Post-Operative Hypertension after Total Knee Arthroplasty and the Effects on Transfusion Rates

Transfusions are a cause of significant patient morbidity as well as expense. Anesthesia literature has examined controlled intraoperative hypotension as a means for reducing blood loss and transfusions. Our hypothesis is that inversely increased blood pressure post-operatively would then lead to increased blood loss and transfusions.We examined 105 consecutive patients who underwent TKA. We found a significant odds ratio of 1.123 for pre-operative hematocrit. For post-operative blood pressure, we calculated an insignificant odds ratio of 1.007, proving no relationship between post-operative blood pressure and transfusions.This is the first study to examine increased post-operative blood pressure''s contribution to transfusion rates. Although we confirmed that low pre-operative hematocrit contributes to increased transfusions, we did not find a relationship between post-operative blood pressure and transfusions.     

Autologous versus allogeneic transfusion: patients' perceptions and experiences

BACKGROUND: Preoperative autologous donation is one way to decrease a patient''s exposure to allogeneic blood transfusion. This study was designed to determine patients'' perceptions about the autologous blood donation process and their experiences with transfusion. METHODS: To assess patient perception, a questionnaire was administered a few days before surgery to patients undergoing elective cardiac and orthopedic surgery in a Canadian teaching hospital. All patients attending the preoperative autologous donation clinic during a 10-month period were eligible. A convenience sample of patients undergoing the same types of surgery who had not predonated blood were selected from preadmission clinics. Patient charts were reviewed retrospectively to assess actual transfusion practice in all cases. RESULTS: A total of 80 patients underwent cardiac surgery (40 autologous donors, 40 nondonors) and 73 underwent orthopedic surgery (38 autologous donors, 35 nondonors). Of the autologous donors, 75 (96%) attended all scheduled donation appointments, 73 (93%) said that they were "very likely" or "likely" to predonate again, and 75 (96%) said that they would recommend autologous donation to others. There was little difference in preoperative symptoms between the autologous donors and the nondonors, although the former were more likely than the latter to report that their overall health had remained the same during the month before surgery (30 [75%] v. 21 [52%] for the cardiac surgery patients and 30 [79%] v. 18 [51%] for the orthopedic surgery patients). When the autologous donors were asked what they felt their chances would have been of receiving at least one allogeneic blood transfusion had they not predonated, the median response was 80%. When they were asked what their chances were after predonating their own blood, the median response was 0%. The autologous donors were significantly less likely to receive allogeneic blood transfusions (6 [15%] for cardiac surgery and 3 [8%] for orthopedic surgery) than were the nondonors (14 [35%] for cardiac surgery and 16 [46%] for orthopaedic surgery). They were, however, more likely to receive any transfusion (autologous or allogeneic) than were the nondonors (25 [63%] v. 14 [35%] for cardiac surgery and 31 [81%] v. 16 [46%] for orthopedic surgery). INTERPRETATION: Patients who underwent preoperative autologous blood donation were positive about the experience and did not report more symptoms than patients who did not donate blood preoperatively. Autologous donors overestimated their chances of receiving allogeneic blood transfusions had they not predonated and underestimated their chances after they had predonated. They were less likely to receive allogeneic transfusions, but more likely to receive any type of transfusion, than were patients who did not predonate.     

Editor's preface

OBJECTIVE: To describe the process used to notify pediatric patients who received transfusions of blood or blood products at our institution before donor blood was routinely screened for antibodies to HIV (1985) and hepatitis C virus (1990), and to evaluate the effectiveness of the notification program. DESIGN: Patients who had received transfusions were identified through the hospital''s medical records and the records from the Transfusion Medicine Laboratory. Patients were contacted by registered mail to provide notification of transfusion. A questionnaire was included with the notification to obtain information about the patient''s awareness of the transfusion and whether he or she had undergone or planned to undergo testing for HIV and hepatitis C virus. SETTING: Tertiary care university-affiliated teaching hospital in Hamilton, Ont. PATIENTS: Patients 16 years of age or younger who had received blood products between February 1978 and November 1985. Patients who had received only albumin or immune serum globulin were not included as these products were not associated with viral transmission in Canada. RESULTS: Notification letters were sent to 1546 patients. Of these letters 522 (33.8%) were returned undelivered. Of the 1024 patients contacted 493 (48.1%) responded to the questionnaire, of whom 157 (31.8%) were not aware of their transfusion. A total of 130 (26.4%) of the respondents had already undergone testing for HIV, and 342 (69.4%) indicated that they would undergo such testing as a result of the notification. In contrast, only 30 (6.3%) of 474 respondents had undergone testing for hepatitis C virus, but 425 (89.7%) indicated that they would undergo such testing. Overall, the patients'' response to the notification was neutral or positive; however, a number of patients expressed dissatisfaction and anxiety. CONCLUSIONS: The high proportion of patients who were unaware that they had undergone transfusion and who decided to undergo testing for HIV and hepatitis C virus as a result of notification supports the use of notification programs such as this one.     

