A comparison of autologous and homologous blood transfusions for the elective orthopaedic surgical patient

O R I G I N A L

A R T I C L E

A comparison of autologous and homologous blood transfusions for the elective orthopaedic surgical patient Petrina Taylor This article identifies the need for blood transfusions for the elective orthopaedic surgical patient, incorporating a brief review of the history surrounding blood transfusions in an attempt to gain an understanding of where we are today. It will critically review the use of homologous and autologous blood transfusions. Autologous transfusions will be described in more detail to give an insight into its available uses. Benefits as well as risks of both types of transfusion will be examined to acknowledge both the advantages and disadvantages for use. The nursing role in relation to blood transfusions will also be highlighted acknowledging where gaps in available research C 2002 Harcourt Publishers Ltd exist. °

Editor’s comment Blood transfusion always carries a risk but if the patient’s own blood can be used the risks are reduced. This study reviews transfusion practice. However, orthopaedic nurses need to understand that the process of autologous blood transfusion requires a high level of nursing expertise and that other non-blood derivatives can be used for post-surgery transfusion. PD

KEY WORDS: autologous blood transfusion, homologous blood transfusion, orthopaedic nursing

INTRODUCTION

Petrina Taylor RGN ENB 998, Staff Nurse, Royal Bournemouth Hospital, UK. Correspondence to: Petrina Taylor, Staff Nurse, Orthopaedic Unit, Royal Bournemouth Hospital, Bournemouth, UK.

The need for blood transfusions in the elective orthopaedic surgical patient has been acknowledged by Geire (1998, p 6) who states ‘total joint arthroplasty can be associated with large volume blood loss’. A variety of circumstances can determine the amount of blood lost. For example, the amount of postoperative bleeding will be affected by the amount of tissue and bone dissection. Also cemented knee and hip replacements appear to have a lower blood loss than the uncemented type due to possible bleeding sites being plugged by cement. The use of non-steroidal anti-inflammatory agents appears to affect platelet activity by reducing their aggregation (Geire 1998). To combat this large volume of blood loss homologous blood transfu-

C 2002 Harcourt Publishers Ltd Journal of Orthopaedic Nursing (2002) 6, 35–38 doi:10.1054/joon.2001.0222, available online at http://www.idealibrary.com on

sions have often become normal medical practice within our unit. Blood transfusion, as stated by Mosby (1997) is ‘giving whole or a part, as red cells, to replace blood loss through injury, surgery or disease’.

HOMOLOGUS BLOOD TRANSFUSION Blood transfusions have been undertaken with some success dating back to the time of the Incas. For the Incas, no adverse reactions occurred, as all of them had the same blood type. However many failures in blood transfusions followed as physicians transfused animal blood to humans. Until it was proven scientifically that transfusion

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should only occur between the same species, mortality was high. The discovery of blood groups AB, A, B and O, along with the Rhesus factor in 1930, provided the physicians with more information. It was discovered that antigens and antibodies in the blood induced clumping when mixed with another blood type. Therefore, blood grouping is dictated by the non-existence or existence of particular agglutinogens on the red cell surface (Britannica 1999). The Rhesus factor appears to be found within the red cells of 84% of people in the United Kingdom (National Blood Service 2001). Even further information is available today as cited by Tortora & Grabowski (2000, p 627) ‘There are at least 24 blood groups and more than 100 isoantigens can be detected on the surface of red blood cells’. With this number of blood groups it is not surprising that incompatibility reactions may occur, as stated by Tortora & Grabowski (2000, p 629) ‘The normal components of a donor person’s red blood cell (RBC) plasma membrane can trigger damaging antigen antibody responses in a transfusion recipient. In an incompatible blood transfusion, antibodies in the recipient’s plasma bind to the isoantigens on the donated RBCs when these antigen antibody complexes form, they activate plasma proteins of the complement family’.

Reactions Blood transfusion reactions have been extensively researched and acknowledged by a number of authors. Kay (1995) suggests one in 30 transfusions can be associated with an allergic, febrile, haemolytic or respiratory event, whereas Grogan (1999) suggests the patient can be predisposed to infection and the reactivation of a virus that has become dormant as the result of receiving a blood transfusion. Virus transmission during a blood transfusion still accounts for approximately 40 new cases of hepatitis, as during the early stages of the disease HBSAg vanishes from the blood stream leaving the tests ineffective. This leaves a window of opportunity for infected blood to reach the donor supply (Kay 1995). There is also concern that variant CJD may also be transmitted in homologous blood transfusions (National Blood Service 2000). Transfusion reactions can be classified into two groups as suggested by Johnson (1999). Immune haemolytic and non-haemolytic immune both have slightly different signs and symptoms. Immune haemolytic reaction is caused by the disintegration of the red cells in the recipient’s circulation. The symptoms of which include anxiety, headache, chest pain, rigors, back pain, diarrhoea, vomiting, dyspnoea, tachycardia, hypotension, shock and renal impairment. These signs may occur within five minutes of commencing the transfusion and can occur in quick succession.

