Allogeneic transfusion requirements after autologous donations in posterior lumbar surgeries

STUDY DESIGN

A retrospective study of blood transfusion practices after posterior lumbar spine surgery was performed.

OBJECTIVES

To determine the overall use rate of autologous blood donations for different spine surgeries, and to identify the risk of requiring additional allogeneic blood transfusions.

SUMMARY OF BACKGROUND DATA

In an attempt to avoid allogeneic blood transfusions and its associated risks, patients frequently are asked to donate autologous blood before many elective spine surgeries. There is a lack of published data on the use rate for these autologous blood donations, and on their ability to prevent allogeneic blood exposure.

METHODS

A retrospective review of hospital charts and blood bank records was conducted on 191 consecutive patients who had undergone three categories of lumbar spine surgery: laminectomy alone, laminectomy with a noninstrumented posterolateral fusion, and laminectomy with an instrumented posterolateral fusion.

RESULTS

Nearly 80% of the autologous blood donated by patients who underwent simple laminectomies was wasted. However, the vast majority (70-90%) of patients who underwent fusion used their autologous blood. In the patients who underwent fusion, autologous blood donations decreased the risk of allogenic blood transfusions by 75% in noninstrumented fusions and 50% in instrumented fusions, as compared with the patients who elected not to donate blood before the fusion (P < 0.05). A substantial number of patients who underwent instrumented fusions (nearly 40%) required additional allogeneic blood transfusions despite predonation of blood.

CONCLUSIONS

Autologous blood donations are indeed advantageous in decreasing allogeneic blood usage of patients undergoing fusion, but additional methods of blood conservation (intraoperative salvage and preoperative erythropoietin) seem necessary to diminish the allogeneic blood requirements further, especially in those patients undergoing instrumented lumbar fusion.

[Factors associated with blood transfusion during anesthesia for scheduled hip or knee arthroplasty in France]

GOAL OF THE STUDY

To determine over a whole country what are the factors associated with an intraoperative homologous blood transfusion and with the use of autologous techniques (preoperative autologous blood donation: PABD; acute normovolemic hemodilution: ANVH; intraoperative red cell salvage: IRCS).

STUDY DESIGN

National enquiry using a large representative sample (3 days of anaesthesia in France).

METHODS

Univariate followed by multivariate analyses of data gathered in 1996 during the survey leaded by the French society of anaesthesia and intensive care (Sfar) and corresponding to 884 scheduled hip and knee prosthesis surgical procedures.

RESULTS

Factors associated with a decreased use of PABD programme were: 1--old age and high ASA physical status; 2--procedures of short duration. By contrast, an increased use of PABD was associated with anaesthetics in which a closed circuit had been used. Except for a significant association with increasing age and with absence of PABD used, no additional factor was found to be linked with ANVH. No factor among those studied was found related to the use of IRCS. Homologous blood transfusion was more frequently used in ASA > or = 3 patients, in long duration surgeries while its use was decreased in patients with PABD (odds ratio--for reduction by PABD: 4.4 [95% confidence interval: 2.2-8.8]). Homologous blood transfusion was not related to the use of ANVH or IRCS.

CONCLUSION

These data obtained from a large national survey confirm previously published studies and meta-analyses and are in agreement with current recommendations. An unexpected relation between PABD and closed circuit anaesthesia has been found.

Autologous blood transfusion in the United States: clinical and nonclinical determinants of use

BACKGROUND

Preoperative donation of blood lowers the risk of allogeneic RBC transfusion. The use of autologous blood is not well quantified. This study aimed at identifying the frequency and determinants of use of autologous transfusion in the United States.

STUDY DESIGN AND METHODS

This national cross-sectional study, using the Nationwide Inpatient Sample, included all patients admitted to 900 hospitals in 19 states in 1996. Logistic regression with weighting yielded nationally representative results for the independent effects of clinical and nonclinical patient characteristics on autologous blood use.

