Preoperative Autologous Blood Donation Research Articles

Bar code-based pre-transfusion check in pre-operative autologous blood donation

Background The objective of this study was to demonstrate the feasibility of a bar code-based identification system for the pre-transfusion check at the bedside in the setting of pre-operative autologous blood donation (PABD). Materials and methods Between July 2003 and December 2008 we determined the compliance rate and causes of failure of electronic bedside checking for PABD transfusion. Results A total of 5627 (9% of all transfusions) PABD units were administered without a single mistransfusion. The overall rate of compliance with electronic checking was 99%. Conclusions The bar code-based identification system was applicable to the pre-transfusion check for PABD transfusion.

Ten years of preoperative autologous blood donation in Accra

Preoperative autologous blood donation (PABD) is utilized to circumvent the use of allogenic blood for various reasons. To describe the distribution in terms of demographic characteristic, trends in participation and result of screening test of the PABD programme of the Accra Area Blood Center from 1993-2003. Retrospective descriptive study of PABD in patients scheduled for a variety of elective surgical procedures. Different levels of institutional health care in Accra, Ghana. Data from existing records of patients who had participated in PABD were collated and analyzed Five hundred and forty six (546) females and 89 males participated, with ages ranging between 14-74 years. Majority of the patients (76.7%) underwent gynaecological surgery. A total of 330 (52%) donated one unit only, and 299 (47.1%) donated two units. Majority of the patients (56.4%) had the surgery at the Korle-Bu Teaching Hospital (KBTH). Of the donations, 21 (3.3%), 1 (0.2%), 1 (0.3%) and nil were positive for HBV, HIV I & II, HCV and VDRL respectively. A total of 848 (89.4%) autologous cross-matched units were issued out. There was a steady progressive increase in participation. Mainly adult females scheduled for gynaecological surgeries in KBTH participated, while almost equal proportions donated one or two units of blood which meets the blood needs of most elective surgeries. Therefore healthy patients going for elective surgeries in regions with limited blood supply must be encouraged to enter a PABD Programme. Further studies in this field should evaluate motivational factors for participation.

Efficiency and safety of preoperative autologous blood donation in cardiac surgery: a matched-pair analysis in 432 patients

A shortage of blood products is predicted for the near future in many countries all over the world. Preoperative autologous blood donation (PABD) in cardiac surgery is considered an option to reduce the need of allogeneic blood products. We analysed a 1-year period of our institutional database according to the safety and efficiency of our autologous blood donation programme. All patients who donated autologous blood prior to cardiac surgery were matched to a non-donor according to age, body weight, body mass index, sex, haemoglobin concentration, EuroSCORE, antifibrinolytic therapy and risk for bleeding. We analysed the occurrence of adverse effects during donation in all donors as well as the main perioperative data, haemoglobin levels and the need for allogeneic blood transfusion in all patients. There were no major cardiac events such as myocardial infarction, worsened cardiac insufficiency or death in the donor group during the PABD process. A total of 216 patients could be matched. Exposure to allogeneic blood products was significantly reduced in the donor group (packed red cells 70 patients (pts) vs 118 pts (p<0.001), fresh frozen plasma 26 pts vs 54 pts (p=0.001), platelets 10 pts vs 22 pts (p=ns)). There were no reports of transfusion-related side effects. Further, there was no difference in haemoglobin concentrations at postoperative day 1 and at discharge. In this large matched-pair analysis without the need for risk stratification, PABD reduces the need for allogeneic blood products in adult cardiac surgery. In a carefully selected cohort, PABD is a safe and efficient alternative to allogeneic transfusion.

Major Factors of Homologous Blood Transfusion in Valvular Heart Operation with Intraoperative Autologous Blood Predonation in Cases with Difficulty in Preoperative Predonation

Intraoperative autologous blood predonation is reported to be useful for the prevention of homologous blood transfusion in cardiac operations, especially in on-pump coronary artery bypass grafting (CABG). However, CABG is now performed more often off-pump than on-pump. We analyzed the major factors of homologous blood transfusion in 25 consecutive cases of valvular heart operation with intraoperative autologous blood predonation except those with preoperative autologous blood donation. Homologous blood was not transfused in 18 cases, but was in 7 cases only after cardiopulmonary bypass (CPB). The homologous transfusion was not correlated with body weight, CPB dilution or duration, or preoperative hematocrit level, but was found to correlate with age (R2=0.289, p=0.0413), bleeding output (R2=0.197, p=0.0485), and predonation blood volume (R2=0.436, p=0.0152). In conclusion, suitable intraoperative predonation may reduce the necessity for homologous blood transfusion in valvular heart operations.

