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Managing an autologous blood program.

Managing an autologous blood program

Transfusion anxiety continues to disrupt blood banking, constricting inventories and fanning patient doubts about the safety of the blood supply.

Some potential donors still hold back, out of a mistaken belief they can contract a disease from giving blood. And some donated blood is lost because of false-positive results on early AIDS screening tests. (The Food and Drug Administration has yet to issue a ruling clearing these donors, even though their Western Blot tests were negative.) Conversely, a number of patients refuse elective but necessary surgery for fear they may receive contaminated blood if transfused.

Autologous transfusions ease patient concerns and blood shortages. Surgical candidates gain peace of mind by donating for their own transfusions, and these units augment an often depressed blood supply.

Our 200-bed hospital, specializing in orthopedic surgery, is a leader in offering this alternative to patients. Most of the hospital's procedures are elective, which is ideal for an autologous blood program.

As figure I shows, participation grew from a starting level of 59 autologous transfusions in 1980, or 2 per cent of total red cell transfusions, to 1,179 autologous transfusions in 1986, or 36 per cent of total red cell transfusions. Such volume is especially important now: Our inventory is down by about 30 per cent due to the chronic blood shortage.

First introduced in 1979, after much prodding by one of our orthopedic surgeons, the program officially began in 1980. Although the blood bank strongly supported the concept, guidelines and procedures had to be defined. Cooperative participation by the blood bank and donor room, the surgery and anesthesia departments, hospital administration, and patients was also essential. Communication was and still is a vital component for making the program work.

Our autologous donation procedure is outlined in Figure II. Patients must be referred by a physician and provide written consent in order to enter the program. The consent form authorizes transfusion of non-autologous blood if the patient needs extra units; conversely, the form releases any unused autologous units to the blood bank inventory. No one has ever refused to sign the form. We generally have enough autologous blood on hand for transfusion into patient-donors, and they are happy to share whatever they don't need. In 1986, 139 autologous units were cleared for homologous transfusion. Eighty-five additional units were discarded.

Once surgery is scheduled, the donor room sets up the patient's appointments and sends a copy of the dates to the blood bank for the permanent record. As with any blood donation, we take precautions to protect both the donor and the recipient--in this case, the same person.

We follow American Association of Blood Banks guidelines for donor selection and conduct a comprehensive medical interview. Autologous donors need not meet all the requirements outlined in the AABB Standards, however. For example, while a patient with AIDS or another infectious disease would be rejected for homologous donation, he or she can donate blood for personal use. (There is much discussion in the blood banking community about accepting patients with a known positive Western Blot for autologous transfusion. We do accept these patients, but they must sign a consent form that releases their test results to a designated physician. However, blood bankers must be especially vigilant because of the increased risk if a unit is mislabeled or transfused to the wrong recipient.)

The following criteria must still be met by autologous donors:

* Donors should be able to withstand the donation. We choose individuals who are not likely to have an adverse reaction to the phlebotomy.

*Donors generally should be younger than 70 years of age, although we do make exceptions based on written approval from the referring physician and consultation with the blood bank physician. This often comes down to the patient's attitude and the possibility that he or she may decide to forgo surgery if the transfusion is homologous. One 90-year-old patient, concerned about the safety of transfusion, pressed hard for autologous blood. She signed the consent form, donated, and did fine.

The lower age limit depends on the donor room staff's ability to deal with children--the literature does not cite a specific age. Our youngest autologous donors have been 13 years old.

* In general, donors should weigh at least 45 kg or 99 lbs.

* A patient on prescription medication must be cleared as a donor by the referring physician. We do not define acceptable or unacceptable medications.

* Hypertensive patients with a diastolic blood pressure greater than 100 mm Hg are generally not accepted as donors.

* Donors should not be severely anemic. Prior to each donation, the patient must demonstrate a hemoglobin concentration of at least 11 gm/dl and a hematocrit of 34 per cent. In this respect, we veer from the AABB Standards, which require a slightly higher hemoglobin concentration. However, we do labelt he blood "autologous only."

