All Blood Counts

A manual for blood conservation and patient blood management

Thomas, Dafydd, Thompson, John, Ridler, Biddy

• Publisher: tfm Publishing Ltd
• Year: 2016
• ISBN:
  9781910079492
• Topic: Medicine
• Subtopic: Surgery & Surgical Medicine

This book gathers together the collected wisdom of an experienced group of practitioners from the world of blood conservation including surgeons, anaesthetists, haematologists, transfusion specialists, microbiologists, and legal advisors. Topics included are: an historical overview, transfusion-transmitted diseases, changing demographics and the projected impact on blood supplies, who needs transfusion, practicalities and tips - how to do it, the laboratory perspective, haemodilution, intra-operative cell salvage, surgical methods to minimise blood loss, anaesthetic methods to minimise blood loss, pharmacological methods to minimise blood loss, postoperative salvage, postoperative haemoglobin, cancer patients, patient consent and refusal, trauma management, patient ID and documentation, audit/clinical governance, the role of the Hospital Transfusion Team, education, national reports including European Directives, further information. Additional chapters will include pre-operative blood management, near-patient testing, the incidence and relevance of pre-operative anaemia, anaemia management in obstetrics, pre-operative anaemia in orthopaedics, haemostatic sealants, the effect of transfusion in cardiovascular surgery, transfusion alternatives.

Chapter 1

Historical perspective

Phil Learoyd

Honorary Historian, British Blood Transfusion Society; Past — Scientific and Technical Training Manager, NHS Blood and Transplant (NHSBT), (retired 2009), Leeds, UK

•“The discovery of ABO groups was not directly related to improving the safety of transfusion.”

•“Delays were commonly encountered regarding the implementation of new techniques.”

•“Blood provision — many changes have been implemented related to the needs of war.”

•“Blood safety has always been an issue.”

The provision of blood for transfusion

Introduction

Whilst the pioneering work of Jean-Baptiste Denys in France and Richard Lower in England dates from 1667, it was not until the beginning of the 19th Century that James Blundell began using blood transfusion primarily as a method for the treatment of postpartum haemorrhage. It was, however, to be the introduction of sterile methodologies, the development of practical anticoagulation and the discovery of the ABO blood group system at the beginning of the 20th Century that paved the way for more modern practical blood transfusion procedures.

However, it would be a mistake to assume that the resolution of these problems immediately led to improved technologies, increases in transfusion events and a reduction in the adverse effects of transfusion. This delay may be exemplified by the opening comment of the Ministry of Information film Blood Transfusion that was produced by Paul Rotha in 1941, 40 years after the discovery of the ABO blood groups: “Today, doctors and research workers are at last able to place blood transfusion therapy in its right perspective with other kinds of therapeutic medicine”.

Prior to the end of the First World War

Whilst the discovery of the ABO blood groups by Karl Landsteiner in 1901 is often quoted as the seminal moment in the development of safer blood transfusions, the original work was not conducted with this as its objective and blood transfusion did not in fact become the focus of Landsteiner’s work until after 1921 when he was working in America. In addition, it would be more than half a century later that the nature, origins and significance of ABO antibodies would be appreciated and the structure of the A and B antigens understood¹.

Effective anticoagulation of blood by citrate was identified independently by Hustin (1914), Agote (1915) and Lewisohn (1915). However, again, there were delays in its general acceptance and a move away from direct donor to recipient transfusion methods. It is probable that this was at least partly due to the fact that the use of citrated blood was associated with an increased frequency of febrile transfusion reactions, subsequently shown to be due to the bacterial contamination of the distilled water used to make the citrate anticoagulant as well as inadequately cleaned transfusion equipment, rather than to the citrate itself².

The American surgeon Oswald Robertson (1886-1966) set up a ‘blood depot’ and used citrate-dextrose blood stored in ice boxes at casualty clearing stations during the First World War³. One of his English surgical colleagues during the war, Mr Geoffrey Keynes, became convinced that blood transfusion not only saved the lives of soldiers who were in shock from blood loss but that it could also help in the provision of possible life-saving surgery. After the war when working at St Bartholomew’s Hospital in London, Keynes was surprised to find that his medical colleagues placed little importance on the value of blood transfusion⁴.

The nature of the trench warfare that was such a feature of the First World War meant that some medical units could be placed near to the front line enabling direct donor to patient transfusion to be used for wounded soldiers as required. However, the subsequent changes in the methods of waging war led to the need for greatly increased mobility. The use of citrate anticoagulant enabled blood to be donated, stored and transported to a wounded soldier at a distant location — which characterised transfusion in the Second World War.