Although a haemolytic reaction can occur before 50 mL of blood is transfused. Non-haemolytic immune reaction is caused by hypersensitivity to foreign proteins both leukocyte and pyogens in the transfusion fluid. The symptoms of which include a rise in temperature, flushing, rigors, tachycardia, palpitations and headache. These signs can have a delayed onset occurring possibly between five and ten days after the transfusion. Britannica (1999) suggests that following a blood transfusion the patient may become sensitized to the transplanted antigens and as a consequence their immune system is altered. Kay states (1995, p 583) there can be ‘immunosuppressive effects of homologous blood transfusions. Following transfusion there are a reduction in T-helper cell numbers and activity, and in interleukin-2 and gamma interferon production’. Although Fitzpatrick & Fitzpatrick (1997, p 39) states transfusion reactions could include ‘transfusion-related lung injury and anaphylactic’. In Britain, reporting of a transfusion-related event relies on hospitals reporting voluntarily, so accurate figures may not be obtained, although Godfrey (2000, p 26) states in the report of serious transfusion hazards ‘nine deaths, 100 cases of morbidity with 20 serious enough to require intensive care admission’ were acknowledged. Coupled with the reduction in the number of available donors and the increased demand on the blood stocks brought about by surgical advances, Geire states (1998, p 7) ‘The supply does not currently meet the demand’. Many countries have recognized potential problems with red cell donor transfusions with alternative options being considered. One of these options is autologous blood transfusion.

AUTOLOGOUS BLOOD TRANSFUSION Autologous blood transfusion does not appear to be a new concept, as history suggests. In 1818 James Blundell successfully re-infused blood into a patient following a haemorrhage occurring as a result of childbirth and Duncan in 1886 re-infused the patient’s blood following a railway accident (Kay 1989a). Autologous blood can be supplied by three main methods: • Pre-surgery deposit • Intra-operative salvage • Post-operative salvage (Kay 1989b). Each method is reviewed separately as the criterion for patient selection varies to some degree.

Pre-surgery deposit This is viewed as a viable alternative to homologous transfusion for the fit elective surgical patient, with no age barrier selected and no evidence of a

Blood transfusions for orthopaedic surgical patients

bacterial infection present at time of donation. A doctor should have gained written consent, with the patient being acquainted with all the facts, risks and benefits of donation. The patient is able to donate up to four units of their blood for later use, preferably at weekly intervals with donations completed four days prior to surgery. The patient’s haemoglobin (HB) prior to each donation should be no lower than 11 g/dl and for the period before the first donation, to the time of surgery should take ferrous sulphate (Voak et al. 1993). Patients not considered for donation are those with severe angina, untreated heart failure, respiratory decompensation, those taking beta-blockers or a history of epilepsy (Kay 1993). Donated blood can be stored for up to 35 days in a fridge at 4◦ C, therefore, reliable dates for elective surgery need to be considered. The blood is not screened for viral signals and should be labelled ‘for autologous use only, untested blood’ as stated by Johnson (1999, p 10). Although Kay suggests in 1993 that autologous blood should have the same checks as homologous blood because of the risk of misidentification, which includes the testing for HIV and hepatitis, therefore patients would need to be counselled prior to donations. Pre-infusion identity checks should still be undertaken and completed in accordance with hospital policy (Napier et al. 1997).

Intra-operative salvage This methods uses specialized equipment to salvage blood that is shed at the time of operation, which is then cleaned and recycled. The blood collected should be uncontaminated by bile pancreatic juice, carcinoma and bowel bacteria. Its use appears to be of greatest benefit for patients going through vascular or cardiac surgery, who have been anticoagulated.

Post-operative salvage and transfusion This method uses equipment where blood that has drained from the wound following surgery, is collected by a suitable device, which can be re-infused by a closed circuit device within four hours of collection. The drainage device would be set up in theatre at the time of surgery and must be from a clean wound. Post-operative salvage appears to be an uncomplicated system that uses autologous blood normally disposed of, but it is a relatively new concept with little research evidence available at the present time (Kay 1995).

ADVANTAGES/DISADVANTAGES OF AUTOLOGOUS TRANSFUSION Advantages Current evidence suggests there are a number of advantages of autologous transfusions. The use of

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pre-donated autologous blood eradicates the risks of acquiring new viral infections and as the blood is donated by the patient it is free of alien antigens. The post-operative infection risk appears to be reduced possibly resulting in a shorter hospital stay. It appears to encourage erythropoiesis. Also, due to the lower levels of haematocrit, organ perfusion is improved resulting in an improvement in oxygen distribution to the tissues (Thompson & Kay 1995). Autologous transfusions can offer patientcentred treatment based on individual needs, in this way increasing the patient’s confidence and may contribute to feelings of being involved in the planning for surgery (Kay 1988).