Transfusion strategy for patients in therapeutic aplasia. Experience of the Henri Mondor Hospital apropos of 2 successive protocols

Retrospective analysis of two transfusion protocols applied in our institution to the bone marrow transplanted patients was conducted. Granulocyte transfusions should be only proposed as a therapeutic treatment to patients with severe well documented bacterial infection resistant to an adapted antibiotherapy. Leukocyte-depleted blood products reduce the incidence of HLA-immunization but do not influence the frequency of CMV infections. Random single donor platelet concentrates (obtained by cytapheresis) could decrease the incidence of polyspecific HLA-antibodies in comparison with the use of random standard platelet concentrates. The best transfusion protocol should associate leukocyte-depleted blood products with transfusion of prophylactic single donor platelet concentrates. In our institution, this protocol is less expensive than the protocol with prophylactic white blood cell transfusions and has the same cost than other protocols using standard blood products.     

Association of sex, age and ABO-Rh(D) type with unexpected antibodies among multitransfused thalassemia patients in Bikaner, Rajasthan, India

The thalassemia has become a sensitive issue for clinical and public health owing to the morbidity and mortality caused and potential risks associated with multiple transfusions. Here, a blood bank based cross sectional analytical study was carried out during the period of three months from January 2017 to March 2017, among transfusion dependent beta thalassemia major patients. ABO-Rh(D) blood grouping and screening for unexpected red cell antibodies (other than anti-A and anti-B antibodies) were performed on a Immucor Galileo Neo System (fully automated immunohematology analyzer). Out of 56 patients, 37 (66%) were males and 19 (34%) were females with a male to female ratio of 1.95:1. Two cases (3.6%) were detected positive by antibody screening. Alloimmunization was statistically analyzed on the basis of age, sex and subjects'' ABO-Rh blood group. This study underlines the need for unexpected antibody screening among thalassemic patients receiving blood transfusion therapy.     

The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children

The vast majority of infants and children undergoing craniosynostosis correction receive a blood transfusion. The risks of blood transfusion include, but are not limited to, acute hemolytic reactions (approximately 1 of 250,000), human immunodeficiency virus (approximately 1 of 200,000), hepatitis B and C (approximately 1 of 30,000 each), and transfusion-related lung injuries (approximately 1 of 5000). This prospective, single-blinded, randomized study was undertaken to examine the safety and efficacy of preoperative single weekly dosing with erythropoietin (epoetin alfa) in reducing the rate of transfusion in infants and small children undergoing craniosynostosis repair. A total of 29 patients (<8 years) undergoing craniosynostosis repair were randomized into two groups: one received preoperative erythropoietin (600 U/kg) weekly for 3 weeks, and the other served as a control. All caregivers responsible for blood transfusions were blinded, and strict criteria for transfusion were established. A pediatric hematologist monitored both groups, and all patients received supplemental iron (4 mg/kg). Fourteen patients were randomized to receive erythropoietin, and eight of these 14 patients (57 percent) required transfusion (mean age, 17 months; mean weight, 10.1 kg). Of the six patients not requiring transfusion, three were younger than 12 months old (mean, 6 months). Fourteen of 15 patients (93 percent) in the control group (mean age, 13 months; mean weight, 9.3 kg) required a blood transfusion during the study. The only control patient not requiring transfusion was the eldest (5 years old). The difference between the two groups was statistically significant (Fisher's exact test = 0.03). The control group showed no change in hemoglobin levels from baseline to preoperative levels, but the erythropoietin group increased their average hemoglobin levels from 12.1 to 13.1 g/dl. There were no adverse effects noted among children receiving erythropoietin, nor were there any surgical complications. The authors conclude that the preoperative administration of erythropoietin significantly raised hemoglobin levels and reduced the need for a blood transfusion with craniosynostosis correction. More suggestions are made that may further reduce the need for blood transfusions, and a cost-benefit analysis is discussed.     

