Transfusion and coagulation: an overview and recent advances in practice modalities. Part II: Pharmacologic adjuncts, cell salvage mechanisms, alternatives in blood donation

Increasing public awareness of the risks associated with the transfusion of blood products has encouraged the development of alternatives to the use of homologous blood. Pharmacologic agents, cell salvage, and directed donations are three such mechanisms being utilized with greater frequency for blood and component therapy. At present, only three drugs are available for clinical use: DDAVP, epsilon-aminocaproic acid, and tranexamic acid. Cell salvage is available in two system types. Salvage of whole blood in passive collection systems is simplest to use and returns more coagulation factors, but yields a larger volume with a lower hematocrit. Whole blood salvage with subsequent washing and resuspension in normal saline returns only red cells in saline with the majority of coagulation factors removed. The quality of red cells in each system remains relatively constant and the decision regarding which system to employ should be based on the nature of the surgical procedure and the anticipated blood loss. The development of directed donation programs, including autologous predonation and directed homologous donation, permits a reduction in the frequency and total number of units of homologous volunteer blood administered. Directed blood donation provides an additional source of donated blood, but is not demonstrably safer than the volunteer homologous pool, and in fact, may even be less safe. Given the increased complexity of maintaining a designated donor program, these issues of safety play an important role in the ability to maintain operation of large scale directed donation programs.     

Infectious disease markers in autologous and directed donations

SUMMARY. Autologous collections are strongly advocated by the New South Wales Red Cross Blood Transfusion Service (BTS) and have increased more than sevenfold since 1988. Directed donations, although not promoted, have also increased during this time. The prevalence of infectious disease markers (HIV, hepatitis C, hepatitis B and syphilis) in donations collected by the BTS from different donor groups including overall volunteer homologous, first-time volunteer homologous, autologous and directed were evaluated over a 42-month period. Donations from first-time volunteer homologous donors had the highest prevalence of hepatitis B and C. Autologous donations had a significantly higher prevalence of hepatitis B, hepatitis C and syphilis compared with overall volunteer homologous donations. The percentage of directed donations testing positive for either hepatitis B or C was higher than overall volunteer homologous donations, but not statistically significant. This study demonstrates that donations from first-time donors are the least safe, that the crossover of autologous blood into the volunteer homologous pool decreases the safety of that pool and suggests that directed donations may not be as safe as volunteer homologous donations and cannot be generally advocated at this time.     

A comparison of human immunodeficiency virus,hepatitis C virus,hepatitis B virus,and human T‐lymphotropic virus marker rates for directed versus volunteer blood donations to the American Red Cross during 2005 to 2010

BACKGROUND: At most US blood centers, patients may still opt to choose specific donors to give blood for their anticipated transfusion needs. However, there is little evidence of improved safety with directed donation when compared to volunteer donation. STUDY DESIGN AND METHODS: The percentage of directed donations made to the American Red Cross (ARC) from 1995 to 2010 was determined. Infectious disease marker rates for human immunodeficiency virus (HIV), hepatitis C virus (HCV), hepatitis B virus (HBV), and human T‐lymphotropic virus (HTLV) were calculated for volunteer and directed donations made from 2005 to 2010. Odds ratios (ORs) were calculated to compare marker‐positive rates of directed donations to volunteer donations. RESULTS: The percentage of donations from directed donors declined from 1.6% in 1995 to 0.12% in 2010. From 2005 to 2010, the ARC collected 38,894,782 volunteer and 69,869 directed donations. Rates of HIV, HCV, HBV, and HTLV for volunteer donations were 2.9, 32.2, 12.4, and 2.5 per 100,000 donations, respectively; for directed, the rates were 7.2, 93.0, 40.1, and 18.6 per 100,000. After demographics and first‐time or repeat status were adjusted for, corresponding ORs of viral marker positivity in directed versus volunteer donations were not significant for HIV, HBV, or HTLV and significant for HCV (OR, 0.7; 95% confidence interval, 0.50‐0.90). CONCLUSIONS: Directed donations have declined by 92% at the ARC since 1995, but have higher viral marker rates than volunteer donations. The difference can be explained in part by the effects of first‐time or repeat status of the donors. Patients considering directed donation should be appropriately counseled about the potential risks.     

