The New York Times - Tuesday, December 2, 1986
Lawrence K. Altman, M.D.

When Loretta Norrell's doctor recommended back surgery, he told her to donate blood ahead of time so that if she needed a transfusion she would get the safest kind -her own. In her hometown of Little Rock, Ark., Mrs. Norrell gave two units of blood that were shipped to New York to remain in the operating room during her surgery at Columbia-Presbyterian Medical Center.

Giving one's own blood for use in or after elective surgery is not new. Autologous blood transfusion, as it is known, has been used for years, mainly for those with rare blood types.

Now autologous transfusions are catching on with a growing number of Americans with common blood types, though the method remains underused.

A primary reason for the initial increase of such transfusions was the appearance of AIDS, which can be spread through contaminated blood and blood products. Screening tests for antibodies to acquired immune deficiency syndrome have now made the nation's supply of donated blood nearly 100 percent safe, although a trickle of AIDS-contaminated blood, perhaps a hundred or so units a year, slips through because no antibodies are yet present.

But the interest in autologous transfusions has kept rising. And for good reason. Autologous blood eliminates not only the risk of AIDS and other potentially fatal infections that can result from transfusions of contaminated blood, but also the risk of fevers, jaundice and other adverse effects that can result from immunologic reactions to uncontaminated blood.

Blood transfusions are not needed for most operations, and an underlying principle of good surgical practice is to keep bleeding to a minimum. But bleeding usually accompanies many operations, principally orthopedic, heart, chest, plastic, blood vessel and gynecological procedures. Blood bank groups, the American Medical Association, the National Institutes of Health and President Reagan are urging people planning such surgery to store some of their own blood in advance.

The recommendations focus on donating blood in the month or so before elective surgery and not the blood-freezing service commercial companies offer. To most health officials, there is no clear economic or health justification for people to have their own blood frozen and stored for use in an emergency. Among the criticisms: the blood could not be shipped long distances in time to save lives and storage space is short.

Still, there is general agreement that, next to needing no blood at all, receiving one's own blood is safest. Although many people may not be able to donate enough of their own blood to meet their entire needs, even partial use of autologous blood will decrease their chances of infection and adverse reactions.

Interest in autologous transfusions has further intensified with the public awareness that tests are either not available or fail to screen out many viruses such as those that produce a form of hepatitis called non-A, non-B and cytomegalovirus infection. Treatments do not exist for these and some other complications.

Many patients who have undergone perfectly successful operations recover for a brief period, then are forced back to bed for weeks because of complications from transfusions. Some die. Pope John Paul II suffered cytomegalovirus infection from transfusions after he was shot in 1981.

At present, autologous blood is less than 1 percent of the blood transfused in the United States each year. Very few patients used autologous transfusions a decade ago because few hospitals and blood banks offered this service. Last year, however, a total of 80,419 units were collected in 745 autologous programs, up from 45,583 units in 656 programs in 1984, according to the American Association of Blood Banks in Arlington, Va.

Dr. Robert L. Thurer, who heads the association's committee on autologous blood transfusions, predicts that in two years 5 percent or more of transfused blood will be the recipient's own.

At the Beth Israel Hospital in Boston, 180 people, or 12 percent of patients undergoing elective surgical procedures for which standard practice was to order blood on a standby basis, agreed to participate in a study. The study showed that most patients could donate one unit of blood weekly without becoming anemic but that autologous donations had to be deferred at least once in about half the participants. Nearly two-thirds of the participants needed no blood from other people; 29 percent of the participants needed no blood at all, and 37 percent used only their own blood.

Age limits and other restrictions for potential blood donors are not applicable to autologous collections, where the major determinant is the patient's physical condition. Recent studies show that autologous transfusions are safe in children and in pregnant women.

Heart disease and other conditions that often prevent someone from donating blood to others do not preclude autologous blood donation. For example, people who have had hepatitis and may still be carriers of the viruses that cause it can give blood to themselves. The same applies for people who would be ineligible to give blood because they take medications.

The only people who absolutely should not supply their own blood for later use themselves are those with active infections, of which upper respiratory infections are most common.

People donating blood for their own use can give one unit a week up to a total of six. A unit of blood, just under a pint, is about 10 percent of the body's total. The last donation should be made no closer than three days before surgery, to allow the body time to replenish the fluid removed.

Donations to blood banks in the United States have fallen off over the last four years because of AIDS. Male homosexuals, intravenous drug users and others at high risk of being carriers of the main AIDS virus have been asked to refrain from donating blood. Many other people have not given, in the mistaken belief they could contract AIDS from the donation itself. Still others are believed to have stayed away out of fear of learning they are carriers of the virus.

The resulting blood shortages have led at times to the postponement of scheduled surgery, which is one reason more doctors have been asking more patients to donate their own blood. Although proponents of autologous blood transfusions contend that greater use of autologous donors could prevent further shortages in the nation's blood supply, Dr. Peter Page, who heads blood services in the Northeast region of the American Red Cross, stressed: "We're not doing autologous programs because of a shortage and people wouldn't get blood otherwise. We're doing it because we think it is optimal therapy for each individual."

Autologous blood transfusion dates at least to 1886, when doctors salvaged blood spilled in the body during surgery. Such salvaging began to become more popular in the 1960's with the development of new devices.

Many critics of the blood industry ask why the push for a new use of an old technique has come now when earlier use could have prevented tens of thousands of serious infections.

Many experts say the AIDS scare has put much pressure on the blood industry to become more responsive. For example, many blood banks recently began using an indirect test for evidence of contamination by non-A, non-B hepatitis and another one to screen for a virus called HTLV-1 that can cause a rare form of leukemia and brain damage.

Added administrative work and problems in scheduling patients to come to a blood bank at specific times before planned surgery can make autologous transfusions more costly than others.

Blood banks use a variety of labeling techniques and often keep autologous blood in separate refrigerators from those in which the conventionally donated blood is kept. Nevertheless, patients have occasionally received someone else's blood, though of the correct blood type, rather than their own. Sometimes a patient's own blood is given to someone else instead of the donor.

Mrs. Norrell said she "wouldn't have thought about giving my own blood" had her surgeon, Dr. Christopher B. Michelsen, not suggested it. Given the nature of her surgery, he recommended that she store four units. "The more I thought about it, the more it made sense," Mrs. Norrell said.

Dr. Michelson said he had been recommending autologous blood transfusions to all his patients for three years, but, like many other doctors, he denied this was in response to AIDS.

Mrs. Norrell, who weighs 104 pounds, said she had been concerned that a donation of four units might weaken her too much before surgery. If it turned out that she could not donate the full amount, she asked whether friends and relatives could make up the difference by donating their blood for her. This is a controversial practice called directed donation, one that the Red Cross and many other health professionals oppose because there is no evidence that such blood is any safer than the general public's and because it may pressure people to give blood when they should not. For example, the potential donor may be at high risk for AIDS and the recipient might not know it.

Mrs. Norrell rejected this reasoning, as do some health professionals, and so she turned to the University of Arkansas Medical Center, where doctors agreed to collect both autologous and directed donations. Doctors also advised her to take iron supplements to help replace red cells lost in the donations. After Mrs. Norrell gave two units, she said blood bank workers advised against further donations because she was not absorbing enough iron. A cousin and her mother-in-law each volunteered to donate an additional unit.

The good news for Mrs. Norrell: Not only was her surgery successful but she also did not need any transfusions. And because she and her relatives met the general blood banking qualifications, their blood was given to others who did need it.

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