PREOPERATIVE BLOOD DONATION
Patient Selection
The criteria for autologous donors are not as stringent as those
for allogeneic donors. The American Association of Blood Banks (AABB) Standards
for Blood Banks and Transfusion Services requires that the donor-patient's
hemoglobin (Hb) be no less than 11 g/dL or the hematocrit 33% before each donation.
[21]
There are no age or weight limits. Patients
may donate 10.5 mL/kg, in addition to testing samples. Donations may be scheduled
more than once a week, but the last should occur no less than 72 hours before surgery
to allow time for restoration of intravascular volume and for transport and testing
of the donated blood.
Transfusion service policies, implemented under the auspices of
hospital transfusion committees, differ regarding collection and use of autologous
blood with positive viral markers. It is common practice to preclude use of blood
reactive for hepatitis B surface antigen and the human immunodeficiency virus because
of concerns for the safety of both patients and personnel. Some hospitals accept
and transfuse autologous blood with any positive viral markers, and denying patients
infected with human immunodeficiency virus the opportunity to receive their own blood
could be a violation of the Americans with Disabilities Act.[22]
Candidates for preoperative collection are stable patients scheduled
for surgical procedures in which blood transfusion is likely. For procedures that
are unlikely to require transfusion (i.e., a maximal surgical blood ordering schedule
(MSBOS) does not suggest that crossmatched blood must be available),[23]
the use of preoperative blood collection is not recommended.
In selected patient subgroups, preoperative collection of autologous
blood can significantly reduce exposure to allogeneic blood. Preoperative autologous
collections should be considered for patients scheduled for procedures in which they
are likely to receive transfusion, such as major orthopedic procedures, vascular
surgery, cardiac or thoracic surgery, and radical prostatectomy.[24]
The most common surgical procedures for which autologous blood is predonated are
total joint replacements.[25]
Autologous blood
should not be collected for procedures that seldom (less than 10% of cases) require
transfusion, such as cholecystectomy, herniorrhaphy, vaginal hysterectomy, and uncomplicated
obstetric delivery.[26]
In special circumstances, preoperative autologous blood collection
can be performed for patients who would
TABLE 48-2 -- Contraindications to participation in autologous blood donation programs
|
1. Evidence of infection and risk of bacteremia |
|
2. Scheduled surgery to correct aortic stenosis |
|
3. Unstable angina |
|
4. Active seizure disorder. |
|
5. Myocardial infarction or cerebrovascular accident within 6
months of donation |
|
6. Patients with significant cardiac or pulmonary disease who
have not yet been cleared for surgery by their treating physician |
|
7. High-grade left main coronary artery disease |
|
8. Cyanotic heart disease |
|
9. Uncontrolled hypertension |
not ordinarily be considered for autologous donation. Availability of medical support
is important in assessing patient suitability. With suitable volume modification,
parental cooperation, and attention to preparation and reassurance, pediatric patients
can participate in preoperative collection programs.[27]
Patients with significant cardiac disease are considered poor risks for autologous
blood donation. Despite reports of safety in small numbers of such patients who
underwent autologous blood donation,[28]
the risks
that are associated with autologous blood donation[29]
in these patients are greater than estimated current risks of allogeneic transfusion.
[6]
[7]
Table
48-2
summarizes the medical contraindications to a patient's participation
in an autologous blood donation program.[30]
The
collection of autologous blood from women during routine pregnancy is unwarranted,
[31]
since blood is so seldom needed. PAD can be
considered for women with alloantibodies to multiple or high-incidence antigens or
with placenta previa or other conditions placing them at high risk for ante- or intrapartum
hemorrhage.[26]
AABB
TABLE 48-3 -- Endogenous erythropoietin-mediated erythropoiesis
*
|
|
RBC (mL) |
Net RBC |
|
|
Patients (n) |
Removed (Donated) |
Produced |
Expansion (%) |
Iron Therapy |
Reference |
|
Standard Phlebotomy |
|
|
|
|
|
|
|
108 |
522 |
351 |
19% |
PO |
[33]
|
|
22 |
590 |
220 |
11% |
None |
[34]
|
|
45 |
621 |
331 |
17% |
PO |
[34]
|
|
41 |
603 |
315 |
16% |
PO + IV |
[34]
|
|
Aggressive Phlebotomy |
|
|
|
|
|
|
|
30 |
540 |
397 |
19% |
None |
[35]
|
|
30 |
558 |
473 |
23% |
PO |
[35]
|
|
30 |
522 |
436 |
21% |
IV |
[35]
|
|
24 |
683 |
568 |
26% |
PO |
[38]
[39]
|
|
23 |
757 |
440 |
19% |
PO |
[40]
|
|
PO, oral; IV, intravenous. |
|
From Goodnough LT, Skikne B, Brugnara C: Erythropoietin,
iron, and erythropoiesis. Blood 96:823–833, 2000. |
*Data
are expressed as means.
Standards no longer permits allogeneic transfusion
of unused autologous units ("crossover") because autologous donors are not, in the
strictest sense, volunteer donors.[21]
Attempts to stratify patients into groups at high and low risk
for needing transfusion based on the baseline level of hemoglobin and on the type
of procedure show some promise. In a Canadian study using a point score system,
80% of patients undergoing orthopedic procedures were identified to be at low risk
(<10%) for transfusion, and therefore autologous blood procurement for these patients
would not be recommended.[32]
However, one problem
with algorithms that consider the estimated blood loss and preoperative hematocrit
is that blood losses are difficult to measure[33]
or predict, because specific surgical procedures performed even by the same surgeon
can be accompanied by a wide range of blood loss.
