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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?