Guidelines for red blood cell and plasma transfusion for adults and children
Autologous blood transfusion
Autologous blood transfusion is a general term used to describe a procedure by which previously donated (or shed) blood is transfused (or re-infused) into the same donor or patient. Autologous blood can be obtained by
- predonation (predeposit) of blood
- perioperative normovolemic hemodilution (withdrawal of blood immediately before surgery, with volume replacement by crystalloid solutions) and subsequent reinfusion of the removed blood
- intraoperative blood salvage
- postoperative blood salvage.
The EWG considered only predonation.
A substantial proportion of patients who require blood are not candidates for autologous blood donation; for example, those with acute or chronic anemia; those with active infection; those requiring urgent surgery; small children; and some patients who require cancer surgery.57,58 Use of autologous blood reduces the likelihood that allogeneic blood will be used (Andreas Laupacis et al. See citation on page S3.), and thus would be expected to reduce certain risks associated with blood transfusion -- for example, the risk of exposure to transmissible infections such as HIV and hepatitis C; alloimmune hemolysis; allergic reactions; immunization to foreign antigens; graft-versus-host disease; and, possibly, immunosuppression. There is conflicting evidence as to whether predonation of autologous blood reduces postoperative infection because of avoidance of transfusion-associated immunosuppression.59,60 Also, of autologous blood transfusion does not prevent other adverse effects: septicemia from bacterial contamination;6164 nonhemolytic (febrile) transfusion reactions caused by plasma factors generated during blood storage; clerical or laboratory error leading to transfusion of the wrong blood unit65; and circulatory overload. Because these risks remain, autologous blood should not be routinely reinfused to patients in the absence of an indication.
The risks associated with allogeneic blood that can be avoided by using autologous blood are rare. Furthermore, specific risks are associated with autologous blood. The risks from predeposited autologous blood include a higher likelihood of receiving blood in the postoperative period (Andreas Laupacis et al. See citation on page S3.) and adverse events associated with blood donation, particularly in cardiac patients.66,67 In addition, surgery may have to be rescheduled to avoid wastage of blood already collected.
There is insufficient evidence to indicate overall whether using autologous blood is more, equally or less safe than using allogeneic blood. Nevertheless, other considerations support the use of autologous blood for transfusion. First, it would theoretically prevent exposure to new infectious or other noxious agents that might contaminate the blood supply in the future. Second, there is a widespread perception among patients and health care workers that autologous blood is likely to be safer. Third, the interim report of the Commission of Inquiry on the Blood System in Canada14 has made several recommendations in favour of wider availability and use of autologous blood. Fourth, use of autologous blood reduces demand for banked allogeneic blood and thus helps alleviate blood shortages. (Note: At present, unused autologous blood units do not meet Canadian Red Cross donor criteria and, therefore, cannot be added to the general blood supply.) Fifth, autologous donation is helpful for elective surgical patients with rare blood groups or antibodies to multiple or high-incidence alloantigens.
The cost of providing autologous blood is higher than for providing allogeneic blood.68 Minimizing the waste of autologous units by focusing on patients who are most likely to use blood is important in improving the cost-effectiveness of autologous blood.69,70
A recent meta-analysis provides insight into the potential benefits and risks of a program for the predeposit of autologous blood (Table 2). This review of 6 randomized, controlled trials and 9 nonrandomized comparator-controlled studies revealed that the predeposit of autologous blood reduced the amount of allogeneic blood transfused (the odds ratio [OR] for the randomized, controlled trials was 0.17, 95% confidence interval [CI] 0.080.32) (Andreas Laupacis et al. See citation on page S3.). There was a direct relation between the proportion of patients transfused in the control group and the absolute benefit of predeposited autologous blood for reducing exposure to allogeneic blood (i.e., the benefit is greatest when the expected use of blood is highest). Interestingly, this meta-analysis also showed that patients who predeposit autologous blood were significantly more likely to receive any blood product (including their own) than control patients (OR 6.69, 95% CI 3.6312.32). The authors offered 2 reasons for this observation: lower preoperative [Hb] and a more liberal transfusion policy for patients who had predeposited their own blood. This analysis suggests that patients who predeposit autologous blood may be at greater risk for certain complications associated with transfusion (e.g., septicemia from contaminated blood units, transfusion of the wrong blood unit due to laboratory or clerical error).
Recommendations regarding the use of autologous blood
- Predonation of autologous blood should be considered a therapeutic option for adolescents and adults undergoing elective surgery in which the likelihood of transfusion is substantial (i.e., 10% or more).
Level of evidence: III
- Indications for the transfusion of autologous blood should be the same as those for allogeneic blood.
Level of evidence: III
