Is Preoperative Autologous Blood Donation the Answer?

“Autologous blood donation and the transfusion of autologous blood are each associated with risks.”  -Critical Care

“Autologous predonation can be very effective in reducing reliance on allogeneic blood, but it has been shown to increase overall exposure to transfusion and to increase the chance of perioperative anemia.”  -Anemia.org

Preoperative autologous blood donation (PABD) is a procedure where blood is removed from the patient before surgery and is stored – possibly for weeks – and is then transfused back into the patient at the time of surgery.

How PABD works
“A person might give one unit of blood each week for up to six weeks before surgery, because blood can be stored in its liquid form for up to 42 days. Patients can make autologous donations up until 72 hours prior to their surgery. This is to allow the body enough time to replenish its blood supply before the surgical procedure.” AABB

“Self-donated blood has a shorter shelf life than volunteer-donated blood (35 v. 42 days) because of differences in processing methods.” Canadian Medical Association Journal
Preoperative Autologous Blood Donation Verses Bloodless Surgery: Four cited benefits of preoperative autologous blood donation

“PABD avoids mismatched blood typing errors.”
“Typically, when blood is donated, the blood is prepared and typed according a universal blood typing system: A, B, AB, and O wherein AB is a universal recipient and O is a universal donor. The rh-factor of blood is also typed as positive (+) or negative (-). Hence, each bag may contain any one of eight different blood types and is so labeled for future use and for cold storage.” patentstorm

When a patient is transfused with their own blood they avoid receiving a mismatched blood type. Mismatched blood due to human error is more common than desired. Though death resulting from mismatched blood is rare it does occur, as the following news report shows:

“A [California] state Department of Public Health investigation found that in October a patient at Hollywood Presbyterian Medical Center was given a blood transfusion that wasn't needed and was the wrong blood type. Two nurses failed to follow the hospital's policy for blood transfusions, allowing a blood transfusion to go on for 15 minutes before realizing the error. According to the state investigation, the nurse who discovered the incorrect transfusion did not report the error to a doctor.”  -An Associated Press Article found in The San Francisco Chronicle

Sadly mismatching does occur and since few statistics are available it is difficult to determine how often preoperative autologous blood is mismatched.

The longer blood is stored, transported, moved and shifted around in a blood bank the greater the chance of human error creeping in. Bags of blood are like any other commodity – they are handled by stressed out lab workers, transported and handled by people with problems that affect their concentration, labeled by imperfect humans and processed by people who make mistakes. Just as a test tube of blood or a pregnancy test can be mishandled so can a bag of preoperative autologous blood.

Note: In a world of endless statistics – from how many people in Moldova die in lawnmower accidents to the number of people that speak Swahili in Los Angeles it is odd the statistics on the number of adverse reactions to blood type mismatching are hard to find. However, statistics mean nothing if you are the one patient in a million that dies from a mismatched bag of blood. But the reality is this; Bloodless Surgery eliminates the chance, however small, of a patient receiving mismatched blood – even if it supposed to be his own.

Bloodless Surgery eliminates these problems.

More Quotes
Another quote highlights two interesting facts, first that mismatching is a worldwide phenomenon and second, that with many things connected to blood “few statistics are available”:

“Few statistics are available, but most experts agree that hospital workers around the world continue to mismatch blood and patients, with potentially devastating consequences.”

“PABD avoids adverse reactions to allogeneic blood.”
Another cited benefit is that when a patient is auto transfused with their own blood they avoid all the reactions. It is sometimes referred to as ‘the safest transfusion’ because it is the patient’s own blood. In a perfect world this might be true but in reality it seems not to be.

“One in 16,783 autologous donations is associated with an adverse reaction severe enough to require hospitalization, which is 12 times the risk associated with community donations by healthy individuals.” Critical Care

“[Preoperative auto] transfusion of your own blood does not make a transfusion risk free.”  -London Health Sciences Center

“Preoperative autologous blood donation conserves the community blood supply.”
An additional argument for preoperative autologous blood donation is that it conserves the local community blood supply by freeing up banked blood for others. True, there is a constant shortage of blood in many of the countries that form the international  blood trade – for example blood is imported to the United States from many third-world countries. Autologous blood donation could reduce the importation of foreign blood from countries with poor blood testing and with less than rigorous controls.

