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Surgical blood conservation: Preoperative autologous blood donation

Surgical blood conservation: Preoperative autologous blood donation
Author:
Lynne Uhl, MD
Section Editor:
Steven Kleinman, MD
Deputy Editor:
Jennifer S Tirnauer, MD
Literature review current through: Sep 2023.
This topic last updated: Jul 19, 2022.

INTRODUCTION — Preoperative autologous donation (PAD) remains the most widely known, though perhaps no longer the most widely used, of the autologous options for surgical blood conservation, which also include intraoperative hemodilution and intraoperative and postoperative blood salvage.

This topic discusses the limited use of PAD, for individuals likely to require perioperative transfusion for whom crossmatch compatible blood is not available, and the reason PAD is generally avoided for the vast majority of other patients.

Separate topic reviews discuss other surgical blood conservation methods and directed donations:

Normovolemic hemodilution – (See "Surgical blood conservation: Acute normovolemic hemodilution".)

Intraoperative and postoperative blood salvage – (See "Surgical blood conservation: Blood salvage".)

Directed donations – (See "Blood donor screening: Overview of recipient and donor protections", section on 'Directed donations'.)

Other means of maintaining blood safety (for allogeneic transfusion) are also discussed separately:

Donor medical history – (See "Blood donor screening: Medical history" and "Blood donor screening: Overview of recipient and donor protections", section on 'Protection of the recipient'.)

Laboratory testing – (See "Blood donor screening: Laboratory testing".)

Pathogen inactivation procedures – (See "Pathogen inactivation of blood products".)

HISTORICAL PERSPECTIVE

Chronology — Use of PAD has shifted over time.

As early as 1983, interest in PAD (and all forms of autologous transfusion) greatly expanded in response to the acquired immunodeficiency syndrome (AIDS) epidemic.

Participation in PAD peaked by 1993, at which time approximately 6 percent of all blood collected in the United States was intended for autologous use. During the height of PAD activity, advocacy for participation in PAD centered on purported benefit derived from the mitigation of transfusion-associated infections, in particular, viral disease. Additionally heralded was the consideration for general enhancement of the blood supply, both in terms of use of autologous products in lieu of allogeneic products, and the potential for "crossover" of unused autologous units to general inventory.

Since the peak of use in 1993, there has been a steady decline, according to the National Blood Collection and Utilization Survey (NBCUS) that is published every two years [1].

By 2019, PAD accounted for 0.3 percent of donations; the number of recipients of autologous blood has similarly declined [1].

Reasons for declining use — Use of PAD has declined for a number of reasons. As a result, the true benefit of PAD has become questionable [2].

Factors that have influenced the decline of PAD usage include:

Increasing safety of the general blood supply – Over time, the safety of the blood supply has increased due to introduction of nucleic acid testing and other infectious disease screening. The risk of transfusion-transmitted HIV has declined to 1 in 2 million units. Enhanced laboratory testing of donated blood has increased confidence among surgical patients and clinicians and reduced motivation to bank autologous blood. (See "Blood donor screening: Laboratory testing", section on 'HIV-1 and HIV-2'.)

Greater likelihood of transfusion – Studies performed at the height of PAD activity showed that the rate of perioperative transfusion was increased in patients who donated autologous blood compared with those who did not. As examples:

A 2002 trial randomly assigned 96 patients undergoing elective total hip replacement who had a baseline hemoglobin of ≥12 g/dL to donate or not donate two units of blood for autologous transfusion and found that approximately 40 percent of the autologous units were wasted [3]. No patient in either group received an allogeneic transfusion. Mean hemoglobin values were lower in the autologous donors on admission to the hospital (12.9 g/dL, versus 13.8 g/dL in the controls), and 69 percent of the autologous donors received one or two units of their own blood. None of the controls received a transfusion.

A 1996 study involving patients undergoing elective hysterectomy found that, of 140 individuals who donated autologous blood prior to hysterectomy, the mean admission hemoglobin was 11.9 g/dL, and 25 (18 percent) were transfused; of 123 who did donate autologous blood, the mean admission hemoglobin was 13.2 g/dL, and only 1 (0.8 percent) was transfused (p <0.001) [4]. Logistic regression confirmed that autologous donation was an independent risk factor for transfusion.

