[Skip to Content]
Sign In
Individual Sign In
Create an Account
Institutional Sign In
OpenAthens Shibboleth
Purchase Options:
[Skip to Content Landing]
Table 1. Risks of Major Infectious and Noninfectious Complications of Transfusion in the United States8-11
Table 1. Risks of Major Infectious and Noninfectious Complications of Transfusion in the United States
Table 2. Efficacy of Perioperative Recombinant Erythropoietin in Elective Orthopedic Surgerya
Table 2. Efficacy of Perioperative Recombinant Erythropoietin in Elective Orthopedic Surgerya
1.
Holland PV. Consent for transfusion: is it informed?  Transfus Med Rev. 1997;11(4):274-2859345709PubMedGoogle ScholarCrossref
2.
Killion DF, Schiff PD, Lipton KS. Informed consent: working toward a meaningful dialogue.  Transfusion. 2007;47(4):557-55817381609PubMedGoogle ScholarCrossref
3.
World Health Organization.  10 Facts on blood transfusion. June 14, 2009. http://www.who.int/bloodsafety/FactFile2009.pdf. Accessed August 23, 2011
4.
Whitaker B, Schlumpf KS, Schulman J, Green J. Report of the US Department of Health and Human Services: The 2009 National Blood Collection and Utilization Survey Report. Washington, DC: Dept of Health and Human Services; 2011
5.
Elmistekawy EM, Errett L, Fawzy HF. Predictors of packed red cell transfusion after isolated primary coronary artery bypass grafting—the experience of a single cardiac center: a prospective observational study.  J Cardiothorac Surg. 2009;4:2019422707PubMedGoogle ScholarCrossref
6.
Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors.  J Bone Joint Surg Am. 2002;84-A(2):216-22011861727PubMedGoogle Scholar
7.
Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study.  Transfusion. 2007;47(8):1468-148017655591PubMedGoogle ScholarCrossref
8.
Epstein JS, Holmberg JA. Progress in monitoring blood safety.  Transfusion. 2010;50(7):1408-141220636529PubMedGoogle ScholarCrossref
9.
Eder AF, Chambers LA. Noninfectious complications of blood transfusion.  Arch Pathol Lab Med. 2007;131(5):708-71817488156PubMedGoogle Scholar
10.
Blajchman MA, Vamvakas EC. The continuing risk of transfusion-transmitted infections.  N Engl J Med. 2006;355(13):1303-130517005947PubMedGoogle ScholarCrossref
11.
Stramer SL. Current risks of transfusion-transmitted agents: a review.  Arch Pathol Lab Med. 2007;131(5):702-70717488155PubMedGoogle Scholar
12.
Shander A. The cost of blood: multidisciplinary consensus conference for a standard methodology.  Transfus Med Rev. 2005;19(1):66-7815830329PubMedGoogle ScholarCrossref
13.
Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at 4 hospitals.  Transfusion. 2010;50(4):753-76520003061PubMedGoogle ScholarCrossref
14.
Goodnough LT, Shander A. Blood management.  Arch Pathol Lab Med. 2007;131(5):695-70117488154PubMedGoogle Scholar
15.
Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature.  Anesthesiology. 2010;113(2):482-49520613475PubMedGoogle ScholarCrossref
16.
The Joint Commission.  Patient Blood Management Performance Measures Project. June 27, 2011. http://www.jointcommission.org/patient_blood_management_performance_measures_project. Accessed August 26, 2011
17.
Barr PJ, Donnelly M, Morris K, Parker M, Cardwell C, Bailie KE. The epidemiology of red cell transfusion.  Vox Sang. 2010;99(3):239-25020576024PubMedGoogle ScholarCrossref
18.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty.  J Bone Joint Surg Am. 1999;81(1):2-109973048PubMedGoogle Scholar
19.
Bern MM, Bierbaum BE, Katz JN, Losina E. Autologous blood donation and subsequent blood use in patients undergoing total knee arthroplasty.  Transfus Med. 2006;16(5):313-31916999753PubMedGoogle ScholarCrossref
20.
Moskowitz DM, Klein JJ, Shander A,  et al.  Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center.  Ann Thorac Surg. 2004;77(2):626-63414759450PubMedGoogle ScholarCrossref
21.
Alghamdi AA, Davis A, Brister S, Corey P, Logan A. Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs.  Transfusion. 2006;46(7):1120-112916836558PubMedGoogle ScholarCrossref
22.
Goodnough LT, Maniatis A, Earnshaw P,  et al.  Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines.  Br J Anaesth. 2011;106(1):13-2221148637PubMedGoogle ScholarCrossref
23.
Patel MS, Carson JL. Anemia in the preoperative patient.  Med Clin North Am. 2009;93(5):1095-110419665622PubMedGoogle ScholarCrossref
24.
Theusinger OM, Leyvraz PF, Schanz U, Seifert B, Spahn DR. Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study.  Anesthesiology. 2007;107(6):923-92718043060PubMedGoogle ScholarCrossref
25.
Mahadevan D, Challand C, Keenan J. Revision total hip replacement: predictors of blood loss, transfusion requirements, and length of hospitalisation.  J Orthop Traumatol. 2010;11(3):159-16520835744PubMedGoogle ScholarCrossref
26.
Myers E, O’Grady P, Dolan AM. The influence of preclinical anaemia on outcome following total hip replacement.  Arch Orthop Trauma Surg. 2004;124(10):699-70115517315PubMedGoogle ScholarCrossref
27.
Martinez V, Monsaingeon-Lion A, Cherif K, Judet T, Chauvin M, Fletcher D. Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs.  Br J Anaesth. 2007;99(6):794-80017928302PubMedGoogle ScholarCrossref
28.
Gonzalez-Porras JR, Colado E, Conde MP, Lopez T, Nieto MJ, Corral M. An individualized preoperative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty.  Transfus Med. 2009;19(1):35-4219302453PubMedGoogle ScholarCrossref
29.
Faris PM, Ritter MA. Epoetin alfa: a bloodless approach for the treatment of perioperative anemia.  Clin Orthop Relat Res. 1998;(357):60-679917701PubMedGoogle Scholar
30.
Goodnough LT, Skikne B, Brugnara C. Erythropoietin, iron, and erythropoiesis.  Blood. 2000;96(3):823-83310910892PubMedGoogle Scholar
31.
Laupacis A, Feagan B, Wong C.COPES Study Group.  Effectiveness of perioperative recombinant human erythropoietin in elective hip replacement.  Lancet. 1993;342(8867):3788101624PubMedGoogle ScholarCrossref
32.
Faris PM, Ritter MA, Abels RI.American Erythropoietin Study Group.  The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation.  J Bone Joint Surg Am. 1996;78(1):62-728550681PubMedGoogle Scholar
33.
de Andrade JR, Jove M, Landon G, Frei D, Guilfoyle M, Young DC. Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopedic surgery patients.  Am J Orthop (Belle Mead NJ). 1996;25(8):533-5428871751PubMedGoogle Scholar
34.
Goldberg MA, McCutchen JW, Jove M,  et al.  A safety and efficacy comparison study of 2 dosing regimens of epoetin alfa in patients undergoing major orthopedic surgery.  Am J Orthop (Belle Mead NJ). 1996;25(8):544-5528871752PubMedGoogle Scholar
35.
Sowade O, Warnke H, Scigalla P,  et al.  Avoidance of allogeneic blood transfusions by treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing open-heart surgery.  Blood. 1997;89(2):411-4189002942PubMedGoogle Scholar
36.
D’Ambra MN, Gray RJ, Hillman R,  et al.  Effect of recombinant human erythropoietin on transfusion risk in coronary bypass patients.  Ann Thorac Surg. 1997;64(6):1686-16939436556PubMedGoogle ScholarCrossref
37.
Monk TG, Goodnough LT, Brecher ME, Colberg JW, Andriole GL, Catalona WJ. A prospective randomized comparison of 3 blood conservation strategies for radical prostatectomy.  Anesthesiology. 1999;91(1):24-3310422925PubMedGoogle ScholarCrossref
38.
Olijhoek G, Megens JG, Musto P,  et al.  Role of oral vs IV iron supplementation in the erythropoietic response to rHuEPO: a randomized, placebo-controlled trial.  Transfusion. 2001;41(7):957-96311452166PubMedGoogle ScholarCrossref
39.
Moonen AF, Thomassen BJ, Knoors NT, van Os JJ, Verburg AD, Pilot P. Preoperative injections of epoetin-alpha vs postoperative retransfusion of autologous shed blood in total hip and knee replacement: a prospective randomised clinical trial.  J Bone Joint Surg Br. 2008;90(8):1079-108318669967PubMedGoogle Scholar
40.
Karkouti K, McCluskey SA, Evans L, Mahomed N, Ghannam M, Davey R. Erythropoietin is an effective clinical modality for reducing RBC transfusion in joint surgery.  Can J Anaesth. 2005;52(4):362-36815814749PubMedGoogle ScholarCrossref
41.
Wong CJ, Vandervoort MK, Vandervoort SL,  et al.  A cluster-randomized controlled trial of a blood conservation algorithm in patients undergoing total hip joint arthroplasty.  Transfusion. 2007;47(5):832-84117465948PubMedGoogle ScholarCrossref
42.
Jabbour N, ed. Preoperative management and preparation for transfusion-free surgery. In Transfusion-Free Medicine and Surgery. Oxford, England: Blackwell; 2005:60-74
43.
Fergusson DA, Hébert P. The health(y) cost of erythropoietin in orthopedic surgery.  Can J Anaesth. 2005;52(4):347-35115814746PubMedGoogle ScholarCrossref
44.
Vitale MG, Roye BD, Ruchelsman DE, Roye DP Jr. Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes.  Spine J. 2007;7(3):292-30017482112PubMedGoogle ScholarCrossref
45.
Marchetti M, Barosi G. Cost-effectiveness of epoetin and autologous blood donation in reducing allogeneic blood transfusions in coronary artery bypass graft surgery.  Transfusion. 2000;40(6):673-68110864987PubMedGoogle ScholarCrossref
46.
Goodnough LT. Autologous blood donation.  Crit Care. 2004;8:(suppl 2)  S49-S5215196325PubMedGoogle ScholarCrossref
47.
Goodnough LT, Saha P, Hirschler NV, Yomtovian R. Autologous blood donation in nonorthopaedic surgical procedures as a blood conservation strategy.  Vox Sang. 1992;63(2):96-1011441313PubMedGoogle ScholarCrossref
48.
Stowell CP, Chandler H, Jové M, Guilfoyle M, Wacholtz MC. An open-label, randomized study to compare the safety and efficacy of perioperative epoetin alfa with preoperative autologous blood donation in total joint arthroplasty.  Orthopedics. 1999;22(1):(suppl)  s105-s1129927110PubMedGoogle Scholar