The advantage of Bloodless Surgery is that eliminates the need for a community blood bank entirely. For those that do not believe this because perhaps they believe some operations will always require a blood transfusion the accumulated evidence is simply the reverse: "Everything in health care can be done without blood (transfusions)." Dr. Aryeh Shander, Engle Wood Hospital.

For those who may think that this is naïve - perhaps considering the fact that over 100,000 doctors worldwide perform Bloodless Surgery will change their minds.

Bloodless Medicine would also eliminate the international blood trade and the importation of questionable blood being transfused.

“PABD avoids rare blood type matching.”
Another reason given for preoperative autologous blood donation is that persons with rare blood types have no worries about having their specific blood type on hand when surgery is performed.

- This also one of the benefits of Bloodless Surgery – since the patients blood is auto transfused or recycled during surgery there is never a worry of mismatched blood being put into the patient’s body. The advantage of Bloodless Surgery is that it eliminates the risks involved with preoperative autologous blood listed below.

“Preoperative autologous blood donation avoids rescheduled surgeries.”
One more benefit from the supporters of PABD is that a patient’s surgery will not have to be rescheduled due to the unavailability of blood. It is quite a common occurrence for surgeries to be rescheduled due to the unavailability of blood.

- This also one of the benefits of Bloodless Surgery – surgery never has to be delayed because of the unavailability of blood. However, the advantage of Bloodless Surgery is that it eliminates the risks involved with preoperative autologous blood listed below.

Why preoperative autologous blood donation is not supported by many experts

Serious problems with stored blood
New research from Duke University has suggested serious problems with stored blood. While donated blood may legally be stored up to 42 days it starts losing nitric oxide within three hours after leaving the donor’s body and within 24 hours is reduced by 70%. Nitric oxide is a gas produced in the body that promotes oxygen delivery to cells, tissues, muscles and organs.  Nitric oxide aids in the transference of oxygen from the red blood cells to the other cells in the body. Although the red blood cells may have enough oxygen they cannot reach the oxygen depleted cells begging for more oxygen allowing.  “The result can be a heart attack or even death.” link
 
Imagine a truck full of food that comes to a grocery store where the employees are on strike. With no one to open the doors and offload the food from the truck to the store the food stays on the truck. No one can benefit from the ample supply of food because it cannot be delivered. A small town would soon starve if the problem isn’t remedied. Likewise, stored blood loses its ability to deliver the oxygen stored in its red blood cells. The oxygen is there but it can’t be delivered.
 
“Dr. Ford likens the weeks-old blood often used for transfusions to ‘water from a dirty fish tank.’” Depleted of most of its oxygen-carrying capacity, the stored blood is not maximally beneficial to any patient.

No wonder a bag of blood looks like a liquid scab - a bag of blood isa liquid scab.
 
Preoperative autologous blood donation does not eliminate the nitrous oxide dilemma. It is just as deprived of oxygen transferring ability as is allogeneic blood.
 

“Donated blood can be stored for 42 days, but loses its nitric oxide content almost immediately.”  -Darren Swan, Medill reports, Nov 14, 2007

“Of concern to us is that nitric oxide levels become depressed soon after collection, suggesting that even ‘fresh’ blood may have adverse biological consequences.”  -Timothy McMahon, M.D., Ph.D.,

"Nitric oxide opens up the tiny blood vessels, allowing red blood cells to pass and deliver oxygen. If the blood vessels cannot open, the red blood cells back up in the vessel and tissues go without oxygen. The result can be a heart attack or even death."  -Dr. Jonathan Stamler, Duke University Medical Center

More studies needed
More studies will likely be done to verify this new finding. But the fact remains that adverse outcomes are increased when patients receive allogeneic blood – blood not their own. Here we refer not to diseases transmitted by blood transfusion, transfusion reaction etc since these are eliminated by Autologous Transfusion, but we refer to increased post operative transfusion reactions such as heart attack, stroke and death. More research needs to be done to see if those same problems occur in patients that opt for preoperative autologous blood donation.
 