Nonanemic Patients Do Not Benefit from Autologous Blood Donation Before Total Hip Replacement

To avoid the potential risks of allogeneic transfusion during total hip arthroplasty (THA), the use of preoperative autologous blood donation (PABD) has been utilized. We performed a retrospective chart review of 283 patients undergoing THA that either donated 1U of autologous blood (188 patients) or did not donate autologous blood before surgery (95 patients) in order to investigate the difference in postoperative transfusion rate (autologous and allogeneic), the incidence of allogeneic transfusion, and the difference in cost of each protocol. In addition, the study compared transfusion rates in patients with and without preoperative anemia (hemoglobin (Hb) ≤ 12.5g/dL). At 0.75 transfusions per patient versus 0.22 transfusions per patient, the PABD patients had a significantly higher overall transfusion rate. PABD significantly reduced the need for allogeneic blood in anemic patients (Hb ≤ 12.5g/dL) from 52.6% to 11.8%. PABD did not have the same affect in nonanemic patients (allogeneic transfusion rate 5.7% versus 4.0%). The study demonstrated that nonanemic patients undergoing THA do not benefit from PABD, but it is effective for anemic patients.

Combined Preoperative Autologous Blood Donation and Intra-Operative Cell Salvage for Hip Surgery

To review records of 161 consecutive hip surgery patients for whom preoperative autologous blood donation (PABD) was used in combination with intra-operative cell salvage (ICS). 114 women and 14 men aged 41 to 86 (mean, 64) years underwent 135 primary total hip arthroplasties (THAs), whereas 19 women and 7 men aged 16 to 52 (mean, 35) years underwent 26 rotational acetabular osteotomies (RAOs). Two or 3 weeks before the operation, patients deposited one unit (400 ml) of blood weekly, so long as their haemoglobin levels exceeded 110 g/l (if they had osteoarthritis) or 100 g/l (if they had rheumatoid arthritis). Patients were given oral ferrous sulphate, lactated Ringer's solution, and recombinant human erythropoietin. 800 and 1200 ml of blood were deposited for patients undergoing THA and RAO, respectively. Intra-operatively, ICS was carried out using a continuous autotransfusion system. The blood from ICS was transfused first, and then the blood from PABD was transfused during the latter half of the operation. By combining PABD and ICS, homologous blood transfusion was avoided in all patients, even in those with unexpected massive bleeding during surgery. In 3 patients, one unit of deposited autologous blood was discarded, because they showed no sign of anaemia. The mean total blood loss was almost 1.5 times higher in RAO than in THA patients (1095 vs 1550 ml). In the THA and RAO patients respectively, the mean amount of ICS was 181 and 210 ml, whereas the mean total blood transfusion volume was 975 and 1394 ml. No complications (including infection) related to autologous blood transfusion were observed during PABD, the surgery or the postoperative period. Homologous blood transfusion was avoided with the use of PABD and ICS. Preoperative donation of 800 and 1200 ml of blood (combined with ICS) seemed optimal, as only 3 units of blood were discarded.

Juzentaihoto (TJ-48), a traditional Japanese herbal medicine, influences hemoglobin recovery during preoperative autologous blood donation and after hip surgery

Preoperative autologous blood donation is a widely used alternative to allogenic transfusion in hip surgery. However, it has been reported that autologous blood donation may induce preoperative anemia. Juzentaihoto (TJ-48) (Tsumura Co., Tokyo, Japan) is a Japanese herbal medicine that has been used to alleviate anemia. We investigated the effect of TJ-48 on anemia in the perioperative period. 18 hips of 18 female patients who underwent total hip arthroplasty or rotational acetabular osteotomy (RAO) were divided into two groups. Group A consisted of 9 hips of 9 patients who were treated with TJ-48 at a dose of 7.5 g per day from 21 days before surgery to the day before surgery. Group B consisted of 9 hips of 9 patients who did not take TJ-48. Preoperative autologous blood donation was performed 21, 14 and 7 days before surgery. All patients deposited 400 ml each time for a total of 1,200 ml. Hemoglobin level was recorded on preoperative Days 21, 14 and 7 and postoperative Days 1, 4, 7 and 14. During the preoperative period, repeated measures ANOVA showed a significant difference between the two groups in hemoglobin level (p = 0.04). Despite the lack of TJ-48 after surgery, the rate of hemoglobin decline in Group A was less than in Group B at all examination times. No patients with TJ-48 experienced side effects, including gastrointestinal symptoms and unusual laboratory data. TJ-48 is useful for treating anemia during preoperative autologous donation.

