6: Alternatives and adjuncts to blood transfusion
- Transfusion alternatives were mostly developed to reduce blood use in surgery but have much wider application.
- They are most effective when used in combination and as part of a comprehensive patient blood management programme.
- Predeposit autologous blood donation before surgery is of uncertain benefit and now has very restricted indications in the UK.
- Intraoperative cell salvage (ICS) is effective (and may be life-saving) in elective or emergency high blood loss surgery and management of major haemorrhage.
- Postoperative cell salvage (PCS) and reinfusion can reduce blood use in joint replacement and scoliosis surgery.
- ICS and PCS are usually acceptable to Jehovah’s Witnesses.
- Tranexamic acid (antifibrinolytic) is inexpensive, safe and reduces mortality in traumatic haemorrhage. It reduces bleeding and transfusion in many surgical procedures and may be effective in obstetric and gastrointestinal haemorrhage.
- Off-label use of recombinant activated Factor VII (rFVIIa) for haemorrhage does not reduce mortality and can cause serious thromboembolic complications.
- Erythropoiesis stimulating agents (ESAs), such as erythropoietin, are standard therapy in renal anaemia and can support blood conservation in some cancer chemotherapy patients and autologous blood donation programmes. They may also be effective in selected patients with myelodysplasia.
- ESAs may cause hypertension and thromboembolic problems. Careful monitoring is required to keep the haematocrit below 35%.
- Safe parenteral iron preparations are now available and may produce more rapid and complete responses in iron deficiency anaemia. Indications include intolerance of oral iron, support for ESA therapy and as an alternative to transfusion in perioperative and postpartum anaemia.
Transfusion alternatives have largely been developed to reduce donor red cell transfusion in surgery, where they are most effective as part of a comprehensive ‘patient blood management’ programme (see Chapter 7). Many of these techniques have wider application, ranging from traumatic and obstetric haemorrhage to patients who do not accept blood transfusions. This chapter briefly describes the commonly available transfusion alternatives and their rationale. Their use in specific clinical indications is covered in Chapters 7–10 and 12.