RESULTS

Autologous transfusion was used in 19 of 1000 hospitalizations. The procedures using autologous blood most frequently were knee arthroplasty, hip replacement, prostatectomy, spinal fusion, and hysterectomy. Blacks and Hispanics were less likely to receive autologous transfusion than were whites (OR, 0. 64; 95% CI, 0.45-0.83); patients with Medicaid were less likely than the privately insured to receive autologous transfusions (OR, 0.29; 95% CI, 0.20-0.43), with racial differences greatest among the privately insured. Women received autologous blood for cardiovascular surgeries much less often than men (OR, 0.32; 95% CI, 0.20-0.49).

CONCLUSION

Ethnic minorities, women, and patients with Medicaid appear to receive fewer autologous blood transfusions than the rest of the population. Although this could reflect either better or worse quality of care, nonclinical determinants of transfusion practice warrant attention and further investigation.

[Prospective study of the causes for destruction of labile blood products during 1999 at a University Hospital Center]

The destruction of the blood cell product (BCP) is a situation which is hard to accept in the present context of transfusional safety which aims at covering the transfusional needs in the most appropriate way. In our University Hospital, 500 BCP out of 20,000 are destroyed per year, which represent a cost of 100,000 $. A prospective research was carried out from January 1st to December 31st 1999 in order to analyse the causes of the destruction of the BCP and to differentiate the inevitable destructions for the patient's security from the avoidable destructions which might have benefited from corrective measures. For each group of simultaneously destroyed BCP, an information note specified the patient's pathology, the reasons for the prescription, the number and the type of transfused and destroyed BCP in the same day, the time spent between distribution and return, and the causes of destruction. In 1999, a total of 483 LBP out of 19,802 which were distributed, have been returned and destroyed, that is to say 2.4% for a 99.3% traceability which involved 242 patients. Among these destroyed BCP, 28.3% came from inevitable causes--death or acute intensive care which needed a lot of transfusions--69.7% were categorised as being related to avoidable causes depending on the organisation of transport and care, unadapted safety measures. The corrective measures to be taken, concern the improvement of transport procedures, the set-up of a nominative BCP reservation system in the Blood Center, the scheduling of the BCP deliveries from the blood bank, and a better adaptation of the safety measures to the transfusional needs.

Autologous transfusion in surgical patients at Kenyatta National Hospital, Nairobi

OBJECTIVE

To identify autotransfusion strategies and their basis in elective surgery patients.

DESIGN

A cross sectional prospective study.

SETTING

General surgery and orthopaedic wards, Kenyatta National Hospital, Nairobi.

SUBJECTS

Adult patients of both sexes planned for elective surgery.

MAIN OUTCOME MEASURE

Forevery patient, the following were enquired about and documented: age in years, sex, ethnicity, religion, occupation and educational standard. Blood values of haemoglobin, platelet counts, total and differential white cell counts, urea, electrolytes and liver function tests were assayed. Others were the number of units of blood donated before the operation, the type of surgery performed, time taken from diagnosis to performing the operation and whether the blood was transfused preoperatively, intraoperatively and postoperatively.

RESULTS

A total of sixty three cases constituting five per cent of all surgical patients admitted during the period of study were evaluated. Of these 53 (84%) were males and ten (16%) females. The age range was 15 to 65 years with a peak at 45-49 years. There were more Christians (90%) than Muslims (10%). In all, 32 (51.6%) had primary school education, 23 (36.5%) secondary school education, seven (11.3%) no formal education and one (1.6%) had attained college level. Employment pattern showed 50% were civil servants, 30% were self employed and 20% were unemployed. The duration of disease ranged from 1-24 weeks with two peaks at two weeks and six weeks. Orthopaedic cases constituted 78.7% and general surgery 21.3%. Preoperative haemoglobin ranged from 13.5-14.2 g/dl. Transfusions were given intraoperatively to 41 (66.1%) and to 12 (33.9%) postoperatively. Mean duration of hospitalisation was 13 days (range 5 to 21 days). 98.4% deposited only one unit while 1.6% deposited four units of blood. Only one patient required additional transfusion from homologous donors.

CONCLUSION

The strategies and basis for autotransfusion have been demonstrated among a majority of adult patients requiring orthopaedic procedures. Major determinants are shown to be baseline blood count profiles and time to operation.

