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Homologous blood transfusion, despite numerous and serious transfusion associated hazards, is an important treatment modality. Transmission of infectious agents like HIV, hepatitis viruses, malaria, etc is a distinct possibility notwithstanding careful screening of the blood. Predeposit autologous blood transfusion (PABT) and per operative acute normovolemic haemodilution (ANH) are two comparatively safer, simpler and practical alternatives. Unfortunately, their potential remains unexploited. Earnest motivation efforts at PABT and ANH have paid handsome dividends in our hospital. These have now become very popular amongst surgeons as well as the patients. These techniques can be easily adapted at all hospitals to reduce the demand for homologous blood transfusion. ANH can be safely practised even in hospitals without a blood bank.
Transmission of infectious agents through homologous blood transfusions is a reality despite the prevalent screening methods. Homologous blood transfusion can pose many other unexpected, devastating hazards to the recipient. Artificial/synthetic blood, free from these dangers, is a distant dream . Under such predicament PABT and ANH are two simple, safe and practicable alternatives.
We undertook extensive health education and motivation programme for anaesthetists, surgeons, nurses, paramedical staff, patients and their relatives regarding safe blood transfusion. The risks associated with homologous blood transfusion vis a vis advantages of PABT and ANH were emphasized. The patients were carefully screened and selected for these two modalities as per guidelines [1, 2, 3, 4, 5]. When required, relevant investigations were undertaken. Informed consent was obtained from each patient.
Anticipated requirement of blood for each patient, based on clinical condition and planned operative procedure, was worked out. The candidates for PABT were requested to deposit blood in the blood bank on convenient dates. These units of blood were labelled and stored separately in the blood bank.
Blood for ANH was drawn in the operation theatre prior to anaesthesia and circulatory volume was made up by crystalloid transfusion. The anaesthetists monitored this procedure. All units of blood drawn for ANH were carefully labelled and held at ambient temperature in the operation theatre during surgery lasting 90 min to 3 hours. Specimen of blood was subjected to routine screening procedures. Only one such case was taken up for operation on any one day to avoid clerical errors. Blood was retransfused into the patient after securing haemostasis. The available data on blood transfusions for the years 1995 to 1998 was compared.
A total of 430 units of blood were drawn and transfused in Military Hospital Bareilly in 1998. This, compared to previous years, shows an escalating trend of blood transfusion (Table-1). Almost equal number of homologous blood transfusion were instituted in male and female patients in 1998 but the female patients, in all age groups, were way ahead of the male counterparts for PABT and ANH (Table-2). General surgeons utilised PABT more frequently than the gynaecologists who preferred ANH (Table-3). Commonest surgical procedure with PABT was cholecystectomy and with ANH hysterectomy (Table-4). The interval between deposition of blood for PABT and surgery was less than 7 days in 42.84% cases (Table-5). Only one unit of blood was drawn from each patient. None of the patients had any untoward effect of blood withdrawal, haemodilution or blood transfusion and the postoperative recovery was uneventful.
Blood transfusion is an important universal modality of treatment. Transmission of infectious agents and other hazards must be considered before prescribing homologous blood transfusion. Synthetic safe blood substitutes  are not yet available and component therapy is not practicable at most of the centers due to technical reasons. Two important modalities, which eliminate the chances of transmission of infectious agents and reduce other hazards as well, are PABT and ANH. The major hurdle in effective application of these two modalities is ignorance and indifference, amongst the patients as well as the medical fraternity.
We undertook extensive formal and informal educational programmes for the patients, their relatives and medical staff to promote PABT and ANH.
Blood requirement over last four years shows rising trend (Table-1). The initial response to our suggestions of PABT and ANH was, as expected, hesitant. There were only 4.65% PABT/ANH (17 out of 365 transfusions) in 1997. However, the advantages were soon realised and 66 out of 430 (15.34%) transfusions were either PABT or ANH in 1998 (Table-1). This reveals that rising demand of blood can be met by these two modalities. Both methods, PABT and ANH were equally used.
