Preoperative autologous blood donation by 1073 elderly patients undergoing elective surgery: a safe and effective practice

Evaluation of Red Blood Cell Transfusion Practice and Knowledge Among Cancer Surgeons

BACKGROUND

Transfusion of blood products has a negative impact on surgical and cancer outcomes. The objective of the current study was to evaluate surgeons' practice and knowledge of red blood cell transfusion for surgical patients.

METHODS

A survey of residents, fellows, and faculty surgeons at the Ohio State University Wexner Medical Center and surgeons who identified as taking care of cancer patients nationally was conducted. Four domains were addressed including perceived preoperative assessment and management of anemia, perceived use of transfusion alternatives, perceived use of and factors influencing packed red blood cell administration, and transfusion practice knowledge.

RESULTS

Among 158 respondents, 87 (64.5%) were surgeons on faculty at an academic medical center, 26 (19%) were surgeons in private practice, and 24 (15.2%) were surgical residents or fellows. The majority of respondents were surgical oncologists or hepatobiliary surgeons (N = 83, 62.0%) and had been in practice > 10 years (> 10-15 N = 28, 20.6%) and > 15 years N = 59, 43.4%). Only thirteen (N = 13, 8.2%) surgeons reported that they routinely complete a preoperative anemia workup. The majority of providers reported that they rarely or never use alternatives to transfusion such as erythropoietin (N = 135, 91.8%), tranexamic acid (N = 140, 94.6%), autologous blood transfusion (N = 141, 95.3%), or cell saver for benign (N = 107, 72.3%) or malignant cases (N = 133, 90.4%). Provider transfusion knowledge was variable.

CONCLUSIONS

Surgeons varied widely in their transfusion practice and knowledge. Further education of surgeons regarding transfusion medicine and practice, as well as use of transfusion alternatives, could lead to improved patient outcomes. Patient blood management programs may help inform individual surgeon practices.

Impact of Preoperative Platelet Count on Bleeding Risk and Allogeneic Transfusion in Multilevel Spine Surgery

STUDY DESIGN

This was an observational cohort study of patients receiving multilevel thoracic and lumbar spine surgery.

OBJECTIVE

The aim of this study was to identify which patients are at high risk for allogeneic transfusion which may allow for better preoperative planning and employment of specific blood management strategies.

SUMMARY OF BACKGROUND DATA

Multilevel posterior spine surgery is associated with a significant risk for major blood loss, and allogeneic blood transfusion is common in spine surgery.

METHODS

A univariate logistic regression model was used to identify variables that were significantly associated with intraoperative allogeneic transfusion. A multivariate forward stepwise logistic regression model was then used to measure the adjusted association of these variables with intraoperative transfusion.

RESULTS

Multilevel thoracic and lumbar spine surgery was performed in 921 patients. When stratifying patients by preoperative platelet count, patients with pre-operative thrombocytopenia and severe thrombocytopenia had a significantly higher rate of transfusion than those who were not thrombocytopenic. Furthermore, those with severe thrombocytopenia had a higher rate of red blood cells, fresh frozen plasma, and platelet transfusion than those with higher platelet counts. Multivariate logistic regression found that preoperative platelet count was the most significant contributor to transfusion, with a platelet count ≤100 having an adjusted odds ratio (OR) of transfusion of 4.88 (95% confidence interval [CI] 1.58-15.02, P = 0.006). Similarly, a platelet count between 101and 150 also doubled the risk of transfusion with an adjusted OR of 2.02 (95% CI 1.01-4.04, P = 0.047). The American Society of Anesthesiologists classification score increased the OR of transfusion by 2.5 times (OR = 2.52, 95% CI 1.54-4.13), whereas preoperative prothrombin time and age minimally increased the risk.

CONCLUSION

Preoperative thrombocytopenia significantly contributes to intraoperative transfusion in multilevel thoracic lumbar spine surgery. Identifying factors that may increase the risk for transfusion could be of great benefit in better preoperative counseling of patients and in reducing overall cost and postoperative complications by implementing strategies and techniques to reduce blood loss and blood transfusions.

