A randomized trial comparing acute normovolemic hemodilution and preoperative autologous blood donation in total hip arthroplasty

BACKGROUND: The value of acute normovolemic hemodilution (ANH) as compared to preoperative autologous blood donation (PABD) in orthopedic surgery is unknown. Therefore, a prospective, randomized study was conducted to compare these techniques in patients undergoing primary total hip arthroplasty. STUDY DESIGN AND METHODS: ANH patients underwent phlebotomy for up to 3 units, or to a target Hct level of 28 percent after induction of anesthesia. PABD patients were asked to donate up to 3 units before admission. RESULTS: Mean baseline Hct levels were not different in ANH and PABD patients (39. 7 +/- 4.5 vs. 41.8 +/- 3.8%, p = 0.09). No difference was found in allogeneic blood exposure among ANH and PABD cohorts: 4 (17%) of 23 ANH patients received a total of 9 allogeneic blood units, compared to no allogeneic transfusions in the PABD cohort (p = 0.30). Total blood costs associated with ANH were significantly (p<0.05) lower than blood costs associated with PABD ($151 +/- 154 vs. $680 +/- 253, respectively). CONCLUSION: In patients undergoing total hip arthroplasty, ANH is safe, can be considered equivalent to PABD in effectively reducing exposure to allogeneic RBCs, and is less costly than PABD.     

Preoperative autologous blood donation for kidney transplant and end-stage renal disease patients: A single-center study

Although preoperative autologous blood donation (PABD) has many advantages, there has been a decrease in the performance due to a decrease in the residual risk of allogeneic blood transfusion. In allogeneic blood transfusion, anti HLA antibodies and donor-specific antibodies mediate antibody-mediated rejection, which results in graft failure.PABD for anemic patients such as those with end-stage renal disease (ESRD) and a kidney transplant is relatively contraindicated. In this study, we aimed to investigate the characteristics of patients who underwent PABD and elucidate the safety and feasibility of PABD.We performed PABD safely in ten ESRD patients and nine kidney transplant patients and retrospectively analyzed medical records of the hospital. All kidney transplant patients avoided allogeneic blood transfusion, but 4 out of 10 ESRD patients had allogeneic blood transfusion, even if their blood donation volume was larger than those of the kidney transplant patients. It depends on the type of operation; cardiovascular surgery was more common in ESRD patients, and orthopedic surgery was more common in kidney transplant patients. There was profuse bleeding in cardiovascular surgery compared to orthopedic surgery because of longer operation time of the former.Completely avoiding allogeneic blood transfusion in major surgery was rather difficult even if PABD was performed. To prevent the formation of anti- HLA antibodies, PABD would be considered for ESRD patients undergoing kidney transplantation and kidney transplant patients that are potential candidates for secondary kidney transplantation.     

Reduction of allogeneic red blood cell usage during cardiac surgery by an integrated intra‐ and postoperative blood salvage strategy: results of a randomized comparison

BACKGROUND: The amount of allogeneic blood transfusion may relate to worse outcome in cardiac surgery. The reinfusion of red blood cells (RBCs) lost by patients, including those of chest drains, is a promising strategy to minimize allogeneic transfusions. STUDY DESIGN AND METHODS: To verify this hypotheis, 1047 cardiac surgery patients were randomly assigned to either traditional intraoperative blood salvage followed by chest drain insertion or intra‐ and postoperative strategy with the Haemonetics cardioPAT system. Allogeneic RBC transfusion rate (primary endpoint) and postoperative complications (secondary endpoint) were recorded at the time of discharge from the hospital and at first month follow‐up visit, respectively. RESULTS: The cardioPAT arm received 1.20 units of allogeneic RBCs per patient, whereas the control group required 2.11 units per patient, and this difference proved to be highly significant (p = 0.02). We observed a comparable 45‐day mortality rate but a lower rate of deep vein thrombosis (p = 0.04) and atrial fibrillation (p = 0.04) in the cardioPAT arm. DISCUSSION: A significant reduction in patient exposure to allogeneic RBCs was observed in the cardioPAT system arm. Complications were slightly less frequent in the cardioPAT group. The use of the cardioPAT is a safe and effective strategy to reduce allogeneic RBC transfusions in cardiac surgery.     

