Pre-operative predeposit autologous donation in children presenting for elective surgery: a review

Predeposit Autologous blood donation (PAD) in children decreases the life-time complications associated with allogeneic blood. These complications include transmission of known or unknown pathogens and alloimmunization against future blood transfusions, organ transplants and pregnancies. In view of the potential long term benefits of PAD should it be considered a component of paediatric blood conservation programs. This paper reviews the literature to explore the risk of benefit analysis of adopting PAD in paediatric practice.

Explaining Family Caregiver Role Strain Following Autologous Blood and Marrow Transplantation

This research project explores family caregiving processes during the first 100 days following autologous blood and marrow transplantation (ABMT). In this paper, we (1) explore patterns in caregiving, and ABMT recipient function early recovery from ABMT; (2) examine the relationships among caregiver demographics, relationship quality, preparedness, ABMT recipient function, predictability of caregiving, caregiver role strain and rewards of caregiving; and (3) examine the relative contribution of caregiver age, preparedness, relationship quality, and ABMT recipient function on caregiver role strain, and rewards of caregiving. Fifty-two family caregivers of ABMT recipients completed questionnaires about caregiving at hospital discharge, and again 2, 6, and 12 weeks following discharge. The amount of caregiving activities performed, and caregiver role strain, declined steadily from 2 weeks to 12 weeks of recovery. The caregiving situation was relatively predictable during recovery, and caregivers reported that caregiving was consistently rewarding. The caregiving activities rated as most difficult were those related to supporting recipients' emotional well-being. Strain from caregiving, although low, was explained by disruption in recipients' emotional and physical functioning, while caregiving rewards were explained by caregivers' preparedness for caregiving. Relationship quality, a significant predictor of strain in other samples, did not influence caregiving strain or rewards in this population. Caregiving processes delineated in studies of caregivers of persons with chronic illness are quite different from those described in this study. The acuity of the recipients' illness, the life threatening nature of the treatment, and the younger age of caregivers, and recipients, may underlie these differences.

Current perceptions of Canadian autologous blood donors

BACKGROUND AND OBJECTIVES

We determined the perceptions and motivations of autologous donors to establish their regard for this process and the new blood system established in 1999 in Canada.

MATERIALS AND METHODS

Patients were surveyed before and after orthopaedic, cardiac, urological or gynecological procedures.

RESULTS

Patients (n = 100; 57 men and 43 women) ranged in age from 19 to 83 years. Most had finished high school, and 21 had a university degree. Eighty-four had undergone previous surgery and 27 a previous transfusion. Fifty-one had been blood donors and 17 had been autologous donors. Specialists suggested donation to 78 of the patients. Seventy-two participated because they knew that their blood would be there. Three had a mistrust of the blood provider. Sixty-six believed that there is still a risk of receiving contaminated blood. Sixty-nine thought any risk was > or = 1 in 100,000; however, 16 thought the risk was < 1 in 1000. Postsurgery, 83 were happy to have donated their blood and 77 would do it again. Many felt that it improved their outcome. Most felt an increased sense of safety. Eighty-three patients were confident that the Canadian blood system had improved, but 17 were unsure.

CONCLUSIONS

Concern about the safety of the allogeneic blood supply still drives the wish to autodonate. The process gives patients a sense of control and security. A large proportion of people felt that the Canadian blood system had improved, as determined by this 2003 study.

A decision aid for autologous pre-donation in cardiac surgery--a randomized trial

OBJECTIVES

The objective of this randomized, controlled study was to determine the usefulness of a decision aid on pre-donation of autologous blood before elective open heart surgery.

METHODS

The decision aid (DA) group received a tape and booklet which described the options for peri-operative transfusion in detail. The no decision aid (NDA) group received information usually given to patients about autologous donation.