Disadvantages There are a number of disadvantages of autologous transfusion. Patients may receive a bacterial infection as a result of an infection acquired at the time of collection of the blood. The taking of an iron supplement can induce nausea and constipation. Pre-donation by the patient relies on the availability of arrangements being made to plan the surgery well in advance with no disruption in the schedule as the blood could be wasted. This would require a good liaison system with all the multidisciplinary staff involved (Blevins et al. 1993). With the intra-operative salvage system the patient may develop salvage shock syndrome, a condition which appears to be the result of the suctioning of the blood during surgery being too rapid, or as Kay (1988) suggests for the orthopaedic patient bone chips and fat may be re-infused accidentally. The post-operative salvage system has very little research evidence available of its disadvantages, the only readily available literature currently accessible is that provided by the manufacturers of the system and only acknowledges its advantages. The financial cost of implementing an autologous blood transfusion service would have to be considered. Some areas have implemented this service but found the experience difficult with feasibility studies undertaken first, to examine the cost and logistics of providing this service for the elective orthopaedic patient (Kay 1992). In the health service circular HSC1998124 it was proposed that by March 2000, all patients should be made aware of the option of having an autologous blood transfusion where it is appropriate (Department of Health 1998).

THE NURSE’S ROLE Due to the severity of possible reactions to homologous blood transfusions the nurse’s role in caring for patient’s who are receiving a transfusion is of great importance. Policies and procedures exist in

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many areas to give guidance to the frequency and type of nursing observations to be made with a homologous blood transfusion as well as any actions to be taken in the case of a possible reaction. Although with autologous transfusions, there appears to be a lack of research available or even possibly undertaken as to the type and frequency of patient’s observations. Considering it is the patient’s own blood and carries less risk only Johnson (1999) suggests patient’s receiving an autologous blood transfusion should be cared for in the same manner as a patient receiving a homologous transfusion.

CONCLUSION In comparing the use of homologous and autologous blood transfusions, safe and efficient homologous blood transfusion has enabled the growth of a great deal of major surgery. Its advantages cannot be contested, however it does carry many risks. Kay also states (1995, p 583) it use ‘can be unselective and wasteful’, whereas autologous transfusion can be used based on the patient’s need with a view to giving treatment that is specific and designed to reduce risk. The risks short and long term involved with receiving homologous blood compared to autologous blood appear far greater, therefore autologous blood transfusion should be considered as a viable alternative. With significant use of autologous blood many of the complications of conventional red cell transfustions could be resolved. Ten to ninety-five per cent of all blood needs could be provided in this manner bridging the gap between blood supply and demand. This would also provide the patient with a greater choice in the management of their blood loss acquired as a result of the surgery undertaken. Further research would need to be undertaken as to the nursing role in caring for patients receiving an autologous blood transfusion.

REFERENCES Blevins F, Shaw B, Valeair R, Kasser J, Hall J 1993 Reinfusion of shed blood after orthopaedic procedures in children and adolescents. The Journal of Bone & Joint Surgery 75(3): 363–371 Britannica 1999 Encyclopaedia Britannica Multimedia Edition Department of Health 1998 Health Service Circular HSC 19981224 Issue date 11.12.1998 Fitzpatrick L, Fitzpatrick T 1997 Blood transfusions keeping your patient safe. Nursing 34–41 Geire K 1998 Perioperative blood management. Orthopaedic Nursing Jan/Feb supplement: 6–11 Godfrey K 2000 In the bag. Nursing Times 96(14): 26–29 Grogan T 1999 Bringing bloodless surgery into the mainstream. Nursing 99: 58–61 Johnson J 1999 Guidelines for autologous blood donation. Royal Bournemouth Hospital SOP NO. 143: 1–12 Kay L 1988 Autologous blood transfusion for surgery and trauma benefits and methods available. Haematology Reviews 2: 305–326 Kay L 1989a Autologous blood transfusion. The Practitioner 233: 976 Kay L 1989b Methods of autologous blood transfusions. The Practitioner 233: 1147–1151 Kay L 1992 Predeposit autologous blood transfusion logistics and cost in the public and private sector in Britain. Haematology Reviews 17: 7–25 Kay L 1993 Autologous pre donation of blood for elective surgery. Current Practice in Surgery 5: 132–136 Kay L 1995 Answering the patients’ questions about transfusions. The Practitioner 239: 576–586 Mosby 1997 Mosby Medical Encyclopaedia, The Learning Company, London National Blood Service 2000 Pre-deposit autologous blood transfusion. AP/010.APP1, issue 01, p 2 National Blood Service 2001 Blood group basics. UK. [Online] 27.9.01, http://www.blood.co.uk/pages/ e13basic.html Napier JAF, Bruce M, Chapman J et al. 1997 Guidelines for autologous transfusion II. Perioperative haemodilution and cell salvage. British Journal of Anaesthesia 78: 768–771 Thompson JF, Kay L 1995 Autologous blood transfusion. General Anaesthesia 47: 1269–1279 Tortora G, Grabowski S 2000 Principles of anatomy and physiology, 9th ed. John Wiley & Sons, USA Voak D, Finney RD, Forman K et al. 1993 Guidelines for autologous transfusion I. Pre-operative autologous donation. Transfusion Medicine 3: 307–316