Transfusion medicine. First of two parts--blood transfusion

Transfusion risks and transfusion-related pro-inflammatory responses

Despite improvements in blood screening and administration techniques, serious adverse events related to transfusion continue to occur, albeit at a much lower incidence. In addition to the development and implementation of new screening and blood purification/modification techniques and implementation of an optimal blood management program, the incidence and consequences of transfusion reactions can be reduced by a basic understanding of transfusion-related complications. Although acute hemolytic transfusion reactions, transfusion-associated anaphylaxis and sepsis, and transfusion-associated acute lung injury occur infrequently, diligence in administration of blood and monitoring for development of respective signs/symptoms can minimize the severity of these potentially life-threatening complications. In addition, emerging blood-banking techniques such as psoralen-UV inactivation of pathogens and use of patient identification systems may attenuate the incidence of adverse events related to transfusion. With respect to optimizing blood management by means of an effective blood management program involving pharmacologic and nonpharmacologic strategies, the ability to reduce use of blood products and to decrease operative time or re-exploration rates has important implications for disease prevention, blood inventory and costs, and overall health care costs.

Phase II study of two dose schedules of C.E.R.A. (Continuous Erythropoietin Receptor Activator) in anemic patients with advanced non-small cell lung cancer (NSCLC) receiving chemotherapy

BACKGROUND

C.E.R.A. (Continuous Erythropoietin Receptor Activator) is an innovative agent with unique erythropoietin receptor activity and prolonged half-life. This study evaluated C.E.R.A. once weekly (QW) or once every 3 weeks (Q3W) in patients with anemia and advanced non-small cell lung cancer (NSCLC) receiving chemotherapy.

METHODS

In this Phase II, randomized, open-label, multicenter, dose-finding study, patients (n = 218) with Stage IIIB or IV NSCLC and hemoglobin (Hb) or= 2 g/dL or achievement of Hb >or= 12 g/dL with no blood transfusion in the previous 28 days determined in two consecutive measurements within a 10-day interval) was also measured.

RESULTS

Dose-dependent Hb increases were observed, although the magnitude of increase was moderate. Hematopoietic response rate was also dose dependent, achieved by 51% and 62% of patients in the 4.2 and 6.3 microg/kg Q3W groups, and 63% of the 2.1 mug/kg QW group. In the Q3W group, the proportion of early responders (defined as >or= 1 g/dL increase in Hb from baseline during the first 22 days) increased with increasing C.E.R.A. dose, reaching 41% with the highest dose. In the 6.3 microg/kg Q3W group, 15% of patients received blood transfusion. There was an inclination for higher mean Hb increases and lower transfusion use in the Q3W groups than in the QW groups. C.E.R.A. was generally well tolerated.

CONCLUSION

C.E.R.A. administered QW or Q3W showed clinical activity and safety in patients with NSCLC. There were dose-dependent increases in Hb responses. C.E.R.A. appeared to be more effective when the same dose over time was given Q3W than QW, with a suggestion that C.E.R.A. 6.3 microg/kg Q3W provided best efficacy in this study. However, further dose-finding studies using higher doses are required to determine the optimal C.E.R.A. dose regimen in cancer patients receiving chemotherapy.

Red cell transfusions and guidelines: a work in progress

Blood transfusion utilization continues to rise, yet it has never undergone prospective safety and efficacy testing. Recent data regarding oxygen delivery, microcirculation, and inflammation all point toward potential problems with allogeneic transfusion. Outcome data from retrospective data bases are sobering, calling to question the present practices of red cell transfusion.

Blood conservation strategies in cardiac surgery

Despite the continuous efforts to increase the safety of blood components, red blood cell transfusions remain associated with some risks and side effects. Therefore, numerous techniques have been developed to decrease blood use, but they also carry risks and bear costs. Most of them are frequently used in cardiac surgery, which still consumes a large part of the available blood supply. Among western countries the use of alternative techniques, but also transfusion practice, has been shown to vary markedly. 'Blood conservation' is a global concept engulfing all possible strategies aimed at reducing patients' exposure to allogeneic blood components. The development of the 'best strategy' consists of the selection of those techniques that are most appropriate to the local specific situation. It implies the establishment of a reliable system, collecting data both at the surgical team and at the medical level.

Risk factors for post-ICU red blood cell transfusion: a prospective study

Introduction

Factors predictive of the need for red blood cell (RBC) transfusion in the intensive care unit (ICU) have been identified, but risk factors for transfusion after ICU discharge are unknown. This study aims identifies risk factors for RBC transfusion after discharge from the ICU.

Methods

A prospective, monocentric observational study was conducted over a 6-month period in a 24-bed medical ICU in a French university hospital. Between June and December 2003, 550 critically ill patients were consecutively enrolled in the study.

Results

A total of 428 patients survived after treatment in the ICU; 47 (11% of the survivors, 8.5% of the whole population) required RBC transfusion within 7 days after ICU discharge. Admission for sepsis (odds ratio [OR] 341.60, 95% confidence interval [CI] 20.35–5734.51), presence of an underlying malignancy (OR 32.6, 95%CI 3.8–280.1), female sex (OR 5.4, 95% CI 1.2–24.9), Logistic Organ Dysfunction score at ICU discharge (OR 1.45, 95% CI 1.1–1.9) and age (OR 1.06, 95% CI 1.02–1.12) were independently associated with RBC transfusion after ICU stay. Haemoglobin level at discharge predicted the need for delayed RBC transfusion. Use of vasopressors (OR 0.01, 95%CI 0.001–0.17) and haemoglobin level at discharge from the ICU (OR 0.02, 95% CI 0.007–0.09; P < 0.001) were strong independent predictors of transfusion of RBC 1 week after ICU discharge.

Conclusion

Sepsis, underlying conditions, unresolved organ failures and haemoglobin level at discharge were related to an increased risk for RBC transfusion after ICU stay. We suggest that strategies to prevent transfusion should focus on homogeneous subgroups of patients and take into account post-ICU needs for RBC transfusion.

Pädiatrische Transfusionsmedizin

Die Indikation zur Transfusion von Blutprodukten wird in den letzten Jahren zurückhaltender gestellt. Dazu trägt die Sorge vor möglichen übertragbaren Infektionen ebenso bei wie eine verbesserte Kenntnis der Gewebeoxygenierung. Prinzipiell sollten nur die fehlenden Blutkomponenten verabreicht werden, die der Patient benötigt, und alle unnötigen und möglicherweise gefährlichen Bestandteile vermieden werden („Hämotherapie nach Maß“). In der Intensivmedizin erlaubt z.B. die Messung der zerebralen Sauerstoffausschöpfung eine auf die individuelle Oxygenierung des Patienten abgestimmte Entscheidung zur Erythrozytensubstitution; vorgegebene starre Transfusionsgrenzen verlieren dadurch an Bedeutung.