Autotransfusion in cardiac surgery

There are a number of problems with allogeneic blood transfusion. Some of these problems are defined and can be quantified, such as the problem of rising cost or the risk of viral infection, but some of the problems are not well defined and it is only outcome data that point to allogeneic blood transfusion contributing to patient mortality and morbidity. Autotransfusion includes any technique in which the patient's own blood is collected, processed and stored, followed by reinfusion when circumstances dictate. In the perioperative period of cardiac surgery, a number of techniques are recognized as useful in this context. Preoperative autologous donation, with or without erythropoietin supplementation, intraoperative acute normovolaemic haemodilution, intraoperative cell salvage, postoperative cell salvage (reinfusion of shed mediastinal blood) and platelet rich plasmapheresis are all techniques which are used with more or less enthusiasm to reduce the need for an allogeneic blood transfusion. Modification of the priming technique of the cardiopulmonary bypass circuit using an autologous blood prime is included in this review even though it does not fall strictly within the definition of autotransfusion. Although autotransfusion is not the answer to every problem, there is no doubt that it should play a significant part in the strategy of blood conservation.

Current status of bacterial contamination of autologous blood for transfusion

Autologous transfusion, although not without risk, does decrease the risk of transmitted diseases via homologous transfusion. However, strict quality control is required for autologous transfusion. In Japan, a recent enactment requires that written informed consent be obtained prior to blood transfusion, which therefore requires that clinicians provide sufficient explanation of the risks involved with this procedure. To the best of our knowledge, this is the first study to comprehensively evaluate the manner in which the safety of autologous blood transfusion can be compromised by bacterial contamination. For a 24-month period, between April 1996 and March 1998, bacterial contamination of all kinds of autologous blood samples was tested by sampling the culture immediately prior to transfusion. Subculturing, identification and susceptibility testing of the isolates were performed. From the 287 units of all kinds of autologous blood transfused, 18 were culture positive (6.3%). Positive blood cultures were obtained in two of the 59 units (3.4%) of autologous transfusion donated preoperatively (ATDP) that was infused intraoperatively, in three of the 117 units (2.6%) of hemodilution/autologous transfusion (HAT) and in three of the 81 (3.7%) of ATDP infused postoperatively. There was a high percentage (33.3%) of positive blood cultures in the cases of intraoperative blood salvage (IOBS). The total rate of positive blood cultures was 6.3% including IOBS and 3.1% excluding IOBS. The most common microorganism isolated from autologous blood was coagulase-negative Staphylococci in 12 of 18 culture-positive units (66.7%). Alpha Streptococcus uiridans was isolated in 2 units (11%) and Staphylococcus aureus was isolated in 1 unit (5.5%). However, none of the patients who received the culture-positive autotransfusion blood showed clinical signs or laboratory findings of bacteremia. Safe ATDP is threatened by bacterial contamination that can be introduced by numerous sources, such as the donors' blood, the skin at the site of venipuncture, the environment and the phlebotomist's finger. In the cases of IOBS, protection against bacterial contamination at the surgical site is crucial. Here we discuss the relevance of our findings to the efforts to minimize the risks of contamination associated with autologous blood transfusion; risks that must be communicated to the patient in the process of informed consent. Continued research is required to identify the safest method of autologous blood transfusion.

Utilization of technologies to reduce allogeneic blood transfusion in the United States

Concern over safety of the blood supply has led to the use of technologies to reduce allogeneic blood transfusion. The objective of this research was to determine the utilization of these technologies in the United States. We evaluated the following techniques: preoperative autologous donation (PAD), cell salvage (CS) and acute normovolemic haemodilution (ANH); and the following pharmaceuticals: aprotinin (APR), epsilon-aminocaproic acid (EACA), tranexamic acid (TXA), desmopressin (DDAVP) and recombinant human erythropoietin (EPO). In 1997, we conducted a cross-sectional mail survey of service chiefs at 1000 US hospitals randomly selected and stratified by status as a provider of open-heart surgery, geographical location and hospital bed size. Sixty-nine per cent (690) of hospitals responded to at least one of the four surveys sent to each hospital. Hospitals reported use of techniques more than pharmaceuticals (P < 0.001); PAD (83%, n = 206) and CS (82% n = 420) were used most frequently. Lack of familiarity was the most common reason cited for infrequent use of pharmaceuticals. Organizational characteristics (e.g. provision of open-heart surgery, size, geographical location, teaching status and type of hospital) were differentially associated with technology use. There is greater use of techniques than pharmaceuticals in US hospitals to reduce the need for allogeneic blood in the peri-operative setting. Providing open-heart surgery is strongly associated with the utilization of these technologies.

