AUTO TRANSFUSIONAUTO TRANSFUSION

Dr. Lokesh SharoffDr. Lokesh Sharoff

Also known as Autologous transfusionAlso known as Autologous transfusion

Defined as the collection and reinfusion of Defined as the collection and reinfusion of patients own blood / blood componentspatients own blood / blood components

Safest form of blood transfusionSafest form of blood transfusion

More cost effective than allogenic More cost effective than allogenic transfusiontransfusion

HISTORYHISTORY

First Autologous transfusion was done by First Autologous transfusion was done by James Blundell in 1818 before the James Blundell in 1818 before the discovery of blood groups.discovery of blood groups.

Anglo-saxon was the first to publish an Anglo-saxon was the first to publish an article reporting Autotransfusion in 1874.article reporting Autotransfusion in 1874.

Blood salvage was first reported in Blood salvage was first reported in American literature in 1917.American literature in 1917.

In 1974 Cell saver system was introducedIn 1974 Cell saver system was introduced

ADVANTAGESADVANTAGES

Avoidance of complications associated with Avoidance of complications associated with allogenic transfusion like:allogenic transfusion like: Acute and delayed hemolytic reactions due to ABOAcute and delayed hemolytic reactions due to ABO

incompatibilityincompatibility Allo-immunization Allo-immunization Allergic and febrile reactionsAllergic and febrile reactions Transfusion transmitted infectious diseases like HIV, Transfusion transmitted infectious diseases like HIV,

Hep-B and Hep-C, EBV, cytomeglo virus, malaria and Hep-B and Hep-C, EBV, cytomeglo virus, malaria and filaria.filaria.

Immuno suppressionImmuno suppression

Conservation of blood resources.Conservation of blood resources.

Patient with rare blood phenotypes are Patient with rare blood phenotypes are benefited. benefited.

Availability- Instantly available and Availability- Instantly available and requires no cross matching.requires no cross matching.

DISADVANTAGESDISADVANTAGES

-PERIOPERATIVE ANEMIA-PERIOPERATIVE ANEMIA-COSTLIER-COSTLIER-CLERICAL ERROR-CLERICAL ERROR-UNNECESSARY WASTAGE OF BLOOD -UNNECESSARY WASTAGE OF BLOOD -RISK OF BACTERIAL CONTAMINATION-RISK OF BACTERIAL CONTAMINATION-INCREASED COMPLEXITY OF -INCREASED COMPLEXITY OF PROCEDUREPROCEDURE

3 Types of Autotransfusion3 Types of Autotransfusion

1.1. Pre operative blood donationPre operative blood donation

2.2. Acute normovolemic HemodilutionAcute normovolemic Hemodilution

3.3. Intra operative and post operative blood Intra operative and post operative blood recovery.recovery.

Pre operative Autologous Blood Pre operative Autologous Blood DonationDonation

Done before elective surgical procedures Done before elective surgical procedures during significant blood loss may occurduring significant blood loss may occur

Patients selectionPatients selection Hb not less than 11 g/dlHb not less than 11 g/dl Hematocrit- 33%Hematocrit- 33% Last transfusion should occur at least 72 hour Last transfusion should occur at least 72 hour

before surgery.before surgery.

Pt with <50 kg can donate Pt with <50 kg can donate proportionately lower volume.proportionately lower volume.

Can donate up to 6 units if started Can donate up to 6 units if started earlier.earlier.

Children less than weighing 65 Children less than weighing 65 poundpound

Adolescent requiring surgery for Adolescent requiring surgery for Scoliosis ideal candidate for PABDScoliosis ideal candidate for PABD

Contraindications Contraindications Pts with bacteremia/septicemiaPts with bacteremia/septicemia Pts with unstable angina, CHF and M.I Pts with unstable angina, CHF and M.I

within previous 6 monthswithin previous 6 months Pts with procedures which rarely require Pts with procedures which rarely require

transfusion should be discouraged.transfusion should be discouraged. Pre donation not cause harm in obstetric Pre donation not cause harm in obstetric

patients, but justified only in cases like patients, but justified only in cases like placenta previaplacenta previa

CPDA is used as preservativeCPDA is used as preservative Stored as liquid whole bloodStored as liquid whole blood Shelf life is 35-42 daysShelf life is 35-42 days Ferrous sulphate is given to prevent Ferrous sulphate is given to prevent

anemia.anemia.Erythropoietin is given 3-4 weeks Erythropoietin is given 3-4 weeks before surgery.before surgery.

