PREOPERATIVE BLOOD DONATION

2. PREOPERATIVE BLOOD DONATION H.Moeini .MD Anesthesiologist Pediatric Anesthesia Fellowship

3. PREOPERATIVE BLOOD DONATION • The role of autologous blood procurement in surgery is evolving : • based on improved blood safety, • increased blood costs, • emerging pharmacologic alternatives to blood transfusion • PAD became accepted as a standard practice in certain elective surgical settings such as total joint replacement surgery; • substantial improvements in blood safety were accompanied by a decline in PAD, as well as an interest in ANH as an alternative strategy

4. PREOPERATIVE BLOOD DONATION • Nevertheless, public perception of blood safety and the reluctance to accept allogeneic blood transfusion in the elective transfusion setting,along with possible future blood inventory shortages and the potential for new,emerging blood pathogens, continue to give autologous blood procurement strategies an important role in the surgical arena

5. PREOPERATIVE BLOOD DONATIONPatient Selection • The criteria for autologous donors are not as stringent as are those for allogeneicdonors • The AABB (formerly, the American Association of Blood Banks) standards for blood banks and transfusion services require that the donor patient’s hemoglobin be no less than 11 g/dL or the hematocritbe no less than 33% before each donation • No age or weight limits exist, and patients may donate 10.5 mL/kg, in addition to testing samples

6. PAD • Donations may be scheduled more than once a week, • the last donation should occur no less than 72 hours before surgery, to allow time for restoration of intravascular volume and for transport and testing of the donated blood

7. PREOPERATIVE BLOOD DONATION • Transfusion service policies, implemented under the auspices of hospital transfusion committees, differ regarding collection and use of autologous blood with positive viral markers • Some hospitals exclude use of autologous blood reactive for hepatitis B surface antigen , hepatitis C virus, or human immunodeficiency virus (HIV) because of concerns for patients’ safety related to a wrong blood unit transfused to the wrong patient (mistransfusion)

8. PREOPERATIVE BLOOD DONATION • Candidates for preoperative blood collection are patients scheduled for elective surgical procedures in which blood transfusion is likely • The most common surgical procedures ,predonatedare total joint replacements • For procedures that are unlikely to require transfusion (i.e., a maximal surgical blood ordering schedule [MSBOS] suggests that crossmatched blood should not be ordered) , Autologothe use of preoperative blood collection is not recommended • blood should not be collected for procedures that seldom (<10% of cases) require transfusion, such as cholecystectomy, herniorrhaphy, vaginal hysterectomy, and uncomplicated obstetric delivery

10. PREOPERATIVE BLOOD DONATION • Preoperative autologous blood collection can be performed for patients who would not ordinarily be considered for autologous donation • Availability of medical support is important in assessing a patient’s suitability • With appropriate volume modification, parental cooperation, and attention to preparation and reassurance, pediatric patients can participate in preoperative blood collection programs

11. PREOPERATIVE BLOOD DONATION • Donation and storage of blood before elective surgery have reduced the use of allogeneic RBCs • Banked units of PRBCs may be stored for 35 to 42 days in the liquid state, permitting the donation of several units and the time required for the patient (usually teenagers) to regenerate the RBC mass before surgery • Children unable to mount an erythropoietic response to phlebotomy may only succeed in making themselves anemic, so administration of iron, vitamin C, and folate is important, as is monitoring for reticulocytosis to ensure the bone marrow is replenishing the donated RBCs

12. PREOPERATIVE BLOOD DONATION • Autologous donation should not be attempted in children with significant cardiac ischemic disease or those with an active infection because bacteria can seed the collected unit and overgrow during storage • Autologous donation should be discouraged before procedures for which RBC transfusion is unlikely • Donated blood that is not used by the donor must be discarded rather than enter the general blood bank pool • Patients or family of pediatric patients may wish to obtain blood from family members or friends (i.e., directed donation) • Despite the perception that this donor pool may be safer than the pool of volunteer, allogeneic donors, there is no evidence that this is true • Because there is a greater risk of transfusion associated GVHD with cellular components from a donor who is a blood relative, these units are irradiated to eliminate the possibility of this usually fatal complication of transfusion

13. PREOPERATIVE BLOOD DONATION • Compared with acute normovolemichemodilution (ANH), PADhas important disadvantages • The risk of transfusion errors (e.g.,wrongunit or wrong patient) is not less with PAD than with the use of allogeneic blood; the cost of obtaining, storing, and processing the predonatedblood is not less with PAD; and the likelihood of contamination of the unit is not less with PAD • Each of the problems is eliminated or nearly eliminated with ANH • ANH also has the advantage of returning fresh whole blood to the patient, in contrast to PAD, which provides only the RBC component. Furthermore, potassium levels rise in donated blood with increased storage time and have been reported to be over 70 mM • Therefore, PAD should be reserved for older children, and the indications for the use of the predonated blood should be identical to those for allogeneic units

