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Introduction ⬇

Perioperative autologous blood transfusion is the collection and transfusion of the patient’s own blood collected intraoperatively from the operative site or from an extracorporeal circuit. One benefit of this procedure is that the patient can receive autologous blood, thereby, minimizing the need for allogenic blood transfusion.1 , 2 It may be used during vascular or orthopedic surgery (because considerable bleeding can result from these surgeries) and during the treatment of traumatic injury. perioperative autologous blood transfusion is contraindicated when instances occur that increase the risk of blood contamination with bacteria, tumor cells, or other harmful substances.1

Various types of devices are available to retrieve blood from the operative site; apheresis devices are available to prepare the components intraoperatively. (See Autologous blood recovery systems.) Follow the manufacturer’s instructions when collecting, storing, and transfusing the patient’s blood using an autologous blood recovery system.1 , 3

Equipment ⬆ ⬇

Equipment

Gloves • vital signs monitoring equipment • antiseptic pad (chlorhexidine-based, povidone-iodine, or alcohol) • 3-mL syringe • 250-mL bag of normal saline solution • blood administration set with microaggregate filter • IV pole • wall suction with pressure gauge • autologous blood recovery system device with necessary supplies; for a Cell Saver® 5+ unit, suction tubing and collection kit (an autotransfusion drain usually has stand-alone functioning) • AUTOLOGOUS BLOOD label • Optional: mask with face shield or mask and goggles, gown, labels, 14G to 24G venous access catheter and insertion equipment.

Preparation of Equipment ⬆ ⬇

Preparation of equipment

Inspect all IV equipment and supplies; if a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.5

Implementation ⬆ ⬇

Implementation
  • Verify the practitioner’s order for the rate of reinfusion and the amount of blood to be reinfused.
  • Confirm that the informed consent has been obtained and that the signed consent form is in the patient’s medical record.6 , 7 , 8 , 9 , 10
  • Notify the perfusionist to set up the autologous blood recovery system device and connect the tubing to the setup following the manufacturer’s instructions. (Note that the person responsible for this step may vary by facility. A perioperative nurse or anesthesia care provider may set up the device in some facilities.)
  • Perform hand hygiene.11 , 12 , 13 , 14 , 15 , 16 , 17 , 18
  • Confirm the patient’s identity using at least two patient identifiers.19
  • Perform hand hygiene.11 , 12 , 13 , 14 , 15 , 16 , 17 , 18
  • Put on gloves and, as needed, other personal protective equipment to comply with standard precautions. 20 , 21 , 22 , 23 , 24 , 25
  • Make sure the collection chamber and the blood transfer bag are clearly marked with the patient’s first and last name, identifying numbers, date and time of the collection initiation, and an AUTOLOGOUS BLOOD label. If applicable, include the time of, or condition for, expiration.1 , 3 , 26
  • Obtain the patient’s vital signs before the transfusion to serve as a baseline for comparison. 3
  • Ensure that the patient has adequate venous access, either peripheral or central, with an appropriate-size catheter (14G to 24G).27 Verify patency by aspirating for a blood return. Insert an IV catheter if necessary. (See the "IV catheter insertion and removal" procedure.)
  • Insert one spike of the standard Y-type blood administration set into the 250-mL bag of normal saline solution. Close all clamps and hang the blood administration set on an IV pole.
  • The anesthesia care provider, perioperative nurse, or perfusionist will start blood collection according to the device manufacturer’s instructions. (Some devices process and centrifuge the blood automatically.)
  • Monitor the patient’s vital signs closely during the blood collection for signs of hypotension. Hypotension may occur as the result of hypovolemia.
  • Monitor the status of the blood collection.
  • When sufficient blood has been collected, spike the blood transfer bag with the open port of the blood administration set, remove all air from the blood transfer bag, and hang the bag on the IV pole.
  • Open the clamp from the normal saline solution and prime the filter and tubing to remove all air from the tubing. Close the clamp from the normal saline solution.
  • Open the clamp from the blood transfer bag to the drip chamber of the blood administration set and prime the filter 3 and tubing with blood to remove all air from the tubing.
  • If you’re using a postprocedure transfusion device, follow the manufacturer’s instructions to properly connect the device to the patient. (Staff members should receive training on all transfusion devices before use.)
  • Perform a vigorous mechanical scrub of the needleless connector for at least 5 seconds using an antiseptic pad. Allow it to dry completely.28 , 29
  • Attach the blood administration set to the venous access device and trace the tubing from the patient to its point of origin before beginning the transfusion to make sure it’s connected to the proper port. 30 Route the tubing in a standardized direction if the patient has other tubing and catheters that have different purposes. Label the tubing at the distal (near the patient connection) and proximal (near the source container) ends to reduce the risk of misconnection if multiple IV lines will be used.31
  • Begin the transfusion, as ordered.
  • Monitor the patient throughout the procedure.2
  • Obtain vital signs during the transfusion at an interval indicated by the patient’s condition or at a frequency determined by your facility.27
  • Make sure the transfusion is completed in the surgery suite or postanesthesia care unit within the time period defined by the system used1 or within your facility’s recommended time frame.
  • Obtain the patient’s vital signs after the transfusion is complete.3
  • Disconnect the blood recovery system from the patient’s drains, or have the anesthesia care provider, perioperative nurse, or perfusionist do so.
  • Recheck the laboratory data for coagulation profile, hemoglobin, hematocrit, and calcium levels after the transfusion is complete, or as the practitioner orders. Notify the practitioner of critical test results within your facility’s established time frame so that the patient can be treated promptly. 32
  • Discard used supplies in appropriate receptacles.20 , 21 , 33
  • Remove and discard your personal protective equipment.20 , 21 , 33
  • Perform hand hygiene.11 , 12 , 13 , 14 , 15 , 16 , 17 , 18
  • Document the procedure.34 , 35 , 36 , 37 , 38

