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Clinical Crossroads |

Patient Blood Management:  A 68-Year-Old Woman Contemplating Autologous Blood Donation Before Elective Surgery

Lynne Uhl, MD, Discussant
JAMA. 2011;306(17):1902-1910. doi:10.1001/jama.2011.1526.
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Globally, more than 81 million units of red blood cells are transfused annually. Of the 15 million red blood cell components transfused annually in the United States, approximately 40% are transfused to patients undergoing elective surgical procedures. Because of concerns about limited blood availability as well as risks of transfusion-related adverse events, blood products should be used judiciously. Using the case of Ms C, a 68-year-old woman considering autologous blood donation prior to knee replacement surgery, the concept of patient blood management is discussed. This approach entails a complete evaluation of the patient in the preoperative period to assess for bleeding risks and anemia, with a goal to optimize a patient's condition prior to surgery; use of various strategies in the operative period to mitigate the need for allogeneic blood transfusion; and meticulous postoperative care to again avoid the need for blood transfusion.

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A rational approach to minimize the need for blood transfusions
Posted on October 25, 2011
Kai Singbartl, MD, MPH
University of Pittsburgh, Departments of Critical Care Medicine and Anesthesiology,
Conflict of Interest: None Declared
Strategies to minimize the need of blood transfusion for patients facing elective surgery? Potential preoperative, intra-operative and postoperative strategies include the following.[1] Correction of pre-operative low hb-/hct- level.Minimizing surgical blood loss through meticulous surgical hemostasis.If feasible, Esmarch ischemia via tourniquet for orthopedic cases. Acceptance of a low 'transfusion trigger' while accounting for individual co-morbidities and other limitations. Pharmacological reduction of surgical blood loss (e.g., anti-fibrinolytics). Differentiated consideration and use of available blood conservation techniques:[2]
(a) intra- and postoperative RBC-salvage and re-transfusion [3,4],
(b) acute normovolemic hemodilution (ANH), only if the patient can tolerate a 'minimal hct', i.e. transfusion trigger of 20%, and if the expected blood loss >= 40% of the patient's estimated blood volume [5,6], and
(c) if a.) and b.) are not feasible, pre-operative autologous deposit (PAD), only if there is sufficient time left for regenerative erythropoiesis, i.e. time to for patient's hct to return to baseline hct before surgery.[7,8]
What options are available for preoperative patient blood management? Potential preoperative interventions include the following: Correction of nutritional iron and/or vitamin B12 deficiencies to increase the patient's hb/hct-level. Correction of a low hb/hct-level by administration of erythropoietin plus iron. PAD. ANH immediately before surgery.
When should a patient consider preoperative autologous donation? A patient should consider PAD, only if there was enough time left for RBC- regeneration (i.e. >4 weeks between last PAD and surgery [7,8]), and ... if the patient suffered from RBC allo-antibodies, or if the expected blood-loss could not be compensated for with other autologous blood conservation techniques, i.e. - intra-/ postoperative cell salvage, ANH, and anti- fibrinolytics, or if other strategies of autologous blood conservation techniques were not feasible to avoid the risk of developing RBC-allo-antibodies at a young age.
What intra-operative and postoperative measures are available to reduce the need for allogeneic transfusion? Esmarch ischemia/tourniquet in patients without peripheral arterial disease undergoing extremity surgery.[1] Pharmacological reduction of surgical blood loss with anti-fibrinolytics, e.g., tranexamic acid.[1] Intra- and postoperative blood salvage with re-transfusion of washed or unwashed autologous RBC.[3,4]
How should clinicians counsel patients about the risks of transfusion and peri-operative blood management? The patient needs to be made aware of ... the actual risk to require a blood transfusion during/after that particular surgery, feasible autologous blood conservation alternatives, including pharmacological interventions, the true risks of allogeneic blood, including transmission of infectious diseases, ABO incompatibility, bacterial contamination, transfusion- related acute lung injury[9,10], the true risks of autologous blood transfusions, including bacterial contamination, side effects of PAD[1], and the hospital-/surgeon-specific blood loss for the particular procedure.
What is your advice to Ms C? We advise Ms. C. to ... not undergo PAD for this type of surgery[3,7,8], and to accept both dilutional anemia and intra-/postoperative blood salvage.[3]
References
1. Munoz M, García-Erce JA, Villar I, Thomas D. Blood conservation strategies in major orthopaedic surgery: efficacy, safety and European regulations. Vox Sang. 2009;96:1-13.
2. Carless P, Moxey A, O'Connell D, Henry D. Autologous transfusion techniques: a systematic review of their efficacy. Transfusion Medicine (Oxford, England). 2004;14:123-144.
3. Singbartl G, Schreiber J, Singbartl K. Preoperative autologous blood donation versus intraoperative blood salvage: intraindividual analyses and modeling of efficacy in 1103 patients. Transfusion. 2009;49:2374-2383.
4. Carless PA, Henry DA, Moxey AJ, O'Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2010:CD001888.
5. Singbartl K, Schleinzer W, Singbartl G. Hypervolemic hemodilution: an alternative to acute normovolemic hemodilution? A mathematical analysis. J Surg Res. 1999;86:206-212.
6. Singbartl K, Innerhofer P, Radvan J, et al. Hemostasis and hemodilution: a quantitative mathematical guide for clinical practice. Anesth Analg. 2003;96:929-35.