ComplicationsComplications

Reaction rate 1.5 to 5.5%Reaction rate 1.5 to 5.5% More seen in younger donors, women and first More seen in younger donors, women and first

time donors.time donors. Ischaemic episodes after donationIschaemic episodes after donation HypotensionHypotension ArrhthymiasArrhthymias ST-T changesST-T changes SyncopeSyncope Risk of contamination Risk of contamination

RBC production depends uponRBC production depends uponAdequate iron storeAdequate iron storeNo. of units donatedNo. of units donatedFrequency of donationFrequency of donation

Acute Normovolemic HemodilutionAcute Normovolemic Hemodilution

It is removal of blood from surgical pts It is removal of blood from surgical pts immediately before or just after induction immediately before or just after induction of anesthesia, replacement with acellular of anesthesia, replacement with acellular fluid and later reinfusion of withdrawn fluid and later reinfusion of withdrawn blood.blood.

Acute limited/ moderate normovolemic Acute limited/ moderate normovolemic hemodilution – HCT is hemodilution – HCT is 28% 28%

Acute extreme normovolemic hemodilution Acute extreme normovolemic hemodilution HCT is HCT is 20% 20%

AdvantagesAdvantages

Blood does not undergo biochemical Blood does not undergo biochemical alterations (like alterations (like 2-3 diphosphoglycerate) 2-3 diphosphoglycerate)

No influence on oxygen-Hb disscn curveNo influence on oxygen-Hb disscn curve Platelet function preserved.Platelet function preserved. Improvement in tissue perfusion. B/o Improvement in tissue perfusion. B/o

decreased viscosity.decreased viscosity. No iatrogenic anaemia and blood wastageNo iatrogenic anaemia and blood wastage Simple and less expensive Simple and less expensive

When potential bactremia precludes When potential bactremia precludes predonation ANH may be ideal solutionpredonation ANH may be ideal solution

Clerical error is eliminated Clerical error is eliminated

--RBCs are saved as the blood lost during --RBCs are saved as the blood lost during surgery is diluted blood.surgery is diluted blood.

Physiological EffectsPhysiological Effects

Withdrawal of blood and replacement with Withdrawal of blood and replacement with acellular fluid is accompanied by acellular fluid is accompanied by arterial arterial Oxygen. But Oxygen delivery is Oxygen. But Oxygen delivery is unaffectedunaffected in cardiac outputin cardiac output in viscosity - in viscosity - venous return - venous return - per per

resistance - resistance - afterload. afterload. in coronary blood flow(due to coronary in coronary blood flow(due to coronary

vasodilatation)vasodilatation)

Patient selectionPatient selection

For any pt with an adequate Hb who is For any pt with an adequate Hb who is expected to loss more than 25% of blood expected to loss more than 25% of blood volumevolume

Depends on overall health status rather Depends on overall health status rather than chronological agethan chronological age

ContraindicationsContraindications

renal functionrenal function COPDCOPD CoagulopathyCoagulopathy Hepatic disordersHepatic disorders

ANH is performed in operating room ANH is performed in operating room following induction of anaesthesia following induction of anaesthesia

Method of blood collectionMethod of blood collection

Blood is withdrawn from central large veins Blood is withdrawn from central large veins or radial artery.or radial artery.Blood is collected in bags with Blood is collected in bags with anticoagulant-citrate-phosphate-dextroseanticoagulant-citrate-phosphate-dextrosePlasma expanders Crystalloids: RL or NS. 3ml infused for every 1ml collected (moves out of intra-vascular compart Colloids: dextran, gelatin, albumin.1ml infused for1ml blood collected

V = EBV x [(Ho) – (Hf)/HavV = EBV x [(Ho) – (Hf)/Hav

V = Volume to be removedV = Volume to be removed

EBV = estimated blood volumeEBV = estimated blood volume

Ho = Initial HCTHo = Initial HCT

Hf = Minimum allowable HCTHf = Minimum allowable HCT

Hav = average HCTHav = average HCT

ComplicationsComplications

Myocardial ischaemia Myocardial ischaemia Cerebral HypoxiaCerebral Hypoxia CoagulopathyCoagulopathy Peripheral OedemaPeripheral Oedema

Intraoperative blood donationIntraoperative blood donation

It is recovery or salvage of blood shed in It is recovery or salvage of blood shed in surgery. surgery.

