August 2000

Eliminating blood transfusions: new aspects and perspectives
Spahn DR and Casutt M. Anesthesiology 2000;93:242-55
[see abstract below]

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Commentary by Katherine Grichnik, M.D.

This very well written review article about the consequences of allogeneic blood transfusion also includes a discussion of methods to reduce and/or eliminate the need for allogeneic blood transfusion. The article is written by experts in this field and offers practical insights and suggestions.

The first part of the article reviews the efficacy, adverse effects, and costs of allogeneic blood transfusions. The efficacy of transfusion to a certain hemoglobin (Hb) concentration is questioned and results are presented in which ICU patients may benefit from fewer transfusions with respect to morbidity and mortality. The adverse effects of transmission of infectious diseases, immunomodulation and transfusion-related acute lung injury are reviewed. The costs are discussed as the direct red blood cell (RBC) costs (costs associated with obtaining and infusing RBCs) and the indirect costs of additional treatments and/or prolonged hospitalization related to allogeneic blood transfusions.

The major part of the review is a discussion of alternatives to allogeneic blood transfusions. Included are presentations of 1) preoperative autologous donation, 2) preoperative use of erythropoietin, 3) acute normovolemic hemodilution, 4) intraoperative cell salvage and retransfusion, 5) pharmacologic treatment, 6) anesthesia technique, 7) surgical technique, 8) acceptance of minimal Hb levels and transfusion algorithms based on coagulation monitoring, 9) artificial Hb carriers, and 10) combination of different blood conservation strategies.

Autologous donation is presented as a balance of cost, safety and convenience for the patient with the reasonable question discussed of different transfusion triggers for an autologous RBC unit versus an allogeneic RBC unit. The efficacy of preoperative erythropoietin use with an analysis of its side effects, use in high risk patients and use in combination with acute normovolemic hemodilution (ANH) presented.

ANH has been found to reduce allogeneic blood transfusions in clinically relevant settings. The limits and safety are briefly presented here but discussed further in the anesthesia technique and acceptance of minimal Hb sections. The pros and cons of intraoperative cell salvage and retransfusion is presented, including a warning about the metabolic derangements and other problems which can occur with this technique. The authors also present an alternative to the traditional notion that cell salvage cannot be used for nonsterile fields and cancer surgery.

Pharmacological treatment with various antifibrinolytics is outlined. Anesthesia technique is discussed in more detail with sections on maintaining normothermia, optimal fluid replacement (including for use with ANH), hyperoxic ventilation and hypotensive anesthesia. Brief mention is made of the importance of surgical technique in the avoidance of allogeneic blood transfusions.

There is an in-depth discussion on the acceptance of minimal Hb levels, with specific paragraphs on splanchnic circulatory adequacy, cerebral blood flow adequacy, use with ANH, use in various coronary and cardiac disease states, use in the elderly, and what constitutes an adequate Hb level in the perioperative period. This section then combines with the next section of transfusion algorithms based on blood coagulation monitoring.

Artificial oxygen carriers are not really discussed as these drugs are still undergoing clinical testing. The paper ends with a brief summary of the efficacy of combining various strategies to reduce the need for allogeneic blood transfusions.

In all, this review is concise, easy to read and offers the challenge to implement therapies to reduce blood transfusions in our practices.

	ABSTRACTS Eliminating Blood Transfusions: new aspects and perspectives . AUTHORS: Spahn DR and Casutt M. SOURCE: Anesthesiology 2000;93:242-55 No abstract available