49.
Keating EM, Callaghan JJ, Ranawat AS, Bhirangi K, Ranawat CS. 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.  J Arthroplasty. 2007;22(3):325-33317400086PubMedGoogle ScholarCrossref
50.
Yazer M, Triulzi D. Messages from national blood data collection reports.  Transfusion. 2007;47(3):366-36817319812PubMedGoogle ScholarCrossref
51.
Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation.  Transfusion. 2001;41(12):1459-146211778055PubMedGoogle ScholarCrossref
52.
Henry DA, Carless PA, Moxey AJ, O’Connell D, Ker K, Fergusson DA. Preoperative autologous donation for minimising perioperative allogeneic blood transfusion. April 14, 2010. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003602/abstract;jsessionid=1F4C582076EE3DAD19BF1F98BE5DE886.d02t04. Accessed October 12, 2011
53.
Billote DB, Glisson SN, Green D, Wixson RL. A prospective, randomized study of preoperative autologous donation for hip replacement surgery.  J Bone Joint Surg Am. 2002;84-A(8):1299-130412177257PubMedGoogle Scholar
54.
McVay PA, Andrews A, Kaplan EB,  et al.  Donation reactions among autologous donors.  Transfusion. 1990;30(3):249-2522315998PubMedGoogle ScholarCrossref
55.
Newman BH, Pichette S, Pichette D, Dzaka E. Adverse effects in blood donors after whole-blood donation: a study of 1000 blood donors interviewed 3 weeks after whole-blood donation.  Transfusion. 2003;43(5):598-60312702180PubMedGoogle ScholarCrossref
56.
Newman B, Tommolino E, Andreozzi C, Joychan S, Pocedic J, Heringhausen J. The effect of a 473-mL (16-oz) water drink on vasovagal donor reaction rates in high-school students.  Transfusion. 2007;47(8):1524-153317655598PubMedGoogle ScholarCrossref
57.
Etchason J, Petz L, Keeler E,  et al.  The cost effectiveness of preoperative autologous blood donations.  N Engl J Med. 1995;332(11):719-7247854380PubMedGoogle ScholarCrossref
58.
Goodnough LM, Grishaber JE, Birkmeyer JD, Monk TG, Catalona WJ. Efficacy and cost-effectiveness of autologous blood predeposit in patients undergoing radical prostatectomy procedures.  Urology. 1994;44(2):226-2318048198PubMedGoogle ScholarCrossref
59.
Birkmeyer JD, AuBuchon JP, Littenberg B,  et al.  Cost-effectiveness of preoperative autologous donation in coronary artery bypass grafting.  Ann Thorac Surg. 1994;57(1):161-1688279884PubMedGoogle ScholarCrossref
60.
Birkmeyer JD, Goodnough LT, AuBuchon JP, Noordsij PG, Littenberg B. The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement.  Transfusion. 1993;33(7):544-5518333017PubMedGoogle ScholarCrossref
61.
Centers for Medicare and Medicaid Services.  Medicare Benefit Policy Manual Chapter 15—Covered Medical and Other Health Services. July 8, 2011. http://www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed October 11, 2011
62.
Centers for Medicare and Medicaid Services.  Medicare National Coverage Determinations Manual: Chapter 1, Part 2 (Sections 90-160.26): Coverage Determinations. July 8, 2011. http://www.cms.gov/manuals/downloads/ncd103c1_Part2.pdf. Accessed October 11, 2011
63.
Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E. Preoperative acute normovolemic hemodilution: a meta-analysis.  Transfusion. 2004;44(5):632-64415104642PubMedGoogle ScholarCrossref
64.
Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia.  Br J Anaesth. 2010;105(4):401-41620802228PubMedGoogle ScholarCrossref
65.
Waters JH. Indications and contraindications of cell salvage.  Transfusion. 2004;44(12):(suppl)  40S-44S15585004PubMedGoogle ScholarCrossref
66.
Freischlag JA. Intraoperative blood salvage in vascular surgery—worth the effort?  Crit Care. 2004;8:(suppl 2)  S53-S5615196326PubMedGoogle ScholarCrossref
67.
Stehling L, edGuidelines for Establishing an Autologous Program—Pitfalls and How to Avoid Them. Arlington, VA: AABB Press; 1991
68.
Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion.  Cochrane Database Syst Rev. 2010;4(4):CD00188820393932PubMedGoogle Scholar
69.
Domen RE. Adverse reactions associated with autologous blood transfusion: evaluation and incidence at a large academic hospital.  Transfusion. 1998;38(3):296-3009563411PubMedGoogle ScholarCrossref
70.
Shander AS, Goodnough LT. Blood transfusion as a quality indicator in cardiac surgery.  JAMA. 2010;304(14):1610-161120940390PubMedGoogle ScholarCrossref
71.
Hajjar LA, Vincent JL, Galas FR,  et al.  Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.  JAMA. 2010;304(14):1559-156720940381PubMedGoogle ScholarCrossref
72.
Ferraris VA, Ferraris SP, Saha SP,  et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion.  Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline.  Ann Thorac Surg. 2007;83(5):(suppl)  S27-S8617462454PubMedGoogle ScholarCrossref
73.
Seifried E, Klueter H, Weidmann C,  et al.  How much blood is needed?  Vox Sang. 2011;100(1):10-2121175652PubMedGoogle ScholarCrossref
74.
Hébert PC, Wells G, Blajchman MA,  et al; Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.  A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care.  N Engl J Med. 1999;340(6):409-4179971864PubMedGoogle ScholarCrossref
75.
Rhamy JF. Synergies between blood center and hospital quality systems.  Transfusion. 2010;50(12 pt 2):2793-279721128951PubMedGoogle ScholarCrossref
76.
Department of Health and Human Services.  Biovigilance in the United States: Efforts to Bridge a Critical Gap in Patient Safety and Donor Health2009. http://www.hhs.gov/ash/bloodsafety/biovigilance/ash_to_acbsa_oct_2009.pdf. Accessed August 26, 2011
77.
Shaz BH, Stowell SR, Hillyer CD. Transfusion-related acute lung injury: from bedside to bench and back.  Blood. 2011;117(5):1463-147120944069PubMedGoogle ScholarCrossref
78.
Eder AF, Herron RM Jr, Strupp A,  et al.  Effective reduction of transfusion-related acute lung injury risk with male-predominant plasma strategy in the American Red Cross (2006-2008).  Transfusion. 2010;50(8):1732-174220456698PubMedGoogle ScholarCrossref
79.
Stainsby D, Jones H, Asher D,  et al; SHOT Steering Group.  Serious hazards of transfusion: a decade of hemovigilance in the UK.  Transfus Med Rev. 2006;20(4):273-28217008165PubMedGoogle ScholarCrossref
80.
Glynn SA. The red blood cell storage lesion: a method to the madness.  Transfusion. 2010;50(6):1164-116920598098PubMedGoogle ScholarCrossref
81.
Davis RE, Vincent CA, Murphy MF. Blood transfusion safety: the potential role of the patient.  Transfus Med Rev. 2011;25(1):12-2321134623PubMedGoogle ScholarCrossref
82.
Chambers LA, Kruskall MS. Preoperative autologous blood donation.  Transfus Med Rev. 1990;4(1):35-462134615PubMedGoogle ScholarCrossref
83.
Toy P, Hoag MS, Lamberson HV. Higher non-A, non-B hepatitis surrogate marker rates in designated donor units [abstract].  Transfusion. 1988;28:(suppl)  17SGoogle Scholar
84.
Davis M, Sofer M, Gomez-Marin O, Bruck D, Soloway MS. The use of cell salvage during radical retropubic prostatectomy: does it influence cancer recurrence?  BJU Int. 2003;91(6):474-47612656896PubMedGoogle ScholarCrossref
85.
Liang TB, Li DL, Liang L,  et al.  Intraoperative blood salvage during liver transplantation in patients with hepatocellular carcinoma: efficiency of leukocyte depletion filters in the removal of tumor cells.  Transplantation. 2008;85(6):863-86918360269PubMedGoogle ScholarCrossref
86.
 Suitability of donor. 21 CFR §640.3
87.
AABB.  Standards for Blood Banks and Transfusion Services. 27th ed. Bethesda, MD: AABB; 2011
88.
Eder AF. Allogeneic and autologous blood donor selection. In: Roback JD, Combs MR, Grossman BJ, Hillyer CD, eds. Technical Manual. 16th ed. Bethesda, MD: AABB; 2008:137-181
89.
Goodnough LT. Alternatives to allogeneic transfusion in patients with surgical anemia. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles and Practice. 3rd ed. Bethesda, MD: AABB Press; 2011:699-720
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    2 Comments for this article
    EXPAND ALL
    Reassurance for Mrs C from New Zealand
    Richard D Seigne, MBBS FRCA | Christhchurch Hospital, Canterbury District Helath Board (New Zealand)
    I would reassure Mrs. C that the transfusion rate for knee replacement surgery with a pre-operative haemoglobin level of 15.1g/dL should be zero (expected haemoglobin drop approximately 3.5g/dL). Mrs. C should ask her surgeon what his/her transfusion rate is. Strategies to minimize the need of blood transfusion for elective surgery form the basis of the 3 pillars of Patient Blood Management,
    1. Optimising red cell mass
    2. Minimising intra and post operative blood loss
    3. Tolerating post-operative anaemia
    In Mrs. C's case
    1. The red cell mass (haemoglobin) is optimal.
    2. Blood loss
    can be minimised by
    *Enquiring about a history and or family history of coagulation defects, investigate and treat as appropriate
    *Enquiring about the use of prescribed and non prescribed substances that may increase bleeding; cease these pre-operatively. Non prescribed examples include ibuprofen, naproxen, garlic, fish oil, ginkgo, ginger, vitamin E, St John's Wort
    * Cessation of aspirin therapy 4 days pre-operatively
    * The use of an intra-operative tourniquet
    * Intra-operative and post operative intravenous tranexamic acid administration(1)
    * The omission of a drain(2). If a drain is employed then one that enables autologous re-infusion may appeal to Mrs C(3), although evidence suggests this would not be required(4). Re-transfusion would not be advised if local anaesthetic infiltration is utilised
