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Autologous blood: risks for patients, health care workers.

Biohazardous units of blood can be transfused to their donors, but the possiblity of accidental exposure threatens others.

Autologous blood donations are opening new areas of concern for transfusion services. Specifically, the handling of restricted biohazardous units of blood for autologous transfusion raises medicolegal and ethical questions.

Granted, donors themselves may not face any new risk from being transfused with their own blood after it has tested positive for human immunodeficiency virus antibody or hepatitis. The presence of such units nevertheless increases the risk of disease transmission to health care workers involved in the steps of collection, testing, distribution, and infusion.

Other patients serviced by the transfusion facility are also at greater risk. Through clerical error, which is the primary cause of transfusion accidents" these patients could receive infected blood that had been intended for autologous use.

Although it would seem that infected autologous and homologous units present the same degree of risk, they actually do not. If a homologous unit tests positive for hepatitis or HIV antibody, the blood is destroyed. An autologous unit, on the other hand, does not have to be so tested as long as it is earmarked for autologous use. If it is tested and the outcome is positive, the unit can still remain in inventory, where it poses a threat to the patient population and health care workers.

A patient may have the right to seek protection from possible exposure to disease and antigenic stimulation by choosing the safest form of transfusion-i.e. , autologous. But when this practice exposes others to increased risk, whose rights prevail?

Historically, autologous donor requirements have been minimal, aimed at preventing harmful effects on donor health at the time of donation. Criteria in the 12th edition of the Standards of the American Association of Blood Banks provide maximum safety for autologous donors:

The amount of blood collected may not exceed 450 +/-45 ml on donors weighing 50 kg (110 lb) or more. Blood may be drawn from patients weighing less than that at a limit proportionate to their individual weight; the anticoagulant must be adjusted accordingly. This guideline is also used for homologous donors. Age limits are not imposed. The autologous donor's hemoglobin should not be lower than 11 g/dI, nor should the hematocrit be less than 34 per cent at the time of donation.

Blood collections concurrent with transfusion of previously collected autologous units should not be performed at intervals more frequent than three days to allow fluid replacement. (The minimum interval is eight weeks for homologous donors, who don't have the expectation of being transfused that autologous donors have.)

Although autologous phlebotomy during bacteremia is contraindicated by the AABB Standards, the question of what to do about viremia remains unanswered. Testing for HBsAg, HIV, HBc, and ALT is not required. 3

The transfusion service's foremost reponsibility has always been to provide products and services designed to achieve hemostatic equilibrium while maximizing the safety and quality of patient care. Regulatory authorities in the past year have stepped up efforts to make sure employees are also protected from biohazards. A blood donor center was the first facility to be fined by the Occupational Safety and Health Administration for violating Centers for Disease Control AIDS prevention guidelines

The CDC guidelines may not go far enough as legal safeguards. Our conversations with numerous legal consultants indicate that collection and transfusion facilities could be held negligent and liable for damages that result from accepting a tainted unit of blood.

Biohazardous autologous units create health risks for everyone associated with donor collection. Transporters of blood products include a variety of personnel who may not understand the implications of a defect in the blood container. At the transfusing facility, all employees involved as the unit is processed into inventory, crossmatched, and transfused are at risk.

The transfusionist is exposed to numerous possibilities for contamination, from perforation of the unit to defective IV tubing to a recalcitrant patient who pulls the IV out and flings blood on whoever is in the way. Furthermore, as we have noted, having a tainted unit at the transfusion service creates the opportunity for an error in patient identification.

To determine the cuffent state of autologous transfusion practice, we distributed questionnaires to 50 collecting and 50 transfusing facilities across the nation.

Collecting facilities were questioned about donor deferral practice, blood distribution policies, and paperwork used to designate autologous and/or biohazardous units. Seventy- nine per cent of the collecting facilities defer autologous donors according to AABB Standards during the screening process. The other 21 per cent "include a history of viral infection (i.e., hepatitis or AIDS) as a reason for deferral.

Forty per cent of the collecting facilities will not distribute autologous blood units found positive for biohazardous agents after the screening process. The other 60 per cent distribute all autologous units regardless of testing outcome; 19 per cent in this group perform ABO grouping and Rh typing only, per AABB Standards for autologous donation, so that the status of the units they distribute is unknown.

Sixty-one per cent of the collecting facilities do not allow release of unused autologous units for homologous transfusion. This proportion may increase due to a 1987 Food and Drug Administration Blood Products Advisory Committee recommendation that autologous-homologous crossover not be allowed pending studies that address this issue .

The 39 per cent of collecting facilities allowing crossover employ tie-tags, adhesive tags, or a combination to denote which autologous units may be transfused homologously and which cannot. We feel none of these methods eliminates the possibility of clerical effor.

For example, a study from January 1986 to April 1987 found that 6 per cent of the autologous blood units received at our facility were supposed to be restricted for transfusion to their donors only, because they contained biohazardous agents-yet one of the units, positive for HIV antibody, had been labeled "Suitable for homologous use."

A higher proportion of transfusing facilities (45 per cent) than the surveyed collecting facilties permit autologous-homologous crossover. Clearly, opinion is almost equally divided on the issues of crossover and the risk posed by biohazardous units of blood.

There are two protocols for autologous transfusion. One restricts the transfusion of autologous blood to autologous donors only. If biohazardous units are to be allowed in circulation, the success of this system depends upon two factors-elimination of clerical error by collecting and transfusing facilities, and elimination of nursing administration effor.

The second protocol permits autologous-homologous crossover, subject to normal donor criteria. The success of this system depends upon the accuracy and thoroughness of the donor history, and elimination of clerical and nursing administration error.

We maintain that risks will exist as long as tainted blood units are collected and distributed for transfusion. These risks can be minimized by revising established autologous donor criteria and broadening AABB Standards to encompass specific protocols for autologous donor programs. The AABB does not at this time have a standard policy regarding the collection and distribution of biohazardous units. Making donor criteria uniform and eliminating the availability of biohazardous units of blood would insure maximum quality of care for patients and maximum safety for health care workers.

The concept of autologous blood transfusion is a good one. An individual is the sole owner of his or her blood and has the right to receive it when donating for self-use. Precautions must be taken, however, to minimize risk for all involved. A workable and equitable approach, addressing all needs, should be developed.
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Copyright 1989 Gale, Cengage Learning. All rights reserved.

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Author:Sammons, Teresa D.; Sizemore, Jody C.
Publication:Medical Laboratory Observer
Date:Jun 1, 1989
Words:1243
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