Transfusion practice in elective orthopaedic surgery

. The transfusion requirements of 2233 patients who underwent total hip or knee joint arthroplasty procedures at nine Canadian hospitals during 1995-1996 were evaluated. Although 64% of patients were eligible for participation in an autologous blood donation (ABD) programme, only 8% predonated blood. Patients who were eligible for ABD were younger (62 years vs. 70 years) and had fewer medical illnesses (18% vs. 44%) than those who did not predonate. The rate of allogeneic transfusion was 9.0% (95% confidence interval 4.9-13.1%) in patients who predonated as compared with 24.1% (95% confidence interval 22.2-25.9%) in those who did not. Risk factors for the occurrence of an allogeneic transfusion were type of procedure (primary or revision hip arthroplasty), lower baseline haemoglobin, lower body weight, older age and presence of rheumatoid arthritis (P < 0.001). Only patients without risk factors were predicted to have a less than 10% risk of receiving an allogeneic transfusion. Use of preventive strategies was minimal. Two models designed to predict the occurrence of an allogeneic transfusion were evaluated. If allogeneic transfusion rates are to be reduced, eligible patients should be encouraged to participate in ABD programmes. For patients who are ineligible, other preventative strategies should be introduced.

Intra-operative blood salvage in abdominal trauma: a review of 5 years' experience

We performed a retrospective audit of 1235 patients presenting between 1992 and 1997, following the introduction of intra-operative blood salvage at our hospital. Twenty-two cases of severe abdominal trauma requiring emergency laparotomy and intra-operative blood salvage were identified. The impact of intra-operative blood salvage in aiding resuscitation and reducing demand on allogeneic blood supplies is discussed.

Autologous blood donation and transfusion in Europe

BACKGROUND AND OBJECTIVES

The aim of this study was to record practices in autologous blood transfusion in Europe in 1997.

MATERIALS AND METHODS

A questionnaire mainly about predeposit was distributed to the National Representatives of all 41 member states of the Council of Europe's Committee of Experts on Blood Transfusion and Haematology. Replies were received from 29.

RESULTS AND CONCLUSION

Autologous blood units collected in 1997 amounted to 4.2% of the allogeneic units, with wide variations between countries. Predeposit was used most frequently in Italy (8.9%), Germany (7.1%) and France (6.6%). Some countries, notably Scandinavia, do not encourage predeposit, chiefly on the grounds that it is not cost-effective, but others are promoting its use.

[The use of autotransfusion in general surgery]

Authors expose their experience with autotransfusion, made during several years in a general surgery university department. Discussion is made about ethic and economical aspect of the philosophy guiding the most general concept of blood sparing, and different methods of autotransfusion; attention is then focused on practical experience made during two years (1995-1997) when the program worked well. On the whole, in 94 patients, 172 blood units were collected plus 10 plasma units obtained by aferesis. No method-related complications are have been observed. Elements who corresponded to difficulties or obstacles to the fully application of the method have been critically analyzed. Authors propose finally guide-lines which want to be valid proposal to increase method use while respecting at the best ethics, economics, efficacy and efficiency that must guide our work.

[Analysis of a blood use list for orthopedic operations]

OBJECTIVE

Is the documentation of blood utilisation, as demanded in the guidelines of serology and transfusion medicine, a proper instrument of quality control for the use of homologous blood saving techniques?

