Recently several colleagues have inquired what others do when asked to go above and beyond the usual practice of collecting autologous and directed blood donations. The examples below illustrate such requests.

A colleague wanted to know if anyone had experience with drawing autologous units through a Percutaneous Intravenous Catheter (PIC) line. This inquiring colleague's hospital is treating an IgA-deficient obese patient who is scheduled for gastric bypass surgery. The patient has poor vascular access which precludes using an antecubital vein for the collection of a unit of whole blood. The patient's physician wishes to place a PIC line, to 'allow' the blood donor center to be able to draw an autologous unit for the patient, followed by removal of the PIC line. The autologous blood donation process would be repeated a week later as the physician wants to have at least two units of blood available for the surgery. The patient in question is morbidly obese, which is one of the reasons for the limited venous access. The inquiring colleague did not mention whether this IgA-deficient patient had anti-IgA antibodies.

A second example pertains to a colleague who wonders about collecting directed donor FFP from a patient's wife via plasmapheresis for the husband's upcoming surgery. The husband has Factor XI deficiency and has had excessive bleeding during a previous surgery. However, in order to collect the plasma from the wife who has poor antecubital veins, a central line would need to be placed. The inquiring colleague is concerned about the placement of a central line for a plasma donation. He is also concerned about the line being left in place for days in order to collect additional plasma donations, or if limitations in antiseptic technique and concern over bacterial colonization of an indwelling catheter would require that a new line be placed for the second draw 4-5 days later.

The following response has been received.

ADDENDA Oct. 15, 2003

1. A transfusion medicine physician in New York comments that in both the described scenarios, it seems to him that the risk of the procedures to the donor far outweighs any likely medical benefit to the recipient, even in the autologous situation. He shares this opinion as a strong advocate of autologous techniques. He states the following: "Presumably the physicians and/or patients have an unrealistic and exaggerated notion of the risks of allogeneic transfusions. Likewise I am of the opinion that they are underestimating the very real risks of central line placement (infection, bleeding, thrombosis, and death being more frequent complications of central line placement compared with the frequency of serious complications from allogeneic transfusion). The directed donation is an allogeneic transfusion of blood from a woman who has been exposed to her husband's plasma proteins so there is a small, but not zero risk that she has antibodies that could cause anaphylaxis, thrombocytopenia, neutropenia or other immune complications when her plasma is transfused to him." He continues with his opinion saying: "Thus I would advise firmly against both courses of action. If the patient, doctor and donor insisted on going ahead, I'd have some sort of medical release/informed consent drafted by our risk management folks absolving myself, the hospital and the blood bank of any responsibility for non-negligent adverse consequences, both to discourage the ill-advised procedures and emphasize the degree to which I disagreed with the course of action. Physicians and patients who want to do extraordinary, poorly conceived procedures out of the scope of accepted medical practice should bear the burdens of legal risk, not those who object to the decision."

ADDENDA Oct. 16, 2003

2. Dr. Ronald Domen (Penn State) agrees with the comments from New York. He states: "Subjecting allogeneic donors to central line placement in this case would not justify the risks to the donor and I would not support such an approach - except in an extraordinary situation and this case does not seem to meet that criteria. Additionally, PIC line placement - while not as risky as a central line - is not without some risk. I would also be concerned about sterility in placing the PIC line since these are usually placed by non-blood bank personnel and I doubt that the usual skin prep procedure would be up to blood bank standards."

ADDENDA Dec. 29, 2007

3. A physician affiliated with a blood collection center in Northern California reports that occasional therapeutic donors with hemochromatosis may have very difficult or no venous access especially if there is IV drug abuse. The physician's blood bank does not use a "Vein Finder" or "Ultra Sound" equipment to localize vessels. Consequently such individuals are referred back to their personal physician with advice to direct them to a local hospital infusion program for better modes of venous access. The inquiring physician wants to know what other centers do for therapeutic phlebotomy cases where venous access is unachievable, even using ultra sound or vein finders. She would like to know if any blood bank or center would do therapeutic phlebotomy with such devices as PICC lines, central lines (skin-tunneled venous catheters) or implantable ports. If so, does the center have its own staff do the venous access or outsource for venous access?

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