Changing patterns of transfusion practice in a tertiary care hospital from 1977 to 1984

Changes in red-cell transfusion practice in a tertiary care hospital during the 1990s--a 7-year study

Use of red cells for transfusion in a tertiary care hospital has been studied over a 7-year period from 1990-1991 to 1996-1997. In this time, red-cell use has declined by 18% while new patients or admissions to programmes in oncology, trauma or cardiac bypass surgery have increased by 57%, 66% and 73%, respectively. This reduction in red-cell transfusion has been achieved by a combination of less patients (proportionately) receiving red cells and less red cells being transfused to individual recipients. When the trends are analysed for red-cell use in four elective surgical procedures there is a significant reduction in both the proportion of patients transfused and the mean number of units used per patient undergoing the procedure. Autologous presurgical blood deposit met about 45% of the blood requirement for those four procedures. A similar decreasing trend in units per patient and proportion of patients transfused red cells was seen for 'first-time' coronary artery bypass surgery. The question arises as to how far this trend may go before adverse effects of undertransfusion become apparent.

The rational use of homologous blood in elective surgery

The supply of homologous blood in Australia is limited, but the demand for blood and blood products is steadily increasing. Elective surgery is a major part of this demand. In many institutions the blood ordering practices for elective surgery have been haphazard. This study was undertaken to document current patterns of blood use in a major city teaching hospital. A retrospective analysis of blood ordering and transfusion for elective surgical procedures was carried out over a 12 month period. As in several previous studies, an inefficient use of blood was demonstrated. Possible strategies to rationalize the use of blood in elective surgery have been proposed. These include the use of a 'group and screen' procedure instead of a full cross-match when transfusion is unlikely to be necessary, and ordering according to a 'maximum blood order schedule' when transfusion is usually required for a procedure.

Guidelines for transfusion support in patients undergoing coronary artery bypass grafting. Transfusion Practices Committee of the American Association of Blood Banks

We have reviewed the impact of evolving issues in coronary artery bypass grafting (CABG) on transfusion support for these patients. Issues include increased awareness of transfusion risks, reappraisal of traditional indicators triggering transfusion, and evolving alternatives to homologous blood transfusion such as autologous blood and pharmacologic therapy. These issues have been prompted by programs, such as the National Institutes of Health Consensus Conferences, to provide physicians with guidelines for appropriate use of blood components. However, evidence suggests that transfusion practice in coronary artery bypass grafting procedures remains variable and does not take into account the results of recently published clinical studies. We have therefore developed guidelines and recommendations for transfusion support in patients undergoing coronary artery bypass grafting. In summary, they are the following. 1. Institutions with coronary artery bypass grafting programs should establish a multidisciplinary approach to use a combination of interventions designed to minimize homologous blood exposure. 2. Prophylactic transfusion of plasma and platelets are of no benefit and therefore carry an unnecessary risk to the patient. 3. Special request products such as designated blood donation from first-degree relatives should not be used because of the risk of transfusion-associated graft versus host disease. 4. For support of intravascular volume, crystalloids or colloids should be used because they do not have the potential to transmit infection.

High-dose aprotinin: hemostatic effects in open heart operations

Two groups of patients were prospectively studied to evaluate the hemostatic effects of high-dose aprotinin in open heart operations. Group A patients (n = 22) received aprotinin during the entire surgical procedure. Group B patients (n = 12) served as controls. The groups were homogeneous for base variables and for cardiopulmonary bypass duration. Postoperative bleeding was lower in group A (mean, 486 mL) than in group B (830 mL) (p less than 0.01). The need for banked blood decreased by approximately half in the aprotinin patients (mean: group A, 213 mL; group B, 409 mL). Hemoglobin levels were similar in the two groups (postoperative day 7: group A, 11.29 g/100 mL; group B, 11.26 g/100 mL; NS). Platelet count decreased at the end of operation in both groups (99,000 and 95,000/mL, respectively; NS) and then increased beyond baseline levels before discharge. No complications were observed that could be attributed to aprotinin. In conclusion, we believe that the use of high-dose aprotinin is safe and effective. It decreases blood loss and reduces the need for banked blood in cardiac operations, particularly in select groups of patients (eg, those undergoing reoperation, Jehovah's Witnesses, those with renal failure).

Prophylactic treatment of postperfusion bleeding using EACA

To determine the effects of prophylactic treatment with EACA for blood loss after cardipulmonary bypass surgery, 350 consecutive patients undergoing open-heart surgery were studied. One hundred seventy patients received an initial dose of 5 g of EACA prior to skin incision, followed by intravenous administration of 1 g/h for the next 6 to 8 h. The control group received saline solution in the same fashion. The EACA-treated group had decreased chest tube blood loss 24 h postoperatively. In addition, EACA-treated patients had fewer myocardial infarctions, cerebrovascular accidents or reoperations for bleeding. Treated patients needed fewer units of blood transfusions than the nontreated group. There was no incidence of hyperthrombotic state or other side effects in the EACA-treated group. We concluded that prophylactic treatment with EACA for open-heart surgery requiring extracorporeal circulation may reduce the total blood loss and the number of blood transfusions in a safe and tolerable manner.

Effect of aprotinin on need for blood transfusion after repeat open-heart surgery

Of 22 patients undergoing repeat open-heart surgery through a previous median sternotomy wound 11 were randomised to receive the serine proteinase inhibitor aprotinin in high dosage (about 700 mg intravenously from the start of anaesthesia to the end of operation, depending on the length of the surgical procedure). Their mean blood loss was 286 ml compared with 1509 ml in the 11 control patients (p less than 0.001), and mean haemoglobin losses were 8.3 g and 78 g, respectively (p less than 0.001). Blood transfusion requirements were eightfold higher in the control group than in the aprotinin group, 7 of whom received only the single unit of their own blood taken before cardiopulmonary bypass.