Autologous Blood Donation

Patient Blood Management and Its Role in Supporting Blood Supply

Blood donors and voluntary blood donations are essential for ensuring the blood supply that can be maintained by good patient blood management (PBM) practices. This review article explores the role of blood donation in PBM and highlights the importance of donor screening and selection processes in different regions worldwide. The donor health questionnaires and the focused physical examination guidelines have changed in the last decade to increase donor and recipient safety. This article also discusses the status of transfusion practices, including the challenges of ensuring a safe blood supply. Significant among these are the effects of the COVID-19 pandemic on the blood supply chain and the impact of an aging donor population, especially. Promoting autologous donations and other blood conservation strategies are suggested to mitigate these issues. The role of replacement donors and the upper age limit for voluntary blood donation may be decided based on the demography and donor pool. The involvement of C-suite executives is also critical in implementing and running a successful PBM program. The review highlights how these different aspects of blood donation are integral to a successful PBM program and the safety of patients who receive blood transfusions.

Application of cardiovascular interventions to decrease blood loss during hepatectomy: a systematic review and meta-analysis

BACKGROUND

Perioperative bleeding and allogeneic blood transfusion are generally thought to affect the outcomes of patients. This meta-analysis aimed to determine the benefits and risks of several cardiovascular interventions in patients undergoing hepatectomy.

METHODS

In this systematic review and meta-analysis, randomised controlled trials (RCTs) were searched in the Cochrane Library, Medline, Embase, and Web of Science to February 02, 2023. RCTs focused on cardiovascular interventions aimed at reducing blood loss or blood transfusion requirements during hepatectomy were included. The primary outcomes were perioperative blood loss amount, number of patients requiring allogeneic blood transfusion and overall occurrence of postoperative complications. The secondary outcomes were operating time, perioperative mortality rate, postoperative liver and kidney function and length of hospital stay.

RESULTS

Seventeen RCTs were included in the analysis. A total of 841 patients who underwent hepatectomy in 10 trials were included in the comparative analysis between low central venous pressure (CVP) and control groups. The forest plots showed a low operative bleeding volume [(mean difference (MD): -409.75 mL, 95% confidence intervals (CI) -616.56 to -202.94, P < 0.001], reduced blood transfusion rate [risk ratio (RR): 0.47, 95% CI 0.34 to 0.65, P < 0.001], shortened operating time (MD: -13.42 min, 95% CI -22.59 to -4.26, P = 0.004), and fewer postoperative complications (RR: 0.76, 95% CI 0.58 to 0.99, P = 0.04) in the low CVP group than in the control group. Five and two trials compared the following interventions, respectively: 'acute normovolaemic haemodilution (ANH) vs control' and 'autologous blood donation vs control'. ANH and autologous blood donation could not reduce the blood loss amount but greatly decreased the number of patients requiring allogeneic blood transfusion. No benefits were found in the rate of mortality and length of postoperative hospital stay in any of the comparisons.

CONCLUSION

Lowering the CVP seems to be effective and safe in adult patients undergoing hepatectomy. ANH and autologous blood donation should be used as a part of blood management for suitable patients in certain circumstances.

TRIAL REGISTRATION

PROSPERO, CRD42022314061.

Prospective study of preoperative autologous blood donation for patients with high risk of allogeneic blood transfusion in lumbar fusion surgery: a study protocol of a randomised controlled trial

INTRODUCTION

Preoperative autologous blood donation (PABD) can be used to reduce the exposure of allogeneic blood transfusion in patients undergoing elective surgery. Better blood management to avoid anaemia and reduce allogeneic blood transfusion after spine surgery become increasingly important with development of enhanced recovery after surgery. We present here the design of a randomised controlled trial with three groups to verify the clinical effectiveness of PABD in patients at high risk of transfusion for lumbar fusion surgery and explore the optimal timing of autologous blood donation.