With improved surgical techniques leading to less blood loss and uniform acceptance of lower transfusion thresholds, it is probable that similar studies, if performed today, would demonstrate a narrowing of the differences in rate of perioperative transfusion for those who used PAD and those who did not. However, this does not take away from the observation that PAD results in lower admission hemoglobin (and in some cases in anemia), which is not beneficial to the patient.

Historically high rate of PAD unit discard – Blood donated for autologous transfusion is not transferred to the general blood supply if not used by the autologous donor; it is discarded. During the peak of PAD participation in the late 1980s, as few as 40 percent of units were used, resulting in as many as 60 percent being discarded [5-7]. (See 'Crossover (release to other recipients) is no longer used' below.)

Reduced transfusion rates with patient blood management – Institution of patient blood management (PBM) programs has led to an emphasis on restrictive transfusion thresholds and reduction in the rate of transfusion overall; changes are largely based on data from randomized trials demonstrating equivalent or better outcomes when restrictive transfusion thresholds are used. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Restrictive transfusion strategy for most stable patients'.)

Other contributions to the decline in transfusion rates include the use of cell salvage and other blood recovery approaches, as well as improved surgical techniques and incorporation of antifibrinolytic agents. (See "Surgical blood conservation: Acute normovolemic hemodilution" and "Surgical blood conservation: Blood salvage".)

Increased cost of PAD – Use of PAD adds costs related to the extra time and attention required for obtaining and processing the units (additional labels, separate storage, early delivery to the hospital), administering them when needed, discarding when not used (applies to more than half of PAD units collected), and enhanced clerical requirements [8]. As a result, autologous blood is considerably more expensive than allogeneic blood.

Decision analysis models evaluating the costs of all potential outcomes, published >2 decades ago, at a time when transfusion-transmitted viral infections were of significant concern, suggested that PAD was not cost-effective [2]. Greatly improved screening assays for infectious diseases plus the high discard rate of autologous units have likely magnified the lack of cost-effectiveness [1,2].

Potential for complications related to PAD – With the decline in PAD, the number of hospital-based autologous blood collection programs has waned. Instead, patients are referred to local blood centers who have expertise in donor collection, processing, labeling, and shipping. Despite the shift to blood centers for collection and donor unit management, there remains the potential, as with any collected and distributed blood product, for undetectable bacterial growth during liquid storage and for clerical error, resulting in the donor/patient receiving allogeneic blood rather than the pre-donated autologous units [2]. Additionally, processing errors or technical errors at the collection facility may render units inappropriate for distribution and transfusion [2].

Elimination of crossover – (See 'Crossover (release to other recipients) is no longer used' below.)

Crossover (release to other recipients) is no longer used — When PAD programs first gained popularity, most programs allowed autologous blood that met all criteria applied to allogeneic blood, including medical history screening and laboratory testing, and was not used by the original patient (donor) to be "crossed-over" and made available to other recipients as allogeneic blood.

As late as 1987, crossover was allowed in 65 percent of PAD programs; by 1990, however, only 2 percent of programs continued this practice [5]. The practice of crossover of autologous units into the general inventory has disappeared.

Safety concerns exist about the patient/donor's understanding of the nature of their underlying illnesses and medical history. The donor may also be motived to omit pertinent information about infectious risks to allow them to use PAD, in contrast with the community donor's presumed altruistic motivation.

The concern about increased infectious risk from PAD units is supported by data that indicate a higher frequency of positive viral markers in red blood cell units drawn from PAD donors compared with units drawn from volunteer allogeneic donors. In a study from 1989, the following higher risk ratios [RR] for autologous PAD units eligible for crossover based on donor history versus volunteer allogeneic units were noted [9]:

1.8 (99% CI 0.34-7.68) for hepatitis B surface antigen (HBsAg)

2.5 (99% CI 1.90-3.24) for anti-hepatitis B core antigen (anti-HBc)

3.5 (99% CI 1.31-8.86) for rapid plasma reagin (RPR; screening test for syphilis)

Another concern with crossover is the reluctance of many surgeons to release autologous blood until so late in its dating period that it is difficult to guarantee its use for another patient. As a result, there was an added burden of needing to make a separate crossover eligibility determination for each donated unit and an increase in complexity of record keeping and billing for a relatively small benefit in terms of the number of units added to the system.

APPROPRIATE USE OF PAD

Indications — Ideally, PAD would be used to collect autologous units from individuals who are most likely to use them.