Declining value of preoperative autologous donation

BACKGROUND: Preoperative autologous blood donation (PABD) has been shown to decrease allogeneic blood transfusion requirements in major elective surgery. Changes in transfusion practice motivated an examination of blood use from 1993 to 2000 of patients participating in the Héma-Québec PABD program. STUDY DESIGN AND METHODS: Blood donation and transfusion, type of surgery, and demographic characteristics were prospectively entered into a computer database for patients participating in the Héma-Québec PABD program. RESULTS: Autologous donations represented from 0.8 to 2 percent of total blood collections and have declined by 26 percent after peaking in 1995. The mean number of units collected per patient declined, as did the number of units transfused per patient and the utilization rate. For radical prostatectomy, knee replacement surgery, hip replacement surgery, and scoliosis, utilization rates were 72, 60, 83, and 78 percent in 1993 compared with 50, 50, 58, and 58 percent in 2000, respectively. In 2000, 18 percent of patients were receiving a 1-unit autologous transfusion. Depending on the surgical procedure, 85 to 95 percent of patients avoided allogeneic transfusion; this did not change significantly from 1993 to 2000. CONCLUSION: Patients participating in the PABD program successfully avoided allogeneic transfusion in over 85 percent of cases. However, declining utilization rates and frequent 1-unit transfusions demonstrate the decreasing utility of PABD over time.     

血浆与红细胞不同输注比例对创伤性失血患者大量输血救治的影响

目的探讨大量输血时,输注不同比例的血浆和红细胞对创伤性失血患者救治的影响。方法回顾性分析本院2008年1月～2011年8月间,因创伤性失血需要输注悬浮红细胞10U以上的患者131例次。根据入院24h内输注血浆与悬浮红细胞(FP∶RBC)的比例,将患者分为高比例组(FP∶RBC≥1∶1,n=56)、中比例组(FP∶RBC=1∶2～1∶1,n=43)、低比例组(FP∶RBC≤1∶2,n=32)。采用单变量方差分析、配对t检验和Kaplan-Meier的统计方法,比较患者大量输血前后和3组之间凝血功能指标、在院期间红细胞输注总量、生存率的差异。结果与输血前相比,高比例组和中比例组患者输血后APTT、PT-INR均无明显变化,低比例组APTT、PT-INR均明显升高(P<0.01)。3组之间输血后的凝血功能指标、在院期间红细胞输注总量差异有统计学意义[输血后APTT,高vs中vs低:(37.3±12.4)vs(41.1±11.5)vs(49.9±14.0),P<0.05;输血后PT-INR,高vs中vs低:(1.11±0.19)vs(1.20±0.37)vs(1.66±0.62),P<0.05;在院期间红细胞输注总量,高vs中vs低:(19.8±6.3)vs(25.8±11.3)vs(26.6±8.0),P<0.01],但生存率差异无统计学意义。输血后高、中比例组凝血功能均显著优于低比例组(P<0.05),高比例组在院期间红细胞输注总量显著少于其他2组,低比例组与中比例组相比无差异。结论大量输血时,较高比例地输注血浆,有利于预防创伤性失血患者发生凝血功能障碍,降低患者住院期间红细胞输注总量,达到节约血液资源的目的。     

A cost study of postoperative cell salvage in the setting of elective primary hip and knee arthroplasty

BACKGROUND: The increasing costs, limited supply, and clinical risks associated with allogeneic blood transfusion have prompted investigation into autologous blood management strategies, such as postoperative red blood cell (RBC) salvage. This study provides a cost comparison of transfusing washed postoperatively salvaged RBCs using an orthopedic perioperative autotransfusion device (OrthoPat, Haemonetics Corporation) versus unwashed shed blood and banked allogeneic blood. STUDY DESIGN AND METHODS: Cell salvage data were retrospectively reviewed for a sample of 392 patients who underwent primary hip or knee arthroplasty. Mean unit costs were calculated for washed salvaged RBCs, equivalent units of unwashed shed blood, and therapeutically equivalent volumes of allogeneic RBCs. RESULTS: No initial capital investment was required for the establishment of the postoperative cell salvage program. For patients undergoing total knee arthroplasty (TKA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $758.80, $474.95, and $765.49, respectively. In patients undergoing total hip arthroplasty (THA), the mean unit costs for washed postoperatively salvaged cells, unwashed shed blood, and allogeneic banked blood were $1827.41, $1167.41, and $2609.44, respectively. CONCLUSION: This analysis suggests that transfusing washed postoperatively salvaged cells using the OrthoPat device is more costly than using unwashed shed blood in both THA and TKA. When compared to allogeneic transfusion, washed postoperatively salvaged cells carry a comparable cost in TKA, but potentially represent a significant savings in patients undergoing THA. Sensitivity analysis suggests that in the case of TKA, however, cost comparability exists within a narrow range of units collected and infused.     