Evaluation of red blood cell transfusion practices with the use of preset criteria.

OBJECTIVE: To assess current red blood cell (RBC) transfusion practices and to determine the potential impact of implementing recently published guidelines on RBC transfusion from the American College of Physicians (ACP). DESIGN: Medical chart review. SETTING: A 219-bed teaching hospital in Kingston, Ont. PARTICIPANTS: All patients over 12 years of age who received RBC transfusions in March 1992. MAIN OUTCOME MEASURES: Need for transfusion according to the ACP guidelines and the number of blood units ordered for each transfusion. RESULTS: A total of 55 patients received 170 RBC units. According to the ACP guidelines 94 (55.3%) of the units were judged unnecessary. The departments of Surgery and Internal Medicine did not differ significantly in the number of unnecessary units (56.4% v. 52.8%). Among the surgical subspecialties, unnecessary transfusion was most common in the orthopedics service (73.5%, p < 0.05). Blood was most frequently ordered 2 units at a time (51.8% of units). Transfusion in normovolemic, hemodynamically stable patients with anemia and unnecessary multiple-unit transfusions were the most common violations of the ACP guidelines. CONCLUSIONS: According to the ACP guidelines, there was significant unnecessary blood use in the hospital surveyed. The guidelines provide a useful framework for assessing transfusion practices but may require further refinement to apply to a broader spectrum of clinical settings.     

Blood transfusion and renal allograft survival.

Thirty-two first renal transplantations with cadaveric allografts were reviewed to see how many of the recipients had received blood transfusions preoperatively. There was a significant difference in transplant survival between patients who had and patients who had not received blood transfusion before transplantation; this difference was entirely due to acute rejection within three months after transplantation in patients who had not received transfusion. Other factors studied had no effect on survival.     

CRITERIA FOR BLOOD TRANSFUSIONS

A review of the use of blood transfusions used in a small community hospital over a two-year period revealed a high incidence of instances in which the clinical record did not show essential need for the procedure. Educational efforts in hospital staff meetings resulted in some improvement in this respect during the two-year period. Of single unit transfusions given during the first year, 80 per cent were deemed to have been nonessential; during the second year, 52 per cent.Methods which will reduce the use of blood except when it is essential are (1) continuation of staff education; (2) providing the staff with accurate methods of measurement of blood volume and of monitoring blood loss; (3) use of a separate blood transfusion chart in the patient''s hospital record; and (4) establishment of a hospital transfusion committee to review the criteria in all cases in which blood is transfused.     

Concerns of patients,MDs are transforming transfusion medicine.

Fear of HIV and AIDS has been the driving force in reducing physicians'' use of blood and blood products. Nancy Robb interviewed doctors across the country to determine steps they are taking to lower the number of transfusions and discovered that transfusion medicine in Canada has undergone a sea change.     

Intrauterine blood transfusions in the treatment of severe serologic conflict]

Efficacy of the intraperitoneal and intravenous blood transfusions guided ultrasonographically was evaluated in severe cases of fetal hemolytic disease due to Rh conflict. It was shown, that survival rate of fetuses without generalized edema is two-fold higher in the group treated with intraperitoneal blood transfusions in comparison with the control group. It was found, that the proportion of erythrocytes containing HbA in umbilical blood of newborn is related to the number of intraperitoneal transfusions. One has to underline the failure of such a treatment in features with generalized edema. In such case intravenous blood transfusion is a method of choice.     