The most compelling indication is for an individual scheduled for a surgical procedure with recognized high probability for transfusion who has developed multiple antibodies or alloantibodies to high frequency antigens and for whom a sufficient number of allogeneic units may not be guaranteed. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult" and "Red blood cell (RBC) transfusion in individuals with serologic complexity", section on 'Alloantibodies'.)

Another group of patients are those who refuse allogeneic units for religious or other personal reasons, although devout Jehovah Witnesses do not consider transfusion of autologous blood to be an acceptable alternative to allogeneic transfusion. (See "Approach to the patient who declines blood transfusion", section on 'Jehovah's Witnesses'.)

If indicated, autologous donation can be used in children >40 to 45 kg and when phlebotomy of 15 percent of the blood volume is feasible. The amount of blood stored needs to correlate with the equipment and blood bags for storage (eg, storage of half units). (See "Red blood cell transfusion in infants and children: Selection of blood products".)

Contraindications — There are no specific contraindications to PAD; the physician referring the patient needs to make the assessment with thoughtful consideration of the patient's general health and comorbidities. The blood collection center will make the ultimate decision regarding whether donation is safe.

General exclusions from PAD would include conditions that would be exacerbated by transient anemia (eg, unstable angina or aortic stenosis).

Individuals with an acute infection cannot donate; the contraindication particularly applies if it could be associated with bacteremia. Although most bacteria will not proliferate in the cold (during blood storage), some psychrophilic organisms such as Yersinia enterocolitica can reach peak concentrations in blood within one or two weeks of storage at 4°C. Transfusion of this blood after prolonged cold storage has been associated with fatal reactions [10]. (See "Blood donor screening: Medical history", section on 'General symptoms of active infection'.)

Adhering to transfusion guidelines — Transfusion of autologous blood is not without potential toxicity, including:

Hemolysis secondary to improper handling of the saved units [11]

Sepsis resulting from bacterial contamination of the saved units [12]

Pulmonary edema induced by volume overload (TACO) or possibly transfusion-related acute lung injury (TRALI) [13]

Transfusion of the wrong unit of blood due to patient misidentification [14]

These potential complications make it imperative that autologous blood be transfused wisely and only when specifically indicated. It is never reasonable to transfuse an autologous unit simply because it is available or would otherwise be discarded. Similarly, autologous blood should not be transfused to replace iron, to promote wound healing or general well-being, or to normalize the hemoglobin level.

Compatibility testing — Pretransfusion compatibility testing can be abbreviated for the autologous donor/patient. Nevertheless, it is good practice to perform the following testing:

ABO group and RhD type on a patient specimen.

Antibody screen on a patient specimen.

Confirmation of ABO group and RhD type on the autologous unit.

Prior to issuing the unit for transfusion, as a precaution against a clerical or labeling error, crossmatch in accordance with transfusion service practice.

The extent of infectious disease testing is discussed below. (See 'Extent of infectious disease testing' below.)

HOW TO ACCESS PAD — In light of the waning interest (see 'Reasons for declining use' above), PAD programs are largely the purview of blood collection centers. Should the physician/surgeon and patient determine that PAD is appropriate, the following actions/recommendations should be considered.

Physician request — Patients are accepted into PAD programs at the request of their physician, usually the surgeon who will perform the surgery or the anesthesiologist. This clinician, or a colleague with credentials in family practice, internal medicine, or cardiology, must certify that the phlebotomies pose no undue risk to the patient. The final decision regarding acceptability rests with the medical director of the blood collection facility.

The number of PAD units donated depends on the procedure (how many units are likely to be needed) and the individual's hemoglobin (how well they can tolerate the donation procedure). Most donor centers monitor the patient's hemoglobin prior to each donation.

Scheduling — The most practical schedule for obtaining more than one unit of autologous blood is to draw units at weekly intervals, with the last unit drawn approximately two weeks prior to surgery.

It is allowable to donate the final unit as close as 72 hours prior to surgery, as this allows for the volume and protein losses to be replaced. However, we strongly discourage this practice, since there is no useful purpose served by drawing blood when there is insufficient time for red blood cells to be substantially replenished, which takes approximately two weeks.

