When acute normovolemic hemodilution is used for surgery lasting over 8 hours, should the collected blood be kept at room temperature and reinfused within 8 hours (to comply with AABB Standards) or should it be refrigerated until needed?

A transfusion medicine physician who works in the Pacific Northwest reports that on page 14 in the First Edition of Standards for Perioperative Autologous Blood Collection and Administration, it is stated that intraoperatively collected blood which is kept at room temperature expires 8 hours from the start of the collection. This implies that blood collected for acute normovolemic hemodilution (ANH) must be reinfused within 8 hours, or refrigerated for longer storage. In many circumstances her group performs ANH for Jehovah's Witnesses and that some of these cases are extremely long, sometimes as long as 20 hours. This is especially true of their neurosurgical cases where reinfusion of autologous blood containing functioning platelets is extremely important. The problem they face is that if they refrigerate the intraoperatively collected blood, in their opinion, the function of the platelets in the autologous blood would be impaired, but if they reinfuse the intraoperatively collected blood before the eighth hour of the surgery, giving the blood back to the patient that early in the case defeats the purpose of ANH to a large extent. The risk of bacterial contamination from keeping the product beyond 8 hours at room temperature would seem to be extremely low in any case, because the blood is collected in an aseptic fashion and in no circumstance would be kept for more than 24 hours. The inquiring physician wants to know if colleagues are refrigerating all ANH blood collected within 8 hours for cases that are longer than 8 hours, or if colleagues are reinfusing the blood before the 8-hour deadline for room temperature storage? Are Jehovah's Witness patients approached differently?

The following responses have been received.

1. A colleague in Saudi Arabia suggests that a system called "Compocool® plates" (by Fresenius Company, Germany) could be used to rapidly cool collected blood units to a controlled 20C. For more details see the following:
   • Fretz, C et al. ISBT 2001 (abstract)
   • Fresenius Kabi website
   According to the responding colleague, the Compocool® plate system is widely used in the EU and approved for overnight storage of whole blood units at a controlled 20C, to rationalize the work in component sections.
   
   Editor's Note: Before any facility in the USA uses such equipment it would be prudent to confirm that the equipment is FDA approved for the intended use.
   
   Outside the USA, this equipment is used to store units overnight in a controlled 20C environment. According to the responding colleague, such equipment should be useful in relation to units obtained by normovolemic hemodilution if a surgery carries beyond the 6-8 hours, because platelets obtained from such units are of acceptable quality. He concludes by stating that his facility is AABB-accredited, and that their blood bank and transfusion service is re-validating the Compocool plates on platelets etc. in preparation for their next AABB inspection which is set for 2004.

ADDENDA Mar. 11, 2003

2. An anesthesiologist in Texas reports that (in his opinion) the risk of bacterial growth in whole blood collected with acute Normovolemic Hemodilution (ANH), kept in an operating room at 20 C is a theoretical concern. He says "theoretical" because he is unaware of anyone who has studied this issue. (Editor's Note: References germane to this point are solicited.) However, he concedes that it is reasonable to conclude that one cannot store blood indefinitely at room temperature. He is also of the opinion that platelet function decreases in response to temperature change, and even storing whole blood at ambient temperature is associated with decrements in platelet function, based on a personal communication (Tanox, Inc. Houston, Tx). He adds that one of the advantages of ANH is that it enables preservation of platelets and coagulation factors in the collected autologous blood. Based on the aforementioned, his recommendation at present, taking into consideration the limitations of "current" technology, is that if ANH is being used for a surgical procedure that runs in excess of 10-12 hours, a blood component sequestration device such as a Medtronic Sequestra™ Autotransfusion System, might be useful. (Editor's Note: Colleagues are encouraged to share their experiences with this and similar devices.) If one uses such a device, the platelet concentrate and plasma fraction can be maintained at room temperature while the red blood cell components can be cooled and stored. The actual time of reinfusing platelet and plasma fractions would need to be coordinated with the surgical procedure.

Submit comments to the e-Network Forum at enetworkforum@cbbsweb.org

Ira A. Shulman, MD
CBBS e-Network Forum Senior Editor & Moderator

W. Tait Stevens, MD
CBBS e-Network Forum Editor & Moderator

Elizabeth M. St. Lezin, MD
CBBS e-Network Forum Associate Editor & Moderator