Benefits of autotransfusion Overview of applications & indications © 2012 Haemonetics Corp COL-COPY-000481(AA)

Content Allogeneic Transfusions - Potential Risks Quality of Stored blood Washed versus unwashed blood Hematocrit of different Blood Products Applications for Autotransfusion Indications for Autotransfusion Contraindications for Autotransfusion Intraoperative Autotransfusion - Benefits

Allogeneic Transfusions - Potential Risks Viral infection Bacterial infection Transfusion reactions Immune suppression

Quality of Stored blood Stored cells breakdown over time and the breakdown begins within hours of collection. Stored RBC biochemical defects which are called collectively the “storage lesion.” These changes include decreased 2,3-DPG and ADP and ATP, poor deformability. Deformability is important for normal RBC function. Cytokines are released from white blood cells and free hemoglobin and potassium leak from the cells. This results in poorer performance at the tissue level, where it matters most. Oxygen is not released as well in stored RBC compared to fresh RBC. Investigators have found that oxygen extraction is 54% worse in stored RBC. Source: Tsai et al. Transfusion 2004;44:1626-34

Washed versus unwashed blood Relative risk of exposure to allogeneic RBC Washed: 54% transfused Unwashed: 73% transfused Washed RBCs are high quality (measured by post-transfusion survival) Unwashed blood Lower Hct Platelets present, but function may be impaired Anticoagulant present in measurable amounts Coagulation components could cause coagulation abnormalities In a meta analysis involving 19 studies comparing washed versus unwashed RBC in a variety of surgical applications, patients who received unwashed RBC were much more likely (73% vs 54%) to be transfused with allogeneic blood. Source: The Cochrane Library 2006, Issue 1

Hematocrit of Different Blood Products There are significant differences in the hematacrit of RBC being reinfused to the patient, depending on the type of autotransfusion system used. In unwashed RBC systems (“flip and drip”) the hematacrit is around 30%. In banked, allogeneic blood, the hematacrit is 50 – 60%. With the OrthoPat system, the RBC’s are washed and concentrated, resulting in a product with a 70 – 80% hematacrit. Unwashed Autotransfusion ~30% Hematocrit Banked Blood 50%–60% Hematocrit OrthoPAT Blood Product Up to 70% Hematocrit

Applications for Autotransfusion Widely applied technology Used for high blood loss surgeries aortic aneurism Used for elective surgeries with medium blood loss orthopedic surgeries cardiac surgeries Obstetric surgeries caesarean section with high risk factors for hemorrhage – amniotic fluid needs to be removed and leucodepletion filter use is recommended Acceptable by patients with specific religious beliefs

Indications for Autotransfusion Anticipated blood loss (adult) ≥ 20% of estimated blood volume Anticipated blood loss (child) ≥ 15% of estimated blood volume Undergoing procedure for which blood is routinely cross-matched Procedure for which more than 20% of patients are transfused

Indications for Autotransfusion (cont.) Mean transfusion volume exceeds one unit The patient has alloantibodies The patient has a low hematocrit and/or no predeposit units of blood Compatible allogeneic blood is not available.

Contraindications for Autotransfusion Physician must determine risk/benefit factor Autotransfusion with cancer surgery is normally contraindicated Contamination of the surgical site e.g. abdominal procedure pose the risk of contamination of shed blood Presence of amniotic fluid is a potential contamination: removal of amniotic fluid and use of leucodepletion filter are recommended Every decision is under the responsibility of the physician(s) treating the patient.

Intraoperative Autotransfusion - Benefits Reduces need for allogeneic blood by 40-60% Prevents transfusion- transmitted disease Prevents red cell alloimmunization Higher O2 delivery capacity Washed RBC reduces exposure to activated clotting factors, biologic modifiers, surgical debris Improved tissue perfusion Source: Yomtovian R. In Transfusion Reactions 2001, Tsai A. Transfusion 2004;44:1626

Intraoperative Autotransfusion – Benefits (cont.) Autotransfusion & Length of Stay (LOS) Scott et al. Cardiac surgery, CABG N=1746 Prospective, randomized, controlled trial Allogeneic transfusion vs. not transfused Reduced LOS by 2.9 days Transfused Not transfused 7.2 days 4.3 days p  0.001 In a prospective, randomized controlled study of patients undergoing cardiac surgery, patients that did not receive a transfusion had a shorter length of stay than those receiving a transfusion. Suggested Slide Use: Slide should be used in the General and Clinical presentations Source: Scott et al. American Society of Anesthesiologists Abstract 2006

Intraoperative Autotransfusion – Benefits (cont.) Autotransfusion & Length of Stay (LOS) Innerhofer et al. Prospective, observational study N=385 Elective orthopedic surgery (primary/revision hip replacement, spinal surgery) Recipients of autologous blood: 0.8 day less LOS In this prospective study the rate of complications and length of stay were evaluated in elective orthopedic surgery (THA/TKA/spines) patients receiving autologous blood, allogeneic blood or no transfusions. Infectious complications were fewer and length of stay shorter (about 1 day) in the recipients of autologous blood compared with recipients of allogeneic blood. Suggested Slide Use: Slide should be used the General and Clinical presentations (if interested in orthopedic solution) Source: Innerhofer et al. Transfusion 1999;39:625-632

Intraoperative Autotransfusion – Benefits (cont.) OrthoPAT® System reduced the need for allogeneic transfusions Procedure Allogeneic Transfusion Risk Reduction P Primary/revision hip 2.7-fold  .05 Primary/revision Knee 2.3-fold This study looked at primary hip and knee surgery in patients utilizing the OrthoPAT but not PAD, compared to patients not using blood salvage technology. OrthoPAT reduced the need for allogeneic blood 2.3 – 2.7 fold, a statistically significant difference. Clark et al N = 398; 5 hip or knee cohorts OrthoPAT used, without preoperative autologous blood donation Source: J Arthroplasty 2006;21:23-35 14

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