Immunologic changes after transfusion of autologous or allogeneic buffy coat-poor versus white cell-reduced blood to patients undergoing arthroplasty. I. Proliferative T-cell responses and the balance of helper and suppressor T cells

BACKGROUND: Donor white cells (WBCs) contained in red cell (RBC) transfusions are thought to provoke down-regulation of T-cell-mediated immunity. This study investigated this topic in otherwise healthy patients receiving buffy coat-depleted or WBC-filtered RBCs and undergoing standardized perioperative management. STUDY DESIGN AND METHODS: Patients undergoing elective orthopedic surgery (primary hip and knee replacement surgery) were enrolled in a prospective study. Perioperative changes in T-cell proliferation (stimulation with phytohemagglutinin and mixed lymphocyte culture) and T-cell balance (T-lymphocytes, helper T cells, and suppressor T cells) were compared after random assignment to allogeneic buffy coat-depleted (Group 2, n = 8) or WBC-reduced RBC (Group 3, n = 11) transfusion regimens. Recipients of autologous buffy coat-depleted RBC transfusions (n = 15) served as controls (Group 1). RESULTS: Compared to that in autologous transfusion recipients, alloantigen-induced T-cell proliferation was significantly reduced in recipients of allogeneic WBC-reduced RBCs (Day 3, p = 0.0274). After the transfusion of allogeneic buffy coat-depleted RBCs, a weak trend toward decreased T-cell proliferation was observed (p = 0.0933) and the numbers of CD4+ T cells were also significantly lower (Day 7, p = 0.0389). On Day 10, alloantigen-induced T-cell proliferation remained significantly below baseline after transfusion of WBC-reduced RBCs (p = 0.05), the numbers of CD3+ cells decreased in allogeneic RBC recipients (Group 2, p = 0.078; Group 3, p = 0.05), and those of CD8+ cells decreased significantly after the transfusion of allogeneic buffy coat-depleted RBCs (p = 0.0234) concomitant with an increased CD4:CD8 ratio (p = 0.0391). CONCLUSION: Results of the present study confirm the hypothesis of impaired T-cell-mediated immunity after allogeneic transfusion.     

The effect of unmodified or prestorage white cell-reduced allogeneic red cell transfusions on the immune responsiveness in orthopedic surgery patients

BACKGROUND: The immunomodulatory effects of allogeneic blood transfusions have been attributed to the white cells (WBCs) present in the cellular blood components transfused to patients. STUDY DESIGN AND METHODS: The effect of the transfusion of allogeneic red cells (RBCs) or allogeneic prestorage WBC-reduced RBCs (WBC-reduced RBCs) on host immune responsiveness was evaluated by measuring the lymphocyte subsets and the in-vitro cytokine production in response to phytohemagglutinin stimulation of WBCs of orthopedic surgery patients. Forty-seven patients undergoing hip replacement surgery were randomly assigned to receive allogeneic RBCs (n = 17) or WBC-reduced RBCs (n = 14; 99.95% WBC removal). Sixteen patients were not transfused. Patient blood samples taken before surgery and on Days 1 and 4 after surgery were tested for complete blood count, lymphocyte subset analysis, and measurement of cytokine levels. RESULTS: After surgery, the lymphocyte count was significantly decreased in patients transfused with > or = 3 units of allogeneic RBCs (2.0 +/- 0.5 vs. 1.3 +/- 0.3 x 10(9)/L; p = 0.017), but not in patients transfused with > or = 3 units of WBC-reduced RBCs (2.0 +/- 0.9 vs. 1.7 +/- 0.8 x 10(9)/L). Compared with preoperative levels, on Day 4 after surgery, patients transfused with > or = 3 units of allogeneic RBCs also had a decrease in the number of natural killer cells (0.07 +/- 0.05 vs. 0.04 +/- 0.03 x 10(9)/L; p = 0.018). Postoperatively, interleukin-2 was decreased in one patient who received WBC-reduced RBCs compared with that in four patients transfused with allogeneic RBCs (p = 0.32), and eight untransfused patients (p = 0.01). On Day 4, about 70 percent of patients transfused with allogeneic RBCs showed a 20-percent decrease in the interferon gamma level. CONCLUSION: Taken together, these data support the hypothesis that transfusion of > or = 3 units of allogeneic RBCs is associated with early postoperative lymphopenia in otherwise healthy individuals undergoing surgery. These findings were not observed in those individuals transfused with RBCs that had undergone prestorage WBC reduction.     

