Trauma continues to be the predominant cause of death for individuals up to the age of 44 years old. There were a reported 1.2 million deaths due to road traffic crashes in 2018 globally. And even though traumatic brain injury is the leading cause of death from trauma, exsanguination continues to play a significant role. Among patients who arrive at the emergency department for trauma, hemorrhage is the leading cause of death within the first hour. Within the first 24 hours of arrival to the emergency department nearly 50% of deaths are a result of hemorrhage.
Trauma patients also require large amounts of hospital resources and are responsible for using approximately 70% of all blood transfused at a trauma center. Transfusions also place a high burden on the cost of treatment. One study found in England found that in the traumatic patient nearly 12% of their total financial cost was due to transfusions.
Transfusion protocols from donated cross-matched blood remain the standard treatment for the hemorrhagic patient although it is not without risk and potential adverse side effects. Transfusion of donated blood carries the risk of disease transmission, citrate toxicity, hyperkalemia, hypothermia, hypomagnesemia, acidosis, sepsis, respiratory failure, and thrombotic complications. For these reasons, autotransfusion has widely been known as an alternative or adjunct to cross-matched transfusion therapy with fewer risks.
Autotransfusion has not always been a safe procedure. The first known documented procedure of autotransfusion was performed in 1818 by Dr. James Blundell. Dr. Blundell became frustrated by the loss of a patient due to uterine hemorrhage. Blood transfusions had been attempted for many years before Dr. Blundell, but he was the first to attempt autotransfusion from experimentation with canine specimens. Later he would try his procedure on humans but not without risk. The estimated mortality rate from his procedures was approximately 75%. Thanks to modern advancements in filtration and sterile technique, autotransfusion is widely accepted as a relatively safe procedure.
The indications for autotransfusion are relatively straightforward and merit consideration in every trauma patient with active extravasation. Often the more important question is to consider the contraindications.
For autotransfusion to be a worthwhile procedure, there should be signs of significant blood loss, typically greater than 1000 mL. Additional indications include the need for immediate blood, inability to obtain or provide cross-matched blood, and if the patient is unwilling to receive cross-matched blood.
Although the indications may be relatively straightforward, it is important to note that there are numerous contraindications and if ignored can result in serious consequences. The first question is whether or not the source of blood has suffered contamination. Contamination can present as an infectious vs. noninfectious source. Infectious contamination can occur to any penetrating chest wound that may have violated the diaphragm and involved the gastrointestinal tract. Careful inspection of the wound site is necessary if possible, before the use of collected blood and if there is any question to its sterility, cross-matched blood should be used instead. Another source of contamination can include non-infectious sources. The use of blood from a site where a sterile solution may have mixed with the blood (e.g., iodine, sterile water, alcohol, irrigation solutions, or chlorhexidine) should be avoided. It should also worth noting that any form of cavity introduced to hemostatic agents such as thrombin should also not be used.
If it has been determined that the source of autotransfusion is contamination-free, there should be careful consideration for underlying pathology. If there is evidence of coagulopathy or evidence of disseminated intravascular coagulopathy (DIC), this requires management with specific blood component therapy instead of autotransfusion.
There are three types of autotransfusion systems including in-line, self-filling, and continuous. In-line involves the use of a blood bag that collects the fluid for later use. The self-filling bag utilizes a vacuum to help improve the flow of fluid into the bag. Finally, the continuous autotransfusion uses an infusion pump and filter to place the blood directly back into the patient’s venous access. The advantage of a continuous system is that it is faster to transfuse, requires less staffing involvement after initial set up, and poses less risk of contamination. Continuous autotransfusion is often the method in the operating room, but many emergency departments do not have this type available and are more likely to utilize an in-line technique. There are various manufacturers of autotransfusion systems. Facilities should contact their supplier to see which system is available in your hospital as each may require additional, product-specific training.
The following equipment will be required to perform in-line autotransfusion.