    * Elevation of the knee in extension for 6 hours post- operatively(5)
    3. Post-operatively, if Mrs C does not have signs or symptoms of anaemia, a haemoglobin level of 6g/dL may be tolerated(6). Symptoms such as dizziness and light headedness within 48 hours of surgery may be secondary to hypovolaemia rather than anaemia. I would reassure Mrs C that the risk of an infectious complication(7) such as hepatitis C (1/200,000) or hepatitis B or HIV (both 1/1-2 million) is less than the risk of dying from a lightning strike -- about a 1/100,000 risk. Less rare but serious risks include transfusion-associated circulatory overload (TACO) and wrong blood to wrong patient.
    Autologous blood donation seems attractive but the evidence does not support its routine use(8). This is because the pre-operative haemoglobin is commonly reduced, the lower the pre-operative haemoglobin the more likely the need for a peri-operative blood transfusion. Autologous donation does reduce the risk of requiring an allogeneic transfusion i.e. blood from someone else, but the overall risk of transfusion is generally increased. An autologous blood transfusion is not risk free e.g. wrong blood to wrong patient. "Directed donations" by relatives and friends are possible, although not permitted by some countries' Blood Service, e.g. New Zealand as they do not increase safety and may result in waste.
    My advice would be to Mrs C would be
    * Do not undergo autologous blood donation
    * Do not ask friends or family to donate for you
    * Find a surgical centre that practices patient blood management and can evidence this with data for transfusion rates after knee replacement surgery, preferably the rate for a female with a pre-operative haemoglobin of 15.1g/dL.
    References
    1. Henry DA, Carless PA, Moxey AJ, O'Connell D, Stokes BJ, Fergusson DA, Ker K. Anti-fibrinolytic use for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD001886. DOI: 10.1002/14651858.CD001886.pub4 (http://www2.cochrane.org/reviews/en/ab001886.html)
    2. Parker MJ, Livingstone V, Clifton R, McKee A. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD001825. DOI: 10.1002/14651858.CD001825.pub2 (http://www2.cochrane.org/reviews/en/ab001825.html)
    3. Huet C, Salmi LR, Fergusson D, Koopman-van Gemert AWMM, Rubens F, Laupacis A. A Meta-Analysis of the Effectiveness of Cell Salvage to Minimize Perioperative Allogeneic Blood Transfusion in Cardiac and Orthopedic Surgery. A & A 1999: 89 (4) 861-9
    4. Steinberg EL, Peleg Ben-Galim P, Yaniv Y, Dekel S, Menahem A. Comparative analysis of the benefits of autotransfusion of blood by a shed blood collector after total knee replacement. Arch Orthop Trauma Surg. 2004 124 : 114-118
    5. Ong SM, Taylor GJ. Can knee position save blood following total knee replacement? Knee. 2003 Mar;10(1):81-5.
    6. A Compendium of Transfusion Practice Guidelines. American Red Cross. 2010. Accessed from http://www.redcrossblood.org/sites/arc/files/pdf/Practice-Guidelines- Nov2010-Final.pdf
    7. National Heart Lung and Blood Institute website, accessed 17.10.11. http://www.nhlbi.nih.gov/health/health-topics/topics/bt/risks.html
    8. Henry DA, Carless PA, Moxey AJ, O'Connell D, Ker K, Fergusson DA. Pre-operative autologous donation for minimising perioperative allogeneic blood transfusion. Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD003602. DOI: 10.1002/14651858.CD003602 (www2.cochrane.org/reviews/en/ab003602.html)
    Conflict of Interest: Member of Expert Working Group of the "Patient Blood Management Guidelines" National Blood Authority, Canberra, Australia. Member of the Clinical Reference Groups for Patient Blood Management Guidelines: Module 1 Critical Bleeding / Massive Transfusion (2011). and Patient Blood Management Guidelines: Module 2 Perioperative (2012).
    CONFLICT OF INTEREST: None Reported
    READ MORE
    A rational approach to minimize the need for blood transfusions
    Kai Singbartl, MD, MPH | University of Pittsburgh, Departments of Critical Care Medicine and Anesthesiology,
    Strategies to minimize the need of blood transfusion for patients facing elective surgery? Potential preoperative, intra-operative and postoperative strategies include the following.[1] Correction of pre-operative low hb-/hct- level.Minimizing surgical blood loss through meticulous surgical hemostasis.If feasible, Esmarch ischemia via tourniquet for orthopedic cases. Acceptance of a low 'transfusion trigger' while accounting for individual co-morbidities and other limitations. Pharmacological reduction of surgical blood loss (e.g., anti-fibrinolytics). Differentiated consideration and use of available blood conservation techniques:[2]
    (a) intra- and postoperative RBC-salvage and re-transfusion [3,4],
    (b) acute normovolemic hemodilution (ANH), only if the patient can tolerate a 'minimal hct', i.e.
    transfusion trigger of 20%, and if the expected blood loss >= 40% of the patient's estimated blood volume [5,6], and
    (c) if a.) and b.) are not feasible, pre-operative autologous deposit (PAD), only if there is sufficient time left for regenerative erythropoiesis, i.e. time to for patient's hct to return to baseline hct before surgery.[7,8]
    What options are available for preoperative patient blood management? Potential preoperative interventions include the following: Correction of nutritional iron and/or vitamin B12 deficiencies to increase the patient's hb/hct-level. Correction of a low hb/hct-level by administration of erythropoietin plus iron. PAD. ANH immediately before surgery.
    When should a patient consider preoperative autologous donation? A patient should consider PAD, only if there was enough time left for RBC- regeneration (i.e. >4 weeks between last PAD and surgery [7,8]), and ... if the patient suffered from RBC allo-antibodies, or if the expected blood-loss could not be compensated for with other autologous blood conservation techniques, i.e. - intra-/ postoperative cell salvage, ANH, and anti- fibrinolytics, or if other strategies of autologous blood conservation techniques were not feasible to avoid the risk of developing RBC-allo-antibodies at a young age.
    What intra-operative and postoperative measures are available to reduce the need for allogeneic transfusion? Esmarch ischemia/tourniquet in patients without peripheral arterial disease undergoing extremity surgery.[1] Pharmacological reduction of surgical blood loss with anti-fibrinolytics, e.g., tranexamic acid.[1] Intra- and postoperative blood salvage with re-transfusion of washed or unwashed autologous RBC.[3,4]
    How should clinicians counsel patients about the risks of transfusion and peri-operative blood management? The patient needs to be made aware of ... the actual risk to require a blood transfusion during/after that particular surgery, feasible autologous blood conservation alternatives, including pharmacological interventions, the true risks of allogeneic blood, including transmission of infectious diseases, ABO incompatibility, bacterial contamination, transfusion- related acute lung injury[9,10], the true risks of autologous blood transfusions, including bacterial contamination, side effects of PAD[1], and the hospital-/surgeon-specific blood loss for the particular procedure.
    What is your advice to Ms C? We advise Ms. C. to ... not undergo PAD for this type of surgery[3,7,8], and to accept both dilutional anemia and intra-/postoperative blood salvage.[3]
    References
    1. Munoz M, García-Erce JA, Villar I, Thomas D. Blood conservation strategies in major orthopaedic surgery: efficacy, safety and European regulations. Vox Sang. 2009;96:1-13.
    2. Carless P, Moxey A, O'Connell D, Henry D. Autologous transfusion techniques: a systematic review of their efficacy. Transfusion Medicine (Oxford, England). 2004;14:123-144.
    3. Singbartl G, Schreiber J, Singbartl K. Preoperative autologous blood donation versus intraoperative blood salvage: intraindividual analyses and modeling of efficacy in 1103 patients. Transfusion. 2009;49:2374-2383.
    4. Carless PA, Henry DA, Moxey AJ, O'Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev. 2010:CD001888.
    5. Singbartl K, Schleinzer W, Singbartl G. Hypervolemic hemodilution: an alternative to acute normovolemic hemodilution? A mathematical analysis. J Surg Res. 1999;86:206-212.
    6. Singbartl K, Innerhofer P, Radvan J, et al. Hemostasis and hemodilution: a quantitative mathematical guide for clinical practice. Anesth Analg. 2003;96:929-35.
    7. Singbartl G. Preoperative autologous blood donation - part I. Only two clinical parameters determine efficacy of the autologous predeposit. Minerva Anestesiol. 2007;73:143-151.
    8. Singbartl G, Malgorzata S, Quoss A. Preoperative autologous blood donation - part II. Adapting the predeposit concept to the physiological basics of erythropoiesis improves its efficacy. Minerva Anestesiol. 2007;73:153-160.
    9. Vamvakas EC, Blajchman MA. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the available strategies for their prevention. Blood. 2009;113:3406-3417.
    10. Dwyre DM, Fernando LP, Holland PV. Hepatitis B, hepatitis C and HIV transfusion-transmitted infections in the 21st century. Vox Sang. 2011;100:92-98.
    Conflict of Interest: None declared
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Clinical Crossroads
    November 2, 2011