Storage time of transfused red blood cells and impact on clinical outcomes in hematopoietic stem cell transplantation

BACKGROUND: Red blood cell (RBC) transfusion may prolong recovery in some patients, perhaps due to changes that occur during more prolonged RBC storage. We examined the impact of RBC transfusion and the age of transfused RBC units on clinical outcomes in hematopoietic stem cell transplantation (HSCT). STUDY DESIGN AND METHODS: Data concerning RBC transfusions between Day 0 and Day +30 were analyzed for patients undergoing HSCT (n = 555) at a single institution. “Old” RBC units were defined as those stored for 15 days or longer. RESULTS: The proportion of old RBC units transfused and the mean age of transfused units did not correlate with 100‐day nonrelapse mortality, organ‐specific toxicity, length of stay (LOS), or incidence of intensive care unit (ICU) admission (p > 0.05). In comparing the 71 patients who received only old RBC units with 218 patients who received only “new” RBC units, there was no increase in adverse clinical outcomes after HSCT. Autologous transplant recipients (n = 355, 3.8 units/patient) were more likely to avoid RBC transfusion and received fewer units compared with allogeneic recipients (n = 200, 6.4 units/patient, p < 0.0001). The mean number of transfused RBC units was greater in patients admitted to the ICU (10.5 units vs. 3.7 units/patient, p < 0.01), correlated with longer LOS (p < 0.0001), and correlated with increasing number of organ systems with toxicity of at least Grade 2 (p < 0.0001). CONCLUSION: The importance of RBC storage time does not appear to influence clinical outcomes in HSCT. Patients with increased RBC transfusion requirements have greater toxicity after HSCT. Whether RBC transfusion contributes to toxicity, however, remains unclear.     

Number of RBC units and rate of transfusionto anemic HIV-positive patients assigned to receiveWBC-reduced or non-WBC-reduced RBCs: the viral activation transfusion study experience

BACKGROUND: It is known that the use of filtration to reduce WBCs in RBC units is associated with a 6- to 15-percent loss of RBCs. It is not known if the use of such WBC-reduced RBCs results in an increased need for RBC units or in the transfusion of more units per year to patients with anemia. STUDY DESIGN AND METHODS: In the multicenter Viral Activation Transfusion Study (VATS), anemic HIV-positive patients were randomly assigned to receive either WBC-reduced or non-WBC-reduced RBCs. The number of RBC units transfused per patient and the rate of RBC use were studied. All RBC units given after the enrollment transfusion were counted, until the end of follow-up or the occurrence of bleeding (receiving >5 RBCs within 2 consecutive days). RESULTS: As expected, the WBC-reduced RBC units in VATS were lighter in weight than the non-WBC-reduced units (median weight: WBC-reduced, 300 g; non-WBC-reduced, 330 g; p<0.0001). After the enrollment transfusion, 258 WBC-reduced arm patients received 1279 units of RBCs (average, 5.0 units/patient, median, 2 units) while 262 patients in the non-WBC-reduced arm received 1111 RBCs (4.2 units/patient; median, 2 units). The number of units transfused for anemia was slightly greater in the WBC-reduced arm, but the difference was not significant (p = 0.41). Similarly, the rate of RBC use was somewhat higher in the WBC-reduced arm, but the difference was not significant (p = 0.14). The median was 2.3 units per patient per year of follow-up in the WBC-reduced arm; the median in the non-WBC-reduced arm was 1.2 units. CONCLUSION: This study confirms that WBC-reduced RBC units are significantly lighter in weight than non-WBC-reduced RBCs. However, in the setting of a large, randomized, blinded study of transfusion for anemia, the smaller size of the WBC-reduced RBC units had no significant effect on the number of RBC units transfused or on the rate at which RBC units were used. In this study, the frequency of blood transfusion may have had a greater relationship to the frequency of routine, scheduled appointments or transfusion orders for a specified Hb trigger than to the actual Hb content of the unit.     