Is There Still a Role for Aprotinin in Cardiac Surgery?

Cardiac surgery is associated with a systemic inflammatory response and systemic coagulopathy, which can result in significant organ dysfunction and bleeding. Aprotinin, a serine protease inhibitor, can limit systemic inflammation, and has been associated with myocardial, pulmonary and cerebral protection in addition to its proven haemostatic efficacy. Data are currently conflicting regarding the haemostatic efficacy of aprotinin relative to alternative agents including tranexamic acid. Recent studies have demonstrated aprotinin usage is associated with increased rates of thrombotic and renal complications, but these findings are at odds with the majority of studies relating to aprotinin safety to date. The lack of adequately powered, randomised studies evaluating aprotinin and alternative agents limits drawing conclusions about the complete use or disuse of aprotinin presently and requires individualised patient selection based on bleeding risk and co-morbidities for its usage.

Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery

PURPOSE

Radical prostatectomy is associated with substantial blood loss frequently requiring allogeneic blood transfusion. We investigated the efficacy of deliberate hypotension using combined epidural/general anesthesia in reducing allogeneic transfusion requirements in patients undergoing radical prostatectomy.

METHODS

In a prospective, randomized, single-blind trial, 102 patients undergoing radical prostatectomy were allocated to either an epidural group (n = 51) or a control group (n = 51). In the epidural group, deliberate hypotension was achieved with a target mean arterial pressure of 55-60 mmHg. The trigger for allogeneic blood transfusion in both groups was a hematocrit value < 0.25.

RESULTS

Operative blood loss in the epidural group was significantly less than that in the control group (955 +/- 517 mL vs 1477 +/- 823 mL respectively, P < 0.001). The percentage of patients who reached the threshold trigger for allogenic transfusion was significantly less in the epidural group (8% vs 26%, respectively, P = 0.019) and the number of patients who were actually transfused during hospitalization was also significantly less (P = 0.028). There were no serious adverse events in either group during the study.

CONCLUSION

Controlled hypotension using a combined epidural/ general anesthetic technique is associated with significantly less blood loss, and a reduction in the use of allogeneic blood in patients undergoing radical prostatectomy compared to general anesthesia alone.

Clinical strategies in the medical care of Jehovah's Witnesses

Jehovah's Witnesses are primarily known to physicians for their refusal of blood transfusions. Conflict arises at times with the medical staff concerning how best to manage their care. This article will begin with a brief description of the beliefs of Jehovah's Witnesses and will then recommend specific clinical strategies highlighting newer potential therapies according to the principles of bloodless medicine. The scenarios of bleeding and acute and chronic anemia will be discussed in detail for the care of these patients refusing red blood cell transfusions. An update in the use of blood substitutes will be mentioned as well as the surgical advances used today that can minimize blood loss for all patients. The experience of organ transplantation in Jehovah's Witnesses will be detailed. Further resources for physicians with questions in the care of these patients will be listed. Stressed throughout the article will be the need for a team approach and good communication between physicians to successfully care for their patients who are Jehovah's Witnesses.

Allogeneic blood transfusions explain increased mortality in women after coronary artery bypass graft surgery

BACKGROUND

Postoperative mortality is greater in women than men after coronary artery bypass graft surgery. Because allogeneic blood transfusions are more common in women and have been associated with immunomodulation, the impact of transfusion on sex differences in infection and mortality was examined.

METHODS

A cohort study was conducted using Michigan Medicare beneficiaries who had undergone coronary artery bypass graft surgery. Information was used regarding allogeneic blood transfusion, infection, and mortality within the 100-day period after surgery.

RESULTS

Blood transfusions were more common in women than in men (88.2%, 95% CI 87.1%-89.2% vs 66.7%, 95% CI 65.5%-67.9%). Patients who received transfused blood were more likely to have an infection than patients who did not (14.6%, 95% CI 13.8%-15.5% vs 4.9%, 95% CI 4.1%-5.9%). There was a dose-response relationship between the number of units of whole blood or packed red cells received and the prevalence of infection (P = .035). The unadjusted risk of mortality attributable to female sex was 13.9% (95% CI 8.1%-19.6%), but was no longer statistically significant when adjusted for blood transfusion (population attributable risk 0.6%, 95% CI -6.0% to 6.6%). Patients who received a transfusion were 5.6 times as likely to die within 100 days after surgery as those who did not receive a transfusion (95% CI 3.7-8.6).

CONCLUSION

The increased risk of mortality in women after bypass surgery may be explained by transfusion-related immunosuppression.

Impact of platelet testing on presurgical screening and implications for cardiac and noncardiac surgical procedures

Bleeding is a common complication of cardiac surgery, accounting for a significant portion of the total transfusions performed in the United States. This may be due in part to surgical factors and to the fibrinolysis and platelet activation induced by cardiopulmonary bypass. The increasing frequency with which antiplatelet medications are used to prevent thrombosis in cardiac surgical patients with cardiovascular disease also elevates the risk for postoperative bleeding. The resulting coagulopathy and need for transfusions may increase morbidity and mortality risk in cardiac surgical patients, depending on the specific antiplatelet agent used, as well as on patient factors. Empiric platelet transfusion, the frequency of which varies greatly among institutions, does not reliably prevent these complications and may even increase the risk for adverse outcomes. Platelet function testing, particularly with newer testing systems, may be a valuable tool for making decisions about stopping antiplatelet drug administration, surgical timing with respect to bleeding risk, and platelet transfusion in cardiac surgical patients.

Transfusion audit of fresh-frozen plasma in southern Taiwan

BACKGROUND AND OBJECTIVES

The demand for transfusions has increased rapidly in southern Taiwan. Between 1993 and 2003, requests for fresh-frozen plasma (FFP) in particular rose dramatically at Kaohsiung Medical University Hospital (KMUH). Transfusion orders were not tightly regulated, and inappropriate use of blood products was common.

MATERIALS AND METHODS

We carried out a prospective analysis of transfusion requests from October 2003 to January 2004 at KMUH, and then repeated the audit for another 3-month period after the clinical faculty had undergone five sessions of education on transfusion guidelines. Later, our consultant haematologist applied computerized guidelines to periodic audits.

RESULTS

A 5.2% decrease in inappropriate FFP usage followed the educational programme and a further 30% reduction took place after the application of computerized transfusion guidelines. With the guidelines and periodic audits, FFP transfusions decreased by 74.6% and inappropriate requests from 65.2% to 30%.

CONCLUSIONS

Hospital policy, computerized transfusion guidelines and periodic audits greatly reduced inappropriate FFP transfusions. An educational campaign had a more limited effect.