By – semicontinuous flow centrifugationBy – semicontinuous flow centrifugation Recovered blood mixed with anticoagulant Recovered blood mixed with anticoagulant

and collected in disposal reservoir with a filterand collected in disposal reservoir with a filter Filtered blood passed into wash bowl with Filtered blood passed into wash bowl with

centrifugation of 5000 per minutecentrifugation of 5000 per minute Washed with salineWashed with saline RBC’s are pumped in reinfusion bagsRBC’s are pumped in reinfusion bags

WBC, cell fragments and activated clotting WBC, cell fragments and activated clotting factors are eliminated into waste bag.factors are eliminated into waste bag.

Max. vacuum level 100 to 150 mm of HgMax. vacuum level 100 to 150 mm of Hg Blood contaminated with intestinal Blood contaminated with intestinal

contents should not be reinfusedcontents should not be reinfused

ComplicationsComplications

Air and fat embolismAir and fat embolism Pulmonary dysfn. Due to infusion of debrisPulmonary dysfn. Due to infusion of debris CoagulopathyCoagulopathy Renal dysfn.Renal dysfn. Dissemination of malignant cellsDissemination of malignant cells

Clinical usesClinical uses

When it is anticipated that blood will shed into a When it is anticipated that blood will shed into a clean wound from which can aspirated without clean wound from which can aspirated without HemolysisHemolysis

Used in Used in CardiacCardiac VascularVascular OrthopaedicOrthopaedic TraumasurgeryTraumasurgery Liver transplantationLiver transplantation

Post Operative Blood DonationPost Operative Blood Donation

Postoperative Blood salvagePostoperative Blood salvage: Blood is : Blood is collected after the surgical procedure is collected after the surgical procedure is complete by drainage of the operative complete by drainage of the operative area and re-infused. area and re-infused.

Postoperative blood salvage is used Postoperative blood salvage is used most frequently for cardiac and orthopedic most frequently for cardiac and orthopedic surgery.surgery.

Cardiac surgeryCardiac surgeryReinfusion done without washing of salvaged Reinfusion done without washing of salvaged blood obtained from mediastinal drainage blood obtained from mediastinal drainage after cardiac surgery. after cardiac surgery.

Safe and effective.Safe and effective.

reinfusion of unwashed blood may affect reinfusion of unwashed blood may affect laboratory tests. the blood may contain laboratory tests. the blood may contain cardiac enzymes, such as creatine kinase, so cardiac enzymes, such as creatine kinase, so its reinfusion may complicate the diagnosis of its reinfusion may complicate the diagnosis of perioperative myocardial infarction.perioperative myocardial infarction.

Orthopedic surgeryOrthopedic surgery

Blood salvaged and reinfused after Blood salvaged and reinfused after orthopedic surgery (e.g., hip arthroplasty orthopedic surgery (e.g., hip arthroplasty and spinal fusion with instrumentation) and spinal fusion with instrumentation) may be safe and reduce the amount of may be safe and reduce the amount of allogeneic blood given.allogeneic blood given.

Blood from mediastinal and chest drain Blood from mediastinal and chest drain does not require anticoagulation does not require anticoagulation because it is defibrinogenated.because it is defibrinogenated.

TRAUMATIC HEMOTHORAXTRAUMATIC HEMOTHORAX Blood that collects in the thoracic Blood that collects in the thoracic

cavity following blunt or penetrating cavity following blunt or penetrating trauma is analogous to blood shed trauma is analogous to blood shed following cardiac or orthopedic following cardiac or orthopedic surgery. It is defibrinogenated and surgery. It is defibrinogenated and may be collected and transfused. may be collected and transfused.

ComplicationsComplications

Febrile reactions (6-12 hrs after operation)Febrile reactions (6-12 hrs after operation) HypotensionHypotension Upper airway oedemaUpper airway oedema

Post operative blood donationPost operative blood donation

- Collected from drains but is rarely used - Collected from drains but is rarely used - To be used within 6 hrs – if not discarded- To be used within 6 hrs – if not discarded- blood collected is diluted , partially - blood collected is diluted , partially hemolysed but rich in interleukinshemolysed but rich in interleukins

!!!!

NOTE: Always autologous blood should be trans before any allogenic blood