Serum transferrin receptor is a marker of iron deficiency in patients included in programs for preoperative autologous blood donation.

Recently programs for preoperative autologous blood donation (PABD) have expanded to reduce the need for allogenic blood transfusion. Nevertheless, the ability of the patients's bone marrow to replace the red blood cells (RBCs) mass reduced by phlebotomies determines the efficacy of PABD. In mild anemia, known as iron-deficient erythropoiesis (IDE) or iron deficiency without anemia, precipitated by PABD, the marrow response is suboptimal and needs adjuvant therapy. The aim of this study was to evaluate the use of the serum transferrin receptor (sTfR) for the assessment of IDE in patients undergoing PABD. METHODS: Two autologous blood units from 50 consecutive patients scheduled for elective orthopedic surgery were collected preoperatively. Serial measurements of RBCs, haematocrit (Hct), haemoglobin (Hb), serum iron, serum ferritin, reticulocyte count, reticulocyte maturity index (RMI), endogenous erythropoietin (EPO) and sTfR were performed throughout the phlebotomy program. RESULTS: RBC, Hct, Hb and serum iron significantly decreased although within the normal range. There was no change in serum ferritin levels. Reticulocytes, RMI and EPO significantly increased as did sTfR which significantly exceeds the normal range. CONCLUSIONS: These results demonstrate that the sTfR is a reliable laboratory marker for detecting mild anemia or IDE. In patients undergoing PABD increased sTfR levels may suggest a treatment with recombinant human EPO (rh-EPO) or iron to improve the bone marrow performance.     

Prestorage universal WBC reduction of RBC units does not affect the incidence of transfusion reactions

BACKGROUND: Febrile nonhemolytic transfusion reaction (FNHTR) has been identified as a pivotal reason for prestorage universal WBC reduction. A regional blood center implemented universal prestorage WBC reduction for RBCs on January 1, 2000. Whether prestorage universal WBC reduction of RBC units will affect FNHTR is not known. STUDY DESIGN AND METHODS: All reports of RBC transfusion reactions at Barnes-Jewish Hospital submitted for evaluation to the blood bank, before and after the implementation of WBC reduction of RBCs, were retrospectively evaluated. RESULTS: For the 36,303 allogeneic RBC transfusions administered in 1999, 85 reactions (0.23%) were reported. These reactions were classified as FNHTR in 43 cases, allergic in 13, delayed hemolytic in 19, and miscellaneous in 10. For the 31,543 non-WBC-reduced RBC transfusions performed in 1999, 78 reactions (0.25%) were reported. These reactions were classified as FNHTR in 39 cases, allergic in 13, delayed hemolytic in 19, and miscellaneous in 7. In the first half of 2000, 32 reactions (0.20%) were reported for 16,093 prestorage WBC-reduced RBC transfusions (p = 0.41). There were 13 FNHTRs and 10 allergic, 7 delayed hemolytic, and 2 miscellaneous reactions. The use of prestorage WBC-reduced RBCs did not significantly affect the rate of reactions classified as allergic (0.04% in 1999; 0.06% in 2000; p = 0.43) or as FNHTR (0.12% in 1999; 0.08% in 2000; p = 0.33). For all patients, universal WBC reduction in 2000 did not reduce the rate of FNHTR from the rate seen with selective bedside WBC reduction, the practice used in 1999 (0.12% in 1999; 0.08% in 2000; p = 0.36). CONCLUSION: No significant difference was found in the incidence of transfusion reactions in patients receiving prestorage WBC-reduced RBCs and non-WBC-reduced RBCs. In addition, no difference was found in transfusion reaction rates when periods of prestorage universal WBC reduction were compared to those of selective WBC reduction.     

