Preoperative Autologous Donation Research Articles

Fremdblutsparende Maßnahmen bei orthopädischen Eingriffen

Major transfusion-free orthopaedic surgery can be performed successfully. This requires advanced planning, good routines and close collaborative team efforts. Since most blood saving techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative and postoperative blood saving approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, intraoperative autotransfusion, individualized assessment of anemia tolerance, meticulous surgical techniques and the use of pharmacologic agents for limiting blood loss. For various reasons, we do not recommend the transfusion of wound drainage. This article describes the various methods for bloodless medical care.

A Randomized, Parallel-Group, Open-Label Trial of Recombinant Human Erythropoietin vs Preoperative Autologous Donation in Primary Total Joint Arthroplasty: Effect on Postoperative Vigor and Handgrip Strength

This randomized trial assessed the effect of recombinant human erythropoietin (EPO) vs preoperative autologous donation (PAD) on postoperative vigor and handgrip strength in patients undergoing primary total joint arthroplasty. Adults with baseline hemoglobin level of 11 to 14 g/dL received EPO (600 IU/kg once weekly for 4 doses, n = 130) or PAD (n = 121) before primary, unilateral hip or knee arthroplasty. Mean changes in vigor score and handgrip strength from baseline were not significantly different between treatment groups. Multivariate analyses found a significant treatment effect favoring EPO over PAD for vigor, but not for handgrip strength. Patients in the EPO group had higher hemoglobin levels and required fewer transfusions. Both treatments were well tolerated. Additional study is needed to elucidate the influence of blood management strategies on postoperative vigor.

Peri-operative blood management in elective orthopaedic surgery. A critical review of the literature

Blood loss during orthopaedic procedures can be extensive and the need for allogeneic blood is a common requirement. However, blood transfusion conceals a number of well-recognised risks and complications and blood products have become more expensive because of their specific preparation procedure. Surgical technique, awareness of the problem and restriction of transfusion triggers are important factors affecting the management of blood loss. Several studies have additionally shown the efficacy of epoetin injections in increasing the pre-operative haemoglobin level. On the other hand, the true benefit of pre-operative autologous donation, acute normovolemic haemodilution and COX-2 selective NSAIDs remains under dispute. Regarding the role of platelet rich plasmapheresis, fibrin sealing and anti-fibinolytic drugs more data are needed. Hypotensive epidural anaesthesia seems to be an advantageous method in minimising peri-operative blood loss. However, this is not a widely performed technique in orthopaedic surgery. In addition, post-operative blood cell saving systems after total knee or hip arthroplasty have been reported to significantly minimise allogeneic blood transfusions when compared to control groups. It can be concluded that many interventions diminish more or less allogeneic blood transfusion in elective orthopaedic surgery. Nevertheless more prospective studies are needed and appropriate algorithms should be applied in peri-operative blood loss management. This review presents an overview of the available interventions which aim to diminish the use of allogeneic blood in elective orthopaedic surgery.

Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes

Background context Spine surgery for scoliosis is associated with significant blood loss and may require blood transfusion. The risks inherent in blood transfusion have inspired interventions, including human recombinant erythropoietin (rHuEPO), which has emerged as a safe and effective adjunct in minimizing exposure to allogenic blood in children undergoing scoliosis surgery. However, there is little information in the literature on their economic impact on the health-care system. Purpose The purpose of this study was to evaluate the cost-effectiveness of rHuEPO in adolescent idiopathic scoliosis. Study design/setting We designed a decision analytic model capturing costs and potential long-term outcomes of transfusion-related complications to compare the cost-effectiveness of preoperative rHuEPO with a control group and a common alternative, preoperative autologous donation (PAD). Patient sample This is a decision analytic model. Decision modeling relies on a summation of the probability of different clinical studies; no patients were specifically studied. Outcome measures The standard cost-effectiveness ratio (C/E) of $50,000 per quality-adjusted life year (QALY) was used as the threshold value for determining the cost-effectiveness of these two preoperative intervention strategies. Methods From the model we calculated the probability that a patient would experience transfusion-related complications based on the mean number of allogenic units transferred as a result of scoliosis surgery. The standard C/E of $50,000 per QALY was used as the threshold value for determining the cost-effectiveness. Some aspects of the model were derived from retrospective data from the literature. Sensitivity analyses were also conducted to discover which variables, when changed within the accepted range, caused the final result of the model to change significantly. Results Results indicated a cost per year-of-life-saved exceeding $1 million for the PAD arm and over $1.5 million for the rHuEPO arm. The low rates of transfusion in adolescent idiopathic scoliosis surgery and the relative safety of the blood supply create a scenario where even inexpensive interventions are not cost-effective. However, rHuEPO would become cost-effective if decreased transfusion rates or higher postoperative hematocrit resulted in decreased length of stay. Conclusion The use of rHuEPO preoperatively and the use of PAD are not cost-effective although both techniques remain clinically effective tools.

