Last’s week’s Journal of the American Medical Association included a clinical crossroads case study on autologous predonation (1). The scenario was a relatively healthy, non-anemic woman (“Mrs. C”) who was scheduled for elective knee replacement surgery and was asking for advice on blood avoidance options. Her specific concerns were voiced as: “Personally, I do not want anyone else’s blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That’s my concern; I have never had an infectious disease in my life and at this age, I don’t think I want to get one.”(1) From her standpoint, she logically inquired about options such as predonating her own blood prior to surgery or using a directed donor.
I am sure that this is still a common question from patients, and I view it as a great opportunity to provide patient education and an informed consent discussion for transfusion. Mrs. C is right to be concerned about the risks of transfusion, but she is right for the wrong reason. While the general public is concerned about the risk of transmittable disease such as HIV and hepatitis, these risks have been reduced to less than 1:1,000,000 through the use of donor deferrals and donor testing. While the blood industry remains vigilant for the next emerging threat such as Chagas Disease and Babesiosis, the clear and present danger is the non-infectious serious hazards of transfusions, which occur with a frequency that is 10x- 100x times more frequent than viral transmission. The most significant of these adverse events are mistransfusion due to clerical errors, transfusion related acute lung injury (TRALI), transfusion associated circulatory overload (TACO), and transfusion related immunomodulation (TRIM) (2, 3). There is also growing concern about the adverse effects of blood related to its storage (4). Patients and providers are often unaware of these non-infectious hazards, and that lack of awareness can lead to inappropriate risk-benefit treatment decisions and improper informed consent.
The second issue is Mrs. C’s concern to reduce her need for a blood transfusion. Mrs. C should be reassured that she is at low risk for transfusion given her ample hemoglobin and expected blood loss. Pierson published an algorithm for orthopedic blood conservation based upon the expected blood loss from a procedure and the preoperative hemoglobin (5). For a unilateral primary knee replacement, the expected blood loss would be 4.8 gm/dL, which includes an extra 1 gm/dL safety factor. Given her starting hemoglobin of 15.1 and expected nadir hemoglobin of 10.3 gm/dL, it is highly unlikely she would need a transfusion, at least if evidence-based transfusion guidelines were used.
If Mrs. C was undergoing a revision or bilateral joint replacement, or if she was significantly anemic preoperatively, I would then counsel her on the best available options for blood management. While predonation was a great option in the early 1990’s, the risk-benefit ratio has evolved to the point that predonation now offers little safety benefits over allogeneic blood. The risk of transmissible disease has dropped significantly, blood storage issues are universal and non-infectious risks such clerical errors and TACO can occur just as readily with autologous blood as with allogeneic. In fact, the anemia of predonation moves patients closer to a transfusion trigger and some physicians use more liberal transfusion triggers for predonated blood in spite of recommendations against this practice (6, 7). Coupled with the fact that patients are typically not given sufficient time to restore red blood cell mass after donating, predonation is no longer a recommended blood conservation approach in orthopedic surgery (8).
Current blood management recommendations for orthopedic surgery include preoperative anemia management protocols, intraoperative use of meticulous hemostasis, regional anesthesia, topical hemostatics, minimization of surgical drains, and the use of autotransfusion in selected cases (8). The use of antifibrinolytics such as tranexamic acid also seems promising (9). Coupled with conservative transfusion practice driven by evidence based guidelines, transfusion in joint replacement can be avoided in the vast majority of cases. The overall strategy has become maintenance of the patient’s own red cell mass, or as Woody Allen quipped, “the best place for blood is in our veins.”
Perhaps the most important modifiable risk factor for transfusion is what hospital door Mrs. C walks through on the morning of surgery. Transfusion practice is notoriously variable in the U.S., and can vary tremendously from hospital to hospital and among surgeons within the same hospital (10). Asking her surgeon about available blood management options and his or her transfusion rate should be questions at the top of her list.
- Uhl, L. A 68-year-old woman contemplating autologous blood donation before elective surgery. JAMA 2011;306(17):1902-1910.
- Boucher BA, Hannon TJ. Blood management: a primer for clinicians. Pharmacotherapy, 2007;27(10):1394-1411.
- Despotis G, Eby C, Lublin DM. A review of transfusion risks and optimal management of perioperative bleeding with cardiac surgery. Transfusion 2008;48:2S-30S.
- Spinella PC, Doctor A, Blumberg N, Holcomb JB. Does the storage duration of blood products affect outcomes in critically ill patients? Transfusion 2011;51(8):1644–50.
- Pierson J, Hannon TJ, Earles DR. A blood conservation algorithm to reduce blood transfusions after total hip and knee arthroplasty. JBJS 2004;86A(7):1512-18.
- Shander A. Surgery without blood. Crit Care Med 2003;31:S708–14.
- Gould SA, Forbes JM. Controversies in transfusion medicine: indications for autologous and allogeneic transfusion should be the same: pro. Transfusion 1995;35:446–49.
- Hannon TJ, Pierson J. Blood management. In: American Academy of Orthopaedic Surgeons Comprehensive Orthopaedic Review, Lieberman JR, editor. AAOS 2009; Rosemont, IL.
- Alvarez JC, Santiveri FX, Ramos I, et al. Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion 2008;48(3):519–25.
- Bennett-Guerrero E, Zhao Y, O’Brien SM. Variation in use of blood transfusion in coronary artery bypass graft surgery. JAMA 2010;304(14):1568-75.