Blood TransfusionJoanne Simpson

Anaesthetic SHO

Indications

Blood LossBone Marrow FailureInherited RBC disordersAcquired RBC disordersNeonatal and Exchange Transfusions

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

Risks of Allogenic Transfusion

Transmission of infectionsImmunomodulationTransfusion Reaction

Long Term Concerns

CostlyHuman Errors in TransfusionLimited supplyViruses and Bacteria not screened for

Blood Sparing Strategies

Who will benefit?

Jehovah’s WitnessesPatients with multiple antibodiesPatients anxious about receiving blood

transfusions from unknown donors

However,Only available to selected patients in

practice

Preoperative Autologous Blood TransfusionThis 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 givenSome centres give the patient

erythropoietin to enable greater numbers of units to be collected.

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

Disadvantages

Patient SelectionClose collaboration between surgeon,

patient and transfusion lab essentialHigh costUnits may still become contaminated in

storagePatient may still require extra unitsBlood may be wasted if operation is

cancelled

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

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

Disadvantages

CostRisks of hypertensionRisks of thrombosis

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

Disadvantages

Patient SelectionShould 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

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

Disadvantages

Increased risks of thrombosisDeterioration in renal functionAllergyLack of evidence for the use of

antifibrinolytic drugs in certain operations

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

Advantages to patient and clinician

No transfusion reactionsNo disease transmissionsNo alloimmunisationsNo immunomodulationSaferReadily available blood in major

haemorrhageCheaper than using donor blood

Disadvantages

Coagulation Disorders when large volumes (>1500ml) are reinfused

Unwashed systems may give bacterial transmission

Initial set up costs

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

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

Summary

Allogenic Transfusion is not without risksThere are feasible alternatives available to

allogenic transfusionJehovah’s witnesses present an ethical

problem when it comes to blood transfusion, but there are acceptable alternatives

References

SIGN Guideline number 54Oxford Handbook of HaematologyBMJ Volume 311, 28/5/95 – Management

of Blood loss in Jehovah’s WitnessesHaemoclaim, Blood Salvage Website,

www.nwpgroup.comwww.urology.medsch.ucla.edu/blood_tran

sfusions.htm

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.

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.

Questions?