Cost-effectiveness of cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion: a systematic review and economic model

To compare patient outcomes, resource use and costs to the NHS and NHS Blood Transfusion Authority (BTA) associated with cell salvage and alternative methods of minimising perioperative allogeneic blood transfusion. Electronic databases covering the period 1996-2004 for systematic reviews and 1994-2004 for economic evidence. Existing systematic reviews were updated with data from selected randomised controlled trials (RCTs) that involved adults scheduled for elective non-urgent surgery. Any resource use or cost data were extracted for potential use in populating an economic model. Relative risks or weighted mean difference of each outcome for each intervention were assessed, taking into account the number of RCTs included in each outcome and intervention and the presence of any heterogeneity. This allowed indirect comparison of the relative effectiveness of each intervention when the intervention is compared with allogeneic blood transfusion. A decision analytic model synthesised clinical and economic data from several sources, to estimate the relative cost-effectiveness of cell salvage for people undergoing elective surgery with moderate to major expected blood loss. The perspective of the NHS and patients and a time horizon of 1 month were used. The economic model was developed from reviews of effectiveness and cost-effectiveness and clinical experts. Secondary analysis explored the robustness of the results to changes in the timing and costs of cell salvage equipment, surgical procedure, use of transfusion protocols and time horizon of analysis. Overall, 668 studies were identified electronically for the update of the two systematic reviews. This included five RCTs, of which two were cell salvage and three preoperative autologous donation (PAD). Five published systematic reviews were identified for antifibrinolytics, fibrin sealants and restrictive transfusion triggers, PAD plus erythropoietin, erythropoietin alone and acute normovolaemic haemodilution (ANH). Twelve published studies reported full economic evaluations. All but two of the transfusion strategies significantly reduced exposure to allogeneic blood. The relative risk of exposure to allogeneic blood was 0.59 for the pooled trials of cell salvage (95% confidence interval: 0.48 to 0.73). This varied by the type and timing of cell salvage and type of surgical procedure. For cell salvage, the relative risk of allogeneic blood transfusion was higher in cardiac surgery than in orthopaedic surgery. Cell salvage had lower costs and slightly higher quality-adjusted life years compared with all of the alternative transfusion strategies except ANH. The likelihood that cell salvage is cost-effective compared with strategies other than ANH is over 50%. Most of the secondary analyses indicated similar results to the primary analysis. However, the primary and secondary analyses indicated that ANH may be more cost-effective than cell salvage. The available evidence indicates that cell salvage may be a cost-effective method to reduce exposure to allogeneic blood transfusion. However, ANH may be more cost-effective than cell salvage. The results of this analysis are subject to the low quality and reliability of the data used and the use of indirect comparisons. This may affect the reliability and robustness of the clinical and economic results. There is a need for further research that includes adequately powered high-quality RCTs to compare directly various blood transfusion strategies. These should include measures of health status, health-related quality of life and patient preferences for alternative transfusion strategies. Observational and tracking studies are needed to estimate reliably the incidence of adverse events and infections transmitted during blood transfusion and to identify the lifetime consequences of the serious hazards of transfusion on mortality, health status and health-related quality of life.

