West Midlands Regional Training Package for Safe Blood Transfusion Practice

1
West Midlands Regional Training Package for Safe
Blood Transfusion Practice
Version 3 (2008)
MODULE 4 Alternatives to Allogeneic Blood
Transfusion
DISCLAIMER NOTE The information contained in this
training package has been produced as a training
aid only. Neither authors nor publisher can
accept any responsibility for any errors or
omissions. The British Committee for Standards in
Haematology (BCSH) issue guidelines relating to
blood transfusion this training document is not
intended as a substitute. Local hospital policies
and procedures must be followed at all times.
2
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Contents
• Pre-operative procedures
• Intra-operative procedures
• Post-operative procedures
• Autologous transfusion techniques
• Pre-deposit autologous donation
• Perioperative cell salvage
• Postoperative cell salvage
• Acute normovolaemic haemodilution
• Directed Donations
• Erythropoietin and Iron Supplementation
• Pharmacological agents to reduce bleeding
• Contingency Planning

3
Module 4 Alternatives to Allogeneic Blood
Transfusion
Aims To demonstrate an awareness of the
different techniques available as alternatives to
allogeneic blood transfusion and an awareness of
their appropriate use.

• Objectives
• To develop an awareness of better transfusion
  practice.
• Discuss different autologous transfusion
  techniques available.
• Identify alternative care strategies to avoid the
  use of allogeneic blood.
• To promote the appropriate and timely use of
  transfusion alternatives.

4
Module 4 Alternatives to Allogeneic Blood
Transfusion
Although the risks of blood transfusion have been
considerably minimised, the incidents highlighted
in the Serious Hazards of Transfusion (SHOT)
reports show the importance of continuing
education in the appropriate use of blood.
TRANSFUSE ONLY WHEN THE BENEFITS OUTWEIGH THE
RISKS
5
Good Transfusion Practice - General Considerations
Module 4 Alternatives to Allogeneic Blood
Transfusion
6
Reducing transfusion requirements
Module 4 Alternatives to Allogeneic Blood
Transfusion
Pre-operative procedures include
7
Reducing transfusion requirements
Module 4 Alternatives to Allogeneic Blood
Transfusion
Intra-operative procedures include
8
Reducing transfusion requirements
Module 4 Alternatives to Allogeneic Blood
Transfusion
Post-operative procedures include
9
What does Autologous Transfusion mean?
Module 4 Alternatives to Allogeneic Blood
Transfusion
10
What does Autologous Transfusion mean?
Module 4 Alternatives to Allogeneic Blood
Transfusion
11
Pre-Operative Autologous Donation
Module 4 Alternatives to Allogeneic Blood
Transfusion
PAD involves the collection of units of blood
from the patient at weekly intervals in the 4
weeks prior to the surgery date
Further information can be found in the BCSH
(2007) Guidelines for policies on alternatives to
allogeneic blood transfusion 1. Pre Autologous
Blood Donation and Transfusion. Transfusion
Medicine 2007 17(5) 354-65 www.bcshguidelines.or
g/pdf/alt_allogeneic_blood_transfusion.pdf
12
Cell Salvage
Module 4 Alternatives to Allogeneic Blood
Transfusion
Principle
In operations where haemorrhage is large, blood
collected from the surgical field can be
processed and re-transfused to the patient.
13
Intra-Operative Cell Salvage (ICS)
Module 4 Alternatives to Allogeneic Blood
Transfusion
ICS - collection re-infusion of blood aspirated
from the operative field during surgery
14
Intra-Operative Cell Salvage (ICS)
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Disadvantages
• Allogeneic blood may still be required as not
  ALL of the lost blood is recovered.
• Cannot be used where wound site has an infection.
• Not normally used where cancer cells are in the
  operative field (used in some cancer cases often
  with an additional leucocyte or white blood cell
  filter).
• Not generally suitable for patients with sickle
  cell disease as cells may sickle in the low
  oxygen tension of the machine.
• Some clinicians are reluctant to use in
  obstetrics due to the potential risk of amniotic
  fluid contamination.
• Requires capital outlay and trained operators -
  needs sufficient suitable operations to be cost
  effective.
• Only red cells are returned without platelets
  or plasma.

• Advantages
• Reduction in allogeneic blood usage.
• Can be used regardless of patients medical
  fitness.
• It may be ife saving where there is
  uncontrolled bleeding.
• System accepted by some Jehovahs Witnesses
  (see module 15)

15
Postoperative Cell Salvage (PCS)
Module 4 Alternatives to Allogeneic Blood
Transfusion
PCS - collection of blood from surgical drains
followed by re-infusion - most commonly used to
collect blood after release of tourniquet
following knee surgery

• Advantages
• Capital outlay minimal, no expensive equipment
  or specially trained staff required.
• Reduction in allogeneic blood usage.
• Closed system ensures maximum safety for staff
  and patient.
• Can be used regardless of patients fitness.