All adverse events in autologous blood donors with cardiac disease are not necessarily caused by blood donation

BACKGROUND: Autologous blood donation before elective cardiac surgery has become a standard of care at many institutions. However, the safety of autologous blood donations by patients with cardiac disease is subject to controversy. CASE REPORTS: Two life-threatening cardiac arrests and one fatal myocardial infarction that occurred in three patients who were scheduled to donate blood for autologous use in elective cardiac surgery are reported. All three patients met the institution's selection criteria for autologous blood donors, and all of them had given written informed consent for their participation in the autologous blood donation program. One of the two cardiac arrests and the myocardial infarction occurred in the patients prior to any blood donations, and the other cardiac arrest occurred 7 days after the patient donated blood uneventfully. CONCLUSION: Life-threatening and fatal adverse events may occur during the donation period in autologous blood donors with cardiac disease. Not all adverse events are necessarily caused by blood donation.     

Structuring a safer donor-replacement program

BACKGROUND: Replacement donors are more likely than volunteer donors to have positive or abnormal tests for transfusion-transmissible disease. In an effort to increase the donor pool, workers sought to identify a safer replacement-donor subgroup that may be acceptable for routine donations. STUDY DESIGN AND METHODS: In a retrospective review and cohort study, the replacement-donor effect was separated from the new- donor effect. The relative effect the replacement donor has on the risk of transfusion-transmissible diseases, donor retention, and frequency of returning donations was then quantified by comparison against the effect of repeat volunteer donors. RESULTS: The replacement donor had 3.1 times the risk and 0.72 times the donor retention rate and made 0.81 times as many returning donations as the repeat volunteer donor. The figures for the new-donor effect were similar. The two risks were additive, making a new replacement donor particularly hazardous. If replacement donations only from repeat replacement donors were considered, the donor risk and the number of donations per returning donor were made comparable to those for the general (combined) volunteer donor. CONCLUSION: The negative effect of the replacement donor is similar in magnitude to that of the new volunteer donor. A replacement-donation program targeting repeat replacement donors has an acceptable risk profile and may be a valuable adjunct to the collection of blood from general volunteer donors.     

Perceptions and motivations of Canadian autologous blood donors

Preoperative autologous blood donation in Canada has increased in the last decade due to concerns about allogeneic blood safety. As economic policies necessitate the validation of autologous blood donation, it is important to assess potential changes. This study examines the motivations and perceptions of patients participating in a Canadian autologous blood donation programme. The study was conducted at the Ottawa Hospital, Civic Campus. Questionnaires were developed and then administered to 100 consecutive adult autologous blood donors. The questionnaires assessed patient demographics, motivation for participation and perceptions about blood safety. Autologous donation was presented to 82% of patients as an option by their physicians. However, 59% of all patients felt that they were motivated to donate by their own fears. Patients (87%) also felt that directed blood donation should be offered due to their perception that directed donation is safer. Three-quarters of patients would be willing to pay for autologous donation. Patients are concerned about the safety of allogeneic blood and they are motivated to seek other alternatives despite the fact that allogeneic blood is very safe. These perceptions and motivations must be taken into account as health care policy changes are considered.     

A pool of repeat blood donors can be generated with little expense to the blood center in sub-Saharan Africa

BACKGROUND: In sub-Saharan Africa, most collected blood originates from accessible and cheaper replacement donors while recruiting and retaining volunteers requires considerable costs not all countries can afford. The Kumasi Teaching Hospital Blood Center and a local FM radio station developed a partnership calling three times a year for donation at the radio station where music, entertainment, and token gifts were available. STUDY DESIGN AND METHODS: To assess the program's impact, attendance, deferral, age, sex, identification, and viral test results of donors attending 12 consecutive sessions in 2003 through 2006 were analyzed, and this donor population was compared to other types of donors in Kumasi, Ghana. RESULTS: A total of 3801 donors attended the program and 92 percent of the potential FM donors were eligible to donate compared to 85.5 and 70.3 percent of other volunteer and replacement donors, respectively. Ninety percent of donors were male (median, 25 years) and 4.9 percent were hepatitis B surface antigen-positive compared to 11 and 15 percent in other volunteer and replacement donors. This reflected 63.6 percent spontaneous repeat donations from donors responding to the radio appeal compared to 15 to 30 percent in other volunteer donors. CONCLUSIONS: It has been demonstrated that the use of a culturally and socially adapted environment to make the gift of blood a pleasurable and festive experience generated a new pool of blood donors spontaneously repeating donations. This program indicates that retaining Ghanaian blood donors is possible at little extra cost to the blood center and that such an approach may represent a substantial help in the efforts of sub-Saharan Africa to collect volunteer blood.     