Red blood cell use outside the operating theater: a prospective observational study with modeling of potential blood conservation during severe blood shortages

BACKGROUND: National guidance recommends planning for future blood shortages, but few studies have evaluated how reduced demand could be achieved acutely.
STUDY DESIGN AND METHODS: A trained observer collected data concerning red blood cell (RBC) transfusion events outside the operating theater during 68 hours of blood bank monitoring over 7 weeks. Data were gathered at the patients' bedside from clinical staff and charts. Transfusions were classified according to the presence of bleeding and medical specialty (medical, surgical, other). Hemoglobin (Hb) transfusion triggers, RBCs transfused, and posttransfusion Hb values were collected. Evidence-based scenarios were used to model the potential RBC savings that could be achieved if acute shortages occurred, incorporating ischemic heart disease as a potential decision modifier.
RESULTS: A total of 83 patients received 100 transfusion events, comprising 207 RBC units, during the sampling periods. The relative use of RBC units across specialties was as follows: medical, 74%; surgical, 22%; and other, 4%. For medical and surgical patients, respectively, 31 and 10% of all RBC units were transfused for anemia without evidence of bleeding, and 38 and 12% were transfused for non–life-threatening bleeding. Eight-five percent of all patients who received transfusions had stable vital signs before transfusion. Our model suggested that only 11% of RBCs would be conserved by cancellation of major surgery, whereas 23% to 47% of all RBCs could be conserved by controlling transfusions to medical patients.
CONCLUSION: In institutions with patterns of blood use similar to ours, control of transfusions to medical patients is the most effective response to acute blood shortages.     

Anemia and blood transfusion in the critically ill patient: role of erythropoietin

Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units receive at least 1 red blood cell (RBC) unit during their stay, and the average is close to 5 RBC units. RBC transfusion is not risk free. There is little evidence that 'routine' transfusion of stored allogeneic RBCs is beneficial to critically ill patients. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically ill patients with multiple organ failure, rHuEPO therapy will also stimulate erythropoiesis. In a randomized, placebo-controlled trial, therapy with rHuEPO resulted in a significant reduction in RBC transfusions. Despite receiving fewer RBC transfusions, patients in the rHuEPO group had a significantly greater increase in hematocrit. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the intensive care unit, and they decrease the transfusion threshold in the management of all critically ill patients.     

A clinical prediction tool to estimate the number of units of red blood cells needed in primary elective coronary artery bypass surgery

BACKGROUND: Red blood cell (RBC) transfusion is common during cardiac surgical procedures. Empiric crossmatching, without attempting to estimate individual transfusion requirements is typical. We hypothesized that a clinical prediction tool could be developed to estimate the number of units of RBCs needed for coronary artery bypass grafting (CABG) surgery. STUDY DESIGN AND METHODS: With institutional review board approval, detailed demographic, risk factor, and transfusion data of primary elective CABG procedures (n = 5887) from September 1, 1993, to June 20, 2002, were studied and the data set was divided into development and validation subgroups. Multivariable ordinal logistic regression was used to develop and validate transfusion risk factors, assign them a relative weight, and create a model to stratify patients into groups depending on predicted need for 0, 2, 4, or more than 4 RBC units. The model was compared with current standard practice of crossmatching 4 RBC units in terms of observed blood product usage over the study period. RESULTS: Demographic and transfusion risk factor variables in the development (n = 3876) and validation (n = 2011) data sets were similar. The predictive value of the model was good for the development and validation groups, with a c‐index of 0.79 and 0.78, respectively. Applying the predictive model reduced the number of crossmatches by 30% without underproviding RBC units and increased the percentage of patients crossmatched exactly for the required number of units from 11% to 21%. CONCLUSIONS: Predictive factors for RBC transfusion were identified and used to construct a clinical tool to conserve blood bank resources without increasing patient risk.     