    Patient Blood Management: A 68-Year-Old Woman Contemplating Autologous Blood Donation Before Elective Surgery

    Author Affiliations

    Author Affiliations: Dr Uhl is Director, Division of Laboratory and Transfusion Medicine, Beth Israel Deaconess Medical Center and Associate Professor of Pathology, Harvard Medical School, Boston, Massachusetts.

    JAMA. 2011;306(17):1902-1910. doi:10.1001/jama.2011.1526
    Abstract

    Globally, more than 81 million units of red blood cells are transfused annually. Of the 15 million red blood cell components transfused annually in the United States, approximately 40% are transfused to patients undergoing elective surgical procedures. Because of concerns about limited blood availability as well as risks of transfusion-related adverse events, blood products should be used judiciously. Using the case of Ms C, a 68-year-old woman considering autologous blood donation prior to knee replacement surgery, the concept of patient blood management is discussed. This approach entails a complete evaluation of the patient in the preoperative period to assess for bleeding risks and anemia, with a goal to optimize a patient's condition prior to surgery; use of various strategies in the operative period to mitigate the need for allogeneic blood transfusion; and meticulous postoperative care to again avoid the need for blood transfusion.

    DR TESS: Ms C is a 68-year-old woman who presented with progressive right knee pain and swelling. She first developed pain and swelling in her right knee in 2003 and was diagnosed as having osteoarthritis. She underwent arthroscopy and bursectomy in 2006, but in the last few years, she has experienced worsening of her pain as well as significant physical limitations. Joint injections with steroids have resulted in little improvement, and now she is planning to undergo knee replacement surgery in 8 weeks.

    Ms C's medical history includes osteoarthritis, hypertension, hyperthyroidism, hypercholesterolemia, and uterine fibroids in addition to the arthroscopy in 2006. Her medications include hydrochlorothiazide, levothyroxine, simvastatin, and aspirin. She has no known drug allergies.

    On examination, Ms C is a healthy-appearing woman with normal vital signs. Her physical examination results were normal except for pain on palpation of her medial right knee, an antalgic gait, and difficulty with toe and heel walking due to pain. A routine complete blood cell count revealed a white blood cell count of 7900/μL, hemoglobin level of 15.1 g/dL, mean corpuscular volume of 92 fL, red blood cell (RBC) distribution width of 13.4%, and platelet count of 290 × 103/μL.

    Ms c: her view

    Personally, I do not want anyone else's blood. I believe I should give my own blood for safety reasons. I read the paper a lot and watch the news, and you hear so much about infectious diseases. That's my concern; I have never had a [serious] infectious disease in my life and at this age, I don't think I want to get one.

    I was thinking about donating my own blood for after my surgery so I wouldn't have any worries at all about infection. Did I get hepatitis? Did I get some other kind of disease? I think a doctor should always counsel their patients about the do's and the don’ts of transfusion and explain the risks and options to them.

    If I am not able to donate my own blood for my surgery, I would first discuss it with my family and see if they would donate some blood for me. If my family is not able to, then I would have to make the decision about whether to take the blood from the hospital. I would like Dr Uhl to answer the question, “What is my risk if I do not donate my own blood and I have to take the blood from the hospital?”

    At the crossroads: questions for dr uhl

    What is the prevalence of blood transfusion and associated risks and cost in the acute surgical setting? What strategies can be used to minimize the need for blood transfusion for patients facing elective surgery? What options are available for preoperative patient blood management? When should a patient consider preoperative autologous donation? What intraoperative and postoperative measures are available to reduce need for allogeneic transfusion? How should clinicians counsel patients about the risks of transfusion and perioperative blood management? What does the future hold? What is your advice for Ms C?

    DR UHL: Ms C, a 68-year-old woman with a long-standing history of knee pain who has undergone numerous nonsurgical interventions without relief, is scheduled for elective total knee replacement, and may need blood transfusion during her recovery period. Because she has concerns about the safety of the blood supply, she is seeking guidance as to whether to donate her own blood for the upcoming surgery. Allogeneic blood transfusion is considered a therapeutic intervention and, as with other medical interventions, requires that a patient provide informed consent.1,2 The physician responsible for prescribing blood component transfusion is also responsible for explaining to the patient the risks and benefits of transfusion. Equally important to the discussion is information on the alternatives to allogeneic transfusion, including preoperative autologous blood donation and intraoperative cell recovery. This discussion should be carried out in an unhurried and unpressured manner with ample opportunity for the patient to ask questions. A careful and thorough description of the transfusion process, including possible adverse effects, improves a patient's understanding of blood transfusion. On conclusion of the informed consent discussion, the mutually agreed-on course of action regarding the approach to transfusion management should be documented in the medical record.1,2 Ms C's desire to understand her options related to transfusion management for her upcoming surgery presents a ripe opportunity for her physicians to embark on the informed consent process.

    Epidemiology and Costs of Blood Transfusion in the Surgical Setting

    Globally, more than 81 million units of RBCs are transfused annually.3 According to the 2009 US National Blood Collection and Utilization Survey, approximately 15 million RBCs were transfused in 2008 in the United States, 40% of which were transfused to surgical patients.4 The possible deleterious effects of blood transfusion and the associated costs of transfusion require that both primary care physicians and surgeons look for opportunities to improve the preoperative status of patients, in particular hemoglobin concentration, to attempt to reduce the need for blood transfusion.5-7 The risks of transfusion include transfusion-associated infections and noninfectious complications and occur at different rates (Table 1).8-11Quiz Ref IDFortunately, in the United States and other developed countries, the risk of transfusion-associated infectious disease has dramatically declined during the last 20 years because of improved donor screening and laboratory testing as well as decreased prevalence of transmissible diseases (eg, hepatitis C).10 Currently in the United States, all whole blood donations are screened for human immunodeficiency virus (HIV) types 1 and 2, hepatitis B and C virus, human T-cell lymphotrophic virus types 1 and 2, West Nile virus, Chagas disease, and syphilis.8,11 Epidemiological studies carried out by major US blood suppliers demonstrate the current risk of HIV and hepatitis C virus to be approximately 1 in 1.5 million whole blood units transfused and for hepatitis B virus, 1 in 280 000 to 357 000 whole blood units.8 Despite these reduced risks, however, the potential persists for new and emerging infectious agents to affect the safety of the blood supply. By comparison, transfusion-related noninfectious complications occur with much higher frequency (Table 1).9

    Determining the cost of blood transfusion is complex and requires consideration of not only the direct acquisition cost of an RBC unit but also the costs associated with regulatory management of donor services, transfusion services, patient laboratory testing and preparation for transfusion (eg, type and screen and cross-match), administration and patient monitoring during transfusion, and evaluation of any adverse events related to the transfusion event.12 Through the use of a carefully constructed model that took into consideration critically important variables related to blood transfusion and applied them to 4 different institutions (2 US and 2 European), Shander et al13 estimated the total cost per RBC unit to be $760.82 ± $293.74. The total cost of transfusions for surgical patients at participating institutions ranged from $1.61 million (at a center with 451 surgical patients receiving transfusions) to $6.03 million (at a center with 2237 surgical patients receiving transfusions) during the period evaluated. These costs are driven by the proportion of surgical patients receiving transfusions as well as the number of units transfused per patient.

    Reducing Need for Perioperative Blood Transfusion

    The concept of patient blood management, recently embraced by surgeons and anesthesiologists, is broad in scope, is multifaceted, and includes interventions that are used in the prehospitalization period, the intraoperative period and the postoperative period (Box).14,15 More recently, the concept of patient blood management has caught the attention of organizations responsible for patient quality and safety initiatives, including the Joint Commission,16 which has set forth performance measures directed at preoperative patient assessment for anemia and clinical decisions regarding blood component transfusion.

    Box. Patient Blood Management: Interventions That May Reduce Allogeneic Transfusion in the Elective Surgical Settinga

    • Preoperative

           Clinical assessment for anemia and bleeding risk

           Iron supplementation

           Erythropoietin

           Preoperative autologous blood donation

    • Intraoperative

           Acute normovolemic hemodilution

           Intraoperative blood recovery

           Use of topical/systemic hemostatic agents

    • Postoperative

           Restrictive use of transfusion

           Restrictive use of phlebotomy

           Use of topical/systemic hemostatic agents

           Judicious use of anticoagulants and platelet inhibitors

    aSee text for evidence and caveats regarding interventions.

    Patients undergoing elective surgical procedures for which there is a high likelihood of significant intraoperative blood loss represent the target population for patient blood management programs.7,17 Patients who because of religious preferences are not accepting of allogeneic blood transfusion or patients who have complex RBC alloantibodies and therefore present difficulties in finding appropriately matched RBCs also represent ideal candidates for patient blood management programs.

    Ms C is facing an elective surgical procedure that is often associated with a need for blood transfusion during the postoperative period.18,19 As such, she is an ideal candidate for careful consideration of blood management to mitigate the need for allogeneic transfusion.

