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

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

Should autologous blood that tests positive for infectious diseases be used or discarded?

Decision analysis was applied to the question of whether to keep or discard autologous blood donations that test positive for viral markers. The decision is reached by analyzing a series of different events that lead to different outcomes. The probability of each event must be estimated and a value ("utility") assigned to specific outcomes. The underlying assumptions of the analysis are reviewed. After assigning a probability to each event and a utility to each outcome, one can compute a probability (P*) that is compared to the likelihood that the autologous donor will need transfusion. If the probability of transfusion exceeds P*, then keeping the infectious unit is favored. Otherwise, discarding the infectious unit is preferred. The analysis argues against a single, uniform national policy regarding the disposition of infectious autologous units. The method outlined provides a rational basis for setting policy regarding a controversial issue in Transfusion Medicine.     

Do reactions after whole blood donation predict syncope on return donation?

BACKGROUND: Adverse reactions after whole blood donation reduce the likelihood of a subsequent donation. Still, many donors return to give blood even after experiencing a reaction. Consequently, we evaluated the risk of recurrent syncope among returning donors. STUDY DESIGN AND METHODS: Allogeneic whole blood donors in 2009 who had vasovagal‐type reactions including syncope were evaluated for return donation within 12 months and subsequent reactions, based on donation status (novice [first‐time] or active [repeat]) or age at index donation. RESULTS: Syncope after a first whole blood donation significantly reduced the frequency of return donation (18%), compared to either presyncopal symptoms (27%; p < 0.0001) or no reaction (35%; p < 0.0001). Among novice donors who returned to donate, syncope was more likely among donors who had any reaction (0.8%) or syncope (3.5%) at their first donation, compared to donors who had no reaction (0.3%; p < 0.0001). Syncope at a first donation identified only 2% (19 of 1062) of syncopal reactions among returning donors. For active, repeat donors who experienced syncope in 2009, a history of prior reactions had no effect on the likelihood of return donation or recurrent syncope. CONCLUSION: Donation experience strongly influences the likelihood of return donation and the risk of subsequent reactions, but a prior reaction after whole blood donation does not reliably predict recurrent syncope among returning donors.     

Erythropoietin and preoperative autologous blood donation in the prevention of hepatitis C infection:necessity or luxury?

BACKGROUND: Prevention of exposure to allogeneic blood transfusion during surgery is an important financial issue when recombinant human erythropoietin (rHuEPO) is used in addition to preoperative blood donation. STUDY DESIGN AND METHODS: The aim of this study was to carry out a cost-effectiveness analysis of the use of rHuEPO in preoperative blood donation in orthopedic surgery. The study, based on a decision tree analysis of the use of rHuEPO, was conducted from the perspective of the French health care system. The efficacy criterion was the number of hepatitis C infections prevented. The decision tree analysis was constructed as follows: the residual risk of hepatitis C infection was 8.26 per million units transfused, and the chance node was defined according to the number of units transfused. RESULTS: With the use of rHuEPO in preoperative blood donation, 0.30562 cases of hepatitis C infection per 100,000 patients were prevented. The incremental cost of one prevented hepatitis C infection amounted to $888,000,000 (US). CONCLUSION: Despite the limitations of our model, the cost-effectiveness ratio was so large that variations only slightly modified the size of the result. From the societal perspective, it was not cost-effective to add rHuEPO to preoperative blood donation.     

Should nurses prescribe blood components?

AIM: To explore the feasibility of nurses prescribing blood components. METHOD: Using a convenience snowball sample, a UK-wide questionnaire survey was undertaken to identify transfusion practices and canvass the opinions of nurses and doctors. RESULTS: A total of 179 (59%) of 302 respondents were supportive of nurses prescribing blood components, saying it would have a positive effect on the quality of patient care, result in fewer treatment delays and help doctors and nurses to use their time more effectively. The remaining 123 (41%) respondents had reservations about time and resource constraints and worries about undermining medical care and responsibility. CONCLUSION: Development of non-medical prescribing to allow nurses to prescribe blood components has the potential to deliver a more patient-centred quality service.     

Should hospitals collect blood components?: no

Over the last decade, the costs of blood procurement have increased as a result of regulatory pressure and scientific progress in understanding transfusion-transmitted disease. At the same time, hospitals are under tremendous pressure to reduce costs. Hospital blood banks are evaluating different strategies, including in-house or "out-sourced" blood collection, as a means of reducing collections. These decisions, however, should be made on assessments of the total cost of a safe and reliable blood supply: recruitment, collection, donor management, testing, manufacturing/processing, quality control, inventory management, quality assurance, regulatory, overhead and availability. If all of these costs are considered, it is unlikely that cost reduction can be achieved through hospital collections.     

How do we mobilize and collect autologous peripheral blood stem cells?

Autologous stem cell transplantation (ASCT) with mobilized peripheral blood stem cells (PBSCs) has become a widely applied therapeutic approach for many hematologic and nonhematologic diseases. Adequate PBSC mobilization is critical to the success of ASCT. However, many factors can contribute to poor mobilization. Plerixafor is an effective yet costly adjunct agent that has been increasingly used to improve mobilization in a variety of diagnoses and clinical settings. However, to achieve both optimal cell collection yields and cost‐effectiveness, the role of plerixafor in PBSC mobilization needs to be well defined in terms of triggers for initiating its use and criteria for monitoring response. As one of the largest hematopoietic transplant centers in the country, we have developed an approach to PBSC mobilization and collection that incorporates patient laboratory assessments, monitoring of the collection yields, and judicious use of plerixafor as well as various patient support and education programs. These measures have resulted in an increase in our collection success rate and a decrease in the mean number of collection days. In this article we describe our approach to autologous PBSC mobilization and collection. Pertinent reports in the literature are also reviewed and discussed.     

Should the blood pressure or the blood vessel be the target of therapy?

Measured blood pressure is an insensitive and moderately nonspecific guide to the presence of vascular or cardiac diseases likely to progress to cardiovascular morbid events. Since the goal of the diagnosis and treatment of hypertension is to prevent or forestall such morbid events, blood pressure measurements should be supplemented by studies of the health of the cardiovascular system in defining the syndrome of hypertension and in monitoring its response to therapy.     

Should the blood pressure or the blood vessel be the target of therapy?

Measured blood pressure is an insensitive and moderately nonspecific guide to the presence of vascular or cardiac diseases likely to progress to cardiovascular morbid events. Since the goal of the diagnosis and treatment of hypertension is to prevent or forestall such morbid events, blood pressure measurements should be supplemented by studies of the health of the cardiovascular system in defining the syndrome of hypertension and in monitoring its response to therapy.     

Should fresh blood be recommended for intensive care patients?

Fresh blood has many potential advantages over older blood, but there is no evidence that these properties translate into clinical benefit for intensive care patients. The observational multicenter study by Karam and colleagues provides some evidence suggesting that blood stored for less than 14 days is better than older blood in terms of new organ failure and reduction in length of stay in pediatric intensive care units. Though in favor of using young blood, this study suffers from several limitations. As a consequence, it is ethical and certainly pertinent to conduct a randomized clinical trial in order to test the hypothesis that fresh blood might reduce mortality. The rationale is strong and the potential benefit of fresh blood is substantial.