Tropical Doctor, April 1992
SHORT REPORTS
Autologous transfusion for elective surgery and caesarean section in Uganda Alberto Reggiori, L Belli, E Cocozza Hoima Hospital, PO Box 5, Hoima, Uganda TROPICAL DOCTOR,
1992, 22, 79-80
Blood transfusion can be life saving, but it is increasingly risky. The major dangers are transfusion reactions and the transmission of infection. Approximately 1-4070 of blood transfusion recipients develop alloantibodies to red cell antigens. The spread of the HIV epidemic is well known (in some urban areas almost 25070 of blood donors are HIV positive); even when testing is done, a few donors are virus positive but antibody negative (the 'window period') and HIV infection may be transmitted I. Hepatitis B or C occur in an estimated 7-15070 of blood transfusion recipients, and syphilis is also a recognized hazard-, The use of 'directed' donations from family members is common, but the incidence of transmitted infections is not reduced by making use of such hand-picked donors. In order to minimize these risks, when a blood transfusion is likely to be needed for a scheduled operation, transfusion of the patient's own predeposited blood, or autologous transfusion, can be valuable. This method can be employed for obstetric procedures. PATIENTS AND METHODS
In 1989, 60 patients scheduled to undergo elective surgery, including caesarean sections, were eligible to donate blood for autologous use in an experimental protocol in Hoima Hospital, a district hospital of West Uganda. Twenty-eight were Correspondence to: Dr A Reggiori, c/o AVSI, PO Box 6785, Kampala, Uganda
79 women in the third trimester of pregnancy with a planned caesarean section for different indications; the other 32 patients were admitted for various elective surgical procedures (total abdominal hysterectomy, subtotal thyroidectomy, laparotomy, etc.). Participation required a signed autologous blood order from the surgeon and a written consent from the patient. A patient was selected for preoperative donation if she/he was likely to need blood transfusion during or after surgery, and had a haemoglobin level greater than 10 g/dl. Age was not used as an exclusion criterion: the volume of blood donated was calculated according to the weight of the patient. A phlebotomy loss equal to 10070 of blood volume is very well tolerated", Patients with bacteraemia, malignant cancer, sickle cell anaemia (ss homozygotes) and severe cardiovascular disease were not eligible for enrolment. One week before surgery each patient donated one unit of blood; in five cases two units were donated by the same individual with an interval 6 days between donations, because considerable blood loss was expected. In these 5 cases the haemoglobin level was higher than 10 g/dl even after the first donation. Pregnant women donated one unit only, and were admitted to hospital at the time of venesection. The non-obstetric patients were admitted to hospital the day before surgery. Vital signs (including fetal monitoring) were verified before, during and after blood donations: no important changes or reactions occurred. The blood was collected in a bag containing CPD-adenine anticoagulant solution, labelled with the patient's name, ward, inpatient number and date of collection. All units were labelled 'for autotransfusion only' and stored in the solar refrigerator of our hospital. All the non-obstetric patients received a daily oral supply of ferrous sulphate (400 mg) and folic acid (1 mg) from the time they were judged eligible for the donation, until the time of surgery (average about 2 weeks). Almost all the pregnant women were already on supplements. Even autologous transfusion carries some blood administration costs and health risk. Autologous blood was therefore not infused automatically during surgery merely because it was available, but only if it was clinically indicated.