It is interesting to note that the use of homologous blood transfusion for male and female patients was almost equal. However, PABT and ANH, were more extensively used for female patients (80.30%) (Table-2). This observation is important as it refutes the belief that female patients may have more adverse effects of blood letting. The age distribution was from 21 to 70 years but majority of cases were in 31 -50 year age group. If cases are selected carefully, sex and age is no bar to PABT or ANH.
The operating surgeons have individual preference. General surgeons preferred PABT while the gynaecologists opted for ANH (Table-4). This decision to use PABT or ANH also depends upon the patient's condition, the number of visits to hospital and the time lag between decision of operation and the actual date of operation. The safety of PABT and ANH in almost all types of surgery has been well-recorded [3, 6, 7, 8, 9]. In our study, cholecystectomy was the commonest elective procedure where PABT was resorted to (Table-5), followed by thyroidectomy and nephrectomy. Hysterectomy was the commonest operation undertaken with ANH. At superspecialist centers the utilisation of PABT has been more varied . The confidence gained over last one year will help us in effective use of these modalities for other type of surgeries as well.
The interval between withdrawal of blood and its transfusion in cases of PABT was less than 7 days in 42.84% cases (Table-5). The longest time lag was 22 days in one case. Ideally blood for PABT should not be withdrawn within the week preceding operation , but in many cases, we could not stick to this dictum due to logistic problems. One should try to plan the surgery well in time and encourage patients to deposit blood accordingly for PABT. Upto 4-5 units of blood, within a span of 5 weeks, can be collected for PABT by leap frog technique though the deleterious effects of transfusion of stored blood cannot be avoided. This advantage of PABT, making more than one unit of blood available, was not utilised in our hospital. None of the patients were asked to deposit more than one unit of blood. Single unit blood transfusion as replacement of per operative blood loss, though of minimal therapeutic value, is common practice even in our hospital. All the blood units drawn for PABT were retransfused in the same patient. We did not face nonutilisation of these units as observed by Dhot et al . It is recommended that if blood has been drawn for PABT it should be transfused into the same patient. Diverting it to other patient as homologous blood transfusion might lead to legal, ethical and moral tangles. Though the blood specimens were screened for HIV, HbsAg, VDRL and malaria parasite, none were found to be positive.
Many surgeons and patients are reluctant for ANH. Withdrawing blood from a patient, who is likely to lose blood during operation, appears paradox to them. However, when the benefits of haemodilution (improved perfusion due to decreased viscosity, reducing the actual amount of per operative blood loss and making safe, fresh blood available at the end of surgery), [7, 10, 11] were explained, the procedure was readily accepted. Significant amount of blood, (1500–2000 ml/patient) can be made available by ANH also, depending on the haematocrit level of the patient [3, 12]. In our patients, only one unit (350 ml/patient) was drawn for ANH. This hesitation to draw more blood was due to lack of experience. The patients accept ANH more than PABT as it avoids extra visit to hospital, discomfort of additional venepuncture and delay in surgery. This valuable experience at ANH has bolstered us and in future we plan to utilise this facility more aggressively. ANH can be practised even in hospital bereft of blood bank facilities. This is of great practical value for service hospitals located in far-flung places.
Homologous blood transfusion is associated with numerous hazards. Safe, synthetic blood substitutes are not available and component therapy is not practicable. PABT and ANH techniques are safe, simple and practicable in most of the hospitals. Careful patient selection and meticulous attention to proper procedures is essential for its success. These modalities can be used for all types of elective surgery, in all age groups, both in male and female. Success of these programs entirely depends upon motivation of all concerned, the anaesthetists, surgeons, nursing staff, paramedical staff, patients and their relatives. If implemented effectively, the ever-increasing demands for blood can be safely met by PABT and ANH and the hazards of homologous blood transfusion reduced significantly.
We are thankful to Col H Ramachandran, Senior Adviser (Surgery), Lt Col SN Shirbur and Maj RS Rengan of Surgical Div, Maj BK Goyal and Maj Gurnesh Singh, our gynecologists, for their active participation and co-operation in this endeavour.