Table of Contents

HK J Paediatr (New Series)
Vol 1. No. 1, 1996

HK J Paediatr (New Series) 1996;1:67-69

Original Article

Autologous Transfusion for Paediatric Marrow Donor

HY Chan, SY Ha, ACW Lee, CF Chan, G Cheng, YL Lau


Abstract

Autologous blood was pre-deposited for 11 children who were marrow donors for siblings undergoing bone marrow transplantation for haematological and oncological conditions. Their age ranged from 2 to 15 years (mean 8.4 years) and their body weight from 12.5 to 47 kg (mean 27.1 kg). Ten donors had single collection and one had two. The collection period varied between 7 to 21 days before marrow harvest. Volume of autologous blood harvested ranged from 100 ml to 450 ml with a total of 6.52 ml/kg to 14.5 ml/kg body weight (mean 9.49 ml/kg). Nine donors received autotransfusions during or after marrow harvest. No adverse reaction was observed. Two donors were not transfused. Only one donor required additional allogeneic blood transfusion. Our autologous transfusion policy minimized the risk of allogeneic blood exposure for marrow donor. This policy is feasible in the paediatric population.

Keyword : Autologous transfusion; Bone marrow transplantation; Donor


Abstract in Chinese

Introduction

The risk of transfusion-transmitted infection is now substantially reduced since blood products are screened for increasing number of infective agents. However, the risk cannot be completely eliminated.1 Another disadvantage of using allogeneic blood is that recipient may be alloimmunised by the donor's blood resulting in formation of alloantibodies against red cells, platelets, white cells or plasma protein antigens. The recipient may encounter difficulties in future transfusion. Therefore exposure to allogeneic blood should be avoided whenever possible. It is in particular important for the marrow donors who are normal and healthy.

Autologous transfusion is defined as the collection and reinfusion of a patient's own blood.2,3 Autologous transfusion has been practiced in some centers for selected adult patients undergoing elective surgery in order to minimize the utilization of allogeneic blood. There are essentially three methods of autologous transfusion but the most widely practiced is pre-deposit whereby blood is collected before blood-demanding operation and infused at the operation. The other methods are intraoperative salvage and normovolaemic haemodilution. There are widely accepted standards, guidelines and regulations for patient selection as well as for the procedure and transfusion of blood collected by these techniques. 4-6

In contrast to adult subjects, there is limited experience with paediatric population.7-9 It is the policy of our department to organize autologous blood transfusion by pre-deposit method for paediatric marrow donor when blood transfusion is anticipated. This survey reviewed our experience of autologous transfusion for paediatric bone marrow donors between 1991-1994.

Methods

Only marrow donors who were anticipated to require blood transfusion during harvest would be considered for autologous transfusion program. The children were then assessed for the suitability of pre-deposit. They should have normal haemoglobin level, good sized veins for blood collection and were expected to be co-operative. Consent was obtained from patient's parent.

EMLA cream was applied prior to the collection. An angiocath of at least 19G was inserted to ante-cubital vein of the donor. A heparin lock (jelco) was connected to the angiocath. The 16G needle attached to the collection bag was inserted to the jelco (Figure). In a few circumstances, the latter could be inserted directly to the ante-cubital vein. The collection pack was weighed before, during and after collection to ensure that an accurate volume was collected.

Blood from children weighing between 20 and 30 kg was collected into 250 ml paediatric blood pack. A standard adult blood packs (300 to 400 ml) was used for children weighing between 30 and 50 kg. An appropriate proportion of anitcoagulant was discarded first if the blood to be collected was less than 300 ml. About 10 ml/kg of autologous blood was pre-deposited for each collection. Donation was done 7 to 21 days before surgery. Iron supplement was prescribed routinely afterwards. Correct identification of autologous blood is required to avoid mistake and transfusion error. Blood collected was stored in blood bank for later use.

Fig Modified method for blood collection from small children with small veins. A 19G angiocath was put in and connected to a Jelco. The 16G needle of the collection bag then drained blood from the Jelco.