80
Tropical Doctor, April 1992
RESULTS
Only 50 patients out of 60 were autotransfused; in 10 cases the blood loss was negligible. A total of 55 autologous blood units were transfused (45 to one-unit donors and 10 to two-unit donors); out of 28 obstetric patients who previously donated blood, 23 were found in need of it and were transfused. The criteria for transfusion were mainly clinical, based on the amount of blood lost during the operation and on the monitoring of vital signs, keeping in mind the preoperative haemoglobin level. None of the transfused patients required an extra homologous blood transfusion. Blood not used for the donor was not used for transfusion in another patient. All donated blood was sent to Nakasero Blood Bank (Kampala) where, as routine procedure, it was tested for syphilis, hepatitis Band HIV: the donor was asked to report later to the hospital to discuss the results. Thirty patients (60070) were transfused intraoperatively and 20 (40%) postoperatively. No transfusion reactions occurred. DISCUSSION
CONCLUSION
The use of autologous blood donations is recommended even in obstetric patients when the need for blood can be foreseen, when the patient is able to donate and when there is sufficient time before the expected need. REFERENCES
2 3
Autologous blood transfusion has received recent international support especially in developing countries! for two main reasons; (a) concern about the transmission of infection and (b) concern about limited community availability of blood. Autologous
Improving drug utilization at local level- an opinion Duncan Mark Ross MB ChB MRCGP Micheweni Cottage Hospital, Pemba, Tanzania TROPICAL DOCTOR,
blood transfusion side-steps each of these concerns. There is ample documentation of the safety of this method for healthy adults and children; but experience with pregnant women is still limitedv>. During our experience of 60 patients provided with 65 units of blood, we encountered no adverse effects: observations of the 28 mothers and the results of fetal monitoring suggest that autologous blood donation is safe for selected pregnant women and their fetuses",
1992, 22, 80-81
'We must have more drugs!'. This is the almost universal request which is presented when visiting hospitals or dispensaries in the developing world. Without doubt the drug supply is limited due to financial restrictions, but much has certainly been done in recent years to improve and rationalize the supply of drugs, especially at the peripheral level, through the work of the Essential Drugs Programme Correspondence to: Dr D M Ross, Old Lavenders, Cuilfail, Lewes, Sussex BN7 2BE, UK
4 5
AIDS control programme - Ministry of Health, Republic of Uganda. Indication for blood transfusion in Uganda. Health Education Printing Unit, 1989 Kempen P. Autologous blood donation. lAMA 1988; 259:2404-5 The National Blood Resource Education Program Expert Panel. The use of autologous blood. lAMA 1990;263:414-17 Herbert W, Owen H, Collins M. Autologous blood storage in obstetrics. Obstet Gynaecol 1988;72: 166-70 Kruskall M, Leonard S, Klapolz H. Autologous blood donation during pregnancy: analysis of safety and blood use. Obstet Gynaecol 1987;70:938-40
(EDP). Perhaps, though, too much attention has been paid to the supply side and not enough to the demand side of the problem. Prescribers often fail to realize that it is they themselves who have written the prescriptions, and it is they who can control demand and the way that drugs are used. There are many factors which influence the decision whether or not to prescribe drugs: these may be peculiar to the individual, being linked to previous training and attitudes', or broader factors concerned with the degree of promotional pressure from drug companies and the type of health system in use. These diverse factors are illustrated by the fact that drug utilization is known to vary widely both between practitioners in the UK2, and between countries in their use of certain drugs". Few studies have been made in developing countries, but the suggestion is that these variations are even more marked". There is evidence that EDP programmes do have an impact in rationalizing the use of drugs", Not withstanding the many wider factors and considerations, how can drug utilization be improved at a local level?
SHORT REPORTS
Autologous transfusion for elective surgery and caesarean section in Uganda Alberto Reggiori, L Belli, E Cocozza Hoima Hospital, PO Box 5, Hoima, Uganda TROPICAL DOCTOR,
1992, 22, 79-80
Blood transfusion can be life saving, but it is increasingly risky. The major dangers are transfusion reactions and the transmission of infection. Approximately 1-4070 of blood transfusion recipients develop alloantibodies to red cell antigens. The spread of the HIV epidemic is well known (in some urban areas almost 25070 of blood donors are HIV positive); even when testing is done, a few donors are virus positive but antibody negative (the 'window period') and HIV infection may be transmitted I. Hepatitis B or C occur in an estimated 7-15070 of blood transfusion recipients, and syphilis is also a recognized hazard-, The use of 'directed' donations from family members is common, but the incidence of transmitted infections is not reduced by making use of such hand-picked donors. In order to minimize these risks, when a blood transfusion is likely to be needed for a scheduled operation, transfusion of the patient's own predeposited blood, or autologous transfusion, can be valuable. This method can be employed for obstetric procedures. PATIENTS AND METHODS
In 1989, 60 patients scheduled to undergo elective surgery, including caesarean sections, were eligible to donate blood for autologous use in an experimental protocol in Hoima Hospital, a district hospital of West Uganda. Twenty-eight were Correspondence to: Dr A Reggiori, c/o AVSI, PO Box 6785, Kampala, Uganda
79 women in the third trimester of pregnancy with a planned caesarean section for different indications; the other 32 patients were admitted for various elective surgical procedures (total abdominal hysterectomy, subtotal thyroidectomy, laparotomy, etc.). Participation required a signed autologous blood order from the surgeon and a written consent from the patient. A patient was selected for preoperative donation if she/he was likely to need blood transfusion during or after surgery, and had a haemoglobin level greater than 10 g/dl. Age was not used as an exclusion criterion: the volume of blood donated was calculated according to the weight of the patient. A phlebotomy loss equal to 10070 of blood volume is very well tolerated", Patients with bacteraemia, malignant cancer, sickle cell anaemia (ss homozygotes) and severe cardiovascular disease were not eligible for enrolment. One week before surgery each patient donated one unit of blood; in five cases two units were donated by the same individual with an interval 6 days between donations, because considerable blood loss was expected. In these 5 cases the haemoglobin level was higher than 10 g/dl even after the first donation. Pregnant women donated one unit only, and were admitted to hospital at the time of venesection. The non-obstetric patients were admitted to hospital the day before surgery. Vital signs (including fetal monitoring) were verified before, during and after blood donations: no important changes or reactions occurred. The blood was collected in a bag containing CPD-adenine anticoagulant solution, labelled with the patient's name, ward, inpatient number and date of collection. All units were labelled 'for autotransfusion only' and stored in the solar refrigerator of our hospital. All the non-obstetric patients received a daily oral supply of ferrous sulphate (400 mg) and folic acid (1 mg) from the time they were judged eligible for the donation, until the time of surgery (average about 2 weeks). Almost all the pregnant women were already on supplements. Even autologous transfusion carries some blood administration costs and health risk. Autologous blood was therefore not infused automatically during surgery merely because it was available, but only if it was clinically indicated.
