Article Type : Review Article
Authors : Avgoustou E, Jannussis D and Avgoustou C
Keywords : Massive haemorrhage; Salvage autologous blood transfusion; Armed conflict field
Increasing shortages of allogenic blood
and risks of transmitted infections have prompted the use of a range of blood
sparing techniques associated with emergent surgery under specific
circumstances . Salvage autologous blood transfusion (ABT) is a safe and
feasible method for rapid blood volume replacement to correct haemorrhagic
shock , usually from bleeding in body cavities or wounded extremities, in areas
with limited or, even, non-existing blood donor resources, such as those of
armed conflicts and natural or environmental disasters. Blood autotransfusion
must be placed in the context of an early surgical approach to the haemorrhagic
patient, either preoperatively or once the operation commences.
Autologous blood transfusion (ABT) was used for the first time in 1818 by James Blundell, a British obstetrician [1,2]. At the beginning of the 20th century, Landsteiner’s classification of blood groups resulted in the widespread use of the allogenic donated blood as a standard practice in health care [2,3]. In modern times, after the development of cardiac surgery and the advent of highly sophisticated equipment, ABT has been “re- discovered” and is widely used in cardio-thoraco-vascular, transplantation, neuro- and orthopaedic surgery [2,4]. Scarce resources of allogenic donor blood, which worldwide exerts real social and economic pressure and the risk for viral/prion transmission have prompted the use of a range of blood sparing techniques in the perioperative period [3-5]. In armed conflicts and other situations of massive violence, where surgeons and rescue team work with limited or non-existing blood resources on the field, facing patients who are bleeding to exsanguination and death, either due to a severe but survivable injury (i.e., abdominal, thoracic, of the extremities) or acute rupture (i.e., on ectopic pregnancy), autotransfusion during urgent haemostasis can rapidly and safely replenish the patient’s blood volume [2,3,6]. The International Committee of the Red Cross (ICRC, Geneva) and the Medicines Sans Frontieres (MSF) intentionally have the accumulated experience of emergent transfusion in high intensity war front lines and areas of natural disaster all around the world .
ABT is placed in the setting of a surgical approach to the haemorrhagic patient, which includes timely control of bleeding and meticulous haemostasis [9,15]. Based on the ICRC recommendations [2], in most bleeding patients whose evacuation is delayed and total blood loss is 1000 ml or more, but arrive in a relatively stable hypovolaemic condition, initial treatment requires basic resuscitation with I.V. crystalloids, plasma, and plasma expanders (if available) prior to surgery. In patients with acute and massive haemorrhage, the degree of urgency, the desperate need for blood transfusion to save them, and the lack of any other source of blood appears to define the deadline for ABT more than anything else [2,6,15]. In these cases, the rapid loss of over 20 % of estimated blood volume (i.e. ,1000 ml blood), or a haematocrit value of less than 35 % on admission with expected crystalloid requirements of more than 2000 ml, should alert the surgeon and anaesthetist for the need for possible autotransfusion [2,15]. The most common use has been for ectopic pregnancy and massive haemothorax. Other indications for ABT concern cases with substantial blood loss occurring either when the operation commences (usually, a laparotomy with ruptured spleen and packed liver ,and the bleeding control of wounded limps) or in the postoperative setting [2,3,12,14].
ABT lacks some important disadvantages of the allogenic blood transfusion, such as immunosuppression, transmission of diseases (including viral, such as hepatitis and human immunodeficiency, but also bacterial or parasitic), haemolytic reactions/technical errors in histocompatibility, scarcity of resources and uncertainty in patients with rare blood groups and multiple auto-antibodies [3,4,13,15]. On the other hand, autotransfusion may cause transient haematological abnormalities (i.e., coagulopathies, especially when more than three liters of unprocessed blood are given) and possibly febrile reactions that disappear within 72 hours [2,11]. One should also not forget that laboratory results (i.e., hematocrit) are influenced through the haemodilution from the synchronous rapid infusion of crystalloids.
Clinically, ABT has proven safe and effective as it has not resulted in significant increase of infectious complications, even with blood harvested from war wounds, which is obviously not sterile [2]. Other potential complications of ABT, reported but rarely causing significant risks, are haemolysis/haemoglobinuria with transient deterioration of renal function (treatment with aggressive hydration and urine alkalinization), electrolyte disorders, pulmonary hypertension and Acute Respiratory Distress Syndrome (ARDS) [3,4]. In the setting of the patient massively bleeding, with little or no blood available for homologous transfusion, the great benefits of ABT have proven to outweigh by far the possible risks, even of multiple organ dysfunction/ failure [2,15]. Finally, there are only a small number of studies indicating that reinfusion of fetal cells in salvage blood during caesarian section can be used without the complications of amniotic fluid embolism and rhesus sensitization [4]. Larger cohort-studies are certainly required.
Conclusively, in circumstances where blood for transfusion is scarce, recovery ABT for massive haemorrhage is time and lifesaving. ABT, as a simple method of blood replacement requiring no specific equipment, is placed in the setting of the emergency approach to the haemorrhagic patient ,which includes timely control of bleeding and haemostasis .
None declared.
EA-reference research, manuscript submission; DJ (MSF surgeon in conflict areas)-manuscript conception; CA-manuscript conception, design, writing.