The Efficacy and Cost-Effectiveness of Cell Saver Use in Instrumented Posterior Correction and Fusion Surgery for Scoliosis in School-Aged Children and Adolescents

Posterior spinal instrumentation and fusion surgery in school-aged children and adolescents is associated with the potential for massive intraoperative blood loss, which requires significant allogeneic blood transfusion. Until now, the intraoperative use of the cell saver has been extensively adopted; however, its efficacy and cost-effectiveness have not been well established. Therefore, the aim of this study is to determine the efficacy and cost-effectiveness of intraoperative cell saver use. This study was a single-center, retrospective study of 247 school-aged and adolescent patients who underwent posterior spinal instrumentation and fusion surgery between August 2007 and June 2013. A cell saver was used intraoperatively in 67 patients and was not used in 180 patients. Matched case-control pairs were selected using a propensity score to balance potential confounders in baseline characteristics. Allogeneic red blood cell (RBC) and plasma transfusions as well as blood transfusion costs were analyzed. The propensity score matching produced 60 matched pairs. Compared to the control group, the cell saver group had significantly fewer intraoperative allogeneic RBC transfusions (P = 0.012). However, when the combined postoperative and total perioperative periods were evaluated for the use of allogeneic RBC transfusion, no significant differences were observed between the two groups (P = 0.813 and P = 0.101, respectively). With regard to the total cost of perioperative transfusion of all blood products (RBC and plasma), costs for the control group were slightly lower than those of the cell saver group, but this variance did not reach statistical significance (P = 0.095). The use of the cell saver in posterior spinal instrumentation and fusion surgery in school-aged children and adolescents was able to decrease the amount of intraoperative allogeneic RBC transfusion but failed to decrease total perioperative allogeneic RBC transfusion. Moreover, the use of the cell saver was not cost-effective.     

Pulmonary complications in patients receiving granulocyte transfusions and amphotericin B.

To evaluate the possibility that in febrile granulocytopenic patients amphotericin B given along with granulocyte transfusions could increase the incidence of pulmonary complications, we studied 43 severely granulocytopenic patients during 46 episodes of fever. Granulocytes were administered as part of the clinical protocol to all 19 patients who had clinically or microbiologically documented infection; the other 24 patients were randomly allocated to treatment with granulocytes (13 patients) or without granulocytes (11 patients). In all, 32 patients received granulocyte transfusions during 35 episodes of fever. Pulmonary complications developed in six patients in each of the two randomized groups. The incidence of pulmonary complications was not influenced by the number of granulocyte transfusions or by the number of granulocytes per transfusion. Pulmonary complications were significantly more likely to occur in patients with fungal infections. Amphotericin B was given according to clinical indications; 21 patients in all received it. Survival was significantly poorer in patients with pulmonary complications, but the administration of amphotericin B was not related either to survival or to the incidence of pulmonary complications. We conclude that pulmonary complications and poor prognosis are related to underlying pulmonary fungal infection and not to any interaction between amphotericin B and granulocyte transfusions.     

Trends in incidence of AIDS associated with transfusion of blood and blood products in Europe and the United States, 1985-93.

OBJECTIVE--To quantify patterns and trends in incidence of AIDS associated with transfusion of blood and its products in 14 European countries and the United States. DESIGN--Data were derived from the World Health Organisation''s European non-aggregate AIDS dataset and, for the United States, from the Centers for Disease Control AIDS public information dataset. Rates were standardised by using the world standard populations and adjusted for reporting delays in each country. SUBJECTS--Cases of AIDS in patients with haemophilia and recipients of transfusions. RESULTS--Overall, between 1985 and 1993 almost 6000 cases of AIDS associated with transfusions were registered in the 14 European countries considered and over 8000 in the United States between 1985 and 1992. Most European countries had annual age adjusted rates lower than 0.5 per million children aged 12 or less and between 1 and 2 per million adults. The United States had rates around 1 per million children and 5 per million adults in the most recent period. For children, the highest rates were generally reached in 1985-7, whereas in adults the highest rates were in the late 1980s. France had the highest overall incidence of AIDS related to transfusion in Europe (3.3 per million). Romania had a major epidemic in children (over 30 cases per million children in 1988-90). Incidence rates of AIDS associated with transfusion were still increasing in some southern European countries in the early 1990s. CONCLUSIONS--Apart from in France and Romania it is clear that rates of bloodborne AIDS in European countries are lower than those registered in the United States.     