LEVEL OF EVIDENCE

2.

Decreasing preoperative autologous blood donation: collaboration between a hospital and a blood center to prompt change in physician ordering behavior

OBJECTIVE

To describe the collaborative efforts of a large healthcare institution and its local blood center in reducing preoperative autologous blood donation (PABD).

METHODS

Through an educational letter-based campaign, we contacted physicians who historically had ordered PABD units. Follow-up educational efforts occurred at departmental and individual meetings.

RESULTS

Our educational campaign to reduce PABD achieved complete elimination of PABD orders and the resultant waste of PABD units within 3 years of the start of the program. These changes were sustained for at least 2 subsequent years without the need for additional educational efforts.

CONCLUSION

Targeted educational efforts directed at practitioners of PABD were successful in significantly decreasing the use and waste of PABD at the health care institution we studied and may yield the same results in comparable institutions.

Anaemia in the older surgical patient: a review of prevalence, causes, implications and management

This review provides the clinician with a summary of the causes, implications and potential treatments for the management of anaemia in the older surgical patient. The prevalence of anaemia increases with age and is frequently identified in older surgical patients. Anaemia is associated with increased postoperative morbidity and mortality. Allogenic blood transfusion is commonly used to treat anaemia but involves inherent risks and may worsen outcomes. Various strategies for the correction of pre- and postoperative anaemia have evolved. These include correction of nutritional deficiencies and the use of intravenous iron and erythropoesis stimulating therapy. Clear differences exist between the elective and emergency surgical populations and the translation of research findings into these individual clinical settings requires more work. This should lead to a standardized approach to the management of this frequently encountered clinical scenario.

The impact of a regular blood donation on the hematology and EEG of healthy young male blood donors

The aim of this study was to investigate the effect of 400 ml whole blood donation on the human electroencephalogram (EEG) and hematology, not earlier reported in the literature. EEG activity was recorded from ten male blood donors (experiment group) before, during and after blood donation (i.e., 400 ml whole blood withdrawal). EEG topography and regional spectral field powers analyses were carried out via fast Fourier transformation. The venous hemoglobin (Hb) concentration was measured with a hematology analyzer. In the control investigation, 12 male age-matched volunteers (control group) were kept in semi-sitting position for the duration of a blood donation without actually vena puncture. The volunteers had no prior experiences of blood donation. Within the experiment group, post-donation Hb concentration decreased by 3.7% compared with the pre-donation Hb values (P < 0.01). Before blood donation, Hb concentration in control group was significantly higher compared to the experiment group (P < 0.05). For the experiment group, the field power of alpha-1 (7.5-9.5 Hz) EEG during blood withdrawal was significantly lower compared to that after blood withdrawal (P < 0.05). In contrast for the control group, all seven bands of regional spectral field powers showed no significantly discrepancies in the three periods. Blood donation attenuates the alpha-1 at the parietal-frontal area on human EEG-DMN transiently with no lasting effect at post-donation period. The blood donation-related effects on brain function may be of little consequence due to slight hemodynamic change and the results may facilitate the opinion that blood donation is a safe process and that should not discourage volunteers.

Use of tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement

Background & Purpose

Allogenic blood transfusion in elective orthopaedic surgery is best avoided owing to its associated risks. Total knee replacement often requires blood transfusion, more so when bilateral surgery is performed. Many strategies are currently being employed to reduce the amount of peri-operative allogenic transfusions. Anti-fibrinolytic compounds such as aminocaproic acid and tranexamic acid have been used systemically in perioperative settings with promising results. This study aimed to evaluate the effectiveness of tranexamic acid in reducing allogenic blood transfusion in total knee replacement surgery.

Methodology

This was a retrospective cohort study conducted on patients undergoing total knee replacement during the time period November 2005 to November 2008. Study population was 99 patients, of which 70 underwent unilateral and 29 bilateral knee replacement. Forty-seven patients with 62 (49.5%) knees (group-I) had received tranexamic acid (by surgeon preference) while the remaining fifty-two patients with 66 (51.5%) knees (group-II) had did not received any tranexamic acid either pre- or post-operatively.

