfants with NAIT or HDNchildren with major blood loss surgery where designated donors may decrease donor exposurechildren with anticipated lifelong transfusion requirements (thalassemia, sickle cell anemia)patients with leukemia in relapse after bone marrow transplantation(donor leukocytes are used as adoptive immunotherapy to induce graft versus leukemia)HLA – matched apheresis plateletsDesignated Donors may, or may not be known or selected by their recipientThey may be selected by the Blood CentreCrossover is acceptable if the donor has met all criteria for allogeneic donation.
33Case Presentation #248 year old male post bone marrow transplant for CMLBone marrow donor is identical twin (therefore identical match) (*but has never donated blood)Post transplant:patient bleeding, first mucosal and bladder, finally GI tractplatelet count 5random platelet transfusions from hospital blood bank fail to produce incrementOncologist wants plateletpheresis product(s) from twinWants to transfuse “urgently" prior to completion of testingWhat are the issues to consider?