    Preoperative Blood Management Options

    Quiz Ref IDAny patient facing an elective surgical procedure associated with a high likelihood of major blood loss should be fully evaluated to assess for factors predictive of preoperative and postoperative anemia and the need for transfusion. These include comorbidities associated with high likelihood of postoperative transfusion (eg, renal insufficiency, adult-onset type 1 diabetes, peripheral vascular disease)20,21; personal or family history of bleeding problems that could contribute to blood loss during the surgical procedures (eg, a history of von Willebrand disease or specific clotting factor deficiency [eg, factor XI deficiency]); history of use of drugs that interfere with either primary or secondary hemostasis (eg, aspirin, antiplatelet agents, anticoagulants); or evidence of anemia either by history or by laboratory assessment.22

    Administration of iron and erythropoietin are 2 preoperative blood management approaches that have been evaluated. Preoperative anemia is common in the elective surgical patient population,23 with a reported prevalence of 34% to 76% among various surgical patient populations.24 Studies demonstrate that the clinical consequences of preoperative anemia include a higher likelihood of allogeneic blood transfusion5,6,25 and increased incidence of postoperative infection and longer lengths of stay.26 The presence of anemia in any patient should prompt a thorough evaluation to determine its cause. In some patients, it may be the result of an occult colon cancer; in others, it may reflect poor nutritional status.

    Iron deficiency is the underlying cause in approximately 30% of preoperative anemia cases. Fortunately, preoperative anemia due to iron deficiency, particularly in elective orthopedic surgical patients, appears to be readily reversible with preoperative iron supplementation.26-28 For example, Theusinger et al24 demonstrated a clear benefit of preoperative iron supplementation in patients scheduled for major elective orthopedic surgery who were anemic (men with hemoglobin concentrations of 10.0-13.0 g/dL and women with hemoglobin concentrations of 10.0-12.0 g/dL) and having marginal iron stores based on an absolute ferritin concentration of less than 100 μg/L or ranging between 100 and 300 μg/L with iron saturation of less than 20%. In that study, patients meeting inclusion criteria were administered intravenous infusions of iron sucrose for 10 days prior to scheduled surgical procedures. Mean hemoglobin concentration increased significantly (P < .001) from baseline (1.0 [SD, 0.6] g/dL; 95% CI, 0.8-1.3 g/dL). Iron stores as assessed by ferritin also increased significantly (P < .001) from baseline values (median increase, 638%; 95% CI, 523%-958%).

    Erythropoietin, a key regulator of erythropoiesis, is a hormone that promotes cellular differentiation and maturation of erythroid precursors in bone marrow, leading to enhanced hemoglobin synthesis and release of reticulocytes into the systemic circulation.29 Erythropoietic response to acute blood-loss anemia is modest,30 but because exogenous erythropoietin (recombinant erythropoietin) improves compensatory hematopoiesis, the role of erythropoietin therapy in patient populations undergoing surgical procedures associated with significant blood loss (eg, major orthopedic, cardiovascular, and urological surgical procedures) has been studied.31-37 As summarized in Table 2, clinical trials in the orthopedic patient population, using a variety of dosing regimens, demonstrated increased preoperative hemoglobin concentrations and reduced allogeneic transfusions.31-34,38,39 Patients with preoperative hemoglobin concentrations ranging between 10 and 13 g/dL appeared to benefit the most from preoperative administration of erythropoietin.33 Erythropoietin therapy was approved in 1996 for perioperative use in patients scheduled for elective noncardiovascular surgical procedures. Quiz Ref IDMore recent trials in orthopedic patient populations have confirmed that erythropoietin administration can reduce allogeneic RBC transfusion, particularly when coupled with iron repletion and restricted use of preoperative autologous blood donation.27,40,41 However, erythropoietin has not been widely used for preoperative blood management because of the inconvenience of self-administration; restrictive reimbursement by insurance companies; concern about thrombosis, particularly in the cardiovascular surgical patient population42; and lack of demonstrable cost-effectiveness with respect to patient morbidity and mortality.43 Studies of cost-effectiveness have found high marginal cost.44,45 In a model of cost-effectiveness of erythropoietin use in young patients undergoing extensive spine surgery for scoliosis repair, Vitale et al44 reported a cost-effectiveness ratio of more than $1.5 million per quality-adjusted life-year.

    Autologous Donation

    Preoperative autologous blood donation (PAD), in which a patient donates 1 or more units of his or her own blood preoperatively, has traditionally been advocated for patients who are undergoing elective surgical procedures that are associated with significant blood loss procedures associated with greater than 90% likelihood of requiring blood transfusion.46 In contrast, PAD is of limited medical value for patients scheduled for procedures with little or no anticipated blood loss; for example, vaginal hysterectomies.47 PAD has been widely used in the management of patients undergoing elective major orthopedic procedures including total knee arthroplasty.18,19,41,48,49

    The success of PAD is dependent on a patient's underlying nutritional status, clinical status, and timing of preoperative autologous donation.46 For patients with baseline anemia, PAD may not be possible because the patient does not meet donation eligibility requirements; moreover, PAD may exacerbate anemia since the erythropoietic response replaces only a small amount of blood from the time of donation to surgery. Consequently, PAD may not reduce allogeneic blood transfusion in the perioperative period. Patients with significant underlying cardiac disease (eg, aortic stenosis), for whom acute blood loss by phlebotomy of 500 mL of whole blood could exacerbate underlying medical conditions, or underlying infections (eg, infected prosthesis), which risks the collection of a contaminated blood component, are not appropriate candidates for PAD and should not be referred for autologous donation.

    Concern about the safety of the blood supply appears to be the primary motivation for Ms C's consideration of autologous blood donation in advance of her surgical procedure. This concern was also prevalent 25 years ago, when the threat of transfusion-transmitted disease, in particular HIV, spawned the implementation of hospital-based autologous whole blood donation programs. These programs continued into the 1990s, but more recently the number of units collected nationally for autologous transfusion declined 26.9% from 2004 to 2006 and 24.5% from 2006 to 2008.4,50Quiz Ref IDA number of factors are thought to have contributed to this downward trend,51 including the decline in the risk of transfusion-associated disease, the lowering of clinical transfusion thresholds over the last 10 to 15 years, and the realization that PAD may actually increase the likelihood of transfusion. The latter point is supported by a systematic review by Henry et al52 of randomized controlled trials evaluating the efficacy of PAD with respect to mitigation of allogeneic blood exposure and overall transfusion exposure. They found that although PAD is associated with a reduction in allogeneic blood exposure, patients participating in PAD had a higher likelihood of transfusion (allogeneic and autologous blood) compared with patients who did not participate in PAD. Reasons for this include lower preoperative hemoglobin concentrations resulting in increased probability of intraoperative and/or postoperative blood transfusion and, possibly, more liberal use of autologous blood transfusion based on the knowledge of availability and perceived safety (compared with allogeneic blood). The results of Billote et al53 in particular demonstrated PAD's limited reduction of allogeneic blood exposure in patients undergoing unilateral primary total hip replacement. In this study, patients were randomized to PAD that was completed 2 weeks prior to the elective surgical procedure vs no PAD. Intraoperative and postoperative transfusion, applied to both treatment groups, was guided by a standard transfusion protocol. This study found that no patient required allogeneic blood transfusion, only patients randomized to the PAD group required any transfusion (with their autologous blood), and PAD contributed to significant wastage of blood components (41% of the collected autologous units were discarded). More pertinent to Ms C is the prospective observational study by Bierbaum et al18 examining transfusion requirements in patients undergoing major total joint arthroplasty (hip and knee). In this study, only 18% of patients who had primary unilateral knee replacement surgeries and who did not participate in PAD required allogeneic transfusion.

    Autologous donation carries no more risk than allogeneic donation in patients who qualify for donation (eg, patients who pass the basic eligibility physical for heart rate, blood pressure, and hemoglobin concentration; have no significant medical comorbidities; and have no signs or symptoms of active infection). In both populations, the risk of adverse reactions related to donation is approximately 2% to 5%54 and includes vasovagal reactions, hematoma at the phlebotomy site, and nerve damage. Similar to allogeneic donation, the occurrence of donor reactions is associated with female sex, first-time donation, and increasing age.55 An individual's familiarity with blood donation as well as adequate hydration has been shown to mitigate risk of adverse reactions.56

    The cost-effectiveness ratio for PAD is high; several studies published in the mid-1990s found that PAD had a cost ranging from $235 000 to more than $23 million per quality-adjusted life-year saved, depending on the surgical procedure and associated blood transfusion requirements as well as the number of autologous units collected.57-60 More specifically, cost-effectiveness analyses for major orthopedic procedures showed a cost of $1.4 million per quality-adjusted life-year saved in the patient population undergoing primary unilateral knee replacement.60 The primary contributors to these high costs were the expense of autologous donation compared with allogeneic donation; the discard rate of autologous blood units; and the low risk of the adverse outcomes associated with allogeneic transfusion included in the analyses (eg, risk of transfusion-transmitted HIV and hepatitis C and B viruses). Given the progressive decline in risk of transfusion-transmitted viral disease and more restrictive use of allogeneic transfusion, the current cost-effectiveness ratios for both PAD and erythropoietin are likely even higher than studies have shown to date. In the United States, insurance carriers cover costs related to PAD or erythropoietin provided a patient meets certain clinical and laboratory requirements (eg, hemoglobin level <12.5 g/dL). The requirements for coverage of either PAD or preoperative erythropoietin therapy vary among insurance providers, so patients and physicians are encouraged to seek guidance prior to embarking on a course of action.61,62

    Perioperative Strategies to Reduce Need for Transfusion

    Strategies to reduce risk of allogeneic transfusion in the perioperative period include acute normovolemic hemodilution (ANH) and RBC recovery techniques. In addition, agents that reduce surgical blood loss (eg, antifibrinolytic drugs and fibrin sealants) can reduce the need for allogeneic transfusion.