Effect of fresh-frozen plasma transfusion on prothrombin time and bleeding in patients with mild coagulation abnormalities

BACKGROUND

Fresh-frozen plasma (FFP) is frequently transfused to patients with mild prolongation of coagulation values under the assumption that FFP will correct the coagulopathy. There is little evidence to support this practice, however. To determine the effect of FFP on coagulation variables and correlation with bleeding in patients with mildly prolonged coagulation values, a prospective audit of all FFP transfusions at the Massachusetts General Hospital between September 2, 2004, and September 30, 2005, was performed.

STUDY DESIGN AND METHODS

All patients transfused with FFP for a pretransfusion prothrombin time (PT) between 13.1 and 17 seconds (international normalized ratio [INR], 1.1-1.85) and with a follow-up PT-INR within 8 hours of transfusion were included. Of 1091 units of FFP transfused, follow-up coagulation values within 8 hours were available for 121 patients (324 units).

RESULTS

Transfusion of FFP resulted in normalization of PT-INR values in 0.8 percent of patients (95% confidence interval [CI], 0.0020-0.045) and decreased the PT-INR value halfway to normalization in 15.0 percent of patients (95% CI, 0.097-0.225). Median decrease in PT was 0.20 seconds (median decrease in INR, 0.07). Pretransfusion PT-INR, partial thromboplastin time, platelet count, and creatinine values had no correlation with red blood cell loss.

CONCLUSION

It is concluded that transfusion of FFP for mild abnormalities of coagulation values results in partial normalization of PT in a minority of patients and fails to correct the PT in 99 percent of patients.

The impact of administration of tranexamic acid in reducing the use of red blood cells and other blood products in cardiac surgery

Background

To study the effect of administration of tranexamic acid on the use of blood and blood products, return to theatre for post-operative bleeding and the length of intensive care stay after primary cardiac surgery, data for 4191 patients, of all priorities, who underwent primary cardiac operation during the period between 30/10/00 and 21/09/04 were analysed.

Methods

Retrospective analysis of data collected prospectively during the study period. The main outcome measures were whether or not patients were transfused with red blood cells, fresh frozen plasma or any blood product, the proportion of patients returned to theatre for investigation for post-operative bleeding and length of stay in the intensive care unit. We performed univariate analysis to identify the factors influencing the outcome measures and multivariate analysis to identify the effect of administration of tranexamic acid on the outcome measures.

Results

Administration of tranexamic acid was an independent factor affecting the transfusion of red blood cells, fresh frozen plasma or any blood product. It was also an independent factor influencing the rate of return to theatre for exploration of bleeding. The odds of receiving a transfusion or returning to theatre for bleeding were significantly lower in patients receiving tranexamic acid. The administration of tranexamic acid also significantly decreased blood loss. We did not find any association between the administration of tranexamic acid and the length of intensive care stay.

Conclusion

Based on the analysis of 4191 patients who underwent a primary cardiac operation, administration of tranexamic acid decreased the number of patients exposed to a transfusion or returned to theatre for bleeding in our institute.

Infection risks following accidental exposure to blood or body fluids in health care workers: a review of pathogens transmitted in published cases

Hospital staff and all other human or veterinary health care workers, including laboratory, research, emergency service, or cleaning personnel are exposed to the risk of occupational infection following accidental exposure to blood or body fluids (BBF) contaminated with a virus, a bacteria, a parasite, or a yeast. The human immunodeficiency virus (HIV) or those of hepatitis B (HBV) or C (HCV) account for most of this risk in France and worldwide. Many other pathogens, however, have been responsible for occupational infections in health care workers following exposure to BBF, some with unfavorable prognosis. In developed countries, a growing number of workers are referred to clinicians responsible for the evaluation of occupational infection risks following accidental exposure. Although their principal task remains the evaluation of the risks of HIV, HBV, or HCV transmission and the possible usefulness of postexposure prophylaxis, these experts are also responsible for evaluating risks of occupational infection with other emergent or more rare pathogens and their possible timely prevention. The determinants of the risks of infection and the characteristics of described cases are discussed in this article.

Cancer-related anemia and recombinant human erythropoietin--an updated overview

For cancer patients, anemia can be a debilitating problem that negatively influences their overall quality of life and worsens their prognosis. The condition is caused either by the cancer itself or by cytotoxic treatment. Anemia is the primary indication for transfusion of red blood cells, but the development of recombinant human erythropoietins (epoetins) provides an alternative to red blood cell transfusions. Treatment with epoetins has been shown to reduce transfusion rates and increase hemoglobin response. There is some evidence that epoetins improve quality of life. It remains unclear, however, whether erythropoietin affects tumor growth and survival, and this area requires further investigation. Data from clinical trials suggest that erythropoietin increases the risk of thromboembolic complications. In the management of anemic patients, physicians should follow closely the dosing recommendations in products' package inserts or the ASCO/American Society of Hematology guidelines. Treatment of patients beyond the correction of anemia, however, has to be regarded as experimental and is potentially harmful, so should only be conducted in clinical trials.

Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs

BACKGROUND

Allogeneic blood transfusion is associated with transfusion reactions, infection transmission, and postoperative morbidity and mortality. The objective of this study was to develop and validate an accurate and simple clinical index to stratify cardiac surgery patients according to their blood transfusion needs.

METHODS AND RESULTS

Data on consecutive adult patients who underwent cardiac surgery at Toronto General Hospital (n = 11,113) and Sunnybrook and Women's College Health Sciences Center (n = 5316) between May 1999 and June 2004 were collected for the development, validation, and external validation of the index. Primary outcome was the exposure to blood transfusion in the operative and first postoperative days. Multivariable logistic regression modeling techniques were used to determine the relationship between each independent variable and the exposure to allogeneic blood transfusion. Score assignment for each predictor variable was based on its regression coefficient. The predicted probabilities at each total score were compared to the observed proportions of patients exposed to blood transfusion. The clinical tool consists of eight preoperative variables: preoperative hemoglobin, weight, female sex, age, nonelective procedure, preoperative creatinine, previous cardiac surgical procedure, and nonisolated procedure.

CONCLUSIONS

Based on the standards of measurement in clinical research, a valid clinical tool was developed for predicting the need for blood transfusion in patients undergoing cardiac surgery. The clinical tool was internally and externally validated, and the results suggest that it should perform well at other institutions.

Long-term neurodevelopmental outcome and brain volume after treatment for hydrops fetalis by in utero intravascular transfusion

OBJECTIVE

We tested the hypothesis that long-term neurodevelopmental outcomes of successfully treated fetuses with immune hydrops are similar to their unaffected siblings according to a protocol that addresses the underlying pathophysiologic condition.

STUDY DESIGN

Sixteen of 18 consecutive hydropic fetuses (89%) who were treated in a dedicated fetal medicine unit between July 1985 and October 1995 survived. The transfusion protocol used a 2-step correction over a 2 to 4 day interval, combined with umbilical venous pressure measurements to avoid over transfusion and bicarbonate administration to assure a posttransfusion UV pH of >7.30. Survivors were evaluated at a mean age of 10 years. Statistical analyses included t-test, Wilcoxon rank-sum test, Fisher's exact test, and Pearson coefficients.