While the medical community waits for more research to verify the nitrous oxide dilemma patients may needlessly be dying. Since there is a solution – Bloodless Surgery – it seems to make sense to err on the side of caution. Death is permanent, waiting for further research is not; it will come.
 
Contamination - another problem with preoperative autologous blood donation
“The longer the blood is stored, the more chances there are for problems including contamination.” Dr. Smyke. The contamination problem applies just as equally to preoperative autologous blood as to allogeneic blood. Bloodless Surgery eliminates these problems.

“Patients who are considering donating their own blood before surgery should weigh the reduced risk of viral transmission against the increased risk of… bacterial contamination.”  -Canadian Medical Association Journal

Increased risk of anemia and allogeneic blood transfusion
Oddly, preoperative autologous blood donation increases the risk in many patients of actually needing a blood transfusion. Why? Due to the shorter shelf life of preoperative autologous blood a patient may have less time to build up his own red blood cell count prior to surgery. This creates an anemic condition in the patient and anemia is the most common reason for administering blood transfusions.

“The short storage time may contribute indirectly to the increased risk of having a transfusion of either type of blood [pre-donated patient blood or donor blood] in patients who have donated their own blood, because there may not be adequate time in some patients for regeneration of red blood cells before surgery.”  -Canadian Medical Association Journal

Cardiac complications
A patient with heart disease should discuss any risks that may be involved with Bloodless Surgery as well. No operation is without risks. The risks of preoperative autologous blood donation should be weighed against those of intraoperative autologous blood donation.

“Among patients with heart disease, there is an increased risk of cardiac complications after donating blood.”  -healthline.com

Vasovagal attack and preoperative autologous blood donation
“There is a higher chance of a vasovagal reaction with autologous blood donation than with allogeneic blood donation.” healthline.com

What is a vasovagal attack? It is defined as:

“A reflex of the involuntary nervous system that causes the heart to slow down and that, at the same time, affects the nerves to the blood vessels in the legs permitting those vessels to dilate (widen). As a result the heart puts out less blood, the blood pressure drops, and what blood is circulating tends to go into the legs rather than to the head. The brain is deprived of oxygen and the fainting episode occurs.” medterms.com

Fainting may not sound serious but a patient should discuss with his surgeon.

Risk of viral transmission still exist
Human error can cause a product mix up where a bag of the donor/patient’s blood is confused with another bag or volunteer donor blood. When this occurs then the same dangers associated with a donated bag of blood from an unknown donor will affect the patient/donor.

These include but are not limited to the following:
• transmission of HIV due to mismarking and product mix up
• transmission of hepatitis B due to mismarking and product mix up
• transmission of hepatitis C due to mismarking and product mix up

“The life of every person who receives blood depends on the honestof the individual donors who have given their blood.”  -sanbs.org

"Financial and other ‘rewards’ for [blood] donation attract high-risk populations such as drug abusers and sex workers.”  -Dr Alex Gromyko, WHO Regional Office for Europe World Health Organization - United Nations affiliate

Volume Overload
Preoperative autologous blood donation transfusions still have the same risk of volume overload as do normal blood transfusions. Volume overload simply means that the transfusionist gives the patient too much blood too fast. This can lead to death.

“There is a danger, particularly in elderly or very young patients of blood volume overload leading to cardiac failure.”  -Nursing Practice - by Margaret F. Alexander, Josephine N. Fawcett, Phyllis J. Runciman

“Transfusion-associated circulatory overload occurs when the transfusion volume or rate exceeds the ability of the patient's cardiovascular system to handle the additional workload. The incidence is not well documented, but transfusion-induced circulatory overload is thought to be common. In 1 retrospective chart review, 1.1% of elderly surgical patients undergoing total knee or hip replacements had evidence of circulatory overload, sometimes after as few as 1 or 2 units of red blood cells (RBCs).”  -Noninfectious Complications of Blood Transfusion Archives of Pathology & Laboratory Medicine , May 2007   by Eder, Anne F,   Chambers, Linda A

An unnecessary burden to the medical infrastructure

“Most cost-effectiveness analyses of autologous blood donation show very small health benefits for a substantial increase in resource utilization.”