Result

Autologous blood was pre-deposited in eleven paediatric bone marrow donors (7 male and 4 female). They were donors for siblings who suffered from Cooley's anaemia (7), severe combined immunodeficiency (1), dyskeratosis congenita (1), Diamond-Blackfan syndrome (1) and acute myeloid leukaemia (1). Their age ranged from 2 to 15 years (mean 8.4 years) and their body weight 12.5 to 47 kg (mean 27.1 kg).

Haemoglobin level before collection of autologous blood varied from 9.8 to 13.9 g/dl. The ratio of donor's weight to that of recipient is 0.63 to 4.85 (mean 1.64). Most of the donors had one single collection except one donor who had two collections. The collection period varied between 7 and 21 days before marrow harvest. Volume of autologous blood collected ranged from 100 ml to 450 ml.

Volume of marrow harvested per body weight varied from 7.5 ml/kg to 31.2 ml/kg (mean 16.1 ml/kg). That was equivalent to 10.8% to 44.6% of the donor's estimated total blood volume. Nine marrow donors received autotransfusions during or after marrow harvest. There was no adverse reaction observed. Two donors were not transfused. Only one donor required additional allogeneic blood transfusion.

Discussion

Since autologous blood transfusion was introduced, the application in selected adult patients resulted in reduction in many adverse effects of transfusion. However, there were not much data in paediatric population. We documented such technique for children was safe and convenient. Among several methods of autologous blood harvest, the pre-deposit method is the most economical and simple. The intraoperative autologous blood salvage and acute normovolemic haemodilution require expensive equipment, and not feasible for procedures such as bone marrow harvesting. There were reports describing alternative approaches such as the use of erythropoietin10 after autologous blood donation, and post-harvest separation of RBC and reinfusion.9

There are still limitations to pre-deposit autologous blood in paediatric age group; such as anxiety and fear of phlebotomy, problem with venous access, non-availability of small paediatric blood donation pack, complications including pain, haematoma or syncope and wastage of unused blood.

To solve these problems, several modifications were used. For example, careful explanation of the procedure before phlebotomy to the donors so as to get their co-operation. Television was provided during the whole procedure. EMLA cream was used prior to phlebotomy so as to numb the sensation of pain. Appropriate sized angiocath was used instead of the 16 G needle attached to the donation pack. Small paediatric blood donation pack was used for young children. The donor will proceed to the autologous blood donation only when blood transfusion is anticipated. This was to avoid wastage of blood and resources. To conclude, our autologous transfusion policy could minimize the risk of allogeneic blood exposure for paediatric bone marrow donors. This was a safe, simple and economical procedure.


References

1. Dodd RY. The risk of transfusion-transmitted infection. [editorial]. N Engl J Med 1992;327:419-21.

2. Autologous Transfusion Working Party of the National Blood Transfusion Service for the Blood Transfusion Task Force. Autologous transfusion. Transfusion Medicine 1993;3:307-16.

3. Contreras M, Chapman CE. Autologous transfusion and reducing allogeneic blood exposure. Arch Dis Child 1994;71:105-7.

4. Widmann FK, editor. Standards for blood banks and transfusion services, 15th ed. Bethesda American Association of Blood Banks, 1993.

5. Parkman PD. Guidance for autologous blood and blood components. Office of the Director, Centre for Biologics Evaluation and Research, Food and Drug Administration, March 15, 1989.

6. Parkman PD. Guidance for autologous blood and blood components, addendum. Office of the Director, Centre for Biologics Evaluation and Research, Food and Drug Administration, Feb 12, 1990.

7. Louis De Palma, Naomi L.C. Luban. Autologous blood transfusion in paediatrics. Pediatrics 1990;85:125-8.

8. Tasaki T, Ohto H, Noguchi M, et al. Autologous Blood Donation Elective Surgery in Children. Vox Sang 1994;66:188-93.

9. Chan KW, Herd SL, Stanley CE, et al. Autologous Blood Transfusion for Paediatric Bone Marrow Donors. Bone Marrow Transplant 1992;9:365-7.

10. Goodnough LT, Price TH, Friedman KD, et al. A phase III trial of recombinant human erythropoietin therapy in nonanemic orthopedic patients subjected to aggressive removal of blood for autologous use: dose, response, toxicity, and efficacy. Transfusion 1994;34:66-71.

 
 

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