• Disadvantages
• Blood can only be collected for 6-12 hours post
  operation (depending on system used).
• Allogeneic blood may also be required where
  blood loss is high.
• Blood recovered may have some haemolysis.

16
Acute Normovolaemic Haemodilution (ANH)
Module 4 Alternatives to Allogeneic Blood
Transfusion
NOTE ANH is a specialist anaesthetic
technique There is also controversy over the
value of this procedure - in a few small studies
performed to date, it has been shown that it is
only beneficial if significant haemodilution is
achieved and the blood loss is over 20 of the
total blood volume.
17
Acute Normovolaemic Haemodilution (ANH)
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Advantages
• Reduction in surgical blood loss as the blood
  that is lost is more dilute.
• Units remain by patient - therefore reduced risk
  of wrong blood to wrong patient incidents
• (units must be carefully labelled with
  patients full identification details).
• No microbiology testing required.
• Reduced risk of bacterial growth? (short time
  on shelf).
• Haemolytic and allergic reactions should be
  reduced.
• Theoretically, lower haematocrit (volume or
  percentage of red cells in the blood) may
• improve oxygen delivery, but no clinical
  evidence.

• Disadvantages
• Not proven to reduce allogeneic blood use.
• Time consuming to set up before an operation and
  needs sufficient trained staff.
• Units not microbiology tested - staff should
  treat them as high risk.
• Only useful when operative blood loss
  anticipated to be gt1000ml
• Lower haematocrit may increase blood loss?
• Risk of myocardial ischaemia?
• Use of large volumes of crystalloid may
  potentially lead to peripheral oedema.

18
Directed Donations
Module 4 Alternatives to Allogeneic Blood
Transfusion
Occasionally requests are made from individuals
wishing to donate blood for the use of a specific
patient. These are rarely indicated and should
be referred to the National Blood Service by the
local Consultant Haematologist. When a request
is made it is often by a parent or relative
wishing to donate for a child.

• Problems with directed donations
• Relative may not meet criteria e.g. ABO and D
  compatible, Kell negative for female recipients,
  CMV safe and previously tested donor for infants.
• No evidence to support increased viral safety -
  evidence suggests the reverse.
• Donors need to do something to help, along
  with family pressure, may lead to non-disclosure
  of adverse risk factors.
• Donor confidentiality compromised if chosen
  donor is deferred has a reactive screening test.
• Feelings of guilt and recrimination if adverse
  outcome for patient.
• Immunological risks associated with transfusions
  between first-degree relatives can cause TA-GvHD.
  Irradiation of products is recommended.
• Risks of misidentification or bacterial
  contamination, are no less for directed donations
  (SHOT).

No UK National Blood Service endorses the
practice of directed donations. If the
individuals concerned are insistent, the
prospective donor(s) should discuss the procedure
with a consultant at the local Blood Centre.
19
Erythropoietin - EPO
Module 4 Alternatives to Allogeneic Blood
Transfusion
Erythropoietin is a haemopoietic growth
factor. It is a cell-line specific stimulator of
erythropoesis - it stimulates the production of
red blood cells. It is normally produced by the
kidneys, in response to anaemia and low oxygen
tension. Therapeutic product is genetically
engineered recombinant human erythropoietin
(rHuEPO). It is often more effective if used in
conjunction with iron supplementation.

• Uses
• Treating patients with anaemia secondary to
  malignant diseases. Some patients with HIV may
  benefit.
• Treatment of anaemia due to renal failure
  associated with EPO deficiency.
• Licensed for use in PAD to increase the amount
  of autologous blood collected.
• May be considered preoperatively to increase
  haemoglobin level.
• May be considered perioperatively to avoid the
  use of allogeneic blood.
• May be considered in the treatment of
  postoperative anaemia an alternative to
  transfusion.

• Advantages
• Can almost eliminate use of red cell transfusions
  in renal failure cases.
• Literature supports use in some groups of
  patients with malignancy to alleviate anaemia
  symptoms and reduce need for blood transfusions.
• No transmission of known infections e.g. HIV,
  hepatitis B and C.

• Disadvantages
• Expensive product with cost-benefit issues.
• Iron status needs to be monitored as increased
  numbers of erythroid cells can lead to acute iron
  deficiency if iron not given with EPO.
• Increases in blood pressure may occur.
• May increase Hb beyond target if not monitored,
  with dangerous consequences.
• There may be an increased risk of deep vein
  thrombosis (DVT) in at risk patients.