Results

The mean drop in the post-operative haemoglobin concentration in Group-II for unilateral and bilateral cases was 1.79 gm/dl and 2.21 gm/dl, with a mean post-operative drainage of 1828 ml (unilateral) and 2695 ml (bilateral). In comparison, the mean drop in the post-op haemoglobin in Group-I was 1.49 gm/dl (unilateral) and 1.94 gm/dl (bilateral), with a mean drainage of 826 ml (unilateral) and 1288 ml (bilateral) (p-value < 0.001).

Interpretation

Tranexamic acid is effective in reducing post-operative drainage and requirement of blood transfusion after knee replacement.

Strategy of transfusion in cardiac surgery: limits of hematocrit and how much is too low?

The use of blood and blood products in cardiac surgery is higher than necessary and a reduction is imperative due to complications and costs. Hemodilution is unavoidable in cardiopulmonary bypass and is the most likely pitfall when evaluating transfusion needs. Even patients with coexisting cardiovascular diseases tolerate perioperative hemodilution better than most anticipate. Hemodynamic monitoring is important to evaluate the association between hemoglobin level and organ function. Use of both mechanical and medical blood conservation strategies is required to reduce blood transfusion, and most of the methods have a positive cost-effectiveness and cost-benefit. By using the right strategy and policy, transfusion of blood and blood products can be reduced to less than 5% of cardiac patients.

Autologous blood predonation in cardiac surgery

The risk of transfusion of allogeneic blood products on outcome is well documented. Autologous blood donation prior to elective cardiac surgery has repeatedly shown to be an effective practice to reduce the exposure to allogeneic blood, but was criticized because of the alleged high costs. We analyzed the data of 4878 patients undergoing elective open-heart surgery, in whom 18% underwent autologous donation. Overall, autologous blood donation reduced the incidence of allogeneic blood transfusion from 48 to 13% during hospitalization. Additionally, it is shown that diagnosis adjusted autologous blood donation is cost-effective. The higher the probability of transfusion the better is efficacy and cost-effectiveness of predonation. Cardiac surgery is a high-transfusion area, thus, it offers ideal conditions for autologous donation. Autologous blood donation still remains a promising and cost-effective alternative to reduce allogeneic blood transfusion in elective cardiac surgery.

Effect of changing the age criteria for blood donors

BACKGROUND AND OBJECTIVES

The upper age limit for allogeneic blood donation varies among countries and blood operators. We assessed the impact of the removal of the upper age limit for donation in Canada from December 2004 to January 2006.

MATERIALS AND METHODS

Starting in December 2004, regular donors were permitted to continue whole blood or apheresis donation past their 71st birthday, provided an annual external medical assessment was performed by their family physician. Regular donors aged from 70 to 74 were sent a letter about the change in criteria, and encouraged to continue donations. Rates of donor adverse reactions and deferrals were calculated for these donors and donors in other age groups.

RESULTS

In the 13-month period following implementation of the new criteria, 961 (54%) of regular donors who had received a letter initiated a medical inquiry, and 862 inquiries were completed and returned to Canadian Blood Services. In 98% of cases, the donors' family physician approved ongoing donation. Of the 659 donors who presented to donate, 93% successfully donated. There was only one moderate/severe donor reaction out of 3137 donor attendances for donors aged 71 and older. This rate was not statistically different from the rate in the overall donor population. No donors were deferred for high-risk activities or had positive infectious disease test results.

CONCLUSION

Regular blood donors may safely continue to donate past their 71st birthday. Extra steps in the donation process, such as an external medical inquiry, may not be necessary.

