In the 1980s, preoperative autologous blood donation (PABD) became a common practice for orthopaedic patients undergoing total joint replacement. The major rationale for preoperative donation was the concern of transmitting viruses associated with allogeneic blood transfusions, especially HIV. In addition, the supply of blood was being affected by fewer donors, an increasing elderly population, a decline in volunteers as donors, and rising costs of storage. Autologous donation is not danger-free or an inexpensive process. Patient donation often leads to significant wasting of blood, as autologous blood cannot be used for patients other than the original donor. Therefore, the practice of PABD has been controversial and a source of much debate. Many institutions have given up the practice entirely, specifically because patients become anemic preoperatively and cannot recover sufficiently before surgery, leaving the patient weak, postoperatively.
Another set of questions comes to mind when thinking about blood administration. What is the best guide for an appropriate transfusion trigger level in patients? Little appears in the literature to answer this question. Patients who practice the Jehovah's Witness faith have been shown to survive anemia and acute blood loss without transfusions. The need to increase oxygen levels and improve ambulation ability may not be the best rationale for a transfusion level. The benefit of transfusing blood to increase oxygen levels in patients may not be as credible as once thought, as stored blood gradually loses 2,3-diphosphoglycerate concentration, which affects its ability to carry oxygen, resulting in oxygen release (Spence, 2004).
Does evidence-based practice demonstrates a need for preoperative autologous donated blood? Does predonation create more problems for patients by making them weaker in the postoperative period? What are the triggers for transfusion that could be accepted at a lower range, alleviating the need for transfusion?
Think about what you see in your practice. Should the question be raised about the use of preoperative autologous donation? Read these articles for more details and see what are some of the prevailing thoughts about this important area of practice.
Rosencher, N., & Shander, A. (2006). Preoperative autologous blood donation.Transfusion Alternatives in Transfusion Medicine, 8(1), 29-34.
The public's concern with the safety of blood transfusions especially in the area of elective total joint replacement and the shortage of blood supplies continues to be a debate evident in practice with the use of PABD. The major impetus for PABD began in the 1980s with the concern about transmission of viruses, such as HIV, by allogeneic blood transfusions. The use of PABD has declined in recent years with the reduced risk of transfusion-transmitted disease and the increased need for blood conservation. The reduced need for PABD has been spurred by the prevention of blood-borne disease transmission, appropriate selection of donors, leukoreduction, and nucleic acid testing. However, the risks of receiving contaminated autologous blood and allogeneic blood still exist. Studies have also demonstrated that autologous blood donation is not cost-effective, as patients donating two units preoperatively frequently only receive one unit. Thus, the second unit is wasted or discarded. The rationale for the wasting of unused blood is that PABD blood is not donor blood and cannot be added to the blood supply. If not used, it becomes outdated and wasted with a cost ratio attached.
This article discusses the major problems with autologous blood donation and lists the following: (a) discarding of unused units at a considerable cost, (b) potential for preoperative anemia with multiple blood testing and unit collections, (c) poor cost-effectiveness of the technique, and (d) potential risk of anemia that is undiagnosed between blood donations.
How can the need for blood be determined preoperatively in order to avoid some of these problems? These authors suggest several approaches. First, they suggest the use of a formula that estimates blood loss for each patient, taking into consideration the individual needs of the patient. Blood loss could be calculated, retrospectively for a cohort of patients, and used to formulate an algorithm for individual patients, where the need for PABD could be determined more accurately. Second, one must look at the cost-benefit ratio when ordering autologous blood donation. The cost of discarded units, the substantially lowered risk of HIV and hepatitis from allogeneic transfusions, and the continued risk for both autologous and allogeneic blood due to clerical errors, bacterial sepsis, storage demands, and immunomodulation does not mean that risks associated with allogeneic blood outweigh those of autologous blood. PABD is usually an expensive process. Debate continues on the best alternatives. These authors propose that the best answer is to evaluate the need for blood with each patient, in conjunction with his/her medical condition, to estimate the best approach for the patient. The cost-effectiveness of blood use must be decided for each patient. In other words, it should not be a "routine" to have each patient donate autologous blood.
Madjdporu, C., Spahn, D. R., & Weiskopf, R. B. (2006). Anemia and perioperative red blood cell transfusion: A matter of tolerance.Critical Care Medicine, 34(Suppl. 5), s102-s108.
Historically, anemia occurring in the perioperative period has been treated with red blood cell (RBC) transfusion. This practice has not be criticized but rather seen as important to correct anemia in the surgical patient suffering from blood loss and lowered oxygen levels. The accepted standard was to transfuse the patient under the "10/30" rule-when the hemoglobin reached 10 g/dl or the hematocrit was 30. However, the origin of this rule is unclear, and there is no evidence to suggest that this trigger level is the best for all patients. What is important to note is that transfusions have risks that should be avoided if possible.