Preoperative autologous blood donation versus intraoperative blood salvage: intraindividual analyses and modeling of efficacy in 1103 patients

Preoperative autologous blood donation (PABD) and intraoperative blood salvage (IBS) represent established blood conservation measures. However, data comparing PABD to IBS are very sparse. We analyzed data from 1103 patients undergoing PABD and subsequent major orthopedic surgery in one center. We then used a validated model to compare PABD to IBS. We calculated maximal allowable blood losses (MABLs) for both IBS and PABD. We also identified criteria for efficacious use of either PABD or IBS. Our calculations were based on exclusive application of either technique, complete exhaustion of predeposited or salvaged blood, and one round of IBS. The vast majority of patients would have tolerated greater MABLs if subjected to IBS rather than PABD (425 of 432 with 1 PABD unit, 580 of 664 patients with 2 PABD units, 3 of 7 patients with 3 PABD units). For a few patients, however, our model demonstrated greater MABL with PABD than with IBS. These patients were characterized by 1) lower initial hematocrit (Hct), 2) recovery from PABD with return to baseline Hct or above by the time of surgery, and 3) longer time between first PABD and surgery. IBS appears to be the superior blood conservation technique if PABD cannot be performed under optimal conditions. Tolerable predonation anemia and sufficient time for regeneration appear to be crucial for post-PABD erythropoiesis. If these goals cannot be accomplished, PABD should be abandoned and be replaced by IBS.

Transfusion errors and their prevention

Although the current risks of acquiring viral transmission through blood components and products are very small, mistransfusion, in which a blood unit is incorrectly administered to a non‐designated recipient, remains the most common type of error in transfusion practice. ABO‐incompatible blood transfusion attributable to the incorrect identification (ID) of the patient or the blood unit is one of the most serious transfusion hazards. Many studies revealed that transfusion errors occur frequently in clinical areas, with the most common error being failure to perform the final patient ID check at the bedside. Thus, the pretransfusion bedside check is the most critical step for the prevention of mistransfusion. Machine‐readable ID technology, especially a bar code‐based ID system, is ideally suited to bedside check requirements. Our experience at the Juntendo University Hospital shows that the bar code‐based ID system has worked well over a 7‐year period on a hospital‐wide basis, and approximately 70 000 blood components have been transfused without a single mistransfusion. The overall rate of compliance with ‘second’ electronic bedside checking for blood components was 99%. Human error was the most frequent cause of errors leading to the failure of the bedside bar code ID check. The bar code‐based ID system has become applicable to the bedside pretransfusion check for paediatric transfusion, i.e. blood dispensed in syringes, and preoperative autologous blood donation, as well as regular allogeneic blood transfusion. If we want to reduce the risk of mistransfusion to improve transfusion safety, we have to address the issue at the hospital level, with a system‐based approach.

The Effect of Preoperative Recombinant Erythropoietin and Type of Surgical Procedure on Postoperative Hematocrit Following Orthognathic Surgery

Statement of the Problem: Significant blood loss and requirement for blood transfusion have regularly been cited as a risk of orthognathic surgery. Historically, patients provided preoperative autologous blood donation to prevent the risk of disease transmission. Many different surgical and anesthetic techniques have evolved to minimize the risks associated with, and the need for blood transfusions in orthognathic surgery patients. The purpose of this study was to evaluate the efficacy of a single preoperative dose of recombinant erythropoietin alpha (EPO) by comparing postoperative hematocrit and the rate of blood transfusion in healthy orthognathic surgical patients.