7. Singbartl G. Preoperative autologous blood donation - part I. Only two clinical parameters determine efficacy of the autologous predeposit. Minerva Anestesiol. 2007;73:143-151.
8. Singbartl G, Malgorzata S, Quoss A. Preoperative autologous blood donation - part II. Adapting the predeposit concept to the physiological basics of erythropoiesis improves its efficacy. Minerva Anestesiol. 2007;73:153-160.
9. Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009;113:3406-3417.
10. Dwyre DM, Fernando LP, Holland PV. Hepatitis B, hepatitis C and HIV transfusion-transmitted infections in the 21st century. Vox Sang. 2011;100:92-98.
Conflict of Interest: None declared
Reassurance for Mrs C from New Zealand
Posted on October 17, 2011
Richard D Seigne, MBBS FRCA
Christhchurch Hospital, Canterbury District Helath Board (New Zealand)
Conflict of Interest: None Declared
I would reassure Mrs. C that the transfusion rate for knee replacement surgery with a pre-operative haemoglobin level of 15.1g/dL should be zero (expected haemoglobin drop approximately 3.5g/dL). Mrs. C should ask her surgeon what his/her transfusion rate is. Strategies to minimize the need of blood transfusion for elective surgery form the basis of the 3 pillars of Patient Blood Management,
1. Optimising red cell mass
2. Minimising intra and post operative blood loss
3. Tolerating post-operative anaemia
In Mrs. C's case
1. The red cell mass (haemoglobin) is optimal.
2. Blood loss can be minimised by
*Enquiring about a history and or family history of coagulation defects, investigate and treat as appropriate
*Enquiring about the use of prescribed and non prescribed substances that may increase bleeding; cease these pre-operatively. Non prescribed examples include ibuprofen, naproxen, garlic, fish oil, ginkgo, ginger, vitamin E, St John's Wort
* Cessation of aspirin therapy 4 days pre-operatively
* The use of an intra-operative tourniquet
* Intra-operative and post operative intravenous tranexamic acid administration(1)
* The omission of a drain(2). If a drain is employed then one that enables autologous re-infusion may appeal to Mrs C(3), although evidence suggests this would not be required(4). Re-transfusion would not be advised if local anaesthetic infiltration is utilised
* Elevation of the knee in extension for 6 hours post- operatively(5)
3. Post-operatively, if Mrs C does not have signs or symptoms of anaemia, a haemoglobin level of 6g/dL may be tolerated(6). Symptoms such as dizziness and light headedness within 48 hours of surgery may be secondary to hypovolaemia rather than anaemia. I would reassure Mrs C that the risk of an infectious complication(7) such as hepatitis C (1/200,000) or hepatitis B or HIV (both 1/1-2 million) is less than the risk of dying from a lightning strike -- about a 1/100,000 risk. Less rare but serious risks include transfusion-associated circulatory overload (TACO) and wrong blood to wrong patient.
Autologous blood donation seems attractive but the evidence does not support its routine use(8). This is because the pre-operative haemoglobin is commonly reduced, the lower the pre-operative haemoglobin the more likely the need for a peri-operative blood transfusion. Autologous donation does reduce the risk of requiring an allogeneic transfusion i.e. blood from someone else, but the overall risk of transfusion is generally increased. An autologous blood transfusion is not risk free e.g. wrong blood to wrong patient. "Directed donations" by relatives and friends are possible, although not permitted by some countries' Blood Service, e.g. New Zealand as they do not increase safety and may result in waste.
My advice would be to Mrs C would be
* Do not undergo autologous blood donation
* Do not ask friends or family to donate for you
* Find a surgical centre that practices patient blood management and can evidence this with data for transfusion rates after knee replacement surgery, preferably the rate for a female with a pre-operative haemoglobin of 15.1g/dL.
References
1. Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001886. DOI: 10.1002/14651858.CD001886.pub4 (http://www2.cochrane.org/reviews/en/ab001886.html)
2. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001825. DOI: 10.1002/14651858.CD001825.pub2 (http://www2.cochrane.org/reviews/en/ab001825.html)
3. Huet C, Salmi LR, Fergusson D, Koopman-van Gemert AWMM, Rubens F, Laupacis A. A Meta-Analysis of the Effectiveness of Cell Salvage to Minimize Perioperative Allogeneic Blood Transfusion in Cardiac and Orthopedic Surgery. A & A 1999: 89 (4) 861-9
4. Steinberg EL, Peleg Ben-Galim P, Yaniv Y, Dekel S, Menahem A. Comparative analysis of the benefits of autotransfusion of blood by a shed blood collector after total knee replacement. Arch Orthop Trauma Surg. 2004 124 : 114-118
5. Ong SM, Taylor GJ. Can knee position save blood following total knee replacement? Knee. 2003 Mar;10(1):81-5.
6. A Compendium of Transfusion Practice Guidelines. American Red Cross. 2010. Accessed from http://www.redcrossblood.org/sites/arc/files/pdf/Practice-Guidelines- Nov2010-Final.pdf
7. National Heart Lung and Blood Institute website, accessed 17.10.11. http://www.nhlbi.nih.gov/health/health-topics/topics/bt/risks.html
8. Henry DA, Carless PA, Moxey AJ, O'Connell D, Ker K, Fergusson DA. Pre-operative autologous donation for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD003602. DOI: 10.1002/14651858.CD003602 (www2.cochrane.org/reviews/en/ab003602.html)
Conflict of Interest: Member of Expert Working Group of the "Patient Blood Management Guidelines" National Blood Authority, Canberra, Australia. Member of the Clinical Reference Groups for Patient Blood Management Guidelines: Module 1 Critical Bleeding / Massive Transfusion (2011). and Patient Blood Management Guidelines: Module 2 Perioperative (2012).
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