PABD uses up valuable manpower and health care resources for the extra time and effort required. The small return on the investment of resources made is called into question by many. Scant resources need to be redirected to more desirable situations that give a better return on the investment of time, money and personnel. Bloodless Surgery and Medicine Programs are answering this problem; one group estimates that they can save as much as nine million dollars annually in a medium sized hospital alone. Another survey revealed a four million dollar savings in one year.

While facts and figures of the damages done by preoperative autologous blood donation are hard to find the savings of Bloodless Medicine Programs are not. The figures are real enough to be motivating a dozen hospitals in the United States in 2008 to institute Bloodless Programs in their hospitals.

Restrictions
Patients with the following conditions will likely not be able to pre-donate their own blood:
• Heart disease (aortic stenosis, heart attack in the past six months)
• Anemia
• High blood pressure that is not under control
• Active infection, or being treated with antibiotics
• History of seizures in the past year
• Diabetes
• Infection
• Lung disease

Check with your Bloodless Surgeon to find out if the same restrictions apply to Bloodless Surgery.

“You should not donate autologous blood if you have anemia, infection or serious heart or lung disease.”  -Red Cross Donor

The risks of preoperative autologous blood donation are:
• accidental swapping of the patient’s own blood with another’s
• bacterial contamination
• vasovagal attack
• increased risk of anemia
• increased risk of needing an allogeneic blood transfusion
• possibility of heart attack, stroke or death due to decreased oxygen carrying capacity of nitrous oxide depleted blood
• an increased risk of cardiac complications after donating blood for patients with heart disease.
• volume overload leading to heart failure and/or death
• transmission of HIV due to mismarking and product mix up
• transmission of hepatitis B due to mismarking and product mix up
• transmission of hepatitis C due to mismarking and product mix up

Is their a better option?
“PABD in our opinion should not be used because of considerable risks for the donor/patient on the one hand and miniscule benefits on the other hand.” Transfusion Medicine and Hemotherapy

After discussing the risks and morbidity rates of preoperative autologous blood Healthline lists Bloodless Surgery as an alternative.

Bloodless Surgery is not without risks because all surgery has risks. The question for the patient then is this: Do the “considerable risks” and “miniscule benefits” of preoperative autologous blood donation outweigh the negligible risks of Bloodless Surgery which is defined as “safe and of value for individual patients”?

A patient should weigh carefully all the risks involved with preoperative autologous blood donation against the risks and benefits of Bloodless Surgery.

“The decision to employ blood-sparing technology may no longer be based on the safety of the blood supply, but on evidence that blood conservation is safe and of value for individual patients.”  -Critical Care

If you feel that this page is biased please read the following information:
Preoperative autologous blood donation (PABD) can be an adequate solution to a patient’s problem before nonurgent surgery if a high (>10%) probability of perioperative blood transfusion exists in this individual case and, at the same time, pre-existing alloimmunization or a different ethnic background make it difficult to supply this patient with compatible red blood cell concentrates. In times of acute shortness of blood, when nonurgent surgery might be rescheduled and delayed, and in cases of extreme angst-ridden patients fearing homologous blood transfusion, PABD can be considered in rare individual cases as well.

Nonetheless, in all these cases, the patient must be eligible for PABD, and the indication as well as potential contraindications have to weighted against each other in a thorough individual risk-benefit analysis. However, these are relatively rare cases.

Apart from these and few other situations, PABD in our opinion should not be used because of high costs and logistic efforts, high wastage, considerable risks for the donor/patient on the one hand and miniscule benefits on the other hand. PABD cannot significantly contribute to the blood supply. PABD in error-free use, which is unrealistic, reduces the risk of transmission of known and unknown viral pathogens, but possibly not of bacteria.