PATIENTS AND METHODS

We analysed retrospectively a list of blood utilisation based on 12,482 surgical procedures in orthopaedic surgery. This list included the type of operation, the number of transfused packed red cell units and, if applicable, the type of homologous blood saving technique (preoperative blood donation, mechanical autotransfusion and isovolaemic haemodilution). Total hip and knee replacement patients were divided in two groups according to base line haemoglobin (A: Hb > 13 mg%, B: hB < or = 13 mg%).

RESULTS

The increase of the percentage of patients not receiving homologous blood achieved by blood saving techniques is more pronounced in group B. Preoperative blood donation seems to be the most effective technique with a percentage of patients not receiving homologous blood of 93% in group A and 80% in group B of total hip replacement. This high percentage cannot be improved when preoperative blood donation is combined with mechanical autotransfusion or isovolaemic haemodilution. The efficiency of mechanical autotransfusion and isovolaemic haemodilution can be improved by combination of the two techniques.

CONCLUSIONS

A list of blood utilisation as presented can serve as a basis for guidelines regarding the use of homologous blood saving techniques. Moreover such a simple statistic provides a means of quality control and provides information about the likelihood of transfusion.

Use of autologous blood in general surgery

BACKGROUND/AIMS

Autologous blood predonation is still not as widespread as it should be in general surgery practice, even if the method is well-known and has benefits established in international literature. Authors describe the impact of an autotransfusion program, in a general surgery university department, focusing on management and cost problems.

METHODOLOGY

A description of the efficacy of the program during a yearlong activity period is presented. An analysis has been made about the quantity of predonated blood/plasma units, the quantity actually transfused and use of homologous blood. The problems which occurred and the cost are discussed.

RESULTS

The most used autotransfusion method was preoperative predeposit of autologous blood. The analysis of results focused on some organizational problems that need to be avoided in order to show the methods maximum benefits. In a large number of cases (some 50%) predeposit was not made because of several managing/technical problems. In another large number of cases (38%) the quantity of units predonated did not fully supply the needs and several patients received homologous products. In another number of cases predonated blood units were not used at all (61/34%).

CONCLUSIONS

Predeposit, preoperative hemodilution and intraoperative recovery, are methods that should all be available in a general surgery department to manage in the best way the single patients blood/plasma needs, reducing post-transfusion complication. To optimize the program and minimize waste some guidelines must be established, with the aim of a rational and correct use of the procedure. Despite the value of the method, and the favor encountered by the patients, we must not forget that the use of autologous blood is not costless.

[Preoperative autologous blood donation and transfusion in gynecology]

BACKGROUND

Autologous transfusions reduce the risk of alloimmune and infectious complications of allogenic blood transfusions. We have evaluated preoperative autologous blood donation practice in relation to patients characteristics and surgical technique.

METHODS

In the Obstetrics and Gynecology Department of Genoa University, we enrolled 462 patients in an autologous transfusion program during 1997. We did not analyze 105 patients who underwent minor surgery. Patients with hemoglobin lower than 11 g/dl or with other risks related to autotransfusion have been excluded; 284 (79.5%) patients have been able to make preoperative autologous blood donations. Patients who did not undergo predeposit have utilised type screen or cross reaction for a possible who did eterologous transfusion. We have analysed the two groups of patients for kind of pathology, for number of heterologous blood units used, for number of transfused patients and we have considered the mean of the units received by each of them.

RESULTS

44 of the 284 predeposited blood units were reinfused while 10 patients, who did not undergo predeposit, were transfused. Heterologous transfusion was done in 1.06% of the cases that underwent predeposit. Oncologic patients underwent predeposit in 83% of the cases.

CONCLUSIONS

We have concluded that autologous blood donation reduces the risk of allogenic blood transfusion especially in oncologic surgery.

An analysis of a preoperative pediatric autologous blood donation program

OBJECTIVE

To determine the efficacy of a pediatric autologous blood donation program.

DESIGN

A retrospective study of patient charts and blood-bank records.

SETTING

The Children's Hospital of Eastern Ontario, Ottawa, a tertiary care, pediatric centre.

PATIENTS

One hundred and seventy-three children who received blood transfusions for a total of 182 procedures between June 1987 and June 1997.

INTERVENTIONS

Autologous and homologous blood transfusion required for major surgical intervention, primarily spinal fusion.