Objectives and limitations of bloodless medical care

To outline the rationale, limitations, and execution of bloodless medical and surgical programs, highlighting characteristics that contribute to successful outcomes. Clinical experiences with patients who refuse blood transfusions for religious reasons have provided valuable lessons and raise intriguing questions about the necessity of routine blood transfusions. Healthcare centers with bloodless medicine and surgery programs feature a novel concept of patient care aimed at improving outcomes. A one-tiered approach to minimize blood usage for all patients, regardless of religious beliefs, is being successfully adopted at an increasing number of institutions. Since most single blood-conservation techniques reduce blood usage by just 1-2 units, a series of integrated preoperative, intraoperative, and postoperative conservation approaches is required. These include preoperative autologous donation, erythropoietic support, acute normovolemic hemodilution, individualized assessment of anemia tolerance, implementation of conservative transfusion thresholds, meticulous surgical techniques, and judicious use of phlebotomy and pharmacologic agents for limiting blood loss. The objectives of bloodless medicine and surgery programs are straightforward but require staff with expertise in transfusion medicine, intensive teamwork, patient-specific customization, careful planning, and integrated use of multimodal strategies.

Intravenous Iron in Colorectal Cancer Surgery

Patients requiring elective colorectal cancer surgery have a high prevalence of anemia and iron deficiency. Intravenous iron therapy, with or without recombinant erythropoietin (EPO), may play an important role in the correction of perioperative anemia and facilitate preoperative autologous donation, thus reducing the risk of patient exposure to allogeneic red blood cell (RBC) transfusion and improving patient outcomes. In addition, the use of intravenous iron allows for a significant reduction in EPO dose requirements. However, large and well-conducted randomized controlled trials are needed to define more cost-effective intravenous iron and EPO regimens.

Une pratique transfusionnelle optimale

RANSFUSION therapy has undergone several changes over the years with supply challenges and the realization that blood transfusions are not innocuous. Blood conservation strategies have taken the forefront in research communities. Hematinic agents have been advocated as a means of increasing the hemoglobin concentration to counterbalance blood loss. Reducing preoperative exposure to anticoagulants has been debated to reduce the risk of perioperative bleeding. Alternatives to allogeneic blood such as autologous blood (i.e., preoperative autologous donation, acute normovolemic hemodilution, red cell salvage) have gained some acceptance in their role in reducing expo

Acute normovolemic hemodilution in orthopedic surgery

SUMMARYAcute normovolemic hemodilution (ANH) is an autologous blood collection technique that involves the removal of whole blood from a patient on the day of surgery shortly before an anticipated significant surgical blood loss. ANH is one of the least expensive blood‐conservation practices because it is a ‘point‐of‐care’ strategy that is performed in the operating room at the time of surgery. As ANH and preoperative autologous donation (PAD) have equivalent efficacy but ANH is much less expensive than PAD, ANH is the logical choice for the procurement of autologous blood.

A provincial program of blood conservation: The Ontario Transfusion Coordinators (ONTraC)

Purpose Although often life-saving, blood transfusions are associated with significant risk to the patient and escalating costs to the blood system and hospital. Transfusions are often given unnecessarily. Blood conservation represents the use of alternatives to transfusion. The ONTraC program attempts to enhance transfusion practice outside the blood transfusion laboratory, promote blood conservation in surgery patients, and reduce allogeneic red cell use. Methods In the first such large scale program, funding was obtained from the Ontario MOHLTC for a Transfusion Coordinator in 23 Ontario hospitals selected based on blood utilization and geography. At specific time periods, detailed anonymized information was collected in a defined number of all consecutive patients admitted for the three designated surgical procedures: knee arthroplasty ( N = approximately 1200 at each time point), abdominal aortic aneurysm (AAA; N = 300 at each time) and coronary artery bypass graft (CABG) surgery ( N = 300 at each time point). Results Considerable inter-institutional variation was observed in the proportion of patients and amount of blood transfused. At the 12 month analysis, most, although not all, hospitals had decreased use of allogeneic blood and there was an overall 24% reduction in blood use in patients undergoing knee surgery, 14% in AAA and 23% in CABG. In addition to reduction in proportion of patients transfused, transfused patients received fewer units of allogeneic blood. Patients who did not receive allogeneic transfusions had significantly lower postoperative infection rates ( p < 0.05) and length of stay ( p < 0.0001); multivariate analysis showed that allogeneic transfusion was an independent predictor of increased length of stay. Eighteen-month analysis indicates even greater reduction in allogeneic transfusion. The main measures of blood conservation employed were preoperative autologous donation and education, with recent increasing use of erythropoietin and the cell saver. These measures have been demonstrated to be very effective in avoiding allogeneic transfusion. Conclusions The ONTraC have become leaders locally, nationally and internationally in blood conservation. The reduction in allogeneic transfusion associated with the implementation of the ONTraC program represents important savings in costs associated with blood components, hospital stay and work in transfusion laboratories and nursing units, as well as enhancing patient satisfaction and safety.