Blood loss minimization and blood salvage techniques for complex spinal surgery

Several techniques to limit blood loss and salvage lost blood are available to surgeons, physicians, and personnel who treat complex spinal disorders. These techniques include red blood cell augmentation, intraoperative antifibrinolytic administration, use of topical hemostatic agents, and intraoperative blood salvage and postoperative blood salvage. A substantial amount of research has been directed toward reducing perioperative blood loss in spinal surgery. More efforts need to be directed toward effective perioperative blood management in complex spinal surgery.

Wasting of preoperatively donated autologous blood in the surgical treatment of adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective, case-control.

OBJECTIVE

Evaluate the utility of preoperative autologous blood donation (PABD) for surgical treatment of adolescent idiopathic scoliosis (AIS).

SUMMARY OF BACKGROUND DATA

Recent data have highlighted overuse of PABD in elective surgery; however, PABD is a major blood conservation strategy for AIS surgery.

METHODS

Medical records of 123 patients treated for AIS between June 1995 and November 2004 were reviewed. Patients were divided into PABD (n = 104) and nondonors (NPABD; n = 19).

RESULTS

No differences existed between PABD and NPABD for age, major curve size, or operative procedures. Average PABD preoperative hematocrit was lower than NPABD (37.8 vs. 40.2; P < 0.005). PABD patients were 9 times more likely to be transfused than NPABD, and 3 times more likely to be transfused for each unit donated. There was a 25% transfusion risk reduction for each percent preoperative hematocrit increase. Minimum one autologous unit was not transfused in 32 patients (31%). Twenty-nine PABD patients (28%) were transfused for hematocrit >30. Fifty-three PABD patients (51%) wasted at least one unit or were transfused for hematocrit >30.

CONCLUSIONS

The majority of PABD patients (51%) wasted minimum one autologous unit or were transfused at a high hematocrit (>30). More precise PABD guidelines are needed to limit unnecessary transfusion and wasted resources.

Safety of RBC apheresis and whole blood donation in allogeneic and autologous blood donors

Automated red cell collection is now a well-established technology. As with any new method, the risks and benefits must be weighed against older approaches, in this case manual collection. Although widely perceived to be safe, manual collection is associated with a number of potential complications, some of which can be serious, even debilitating. The safety record of 2-RBC and other RBC automated procedures is excellent. Physiologic, cardiovascular, and neurocognitive responses are modest and fall within those seen for manual collection. The long term effects related to erythropoietic response and iron loss are manageable and are similar to the effects of repeated whole blood donation. The collection of whole blood by manual means has been performed for nearly a century and as result the safety of this procedure is assumed. Conversely, the safety of automated collection in general and particularly RBC has had to "prove" itself, primarily because it is much more recent and is a different paradigm. Millions of procedures have been performed using both approaches. The blood donor, the "raw material" which makes hemotherapy possible, is the essential enabler in these processes. This article examines the complications of both manual and automated RBC collection.

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.

Eritropoyetina preoperatoria como estrategia de ahorro de sangre en cirugía ortopédica mayor en pacientes de edad avanzada

BACKGROUND AND OBJECTIVE

Preoperative anemia is a major risk factor for perioperative transfusion in orthopedic surgery and aging is associated with an increased risk for developing anemia. The aim of this study was to compare the efficacy and safety of preoperative epoetin alfa in patients older and younger than 65 years in orthopedic surgery. PATIENTS AHD METHOD: This study involved 75 patients scheduled for total joint arthroplasty who had an hemoglobin level between 100 and 130 g/l. Patients were assigned to receive weekly doses of subcutaneous epoetin alfa (40000 IU) on days -21, -14, -7, -1 before surgery. We tabulated age, weight, gender, baseline analytic parameters, perioperative evolution of the mean hemoglobin level, transfusion, side effects and complications.

RESULTS

Fifty-four patients were included in group A (> or = 65 years) and 21 in group B (< 65 years). The two study groups did not differ in terms of demographic characteristics and baseline analysis but differed in age and associated diseases. The preoperative increase in mean hemoglobin level (20 and 18 g/l) and transfusion rate (15% and 14.3%) were similar in both groups. There were no complications associated with the use of epoetin alfa.