These authors very nicely discuss the risks of transfusions, the function of the RBCs to carry oxygen, review physiologic responses to acute anemia, the tolerance to anemia as an individual response, and give some recommendations about transfusions triggers.
The risks of blood transfusions can be categorized into two groups-namely those of transfusion-transmissible infections (TTIs) and immunologic risks. The current safety precautions related to the acquisition and storage of RBCs in Western countries have made viral TTIs extremely rare. Bacterial contamination and posttransfusion sepsis are more common. RBCs can lead to immunosuppression and a resulting postoperative infection. One of the newest concerns about immunosuppression is a disease called transfusion-related acute lung injury (TRALI), which can be confused with acute respiratory distress syndrome (ARDS), volume overload, or congestive heart failure (see the following articles about TRALI).
The hemoglobin molecule on the RBCs is responsible for carrying oxygen from the pulmonary to the peripheral capillaries. When a patient is anemic, the ability of the hemoglobin to deliver oxygen remains the same until the hemoglobin concentration falls below 7 g/dl. These authors stress that the long-held belief that maximal oxygen concentration is threatened if the hemoglobin falls below 10 g/dl is not valid for humans. The tachycardia seen in patients who have acute anemia postanesthesia may be more related to hypovolemia, which can be managed by the use of crystalloids and colloids, than to blood transfusions, thus avoiding the complications of transfusions.
Each patient's tolerance to anemia is individual, thus making the decision to transfuse a patient a very individual physiological systems' response to acute anemia. Therefore, what is the patient's ability to respond to anemia based on his/her current cardiac, renal, or pulmonary status. What is the age of the patient, as older adults with numerous co-morbid conditions may respond adversely to hemodilution. A transfusion may not be the best solution to the problem.
The recommendations noted in this article suggest that a patient who may need transfusion should be evaluated in terms of his/her individual ability to tolerate and compensate for acute anemia, postoperatively. The point stressed is that a "universal trigger" for transfusion does not exist. Rather, the physiological responses of a patient to hemoglobin concentrations and oxygen needs should be the primary consideration assessed before transfusion is introduced. Treatment with crystalloids and colloids to ensure adequate volume restoration may be a better alternative to transfusion.
Grover, M., Talwalkar, S., Casbard, A., Boralessa, H., Contreras, M., Boralessa, H., et al. (2006). Silent myo-cardial ischaemia and haemoglobin concentration: A randomized controlled trial of transfusion strategy in lower limb arthroplasty.Vox Sanguinis. The International Journal of Transfusion Medicine, 90(2), 105-112.
In older adults, the incidence of myocardial infarction during elective joint replacement is a constant concern, as the rates of this complication are high. Adequate perioperative assessment and treatment with beta-blockers, as needed, are the gold standard of care to prevent myocardial infarction. If the older patient becomes anemic and is potentially at higher risk for a heart attack, what is the proper treatment regime for that individual? The question addressed in this multicenter, controlled trial was to ask whether a restrictive transfusion strategy, for an older adult with anemia, would put the patient at a greater risk for a silent myocardial infarction (SMI). As the number of older adults undergoing joint replacement has increased and will increase further with the baby boomers, this is a valid concern for surgeons and nurses who care for these patients. Because there is no standard of evidence for transfusion triggers in the older patient who might have cardiac disease, this is an important question to address.
This study was performed in the United Kingdom where 260 patients having elective total hip and knee replacements were randomized (an equal chance to be in either group) to two transfusion trigger groups. The restrictive group was given a transfusion if the hemoglobin fell below 8 g/dl or less and then was maintained with a hemoglobin between 8 and 9.5 g/dl. The liberal group received blood when the hemoglobin fell below 10 g/dl and was maintained at 10-12 g/dl. Each patient was placed on oxygen and wore a Holter monitored to detect any episodes of silent ischemia. There is clinical evidence to suggest that the risk of an SMI increases with anemia but little evidence to identify the relationship between hemoglobin levels and the incidence of SMI in total joint patients.
As evidence exists that RBC transfusions have associated risks such as an SMI, it is important to know if older adults are placed in a more precarious position if they have anemia and face a transfusion to raise the hemoglobin level. The outcomes of this study indicated that those patients who did not have a history of myocardial ischemia before hip or knee surgery were not placed at greater risks of an SMI with a restrictive trigger for transfusion protocol. The use of a restrictive transfusion trigger could lead to fewer complications from transfusions, decreased cost for the patient, a decrease in the use of transfusions for orthopaedic patients, and did not adversely affect the length of hospital stay. As more clinical evidence is needed in this area, it is prudent, as suggested in the article above, to individualize the restrictive trigger for transfusion to each patient rather than accepting one method for all clients.