Retrospective analysis of autologous blood use in bimaxillary repositioning osteotomy surgery: a quality improvement study

Multiple studies have considered the necessity of preoperative autologous blood donation before bimaxillary orthognathic osteotomies. In the context of a quality improvement project, this topic was also investigated in our institution. Furthermore, the transfusion practice was analyzed and the correlations between patient, operative variables, and blood loss were studied. In accordance with the recommendations of the Federal Medical Association and the Federal Ministry for Health and Social Security, a transfusion demand list was compiled using data of 82 patients who underwent bimaxillary orthognathic surgery between 1997 and 2005. The maximum blood loss tolerable without transfusion (MBL) was calculated for each patient on the basis of sex, weight, height, and preoperative hematocrit (Hct). This was compared with the actual transfusion and blood loss data. An autologous blood donation was carried out in 65 of 82 patients (79.3%). Sixty-two of 65 autologous blood donors (95.4%) and 2 of 17 patients (11.8%) without autologous blood donation received transfusion. The actual blood loss did not exceed the calculated MBL in 48 of the 82 cases. Nevertheless, 31 of these 48 patients (64.6%) received transfusions. For patients with a low calculated MBL, only a trend to a higher transfusion rate was observed, although the actual blood loss in these cases more often exceeded the individually calculated MBL (p < 0.01). In addition, transfusion triggers (Hct 0.22 or hemoglobin 7.5 g/dL) were also more often seen in cases with low calculated MBL (p < 0.05). In this study, an inappropriate transfusion practice in patients undergoing bimaxillary orthognathic osteotomies after preoperative autologous blood donation was detected. Calculation of the individual MBL should be used to help identify patients at high risk for transfusion and guide adequate methods to decrease the need of homologous blood.

Impact of intraoperative red blood cell salvage on transfusion requirements and outcomes in radical prostatectomy

Preoperative autologous blood donation lowers preoperative hemoglobin (Hb) levels, and the collected blood is frequently wasted. Intraoperative red blood cell (RBC) salvage provides fresher autologous blood in proportion to surgical blood loss, making cell salvage (CS) in radical prostatectomy (RP) feasible for study. This retrospective study compared two strategies to reduce allogeneic RBC transfusion requirements in RP: preoperative autologous donation (PAD) versus CS. Patients underwent RP by one surgeon at one institution during two comparable time periods in 2005 (PAD-Group 1) and 2006 (CS-Group 2). Group 1 patients (n = 40) underwent PAD, collecting 63 autologous RBC units; 36 units (57.1%) were reinfused and 27 (42.9%) were wasted. No Group 1 patient received allogeneic blood. Group 2 patients (n = 63) underwent intraoperative CS and received a mean of 287 mL of salvaged blood. In Group 2, two patients (3.2%) with preoperative Hb levels too low to permit autologous donation each received 2 units of allogeneic RBCs. Group 1 patients had significantly lower preoperative (-1.4 g/dL) and postoperative (-0.8 g/dL) Hb values compared to the CS group. There were no significant differences between groups in procedure times, length of stay, or numbers of cancer recurrences over the 24- to 36-month follow-up period. Perioperative CS can effectively replace PAD for RP patients, offering similar avoidance of allogeneic transfusion, with greater convenience and superior postoperative Hb levels.

Dutch orthopedic blood management surveys 2002 and 2007: an increasing use of blood-saving measures

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007. In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively). The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6–66.1%) as well as knee (24.0–55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3–28.4%) as well as knee arthroplasty (8.9–16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5–51.0%) and knee arthroplasty (15.9–59.3%). There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.

Predictors of allogenic blood transfusion in elective cardiac surgery after preoperative autologous blood donation

Preoperative autologous blood donation (PAD) is important for reducing exposure to allogenic blood in cardiac surgery. Unfortunately, even after PAD, allogenic blood transfusion is not always avoided. We investigated the predictors of blood component usage during elective cardiac surgery in patients prepared with PAD. Clinical data were collected for 143 consecutive patients (103 men and 40 women; mean age, 62 +/- 9 years) who underwent elective cardiac surgery after PAD (959 +/- 240 ml), often using iron supplement and recombinant human erythropoietin. Allogenic blood transfusion was avoided during and after surgery in 107 patients (75%), whereas 36 patients required an allogenic transfusion (4.1 +/- 3.8 U of packed red cells, 3.4 +/- 4.1 U of fresh frozen plasma, and 5.8 +/- 11.0 U of platelet concentrate). The independent factors for perioperative allogenic blood transfusion in these patients included the pre-donation hemoglobin value, the preoperative platelet count, and the lowest hemoglobin value during cardiopulmonary bypass. Even with PAD for elective cardiac surgery, patients whose pre-donation hemoglobin value and preoperative platelet count are low may require allogenic blood transfusion.