MAIN OUTCOME MEASURES

Surgeons' accuracy in predicting the number of autologous blood units required for a given procedure, compliance rate (children's ability to donate the requested volume of blood), utilization rate of autologous units and rate of allogeneic transfusion.

RESULTS

The surgeons' accuracy in predicting the number of autologous units required for a given procedure was 53.8%. The compliance rate of children to donate the requested amount of blood was 80.3%. In children below the standard age and weight criteria for blood donation the compliance rate was 75.5%. The utilization rate of autologous units obtained was 84.4% and the incidence of allogeneic transfusion was 26.6%.

CONCLUSIONS

There was a high rate of compliance and utilization of predonated autologous blood in the children in the study. Preoperative blood donation programs are safe and effective in children, even in those below the standard age and weight criteria of 10 years and 40 kg.

[Epidemiological information obtained from anti-hepatitis C virus screening in blood donors and candidates for autologous transfusion from 1992 to 1996 in the Alpes-Maritimes region]

OBJECTIVES

To determine the evolution of the frequency of anti-hepatitis C virus antibodies from 1992 to 1996 in blood donors and in candidates for autologous transfusion in the Alpes-Maritimes region and to assess risk factors.

METHODS

Anti-hepatitis C virus antibodies were assessed by second generation ELISA in 1992 and in the first quarter of 1993, and then by third generation ELISA; in all cases, anti-hepatitis C virus antibodies were confirmed by RIBA test.

RESULTS

Since 1992 (when the second generation ELISA test became available), the prevalence of anti-hepatitis C virus antibodies in blood donors in the Alpes-Maritimes region (0.54% in 1992 to 0.20% in 1996) has decreased. Positive ELISA anti-hepatitis C virus was confirmed by RIBA in 53 to 68% of anti-hepatitis C virus blood donations. The percentage of anti-hepatitis C virus donors with ALT above the upper limit (donation exclusion threshold) was between 28 and 56%.The most frequent age interval for new anti-hepatitis C virus positive donors was between 30 and 40 years. Since 1992, a third of the anti-hepatitis C virus blood donors agreed to participate in a medical history questionnaire. One or several risk factors were found in almost all donors. The most frequent source of infection was nosocomial (50%). During the 5 years of the study, the number of candidates for autologous transfusion increased: 717 in 1992 to 1 528 in 1996. The prevalence of anti-hepatitis C virus in this older population (mean age: 64 years) decreased progressively (2.9% in 1992 to 1.1% in 1996, P<0, 01) since the prevalence of anti-HBc remained stable, near 12%. Among the 96 subjects found to be anti-hepatitis C virus positive before an autologous transfusion, 49 were transfused before 1990 and 40 had a history of surgery.

CONCLUSION

The prevalence of anti-hepatitis C virus has decreased since 1992 in blood donors and in candidates for autologous transfusion which may suggest that there is better screening in the general population and presenting the spread of hepatitis C virus infection.

The use of a blood conservation pressure transducer system in critically ill patients

We tried to determine if a blood conservation pressure transducer system reduced blood transfusions, increased haemoglobin concentration or reduced line infections in critically ill patients. One hundred patients were randomly allocated to conventional or blood conserving systems attached to systemic and pulmonary arterial catheters. Intravascular lines were cultured after removal. There were no significant differences in transfusions or haemoglobin concentration. Blood conservation: median units transfused, 2 (range 0-19); mean haemoglobin at 7 days, 11.2 g.dl-1 (SD, 1.0). Conventional: median units, 2 (range 0-34); mean haemoglobin at 7 days, 11.1 g.dl-1 (SD 1.0). Thirty-seven of 99 arterial lines were colonised in the controls compared with 29 of 96 in the blood conservation group. Patients who required haemofiltration in both groups had significantly increased transfusion requirements. Haemofiltration: median 6 units (range 0-34) vs. non-haemofiltered: median 1 (range 0-14; p < 0.001). There were no significant differences in transfusions, haemoglobin concentration or line colonisation with the blood conservation system. There is considerable potential for blood conservation during haemofiltration.