Autologous Blood Transfusion: is Harmful and Unnecessary · Autologous Blood Transfusion: is...
Transcript of Autologous Blood Transfusion: is Harmful and Unnecessary · Autologous Blood Transfusion: is...
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Autologous Blood Transfusion: is
Harmful and Unnecessary
Ali Salim, MD
Professor of Surgery
Chief, Division of Trauma, Burns, Surgical Critical Care, and Emergency General Surgery
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This Year’s Debate
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Demetriades et al JACS 2005
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Mortality After Trauma
Hemorrhage
39%
CNS + Hem
6%
CNS
42%
MSOF
7%
Other
6%
Sauaia et al. Journal of Trauma 1995:38;185-192.
N = 289
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Hemorrhage Control
1. Surgical Control.
2. Correct Systemic Coagulation Defects.
3. Maintain Normothermia.
4. Balance Acid-Base Status.
5. Endovascular Assist.
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Hemorrhage Control
1. Surgical Control.
2. Correct Systemic Coagulation Defects.
3. Maintain Normothermia.
4. Balance Acid-Base Status.
5. Endovascular Assist.
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The Coagulopathy of Trauma
Tissue injury
Shock
Hemodilution
Hypothermia
Acidemia
Inflammation
Hyperfibrinolysis
Hypocalcemia
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What we know
Damage control resuscitation (hemostatic)
Rapid hemorrhage control
Permissive hypotension
Minimize crystalloid
Immediate delivery of high ratio of plasma and
platelets to RBC’s (1:1:1)
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What we know
Damage control resuscitation (hemostatic)
Rapid hemorrhage control
Permissive hypotension
Minimize crystalloid
Immediate delivery of high ratio of plasma and
platelets to RBC’s (1:1:1)
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Borgman et al., J Trauma 2007
31%
46%
Journal of Trauma 2007
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• Early administration of blood products like plasma
and platelets lowers mortality
2013
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• Early administration of blood products like plasma
and platelets lowers mortality
• With 1:1:1 ratio:
• More patient achieved hemostasis
• Fewer died from exsanguination
2013
2015
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What we know
Damage control resuscitation (hemostatic)
Rapid hemorrhage control
Permissive hypotension
Minimize crystalloid
Immediate delivery of high ratio of plasma and
platelets to RBC’s (1:1:1)
Best replacement for whole blood loss
may be fresh whole blood
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Whole blood is great
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Whole blood is great
Is autologous blood = whole blood??
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Whole blood is great
Is autologous blood = whole blood??
But first, what is autologous blood??
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What is autologous blood
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What is autologous blood
Autos – means self
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What is autologous blood
Autos – means self
Logus – means relation
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What is autologous blood
Autos – means self
Logus – means relation
“related to self”
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What is autologous blood
Autos – means self
Logus – means relation
“related to self”
“Reinfusion of blood or blood components
to the same individual from whom they were
taken”
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What is autologous blood
Cell Saver
Autotransfusion (chest tube)
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Advantages of autologous blood
Immediately available
Technique for resuscitation
Ease the need for allogeneic component
transfusion
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Advantages of autologous blood
May lessen risks of
ARDS
Pneumonia
Transfusion reactions
Blood-borne pathogens
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Advantages of autologous blood
EAST and SCCM suggest autotransfusion
Autotransfusion approved by AABB
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Problems of autologous blood
Inflammatory mediators
Contamination
Impact on coagulation?
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Problems of autologous blood
Inflammatory mediators
Contamination
Impact on coagulation?
↑ clot formation
↓ clot formation
No effect
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Problems of autologous blood
Inflammatory mediators
Contamination
Impact on coagulation?
↑ clot formation
↓ clot formation
No effect Unclear……
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Whole blood is great
Is autologous blood = whole blood??
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What is autologous blood
Cell Saver
Autotransfusion (chest tube)
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What is autologous blood
Cell Saver
Autotransfusion (chest tube)
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Autologous cell saver
Safe
↓ transfusion of PRBC
↓ transfusion of FFP
2010
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What is autologous blood
Cell Saver
Autotransfusion (chest tube)
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What is autologous blood
Cell Saver
Autotransfusion (chest tube)
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Autotransfusion
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Autotransfusion
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Autotransfusion
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2015
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Autologous Blood Transfusion
↓ use of blood products
Is safe
2015
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2015
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However……
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To describe coagulation, hematologic,
and electrolyte profiles of blood from
evacuated hemothorax
2011
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Parameter Pleural
Blood
Venous
Blood
P value
Hematocrit 26.4 33.9 .003
Hemoglobin 9.2 11.7 .004
Platelet 53 174.4 <.001
INR >9 1.1 <.001
aPTT >180 28.5 <.001
Fibrinogen <50 288 <.001
D-Dimer >7,360
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Sufficient concentration of RBC’s
Extremely deficient in coagulation factors
Contains products of fibrinogen degradation
2011
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2011
“direct transfusion of pleural blood
raises safety concerns.”
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2015
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Does time make a difference??
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Analyzed at 1,2,3 and 4 hours
Mixed with normal pooled plasma to
evaluate effect on coagulation
2013
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No difference at different time points
2013
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Hemothorax is hypercoagulable when
mixed with normal pooled plasma
2013
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2014
Simulate hemothorax autotransfusion
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Mixture becomes hypercoagulable
2014
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2014
“…we cannot recommend
autotransfusion of HTX when banked
blood is available.”
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Cytokines??
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Cytokine Levels
↑ pro-inflammatory cytokines
↑ anti-inflammatory cytokines
10 to 100 fold higher
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Cytokine Levels
↑ pro-inflammatory cytokines
↑ anti-inflammatory cytokines
10 to 100 fold higher
Potential for deleterious effects??
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2015
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Autologous Blood
Safe??
Evidence to support its use??
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Autologous Blood
Safe??
Evidence to support its use??
Practicing West Virginia Medicine??