RESULTS

A total of 120 patients were randomized. The DA group rated themselves better prepared for decision making and showed significant improvements in knowledge (p = 0.001) and realistic risk perceptions (p = 0.001). In both groups there was an increase in the proportion of patients choosing allogeneic blood between baseline and follow-up (p = 0.001). Patients in the DA group were significantly more satisfied with the amount of information they received, how they were treated and with the decision they made, than patients in the NDA group.

CONCLUSION

The decision aid is useful in preparing patients for decision making.

PRACTICE IMPLICATIONS

The next stage is to explore strategies to make it available to all appropriate patients.

Blood transfusion and autologous donation: a survey of post-surgical patients, interest group members and the public

Before planned surgery, patients may choose autologous donation in order to avoid the small, but potential, risks of receiving an allogeneic blood transfusion. This study examined the perceived risks of allogeneic blood transfusions, preferences and willingness to pay for autologous donation and the desired role in the decision-making process in three populations: post-surgical patients, special interest group members and the general public. Quantitative and qualitative data were collected from 206 respondents with the help of computer-assisted semi-structured telephone interviews. Thirty-three per cent of the sample voiced concerns about receiving allogeneic blood transfusions. The risks of hepatitis C virus, human immunodeficiency virus, variant Creutzfeldt-Jakob disease and a haemolytic reaction were perceived as being low, but were rated as numerically higher than those of other life events that have equal probability. Autologous donation was perceived as removing all the risks associated with transfusion, and respondents were willing to pay a median $976 AUD ($664 US) to use this technique. Over 80% of respondents preferred to be involved in making the decision about whether to use autologous donation. Even though autologous donation is not 'risk-free' and the blood supply is very safe, people overestimate the associated risks and have a preference for their own blood. Decision aids presenting balanced information on the advantages and disadvantages of both allogeneic and autologous blood may be required.

Evaluation of a decision aid for patients considering autologous blood donation before open-heart surgery

BACKGROUND

Patients undergoing open-heart surgery frequently require one or more blood transfusions. Because of the risks of receiving blood from volunteer donors, some patients choose to donate their own blood before surgery. This reduces their risk of exposure to volunteer-donated blood, but it increases their chance of receiving any transfusion, either of self-donated or volunteer-donated blood. Also, preoperative hemoglobin levels tend to be lower in patients who donate their own blood, and surgeons may be more likely to give transfusions to patients with self-donated blood. To help patients decide whether to donate their blood before surgery, we designed a decision aid comprising a booklet and audiotape and assessed its effectiveness.

METHODS

The 59 study subjects were a sample of consecutive patients referred to the Ottawa Heart Institute between Oct. 1, 1998, and Jan. 5, 1999, for future coronary artery bypass grafting, valve surgery or combined surgery. All were eligible to donate blood. Initial questionnaires were administered in the clinic by a physician or study nurse, and follow-up questionnaires were completed at home and mailed in after use of the decision aid. Outcome measures included patients' knowledge, values (importance ratings), preferences for transfusion methods, decisional conflict (the amount of uncertainty about the course of action to take), risk perception and acceptability of the decision aid.

RESULTS

Mean knowledge scores on a 15-item test increased from 67% correct responses before the decision aid to 85% correct responses after use of the aid (p < 0.001); the effect was similar when the patients were divided into subgroups according to education level. The number of patients favouring donating their own blood increased from 41 (69%) before to 45 (76%) after use of the aid. Nine (64%) of 14 initially uncertain patients preferred autologous donation after use of the aid. The overall mean score for decisional conflict was unchanged, at 1.7, which indicated a low level of uncertainty. Risk perception improved, from 0%-14% correct responses on an 8-item test before the aid to 18%-60% correct responses after use of the aid. The decision aid was acceptable to the majority of patients, and 95% indicated that they would recommend it to others.

INTERPRETATION

The decision aid improved knowledge and risk perceptions of blood donation and transfusion, and it helped uncertain patients to make choices.

