Preoperative autologous blood donation

INTRODUCTION

Preoperative autologous donation (PAD) is the most popular and widely used of the autologous options, which also include preoperative hemodilution and blood salvage. (See "Acute normovolemic intraoperative hemodilution" and "Intraoperative and postoperative blood salvage".) Interest in all forms of autologous transfusion, particularly PAD, mushroomed in response to the AIDS epidemic, beginning as early as 1983. By 1993, when participation in PAD peaked, approximately six percent of all blood collected in the United States was collected for autologous use.

BENEFITS

The most obvious benefit of PAD for the donor/patient is freedom from concern about infectivity of the blood. Assuming that the donor is not bacteremic at the time of donation and/or there are no clerical errors resulting in the inadvertent transfusion of the wrong unit of blood, the patient is also protected against hemolytic, febrile or allergic transfusion reactions; alloimmunization to erythrocyte, leukocyte, platelet or protein antigens; and graft-versus-host disease (GVHD). (See "Transfusion-associated graft-versus-host disease".) An additional benefit is that erythropoiesis may be stimulated by repeated phlebotomies, thereby enabling the patient to regenerate hemoglobin at an accelerated rate after surgery.

The overall efficacy of PAD has been evaluated in both randomized trials and cohort studies [1]. A meta-analysis found that patients who underwent PAD were much less likely than controls to receive allogeneic blood (odds ratio 0.17) but were more likely to undergo any transfusion with autologous and/or allogeneic blood (odds ratio 3.0) [2]. The latter effect is due both to a lower hematocrit in patients undergoing PAD and a more liberal transfusion policy with autologous blood.

DRAWBACKS

PAD programs are not without some drawbacks. Perhaps the most important is that autologous blood is considerably more expensive than allogeneic blood. This problem is compounded by the fact that current reimbursement programs (including Medicare) either deny the medical necessity of PAD or ignore the well-documented increase in cost [3].

The basis for the higher cost include the extra time and attention required by autologous donor/patients; the enhanced clerical requirements; the special handling (additional labels, separate storage, early delivery to the hospital, etc); and the fact that blood that is not transfused to the intended recipient (approximately 50 percent of donated blood) is generally wasted rather than transfused to other patients [4].