Autotransfusion is most commonly used in the emergency department in trauma patients with evidence of a significant hemothorax. If the patient’s signs and symptoms display evidence of hemothorax preparation of autotransfusion should begin immediately before chest tube placement. If a chest tube is placed without the autotransfusion collecting bag in place much of the blood will be lost during chest tube placement and may no longer be a viable option.
Preparation for a chest tube is common in other literature, but it is vital to maintain a strict sterile technique including sterile and gloves, face mask with an eye shield, and a cap. The area of skin should undergo prepping with iodine or chlorhexidine solution, and a sterile drape should be in place. A sterile setup is an essential factor in avoiding complications of infection.
The first step should be attaching the autotransfusion bag to the chest drain. An anticoagulant solution should be used to prime the system, and a steady drip of the anticoagulant solution should be mixed with the collected blood. Two types of anticoagulation are options: heparin and citrate. Heparin requires first mixing with normal saline before administration with blood, whereas citrate can be mixed directly in with the collected blood. Heparin does have the added risk of causing heparin-induced thrombocytopenia, and thus citrate is preferred over the use of heparin by many providers.
Heparin Anticoagulation: A heparin anticoagulant solution can be formulated by mixing 30000 units heparin with 1000 mL normal saline.  The collecting back should initially be primed with at least 100 mL of the anticoagulant solution prior to collecting blood and re-primed for each collecting bag. While collecting the blood, the anticoagulant solution should be running at 13 to 15 mL per 100 mL of collected blood. When approximately 500 mL of blood has been collected, it is ready to be reinfused.
Citrate Anticoagulation: Citrate phosphate dextrose (CPD) can be added directly to the collected blood at a ratio of 1 mL of CPD to every 7 mL of blood. Another common method is to mix 60 mL of CPD into the autotransfusion bag prior to collecting the blood and then stop collection once the bag reaches 500 mL.
A microfilter should be attached to the tubing and air must be removed from the autotransfusion bag. It is important to note that a new filter and tubing is necessary for each autotransfusion bag. The collected blood can be stored at room temperature for up to six hours as needed provided that collection took place under aseptic conditions.
There are various methods of performing autotransfusion with different techniques within the operating room and emergency room. The goal of autotransfusion remains the same, to maintain a sterile field, prevent clotting of the collected blood, filtration of the blood, and administration to the patient. The procedure should not take more than a few minutes to prepare and the typical intent as an alternative or interim to alternative treatments. It is essential to familiarize oneself with the equipment provided at the treating facility so as to minimize the risks of infection and other complications.
The most common complication of autotransfusion is blood loss if not properly connected. A common finding is chest tube placement in which blood is found to be expressed and then wasted. The more serious complication includes blood contamination resulting in infection. This issue is avoidable by using a sterile procedure for chest tube placement and careful handling with the lines and equipment. A continuous autotransfusion system can also help reduce the risk of infection although not readily available in most emergency departments. Other less common complications that merit consideration include hemodilution, hemolysis due to suction or degradation, air embolism, contaminated of activated leukocytes, and thrombocytopenia. Overall complications are avoidable with the use of sterile technique and if less than 3000 mL of blood is reinfused.
An autotransfusion is a tool that should be considered in every trauma patient while in the emergency department. It can also be used in patients undergoing surgery or any patient with anticipated blood loss without contraindications. It has the benefit of reduced risk to the patient for transfusion reactions as well as possible cost-saving benefits. Autotransfusion can be used in conjunction with cross-matched blood and can help provide a temporizing measure while waiting for cross-matched blood to arrive. The setup is relatively straightforward and does not require any significant extra time or resources.
An interprofessional team approach to healthcare can help achieve the best possible outcomes in some of the highest mortality scenarios. Hemorrhage is the number one cause of death in the presenting trauma patient within the first hour, and often cross-matched blood is either not available or painfully delayed. Autotransfusion can provide a segway towards stabilization of the patient and often presents with fewer risks and fewer delays compared to cross-matched blood. Autotransfusion requires a team approach to ensure the procedure is performed effectively, safely, and with as few complications as possible. This interprofessional team approach includes providers and nursing, both in preparation and execution of the procedure. [Level V]
Before autotransfusion, the following should be in place:
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