Special Considerations ⬆ ⬇

Special considerations
  • If multiple units are to be transfused, change the blood administration set and filter after the completion of each unit or every 4 hours. If more than one unit can be infused within 4 hours, the administration set can be used for 4 hours.27
  • Be aware that you may need to replace clotting factors, fresh frozen plasma, or platelets if you’re transfusing large volumes of blood.1
  • Certain religious groups refuse blood transfusions because of their beliefs. However, many of these groups permit autologous blood transfusion if it’s kept in a continuous closed circuit.
  • The Joint Commission issued a sentinel event alert related to managing risk during transition to the new International Organization for Standardization tubing standards; the new standards were designed to prevent dangerous tubing misconnections, which can lead to serious patient injury and death. During the transition, be sure to trace the tubing and catheter from the patient to the point of origin before connecting or reconnecting any device or infusion, at any care transition (such as to a new setting or service), and as part of the hand-off process; route tubes and catheters having different purposes in different, standardized directions; label the tubing at both the distal and proximal ends (when there are different access sites or several bags hanging); use tubing and equipment only as intended; and store medications for different delivery routes in separate locations.31

Complications ⬆ ⬇

Complications

More complications are associated with the reinfusion of filtered, unwashed blood than with the transfusion of filtered, washed blood. These complications include fever, hypotension, myocardial infarction, infections, particulate and air embolism, and thrombocytopenia. Complications are more pronounced when the time from salvage to transfusion is greater than 6 hours. (See Managing problems of autologous blood transfusion.)

Documentation ⬆ ⬇

Documentation

Document the time the collection began, the time the transfusion started and ended3, and the venous access site used for the transfusion. Include the patient’s vital signs before and after transfusion.3 Note the amount of blood collected and transfused, the name of the person who administered the blood, and the system used.1 , 3 Document any adverse reactions, the date and time the practitioner was notified, prescribed interventions, and the patient’s response to those interventions.1 Also document any posttransfusion laboratory studies obtained.3 Document teaching provided to the patient and family (if applicable), their understanding of the teaching, and any need for follow-up teaching.35

References ⬆

  1. AABB. (2018). Primer of blood administration.Bethesda, MD: AABB. (Level VII)
  2. American Society of Anesthesiologists. (2015). Practice guidelines for perioperative blood management:

    An updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management

    . Anesthesiology, 122, 241–275. https://pubs.asahq.org/anesthesiology/article/122/2/241/12287/Practice-Guidelines-for-Perioperative-Blood (Level VII)
  3. AABB. (2019). Standards for perioperative autologous blood collection and administration (8th ed.). Bethesda, MD: AABB. (Level VII)
  4. Haemonetics Corporation. (2012). Cell Saver® 5+ standard of care in intraoperative autotransfusion. https://pdf.medicalexpo.com/pdf/haemonetics/cell-saver-5-standard-care-intraoperative-autotransfusion/78504-168063.html
  5. Standard 12. Product evaluation, integrity, and defect reporting. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 344, S45–S46. (Level VII)
  6. The Joint Commission. (2021). Standard RI.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  7. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Patient’s rights. 42 C.F.R. § 482.13(b)(2)