Blood Management in Total Knee Arthroplasty: A Comparison of Techniques

Patients undergoing total knee arthroplasty (TKA) are at high risk for postoperative anemia and allogeneic blood transfusions. Risks associated with allogeneic blood exposure (ie, infection, fluid overload, and longer hospital stays) have prompted alternative blood management strategies. The main goal of this study was to evaluate whether a single change in the clinical blood management of patients undergoing TKA reduced the severity of postoperative anemia or the need for allogeneic blood transfusions. A second goal of this study was to assess the financial impact of the change on the institution. This study compared perioperative cell salvage, preoperative autologous blood donation, and the practice of using allogeneic blood alone in patients undergoing TKA. Clinical and financial data of 154 unique cases of primary TKA at the Mayo Clinic Arizona were retrospectively reviewed. Transfusion rates were 25%, 18%, and 52% respectively for patients in the cell salvage, preoperative autologous blood donation, and allogeneic blood only groups. Respective relative risk reductions were 51.9% (P=.007) and 65.4% (P=.002) with the use of cell salvage or preoperative autologous blood donation versus allogeneic alone. Cell salvage and preoperative autologous blood donation were found to significantly reduce the requirements for allogeneic blood transfusions; these techniques were found to be roughly equivalent in clinical benefit when compared to the use of allogeneic blood alone. The logistical advantages of cell salvage (ie, no preoperative blood donation, no risk of wasting blood units) were associated with greater costs to the institution.

下顎枝矢状分割術時における貯血式自己血輸血の検討

Blood transfusion is occasionally needed in orthognathic surgery. In our department, to avoid allogenic transfusions and, to obtain autofibrin glue which promotes intraoperative primary hemostasis, we collected blood for autologous blood donation (ABD) during unilateral surgeries such as sagittal split ramus osteotomy (SSRO). We conducted a retrospective survey of the SSRO in our department and investigated the efficacy of ABD. Furthermore, we investigated the factors that could predict those patients whose recovery from anemia would be delayed, before phlebotomy.We investigated the patients who required preoperative ABD before independent SSRO. Within 24 hours following the surgery, the blood was transfused. To investigate the postoperative influence of the preoperative autologous blood collection, we divided the subjects into a recovered group in whom Hb value on day 7 after the surgery was less than 5% of the value prior to ABD, and all other subjects into the non-recovered group. Moreover, we investigated whether our results contained any factors that could predict these non-recovered patients prior to surgery. Significance was established at p < 0.05.There were 4 cases in which bleeding in excess of 20% of the predicted blood circulation was observed. Although there was no significant difference between the Hb value prior to autologous blood collection, the non-recovered group showed a higher value than the recovered group. The lowest Hb value for both groups occurred on day 4 after the surgery, irrespective of whether an ABD was performed. We predicted that, if the blood was not transfused, the Hb value at this period might be further decreased. Even in cases where allogenic transfusions were considered because of the degree of bleeding, we believe that preoperative ABD during SSRO is advantageous.This investigation suggests that it is possible to use the patient's weight and Hb value prior to blood collection for predicting the patient's inclusion in the non-recovered group.We investigated the efficacy of preoperative ABD during orthognathic surgery. In almost all cases, we believe that no indication for allogenic transfusions was present. However, we believe that preoperative ABD, with primary hemostasis using fibrin glue and avoiding allogenic transfusion that can cause unpredictable significant blood loss, is the preferred method of transfusion.

Blood transfusion for the treatment of acute anaemia in inflammatory bowel disease and other digestive diseases

Allogeneic blood transfusion (ABT) is frequently used as the first therapeutic option for the treatment of acute anaemia in patients with inflammatory bowel disease (IBD), especially when it developed due to gastrointestinal or perioperative blood loss, but is not risk-free. Adverse effects of ABT include, but are not limited to, acute hemolytic reaction (wrong blood or wrong patient), febrile non-hemolytic transfusional reaction, bacterial contamination, transfusion-related acute lung injury, transfusion associated circulatory overload, transfusion-related immuno-modulation, and transmission of almost all infectious diseases (bacteria, virus, protozoa and prion), which might result in increased risk of morbidity and mortality. Unfortunately, the main physiological goal of ABT, i.e. to increase oxygen consumption by the hypoxic tissues, has not been well documented. In contrast, the ABT is usually misused only to increase the haemoglobin level within a fixed protocol [mostly two by two packed red blood cell (PRC) units] independently of the patient's tolerance to normovolemic anaemia or his clinical response to the transfusion of PRC units according to a "one-by-one" administration schedule. Evidence-based clinical guidelines may promote best transfusion practices by implementing restrictive transfusion protocols, thus reducing variability and minimizing the avoidable risks of transfusion, and the use of autologous blood and pharmacologic alternatives. In this regard, preoperative autologous blood donation (PABD) consistently diminished the frequency of ABT, although its contribution to ABT avoidance is reduced when performed under a transfusion protocol. In addition, interpretation of utility of PABD in surgical IBD patients is hampered by scarcity of published data. However, the role of autologous red blood cells as drug carriers is promising. Finally, it must be stressed that a combination of methods used within well-constructed protocols will offer better prospects for blood conservation in selected IBD patients undergoing elective surgery.