Economic analysis of the implementation of autologous transfusion technologies throughout England

This study aims to provide the first estimates of the costs and effects of the large scale introduction of autologous transfusion technologies into the United Kingdom National Health Service. A model was constructed to allow disparate data sources to be combined to produce estimates of the scale, costs, and effects of introducing four interventions. The interventions considered were preparing patients for surgery (PPS) clinics, preoperative autologous donation (PAD), intraoperative cell salvage (ICS), and postoperative cell salvage (PoCS). The key determinants of cost per operation are the anticipated level of reductions in blood use, the mean level of blood use, mean length of stay, and the cost of the technology. The results show the potential for considerable reductions in blood use. The greatest reductions are anticipated to be through the use of PPS and ICS. Vascular surgery, transplant surgery, and cardiothoracic surgery appear to be the specialties that will benefit most from the technologies. Several simplifications were used in the production of these estimates; consequently, caution should be used in their interpretation and use. Despite the drawbacks in the methods used in the study, the model shows the scale of the issue, the importance of gathering better data, and the form that data must take. Such preliminary modeling exercises are essential for rational policy development and to direct future research and discussion among stakeholders.

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

Gerard W. Ostheimer “What’s New in Obstetric Anesthesia” Lecture

ANESTHESIOLOGY CME PROGRAM

Anesthesiology’s journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians.The American Society of Anesthesiologists designates this continuing medical education program for a maximum of 1 hour of Category 1 credit toward the AMA’s Physician Recognition Award. Each physician should claim only those hours of credit actually spent in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading the article related to this program, participants should be familiar with advances in obstetric anesthesia in the topics reviewed.Authors – Lawrence C. Tsen, M.D.Grants or research support: NoneConsultantships or honoraria: NoneThe article authored by Dr. Tsen was supported solely from institutional and/or departmental sources.Question Writer – Peter L. Bailey, M.D. Dr. Bailey has no grants, research support, or consultant positions, nor does he receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Tsen entitled “Gerard W. Ostheimer ‘What’s New in Obstetric Anesthesia’ Lecture”http://content.wkhealth.com/linkback/openurl/trusted?issn=0003-3022&amp;volume=102&amp;issue=3&amp;spage=672&amp;part=fulltextin the March issue of Anesthesiology, choose the one correct answer for each question:1. Which of the following statements concerning preeclampsia is most likely true?A. The etiology of preeclampsia is well understood.B. Aspirin prophylaxis increases the incidence of perinatal death.C. Autoregulation of cerebral blood flow remains intact until the very late stages of preeclampsia.D. Isosorbide dinitrate significantly impairs cerebral blood flow autoregulation in preeclamptic patients.2. Which of the following statements concerning the management of preeclamptic patients is most likely true?A. Magnesium is the drug of choice for seizure prevention.B. The goal of blood pressure control should be to achieve normal values.C. Spinal anesthesia for cesarean delivery is contraindicated.D. Mortality after general anesthesia for cesarean delivery is lower than after neuraxial anesthesia.3. Intravenous corticosteroids in patients with the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) have been reported to result in all of the following except A. a reduction in the clinical expression of the syndrome.B. improved recovery from HELLP.C. exacerbation of high blood pressure.D. improved platelet count.4. Which of the following statements concerning management strategies for hemorrhage in the obstetric patients is most likely true?A. Preoperative autologous donation should start one week prior to anticipated delivery.B. Acute normovolemic hemodilution does not have a role.C. Intraoperative blood salvage should be routinely employed during cesarean section.D. A Sengstaken-Blakemore tube, placed in the uterus, can prevent the need for hysterectomy.5. Which of the following statements concerning informed consent in obstetric patients is most likely true?A. It is widely agreed upon that true informed consent is not possible in a laboring patient.B. The informed consent process should be viewed as a tool to foster a better patient–physician relationship.C. The use of a separate consent form for anesthesia is widespread.D. In general, the perception of patients is that anesthesia is associated with significant risks.