    Quiz Ref IDAcute normovolemic hemodilution refers to the process whereby blood is removed from a patient, usually during induction of anesthesia, and replaced with either crystalloid or colloid to maintain circulating blood volume, and the collected and reserved whole blood units are typically transfused back at the conclusion of the surgical procedure. Although considered a relatively safe procedure, reports on the clinical efficacy of ANH are mixed and its use in orthopedic surgery is limited.15,63

    In contrast, perioperative cell recovery has been applied in a variety of surgical settings, including orthopedic, cardiothoracic, vascular, and urological surgery, as well as obstetrics.64 It involves the collection of shed blood during the surgical procedure or from the surgical site during the postoperative period. Intraoperative techniques involve direct suctioning of shed blood, which is collected into canisters, as well as the recovery of blood from surgical sponges. The accumulated shed blood is then prepared for transfusion by 1 of 2 methods. In the first method, hemofiltration, shed blood is drawn into an autotransfusion device equipped with an integral filtration device. The collected product is then simply filtered (ie, without washing the product) and reinfused to the patient.65 The second, RBC wash systems, involves collecting shed blood and processing via automated devices that wash the shed blood free of cellular debris and other contaminants, as well as concentrating the recovered RBCs.65,66 When the practice of cell recovery was originally introduced, it was recommended for surgical procedures in which estimated blood loss was anticipated to be more than 20% of a patient's blood volume or for procedures for which more than 10% of patients require transfusion (and the mean transfusion requirement is >1 unit).67 These recommendations were largely derived from cost comparisons between cell recovery and the cost of allogeneic blood. Given the cost escalation of allogeneic blood, proponents of cell recovery suggest that its use, from a financial perspective, may be appropriate in settings of much smaller blood loss.65

    Whether general use of cell recovery processes contributes to a meaningful reduction in allogeneic blood exposure remains an open question. A review of 75 studies spanning 1979 to 2008 suggests that part of the difficulty in assessing efficacy relates to the methodological problems in this area of investigation, including small numbers of patients studied, heterogeneity in transfusion practice (protocol-driven vs transfusion at the investigators' discretion), and either no reference to whether the study was blinded or the study was definitely unblinded.68 Despite these limitations, the reviewers, having applied strict review criteria, concluded that use of RBC recovery and reinfusion reduced the relative risk of perioperative allogeneic RBC transfusion exposure by a relative 38% (relative risk, 0.62; 95% CI, 0.55-0.70). Moreover, they observed the most pronounced reduction in the orthopedic surgical population (relative risk reduction of 54% vs 23% in the cardiac surgical population).68

    Potential complications of RBC recovery techniques include air embolus, nonimmune hemolysis secondary to traumatic RBC injury during cell collection by suction devices, coagulopathy, and transfusion of recovered blood contaminated with drugs, bacteria, or tumor cells. However, these appear to be rare events.64 A retrospective review by Domen69 performed at the Cleveland Clinic showed the incidence of adverse events associated with reinfusion of salvaged blood to be 0.027%. Thus, when appropriately performed, including the participation of trained operators, cell recovery systems are fairly safe.

    Postoperative management can also reduce allogeneic blood transfusion exposure. Restricted phlebotomy for laboratory testing avoids iatrogenic RBC loss, and the use of topical and systemic hemostatic agents combined with meticulous wound care reduces blood loss. Decisions regarding use of allogeneic blood transfusion should take into account the physiologic condition of the patient and risk of end organ ischemia balanced against the risks associated with RBC transfusion. Although reliance on a numeric “transfusion trigger” should be avoided, particularly because there are few high-quality studies in the surgical patient population to support this practice, transfusion is generally considered reasonable for hemoglobin concentrations of less than 7 g/dL.70-72

    Counseling Patients About Transfusion Risks

    Despite improved surgical management and operative techniques, for many patients undergoing elective surgical procedures, notably cardiac, orthopedic, or complex gynecological/urological surgeries, blood transfusion continues to be a routine part of patient care. Several factors relate to the likelihood of blood transfusion, including sex, age, and preoperative hemoglobin concentration.17,73 Clinicians responsible for the care and referral of patients in need of elective surgical interventions should recognize the associated risk factors for perioperative transfusion needs and, when indicated, offer medical intervention to mitigate those needs (eg, iron replacement therapy).22 Furthermore, clinicians should actively involve their patients in an informed discussion on existing options for patient blood management, including PAD and the available alternatives to PAD (eg, use of perioperative cell recovery and ANH). Careful consideration of a patient's underlying health status (eg, potential risk of PAD-associated anemia), assessment of likelihood of transfusion based on type of elective surgical procedure, and thorough understanding of a patient's wish for PAD are important factors in a patient-physician discussion of the appropriateness of PAD. Primary care physicians should also know the current risks of transfusion, particularly the risks of transfusion-transmitted infection, as this is often patients' primary concern related to blood transfusion. Finally, clinicians should be aware of current literature on evidence-based transfusion practice as well as the indications for transfusion.15,52,68,71,72,74

    What Does the Future Hold?

    National and international blood utilization studies demonstrate that blood component therapy continues to be a regular practice in surgical patient management. Because of recognized complications related to transfusion and observations tying blood transfusion to increased morbidity and mortality, increasing emphasis is being placed on managing predisposing risk factors for transfusion.22 Implementation of patient blood management programs serves to bring multiple caregivers together to assess the opportunities and implement treatment plans that potentially mitigate the need for blood transfusion.75

    The transfusion medicine community has made great strides in reducing the risk of transfusion-transmitted disease, largely through improved donor screening and testing.10 However, the risk of noninfectious transfusion complications has remained largely unchanged, and for some complications there is significant risk of morbidity and mortality (eg, transfusion-associated circulatory overload and transfusion-related acute lung injury).9 Basic science research and prospective data collection initiatives (eg, national biovigilance programs76) are ongoing, with the intent to garner a better understanding of the pathophysiology and the prevalence of these complications as well as potential risk reduction strategies.77-80 Endeavors such as these serve to inform the transfusion medicine and medical communities at large of opportunities to further improve the quality and safety of transfusion practice.

    Recommendations for ms c

    Ms C's interest in preoperative autologous donation stems from her concerns about transfusion-associated disease. She is certainly not unusual; many patients facing the possibility of requiring blood transfusion are concerned about the safety of the blood supply.81 In light of her concerns, I would discuss with her the blood management plan for her upcoming surgery. This would include providing a realistic assessment of anticipated blood loss related to the surgical procedure; ways the effects of the anticipated blood loss could be assessed (eg, complete blood count); a review of alternatives to allogeneic transfusion including PAD, cell recovery, and ANH and their risks and benefits; and a discussion of the risks and benefits of allogeneic blood transfusion. Based on the information provided in the clinical presentation, Ms C meets the eligibility requirements for PAD and has adequate time before her surgery to donate and still avoid donation-associated preoperative anemia. Thus, she could reasonably be referred for donation if it were indicated based on her likelihood of needing a transfusion.41 However, given that she may not complete the donation process (eg, if she has poor venous access or experiences an adverse event during the donation), the current infectious disease risks related to blood transfusion should be clearly communicated to Ms C with the goal of allaying her concerns regarding the safety of the blood supply. Additionally, I would advise her that family-directed donations may be no safer than that supplied by voluntary donors82; in fact, published data suggest that directed donations may carry a higher risk of transfusion-associated disease.83 Finally, I would assure her that allogeneic blood would be used only when needed and when benefit is expected and outweighs the possible risks.

    Questions and discussion

    QUESTION: How does the diagnosis of malignancy affect the strategies you presented?

    DR UHL: A diagnosis of malignancy raises questions about whether intraoperative blood recovery can be used during surgical procedures, given the concern about tumor cell contamination of the recovered blood product and consequent theoretical risk of metastatic disease following transfusion. The literature examining this issue, which is limited to retrospective cohort studies and small prospective studies and thus is potentially insensitive, suggests that the reluctance to use cell recovery for this reason is not well-founded.64 In a retrospective review of 408 of 769 medical records of patients who had undergone radical retropubic prostatectomy and met study inclusion criteria, Davis et al84 found no differences in tumor recurrence rates in patients who were transfused autologous products derived from intraoperative blood recovery techniques [n = 87] as compared to patients who either received transfusions of autologous products collected preoperatively (PAD; n = 264) or received no transfusion (n = 57). More recently, Liang et al85 demonstrated that the use of leukodepletion filters during the processing of recovered shed blood efficiently removed contaminating tumor cells in patients with hepatocellular carcinoma undergoing orthotopic liver transplantation, supporting the consideration that intraoperative blood recovery techniques in conjunction with postcollection leukodepletion can be used safely in patients with significant transfusion requirements.

    QUESTION: Why are unused units of autologous blood donations discarded instead of being put in circulation?

    DR UHL: Blood donations that enter the general blood supply are collected from donors who meet donor eligibility criteria set forth by the Code of Federal Regulations86 and the AABB Standards for Blood Banks and Transfusion Services.87 In general, the donor criteria used to assess autologous donor eligibility for donation are less rigid than those used for allogeneic donor eligibility. For example, the hemoglobin threshold for an autologous donor is 11 g/dL compared with 12.5 g/dL for an allogeneic donor.87 In addition, autologous donors are generally not required to take the rigorous donor history questionnaire that is used to assess suitability of allogeneic donors.88 For these reasons, unused autologous units are not entered into the general blood bank inventory.

    QUESTION: Does PAD decrease the rate of noninfectious complications of transfusion?

    DR UHL: There are no specific data to support or refute risk reduction of noninfectious complications of transfusion with the use of autologous blood except for alloimmunization.89 However, it is generally understood that autologous transfusion carries the same risk as allogeneic transfusion of transfusion-associated circulatory overload, misadministration, and untoward effects related to RBC storage.88 Thus, there should always be a clear indication for transfusion, irrespective of the source of the blood component.