The next two articles discuss the concerns of a serious but little understood outcome of blood transfusions, namely TRALI. The first article (Bux, 2005) gives an excellent description of the complication associated with blood transfusion. The second article appeared in the American Journal of Nursing and highlights the nursing observations and assessments that are crucial for the patient who may face this phenomenon.
Bux, J. (2005). Transfusion-related acute lung injury (TRALI): A serious adverse event of blood transfusion.Vox Sanguinis. The International Journal of Transfusion Medicine, 89(1), 1-10.
It is only recently that the respiratory system has been associated with risks of blood transfusions, as the reactions of transfusion involving pulmonary injuries are usually thought to be circulatory in nature. "The British Serious Hazards of Transfusion (SHOT) initiative has consistently demonstrated, in its annual reports since 1996, that TRALI [transfusion-related acute lung injury] is one of the most common causes of transfusion associated major morbidity and death" (p. 2). The clinical manifestations of TRALI are evidenced by dyspnea and bilateral pulmonary edema. These symptoms usually occur while a transfusion is being given or within 6 hr of a transfusion, but they may appear as late as 48 hr after the transfusion. TRALI may be confused or indistinguishable from ARDS, which can result from causes other than a transfusion. As contrasted with patients experiencing pulmonary edema due to heart failure, the central venous pressure and pulmonary wedge pressures are normal in patients with TRALI.
The causative factors for TRALI are divided into two categories. The first is associated with leukocyte antibodies or is termed "immune." The antibody is identified in the blood donor and not in the recipient. The donor who has the antibody is usually a multiparous woman. This is explained by the antibody formation in the mother (female donor) as a result of exposure to paternal leukocyte antibodies of the fetus during pregnancy. The disease is associated with all blood products including whole blood, platelets, and packed RBCs. The use of leukocyte-depleted blood products will reduce the potential for TRALI complication.
The second cause of TRALI is thought to be "non-immune," where no antibodies are found in either the patient or the donor, leading to the thought that the disease can be triggered by causes other than antibodies. Some of these causes could be a "priming agent" that activates the neutrophil in response to a stimulus (p. 4). TRALI has also been seen in patients with a previous condition, such as surgery, trauma, sepsis, which predisposes the patient to development of TRALI after the transfusion of blood products containing neutrophil factors, priming the patient for a condition but not producing an active disease. Later, if blood products are given to the patient, the neutrophils become activated, causing a latent disease process.
Careful screening is essential at the time of donor collection. Measures to reduce the need for transfusions in an already compromised patient are essential. Treatment of a patient with TRALI requires oxygen, but may eventually lead to intubation and mechanical ventilation. The patient may present with mild or severe, life-threatening symptoms.
Knippen, M. A. (2006). Transfusion- related acute lung injury: A rare but potentially lethal result of allogeneic blood transfusion, TRALI resembles acute respiratory distress syndrome. Early intervention can save lives.American Journal of Nursing, 106(6), 61-64.
This article by Knippen compliments the article by Bux (2005), as she outlines the incidences, symptoms, and etiology of TRALI. She notes that TRALI can also be the result of immune globulin given intravenously, as the source of the globulin is acquired from many pooled donors.
Illustrative of the TRALI process are the case studies that point to the differences in outcomes for two patients. She gives a graphic description of the disease, the treatments given, determination of the causative factors, and the patient outcomes. It is enlightening to read these cases and will help a nurse to be aware of a patient's symptoms and outcomes.
As nurses, we work with patients who may have blood transfusions. Even more than physicians, we are responsible for monitoring the patient during the transfusion. Early identification of the symptoms of TRALI is essential to the patient's survival. Notifying the physician of any unusual patient reactions, especially the first sign of respiratory distress, is crucial. Discontinuation of the transfusion and administration of oxygen are imperative. Careful collection of the discontinued blood transfusion and tubing and obtaining a posttransfusion specimen are vital to the patient's health. Continued monitoring of the patient and documentation of the treatment results will also help to further understand this disease process and its treatment. Encourage your colleagues to read about this disease in order to become aware of the crucial assessments for our patients. Orthopaedic patients receive blood as part of the treatment plan. Let us be aware of the complications that could occur so that we can intervene as appropriate and forestall some of the risks associated with giving blood products.
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