Review of counselling in a transfusion service: the London (UK) experience

Donor (and recipient) counselling within the Transfusion Service in the UK has grown in volume and complexity over the last 10 years. The addition of new tests for donated blood and the growth of bone marrow transplantation have increased the demands on counselling staff. New initiatives, such as the HCV look-back programme, have required an extension of the skills and knowledge of staff involved in counselling.

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.

Autologous versus allogeneic transfusion: patients' perceptions and experiences

BACKGROUND

Preoperative autologous donation is one way to decrease a patient's exposure to allogeneic blood transfusion. This study was designed to determine patients' perceptions about the autologous blood donation process and their experiences with transfusion.

METHODS

To assess patient perception, a questionnaire was administered a few days before surgery to patients undergoing elective cardiac and orthopedic surgery in a Canadian teaching hospital. All patients attending the preoperative autologous donation clinic during a 10-month period were eligible. A convenience sample of patients undergoing the same types of surgery who had not predonated blood were selected from preadmission clinics. Patient charts were reviewed retrospectively to assess actual transfusion practice in all cases.

RESULTS

A total of 80 patients underwent cardiac surgery (40 autologous donors, 40 nondonors) and 73 underwent orthopedic surgery (38 autologous donors, 35 nondonors). Of the autologous donors, 75 (96%) attended all scheduled donation appointments, 73 (93%) said that they were "very likely" or "likely" to predonate again, and 75 (96%) said that they would recommend autologous donation to others. There was little difference in preoperative symptoms between the autologous donors and the nondonors, although the former were more likely than the latter to report that their overall health had remained the same during the month before surgery (30 [75%] v. 21 [52%] for the cardiac surgery patients and 30 [79%] v. 18 [51%] for the orthopedic surgery patients). When the autologous donors were asked what they felt their chances would have been of receiving at least one allogeneic blood transfusion had they not predonated, the median response was 80%. When they were asked what their chances were after predonating their own blood, the median response was 0%. The autologous donors were significantly less likely to receive allogeneic blood transfusions (6 [15%] for cardiac surgery and 3 [8%] for orthopedic surgery) than were the nondonors (14 [35%] for cardiac surgery and 16 [46%] for orthopaedic surgery). They were, however, more likely to receive any transfusion (autologous or allogeneic) than were the nondonors (25 [63%] v. 14 [35%] for cardiac surgery and 31 [81%] v. 16 [46%] for orthopedic surgery).

INTERPRETATION

Patients who underwent preoperative autologous blood donation were positive about the experience and did not report more symptoms than patients who did not donate blood preoperatively. Autologous donors overestimated their chances of receiving allogeneic blood transfusions had they not predonated and underestimated their chances after they had predonated. They were less likely to receive allogeneic transfusions, but more likely to receive any type of transfusion, than were patients who did not predonate.

Perceptions and preferences of autologous blood donors

BACKGROUND

The public's perception of autologous blood donation and transfusion as a worthwhile alternative to allogeneic blood transfusion increased dramatically with discovery of the human immunodeficiency virus. However, new concerns are being raised about the health outcomes and cost-effectiveness of the procedure. As more restrictive guidelines for autologous blood donation evolve, opposition from patients concerned about exposure to allogeneic blood may arise. Physicians' ability to reassure patients and garner their support for more restrictive policies requires an understanding of patients' concerns. The motivations, perceptions, and preferences of patients currently participating in autologous blood donation programs were investigated in this study.

STUDY DESIGN AND METHODS

Results from two questionnaire studies of 647 autologous blood donors are presented. The questionnaires assessed demographics, risk perceptions, preferences, willingness to pay, and reactions to different interventions designed to decrease patient preference for autologous blood donation.

RESULTS

Patients expressed a strong preference for the availability of autologous blood and indicated that they would be willing to pay substantial amounts of money even if the procedure were not covered by insurance. Despite education about the low risks of complications from allogeneic transfusions, an aversion to allogeneic transfusion and a willingness to pay for autologous blood donation persisted. Patients were not reassured by information on better infectious disease testing or physician recommendation against autologous blood donation.