14. PREOPERATIVE BLOOD DONATION • Patients with significant cardiac disease are considered poor risks for autologous blood donation • Despite reports of safety in small numbers of such patients who underwent autologous blood donation, the risks associated with are greater than current estimated risks of allogeneic transfusion

15. PREOPERATIVE BLOOD DONATION

16. Contraindications to Participationin Autologous Blood Donation Programs 1. Evidence of infection and risk of bacteremia 2. Scheduled surgery to correct aortic stenosis3. Unstable angina4. Active seizure disorder5. Myocardial infarction or cerebrovascular accident withinmonths of donation6. Significant cardiac or pulmonary disease in patients who have not yet been cleared for surgery by their treating physician7. High-grade left main coronary artery disease8. Cyanotic heart disease9. Uncontrolled hypertension

17. PREOPERATIVE BLOOD DONATION • The collection of autologous blood from women during routine pregnancy is unwarranted , because blood is so seldom needed • PAD can be considered for women with alloantibodies to multiple or high-incidence antigens or with placenta previa or other conditions placing them at high risk for antepartum or intrapartum hemorrhage

18. PREOPERATIVE BLOOD DONATION • AABB standards no longer permit allogeneic transfusion of unused autologous units (“crossover”) because autologous donors are not, in the strictest sense, volunteer donors

19. PREOPERATIVE BLOOD DONATION • Attempts to stratify patients into groups at high and low risk for needing transfusion based on the baseline level of hemoglobin and on the type of procedure show some promise

21. Minimise amount of phlebotomy for lab samples Base practice on transfusion triggers, targets set by local guidelines, and individual patient assessment Establish target haemoglobin tolerable to the individual patient Good Transfusion Practice - General Considerations

22. PREOPERATIVE BLOOD DONATION • one problem with algorithms that consider the estimated blood loss and preoperative hematocrit is that blood losses are difficult to measure or predict because specific surgical procedures performed even by the same surgeon can be accompanied by a wide range of blood loss • Although autologous blood donation programs are popular with patients, the costs associated with autologous blood collection are higher than are those associated with allogeneic blood

23. The Role of Aggressive Phlebotomy and the Use of Erythropoiesis-Stimulating Agents • The efficacy of PAD depends on the degree to which the patient’s compensatory erythropoiesis increases the production of red blood cells (RBCs) • The endogenous erythropoietin response and compensatory erythropoiesis are suboptimal under “standard” conditions of 1 unit of blood donated weekly

24. The Role of Aggressive Phlebotomy and the Use of Erythropoiesis-Stimulating Agents • Weekly PAD is accompanied by an expansion in RBC volume of 11% (with no oral iron supplementation) to 19% (with oral iron supplementation), which is not sufficient to prevent increasing anemia in patients undergoing PAD • If the erythropoietic response to autologous blood phlebotomy does not maintain the patient’s hematocrit level during the donation interval, the donation of autologous blood actually may be harmful by causing perioperative anemia and an increased likelihood of any blood transfusion • relationships among anticipated surgical blood losses, the desired hematocrit, and the need for autologous blood donation

25. The Role of Aggressive Phlebotomy and the Use of Erythropoiesis-Stimulating Agents • In contrast to autologous blood donation under “standard” conditions, studies of “aggressive” autologous blood phlebotomy (twice weekly for 3 weeks, beginning 25 to 35 days before surgery) have demonstrated that endogenous erythropoietin levels do increase, along with enhanced erythropoiesis representing RBCvolume expansion of 19% to 26%

26. The Role of Aggressive Phlebotomy and the Use of Erythropoiesis-Stimulating Agents • The use of erythropoiesis-stimulating agents to stimulate erythropoiesis further (≤50% RBC volume expansion) during autologous donation has been approved in the European Union, Canada, and Japan, but not in the United States • Perisurgical erythropoietin therapy is also approved in the United States and Canada for anemic (hematocrit < 39%) patients who are scheduled for noncardiac, nonvascular surgical procedures

28. Transfusion Trigger • Disagreement exists about the proper hemoglobin and hematocritlevels (“transfusion trigger”) at which autologous blood should be given • In general, autologous and allogeneicblood transfusion triggers should be similar because the risks from administrative errors associated with both autologous and allogeneic blood are higher than are risks related to the transfusion of allogeneic blood

31. Autologous Sticker