Prevalence of hepatitis A and B infections in multiply transfused thalassaemic patients.

Evidence of hepatitis B virus (HBV) and hepatitis A virus (HAV) infections was south in 148 multiply transfused patients with thalassaemia and in healthy controls (2040 for HBV and 217 for HAV). The prevalence of the HBV surface antigen or antibody to it was significantly higher in patients than in controls and increased with the number of blood transfusions. In contrast, the prevalence of antibody to HAV was significantly lower in patients than in controls and decreased with the number of blood transfusions. These results support the view that blood transfusion does not play any appreciable part in transmitting HAV. Indeed, regular blood transfusion, where donors almost all have HAV antibody, seems to give protection against infection.     

Effect of blood transfusion on erythropoiesis of homozygotic beta-thalassemia patients

The influence of blood transfusion on erythropoiesis (bone marrow erythroblasts, peripheral blood erythroblasts and reticulocytes) has been studied in 20 non splenectomized homozygous beta thalassaemia patients aged 3 to 16 years and in 10 splenectomized patients aged 8 to 24 years affected with the same disease. The number of reticulocytes was the same in the two groups but the number of erythroblasts in the splenectomized group was higher than in the other group. There was no correlation between the erythroblasts and the reticulocytes of the peripheral blood on one hand and the haemoglobin level proceeding from the same sample on the other hand. In the non splenectomized group of patients, an inverse relationship was found between the percentage of bone marrow erythroblasts and the mean annual haemoglobin level (r = -0.71; p less than 0.01). These results demonstrate the effect of blood transfusion on the erythroid cell line in homozygous beta thalassaemia and the delay between the transfusions and the medullary erythroblastic response.     

Five Years' Experience with Intrauterine Transfusion

Five years'' experience with intrauterine transfusion involving 94 transfusions on 50 fetuses forms the basis of the paper. Twenty-three fetuses survived, which represents an overall salvage of 46%. Of 22 fetuses who received intrauterine transfusions before 28 weeks'' gestation, seven (31.9%) survived, which justifies the attempt. Of 28 fetuses who received intrauterine transfusions after 28 weeks'' gestation, 16 (57.1%) survived, which compares favourably with other series. A comparison of two different procedural techniques shows no statistically significant difference in ultimate results. Indications for amniocentesis are outlined and intrauterine transfusion was advised if the optical density difference fell in Liley''s zone III (or a very high zone II) and rose at a rate which anticipated a zone III reading prior to 32 weeks'' gestation. A pediatric assessment and therapeutic management of the 33 live births are presented. Twenty-eight babies received exchange transfusions. Five were excluded for reasons outlined in the text. Ten of the live-born died neonatally. The 23 survivors continue to thrive mentally and physically and follow-up continues.     

HEPATOCYTIC PROLIFERATION IN NORMAL RATS AFTER MULTIPLE EXCHANGE TRANSFUSIONS WITH BLOOD FROM PARTIALLY HEPATECTOMIZED RATS

Either three or four (but not one or two) consecutive exchange transfusions (75–85% washout of blood) of rats with intact livers, utilizing blood from donors partially hepatectomized 24 hr earlier, results in increased incorporation of ³H-thymidine into hepatic DNA and hepatocytic nuclei 20 hr after the first transfusion. Exchange transfusion with blood from sham-hepatectomized animals does not produce this effect.     

An audit of blood component therapy in a Canadian general teaching hospital.

As part of a quality assurance program a retrospective audit of transfusion practices for packed red blood cells, fresh frozen plasma and albumin was undertaken with predetermined criteria in a general teaching hospital. Of 520 transfusion episodes with 1218 units of packed red blood cells given to 297 patients 88% were considered appropriate; of 106 episodes with 405 units of fresh frozen plasma given to 83 patients 90% were deemed appropriate; and of 187 episodes with 320 units of albumin given to 99 patients 64% were considered appropriate. The results of this audit, when compared with those of other surveys of blood use in a similar population, suggest that pretransfusion approval of requested components would reduce the number of inappropriate transfusions.