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Acute normovolaemic haemodilution (ANH)

This involves the donation of up to three units of blood immediately prior to surgery. The patient is then given crystalloids to dilute the circulating volume. This method is only indicated for surgery where considerable blood loss is expected on the principle that the number of red cells lost will be reduced and the patient’s autologous whole blood can be returned after surgery; however, little evidence exists to support the efficacy of ANH (Harrison 2004).

Intraoperative cell salvage (ICS)

Blood loss during surgery is collected, anticoagulated, filtered and held in a sterile reservoir. The collected blood is then processed, washed and suspended in saline for return. Although ICS is not without risks such as embolism, bacterial contamination and enhanced inflammatory responses through reinfusion of inflammatory mediators (Harrison 2004), it has been recommended as the most effective form of autologous transfusion to assist in the conservation of blood supplies (James 2004). Trials in orthopaedic surgery indicate that salvage can reduce the proportion of patients who receive allogeneic red cell transfusions. Results in cardiac surgery trials have also shown a slight reduction in the use of allogeneic red cell transfusions (McClelland 2007).

The 2008 SHOT report recorded 28 cases of reported adverse events, 25 from ICS and three from postoperative cell salvage (PCS). There were five hypotensive reactions reported from ICS, but no major mortality or morbidity.

Monitoring of patients receiving autologous transfusion is as important as it is for those receiving allogeneic transfusion (SHOT 2008).

Blood component donation

Donors of blood components by automated apheresis are subject to the same selection criteria used for donating whole blood and any exception to this must be decided by a designated medical officer. Apheresis can be used to collect plasma, red cells and platelets. Leucopheresis procedures are used for the collection of granulocytes, lymphocytes and peripheral blood progenerator cells (James 2005).

Appropriate use of donated blood components

Donated blood components are a precious gift; they are not a limitless resource and must be used appropriately. The BCSH has guidelines in place for the use of red cell, platelet, fresh frozen plasma, cryoprecipitate and cryosupernatant transfusions, available on the BCSH website www.bcshguidelines.com.

The decision to transfuse must be based on a thorough clinical assessment of the patient and their individual needs. Each blood component should only be given after careful consideration, when there is valid clinical indication or when there are no alternative treatment options available (Oldham et al. 2009).

Blood and blood products have varying shelf-lives and storage requirements. The range of products currently available, indications for use and recommendations for administration are listed in Table 8.9.

Table 8.9 Blood and blood products used for transfusion

Anticipated patient outcomes

Blood component transfusion can be a life-saving and life-enhancing treatment when used appropriately and when patients are cared for safely and by knowledgeable, skilled practitioners (Oldham et al. 2009).

Legal and professional issues

Blood safety and quality in the UK

Approximately 3.4 million blood products are administered in the UK every year (Gray and Illingworth 2005). The transfusion of blood and its components is usually safe and uneventful; however, there are associated risks and there have been significant developments over recent years to improve the quality and safety of transfusion practice in the UK. The Blood Safety and Quality Regulations came into effect in February 2005 and were fully implemented on 8 November 2005. These Regulations cover the collecting, testing, processing, storing and distributing of blood and blood components (Blood Safety and Quality Regulations 2005). The official government agency