Donation reactions among autologous donors

Studies of risk factors associated with reactions among autologous blood donors have been limited. Therefore, 2091 autologous and 4737 homologous donations were examined. Donors at greatest risk for reaction were autologous donors who had reactions at first donation; among 45 who made repeat donations for the same surgery, 17 (38%) had repeat reactions. The group least likely to experience reactions were the autologous donors greater than or equal to 66 years old; they experienced a 1.9 greater than or equal to percent (6/310) incidence of reactions. More reactions were seen in both autologous and homologous donors in the categories of first-time donor, female gender, decreasing age, and lower weight. Multiple logistic regression analysis showed that all of these variables were independent predictors of donor reaction, with first-time donation (odds ratio, 2.4) and female gender (odds ratio, 1.9) being the strongest predictors of reaction. Donor room personnel should be alerted that autologous donors who react at first donation are very likely to react at subsequent donations. Contrary to common concern, elderly autologous donors are least likely to have reactions.     

Increased risk of a positive test for antibody to hepatitis B core antigen (anti-HBC) in autologous blood donors

Controversy exists about the suitability of blood from autologous donors for homologous use. We compared the infectious disease test results of 426 autologous donors, designated by donor history as suitable for homologous use, to those of 86,138 volunteer donations collected over the same 5 month period. Although donor characteristics differed, the relative risk of a positive test for anti-HBc in the autologous group was 2.09. When 413 autologous donors were compared to 413 volunteer donors matched for age, sex, and zip code, the relative risk of a positive test for anti-HBc in the autologous group was 3.2. If anti-HBc is a marker for non-A, non-B hepatitis transmissibility, then our autologous group is not as safe as our volunteer donors. We recommend that autologous blood, even when designated by donor history and laboratory screening results as suitable for homologous transfusion, not be used for other than the intended autologous recipient.     

Lapsed donors: an untapped resource

BACKGROUND: There is a clear need for methods to recruit and retain donors without compromising blood safety. Although prior studies report lower viral prevalence rates in repeat donors than those in first-time donors, it is unknown if this relationship holds after a lapse of several years between donations. STUDY DESIGN AND METHODS: A total of 6.4 million allogeneic donations collected at five US blood centers from 1991 through 1998 were classified by donation history (first-time vs. repeat) and by length of time between donations (lapsed interval length). The prevalence of HCV, HIV, and HBsAg was compared by donation history and lapsed interval length. The relationship between lapsed interval length and donor demographics was explored. RESULTS: Repeat donors who delayed their return for over 5 years were significantly less likely to test positive for a viral infection than were first-time donors. The likelihood of a positive test result appeared to increase steadily with lapsed interval length for HCV and HBsAg, but not for HIV. Younger, less educated, and nonwhite donors were less likely to return than others. CONCLUSIONS: Recruitment of donors who have not returned for several years could be an effective way to increase the blood supply while preserving blood safety. Understanding the relationship of donor demographics to return behavior is important for recruitment efforts.     

Retrospective surveillance of HIV prevalence in blood donors can help in the selection of the best social group for blood donation in Mali

The National Centre for Blood Transfusion, Bamako, Mali has collected data that characterizes trend in HIV prevalence over 10 years by gender, age, occupation, marital status and donor category. These data help to describe national HIV prevalence and assist in formulating blood donation policies. Donations from 1993 to 2002 were categorized by donor age (decade), occupation (student, military and other), marital status (single, married and other), gender and donor status (volunteer, occasional and family). Comparisons were made using conservative estimates of donation frequency/donor category. Donations increased by more than 400%. By 1999, increased HIV prevalence in donations from women was consistently present. Donations from the age group of 30–39 years showed an increased prevalence beginning in 2000, which by 2002 was almost 10 times greater than in the low-prevalence (<20 years) group (5.9 vs. 0.6%). By 2000, both categories - students and military were less likely to be HIV positive than those from other occupational categories, and donations from married persons were less likely to be HIV positive by 1997. The highest prevalence was observed in the 'occasional' donor category, which increased to >14% by 2001; volunteer donation HIV positive peaked at 2.3% in 1999. HIV prevalence in blood donations in Bamako, Mali, demonstrates important trends from 1993 to 2002. The prevalence of > 14% in donations from occasional donors and significant trends by decade, gender, marital status and occupation argue for increased analysis of the blood donor population to improve blood safety and to understand the demographics of HIV infection in Mali.     