20
Iron Supplementation Reducing the need for
transfusion
Module 4 Alternatives to Allogeneic Blood
Transfusion

See West Midlands RTC Guidelines for the
Management of Anaemia in Pre-operative Assessment
Clinics (2007) www.transfusionguidelines.org.uk/d
ocs/pdfs/rtcwmids_edu_anaemia_guide_preop_07_11.pd
f
21
Module 4 Alternatives to Allogeneic Blood
Transfusion
Iron Supplementation Reducing the need for
transfusion
NHS Blood and Transplant have produced a patient
information leaflet Iron in Your Diet. This
leaflet helps patients to understand the
importance of iron in the diet and what can
happen if they have low iron levels. The
leaflet has been produced in collaboration with
the British Dietetic Association and contains
information on foods that are rich in iron. Ask
your Hospital Transfusion Practitioner or
Transfusion Laboratory. This leaflet is also
available to download in a number of other
languages from http//hospital.blood.co.uk/
22
Pharmacological Agents
Module 4 Alternatives to Allogeneic Blood
Transfusion
To prevent excessive bleeding in surgery
To treat established bleeding
23
Contingency Planning for Potential Blood Shortages
Module 4 Alternatives to Allogeneic Blood
Transfusion
Blood Shortages may occur for a variety of
reasons

• Short term shortages may occur due to poor
  weather conditions, or an out break of the flu.

• Very acute shortages may occur due to security
  issues or disease.

• Prolonged shortage may occur, for example, due
  to issues relating to vCJD.

Due to the potential for a blood shortage, the
Department for Health and the National Blood
Service have developed a contingency plan.
The contingency plan has 3 levels of status
Hospitals may be asked to reduce their blood
usage during a blood shortage. www.dh.gov.uk/Publi
cationsAndStatistics/Publications/PublicationsPoli
cyAndGuidance/PublicationsPolicyAndGuidanceArticle
/fs/en?CONTENT_ID4085662chkvMu6/A
24
How to Minimise the impact of the contingency
plan on the care of the patient
Module 4 Alternatives to Allogeneic Blood
Transfusion

• In order to minimise the impact on patient care,
  hospitals should consider
• Hospitals should develop internal policies and
  procedures to follow in the event of a blood
  shortage.
• Emergency Blood Management Plans must be
  developed for Amber / Red status.
• Autologous blood programmes should be developed
  where appropriate.
• Reduced blood reservation period from the
  hospital blood bank.
• Blood Banks should actively participate in
  Blood Stocks Management Scheme (BSMS)
• Where appropriate, blood banks may consider
  electronic issue of units of blood
• Hospitals should develop robust preoperative
  assessment procedures to adequately assess for
  anaemia and maximise patients haemoglobin before
  surgery.

25
Key Points
Module 4 Alternatives to Allogeneic Blood
Transfusion
Reduce the need for allogeneic transfusion by
modifying transfusion practice.
26
Module 4 - Quiz
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 1 of 5
• What is an autologous transfusion?
• A. Any transfusion where the donor and the
  recipient are the same person
• B. The donor pre-donates blood prior to the
  patients surgery
• C. Any transfusion where the donor and the
  recipient are different
• D. Where an individual donates for a specific
  patient

27
Module 4 - Quiz
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 2 of 5
• What do the initials MSBOS stand for?
• A. Minimum Surgical Blood Ordering Schedule
• B. Maximum Surgical Blood Ordering Schedule
• C. Microbiological Screen for Blood Ordering
  Samples
• D. Microbiological Screen for Blood in Operating
  Specialities

28
Module 4 - Quiz
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 3 of 5
• Is the following statement always correct?
• The patient has lost quite a lot of blood in
  theatre..
• transfuse a couple of units and check haemoglobin
  later
• Correct / Incorrect

29
Module 4 - Quiz
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 4 of 5
• What does rHuEPO do?
• A. In the presence of calcium forms a clot of
  fibrin sealant.
• B. Reduces the antiplatelet effect of aspirin.
• C. Competitive inhibitor of plasmin binding to
  fibrinogen.
• D. Cell-line-specific stimulator of
  erythropoiesis.

30
Module 5 - Quiz
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 5 of 5
• Which of the following are pharmacological agents
  which may be used to reduce bleeding? (there may
  be more than one correct answer)
• A. Tranexamic Acid
• B. Warfarin
• C. Desmopressin
• D. Heparin

31
Module 4 Quiz Answers
Module 4 Alternatives to Allogeneic Blood
Transfusion

• Question 1 A
• Question 2 B
• Question 3 Incorrect
• Question 4 D
• Question 5 A and C