After the First World War

Percy Lane Oliver (1878-1944) who was a co-founder of the Camberwell Division of the British Red Cross began to organise a voluntary (unpaid) blood donor panel in 1921 following a request by King’s College Hospital for volunteer blood donors. The Red Cross Blood Transfusion Service expanded rapidly under his leadership and was given official recognition by the British Red Cross in 1926. The blood of potential donors was grouped at any one of the hospitals that wanted to make use of the service. The volunteer donors also received a brief medical examination that basically ensured that they had no history of transmissible disease and that they had accessible veins. A ‘donor records’ index was created by Oliver, which included the donor’s name, address, blood group, and details of when and where the donor had been called to donate in the past. Donors were called wherever possible in ‘rotation’ though the decision to use a particular donor was based not only on their blood group but also on how far they had to travel to donate their blood. Oliver used a ‘transfusion feedback’ form that was completed by the surgeon who made the request for blood and he also issued a certificate to the donor for each donation given (Figure 1). In 1934, this scheme was extended to providing the donor with a medal together with a bar for every ten donations given (Figure 2). In addition, Percy Oliver with the help of Mr. Geoffrey Keynes also drew up rules for the treatment of donors and the method of blood extraction, which formed the basis of an article published in the Lancet in 1926⁵. It would, however, be incorrect to assume that all blood donors used in the UK during the 1920s and 1930 were volunteers, as many hospitals paid so-called ‘professional blood donors’; the fees for individual donations varied around the country⁶.

Figure 1. British Red Cross blood donation certificate (BBTS Archive).

Figure 2. British Red Cross blood donor medal (BBTS Archive).

Percy Oliver delivered lectures on the Society’s activities and also advised a large number of provincial hospitals in England on how to set up their own panel of voluntary non-remunerated blood donors during the 1920s and 1930s but was disappointed by the rather slow growth of these services outside London, which he attributed to a lack of facilities and to a shortage of surgeons with experience of taking and giving blood. At the first Congress of the International Society of Blood Transfusion (ISBT) in 1935, Dr. Arne paid tribute to the British Red Cross Service set up by Percy Oliver with the following statement: “It is the British Red Cross in London that the honour is due to having been the first in 1921 to solve the problem of the blood donor by organising a blood transfusion service available at all hours and able to send to any place a donor of guaranteed health and whose blood group has been duly verified. This service whose encouraging experiences were watched by Red Cross Societies of other nations served both as a model and inspiration for the organisation of similar services in seven other countries”⁷.

The April 1937 edition of the British Red Cross Society Blood Transfusion Service Quarterly Circular bulletin includes a report by Dr. F. Duran Jorda that identifies his experiences and problems in setting up a blood banking system in Barcelona to support the army and civilians during the Spanish Civil War (1936-1939). The report includes a discussion of the logistics of transporting refrigerated stored blood to wounded soldiers. Whilst there appears to have been some resistance during the 1920s-1930s in the UK to the use of stored donor blood, a number of other countries including America, Russia and Spain were routinely using stored blood. Possibly related to the changing events in Europe, the 1937 Congress of the ISBT held in Paris emphasised the need to have stocks of stored blood available in the event of war.

The outbreak of World War II changed the views and methods of blood provision using stored blood in England. A leading figure in facilitating this change was Dr. (later Dame) Janet Vaughan, who was convinced by Dr. Jorda’s argument that it was essential to store blood in emergencies. Using blood taken into sodium citrate solution, Dr. Vaughan and colleagues in 1939 showed that blood stored for several days was no more likely to cause reactions than blood taken into the same anticoagulant and used immediately⁸. Dr. Vaughan and her colleagues also produced comprehensive plans for the creation of four blood storage depots to serve London in the event of war. These plans were formally adopted by the government in April 1939. The directors in charge of these depots would later emphasise the importance of carefully cleaning all transfusion equipment, of using double-distilled water for the manufacture of citrate anticoagulant, and of employing an aseptic technique for taking donor blood.

In 1938, the War Office decided to set up an Army Blood Supply Depot to provide blood and plasma for its troops ‘anywhere in the world’. This was a fundamental development as far as World War II was concerned especially since Germany had decided on a system of bleeding donors ‘as required’ that resulted in blood shortages. The Army Blood Transfusion Service under the command of Dr. (later Sir) Lionel Whitby opened its own blood depot in Southmead Hospital, Bris...