Costs associated with blood transfusions in Sweden--the societal cost of autologous, allogeneic and perioperative RBC transfusion

Anaemia is characterised by an insufficient number of red blood cells (RBCs) and might occur for different reasons, e.g. surgical procedures are often with associated blood loss. Patients who suffer from anaemia have the option of treatment with blood transfusion or medical treatment. In this study, the societal cost, for the case of Sweden, of RBC transfusion using three different techniques, i.e. allogeneic, autologous and intraoperative transfusion, was estimated. The analysis was based on information from interviews with hospital staff at large Swedish hospitals and from published data. The average cost for a 2 units transfusion was found to be Swedish kronor (SEK) 6330 (702 Euro) for filtered allogeneic RBCs and SEK 5394 (598 Euro) for autologous RBCs for surgery patients. Transfusion reactions accounted for almost 35 per cent of the costs of allogeneic RBC transfusions. The administration cost was found to be much higher for autologous transfusions compared with allogeneic transfusions. The cost of intraoperative erythrocyte salvage was calculated to be SEK 2567 (285 Euro) per transfusion (>4 units).     

Prophylactic antigen-matched donor blood for patients with warm autoantibodies: an algorithm for transfusion management

BACKGROUND: Patients with warm autoantibodies are at high risk for delayed hemolytic transfusion reactions due to the presence of alloantibodies. To provide blood safe for transfusion and to avoid adsorption studies in some cases, the provision of prophylactic antigen-matched donor blood where feasible for patients with warm autoantibodies is advocated. STUDY DESIGN AND METHODS: Twenty consecutive adult patients with warm autoantibodies (January 1999 to February 2000) received chronic RBC transfusions by use of this protocol: the serology consistent with warm autoantibodies was confirmed; the alloantibodies were identified; the complete phenotype was determined (i.e., C, E, c, e, K, Jk(a), Jk(b), Fy(a), Fy(b), S, and s); and prophylactic antigen-matched (i.e., donor RBCs matched with the patient's phenotype), WBC-reduced donor RBCs were provided for transfusion. On subsequent admissions, samples were evaluated by panel studies and DATs. If the serology remained consistent with previous findings, prophylactic antigen-matched, WBC-reduced RBCs were transfused without further testing. RESULTS: Eight of 20 (40%) patients had existing, clinically significant alloantibodies. In 12 of 20 (60%) patients, a phenotype was determined and the patients received transfusion of a total of 149 prophylactic antigen-matched RBC units (mean, 15 units per patient) precluding adsorption studies on 51 pretransfusion samples. In 8 of 20 (40%) cases (2 with alloantibodies), phenotypes were indeterminant, necessitating differential allogeneic adsorption studies on 39 samples before transfusion of 144 RBC units (mean, 18 units per patient). CONCLUSIONS: Determining complete phenotypes should be a routine component of the serologic evaluation of patients with warm autoantibodies. Our algorithm for providing prophylactic antigen-matched RBCs to these patients when a complete phenotype can be determined provides flexibility in their transfusion management while maintaining safety and circumvents or simplifies pretransfusion adsorption studies.     

A clinical study on the feasibility of autologous cord blood transfusion for anemia of prematurity

BACKGROUND: The objective was to investigate the use of autologous red blood cells (RBCs) derived from umbilical cord blood (UCB), as an alternative for allogeneic transfusions in premature infants admitted to a tertiary neonatal center. STUDY DESIGN AND METHODS: UCB collection was performed at deliveries of less than 32 weeks of gestation and processed into autologous RBC products. Premature infants requiring a RBC transfusion were randomly assigned to an autologous or allogeneic product. The primary endpoint was an at least 50 percent reduction in allogeneic transfusion needs. RESULTS: Fifty-seven percent of the collections harvested enough volume (> or =15 mL) for processing. After being processed, autologous products (> or =10 mL/kg) were available for 36 percent of the total study population and for 27 percent of the transfused infants and could cover 58 percent (range, 25%-100%) of the transfusion needs within the 21-day product shelf life. Availability of autologous products depended most on the gestational age. Infants born between 24 and 28 weeks had the lowest availability (17%). All products, however, would be useful in view of their high (87%) transfusion needs. Availability was highest (48%) for the infants born between 28 and 30 weeks. For 42 percent of the infants with transfusion needs in this group, autologous products were available. For the infants born between 30 and 32 weeks, autologous products were available for 36 percent of the infants. Transfusion needs in this group were, however, much lower (19%) compared to the other gestational groups. CONCLUSION: Autologous RBCs derived from UCB could not replace 50 percent of allogeneic transfusions due to the low UCB volumes collected and subsequent low product availability.     