CONCLUSIONS

Preoperative epoetin alfa administration seems to be as effective and safe in patients younger as in those older than 65 years.

Cerebral oxygenation and hemodynamics during blood donation studied by near-infrared spectroscopy

BACKGROUND

Blood donation is a safe human model for acute blood loss. This study investigated associated changes in regional cerebral oxygenation and cerebral blood volume (CBV) by near-infrared spectroscopy (NIRS).

STUDY DESIGN AND METHODS

Fifty healthy blood donors donated 450 mL of whole blood within 4 to 9 minutes. Changes in regional cerebral oxygen saturation (rSO2) and cerebral tissue Hb concentration (HbT) were semiquantitatively measured by NIRS. Venous Hb concentration was measured before and after blood donation. The predonation and postdonation CBV was estimated from HbT and venous Hb concentration. Differences between pre- and postdonation study parameters were analyzed by paired t tests (p < 0.05).

RESULTS

Within the study group, rSO2 decreased by 0.44 sat percent (p < 0.01) on average during blood donation, which is still within the range of individual physiologic baseline variation. The average venous Hb concentration decreased significantly by 4.6 percent, whereas HbT increased significantly by 2.5 percent and CBV increased even by 7.5 percent on average.

CONCLUSION

The increase in CBV indicates cerebral vasodilation, which seems to be the major compensation mechanism during acute blood loss. The decrease in rSO2 was relatively small, indicating that cerebral oxygenation was maintained within the physiologic range.

Factors predicting hospital stay, operative time, blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation

STUDY DESIGN

A retrospective chart review was conducted for 112 patients who underwent revision posterior lumbar spine decompression, fusion, and segmental instrumentation.

OBJECTIVE

To ascertain factors predicting hospital stay, operative time, blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation.

SUMMARY OF BACKGROUND DATA

Posterior lumbar spine decompression and fusion with segmental instrumentation is a common procedure in the treatment of degenerative lumbar spine disorders. Many patients undergoing this procedure have had previous lumbar spine surgery, yet little is known about the factors predicting hospital stay, operative time, blood loss, and transfusion.

METHODS

The charts of 112 patients (53 men and 59 women) with degenerative lumbar spinal stenosis who underwent revision surgery from March 1992 to June 1999 were reviewed. Their average age was 54 years (range, 27-84 years). All the surgeries included decompression and fusion with segmental instrumentation. The patients' demographics, comorbid conditions, factors related to previous lumbar spine surgery, diagnosis, number of levels fused, and preoperative hemoglobin and hematocrit were collected and used as the independent variables. Multiple regression analysis was used to ascertain factors predicting length of hospital stay, operative time, intraoperative blood loss, and transfusion.

RESULTS

The mean length of hospital stay was 6 +/- 2.4 days, the operative time 280 +/- 62 minutes, the estimated intraoperative blood loss 1073 +/- 716 mL, and the total volume of blood transfused 1.04 +/- 1.17 U. For 63% of the patients, a blood transfusion was needed. Increasing age was the significant predictor for hospital stay (P < 0.001). The factors predicting operative time were number of levels fused (P < 0.001), diagnosis of degenerative scoliosis (P < 0.05), and excessive body weight (P < 0.01). The factors predicting intraoperative blood loss were number of levels fused (P < 0.01), body weight (P < 0.001), and high preoperative hemoglobin (P < 0.001). Both logistic and linear regression analysis showed that the factors predicting blood transfusion were number of levels fused (P < 0.01), age (P < 0.05), and low preoperative hemoglobin (P < 0.001). Other factors associated with hospital stay and blood transfusion were unemployment associated with three or more comorbid conditions and complications. The women had less intraoperative blood loss (P < 0.01), but received more transfused blood than the men (P < 0.01).

CONCLUSIONS

Number of levels fused and age seem to be the most significant factors predicting hospital stay, operative time, intraoperative blood loss, and transfusion in patients undergoing revision posterior lumbar spine decompression, fusion, and segmental instrumentation.