    .
  8. Accreditation Association for Hospitals and Health Systems. (2020). Standard 15.01.11. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  9. DNV GL-Healthcare USA, Inc. (2020). PR.2.SR.3. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  10. Standard 9. Informed consent. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S37–S39. (Level VII)
  11. The Joint Commission. (2021). Standard NPSG.07.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  12. Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings:

    Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

    . MMWR Recommendations and Reports, 51(RR-16), 1–45. https://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf (Level II)
  13. World Health Organization. (2009). WHO guidelines on hand hygiene in health care:

    First global patient safety challenge, clean care is safer care

    . https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (Level IV)
  14. Guideline for hand hygiene. (2020). In WoodA. (Ed.), Guidelines for perioperative practice:

    2020 edition

    . Denver, CO: AORN, Inc. (Level VII)
  15. Standard 16. Hand hygiene. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S53–S54. (Level VII)
  16. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Infection control. 42 C.F.R. § 482.42

    .
  17. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.21. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  18. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  19. The Joint Commission. (2021). Standard NPSG.01.01.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  20. SiegelJ. D., et al. (2007, revised 2019). 2007 guideline for isolation precautions:

    Preventing transmission of infectious agents in healthcare settings

    . https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf (Level II)
  21. Occupational Safety and Health Administration (2012). Bloodborne pathogens, standard number 1910.1030. https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS (Level VII)
  22. Accreditation Association for Hospitals and Health Systems. (2020). Standard 07.01.10. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  23. DNV GL-Healthcare USA, Inc. (2020). IC.1.SR.2. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)
  24. Guideline for transmission-based precautions. (2020). In WoodA. (Ed.), Guidelines for perioperative practice:

    2020 edition

    . Denver, CO: AORN, Inc. (Level VII)
  25. Standard 17. Standard precautions. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S54–S55. (Level VII)
  26. The Joint Commission. (2021). Standard NPSG.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  27. Standard 64. Blood administration. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S135–S137. (Level VII)
  28. Standard 36. Needleless connectors. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S68–S70. (Level VII)
  29. MarschallJ., et al. (2014). SHEA/IDSA practice recommendation:

    Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update

    . Infection Control and Hospital Epidemiology, 35, 753–771. https://www.jstor.org/stable/10.1086/676533#metadata_info_tab_contents (Level I)
  30. U.S. Food and Drug Administration. (2017). Examples of medical device misconnections. https://www.fda.gov/medical-devices/medical-device-connectors/examples-medical-device-misconnections
  31. The Joint Commission. (2014). Sentinel event alert 53:

    Managing risk during transition to new ISO tubing connector standards

    . http://www.jointcommission.org/assets/1/6/SEA_53_Connectors_8_19_14_final.pdf (Level VII)
  32. The Joint Commission. (2021). Standard NPSG.02.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  33. Standard 21. Medical waste and sharps safety. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S60–S62. (Level VII)
  34. The Joint Commission. (2021). Standard RC.01.03.01. Comprehensive accreditation manual for hospitals. Oakbrook Terrace, IL: The Joint Commission. (Level VII)
  35. Standard 10. Documentation in the health record. Infusion therapy standards of practice (8th ed.). (2021). Journal of Infusion Nursing, 44, S39–S42. (Level VII)
  36. Centers for Medicare and Medicaid Services, Department of Health and Human Services. (2020). Condition of participation:

    Medical record services. 42 C.F.R. § 482.24(b)

    .
  37. Accreditation Association for Hospitals and Health Systems. (2020). Standard 10.00.03. Healthcare Facilities Accreditation Program:

    Accreditation requirements for acute care hospitals

    . Chicago, IL: Accreditation Association for Hospitals and Health Systems. (Level VII)
  38. DNV GL-Healthcare USA, Inc. (2020). MR.2.SR.1. NIAHO® accreditation requirements, interpretive guidelines and surveyor guidance-revision 20.0. Milford, OH: DNV GL-Healthcare USA, Inc. (Level VII)