METHOD AND ANALYSIS

Patients (age 18-70 years) who will receive lumbar fusion surgery for degenerative disease with haemoglobin over 110 g/L and 'high risk' of allogeneic blood transfusion are eligible, unless they refuse participation or are diagnosed with malignant metastases, infection, cardiovascular and cerebrovascular diseases, haematological disorders or relevant drug history and critical illnesses. A total of 1200 patients will be recruited and randomised into three groups. Patients in group A will not receive PABD and be regarded as control group. PABD will be performed for patients in groups B and C. Blood donation will be finished at 1 week (±3 day) before surgery in group B and 2 weeks (±3 day) before surgery in group C. Primary outcome measures will include haemoglobin decline, incidence and amount of allogeneic blood transfusion. Secondary outcome measures will include days of hospitalisation after surgery, haematocrit level and incidence of complications. This study is a single-centre and open-label randomised controlled trial. The sample size is calculated with reference to the retrospective data and previous studies.

ETHICS AND DISSEMINATION

This trial has been approved by the Peking University Third Hospital Medical Science Research Ethic Committee (no: 2020-262-02). Results of the trial will be submitted for publication in a peer-reviewed journal and as conference presentations.

TRIAL REGISTRATION NUMBER

ChiCTR2000039824, preresults.

Mild volume acute normovolemic hemodilution is associated with lower intraoperative transfusion and postoperative pulmonary infection in patients undergoing cardiac surgery -- a retrospective, propensity matching study

Background

Perioperative allogenic transfusion is required in almost 50% of patients undergoing cardiac surgery and is associated with higher risk of mortality and morbidity (Xue et al., Lancet 387:1905, 2016; Ferraris et al., Ann Thorac Surg 91:944–82, 2011). Acute normovolemic hemodilution (ANH) is recommended as a potential strategy during cardiac surgery, but the blood conservation effect and the degree of ANH was still controversial. There is also an increasing concern about the improved outcomes associated with ANH. Therefore, a better understanding of the effect of mild volume ANH during cardiac surgery is urgently needed.

Methods

This retrospective study included 2058 patients who underwent cardiac surgery between 2010 and 2015. The study population was split into two groups (with and without mild volume ANH). Propensity score adjustment analysis was applied. We reported the association between the use of mild volume ANH and perioperative outcomes.

Results

A total of 1289 patients were identified. ANH was performed in 358 patients, and the remaining 931 patients did not receive any ANH. Five hundred of the total patients (38.8%) received perioperative RBC transfusions, 10% (129/1289) of patients received platelet, and 56.4% (727/1289) of patients received fresh frozen plasma transfusions. Mild volume ANH administration was significantly associated with decreased intraoperative RBC transfuse rate (8.5% vs. 14.4%; p = 0.013), number of RBC units (p = 0.019), and decreased postoperative pulmonary infection (6.8 vs. 11.3%; p = 0.036) during cardiac surgery. However, there was no significant difference regarding intraoperative fresh frozen plasma (FFP) and platelet concentrate transfusions, as well as postoperative and total perioperative allogeneic transfusions. Furthermore, there was no significant difference regarding postoperative outcomes including mortality, prolonged wound healing, stroke, atrial fibrillation, reoperation for postoperative bleeding and acute kidney injury. There was also no difference in postoperative ventilation time, length of ICU and hospital stay.

Conclusion

Based on the 5-year experience of mild volume ANH in cardiac surgeries with CPB in our large retrospective cohort, mild volume ANH was associated with decreased intraoperative RBC transfusion and postoperative pulmonary infection in Chinese patients undergoing cardiac surgery. However, there was no significant difference regarding postoperative and total perioperative allogeneic transfusions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0305-7) contains supplementary material, which is available to authorized users.

Selecting patients for acute normovolemic hemodilution during hepatic resection: a prospective randomized evaluation of nomogram-based allocation

BACKGROUND

Acute normovolemic hemodilution (ANH) decreases transfusion rates but adds to the complexity of anesthetic management during hepatectomy. A randomized controlled trial was conducted to determine if selecting patients for ANH using a transfusion nomogram improves management and resource use compared with selection using extent of resection.