Influences of general and traditional Chinese beliefs on the decision to donate blood among employer-organized and volunteer donors in Beijing, China

BACKGROUND: For the past several decades, Chinese blood centers have relied on blood donations from employer-organized donors (blood donors who donate blood in groups with coworkers as prearranged by the employer and the local blood center). Recently the government has decided to phase out employer-organized donors and transition to the use of only volunteer donors (blood donors who donate individually independent of employers). Evaluating the beliefs and attitudes of employer-organized and volunteer donors is critical to maintain an adequate blood supply after this transition. STUDY DESIGN AND METHODS: The study population consisted of 431 volunteer donors and 527 employer-organized donors who completed a structured questionnaire in July 2005. RESULTS: Employer-organized donors tended to be older, male, and married, with higher education and higher income compared to volunteer donors. Volunteer donors were more often motivated by altruism (p < 0.001) and more likely to donate larger volumes (400 mL vs. 200 mL) of blood (volunteer 70.5% vs. employer-organized 7%; p < 0.001). Employer-organized donors were more inhibited by factors related to traditional Chinese beliefs, such as the belief that blood donation affects life energy "Qi" (volunteer 3.1% vs. employer-organized 12.7%; p < 0.001), and requested more time off from work after donating. Employer-organized donors also express a greater concern about contracting disease from donating blood. CONCLUSION: To recruit voluntary donors effectively in China and other countries with traditional cultures, efforts need to counteract traditional beliefs and perceptions of risk that discourage donation by emphasizing the benefits, safety mechanisms, physiology, and epidemiology of blood donation. In China, there is a rich opportunity to convert prior employer-organized donors into volunteer donors, and the institution of a confidential predonation screening system may help to facilitate truthful risk factor disclosure.     

Autologous donation error rates in Canada

BACKGROUND: Although certain transfusion risks are eliminated by the use of autologous blood, clerical errors may still occur. In addition, because of differences in donor selection criteria and donor-patient expectations, the consequences of certain errors may be different in autologous and allogeneic donations. STUDY DESIGN AND METHODS: In January 1996, autologous donation error rates in Canada from 1989 to November 1995 were estimated by 1) a detailed questionnaire sent to hospitals supplied by the Canadian Red Cross, Blood Services, Transfusion Center of Quebec at Montreal autologous donation program (n = 31), 2) a review of that institution's quality assurance non- compliance reports, and 3) a detailed questionnaire sent to other Canadian Red Cross centers with autologous donation programs (n = 16) and hospital-based autologous programs in Canada (n = 3). The total number of autologous donations collected was determined from Canadian Red Cross annual reports and information supplied by hospital-based programs. RESULTS: There were 113 errors reported for 16,873 units collected by the Montreal center (1/149 units) based on collection center and hospital data. The most frequent errors were the late receipt of units for surgery (25% of errors) or the receipt of units in the wrong hospital (23%). Other Canadian programs reported 166 errors for approximately 53,500 units collected (1/322 units). However, this figure was based mainly on collection center, and not hospital, data. The most frequent errors were in labeling (48%) and component preparation (25%). One unit of autologous fresh-frozen plasma was transfused to the wrong recipient. Errors were more frequent if components were produced, if units were drawn in hospitals for interhospital transfer, or it units were shipped between Red Cross centers. CONCLUSION: Errors are not infrequent in autologous donation programs. Autologous transfusion should not be considered as being without risk.     

Matching blood donations to type-specific product needs: A recruitment technique

The conversion of multiple whole blood donors to apheresis donors is a challenge since a rapidly expanding apheresis donor base could erode homologous collections. We addressed this concern with a plan to enhance apheresis recruitment as well as donations among homologous donors with types O and B blood. Focusing the donor's attention on blood type as it relates to type-specific product needs was the basis of our approach. A matrix was used to recruit the desired types for the desired procedures (whole blood, platelet/plasma apheresis). The matrix instructed donors of blood types O, A-, and B- to primarily give whole blood and to give apheresis as a secondary donation. Donors AB, A+, and B+ were primarily directed to apheresis donations, whole blood donation being secondary. A+ and O- donors only gave their secondary donation if they were at maximum donations with the primary donation. The collections by blood type in percentages for 12 months of 1992/93 for whole blood were O+ 38.9, 0- 7.3, A+ 29.5, A- 5.7, B+ 11.9, B- 2.1, AB+ 3.7, AB+ 0.7. For apheresis it was 0+ 36.2, 0- 6.7, A+ 33.0, A- 6.6, B+ 10.4, B- 1.2, AB+ 4.9, AB+ 1.0. In 1992/93, A+ and B+ apheresis collections as compared to total apheresis collections increased by 4.9% and 13.7%, respectively. For O group apheresis donations, a decrease of 2.5% was shown and A+ whole blood donations decreased by 5.35%. During the same period of time, total apheresis collections increased by 3,058 units. We demonstrated that integration of apheresis recruitment with type-specific whole blood recruitment yielded significant increases of type-specific products.     