Preoperative autologous blood donation by elderly patients undergoing orthopaedic surgery

BACKGROUND AND OBJECTIVES

To assess the feasibility of a programme of predeposit in elderly patients undergoing elective orthopaedic surgery.

PATIENTS AND METHODS

We retrospectively studied 789 elderly patient candidates (> 65 years of age) for orthopaedic surgery (total hip and knee replacement and spinal surgery), who were undergoing a programme of preoperative autologous blood donation (PABD) in our city hospital between January 1990 and December 1998.

RESULTS

Six hundred and eighty-eight patients (87.2%) were transfused with autologous blood; 128 (16.2%) also received allogeneic blood. Hip arthroplasty revision was characterized by the greatest blood consumption. The predeposit programme was discontinued in 96 patients (12.2%) because of the following complications: the onset of anaemia (11.0%); vasovagal reactions (0.5%); lack of venous access (0.4%); or cardiac complications (0.2%). No episodes of reaction to autologous transfusion were recorded.

CONCLUSIONS

Our study confirms the feasibility of PABD in elderly patients undergoing elective orthopaedic surgery.

Preparation of a pure autologous biodegradable fibrin matrix for tissue engineering

Parallel to the growing role of tissue engineering, the need for cell embedding materials, which allow cells to stabilise in a three-dimensional distribution, has increased. Although several substances have been tested, fibrin is thus far the only one that permits the clinical application of cultured tissue. To date, autologous fibrinogen has usually been polymerised with bovine thrombin, which can cause severe immunological side effects. The objective of this study was to explore the practicability of obtaining autologous thrombin from a single patient in an adequate concentration and amount. Fibrinogen was cryoprecipitated from 200 ml of freshly-frozen plasma. Thrombin was isolated from the supernatant through ion-exchange chromatography. The thrombin was first bound to Sephadex A-50 and then eluated using 2 ml of a salt buffer (2.0 M NaCl in 0.015 M trisodiumcitrate, pH 7.0). The activity of the thrombin (51 NIH x ml(-1) to 414 NIH x ml(-1) reached levels comparable to those in commercially available fibrin glues (4-500 NIH x ml(-1)). The study has shown that it is possible to obtain a sufficient amount of autologous thrombin from a single donor to create a fibrin matrix of high efficiency without the risk of immunological and infectious side effects.

Cost-effectiveness of epoetin and autologous blood donationin reducing allogeneic blood transfusions incoronary artery bypass graft surgery

BACKGROUND

Coronary artery bypass graft (CABG) surgery accounts for a substantial portion of all allogeneic units of blood transfused. Drugs and autologous blood donation (ABD) are alternative or adjunctive methods for reducing complications and costs induced by allogeneic blood transfusions. Recombinant human erythropoietin (epoetin) has the potential to decrease perioperative need for allogeneic blood during CABG, but its high cost calls for a careful economic evaluation before it can be recommended for widespread use.

STUDY DESIGN AND METHODS

A decision tree was used to compare a hypothetical strategy of no epoetin with one in which epoetin was utilized to control blood transfusion needs in CABG; each strategy was tested with and without ABD. The impact of these strategies on both the quality-adjusted life years (QALYs) and costs ($US) was calculated.

RESULTS

Using epoetin alone and with ABD, respectively, avoided the transfusion of 0.61 and 1.35 units of allogeneic blood per patient and saved 0.000086 and 0.000146 QALYs per patient. This made cost-effectiveness (CE) higher than $7 million and $5 million for each QALY saved, respectively. ABD alone cost more than $1 million per QALY saved. If the risk of bacterial infections following allogeneic transfusions was included in the model, epoetin alone cost $6288 per QALY saved, while ABD, both alone and with epoetin, saved money.

CONCLUSION

On the basis of the existing evidence, neither of the blood-saving strategies modeled was a cost-effective means of avoiding the deleterious health effects of perioperative blood transfusions in CABG. However, if allogeneic blood-related infections were to be considered, both ABD and epoetin would be acceptable interventions.