STUDY DESIGN

One hundred fourteen patients undergoing partial hepatectomy were randomized to a clinical arm (ANH used for resection of ≥ 3 liver segments) or a nomogram arm (ANH used for predicted probability of transfusion ≥ 50% based on a previously validated nomogram). The primary end point was appropriate management, defined as avoidance of ANH in patients at low risk or use of ANH in patients at high risk for allogeneic red blood cell transfusions.

RESULTS

Between September 2009 and May 2011, 58 patients were randomized to the clinical arm and 56 to the nomogram arm. Demographics, diagnoses, extent of resection, blood loss, and incidence and grade of complications did not differ between the 2 groups. There were no differences in perioperative transfusions or laboratory values. Nomogram-based allocation did not change appropriate management overall (80% vs 76% in the clinical arm; p = 0.65), but did result in comparable perioperative outcomes and a trend toward decreased ANH use (30% vs 47%; p = 0.09), particularly in low blood loss (estimated blood loss ≤ 400 mL) cases (12% vs 25%; p = 0.04).

CONCLUSIONS

Although allocation of intraoperative management using a transfusion nomogram did not improve appropriate management overall, it more effectively identified low blood loss cases and reduced ANH use in patients least likely to benefit.

Perioperative blood conservation

This review examines the science and methodology of blood conservation in modern anaesthetic and surgical practice. Blood transfusion is associated with increased morbidity and mortality in all surgical patients, and the reduction or even elimination of transfusion has been and continues to be the subject of much research. Blood substitutes, despite extensive investigation, have not been proved successful in trials to date, and none have entered clinical practice. Pharmacological treatments include antifibrinolytic drugs (although aprotinin is no longer in clinical use), recombinant factor VIIa, desmopressin, erythropoietin and topical haemostatic agents, and the role of each of these is discussed. Autologous blood transfusion has recently fallen in popularity; however, cell salvage is almost ubiquitous in its use throughout Europe. Anaesthetic and surgical techniques may also be refined to improve blood conservation. Blood transfusion guidelines and protocols are strongly recommended, and repetitive audit and education are instrumental in reducing blood transfusion.

Autologous blood programs: what is happening?

Preoperative autologous blood collection has been advocated for many years and has seen increased application following the AIDS epidemic. Such autologous programs have been both applauded and criticized in recent years with little information available regarding actual application.

METHODS

One hundred and fifty-five of the largest hospitals in the province of Ontario received surveys assessing the demographics, logistics and funding of autologous blood programs available to them. Results, a total of 78 hospitals replied, indicating that 77 sites had access to an autologous program with 26 sites having a program within their hospital. The local blood provider, Canadian Blood Services (CBS), provided access to autologous donations either alone or to the hospital in 62 sites. Three hospitals operated the program entirely on their own. Fifteen hospitals had no access to an autologous program at any site. Programs were funded in a variety of ways including patient fees in five hospitals.

DISCUSSION

In the largest Canadian province the autologous blood programs are highly variable with service not provided at all in some regions whereas in others there is a very active program often involving Canadian blood services either as a stand-alone or hospital integrated supplier. This variation in activity of the autologous program is in marked contrast to those for whole blood and apheresis collections where great standardization, through the CBS is the norm.

Transfusion risks and transfusion-related pro-inflammatory responses

Despite improvements in blood screening and administration techniques, serious adverse events related to transfusion continue to occur, albeit at a much lower incidence. In addition to the development and implementation of new screening and blood purification/modification techniques and implementation of an optimal blood management program, the incidence and consequences of transfusion reactions can be reduced by a basic understanding of transfusion-related complications. Although acute hemolytic transfusion reactions, transfusion-associated anaphylaxis and sepsis, and transfusion-associated acute lung injury occur infrequently, diligence in administration of blood and monitoring for development of respective signs/symptoms can minimize the severity of these potentially life-threatening complications. In addition, emerging blood-banking techniques such as psoralen-UV inactivation of pathogens and use of patient identification systems may attenuate the incidence of adverse events related to transfusion. With respect to optimizing blood management by means of an effective blood management program involving pharmacologic and nonpharmacologic strategies, the ability to reduce use of blood products and to decrease operative time or re-exploration rates has important implications for disease prevention, blood inventory and costs, and overall health care costs.