    Back to top
    Article Information

    Corresponding Author: Lynne Uhl, MD, Beth Israel Deaconess Medical Center, Yamins 309, 330 Brookline Ave, Boston, MA 02215 (luhl@bidmc.harvard.edu).

    Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

    Additional Contributions: We thank the patient for sharing her story and for providing permission to publish it.

    The conference on which this article is based took place at the Surgery Grand Rounds at Beth Israel Deaconess Medical Center, Boston, Massachusetts, on February 24, 2010.

    Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Risa B. Burns, MD, series editor; Tom Delbanco, MD, Howard Libman, MD, Eileen E. Reynolds, MD, Marc Schermerhorn, MD, Amy N. Ship, MD, and Anjala V. Tess, MD.

    References
    1.
    Holland PV. Consent for transfusion: is it informed?  Transfus Med Rev. 1997;11(4):274-2859345709PubMedGoogle ScholarCrossref
    2.
    Killion DF, Schiff PD, Lipton KS. Informed consent: working toward a meaningful dialogue.  Transfusion. 2007;47(4):557-55817381609PubMedGoogle ScholarCrossref
    3.
    World Health Organization.  10 Facts on blood transfusion. June 14, 2009. http://www.who.int/bloodsafety/FactFile2009.pdf. Accessed August 23, 2011
    4.
    Whitaker B, Schlumpf KS, Schulman J, Green J. Report of the US Department of Health and Human Services: The 2009 National Blood Collection and Utilization Survey Report. Washington, DC: Dept of Health and Human Services; 2011
    5.
    Elmistekawy EM, Errett L, Fawzy HF. Predictors of packed red cell transfusion after isolated primary coronary artery bypass grafting—the experience of a single cardiac center: a prospective observational study.  J Cardiothorac Surg. 2009;4:2019422707PubMedGoogle ScholarCrossref
    6.
    Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors.  J Bone Joint Surg Am. 2002;84-A(2):216-22011861727PubMedGoogle Scholar
    7.
    Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study.  Transfusion. 2007;47(8):1468-148017655591PubMedGoogle ScholarCrossref
    8.
    Epstein JS, Holmberg JA. Progress in monitoring blood safety.  Transfusion. 2010;50(7):1408-141220636529PubMedGoogle ScholarCrossref
    9.
    Eder AF, Chambers LA. Noninfectious complications of blood transfusion.  Arch Pathol Lab Med. 2007;131(5):708-71817488156PubMedGoogle Scholar
    10.
    Blajchman MA, Vamvakas EC. The continuing risk of transfusion-transmitted infections.  N Engl J Med. 2006;355(13):1303-130517005947PubMedGoogle ScholarCrossref
    11.
    Stramer SL. Current risks of transfusion-transmitted agents: a review.  Arch Pathol Lab Med. 2007;131(5):702-70717488155PubMedGoogle Scholar
    12.
    Shander A. The cost of blood: multidisciplinary consensus conference for a standard methodology.  Transfus Med Rev. 2005;19(1):66-7815830329PubMedGoogle ScholarCrossref
    13.
    Shander A, Hofmann A, Ozawa S, Theusinger OM, Gombotz H, Spahn DR. Activity-based costs of blood transfusions in surgical patients at 4 hospitals.  Transfusion. 2010;50(4):753-76520003061PubMedGoogle ScholarCrossref
    14.
    Goodnough LT, Shander A. Blood management.  Arch Pathol Lab Med. 2007;131(5):695-70117488154PubMedGoogle Scholar
    15.
    Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature.  Anesthesiology. 2010;113(2):482-49520613475PubMedGoogle ScholarCrossref
    16.
    The Joint Commission.  Patient Blood Management Performance Measures Project. June 27, 2011. http://www.jointcommission.org/patient_blood_management_performance_measures_project. Accessed August 26, 2011
    17.
    Barr PJ, Donnelly M, Morris K, Parker M, Cardwell C, Bailie KE. The epidemiology of red cell transfusion.  Vox Sang. 2010;99(3):239-25020576024PubMedGoogle ScholarCrossref
    18.
    Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty.  J Bone Joint Surg Am. 1999;81(1):2-109973048PubMedGoogle Scholar
    19.
    Bern MM, Bierbaum BE, Katz JN, Losina E. Autologous blood donation and subsequent blood use in patients undergoing total knee arthroplasty.  Transfus Med. 2006;16(5):313-31916999753PubMedGoogle ScholarCrossref
    20.
    Moskowitz DM, Klein JJ, Shander A,  et al.  Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center.  Ann Thorac Surg. 2004;77(2):626-63414759450PubMedGoogle ScholarCrossref
    21.
    Alghamdi AA, Davis A, Brister S, Corey P, Logan A. Development and validation of Transfusion Risk Understanding Scoring Tool (TRUST) to stratify cardiac surgery patients according to their blood transfusion needs.  Transfusion. 2006;46(7):1120-112916836558PubMedGoogle ScholarCrossref
    22.
    Goodnough LT, Maniatis A, Earnshaw P,  et al.  Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines.  Br J Anaesth. 2011;106(1):13-2221148637PubMedGoogle ScholarCrossref
    23.
    Patel MS, Carson JL. Anemia in the preoperative patient.  Med Clin North Am. 2009;93(5):1095-110419665622PubMedGoogle ScholarCrossref
    24.
    Theusinger OM, Leyvraz PF, Schanz U, Seifert B, Spahn DR. Treatment of iron deficiency anemia in orthopedic surgery with intravenous iron: efficacy and limits: a prospective study.  Anesthesiology. 2007;107(6):923-92718043060PubMedGoogle ScholarCrossref
    25.
    Mahadevan D, Challand C, Keenan J. Revision total hip replacement: predictors of blood loss, transfusion requirements, and length of hospitalisation.  J Orthop Traumatol. 2010;11(3):159-16520835744PubMedGoogle ScholarCrossref
    26.
    Myers E, O’Grady P, Dolan AM. The influence of preclinical anaemia on outcome following total hip replacement.  Arch Orthop Trauma Surg. 2004;124(10):699-70115517315PubMedGoogle ScholarCrossref
    27.
    Martinez V, Monsaingeon-Lion A, Cherif K, Judet T, Chauvin M, Fletcher D. Transfusion strategy for primary knee and hip arthroplasty: impact of an algorithm to lower transfusion rates and hospital costs.  Br J Anaesth. 2007;99(6):794-80017928302PubMedGoogle ScholarCrossref
    28.
    Gonzalez-Porras JR, Colado E, Conde MP, Lopez T, Nieto MJ, Corral M. An individualized preoperative blood saving protocol can increase pre-operative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty.  Transfus Med. 2009;19(1):35-4219302453PubMedGoogle ScholarCrossref
    29.
    Faris PM, Ritter MA. Epoetin alfa: a bloodless approach for the treatment of perioperative anemia.  Clin Orthop Relat Res. 1998;(357):60-679917701PubMedGoogle Scholar
    30.
    Goodnough LT, Skikne B, Brugnara C. Erythropoietin, iron, and erythropoiesis.  Blood. 2000;96(3):823-83310910892PubMedGoogle Scholar
    31.
    Laupacis A, Feagan B, Wong C.COPES Study Group.  Effectiveness of perioperative recombinant human erythropoietin in elective hip replacement.  Lancet. 1993;342(8867):3788101624PubMedGoogle ScholarCrossref
    32.
    Faris PM, Ritter MA, Abels RI.American Erythropoietin Study Group.  The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation.  J Bone Joint Surg Am. 1996;78(1):62-728550681PubMedGoogle Scholar
    33.
    de Andrade JR, Jove M, Landon G, Frei D, Guilfoyle M, Young DC. Baseline hemoglobin as a predictor of risk of transfusion and response to epoetin alfa in orthopedic surgery patients.  Am J Orthop (Belle Mead NJ). 1996;25(8):533-5428871751PubMedGoogle Scholar
    34.
    Goldberg MA, McCutchen JW, Jove M,  et al.  A safety and efficacy comparison study of 2 dosing regimens of epoetin alfa in patients undergoing major orthopedic surgery.  Am J Orthop (Belle Mead NJ). 1996;25(8):544-5528871752PubMedGoogle Scholar
    35.
    Sowade O, Warnke H, Scigalla P,  et al.  Avoidance of allogeneic blood transfusions by treatment with epoetin beta (recombinant human erythropoietin) in patients undergoing open-heart surgery.  Blood. 1997;89(2):411-4189002942PubMedGoogle Scholar
    36.
    D’Ambra MN, Gray RJ, Hillman R,  et al.  Effect of recombinant human erythropoietin on transfusion risk in coronary bypass patients.  Ann Thorac Surg. 1997;64(6):1686-16939436556PubMedGoogle ScholarCrossref
    37.
    Monk TG, Goodnough LT, Brecher ME, Colberg JW, Andriole GL, Catalona WJ. A prospective randomized comparison of 3 blood conservation strategies for radical prostatectomy.  Anesthesiology. 1999;91(1):24-3310422925PubMedGoogle ScholarCrossref
    38.
    Olijhoek G, Megens JG, Musto P,  et al.  Role of oral vs IV iron supplementation in the erythropoietic response to rHuEPO: a randomized, placebo-controlled trial.  Transfusion. 2001;41(7):957-96311452166PubMedGoogle ScholarCrossref
    39.
    Moonen AF, Thomassen BJ, Knoors NT, van Os JJ, Verburg AD, Pilot P. Preoperative injections of epoetin-alpha vs postoperative retransfusion of autologous shed blood in total hip and knee replacement: a prospective randomised clinical trial.  J Bone Joint Surg Br. 2008;90(8):1079-108318669967PubMedGoogle Scholar
    40.
