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Autologous blood


R1R2

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We moved away from autos about 5 years ago.  I would not say we "don't accept" autos but our blood supplier doesn't routinely draw them, it requires Medical Director input before a unit is drawn.

 

We are a 350 bed hospital that does quite a few ortho cases, at least one hip a week if not more.  Our ortho and urology docs moved away from this practice with lots of input from the blood conservation team of which had doctors on it as members. 

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We do 5-8 hips/knees a week most weeks here (150 beds). We receive autologous blood about once every couple of years for a patient. At one point (horrors) we were drawing as many as 300 autologous units a year, then switched to letting the ARC draw them. After that the numbers started to dwindle dramatically-a little more hassle for the docs as they had to fill out more paperwork for the ARC ;) . We did not discourage the practice, but did provide them with information on how many of those units were being outdated/wasted. The ortho docs must finally have attended a meeting or read articles that convinced them that autologous blood wasn't guaranteed safe (happy day!), because we only get them now if the patient insists. Actually, I think that their surgical techniques have changed as well, because we don't transfuse nearly as many of their patients as we used to - we actually get routine Type and Screen orders instead of Crossmatch orders in PreOp.

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We're the same as Terri:  We allow it, but only get about 3-4 units per year.  It's phased itself out.

 

I don't think it is ethically correct to downright refuse to accept them (unless there is some legitimate reason in a particular case.)  (God forbid if you refuse to allow a patient to donate autologous units, then that patient contracts a transfusion-transmittable disease from a regular transfusion!)

 

We are a 300 bed hospital and do alot of hip and knee joint replacements.  Several years ago we collected our own autologous units and all the orthopedic surgeons were ordering one or two units on every knee replacement and two to four units on hip replacements.  Eventually they realized that these autologous patients usually needed to be transfused during or after surgery, but patient who did not donate autologous units only very rarely ever needed a transfusion.  (Duh!!)  One by one, the surgeons stopped requesting autologous collections.

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I do not think they should be refused for the reasons above. Could get into a lot of legal problems. In the "old" days before HIV and Hep C the only autos we seemed to get were young girls having scoliosis surgery. The idea was to not expose them to antigens that could complicate a furure pregnancy. And of course there are always the people with multiple or difficult antibodies like our local Bombays (had 3 at one time), McLoud (however he passed away), and cellano who should donate autologous units if possible.

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We have been working on our holdout orthopedists so we have done a bit of research recently.  I think their peers have them convinced finally.  We have quoted recommendations stating that the only patients that qualify for autologous collection should be scoliosis surgeries, patients with significant antibody problems and those who would be psychologically harmed or would adamantly refuse any other blood.  That will probably be those few units per year.  We wouldn't refuse them--especially the anti-patient  as Michelle mentions.

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The only ones we do not accept are autos that test NAT positive for HCV or HIV.  We are a 200 bed facility, and we still get a lot of auto units, drawn at the blood center.  More than half are not transfused.  Of the ones that are used, the patients always get bank blood in addition to their auto.  If they did not donate their own blood, they would most likely not even need to be transfused.  Oh, all the autos are drawn on ortho patients.  We also accept directed units, most of which end up going to other patients because the intended recipient either did not need it or was not ABO compatible.

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We maintain an auto donation program for a group of our orthopods that advocate this practice.  We currently have 8 units on the shelf right now that represent 6 patients for next week cases.  We also accept auto and directed units into our inventory from the blood center.  Our medical director is intimately involved with each of the onsite auto donors donation.  However, most of the auto units will be discarded and most directed units will be placed into general inventory.  We are about 120 beds with a large orthopaedic practice (mostly hips, knees, ankles).

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  • 4 weeks later...
  • 4 months later...

Ok. here's one for you.  Just wondering if the thinking has changed.  Yesterday I had orders to transfuse 2 patients with their auto blood.  Both patients were 3 days post-op, orthopedic surgery.  Patient #1 had a Hgb of 11.6; patient #2 had a Hgb of 10.9.  I notified the floor that neither patient met criteria for transfusion.  I immediately got a screaming phone call from the PA.  She wanted the patients transfused.  It was their blood and she didn't want it wasted or given to anyone else.  She also used a few 4 letter words that are not printable.  I told her that if she really wanted to transfuse, she would have to get the pathologist's approval and sign for it.  She finally muttered "oh, just forget it!", but she was mad.  Has the thinking on auto units changed?  Are we back to giving back the blood just because it's theirs, and they donated it and the doctor doesn't want it thrown out?

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Barb, that PA sounds ridiculous!!  Sometimes it's scary to think they can even order blood on people.  Our medical director is having a dinner/lecture this month, inviting all the PAs and NPs in the outpatient area to inform them of how the lab/transfusion service/histology departments work.

 

As for other autologous, we have 179 beds and used to have quite a few autologous donations for our orthopods, but that has really dropped off recently.  We did have one patient that we suggested autologous for, since she had a strong warm and anti-C, anti-e and anti-K! 

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You also have to shake you head at the logic of taking 2 units from a patient pre-op, thereby lowering their hgb from a 13 to a 10, deliberately making them anemic. Then they drop to a symptomatic 7 post-op (where they would have been at 10 or so without the donations) and you have to give them their blood back. It's a self-fulfilling prophecy.

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I know a pathologist who got her own blood back post-op because "it was her own" and she was a "little low". She said she was never so sick in her life. Nasty febrile reaction to the cytokines from non-leukoreduced blood, even though it was her own. Needless to say, she is not a proponent of autologous blood being given back when not really needed, or could have been prevented.

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We fought autologous units for years.  Finally, with some help from Tim Hannon's blood management group, we convinced most of our Ortho MDs that autologous units weren't really good for their patients.  We used to have two shelves full of autologous blood and now we only get an occassional unit (for a 300 bed hospital).  Basically, the physicians finally realized that they were making their patient's anemic prior to surgery and then giving back "stored" blood that wasn't expecially good at moving through capillaries and transporting oxygen.  Good Luck, it's a hard battle.

Edited by mla
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I seem to remember reading a study years ago (probably before many of you were born ...) which showed that a Pre-operative Autologous Donation programme should be stopped as the increased risks from the extra driving involved in donating the units more than outweighed any reduction in possible harm from a post-operative transfusion.

For many years this was my favourite transfusion fact.

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  • 3 weeks later...

Barb, that PA sounds ridiculous!!  Sometimes it's scary to think they can even order blood on people.  Our medical director is having a dinner/lecture this month, inviting all the PAs and NPs in the outpatient area to inform them of how the lab/transfusion service/histology departments work.

 

As for other autologous, we have 179 beds and used to have quite a few autologous donations for our orthopods, but that has really dropped off recently.  We did have one patient that we suggested autologous for, since she had a strong warm and anti-C, anti-e and anti-K! 

You are not alone in your assessment of certain PAs,RNNPs, and CRNAs.  Like physicians when a PA practices within a health care facility they must practice in accordance with the policies of the health care facility.  At my particular hospital we decided as a matter of policy not to allow PAs the athority to perscribe any blood product or order the transfusion of such.  It was difficult at first (with some hard feelings) but over the years it has become accepted as routine practice.

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We still allow them in house, but the patients are usually not willing to collect them since our blood supplier only draws them at certain locations, and even then they limit the hours of collection. Plus they charge the patient for the cost of the unit before they will draw.

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