Autologous blood transfusion Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio) Mahatma Gandhi medical college and research institute – puducherry, India

Definition Autologous blood transfusion is the collection of blood from a single patient and retransfusion back to the same patient when required.

Allogenic blood transfusion contrast ---- where blood from unrelated / anonymous donors is transfused to the recipient Why?? Fear – Infection ,, resource ,,!!

Advantages of ABT - in short Can avoid many complication associated with allogenic transfusion Acute hemolytic reactions ® Allergic & febrile reactions (I) Transmission of diseases Hepatitis – B,AIDS,Syphilis, Malaria, CJD (I) 22 February 2019

RIRIR Conservation of blood resources ® Avoidance of immunosuppressive effects of allogenic transfusion (I) Patient’s with rare blood group are benefited ® allows the availability of fresh whole blood for transfusion

History Reinfusion of blood was employed as early as 1818 & pre-operative donation was advocated in 1930s Blood salvaging was reported during neuro-surgical & obstetric procedures from 1936 Fantus in 1937 when he founded the first blood bank in the USA During the last 20 years there is a increase in the use of ABT.

Techniques of ABT 3 different techniques available Pre-operative blood donation Acute normo-volumic hemo-dilution Intra & post-operative blood salvage Advantages, applications & complications vary with each technique 22 February 2019

Pre-operative Autologous blood donation (PABD) Elective case Blood loss expected Hb > 11 gm % 50 Kg but less 2 – 85 years

This is also ok Adolescents & children below 10 years also can be a candidate if cooperative Elderly patients can safely donate. Obstetric patients A history of Hepatitis-B or AIDS

contraindications Bacteremia Anemia Unstable angina, severe CAD, severe aortic stenosis Disadvantages: Logistic planning , wastage ,

Conduct Pre donation usually begins 4-5 weeks before the proposed surgery, depending on the number of units required Usually one donation per week is done. In 5 weeks we can have 5 units of blood Iron – oral or IV EPO No special complications to pre-donations Vasovagal reactions for which no Rx is needed This is higher is women and first time donors

Time interval between the last donation and the surgery should be more than 72 hours

Conduct Separately labeled ABO & Rh typing is done again Screening for Hepatitis B and AIDS are not mandatory No cross matching is required If CPDA-1 is used as preservative the blood can be stored as whole blood for 35 days Separation into plasma and RBC increases the shelf life to 42 days If more storing is required the RBC can be frozen and stored

Rethink The lower preoperative Hb at the start of surgery increases the need for peri operative transfusion, which may offset some of the benefits. Erythropoiesis !!

Autologous blood should not be given merely because it is available. The same criteria used for the transfusion of homologous blood are generally recommended when transfusing autologous blood

PABT Indications and advantages Contraindications Conduct Disadvantages Complications ??

Acute Normovolaemic Haemodilution removal of blood from the surgical patient immediately before or just after the induction of anaesthesia, and its replacement with asanguinous fluid. No predonation. donation is done at the time of surgery, and the lost volume is replaced by crystalloids or colloids 22 February 2019

Advantages Provides fresh whole blood for transfusion. No biochemical alterations associated with storage. Removed blood is kept in the OR in room temperature, so no chance of hypothermia Platelet function is preserved No reduction in oxygen carrying capacity RBC loss during surgery is less as it is diluted with asanguinous fluid Haemodilution decreases blood viscosity , which improves tissue perfusion

Advantages Possible during emergency surgeries also Patients with systemic diseases also can undergo ANH, as they are not ideal for pre donation Can decrease the use of allogenic transfusions to 50 – 90 % , as we need only 1 or 2 units of blood for most of the surgeries, which is possible by ANH ANH is simple and less expensive than pre-donation & cell savage

Can decrease this

Physiology ↓ in haematocrit,↑ in cardiac output ↓ viscosity, ↑ venous return, improved systolic function (sympathetic drive) Increased oxygen extraction at tissue rightward shift of the ODC Increased CO is due primarily to an increase in stroke volume without significant changes in heart rate. no hypovolemia

Advantages Any patient with an adequate haemoglobin (11gm) - expected to lose 25% of estimated blood volume Both children & elderly can donate, the overall health status of the patient is more important than the chronological age Patients for general, vascular, spine, orthopaedic, obstretric & plastic surgeries are good candidates Jevohah’s witness patients also agree to ANH

Target hematocrit Moderate hemodilution is defined as a final Hct between 25% and 30%; severe hemodilution, which is not routinely employed, is defined as a Hct between 10% and 20%.

Relative contraindication Coagulation defect Renal failure Severe pulmonary disease Severe hypertension Underlying cardiac disease Significant cerebrovascular disease Infant less than 6 months of age

How much to take !! patient’s current blood volume (BV), initial Hct (H1) desired Hct (H2) ANH volume = BV (H1 – H2) / HAV = 5 ( 45-30) / 37.5 = 2 litres

Blood is withdrawn from a central or peripheral vein or radial artery. Blood is collected in standard blood bags containing CPD. Replacement Crystalloid 3:1 Colloids 1:1

Conduct Once the blood is collected, it may be kept at room temperature for up to 4–6 h. If the blood is not to be reinfused within 6 h, it should be refrigerated, used within 24 h. CVP IAP First is the last!!

Complications Myocardial ischemia and Cerebral hypoxia are the major potential complications, but are very rare in usual circumstances. Hct of 15% and 25%. + LVH or CAD !! factors that increase oxygen consumption, pain, shivering and fever, - beware !!

‘augmented ANH’. ANH + artificial blood ANH + erythropoietin therapy

ANH Conduct physiology Advantages Problems

Intra operative blood salvage

nineteenth century – started Initially used in cardiac surgery, the technique is now used in over 3,50 000 cases every year during trauma, vascular, orthopedic and gynecologic surgery, as well as liver transplantation

indications anticipated loss of greater than 20% of the patient’s blood volume or a surgical procedure in which more than 10% of the patients require allogeneic transfusions.

Procedure With the use of special equipments the blood is collected from the operative field and draining sites. Recovered blood is mixed with anticoagulant is collected in a reservoir with a filter. Micro aggregate filter(40 micron) The filtered blood is then washed with saline. The RBCs suspended in the saline are then pumped into a re-infusion bag. Most of the WBCs, platelets, clotting factors, cell fragments and other debris are eliminated.

Three types Continuous Semi continuous devices Disposable where no washing

Pearls The vacuum pressure should be between 0 and 40 mm Hg. The procedure can be carried out for up to 12 h after operation or until a maximum of 1500 ml is transfused. Combined intra- and postoperative cell salvage is increasingly used for joint replacement surgery

Can be done !! Cochrane review of 49 randomized controlled trials over a 24-yr period showed that the use of cell salvage reduced the rate of exposure to allogenic blood transfusion by 40%. It did not adversely affect mortality or complications such as bleeding, infection, myocardial infarction, thrombosis and stroke.

Absolute contraindications Bacterial contamination of the surgical site Presence of amniotic fluid Presence of local hemostatic agents Cancer surgery (?) The reinfusion of salvaged blood from an ectopic pregnancy is considered acceptable

We used to do like this But later abandoned it

Cautions complex specialized equipment Trained personnel The blood salvaged may contain cell debris, free haemoglobin and micro-aggregates. several devices available

Complications Infection Disseminated intravascular coagulopathy Hemolysis- renal dysfunction Pulmonary dysfunction Air/fat embolism

Routine use of intra & post op blood salvage ??? Not much useful

Thank you all