In real life situations, the residual risk for transmission of transfusion-relevant viruses such as HIV, HVC or HBV is not diminished by PABD. The same is true for clerical errors and ABO incompatibility or acute hemolytic transfusion reactions due to a mix-up of products. PABD reduces the risk of (allo)immunization and therefore has its indication in special clinical situations. PABD on the other hand increases the risks for the donor at the time of donation and afterwards. Autologous blood products seem to have higher rates of bacterial contamination.

The risk for the patient to receive any transfusion perioperatively is increased due to the lower hemoglobin levels at admission (iatrogenic anemia) as well as due to a wrongly more liberal transfusion strategy in autologous hemotherapy compared to transfusion of homologous blood. A significant number of patients, who would never receive any transfusion perioperatively at all, enter the transfusion chain due to PABD procedures, facing the risks of a blood donor as well as the risks of a transfusion recipient. Copyright © 2006 S. Karger GmbH, Freiburg Transfusion Medicine and Hemotherapy

Decide for yourself
A medical decision is a personal one. Doctors, like all of us, can sometimes be biased. But in critical matters of health each individual must make his own decision and not be swayed by personal opinion. Facts should carry the day.

The more accurate information we have the better the decision we can make. But accurate information is often hard to find. New and more correct information is often mired in tradition, custom, comfort and the lack of inertia on the part of the old guard to accept the truthfulness of the new guard.

The facts about blood transfusions are mired in 100 year old myths and personal opinion handed down from one generation of doctors to the next. Much of what has been accepted as fact is in reality supposition created decades ago and perpetuated thoughtlessly by well meaning doctors – generations of which have been “hard wired” to believe the myths they were taught in medical schools.

"For 100 years we've assumed blood transfusions are good for people, but most of these clinical practices grew before we had the research to support it."

Neil Blumberg, M.D., professor of Pathology and Laboratory Medicine and director of Transfusion Medicine at the University of Rochester Medical Center. link

That time is past. Cold hard facts, solid research and scientific truth will carry the day. The errors of the past have haunted us long enough and science is freeing this generation from the error and ignorance of our forefathers.

How will you decide? Will you base your decision on a century old presumption or on modern science? The choice is yours.

Listen to the Experts
“The transfusion of autologous blood has many of the same complications as transfusion of allogeneic units, including bacterial contamination, hemolysis due to errors in the administration of units, and volume overload. Because mortality from allogeneic blood transfusion is now more likely due to administrative error than to blood-transmitted infection, the risks associated with banked autologous blood units are similar to those with banked allogeneic blood units.”  -Critical Care

“Stored blood is impaired in its ability to deliver oxygen.”

Dr Jonathan Stamler (Duke University Medical Center  -medscape

“Dr. Ford likens the weeks-old blood often used for transfusions to “water from a dirty fish tank.” Depleted of most of its oxygen-carrying capacity, the stored blood is not maximally beneficial to any patient.  -EurekaAlert.org

"Nitric oxide opens up the tiny blood vessels, allowing red blood cells to pass and deliver oxygen. If the blood vessels cannot open, the red blood cells back up in the vessel and tissues go without oxygen. The result can be a heart attack or even death."

Dr. Jonathan Stamler, Duke University Medical Center Duke University – Office of Licensing and Ventures

“Autologous blood products seem to have higher rates of bacterial contamination [than allogeneic blood].”  -Transfusion Medicine and Hemotherapy

"[Blood] is the most dangerous substance we use in medicine."    -Dr. Charles B Huggins, Nobel Prize Recipient

“The place here will not allow you to donate if you have a pulse under 50. So I have to go to the bathroom stall right before I donate, and jog in place for 5 minutes.”  -Michael Tal – Enthusiastic Blood Donor

“They take [blood] from a vein, which carries deoxygenated blood back to the heart...”

“In real life situations, the residual risk for transmission of transfusion-relevant viruses such as HIV, [Aids virus] HVC [Hepatitis C virus] or HBV [Hepatitis B virus] is not diminished by PABD (Preoperative autologous blood donation.)”  -Transfusion Medicine and Hemotherapy