Blood loss minimization and blood salvage techniques for complex spinal surgery

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.

Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective, case-control.

OBJECTIVE

Evaluate the utility of preoperative autologous blood donation (PABD) for surgical treatment of adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Recent data have highlighted overuse of PABD in elective surgery; however, PABD is a major blood conservation strategy for AIS surgery.

METHODS

Medical records of 123 patients treated for AIS between June 1995 and November 2004 were reviewed. Patients were divided into PABD (n = 104) and nondonors (NPABD; n = 19).

RESULTS

No differences existed between PABD and NPABD for age, major curve size, or operative procedures. Average PABD preoperative hematocrit was lower than NPABD (37.8 vs. 40.2; P < 0.005). PABD patients were 9 times more likely to be transfused than NPABD, and 3 times more likely to be transfused for each unit donated. There was a 25% transfusion risk reduction for each percent preoperative hematocrit increase. Minimum one autologous unit was not transfused in 32 patients (31%). Twenty-nine PABD patients (28%) were transfused for hematocrit >30. Fifty-three PABD patients (51%) wasted at least one unit or were transfused for hematocrit >30.

CONCLUSIONS

The majority of PABD patients (51%) wasted minimum one autologous unit or were transfused at a high hematocrit (>30). More precise PABD guidelines are needed to limit unnecessary transfusion and wasted resources.

The economics of blood: Gift of life or a commodity?

Objectives:To calculate the costs of blood collection, testing, storage, and transfusion in Greece.

Methods:Costing information was collected from two large public hospitals, in Athens and Crete, that also act as blood banks. Given that private health care accounts for 40 percent of total health spending, the same costs were also considered in a private setting by collecting key reagent cost data from a leading private hospital in Athens. Mainly direct costs were considered (advertising campaigns, personnel, storage and maintenance, reagent costs, transportation costs from blood bank to end-use hospitals, and cross-matching and transfusion costs in receiving hospitals) and some indirect costs (opportunity cost of blood donorship).

Results:Captive donorship accounts for over 50 percent of the national blood supply. A unit of blood transfused would cost between €294.83 and €339.83 in public hospitals and could reach €413.93 in a private facility. This figure may be an underestimate, as it excludes opportunity costs of blood transfusion for patients and the healthcare system.

Conclusions:Blood has a significant cost to the health system. Policy makers and practitioners should encourage its rational use, build on current policies to further improve collection and distribution, encourage further volunteer donorship in Greece, and also consider alternatives to blood where the possibility exists.

A pilot study of continuous ambulatory monitoring of blood pressure in repeated preoperative autologous blood donation

BACKGROUND

The aim of this study was to investigate the occurrence of hypotension in the 24-hour period after preoperative autologous blood donation (PABD) in patients with and without hypertension.

STUDY DESIGN AND METHODS

In 20 patients, 24-hour ambulatory blood pressure monitoring (ABPM) was performed before PABD was started and on every donation day in two repeated phlebotomies.

RESULTS

Seven patients had no hypertension and 11 patients had hypertension. In 2 additional patients, hypertension was diagnosed during the study. Overall, the mean systolic BP (SBP) decreased from 131+/-15 mmHg before donation to 128+/-13 and 127+/-10 mmHg after Donations 1 and 2; the corresponding values for the diastolic BP (DBP) were 77+/-9, 75+/-9, and 73+/-7 mmHg, both without significant differences between the groups with and without hypertension. In single patients, substantial decreases of BP occurred, especially during the night. Two patients with and 2 without hypertension showed a nightly decrease in SBP and DBP of more than 10 percent (in 1 of these patients, more than 20%). Concerning diurnal BP variability, 1 patient with and 1 without hypertension, the latter showing a nightly decrease of SBP and DBP of more than 10 percent, also changed to the pattern of a nightly "extreme dipper" after PABD.

CONCLUSION

In 25 percent of the patients, changes of BP were observed during the 24-hour period after PABD, especially during the night, which are known to be associated with an increased risk of cerebral or myocardial ischemia. Whether those changes of BP lead to major morbidity or mortality requires further investigation.