RESULTS

Overall, death or major neurologic morbidity occurred in 4 of 18 of the fetuses (22%) who were treated (2/16 of survivors [12.5%]). Among the survivors, the children with immune hydrops had physical, neurologic, and cognitive outcomes statistically similar to their siblings, except for a measure of visual attention. Two of the children (12%) had major neurologic sequelae. Brain volumes were statistically smaller than unrelated control subjects by 8.8%, but these control subjects were not matched for height at testing or gestational age at birth. Both groups had brain volumes within the normal range.

CONCLUSION

Intravascular transfusion of fetuses with profoundly anemic immune hydrops results in high survival rates and favorable long-term neuropsychological outcomes.

Costs and benefits of bacterial culturing and pathogen reduction in the Netherlands

BACKGROUND

Bacterial contamination is a life-threatening risk of blood transfusion, especially with platelet (PLT) transfusions. Bacterial culturing (BCU) of PLTs as well as pathogen reduction (PRT) reduce the likelihood of such contamination. The cost-effectiveness (CE) of these interventions was analyzed after the introduction of the diversion pouch during blood collection.

STUDY DESIGN AND METHODS

The balance between costs and benefits of preventing adverse events due to PLT transfusion was assessed with a mathematical decision model and Monte Carlo simulations. Model parameters were obtained from the literature and from Dutch Sanquin blood banks. The balance between costs and benefits is assessed in terms of costs per quality-adjusted life-year (QALY).

RESULTS

The costs per 100,000 PLT concentrates in the Netherlands are estimated at $3,277,032 (euro2,520,794) for BCU and at $18,582,844 (euro14,294,495) for PRT. In comparison to the situation without BCU and PRT, costs per QALY are estimated at $90,697 (euro69,767) for BCU (95% confidence interval [CI], $18,149-$2,088,854) and at $496,674 (euro382,057) for PRT (95% CI, $143,950-$8,171,133). The ratio of differences in costs and QALYs between BCU and PRT (the relative CE) is estimated at $3,596,256 (euro2,766,351; 95% CI, $1,100,630-$24,756,615). Large uncertainty in sepsis complication rates and PLT recipient survival exist, causing large uncertainties in the absolute CE for both interventions.

CONCLUSIONS

As a result of the unknown probability of sepsis complications and PLT recipient survival, the CE ratios of BCU and PRT in the Dutch setting are highly uncertain. Despite these large uncertainties, it can be concluded that BCU is without doubt more cost-effective than PRT.

Platelet gel and fibrin sealant reduce allogeneic blood transfusions in total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is often associated with a considerable amount of post-operative blood loss, necessitating the transfusion of allogeneic blood, which can add to the complications. Optimization of strategies to reduce the need for blood transfusion is desired. This study was designed to evaluate the efficacy of autologous platelet gel and fibrin sealant in unilateral TKA.

METHODS

Consecutive patients were operated on and assigned to the study and control groups. Study group patients (n = 85) were operated on according to our standard TKA protocol, with the application of autologous platelet gel and fibrin sealant on the wound tissues at the end of surgery. Eighty patients were operated on according to the same protocol, but without the use of platelet gel and fibrin sealant, and served as the control group. All blood transfusions, occurrence of wound leakage, wound healing disturbances and incidences of post-operative infections were recorded.

RESULTS

Patients in the treatment group had a significantly higher post-operative haemoglobin level (11.3 vs. 8.9 g/dl, respectively) and a decreased need for allogeneic blood products (0.17 vs. 0.52 units, respectively) than those in the control group (P < 0.001). The incidences of wound leakage and wound healing disturbance were significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. Four patients in the control group, who received blood products, developed wound infection. The hospital stay was decreased by 1.4 +/- 1.5 days for patients in the treatment group (P < 0.001).

CONCLUSION

Peri-operatively applied platelet gel and fibrin sealant may reduce the incidence of allogeneic blood transfusions and complications associated with TKA.

Blood transfusion in critically injured patients: a prospective study

BACKGROUND

Despite evolving evidence that transfusion risks outweigh benefits in some patients, the critically injured continue to receive large quantities of blood. The present study evaluated patterns of red blood cell transfusions and risk factors for transfusions at various stages of admission in trauma patients.

STUDY DESIGN

Prospective, observational study of transfusion practices in patients (n = 120) admitted to a single Level 1 academic trauma centre. Patients were expected to remain in the surgical intensive care unit for greater than 48 h.

RESULTS

Patients had a mean age of 34.1+/- 16.0 years, a mean injury severity score (ISS) of 21.5 +/- 9.5, and were equally distributed by major injury type (48% blunt, 52% penetrating). One hundred and four patients (87%) received a total of 324 transfusions, 20 (6%) of which were given in the emergency room, 186 (57%) in the SICU, 22 (7%) post-SICU and 96 (30%) in the operating room. The mean volume of blood per patient transfused was 3144 +/- 2622 mL. One hundred and one patients received an allogeneic transfusion (mean volume 3126 +/- 2639 mL) and 10 patients received an autotransfusion (844 +/- 382 mL). The mean pre-transfusion Hb level was 9.1 +/- 1.4 g/dL. Transfusion volumes correlated with injury severity score (p = 0.011). Patients with an admission Hb < or =12 g/dL or age >55 years were at significant risk to receive increased transfusions (P < .001 and P = .035, respectively). An admission Hb < or =12 g/dL and any mention of long bone orthopedic operations or laparotomy or thoracotomy were associated with increased risk of blood transfusion during the first week of admission. Logistic regression analysis identified transfusion of >4 units of blood as a significant risk factor for SIRS. After 1 week of ICU stay, ISS > 20 and blunt injury were associated with increased risk of transfusion.

CONCLUSIONS

Trauma patients are heavily transfused with allogeneic blood throughout the course of their hospital stay and transfusions are administered at relatively high pre-transfusion haemoglobin levels (mean of 9 g/dL). Transfusion of >4 units of blood is an independent risk factor for SIRS. Strategies to limit blood transfusions should be investigated in this population.

The utility of an automated electronic system to monitor and audit transfusion practice

BACKGROUND AND OBJECTIVES

Transfusion laboratories with transfusion committees have a responsibility to monitor transfusion practice and generate improvements in clinical decision-making and red cell usage. However, this can be problematic and expensive because data cannot be readily extracted from most laboratory information systems. To overcome this problem, we developed and introduced a system to electronically extract and collate extensive amounts of data from two laboratory information systems and to link it with ICD10 clinical codes in a new database using standard information technology.

