Australian Red Cross Blood Service

Blood conservation can be beneficial for medical and surgical patients. For the surgical patient, blood conservation begins at the time of the patient’s surgical booking and continues through the operation and into the recovery process.(1)

The National Blood Authority Patient Blood Management Guidelines: Module 2 – Perioperative(2) and Module 3 – Medical(3) provide recommendations and practice points on blood conservation strategies.

Medical blood conservation techniques

If a patient requires therapy for anaemia, thrombocytopaenia or coagulopathy, transfusion should not be a default decision. Instead, the decision on whether to transfuse should be carefully considered, taking into account the full range of available therapies, and balancing the evidence for efficacy and improved outcome against the potential risks.

Identification and treatment of reversible causes of anaemia, particularly iron deficiency in patients with chronic heart failure, is vital. The routine use of erythrocyte stimulating agents (ESAs) is not recommended in some patient groups, but may be cautiously used in others. Where a red cell transfusion is indicated, one unit should be followed by clinical assessment to determine the need for further transfusion.

Back to top

Preoperative blood conservation techniques

Assessing the patient for anaemia and bleeding risk, optimising haemoglobin level and maximising coagulation function are key blood conservation techniques. Refer to Anaemia and haemostasis management for further information.

Before and after an operation, restricting phlebotomy to essential tests only and taking smaller samples (microsampling) can limit the amount of non-surgical blood loss.

The routine use of preoperative autologous donation (PAD) is not recommended. From 1 July 2013, the Blood Service will no longer offer PAD collections except for patients with rare blood groups or complex antibodies.

Preoperative autologous donation (PAD):

• reduces the risk of allogeneic red cell transfusion but increases the risk of receiving any red cell transfusion (allogeneic and autologous)(2)
• increases the risk of preoperative anaemia which is associated with worse outcomes (than those who were not anaemic preoperatively)(4,5)
• results in excessive wastage, with approximately 50% of autologous units discarded(6,7)
• results in generally higher costs on balance than the value of reported benefits of the actual autologous donation(4,6)
• carries some of the same risks of allogeneic blood, eg, bacterial contamination; clerical and human errors, including incorrect transfusion; and, febrile reactions(6,8)

Back to top

Intraoperative blood conservation techniques

The Patient Blood Management Guidelines: Module 2 mentions the following intraoperative strategies for blood conservation:

• prevention of hypothermia (Grade A)
• appropriate patient positioning
• deliberate induced hypotension in specific surgeries (Grade C)
• acute normovolaemic haemodilution (Grade C)
• cell salvage (Grade C)
• haemostasis analysis (Grade C)
• use of medications such as tranexamic acid (Grade A, B)
• meticulous operative technique
• topical haemostatic agents

Back to top

Postoperative blood conservation techniques

In select clinical settings, postoperative cell salvage is recommended as a blood conservation strategy (Grade C). This technique involves the collection of a patient’s postoperative blood loss into a wound drain. It is then returned to the patient via a filter, either washed or unwashed depending on the equipment used.(9,10)

Close patient observation and monitoring to identify episodes of uncontrolled bleeding and readiness to return to theatre to control bleeding is important in blood conservation.

Back to top

References

1. Shander A, Waters JH, Gottschall JL. Perioperative Blood Management: A Physician’s Handbook. 2nd edn. AABB, 2009.
2. National Blood Authority. Patient Blood Management Guidelines: Module 2 – Perioperative. Australia, 2012.
3. National Blood Authority. Patient Blood Management Guidelines: Module 3 – Medical. Australia, 2012.
4. Kulier A, Levin J, Moser R, Rumpold-Seitlinger G, Tudor IC, Snyder-Ramos SA et al. Impact of preoperative anemia on outcome in patients undergoing coronary artery bypass graft surgery. Circulation 2007;116:471–479.
5. Keating EM, Meding JB, Faris PM, Ritter MA. Predictors of transfusion risk in elective knee surgery. Clin Orthop Relat Res 1998;357:50–59.
6. Yazer MH, Waters JH. How do I implement a hospital-based patient blood management program. Transfusion 2012;52:1640–1645.
7. Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation. Transfusion 2001;41:1459–1462.
8. Woodfield G, Davis KG, Francis A, Hudson P, Liew YW, Roper T, Theakston E. Topics in Transfusion Medicine Special Edition: Guidelines for Autologous Blood.
9. UK Blood Transfusion & Tissue Transplantation Services. Better Blood Transfusion Toolkit, Appropriate Use of Blood, Post-operative cell salvage. [Cited 2011 Dec 13]. Available from: http://www.transfusionguidelines.org.
10. UK Blood Transfusion & Tissue Transplantation Services. Handbook of Transfusion. [Cited 2011 Dec 13]. Available from: http://www.transfusionguidelines.org.