Iron supplementation — Patients should begin oral iron supplementation as soon as the surgery is scheduled. The optimal supplementation dosing and schedule for blood donors has not been established. Often donors are told to take daily iron, but data in individuals with iron deficiency suggests that alternate day dosing is equally effective and better tolerated. (See "Treatment of iron deficiency anemia in adults", section on 'Oral iron'.)

Preoperative treatment of anemia should be considered first when evaluating a patient in the setting of perioperative blood management [15]. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Preoperative strategies'.)

Erythropoietin (rarely indicated) — In contrast to iron supplementation, the use of recombinant human erythropoietin (r-huEPO) or other erythropoiesis-stimulating agents (ESAs) in autologous donors does not appear to be justified [16]. r-huEPO is primarily indicated in those patients in a PAD program who are anemic prior to the first donation or who have small blood volumes and would otherwise be unable to meet their anticipated needs [17,18]. The dose has ranged from 12,000 to 40,000 units per week (given subcutaneously) and oral iron replacement is given concurrently, if tolerated, or intravenous iron is used. (See "Treatment of iron deficiency anemia in adults".)

Informed consent — The patient considering PAD should understand the risks and benefits of autologous donation and transfusion and should be made aware of transfusion alternatives, such as allogeneic blood transfusion and intraoperative blood salvage [19]. (See "Surgical blood conservation: Blood salvage".)

Autologous donors should sign an informed consent form prior to donation that outlines the advantages, nature, and purposes of autologous transfusion; the risks involved; and the possibility of complications. Permission should also be obtained to share laboratory results with the patient's clinician, if indicated.

Donor criteria — At the time of presentation for donation, patient/donors are assessed by the same criteria as allogeneic donors:

They should be in good health and without evidence of active infection. (See "Blood donor screening: Overview of recipient and donor protections", section on 'Protection of the donor'.)

There should be no medical contraindication to donation. (See 'Contraindications' above.)

In general, there is no age exclusion for donation. Centers vary on the pre-donation hemoglobin requirement; at most collection centers, autologous blood donation can be made with a hemoglobin of ≥11 g/dL, in accordance with AABB (Association for the Advancement of Blood & Biotherapies) standards [20-23].

Labeling — Autologous blood must be labeled to reflect all testing that has been done. In addition, a special autologous tag should be attached to the unit. This tag should contain:

The patient's name

A unique identifying number (date of birth or hospital registration number)

The ABO and Rh group

The date of expiration of the unit

If incompletely tested or otherwise unsuitable for allogeneic use, the tag must also bear the statement "for autologous use only — may not be issued to another patient" [20]. Crossover of PAD units to the allogeneic pool no longer occurs. (See 'Crossover (release to other recipients) is no longer used' above.)

CONTROVERSIAL AREAS — Several aspects of the provision of PAD services remain controversial despite much experience and the purported benefit of protecting the patient from infection.

Extent of infectious disease testing — Autologous blood collected at a donor center and shipped to the transfusing facility must be tested for syphilis, HIV, hepatitis B virus (HBV) and HCV, West Nile virus (WNV), and Babesia. (See "Blood donor screening: Laboratory testing", section on 'Infectious disease screening and surveillance'.).

Autologous blood that will be transfused within the same institution in which it is drawn need not undergo any infectious disease testing, and the extent to which autologous blood from the same institution is tested is clearly discretionary and therefore a continuing source of controversy.

Arguments in favor of lesser or greater infectious disease testing include:

Minimal (or no) testing provides:

Reduced processing costs.

Avoiding the need to obtain a federal license to operate a blood collecting and processing facility.

Simplified bookkeeping (since non-tested autologous blood cannot be crossed-over to another recipient).

Avoiding the awkward and sometimes confusing problems created by finding abnormal results.

More extensive testing (as done for allogeneic donors) provides:

Administrative simplicity (the chance for error is reduced whenever all collected blood is handled in the same manner).

Reduced need to ship partially tested units (which represents a significant administrative burden, since they must be packaged and shipped as though potentially infectious).

Ability of the collecting facility to make appropriate decisions about the disposition of potentially infectious units. (See 'Participation by donors known to have HIV, HBV, and/or HCV' below.)

Participation by donors known to have HIV, HBV, and/or HCV — Controversy surrounds the participation of donors known to have HIV, HBV, or HCV and the handling of autologous blood collected from known positive donors (or units collected from donors with no known history who are subsequently found to be positive for one or more infectious disease markers, particularly HIV, HBV, and/or HCV).