* Patients with a history of cardiac problems should be approved as donors by a cardiologist. These patients don't ordinarily donate, but if they are healthy enough to undergo elective surgery, they can probably handle giving a unit of blood for their own use.

* Patients with active asthma or chronic obstructive pulmonary disease are excluded from autologous donation.

* Patients should not have had major surgery within the last two months or tooth extraction within 72 hours before donating, because of the possibility of infection.

* Donors should not have a history of seizures.

* Iron supplementation may be prescribed for patients donating two or more units of blood.

* The blood bank's attending physician has the final word in dedicing whether to accept someone for autologous donation.

We are currently developing a maximum surgical blood ordering schedule for the operating room. In the meantime, the number of units drawn depends on the surgeon's estimate of need together with how much the patient is willing to donate.

A patient requiring two units will donate once two weeks before surgery and again a week to three days before surgery. If the surgeon feels more blood may be required, drawing begins earlier. Some patients, healthy except for their orthopedic condition, have donated as many as four units. If surgery is postponed, the donor room staff can piggyback a unit to avoid blood spoilage; that is, they transfuse the first donated unit back into the patient, then draw two fresh units.

All units get tagged with an "autologous blood" label as they are collected. The label shows the patient's name, birth date, donor unit number, donation and surgery dates, and Social Security number; the hospital identification number is not issued prior to admission. The patient verifies the blood is his or her own by signing the label. The blood bank stores autologous units--we usually have about 60 on hand--in a designated section of the blood inventory refrigerator.

All blood is tested for group and type, hepatitis B surface antigen, HIV antibody, and syphilis. We also do ALT testing and will soon begin core antibody testing. The test results and information obtained during the medical interview determine whether the units are labeled "suitable for homologous transfusion" or "for autologous transfusion only."

Blood bank logitics are managed with Hemocare software (Woodbury, N.Y.), run on the IBM PC AT. The system, which handles all blood bank functions, stores the blood product code, donor unit number, recipient's name, blood type, and expiration date. Each autologous unit receives a blood product code--APC for autologous packed cells or AWB for autologous whole blood--which precedes the donor unit number.

APC units are suitable for homologous transfusion. In addition, the fresh frozen plasma and platelets are salvaged for blood bank use, provided the donor has met all the requirements outlined in the AABB Standards. AWB units are used only for autologous transfusion. All pertinent information is easily retrieved from the computer at the time of transfusion.

Patients are usually admitted the day before surgery. To guard against any mixup in units--or in the event a patient requires additional blood--we draw a specimen for type, antibody screen, and immediate-spin crossmatch with the autologous blood.

About one week after surgery--or at the time of discharge, if earlier--the leftover autologous units are released to blood bank inventory for homologous use. The blood bank clears this with the patient's physician. Such blood generally has a remaining shelf life of one to two weeks. Using adenine saline as an anticoagulant helps stretch the period another week to 10 days.

The most important benefit of an autologous blood program is that it removes the risk of transmitting infectious disease, thereby relieving the anxiety many patients currently have about transfusion. There is also no risk of a transfusion reaction caused by immunization to donor red cells.

The repeat phlebotomies stimulate the patient's bone marrow to increase its production of red blood cells. Autologous donors are guaranteed compatible blood, a big plus in the case of rare red cell antibodies or community blood shortages.

Patients are referred to our hospital from all over the country, and long-distance donors represent 10 per cent of the autologous blood program's participants. They donate at a local hospital or Red Cross facility, and the blood travels with them or is shipped to us.

In balance sheet terms, an autologous blood program lowers costs by curtailing pretransfusion testing. It is also an effective marketing tool, satisfying the needs of our patient population.
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Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Author:Bello, Kathryn
Publication:Medical Laboratory Observer
Date:Feb 1, 1987
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