Recommendation grades (A-C) and levels of evidence (Ia-IV) are defined at the end of the "Major Recommendations" field.
Particular note needs to be taken of the specific developments in the UK, including:
- A developing consensus for conforming to the recommendations described in the UK Chief Medical Officers' recommendations described in 'Better Blood Transfusion 2'
- The increasing compliance with this as indicated by
- Audit
- The current decline in issues of allogeneic red cells to hospitals in England (from 2,243,000 in 1999/2000 to an estimated 1,900,000 for 2005/2006)
- The fact that all blood donors are non-remunerated volunteers
- The current estimates of risks of infection transmitted by transfusion of allogeneic blood components from UK donors indicated in the Position Statement of the UK Joint Professional Advisory Committee (see www.transfusionguidelines.org.uk), which are
- 1 in 500,000 for hepatitis B virus (HBV)
- 1 in 5 million for human immunodeficiency virus (HIV)
- 1 in 30 million for hepatitis C virus (HCV)
- Continuing developments in surgical techniques resulting in reduced blood requirements
- Increased use of intraoperative autologous transfusion (for which further BCSH guidelines are being developed)
- Growing patient demand for alternatives to allogeneic blood transfusion
Specific Recommendations
Whole Blood
The use of pre-operative autologous blood donation (PAD) is not recommended unless the clinical circumstances are exceptional.
Exceptional circumstances may include
- Rare blood groups where allogeneic difficult to obtain
- Children with scoliosis (Ib, A)
- Patients at serious psychiatric risk if blood transfusion is thought to be likely to cover their elective surgery (IV, C)
- Patients who refuse to consent to allogeneic transfusion but who would consent to PAD
When PAD of whole blood is undertaken, the following criteria are required but do not of themselves justify it if they can be fulfilled.
- Patients considered for the procedure must be candidates for elective surgery, where blood transfusion is expected to be needed (Ib, A).
- The admission and operation days must be guaranteed (IIb, B).
- Sufficient time to enable optimal collection of the blood must be allowed prior to surgery but should not exceed the licensed time for storing the collected blood component. For red cells, this is in practice at least 5 weeks (IIa, B).
- Sufficient time should be given from the date and time of the ultimate PAD collection prior to surgery for the patient to make a full circulatory and volaemic recovery. The 15th edition of the Standards of the American Association of Blood Banks (1993) recommends a minimal interval of 72 hours (IIb, B).
Potential candidates
- Should be judged by a competent clinician to be able to tolerate the repeated loss of the predetermined volume of blood at each collection; this should normally be no more than 10% of their estimated blood volume (IV, C)
- Should be provided with adequate information concerning the eligibility criteria for PAD and the reasons behind such criteria by the physicians providing the PAD service
- Should be considered for supplementation with erythropoietin (Ib, A)
- Should present with the following haemoglobin (Hb) before embarking on PAD (III, B)
- Men, 110 to 145 grams per liter (g/L-1)
- Women, 130 to 145 g/L-1
- For each individual case, there should be a clear reason for preferring PAD to allogeneic blood as PAD is not indicated for most patients fulfilling the above criteria. Indeed, the clinical indications for collecting and using PAD are limited: for the majority of patients undergoing elective surgery of a nature likely to require transfusion to treat surgical and postoperative blood loss, allogeneic blood is the preferred option.
- PAD is not recommended for children younger than 10 years, mainly because of technical difficulties (large bore needle in veins of limited size) and it can be difficult to gain sufficient co-operation (Ib, A).
- Wherever appropriate, supplemental means of reducing use of allogeneic blood should be used, such as cell salvage.
Candidates who meet the criteria for PAD but who are positive for relevant markers of transfusion-transmissible infection present safety issues for staff collecting and processing the donations and also potential for administrative and other errors. For these reasons, the Task Force does not recommend that PAD be offered to such patients unless they also fall into one of the exceptional categories.
Given the costs of erythropoietin, its economic value to supplement PAD must be regarded as doubtful. The Task Force therefore does not recommend that erythropoietin be used unless the clinical circumstances are exceptional.
Although iron therapy prior to PAD has little effect on subsequent transfusion needs in individuals who are iron replete, there are advocates of iron therapy during PAD on a priori grounds though there is no good clinical evidence on which to base such recommendations. Therefore, the Task Force does not recommend prophylactic iron to iron-replete individuals undergoing PAD (Ib, A) and further recommends that PAD be denied to persons who are iron deficient and receiving iron therapy until they have been effectively treated and their iron deficiency reversed.
PAD of Red Cell Components Collected by Apheresis
As the collection of allogeneic red cell component donations by apheresis becomes more widespread, autologous red cell component collection by apheresis may also be suggested. Allogeneic donors selected for red cell component collection (i.e., by apheresis) may also be selected for greater volume and frequency of donation and therefore be heavier, have a higher blood Hb concentration than Hb concentration for standard allogeneic donation (e.g., 140 gL-1) and have adequate iron status. However, there are no studies of such systems applying to PAD. The Task Force does not recommend that PAD be conducted by apheresis until and unless costs become comparable with those for standard donation collection and processing, and even then, only under the exceptional circumstances pertaining to PAD by standard collection already considered.
Definitions:
Statements of Evidence
Ia Evidence obtained from meta-analysis of randomized controlled trials.
Ib Evidence obtained from at least one randomized controlled trial.
IIa Evidence obtained from at least one well-designed controlled study without randomization.
IIb Evidence obtained from at least one other type of well-designed quasi-experimental study.
III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies.
IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities.
Grades of Recommendations
Grade A Requires at least one randomized controlled trial as part of a body of literature of overall good quality and consistency addressing the specific recommendation (evidence levels Ia and Ib).
Grade B Requires the availability of well-conducted clinical studies, but no randomized clinical trials on the topic of recommendation (evidence levels IIa, IIb and III).
Grade C Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality (evidence level IV).