There are no guidelines from the US Food and Drug Administration (FDA) or the Association for the Advancement of Blood & Biotherapies (AABB) that address this issue.

However, the FDA and AABB require a written statement from the receiving transfusion service and the attending physician that HIV or HBV confirmed reactive units are acceptable in order for them to be shipped from the collecting to a transfusing facility.

Considerations for PAD by patients with known HIV, HBV, and/or HCV include:

Allow – Arguments in favor of allowing known infected patients to participate in PAD programs were articulated in the AABB Association Bulletin #98-5, which noted that the Supreme Court decision in Bragdon v. Abbott (Bragdon v Abbott, 118 S. Ct. 2196 [1998]) specifically provides protection to HIV-infected individuals under the Americans with Disabilities Act (ADA) [24]. AABB, the American Red Cross, and the Department of Defense have interpreted (and extended) this decision to HIV-infected individuals wishing to participate in PAD programs, and they suggest that denying participation to these donors may run counter to the intent of the Bragdon decision. The complex medical, ethical, and legal issues related to participation of HIV-infected donors were further addressed by the autologous transfusion committee of the AABB [25].

Not allow – Decision analysis has been used to calculate the anticipated benefits of providing known infected patients with the opportunity to participate in PAD programs versus the risks to them of having to receive allogeneic blood [26]. The benefits attained by these known infected patients were also compared with the adverse consequences potentially experienced by other patients and/or health care workers inadvertently exposed to the infected blood from the autologous patient/donor. The conclusion was that, given the safety of allogeneic blood, the benefit to be derived by providing autologous blood to patients infected with HIV, HBV, or HCV is very small, particularly when compared with the potential harm to health care workers (and other patients) should infectious blood be allowed into the system.

Given the issue of safety to others, it is possible that the Bragdon decision may not apply to participation in PAD programs. However, the question has not specifically been addressed; consultation with legal counsel is advised before adopting a policy that denies participation by known infectious donors or the release of known infected blood units [27].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Transfusion and patient blood management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Beyond the Basics topics (see "Patient education: Blood donation and transfusion (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Historical context – Interest in preoperative autologous donation (PAD) greatly expanded in response to the AIDS epidemic and then declined to the point that it is rarely if ever used. Reasons for the decline in use include the greater likelihood of transfusion when an autologous unit was donated, high rate of discarding autologous units, increasing safety of the blood supply, lower overall rate of transfusion due to patient blood management, and cost. PAD units were once crossed over into the general allogeneic donor pool, but this no longer occurs (See 'Historical perspective' above.)

Indications – The most compelling indication for PAD is for an individual undergoing surgery with high likelihood of requiring transfusion who has developed alloantibodies to high frequency antigens or multiple antibodies and for whom a sufficient number of allogeneic units may not be guaranteed. (See 'Indications' above.)

Contraindications – Exclusions from PAD include conditions that would be exacerbated by transient anemia (especially cardiovascular conditions and heart failure), and any acute infection. (See 'Contraindications' above.)

Avoiding inappropriate use – Autologous blood should never be transfused simply because it is available or would otherwise be discarded. Autologous blood is not appropriate for replacing iron, promoting wound healing or general well-being, or normalizing the hemoglobin level. (See 'Adhering to transfusion guidelines' above.)

Laboratory testing of autologous units – Prior to issuing the unit for transfusion, ABO and RhD compatibility testing and an antibody screen are generally performed on a patient specimen; ABO group and RhD type are confirmed on the autologous unit, and crossmatch is done according to transfusion service practices. (See 'Compatibility testing' above.)

Access to PAD – PAD programs are largely the purview of blood collection centers. Patients can donate up to one unit per week, with the last unit collected two weeks prior to surgery. They should begin oral iron supplementation as soon as surgery is scheduled. Erythropoietin is rarely indicated. The donor should understand the risks and benefits and should provide informed consent; they should generally meet donation criteria for allogeneic donors. (See 'How to access PAD' above.)

Controversies – Several aspects of PAD remain controversial, including the extent of infectious disease testing, release of infectious units, and participation by known infectious donors. Consultation with legal counsel is advised before adopting a policy that denies release of known infected blood or participation by known infectious donors. (See 'Controversial areas' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff gratefully acknowledges the extensive contributions of Arthur J. Silvergleid, MD, to earlier versions of this and many other UpToDate topics.

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