MATERIALS AND METHODS

Three data files were generated from two laboratory information systems, ULTRA (version 3.2) and TM, using standard information technology scripts. These were patient pre- and post-transfusion haemoglobin, blood group and antibody screen, and cross match and transfusion data. These data together with ICD10 codes for surgical cases were imported into an MS ACCESS database and linked by means of a unique laboratory number. Queries were then run to extract the relevant information and processed in Microsoft Excel for graphical presentation. We assessed the utility of this data extraction system to audit transfusion practice in a 600-bed adult tertiary hospital over an 18-month period.

RESULTS

A total of 52 MB of data were extracted from the two laboratory information systems for the 18-month period and together with 2.0 MB theatre ICD10 data enabled case-specific transfusion information to be generated. The audit evaluated 15,992 blood group and antibody screens, 25,344 cross-matched red cell units and 15,455 transfused red cell units. Data evaluated included cross-matched to transfusion ratios and pre- and post-transfusion haemoglobin levels for a range of clinical diagnoses. Data showed significant differences between clinical units and by ICD10 code.

CONCLUSION

This method to electronically extract large amounts of data and linkage with clinical databases has provided a powerful and sustainable tool for monitoring transfusion practice. It has been successfully used to identify areas requiring education, training and clinical guidance and allows for comparison with national haemoglobin-based transfusion guidelines.

Cost and utilization of blood transfusion associated with spinal surgeries in the United States

The purpose of this study was to examine factors associated with the utilization and cost of blood transfusion during and post-spinal fusion surgery. A retrospective, observational study of 42,029 inpatients undergoing spinal fusion surgery in United States hospitals participating in the Perspective( Comparative Database for inpatient use was conducted. Descriptive analysis, logistic regression, and ordinary least squares (OLS) regression were used to describe the factors associated with the use and cost of allogeneic blood transfusion (ABT). Hospitalization costs were $18,690 (SD=14,159) per patient, erythropoietin costs were $85.25 (SD=3,691.66) per patient, and topical sealant costs were $414.34 (SD=1,020.06) per patient. Sub-analysis of ABT restricted to users revealed ABT costs ranged from $312.24 (SD=543.35) per patient with whole blood to $2,520 (SD=3,033.49) per patient with fresh frozen plasma. Patients that received hypotensive anesthesia (OR,1.61; 95% CI, 1.47-1.77), a volume expander (OR,1.95; 95% CI, 1.75-2.18), autologous blood (OR, 2.04; 95% CI, 1.71-2.42), or an erythropoietic agent (OR=1.64; 95% CI, 1.27-2.12) had a higher risk of ABT. Patients that received cell salvage had a lower risk of transfusion (OR=0.40; 95% CI, 0.32-0.50). Most blood avoidance techniques have low utilization or do not reduce the burden of transfusion associated with spinal fusion.

Preoperative autologous blood donation for bone marrow harvests: Are we wasting donors' time and blood?

Predeposit autologous blood donation (PAD) is frequently offered to bone marrow donors, but its cost-effectiveness is dubious. We assessed the impact of PAD and bone marrow donation on transfusion requirements; and the use of donated blood units in a retrospective study of 61 bone marrow donors. The mean haemoglobin (Hb) concentration fell from 12.9 to 11.8 g dL(-1) in women who predonated one unit and from 13.2 to 10.9 g dL(-1) in those who predonated two units. In men who donated two units of blood, the Hb concentration decreased to 12.9 g dL(-1). Bone marrow harvest led to a further decline in Hb concentration by 2.3 g dL(-1) in women and by 2.4 g dL(-1) in men. The postharvest Hb fell to <or=9.0 g dL(-1) in 39% of female and in 6% of the male donors; all but one of them had predonated blood. The utilization rate of autologous units was 45.6%, with 55% of women and 24% of men receiving autologous blood. In females, 59% of transfused autologous units were given with the donor's Hb of >or= 9.0 g dL(-1); overtransfusion was even more apparent in men: 71% units were given with a Hb >or= 10.0 g dL(-1). PAD in bone marrow donors is associated with high wastage and increases the likelihood of requiring a transfusion. We recommend that PAD should not be routinely offered to bone marrow donors.

Clearance Studies During Subsequent Sessions of Double Filtration Plasmapheresis

To evaluate the optimal session of double filtration plasmapheresis (DFP) in terms of the maximal clearance rates for various serum substances, the laboratory parameters of 152 consecutive patients treated with different sessions of DFP following a standard protocol on an alternate-day basis was studied. Immunoglobulin M (IgM) and lipoprotein cholesterol had the most effective clearance by a minimum of two sessions of DFP treatment, and the clearance rates remained relatively constant despite the increase in the number of treatment sessions, while the clearance rates for other serum proteins increased steadily with further treatments. Using the clearance rate of the 2-session group as reference, the highest slopes for clearance of albumin, globulin, and triglyceride were found in the 4-session group, while the slopes for IgA and IgG were highest in the 5-session group. In conclusion, for the clearance of IgM and lipoprotein cholesterol, two sessions of DFP treatment are adequate. However, the best clearance of IgG and other globulins cannot be achieved until the fourth session of DFP treatment. Therefore, a minimum of 4 sessions of DFP treatment at 2-day intervals is needed for most immunological diseases.

Listeria monocytogenes in platelets: a case report

BACKGROUND

Efforts to reduce bacterial contamination in platelets (PLTs) have led to implementation of tests for bacterial detection before product release. Although relatively rare as a human pathogen, Listeria monocytogenes often causes serious illness and has a case-fatality rate of 20 percent.

CASE REPORT

PLTs from an asymptomatic 58- year-old Hispanic male with a long history of PLT donation were culture-positive for the presence of L. monocytogenes. The pulsed-field gel electrophoresis (PFGE) pattern of the isolate matched two other L. monocytogenes isolates in the CDC National PulseNet database. Public health investigation found no evidence that the other two isolates were epidemiologically related to the PLT donor, who remained asymptomatic.

CONCLUSION

A cluster of listeriosis cases was detected by PFGE but the significance is unknown. Organisms of public health significance should be reported to health departments. Better surveillance and reporting are needed in the efforts to improve blood product safety.

Low-dose warfarin does not decrease the rate of thrombosis in patients with cervix and vulvo-vaginal cancer treated with chemotherapy, radiation, and erythropoeitin

OBJECTIVES

We had previously reported an association between the use of recombinant human erythropoietin (rHuEPO) and thrombosis in patients with cervix and vulvo-vaginal cancer treated with chemotherapy and radiation. We hypothesized that low-dose warfarin would be effective prevention for thromboembolic events in this setting.

METHODS

A retrospective analysis of patients with cervical or vulvo-vaginal carcinoma receiving chemoradiation and rHuEpo was performed. Thirty-two patients received rHuEpo alone, and 24 received warfarin (1-2 mg) and rHuEpo. The primary endpoint was objectively proven symptomatic venous thrombosis.