Orthopaedic-Induced Anemia

Total knee arthroplasty is associated with significant blood loss. Despite the initiation of various blood conservation modalities, allogeneic transfusion has yet to be eliminated. One hundred forty-eight patients who had unilateral primary total knee arthroplasties during a 3-year period were evaluated retrospectively for blood loss and transfusion rates. The patients were prescribed one unit of preoperative autologous donation that was to be transfused automatically on postoperative Day 1. Allogeneic transfusion was based on symptoms, and no numerical transfusion triggers were used. The preoperative autologous donation program resulted in increased preoperative anemia. Whereas only 26.2% of patients were in the high transfusion-risk group (hemoglobin >10 g/dL and < or = 13 g/dL) before surgery, 55.7% of patients were in this high-risk category after preoperative autologous donation. The patients did not recover from the autologous donations that occurred 4 weeks before surgery. A mean hemoglobin level of 14.0 g/dL was seen before donation, whereas the mean preoperative hemoglobin level decreased to 12.6 g/dL. We think that a preoperative autologous donation program leads to an increased risk of anemia before surgery.

Blood Loss and Transfusion Rates in Bilateral Total Knee Arthroplasty

From 1994 to 1998, we performed 170 bilateral total knee arthroplasties (TKAs) with cemented, posterior cruciate-substituting prostheses. Blood management included preoperative autologous donation, symptom-based transfusion, and autoreinfusion devices. Perioperative allogeneic transfusion rates for patients who donated 0, 1, 2, 3, or 4 units of blood were 40.00%, 0.00%, 3.70%, 0.00%, and 3.23%, respectively. Preoperative autologous donation >2 units also resulted in lower preoperative hemoglobin levels. For bilateral TKA, a protocol of 2 preoperative autologous donation units and reinfusion of postoperative drainage reduces anemia during the preoperative and postoperative periods.

Autologous Blood Transfusion in TRAM Breast Reconstruction:

Many centers continue to use preoperative donation of autologous blood as part of their reconstructive protocol for pedicled transverse rectus abdominis musculocutaneous (TRAM) breast reconstruction, despite the lack of support for this in the English language literature. This prospective study compares 3 groups of patients undergoing reconstruction with TRAM flaps using 3 different protocols in 3 different centers. Group 1 did not donate blood preoperatively. Group 2 donated 1 to 2 U preoperatively and received their blood intraoperatively or during the early postoperative period. Group 3 did not receive their autologous blood unless they displayed symptoms of hypovolemia or anemia postoperatively. There were no statistical differences between groups in age, length of stay, or number of unilateral versus bilateral procedures. Patients who did not donate autologous blood (group 1) had statistically significantly higher preoperative and postoperative day 3 hemoglobin levels than patients in the groups that did predonate. The authors conclude that preoperative autologous donation of blood does not confer any clinical advantage to patients undergoing autologous breast reconstruction using pedicled TRAM flaps.

Critical Evaluation of Preoperative Autologous Donation (PAD) in Surgery.