80
Tropical Doctor, April 1992
RESULTS
Only 50 patients out of 60 were autotransfused; in 10 cases the blood loss was negligible. A total of 55 autologous blood units were transfused (45 to one-unit donors and 10 to two-unit donors); out of 28 obstetric patients who previously donated blood, 23 were found in need of it and were transfused. The criteria for transfusion were mainly clinical, based on the amount of blood lost during the operation and on the monitoring of vital signs, keeping in mind the preoperative haemoglobin level. None of the transfused patients required an extra homologous blood transfusion. Blood not used for the donor was not used for transfusion in another patient. All donated blood was sent to Nakasero Blood Bank (Kampala) where, as routine procedure, it was tested for syphilis, hepatitis Band HIV: the donor was asked to report later to the hospital to discuss the results. Thirty patients (60070) were transfused intraoperatively and 20 (40%) postoperatively. No transfusion reactions occurred. DISCUSSION
CONCLUSION
The use of autologous blood donations is recommended even in obstetric patients when the need for blood can be foreseen, when the patient is able to donate and when there is sufficient time before the expected need. REFERENCES
2 3
Autologous blood transfusion has received recent international support especially in developing countries! for two main reasons; (a) concern about the transmission of infection and (b) concern about limited community availability of blood. Autologous
Improving drug utilization at local level- an opinion Duncan Mark Ross MB ChB MRCGP Micheweni Cottage Hospital, Pemba, Tanzania TROPICAL DOCTOR,
blood transfusion side-steps each of these concerns. There is ample documentation of the safety of this method for healthy adults and children; but experience with pregnant women is still limitedv>. During our experience of 60 patients provided with 65 units of blood, we encountered no adverse effects: observations of the 28 mothers and the results of fetal monitoring suggest that autologous blood donation is safe for selected pregnant women and their fetuses",
1992, 22, 80-81
'We must have more drugs!'. This is the almost universal request which is presented when visiting hospitals or dispensaries in the developing world. Without doubt the drug supply is limited due to financial restrictions, but much has certainly been done in recent years to improve and rationalize the supply of drugs, especially at the peripheral level, through the work of the Essential Drugs Programme Correspondence to: Dr D M Ross, Old Lavenders, Cuilfail, Lewes, Sussex BN7 2BE, UK
4 5
AIDS control programme - Ministry of Health, Republic of Uganda. Indication for blood transfusion in Uganda. Health Education Printing Unit, 1989 Kempen P. Autologous blood donation. lAMA 1988; 259:2404-5 The National Blood Resource Education Program Expert Panel. The use of autologous blood. lAMA 1990;263:414-17 Herbert W, Owen H, Collins M. Autologous blood storage in obstetrics. Obstet Gynaecol 1988;72: 166-70 Kruskall M, Leonard S, Klapolz H. Autologous blood donation during pregnancy: analysis of safety and blood use. Obstet Gynaecol 1987;70:938-40
(EDP). Perhaps, though, too much attention has been paid to the supply side and not enough to the demand side of the problem. Prescribers often fail to realize that it is they themselves who have written the prescriptions, and it is they who can control demand and the way that drugs are used. There are many factors which influence the decision whether or not to prescribe drugs: these may be peculiar to the individual, being linked to previous training and attitudes', or broader factors concerned with the degree of promotional pressure from drug companies and the type of health system in use. These diverse factors are illustrated by the fact that drug utilization is known to vary widely both between practitioners in the UK2, and between countries in their use of certain drugs". Few studies have been made in developing countries, but the suggestion is that these variations are even more marked". There is evidence that EDP programmes do have an impact in rationalizing the use of drugs", Not withstanding the many wider factors and considerations, how can drug utilization be improved at a local level?