RESULTS

There was no difference in the baseline characteristics (e.g. age, stage, body mass index, mean and peak hemoglobin, WBC and platelet counts, and number of transfusions) between these two groups. The rate of thrombosis also was not statistically different (P = 0.62). Nine of 24 patients had a symptomatic deep vein thrombosis (DVT) while receiving warfarin compared to 10 of 32 patients not on warfarin. There was no difference between the two groups in the percentage of patients with upper extremity DVT (P = 0.83) or lower extremity DVT (P = 0.64).

CONCLUSION

Daily low-dose warfarin did not alter the incidence of symptomatic DVT in patients with cervical or vulvo-vaginal cancer who received rHuEpo in conjunction with chemoradiation.

Perioperative autotransfusion in total hip and knee arthroplasty

We assessed the OrthoPAT Orthopedic Perioperative Autotransfusion System (Zimmer Inc, Warsaw, Ind) in reducing the need for allogeneic blood in hip or knee arthroplasty. Patients (N = 398) were divided into 5 cohorts: unilateral primary hip (n = 131), unilateral revision hip (n = 38), unilateral primary knee (n = 179), unilateral revision knee (n = 26), and bilateral primary knee (n = 24). Primary or revision hip arthroplasties with no preoperative autologous blood donation, knee arthroplasties with no preoperative autologous blood donation, and unilateral primary hip arthroplasties were 2.7, 2.3, and 2 times less likely (P < .05), respectively, to use allogeneic blood with OrthoPAT. We conclude that OrthoPAT use significantly reduced the risk of receiving allogeneic blood transfusions in defined patient subsets.

Resource utilization and costs of blood management services associated with knee and hip surgeries in US hospitals

This article assesses the use and costs of blood transfusion during knee and hip surgery through a retrospective observational study of 92,223 discharged inpatients who had undergone knee or hip surgery from July 1, 2003, through June 30, 2004; a sample of US hospitals that participated in the Perspective Comparative Database (Premier Inc., Charlotte, NC) was used. Descriptive and multivariate analyses were performed to determine the use and costs of allogeneic blood transfusion (ABT). The average cost of ABT per user ranged from $387 (SD=$952) for red blood cells to $6585 (SD=$11,162) for cryoprecipitate. Utilization rates in the sample were as follows: antifibrinolytics, 0.14%; topical sealants, 3.24%; volume expanders, 3.89%; erythropoietin agents, 5.08%; and hypotensive anesthesia, 22.28%. Patients who were given volume expanders ($133.73, SD=$23.00, P<.01) or erythropoietin ($177.72, SD=$34.61, P<.01) had higher costs associated with ABT than did those who did not use volume expanders or erythropoietin. Patients who received hypotensive anesthesia (odds ratio [OR]=1.96; 95% confidence interval [CI], 1.87-2.06), a volume expander (OR=1.71; 95% CI, 1.57- 1.85), a topical sealant (OR=1.61; 95% CI, 1.45-1.79), or an erythropoietic agent (OR=2.30; 95% CI, 2.06-2.57) had a greater likelihood of ABT. Investigators concluded that most transfusion reduction techniques are underused, or they do not reduce the burden of ABT associated with knee or hip surgery.

Pharmacokinetics of Darbepoetin Alfa after Intravenous or Subcutaneous Administration in Patients with Non-myeloid Malignancies Undergoing Chemotherapy

BACKGROUND AND OBJECTIVE

The pharmacokinetics of darbepoetin alfa after intravenous (IV) administration in the oncology setting have not been previously reported. The objective of this study was to evaluate the pharmacokinetics of IV or subcutaneous (SC) darbepoetin alfa in patients with non-myeloid malignancies undergoing multicycle chemotherapy.

METHODS

Fifty-six patients (haemoglobin <or=13.0 g/dL) received weekly darbepoetin alfa 2.25 microg/kg administered either IV (n=27) or SC (n=29) during up to three cycles of chemotherapy. Noncompartmental pharmacokinetic analysis was performed, including analysis of intensive pharmacokinetic profiles collected over 168 hours during week 1 of both the first and third cycles of chemotherapy.

RESULTS

Darbepoetin alfa serum concentrations exhibited a biphasic profile (a rapid distributive phase followed by a slower terminal elimination phase) after IV administration, whereas darbepoetin alfa was slowly absorbed after SC administration. Darbepoetin alfa exhibited limited extravascular distribution after IV administration, with both initial and steady-state mean volumes of distribution (36.1 mL/kg and 55.2 mL/kg, respectively, after a single IV dose) approximating the plasma volume. After a single IV dose, darbepoetin alfa exhibited a mean clearance of 1.05 mL/h/kg, with a mean terminal half-life of 38.8 hours. Similar pharmacokinetic results were observed after single and multiple doses of darbepoetin alfa, for both SC and IV administration.

CONCLUSION

Darbepoetin alfa is cleared slowly after IV administration to patients with cancer receiving chemotherapy, resulting in a terminal half-life of 38.8 hours. No evidence of accumulation and no changes in pharmacokinetic profiles after repeated administration were observed in cancer patients undergoing cyclic chemotherapy, for both IV and SC dosing.

Anemia in the long-term ventilator-dependent patient with respiratory failure

Anemia occurs in virtually all critically ill patients receiving long-term mechanical ventilation and has been associated with increased mortality and poor outcomes. Allogeneic RBC transfusions are routinely administered to critically ill anemic patients, especially during lengthy stays in ICUs or in long-term acute care facilities. Although RBC transfusions are a physiologically rational approach to raising hemoglobin levels, they may increase the risk of complications and have been associated with higher mortality in critically ill patients. Treatment with epoetin alfa, an erythropoiesis-stimulating agent, as a means of reducing transfusion requirements has been studied in the critically ill and in patients receiving long-term mechanical ventilation. Promising results have been reported, including a potential survival benefit, although larger and more definitive studies are needed in order to establish whether raising hemoglobin levels affects clinical outcomes in patients receiving mechanical ventilation.

Factors influencing yield of plateletpheresis using intermittent flow cell separator

Platelet recovery in the recipient is influenced by the transfused dose of platelets, which in turn is dependent on the quality of single donor platelets (SDPs) in terms of platelet yield. Various donor factors such as predonation platelet count and Hemoglobin (Hb) concentration affect the platelet yield. A total of 61 plateletpheresis procedures performed on intermittent flow cell separator (MCS3p, Hemonetics) were evaluated for platelet yield. A relationship between predonation platelet count and Hb concentration with yield of platelets was studied using Pearson Correlation. The mean platelet yield was 2.9 +/- 0.64 x 10(11). While a direct relationship was observed between predonation platelet count and yield (r = 0.51, P < 0.001), no such correlation was noticed with donor Hb concentration (r = -0.05, P > 0.005). The yield was > or =3 x 10(11) in >80% of procedures when the predonation platelet count was > or =250 x 10(3)/mm. Optimization of platelet yield, which is influenced by predonation platelet count, is an emerging issue in blood transfusion services. However, further studies in this regard are needed using more advanced cell separators.