Continuous improvement of our autologous blood donation program carried out during 10 years in 1198 orthopaedic patients

Background We analysed the relationship between baseline haemoglobin levels and the need for post-operative blood transfusion in our patients. The aim of this study was to evaluate and optimize the pre-operative autologous blood donation (PABD) program at our hospital through a constant audit. Materials and methods Between January 1997 and December 2006 we evaluated 1198 consecutive patients who underwent elective, unilateral, primary total hip or knee arthroplasty and who met our inclusion criteria. We determined the baseline haemoglobin level to establish the relationship to the need for post-operative transfusion. Results The results of our study show that the baseline haemoglobin level is a strong predictor of blood transfusion after unilateral, primary total hip or knee arthroplasty. Conclusions The baseline haemoglobin level is a strong predictor of blood transfusion after elective, unilateral, primary total hip or knee arthroplasty. On the basis of these findings, we do not recommend autologous predonation for patients with a baseline haemoglobin level of >14 g/dl moreover we always recommend the use of a blood cell salvage system and a constant audit of pre-operative autologous blood donation (PABD) to avoid unnecessary expense and waste.

Blood conservation strategies in major orthopaedic surgery: efficacy, safety and European regulations

Several major orthopaedic surgical procedures may result in significant blood loss and the need for allogeneic blood transfusion (ABT). However, overall concerns about adverse effects of ABT have prompted the review of transfusion practice and the search for transfusion alternatives to decrease or avoid the use of ABT. These strategies include the correction of perioperative anaemia, pharmacological and non-pharmacologic measures to reduce blood loss, preoperative autologous blood donation and perioperative red blood cell salvage. We have reviewed the efficacy and safety of these strategies and where appropriate offer evidence-based recommendations on their use in orthopaedic surgery. We also reviewed the European regulations on ABT alternatives. Pharmacological alternatives need to be used with a total adherence to European regulations in their legal and off-label use. The administration and use of pharmacological agents to stimulate erythropoiesis or reduce blood loss needs to be within the context of attempting to use allogenic blood in a rational manner. As for autologous blood, European Directives cover preoperative autologous blood donation, but not its clinical use, and perioperative red blood cell salvage devices, but not the product yielded by them. Therefore, the development of quality standards and good practice guidelines for perioperative red blood cell salvage, as well as its inclusion in the haemovigilance programme, is urgently needed. Finally, it is noteworthy that some recommendations given for ABT alternatives are not supported by a high level of evidence and that the goal of performing major orthopaedic surgical procedures without the use of ABT may be better accomplished by combining several of these techniques within a defined algorithm.

Leukodepletion of autologous whole blood has no impact on perioperative infection rate and length of hospital stay

Several mechanisms have been proposed as possible causes of transfusion-related immunomodulation (TRIM) after allogeneic transfusion. If one of these mechanisms, the release of mediators of immunity and inflammation ("biologic response modifiers"[BRMs]) from disintegrating blood cells during storage of blood products, really causes TRIM, it should in principle also occur after autologous transfusion. As a consequence, prestorage leukoreduction of autologous blood should be able to prevent the clinical consequences of TRIM after autologous transfusion. This hypothesis was investigated in a multicenter, double-blind, randomized controlled trial. A total of 1089 patients scheduled for total hip arthroplasty and eligible for preoperative autologous blood donation were randomly assigned to receive autologous whole blood (AWB) either unmodified or leukoreduced when transfusion was indicated. Neither the primary study outcome, that is, the overall postoperative infection rate (17.3% vs. 17.6%, p = 0.59), nor several secondary outcomes like median length of hospital stay (14 days vs. 14 days, p = 0.17) were significantly different between groups, whether analyzed according to the intention-to-treat principle or "as treated." This trial provides strong evidence, from clinically relevant outcome data, that leukoreduction of AWB does not improve postoperative patient outcome and that the release of BRMs from disintegrating blood cells during storage cannot explain the immunomodulatory effect of blood transfusion.