PAD effectively reduces exposure to allogeneic blood and its attendant risks in the surgical setting (JBJS Am. 1999; 81:2–10). However, its use is declining as concerns regarding efficacy, safety, cost and convenience emerge (Crit Care. 2004; 8(suppl2):S49–S52). The objective of this paper is to review the evidence-based risk/benefit profile of PAD in the perisurgical setting. A MEDLINE search (1994-July 2004) was conducted using the following strategy: preoperative autologous blood donation; autologous blood donation; OR autologous blood transfusion AND (safety; adverse events; adverse effects; patient satisfaction; quality of life; cost OR pharmacoeconomics) NOT dialysis AND clinical trial AND English AND human [MeSH]. 130 unique references were evaluated; relevant references are discussed in this section. It is commonly acknowledged that PAD can reduce allogeneic transfusion (tx) rates in the perisurgical setting. Other benefits include: supplementation of the blood supply, provision of compatible blood for patients (pts) with alloantibodies, and prevention of disease transmission, RBC alloimmunization, and some adverse tx reactions (Crit Care. 2004; 8(suppl2):S49–S52). As a result, PAD may reduce hospital LOS (JBJS Br. 1997; 79:630–632). Both donation and tx of autologous blood are associated with unique risks. Donation causes a phlebotomy-induced anemia which may not stimulate erythropoiesis sufficiently to restore the donated blood (Orthopedics. 1999; 22(suppl1):s105–12; JBJS Am. 1998; 80-A:750–762; Arch Orthop Trauma Surg. 2001; 121:162–5; JBJS Am. 2004; 86-A:1512–1518; JBJS Am. 2003; 85-A:2485–6). Safety issues linked to donation include arterial hypotension in pts with cardiovascular disease (Transfusion. 2002; 42:226–231), precipitation of angina and cardiac arrest, and mild dizziness and light-headedness (Cleve Clin J Med. 1996; 63:295–300). Donation is time consuming and inconvenient, thus economically burdensome to patients and to healthcare providers who collect, process, and transfuse the blood (Clin Orthop. 2004;(423):240–4). The total tx burden (autologous + allogeneic) may be increased in those who donate and receive their own blood (Orthopedics. 1999; 22(suppl1):s105–12). When autologous blood is available, a physician may have a low threshold to transfuse, with the result that autologous blood tx is often inappropriate in relation to cardiopulmonary risk (Urology 1999; 54:130–4). Safety issues associated with autologous blood tx include tx reactions due to bacterial contamination during collection and storage (Cleve Clin J Med 1996; 63:295–300, Crit Care. 2004; 8(suppl2):S49–S52) and increased concentrations of IL-6 and IL-8 in recipients (Anesthesiology. 1997; 87:511–6). Autologous blood tx carries many of the same risks as allogeneic: volume overload, ABO incompatibility due to administrative error (Crit Care. 2004; 8(suppl2):S49–S52) and reduced oxygen-carrying capacity as a result of the RBC storage lesion (Orthopedics. 2004; 27(suppl6):s643–51, Crit Care Med. 2004; 8(suppl2):s24–s26). Finally, inability to release unused autologous blood into the general blood pool because of inadequate screening causes a high rate of wastage, and renders PAD extremely cost inefficient (Urology. 1999; 54:130–4, J Clin Anesth. 1997; 9:26–9). PAD in the surgical setting should be used judiciously and cautiously, weighing all associated risks and benefits. Alternative management strategies warrant careful consideration.

3. Internationales Symposium: „Autologe Transfusion - Von der Euphorie zur Ratio: Praktisches Handeln aus wissenschaftlicher Sicht” (Teil II)Autologe Transfusion bei Kindern - Fremdblutsparende Verfahren

It is uncontested that blood-saving strategies should also be applied in children. However, in the past, blood-saving techniques saw limited use in children, although they are well-established in adults. This is due to technical and methodical problems, but also to the physiologically limited compensatory mechanisms for diminished oxygen delivery in this age group. For this reason, the various blood saving-techniques cannot be universally applied to all age groups. During the first year of life most perioperative techniques are of only limited benefit: even only a small amount of blood loss in relation to total blood volume makes a transfusion of allogeneic blood necessary, which is far before enough shed blood can be recovered for retransfusion. Preoperative autologous donation of blood calls for a high degree of cooperation by the child and the parents an is equally demanding in terms of organization and skills. Therefore, this procedure is used mainly in school-age children and in adolescents. Intraoperative blood salvage, by contrast, is already worthwhile in children from age one year with an expected blood loss of 20 % of blood volume. Acute normovolemic hemodilution and deliberate hypotension should be recommended only in an age group where cardiovascular compensatory mechanisms are given. Supporting procedures aimed at avoiding the need for allogeneic blood include perioperative administration of erythropoietin, iron supplementation, blood-saving surgical techniques and careful hemostasis. These prerequisites, the combination of various techniques, as well as the definition of an age-specific low transfusion trigger have contributed to a marked decrease in the need for allogeneic blood products in children in recent years.

