KEY POINTS

1. Reinfusion of shed blood was employed as early as 1818. Preoperative donation of autologous blood was advocated in the 1930s, when the first blood banks were established. Autologous transfusion has grown in popularity in response to the increase in complex operative procedures and new technologic advances that allow its safe use.
2. The two primary reasons for employing autologous transfusion are (a) avoidance of complications associated with allogeneic transfusion and (b) conservation of blood resources.
3. The three types of autologous blood transfusion are preoperative autologous donation (PAD), acute normovolemic hemodilution (ANH), and intraoperative and postoperative blood recovery (salvage).
4. PAD became accepted as a standard practice in certain elective surgical settings such as total joint replacement surgery, so that by 1992 over 6% of the blood transfused in the U.S. was autologous. Subsequently, substantial improvements in blood safety have been accompanied by a decline in PAD as well as an interest in acute normovolemic hemodilution (ANH) as an alternative, lower cost strategy.

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5. The criteria for autologous donors are not as stringent as those for allogeneic donors. 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 the blood reactive for hepatitis B surface antigen and human immunodeficiency virus because of concerns for the safety of both patients and personnel. Contraindications include evidence of infection and risk of bacteremia, scheduled surgery for correction of aortic stenosis, and unstable angina.
6. Although autologous blood collections have become popular, the costs associated with their collection are higher than those associated with the collection of allogeneic blood.
7. ANH is the removal of whole blood from a patient, while restoring the circulating blood volume with an acellular fluid shortly before an anticipated significant surgical blood loss. The chief benefit of ANH is the reduction of red blood cell losses when whole blood is shed perioperatively at lower hematocrit levels after ANH is completed.
8. Since there is no good evidence that either PAD or ANH is effective at eliminating allogeneic blood transfusions, these autologous blood collection techniques cannot be considered cost-effective alternatives to allogeneic blood.
9. The term intraoperative blood collection or recovery describes the technique of collecting and reinfusing blood lost by a patient during surgery. The oxygen-transport properties of recovered red blood cells are equivalent to stored allogeneic red blood cells. The survival of recovered blood cells appears to be at least comparable to that of transfused allogeneic red blood cells.
10. Postoperative blood collection denotes the recovery of blood from surgical drains followed by reinfusion, with or without processing. Postoperative autologous blood transfusion is practiced widely, but not uniformly.
11. Fibrin glue is derived from a source of fibrinogen and Factor XIII (fibrin-stabilizing factor), in which a solution of fibrinogen is mixed with a solution of thrombin and applied to a surgical field. These preparations represent additional allogeneic blood donor exposure. Patients should be made aware of the potential complications as well as the potential benefits.
12. Recombinant FVIIa (rFVIIa) has been approved for treatment of bleeding in hemophilia patients with inhibitors. It has also been successful in nonhemophilia patients with acquired antibodies against FVIII (acquired hemophilia). Pharmacologic doses of rFVIIa enhance the thrombin generation on already activated platelets and, therefore, may also be of benefit in providing hemostasis in other situations, such as those characterized by profuse bleeding and impaired thrombin generation.
13. Bloodless medicine and surgery is defined using a team approach that reduces blood loss and employs the best available alternatives to allogeneic transfusion therapy, while focusing on the provision of the best possible medical care to all patients. Some patients, however, object to receiving blood or blood products as part of their medical treatment on religious grounds or because of concern about the safety of blood transfusions, regardless of their religious background.