Blood salvage autotransfusion during transplantation for hepatocarcinoma: does it increase the risk of neoplastic recurrence?

Impact of intraoperative blood salvage autotransfusion (IBSA) on neoplastic recurrence. during liver transplantations for hepatocellular carcinoma (LT-HCC). Between January 1989 and February 2003, 16 patients received a LT-HCC without IBSA. This group was compared with 31 patients who received the same surgical procedure during the same period, but with IBSA. Data were prospectively collected. All patients had at least a 1-year postoperative follow up. Pairing was made according to the size of the largest nodule. The percentage of recurrence observed in the two groups was similar: 6.4% in the IBSA group vs. 6.3% in the group without IBSA. The median amount of transfused salvage blood was 1558 ml. The differences observed between the two groups concerned the Child score which was A in 58% patients of the IBSA group vs. 80% in the other group; the percentage of severe portal hypertension was 55% in the IBSA group vs. 31%; the median number of packed red blood cell units transfused intraoperatively was 7 in the IBSA group vs. 0, and the median number of frozen fresh plasma units transfused intraoperatively was 11 in the IBSA group vs. 4.5. It appears that IBSA, essentially used during the most haemorrhagic transplantations, could be used in the case of HCC because it does not modify the risk of neoplastic recurrence.

Intraoperative cell salvage during radical prostatectomy is not associated with greater biochemical recurrence rate

OBJECTIVES

To evaluate the risk of long-term biochemical recurrence for patients who receive cell-salvaged blood. Radical retropubic prostatectomy (RRP) is historically associated with the potential for significant blood loss. Different blood management strategies include blood donation, hemodilution, preoperative erythropoietin, and intraoperative cell salvage (IOCS). Oncologic surgeons have been reluctant to use IOCS because of the potential risk of tumor dissemination.

METHODS

We retrospectively analyzed an RRP database and compared those who did and did not receive cell-salvaged blood by baseline parameters, pathologic outcomes, and biochemical recurrence. We also stratified our patients according to the risk of recurrence.

RESULTS

A total of 1038 patients underwent RRP between 1992 and 2003. Of these, 265 (25.5%) received cell-salvaged blood and 773 (74.5%) did not. The two groups had similar baseline characteristics. No differences were found between the two groups when compared by risk of seminal vesicle invasion or positive surgical margins. Those who received cell-salvaged blood had a lower risk of extraprostatic extension. The median follow-up for all patients was 40.2 months. The overall risk of biochemical recurrence at 5 years for those who did and did not receive cell-salvaged blood was 15% and 18%, respectively (P = 0.76). No significant differences were found in the risk of biochemical recurrence when patients were stratified according to low, intermediate, and high risk.

CONCLUSIONS

IOCS is a safe and effective blood management strategy for patients undergoing RRP. The risk of biochemical recurrence was not increased for those who received cell-salvaged blood. Concerns about spreading tumor cells by way of IOCS would seem unwarranted.

Infectious complications after cardiac surgery: lack of association with fresh frozen plasma or platelet transfusions

OBJECTIVE

The purpose of this study was to examine the effect of perioperative transfusion of platelets and fresh frozen plasma (FFP) on infection rates after cardiac surgery.

DESIGN

Retrospective study comparing infection rates after cardiac surgery among patients receiving combinations of packed red blood cells (PRBCs), platelets, and FFP.

SETTING

Tertiary care university teaching hospital.

PARTICIPANTS

All elective primary coronary artery bypass (CABG) surgery patients from July 1995 to January 1998 before introduction of leukocyte-reduced blood products.

INTERVENTIONS

Multivariate logistic and linear regression models were applied to identify clinical risk factors for postoperative infection and to determine the relationship between perioperative administration of PRBCs, platelets, and FFP with postoperative infection.

MEASUREMENTS AND MAIN RESULTS

Transfusion of PRBCs, diabetes, age, preoperative hematocrit, and the duration of cardiopulmonary bypass were significantly associated with postoperative infection; platelet or FFP transfusion added no additional risk to PRBC transfusion alone.

CONCLUSIONS

Infectious complications in a population of adult primary CABG surgery patients were not increased by transfusion of platelets or FFP. It is PRBC transfusion that confers an increased risk of postoperative infection in this population.

Massive Blood Loss and Transfusion in Obstetrics and Gynecology

Massive perioperative or periparturitional bleeding occasionally occurs in obstetric and gynecologic patients. Placenta previa, uterine atony, and ectopic pregnancy are just a few examples of many conditions that could predispose patients to significant blood loss. Therefore, it is important for physicians specializing in obstetrics and gynecology to be proficient in managing episodes of massive hemorrhage and the practice of the most commonly used blood components. We review and update the management of massive hemorrhage for obstetrics and gynecologic patients. In addition, we explore blood component therapy, its risks and benefits.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians Learning.

OBJECTIVES

After completion of this article, the reader should be able to explain the necessity of being proficient in managing episodes of massive hemorrhage, list the indications for use of various blood components, and summarize the risks and benefits of blood component therapy.

Anaemia management strategies: optimising treatment using epoetin beta (NeoRecormon)

Anaemia has a detrimental impact on quality of life and it is important that this condition is recognised and treated in patients with cancer. Epoetin beta is an effective and well-tolerated treatment of anaemia in patients with a wide range of solid and haematological malignancies. A study in patients with lymphoid malignancies confirms that epoetin beta is equally effective at the same overall weekly dose (30,000 IU weekly) when given once-weekly or three-times weekly. This once-weekly regimen has also proved effective in patients with solid tumours. Once-weekly treatment is more convenient for the patient, potentially improving compliance and is associated with reduced hospital administration costs. The majority of patients with cancer will respond to epoetin therapy with an increase in haemoglobin levels. However, it is of value to identify those patients who are likely to respond, so that cost-effectiveness can be improved. Despite much research into potential predictive factors, follow-up studies are required and clinical judgement remains key to managing the anaemia of cancer. In addition, studies suggest that intravenous iron supplementation can improve response to epoetin therapy in patients with functional iron deficiency. Epoetin beta offers an effective, safe and convenient therapy for the management of anaemia in patients with cancer. Ongoing studies are expected to lead to a greater understanding of the optimal use of epoetins in cancer-related anaemia.