The Pharmacoeconomics of Alternatives to Allogeneic Blood Transfusion

SUMMARY Background and Objectives: Pharmacoeconomics provides a standardized methodology for valid comparisons of interventions in different fields of healthcare. The role of pharmacoeconomics in the safety of blood, blood products and alternatives has however been very limited up to today. This paper discusses the pharmacoeconomic evaluations of alternatives to blood transfusion that have been published in the scientific literature. Methods: We reviewed pharmacoeconomic methodology with special reference to cost‐effectiveness and cost‐utility analysis. We searched the literature for such cost‐effectiveness analyses related to alternatives to blood transfusion. Results: Net costs per quality‐adjusted life year (QALY) gained varied from cost‐saving for reduction of blood transfusions by antifibrinolytics and for analyses which included assumed complications caused by transfusion‐related immunomodulation to more than a hundred millions of US$ per QALY gained for preoperative autologous donation by transurethral prostatectomy patients and epoetin augmentation of preoperative autologous donation. Conclusions: Currently preoperative autologous blood donation with or without epoetin augmentation and epoetin in the absence of autologous transfusion cannot be regarded as cost‐effective healthcare interventions for the general population. Perioperative use of antifibrinolytics may be cost‐saving, but at present evidence is scarce. Cost‐effectiveness of alternatives to blood transfusion may improve if the impact of adverse effects of allogeneic transfusion, such as immunomodulation, bacterial infection and TRALI, can be further substantiated, if the costs of allogeneic blood transfusion continue to rise due to the introduction of (more) safety measures or if donor blood becomes scarce.

In Reply

We are very thankful to Muñoz et al. for their interest in our recent article. 1We agree with their speculation that transfusion-related acute lung injury might be one of the various causes explaining prolonged mechanical ventilation. However, the relationship between transfusion and transfusion-related acute lung injury and mechanical ventilation is difficult to establish in cardiac surgery patients, who are known to be under the influence of many other causes of pulmonary dysfunction. 2For instance, the association between the number of units transfused and mechanical ventilation may be due to an overload of transfused units, thus favoring the occurrence of pulmonary edema.In our series, platelet transfusion (as a dichotomous variable) was considered a risk factor for morbidity. However, in the preliminary multivariate analysis, patients transfused with platelets did not show a higher morbidity than those not receiving platelet transfusions. Therefore, platelet storage time was not considered necessary to investigate.We demonstrated an association existing between nosocomial pneumonia and the number of erythrocyte concentrate units transfused, 3and between nosocomial pneumonia and length of storage of erythrocyte concentrate. 1This is not unexpected, though, as the potential deleterious effects of the storage time may multiply according to the number of units transfused.We also agree that blood-saving programs and alternatives to allogeneic transfusion are needed. However, the applicability or effectiveness of many methods remains controversial, so preoperative autologous donation programs are effective in decreasing allogeneic blood transfusion but are costly and applicable to elective patients only. The effectiveness of acute normovolemic hemodilution is too unreliable to decrease the risk of allogeneic blood transfusion in elective cardiac surgical patients with normal cardiac function. 4Moreover, among the pharmacologic strategies for blood conservation, antifibrinolytics such as aprotinin are the only agents that have been shown to reduce the risk of mortality after cardiac surgery. 5We believe that the judicious use of rational transfusion guidelines may still be the most simple and cost-effective means of blood conservation. However, blood consumption is still high and is unavoidable, thus justifying the need for studies designed to clarify the potential deleterious effects of blood transfusion, including storage.