CONCLUSION

Patients currently participating in autologous blood donor programs strongly prefer continued access to this procedure, primarily because they remain concerned about the complications of allogeneic transfusions. They may not be significantly reassured despite increasingly rigorous and costly improvements in donor and component screening.

All adverse events in autologous blood donors with cardiac disease are not necessarily caused by blood donation

BACKGROUND

Autologous blood donation before elective cardiac surgery has become a standard of care at many institutions. However, the safety of autologous blood donations by patients with cardiac disease is subject to controversy.

CASE REPORTS

Two life-threatening cardiac arrests and one fatal myocardial infarction that occurred in three patients who were scheduled to donate blood for autologous use in elective cardiac surgery are reported. All three patients met the institution's selection criteria for autologous blood donors, and all of them had given written informed consent for their participation in the autologous blood donation program. One of the two cardiac arrests and the myocardial infarction occurred in the patients prior to any blood donations, and the other cardiac arrest occurred 7 days after the patient donated blood uneventfully.

CONCLUSION

Life-threatening and fatal adverse events may occur during the donation period in autologous blood donors with cardiac disease. Not all adverse events are necessarily caused by blood donation.

[Autologous blood donation--good clinical practice and good recuperation practice]

Since October 1987, autologous blood donations have been performed in Bern and in 1994 reached a total of 946, representing 3% of all blood donations. This value is lower than the 4.9% for Switzerland as a whole. We report on the motivation and reasons of patients in favour of autologous blood donations and compare the results of 1989 with 1995. In the 6 years' period, the median patient's age increased from 54 to 63 years. The motivation for autologous blood donations changed from "routine surgical office" to "doctors". More than 50% of the patients mentioned the risk of acquiring an infectious disease, especially HIV, as the main reason for autologous blood donations. Labeling, testing or storage of autologous blood products of 37 out of 100 patients was incorrect, and in a another 20% an enquiry at the donation centres was needed to confirm the required quality of the autologous blood products. In 7 cases only one out of several blood bags was screened for viral diseases, and in 5 cases, unfortunately, none of the autologous blood products were tested for HIV or hepatitis B and C. Considering the negative cost-effectiveness of autologous blood transfusion, it is strongly recommended that the intrinsically low clinical benefit of autologous blood product should not be compromised by lack of good clinical practice and good manufacturing practice.

An analysis of autologous blood donor motivational factors

Little is known about the patient's reasons for participating in an autologous blood (AUB) collection program. We surveyed 110 AUB donors in our hospital-based collection program. Although fear of infection from an allogeneic blood transfusion was cited by 20% of AUB donors, 68.2% indicated that their physician's recommendation was a motivating factor. For 18.2% self-initiated motivation was a factor in pursuing AUB. The overwhelming majority (97.1%) stated they would donate AUB even if the risk of getting AIDS from a blood transfusion was zero. Fear of infection does not appear to be the primary reason for patients to donate AUB. Recommendation by their personal physician is an important component in the patients' decision-making process to set aside their own blood for upcoming surgery.

Physician recommendation as the key factor in patients' decisions to participate in preoperative autologous blood donation programs: Preoperative Autologous Blood Donation Study Group

To determine whether the physician or patient had initiated the discussion regarding preoperative autologous blood donation (PABD) and to assess the relative importance of the physician's recommendation in patients' decision to donate, responses were obtained from 254 of 409 patients (62%) who had donated preoperatively during the 3 study months. Nearly all (96%) strongly agreed they would donate again for themselves and nearly all (94%) strongly agreed they would recommend PABD to others. Patients initiated the discussion about PABD 23% of the time, while 71% indicated strong surgeon input. The remaining respondents said their surgeon had "mentioned it, but said it was up to me." The importance of avoiding transfusion reactions was rated significantly greater among those whose surgeons had initiated the discussion, as was the relative weight of the surgeon's recommendation. The desire to alleviate the blood shortage was rated much less important among patients who had initiated the discussion themselves.