Blood Transfusion

Joanne Simpson
Anaesthetic SHO

Indications
Blood

Loss
Bone Marrow Failure
Inherited RBC disorders
Acquired RBC disorders
Neonatal 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 infections
Immunomodulation
Transfusion Reaction

Long Term Concerns

Costly
Human

Errors in Transfusion
Limited supply
Viruses and Bacteria not screened for

Blood Sparing
Strategies

Who will benefit?

Jehovahs

Witnesses
Patients with multiple antibodies
Patients anxious about receiving blood
transfusions from unknown donors
However,
Only available to selected patients in
practice

Preoperative Autologous Blood

Transfusion
This

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 given
Some centres give the patient
erythropoietin to enable greater numbers
of units to be collected.

Advantages
RBCs

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

Selection
Close collaboration between surgeon,
patient and transfusion lab essential
High cost
Units may still become contaminated in
storage
Patient may still require extra units
Blood 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
Cost
Risks

of hypertension
Risks 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

Selection
Should 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 thrombosis
Deterioration in renal function
Allergy
Lack 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 reactions
No disease transmissions
No alloimmunisations
No immunomodulation
Safer
Readily available blood in major
haemorrhage
Cheaper than using donor blood

Disadvantages
Coagulation

Disorders when large

volumes (>1500ml) are reinfused
Unwashed systems may give bacterial
transmission
Initial set up costs

Jehovahs 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

Jehovahs 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 risks

There are feasible alternatives available to
allogenic transfusion
Jehovahs witnesses present an ethical
problem when it comes to blood
transfusion, but there are acceptable
alternatives

References
SIGN

Guideline number 54
Oxford Handbook of Haematology
BMJ Volume 311, 28/5/95 Management
of Blood loss in Jehovahs Witnesses
Haemoclaim, Blood Salvage Website,
www.nwpgroup.com
www.urology.medsch.ucla.edu/blood_trans
fusions.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: metaanalyses 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?