A survey of autologous blood collection and transfusion in Japan in 1997

BACKGROUND: In spite of the fact that autologous blood is safest for a patient to receive, it is not generally appreciated that adverse reactions during donation and transfusion may occur. This study was conducted to assess the state and the risk of autologous blood transfusion in Japan in 1997. STUDY DESIGN AND METHODS: Results of a nation-wide questionnaire-based survey are presented. The questionnaire assessed the number of autologous blood donations, donation procedures, and the adverse reactions associated with donation, preservation, recombination erythropoietin administration and transfusion. RESULTS: Between November 1996 and October 1997, 10,697,000 ml (or 53,485 units, 200 ml = 1 unit) prestorage blood donation were made by 14,200 patients (averages; 1.9 donations/patient, 753 ml/patient, 398 ml/donation). Of these, 87% were transfused to the patients and the remainder were discarded. Using hemodilution and blood salvage intra- or postoperatively some 2,540,000 ml of blood was collected and > 70% of patient-donors received such blood. Adverse reactions were observed with 1.6% (428/26,905) of donations including 6 angina and 2 asthma attacks. There were 63 (0.2%) problems with 28,705 donations and 117 (0.5%) errors/problems reported for 24,929 units transfused; the most frequent problems were clotting on the units and breakage of the bags during storage. Hypotension using hemodilution (3.7%), coagulation (0.9%) or bacterial contamination (0.4%) using salvage were often observed. A 10-20 ml volume of autologous fresh-frozen plasma was transfused to the wrong recipient. CONCLUSION: Autologous blood transfusion accounts for at least 1.1% (2.8% estimated) of the red cell supply in Japan. Errors and adverse reactions are not infrequent in autologous blood programmes. By introducing systematic safety policies, we will be able to make autologous blood transfusion safer.     

Notes on East Anglian blood donors

The record cards of 10,000 donors were examined. Of these, 44.5 per cent were women, and women formed the majority of rhesus (Rh)-negative donors. In addition, 500 donor cards each of male and female donors were examined to obtain information regarding the age of donors when their first donation was given, how many donations were given by each donor, and how long they remained on the panel. The average number of donations per donor was six, given on the average over a four-year period. The age limits for blood donors are 18 to 64 years. Within these limits, only 5 per cent of the population will be blood donors. Responses to a questionnaire indicated three main reasons for not being current blood donors: lack of time, disqualification on health grounds, and lack of information regarding the time and place of blood donor sessions. The study indicates that publicity to recruit donors should be aimed to appeal to both sexes and that the most desirable age range for new donors is from 20 to 45 years of age. If the present policy of not encouraging individuals 60 years of age or older to be donors were changed to limit new donors to individuals less than 54 years old, the number of donations would be initially decreased by only 4.6 per cent. Any advertising campaign should give more information concerning exact places and times of sessions, and should aim to overcome general disinterest in the need for blood donors and the conviction that a personal donation is not really necessary. It might emphasize that giving up at most, an hour every six months is usually possible.     

Feasibility and success of a single-donor red cell program for pediatric elective surgery patients

Although the risks of allogeneic blood transfusions are small, it is wise to limit donor exposure whenever possible. A program has been developed in which one donor provided all red cell (RBC) units for each patient awaiting elective surgery. Patients were mostly children who were ineligible for autologous blood donation. Seventy-three patients and 115 donors (mostly parents) entered the program. Of the 115 donors, 90 (78%) were eligible to participate and 25 (22%) were ineligible; 21 were ineligible because of RBC incompatibility. For each of the 73 patients, one eligible donor was selected to donate all RBC units. Preoperative RBC orders were 1 to 2 units for 41 patients and > or = 3 units for 32 patients. Of the 73 donors, 58 (79%) gave all RBC units ordered; 15 (21%) failed to complete all donations, but only 1 because of anemia (hematocrit < 33% [0.33]). Of 73 patients entered, 46 (63%) underwent transfusion, and 27 (37%) did not. Of 46 patients transfused, 38 (83%) received only single-donor RBCs. Thus, the RBC needs of nearly all pediatric elective surgery patients were provided by a single donor for each patient. Single-donor blood programs should be considered for elective surgery patients who are ineligible for autologous blood donation and who would otherwise be exposed to multiple donors.     

