1. Blood Transfusion Joanne Simpson Anaesthetic SHO

2. Indications Blood Loss Bone Marrow Failure Inherited RBC disorders Acquired RBC disorders Neonatal and Exchange Transfusions

3. Documentation Given the potential risks involved with blood transfusion, the indication for each transfusion should be written clearly in the patients notes The identity of the patient and the units to be transfused should be checked carefully

4. Risks of Allogenic Transfusion Transmission of infections Immunomodulation Transfusion Reaction

5. Long Term Concerns Costly Human Errors in Transfusion Limited supply Viruses and Bacteria not screened for

6. Blood Sparing Strategies

7. Who will benefit? Jehovah’s Witnesses Patients with multiple antibodies Patients anxious about receiving blood transfusions from unknown donors However, Only available to selected patients in practice

8. Preoperative Autologous Blood Transfusion This involves the collection of 2-4 units of blood. The first unit is collected approx 2weeks before surgery, the second is collected around 7-10days before surgery Iron replacement is usually given Some centres give the patient erythropoietin to enable greater numbers of units to be collected.

9. Advantages RBC’s can be stored for up to 5 weeks pre operatively Some people are able to donate up to 4 units pre op Many of the disadvantages of allogenic blood transfusion is avoided

10. Disadvantages Patient Selection Close collaboration between surgeon, patient and transfusion lab essential High cost Units may still become contaminated in storage Patient may still require extra units Blood may be wasted if operation is cancelled

11. Erythropoietin Several studies performed showing the effectiveness of EPO Study by De Andrande showed that by using EPO pre op the allogenic transfusion rate fell from 45% to 16% in the treated group

12. Erythropoietin Sign Guidelines: Erythropoietin use should be targeted to patients aged under 70 years who are scheduled for major blood loosing surgery and who have a presenting haemoglobin of <130g/L Erythropoietin can be used to prepare patients with objections to allogenic transfusion for surgery that involves major blood loss

13. Disadvantages Cost Risks of hypertension Risks of thrombosis

14. Acute Normovolaemic Haemodilution Removal of whole blood and the restoration of blood volume with acellular fluid shortly before anticipated blood loss This blood may then be reinfused either in the operation or post operatively Bryson et al in 1998 conducted a trial and concluded that ANH reduced perioperative allogenic transfusion. This has also been shown by further trials

15. Disadvantages Patient Selection Should only be undertaken where the logistics of intra operative blood removal can be undertaken without detracting from patient care Extra paperwork in labelling Autologous blood intra operatively

16. Antifibrinolytic Drugs The use of Aprotinin, Tranexamic Acid or Epsilon-aminocaproic Acid to reduce intra operative bleeding and the requirement for transfusion These drugs significantly reduce blood loss (p=0.001) and transfusion requirements as found by Laupacis et al in 1997 as well as others

17. Disadvantages Increased risks of thrombosis Deterioration in renal function Allergy Lack of evidence for the use of antifibrinolytic drugs in certain operations

18. Cell Salvage Allows blood to be reinfused into patients using suction catheters and filtration systems Blood may be washed or unwashed May be reinfused intra or post operatively A study by Huet et al in 1998 confirms that cell salvage can reduce the need for allogenic transfusion

19. Advantages to patient and clinician No transfusion reactions No disease transmissions No alloimmunisations No immunomodulation Safer Readily available blood in major haemorrhage Cheaper than using donor blood

20. Disadvantages Coagulation Disorders when large volumes (>1500ml) are reinfused Unwashed systems may give bacterial transmission Initial set up costs

21. Jehovah’s Witnesses Many refuse any type of blood transfusion based on biblical beliefs Also refuse autologous blood transfusion Ethical dilemmas occur in treating this patient group

22. Jehovah’s Witnesses Many accept Recombinant Human Erythropoietin but not the versions with traces of human albumin Will accept Acute Normovolaemic Haemodilution and intra operative cell salvage as long as the blood is kept in continual contact with the patients circulation Some will accept blood transfusion and not tell members of their religion

23. Summary Allogenic Transfusion is not without risks There are feasible alternatives available to allogenic transfusion Jehovah’s witnesses present an ethical problem when it comes to blood transfusion, but there are acceptable alternatives

24. References SIGN Guideline number 54 Oxford Handbook of Haematology BMJ Volume 311, 28/5/95 – Management of Blood loss in Jehovah’s Witnesses Haemoclaim, Blood Salvage Website, www.nwpgroup.com www.nwpgroup.com www.urology.medsch.ucla.edu/blood_tran sfusions.htm www.urology.medsch.ucla.edu/blood_tran sfusions.htm

25. References Huet C, Salmi LR, Fergusson D, Koopman-van Gemert AW, Rubens F, Laupacis A. A meta-analysis of the effectiveness of cell salvage to minimize perioperative allogeneic blood transfusion in cardiac and orthopaedic surgery. International Study of Perioperative Transfusion (ISPOT) Investigators. Anesth Analg 1999; 89: 861-9 Laupacis A, Fergusson D. Drugs to minimize perioperative blood loss in cardiac surgery: meta- analyses using perioperative blood transfusion as the outcome. The International Study of Peri-operative Transfusion (ISPOT) Investigators. Anesth Analg 1997; 85: 1258-67.

26. References Bryson GL, Laupacis A, Wells GA. Does acute normovolemic hemodilution reduce perioperative allogeneic transfusion? A meta-analysis. The International Study of Perioperative Transfusion. Anesth Analg 1998; 86: 9-15. de Andrade JR, Jove M, Landon G, Frei D, Guilfoyle M, Young DC. Baseline haemoglobin as a predictor of risk of transfusion and response to Epoetin alfa in orthopedic surgery patients. Am J Orthop 1996; 25: 533-42.

27. Questions?