Perioperative patient management

Modern perioperative care is complex and involves a large number of staff from multiple disciplines. Patient outcomes depend on well-designed processes, consistent clinical practice, and effective communication. Perioperative care should be a unified process of multiple coordinated steps. There should be a hospital-based multidisciplinary service to manage and plan this process. Early assessment of the patient's comorbidities is essential to plan patient preparation. Ideally, patients should be fully prepared before the day of surgery, and only admitted to hospital shortly before surgery. For many common clinical challenges, there is a range of accepted management regimes. Institutionally consistent clinical practice is necessary to optimise patient outcome. Postoperative management should be based on standardised observations and care protocols, prevention strategies targeted at common problems, and rapid response by high-level teams to early physiological signs of complications.

Preoperative autologous blood donation: a therapy that needs to be scientifically evaluated

The aim of preoperative autologous blood donation (PABD) is to reduce both the risk of transfusion transmitted disease and the need of blood from donors. One advantage of PABD is to prevent transfusion-transmitted disease namely viral infections such as HIV or hepatitis virus or emerging virus. Actually, the very low residual risk of allogeneic transfusion does not argue for PABD. On the other hand, the risk of bacterial contamination must be taken in account for both autologous and homologous transfusion (HT). A meta-analysis showed that ABD reduces the exposure to HT (OR: O.17). Clinical studies evidenced that patients who predonated autologous blood were more likely to receive any blood transfusions (autologous and/or allogeneic) than those who did not (OR: 3.31). More, the reduction of exposure to allogeneic transfusion may be questioned in view of prescription bias. Additionally, PABD is poorly cost-effective. It leads to significant blood wastage while in most studies about half of the units are discarded. In conclusion PABD is a therapy that has not been sufficiently evaluated. The interest of this therapy remains to be demonstrated.

The Impact of Anemia in Patients With Respiratory Failure

Healthy individuals are able to tolerate profound, short-term decreases in hemoglobin levels and oxygen saturation without serious consequences, but critically ill patients in respiratory failure lack the necessary reserve capacity to preserve tissue oxygenation. The development of progressive anemia in ICU patients has led to much interest and debate about transfusion practices, yet optimal hemoglobin levels and how they should be achieved remain unclear. Animal and human studies regarding critical oxygen delivery provide the rationale for optimizing hemoglobin levels and supporting cardiovascular function during respiratory failure. Theoretically, the oxygen-carrying benefit of RBCs should hasten recovery from respiratory failure, and transfusions would therefore be expected to shorten the duration of mechanical ventilation. However, evidence to the contrary has been reported. Controversies related to transfusions and their inability to improve outcomes suggest that further research regarding transfusion alternatives is needed, especially in anemic patients with respiratory failure.

Autologous Blood Donation in Cardiac Surgery: Reduction of Allogeneic Blood Transfusion and Cost-Effectiveness

OBJECTIVE

The purpose of this study was to assess transfusion requirements in patients undergoing cardiac surgery with and without autologous blood donation and to calculate the costs of predonation from the hospital perspective.

DESIGN

Observational study.

SETTING

Single university hospital.

PARTICIPANTS

Four thousand three hundred twenty-five patients undergoing elective cardiac surgery with and without autologous blood donation.

INTERVENTIONS

Eight hundred forty-nine patients (20%) underwent autologous blood donation, whereas 3,476 (80%) did not. Perioperative allogeneic blood transfusion was recorded as the primary endpoint. To avoid selection bias, patients were stratified according to their preoperative risk score. A decision model was derived from acquired data for the optimization of autologous blood donation.

MEASUREMENTS AND MAIN RESULTS

Allogeneic blood transfusion rate was 13% in patients with predonation versus 48% without predonation (p < 0.05). This difference remained statistically significant even after risk stratification. The predonation of 1, 2, or 3 units reduced the probability of receiving allogeneic blood to 24%, 14%, and 9%, respectively. An efficient program of predonation within the department of anesthesiology allowed keeping the costs of predonation low. Decision-tree analysis revealed that predonation of 2 autologous units of blood saved the most allogeneic blood for the smallest increase in costs. Incremental cost for male patients predonating 2 units was dollars 33 (US), whereas for females predonation could be done at no extra cost in comparison to patients without predonation.

CONCLUSION

Autologous blood donation significantly reduces allogeneic blood requirement in cardiac surgery. If adjusted for diagnosis and gender, autologous blood donation is a cost-effective alternative to reduce allogeneic blood consumption.

Liver transplantation in Jehovah's witnesses

For religious reasons, Jehovah's witnesses refuse transfusion of blood products (red cells, platelets, plasma), but may accept organ transplantation. The authors developed a multidisciplinary protocol for liver transplantation in Jehovah's witnesses. In a 6-year period, nine Jehovah's witness patients were listed for liver transplantation. They received preoperative erythropoietin therapy, with iron and folic acid that allowed significant haematocrit increase. Two patients underwent partial spleen embolization to increase platelet count. Seven patients underwent cadaveric whole liver transplantation, and two right lobe living-related liver transplantation, using continuous circuit cell saving system and high dose aprotinin. No patient received any blood product during the surgical procedure. One patient suffering from deep anaemia after living-related liver transplantation was transfused as required by his family, but died from aspergillus infection. One 6-year-old child was transfused against her parent's will. The authors demonstrated that it is possible to increase haematocrit and platelet levels in cirrhotic patients awaiting liver transplantation. They were able to reduce intraoperative need for blood products, allowing liver transplantation in prepared Jehovah's witness patients. This experience may be beneficial for non-Jehovah's witness liver transplant recipients.

Chronic toxicological evaluation of dietary NovaSil clay in Sprague-Dawley rats

NovaSil (NS) clay, a common anti-caking agent in animal feeds, has been shown to sorb aflatoxins in the GI tract and diminish their bioavailability and adverse effects in short-term animal studies. Based on this evidence, it is hypothesized that clay-based enterosorption of aflatoxins may be a useful strategy for the prevention of aflatoxicosis in human populations. However, the potential toxicity of long-term dietary exposure to NS has not been determined. In this research, 5-6-week-old male and female Sprague-Dawley rats were fed rations containing 0, 0.25, 0.5, 1.0, or 2.0% (w/w) levels of NS for 28 weeks. Analysis of the NS showed negligible levels of dioxin and furan contaminants. Total feed consumption, cumulative feed consumption, body weight, total body weight gain, feed conversion efficiency, cumulative feed conversion efficiency, and relative organ weights were unaffected in either sex at the doses tested. No NS-dependent differences in relative organ weights or gross or histopathological changes were observed. Analysis of hematological parameters, clinical chemistry, and selected vitamin and mineral levels revealed isolated significant differences between some treatments and control groups (mean corpuscular hemoglobin, serum Ca, serum vitamin A, and serum Fe). However, the differences observed in each case were not dose-dependent. These results suggest that dietary inclusion of NS at levels as high as 2.0% (w/w) does not result in overt toxicity. These findings (as well as others) support the use of NS clay for dietary intervention studies in human populations at high risk for aflatoxicosis.