Regional and temporal variation in American Red Cross blood donations, 1995 to 2005

BACKGROUND: Maintaining a stable blood supply is a critical goal of the American Red Cross Blood Services. Extensive Red Cross data provided the opportunity to assess both long-term and short-term trends in the variation of weekly blood donations. STUDY DESIGN AND METHODS: Overall trends and week-to-week variation in donation rates were assessed in volunteer, whole-blood donations from 1995 to 2005 among three Red Cross donor regions: the Connecticut region, the Greater Chesapeake and Potomac (Maryland) region, and the Southern California region, adjusting for population change, calendar time, age, sex, and donor region. RESULTS: Weekly donation rates varied widely by region, ranging from 3.5 donations per 10,000 persons in Southern California to 10.2 donations per 10,000 in Connecticut. Week-to-week variation in donation rates within each region was also quite high. Typical swings in weekly donation rates ranged from 38 percent in Connecticut to 56 percent in Southern California. Week-to-week variation was also 103 percent higher (95% confidence interval [CI], 87%-120%) among 18- to 24-year-old donors, compared to 25- to 44-year-olds, ranging from 32 to 49 percent. By comparison, week-to-week variation among adults 25 and older was more stable, ranging from 16 to 21 percent. CONCLUSION: This study suggests that there is a great deal of variation in donation rates, particularly among the youngest donors. Improving recruitment and retention among these donors will be critical to maintaining an adequate blood supply as the donor population ages.     

Attitudes towards blood donation in Trinidad and Tobago

summary .  The aims of this study were to determine the factors that influence blood donation in different demographic groups in a multi-ethnic, multicultural community, and to devise a strategy for a national campaign to increase voluntary non-remunerated blood donations.
The majority (87%) of blood donations in Trinidad and Tobago are replacement donations. Seventy per cent of the country's transfusion needs are not met. In 1998, the World Health Assembly recommended that reliance on replacement donations should be phased out due to their association with an increased risk of transfusion-transmitted infections.
An observer-administered questionnaire was completed by 1423 respondents in a multi-ethnic borough in central Trinidad. Respondents were classified as donors or non-donors and grouped by age, race, religion, employment status and highest level of education. The prevalence of a history of blood donation and the factors that encouraged donation or conversely discouraged donation in each demographic group were recorded.
A total of 1146 (81·2%) respondents had never donated blood. Of the 277 (18·8%) who had previously donated, replacement for a family member or friend was the most common reason (86·9%). The prevalence of donation was low in all racial, religious, gender, educational and age groups. However, there were significant demographic variations. The majority (71·3%) of non-donors cited a lack of information as a major reason for non-donation and expressed a willingness to donate if access to information and donation facilities were improved.
Voluntary blood donation in Trinidad and Tobago could be greatly increased by a national education campaign and increased accessibility to donation centres. This would ensure a safer and more reliable blood supply.     

Nineteen years of experience with autotransfusion for elective surgery in children: more troublesome than we expected

BACKGROUND: Under the rationale that children undergoing elective surgery are the best candidates for autologous blood donors because of their long life expectancy, aggressive donations of autologous blood, even from infants, have been reported. A number of problems are associated with the procedure, however, whereas the risks of homologous blood are very low. STUDY DESIGN AND METHODS: From 1987 through 2005, of 5792 patients referred to blood transfusion services at two Japanese university hospitals for autologous blood donations, 314 children younger than 16 years old served as subjects for assessment. RESULTS: Of 314 children, 7 were not suitable as autologous donors. In most cases this was due to uncooperative behavior. Over a follow-up period of 19 years, the authors encountered 53 cases (17.3%) of donation-related problems, and this rate was higher than the 6 percent rate recorded for adult cases (316/5305). Nine children suffered crucial complications such as vasovagal reactions, and one 14-year-old boy required a vasopressor drug. Important findings were that 6 of these were first-time donors, and the amount of blood drawn was under 10 percent of their estimated blood volume. CONCLUSION: Of 53 donation-related problems, 9 (17.0%) were accompanied by marked hypotension. Drawing autologous blood from children has become easier with advanced devices; however, lessening of anxiety and tension are essential for the safety of children's autologous blood donation programs. Aggressive donation should be avoided.