Meta-analysis of randomized controlled trials investigating the risk of postoperative infection in association with white blood cell-containing allogeneic blood transfusion: the effects of the type of transfused red blood cell product and surgical setting

Previous meta-analyses of the randomized controlled trials (RCTs) investigating the association of perioperative allogeneic blood transfusion (ABT) with postoperative bacterial infection included studies transfusing either autologous or white blood cell (WBC)-reduced allogeneic red blood cells (RBCs) or whole blood to the control arm, and they were unable to investigate the type of RBC product administered as an explanation for the disagreements among the studies. The availability of additional RCTs has permitted investigation of this hypothesis in a meta-analysis restricted to RCTs transfusing WBC-reduced allogeneic RBCs or whole blood to the control arm. In this analysis, across 5 RCTs comparing recipients of non-WBC-reduced versus WBC-reduced allogeneic RBCs, there was no difference (P > .25) in the risk of postoperative infection between recipients of buffy-coat-reduced versus WBC-reduced allogeneic RBCs filtered before storage (summary odds ratio [OR] = 1.19; 95% confidence interval [CI], 0.87-1.63). In contrast, across 3 RCTs, there was an increased (P < .05) risk of postoperative infection in recipients of non-buffy-coat-reduced allogeneic RBCs, or whole blood, as compared with recipients of WBC-reduced allogeneic RBCs, or whole blood, filtered before or after storage (summary OR = 1.77; 95% CI, 1.02-3.09). Moreover, across 3 RCTs that enrolled patients undergoing open-heart surgery, there was an increased (P < .05) risk of postoperative infection in recipients of buffy-coat-reduced (compared with WBC-reduced) allogeneic RBCs (summary OR = 1.39; 95% CI, 1.08-1.80), but the findings of 5 RCTs that enrolled patients having abdominal surgery could not be combined because of extreme variation in the results of the studies. RCTs conducted in the setting of open-heart surgery or transfusing non-buffy-coat-reduced RBCs or whole blood to the treatment arm had administered various RBC products to the control arm, however, and thus the medical heterogeneity of the studies precludes any conclusion about an immunomodulatory (TRIM) effect of ABT mediated by non-buffy-coat-reduced RBC products. To determine whether such a deleterious immunomodulatory effect of ABT exists, additional RCTs transfusing non-buffy-coat-reduced RBCs to the treatment arm should be conducted.     

The role of erythropoietin therapy in the critically ill

Critically ill patients receive an extraordinarily large number of blood transfusions. Between 40% and 50% of all patients admitted to intensive care units (ICUs) receive at least one allogeneic red blood cell (RBC) unit and average close to 5 U of RBCs during their ICU admission. RBC transfusion is not risk-free, and there is little evidence that "routine" transfusion of stored allogeneic RBCs is beneficial to critically ill patients. It is clear that most critically ill patients can tolerate hemoglobin levels as low as 7 g/dL, and therefore, a more conservative approach to RBC transfusion is warranted. Anemia of critical illness is a distinct clinical entity characterized by blunted erythropoietin (EPO) production and abnormalities in iron metabolism identical to what is commonly referred to as anemia of chronic disease. As such, the bone marrow in many of these patients responds to the administration of exogenous EPO, in spite of their underlying critical illness. The efficacy of perioperative recombinant human erythropoietin (rHuEPO) has been demonstrated in a variety of elective surgical settings. Similarly, in critically ill patients, rHuEPO therapy will also stimulate erythropoiesis. In randomized placebo-controlled trials, therapy with rHuEPO resulted in a significant reduction in allogeneic RBC transfusions. Strategies to increase the production of RBCs are complementary to other approaches to reduce blood loss in the ICU and decrease the transfusion threshold in the management of all critically ill patients.