    Karkouti K, McCluskey SA, Evans L, Mahomed N, Ghannam M, Davey R. Erythropoietin is an effective clinical modality for reducing RBC transfusion in joint surgery.  Can J Anaesth. 2005;52(4):362-36815814749PubMedGoogle ScholarCrossref
    41.
    Wong CJ, Vandervoort MK, Vandervoort SL,  et al.  A cluster-randomized controlled trial of a blood conservation algorithm in patients undergoing total hip joint arthroplasty.  Transfusion. 2007;47(5):832-84117465948PubMedGoogle ScholarCrossref
    42.
    Jabbour N, ed. Preoperative management and preparation for transfusion-free surgery. In Transfusion-Free Medicine and Surgery. Oxford, England: Blackwell; 2005:60-74
    43.
    Fergusson DA, Hébert P. The health(y) cost of erythropoietin in orthopedic surgery.  Can J Anaesth. 2005;52(4):347-35115814746PubMedGoogle ScholarCrossref
    44.
    Vitale MG, Roye BD, Ruchelsman DE, Roye DP Jr. Preoperative use of recombinant human erythropoietin in pediatric orthopedics: a decision model for long-term outcomes.  Spine J. 2007;7(3):292-30017482112PubMedGoogle ScholarCrossref
    45.
    Marchetti M, Barosi G. Cost-effectiveness of epoetin and autologous blood donation in reducing allogeneic blood transfusions in coronary artery bypass graft surgery.  Transfusion. 2000;40(6):673-68110864987PubMedGoogle ScholarCrossref
    46.
    Goodnough LT. Autologous blood donation.  Crit Care. 2004;8:(suppl 2)  S49-S5215196325PubMedGoogle ScholarCrossref
    47.
    Goodnough LT, Saha P, Hirschler NV, Yomtovian R. Autologous blood donation in nonorthopaedic surgical procedures as a blood conservation strategy.  Vox Sang. 1992;63(2):96-1011441313PubMedGoogle ScholarCrossref
    48.
    Stowell CP, Chandler H, Jové M, Guilfoyle M, Wacholtz MC. An open-label, randomized study to compare the safety and efficacy of perioperative epoetin alfa with preoperative autologous blood donation in total joint arthroplasty.  Orthopedics. 1999;22(1):(suppl)  s105-s1129927110PubMedGoogle Scholar
    49.
    Keating EM, Callaghan JJ, Ranawat AS, Bhirangi K, Ranawat CS. 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.  J Arthroplasty. 2007;22(3):325-33317400086PubMedGoogle ScholarCrossref
    50.
    Yazer M, Triulzi D. Messages from national blood data collection reports.  Transfusion. 2007;47(3):366-36817319812PubMedGoogle ScholarCrossref
    51.
    Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation.  Transfusion. 2001;41(12):1459-146211778055PubMedGoogle ScholarCrossref
    52.
    Henry DA, Carless PA, Moxey AJ, O’Connell D, Ker K, Fergusson DA. Preoperative autologous donation for minimising perioperative allogeneic blood transfusion. April 14, 2010. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003602/abstract;jsessionid=1F4C582076EE3DAD19BF1F98BE5DE886.d02t04. Accessed October 12, 2011
    53.
    Billote DB, Glisson SN, Green D, Wixson RL. A prospective, randomized study of preoperative autologous donation for hip replacement surgery.  J Bone Joint Surg Am. 2002;84-A(8):1299-130412177257PubMedGoogle Scholar
    54.
    McVay PA, Andrews A, Kaplan EB,  et al.  Donation reactions among autologous donors.  Transfusion. 1990;30(3):249-2522315998PubMedGoogle ScholarCrossref
    55.
    Newman BH, Pichette S, Pichette D, Dzaka E. Adverse effects in blood donors after whole-blood donation: a study of 1000 blood donors interviewed 3 weeks after whole-blood donation.  Transfusion. 2003;43(5):598-60312702180PubMedGoogle ScholarCrossref
    56.
    Newman B, Tommolino E, Andreozzi C, Joychan S, Pocedic J, Heringhausen J. The effect of a 473-mL (16-oz) water drink on vasovagal donor reaction rates in high-school students.  Transfusion. 2007;47(8):1524-153317655598PubMedGoogle ScholarCrossref
    57.
    Etchason J, Petz L, Keeler E,  et al.  The cost effectiveness of preoperative autologous blood donations.  N Engl J Med. 1995;332(11):719-7247854380PubMedGoogle ScholarCrossref
    58.
    Goodnough LM, Grishaber JE, Birkmeyer JD, Monk TG, Catalona WJ. Efficacy and cost-effectiveness of autologous blood predeposit in patients undergoing radical prostatectomy procedures.  Urology. 1994;44(2):226-2318048198PubMedGoogle ScholarCrossref
    59.
    Birkmeyer JD, AuBuchon JP, Littenberg B,  et al.  Cost-effectiveness of preoperative autologous donation in coronary artery bypass grafting.  Ann Thorac Surg. 1994;57(1):161-1688279884PubMedGoogle ScholarCrossref
    60.
    Birkmeyer JD, Goodnough LT, AuBuchon JP, Noordsij PG, Littenberg B. The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement.  Transfusion. 1993;33(7):544-5518333017PubMedGoogle ScholarCrossref
    61.
    Centers for Medicare and Medicaid Services.  Medicare Benefit Policy Manual Chapter 15—Covered Medical and Other Health Services. July 8, 2011. http://www.cms.gov/manuals/Downloads/bp102c15.pdf. Accessed October 11, 2011
    62.
    Centers for Medicare and Medicaid Services.  Medicare National Coverage Determinations Manual: Chapter 1, Part 2 (Sections 90-160.26): Coverage Determinations. July 8, 2011. http://www.cms.gov/manuals/downloads/ncd103c1_Part2.pdf. Accessed October 11, 2011
    63.
    Segal JB, Blasco-Colmenares E, Norris EJ, Guallar E. Preoperative acute normovolemic hemodilution: a meta-analysis.  Transfusion. 2004;44(5):632-64415104642PubMedGoogle ScholarCrossref
    64.
    Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia.  Br J Anaesth. 2010;105(4):401-41620802228PubMedGoogle ScholarCrossref
    65.
    Waters JH. Indications and contraindications of cell salvage.  Transfusion. 2004;44(12):(suppl)  40S-44S15585004PubMedGoogle ScholarCrossref
    66.
    Freischlag JA. Intraoperative blood salvage in vascular surgery—worth the effort?  Crit Care. 2004;8:(suppl 2)  S53-S5615196326PubMedGoogle ScholarCrossref
    67.
    Stehling L, edGuidelines for Establishing an Autologous Program—Pitfalls and How to Avoid Them. Arlington, VA: AABB Press; 1991
    68.
    Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, Fergusson DA. Cell salvage for minimising perioperative allogeneic blood transfusion.  Cochrane Database Syst Rev. 2010;4(4):CD00188820393932PubMedGoogle Scholar
    69.
    Domen RE. Adverse reactions associated with autologous blood transfusion: evaluation and incidence at a large academic hospital.  Transfusion. 1998;38(3):296-3009563411PubMedGoogle ScholarCrossref
    70.
    Shander AS, Goodnough LT. Blood transfusion as a quality indicator in cardiac surgery.  JAMA. 2010;304(14):1610-161120940390PubMedGoogle ScholarCrossref
    71.
    Hajjar LA, Vincent JL, Galas FR,  et al.  Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial.  JAMA. 2010;304(14):1559-156720940381PubMedGoogle ScholarCrossref
    72.
    Ferraris VA, Ferraris SP, Saha SP,  et al; Society of Thoracic Surgeons Blood Conservation Guideline Task Force; Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion.  Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists clinical practice guideline.  Ann Thorac Surg. 2007;83(5):(suppl)  S27-S8617462454PubMedGoogle ScholarCrossref
    73.
    Seifried E, Klueter H, Weidmann C,  et al.  How much blood is needed?  Vox Sang. 2011;100(1):10-2121175652PubMedGoogle ScholarCrossref
    74.
    Hébert PC, Wells G, Blajchman MA,  et al; Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.  A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care.  N Engl J Med. 1999;340(6):409-4179971864PubMedGoogle ScholarCrossref
    75.
    Rhamy JF. Synergies between blood center and hospital quality systems.  Transfusion. 2010;50(12 pt 2):2793-279721128951PubMedGoogle ScholarCrossref
    76.
    Department of Health and Human Services.  Biovigilance in the United States: Efforts to Bridge a Critical Gap in Patient Safety and Donor Health2009. http://www.hhs.gov/ash/bloodsafety/biovigilance/ash_to_acbsa_oct_2009.pdf. Accessed August 26, 2011
    77.
    Shaz BH, Stowell SR, Hillyer CD. Transfusion-related acute lung injury: from bedside to bench and back.  Blood. 2011;117(5):1463-147120944069PubMedGoogle ScholarCrossref
    78.
    Eder AF, Herron RM Jr, Strupp A,  et al.  Effective reduction of transfusion-related acute lung injury risk with male-predominant plasma strategy in the American Red Cross (2006-2008).  Transfusion. 2010;50(8):1732-174220456698PubMedGoogle ScholarCrossref
    79.
    Stainsby D, Jones H, Asher D,  et al; SHOT Steering Group.  Serious hazards of transfusion: a decade of hemovigilance in the UK.  Transfus Med Rev. 2006;20(4):273-28217008165PubMedGoogle ScholarCrossref
    80.
    Glynn SA. The red blood cell storage lesion: a method to the madness.  Transfusion. 2010;50(6):1164-116920598098PubMedGoogle ScholarCrossref
    81.
    Davis RE, Vincent CA, Murphy MF. Blood transfusion safety: the potential role of the patient.  Transfus Med Rev. 2011;25(1):12-2321134623PubMedGoogle ScholarCrossref
    82.
    Chambers LA, Kruskall MS. Preoperative autologous blood donation.  Transfus Med Rev. 1990;4(1):35-462134615PubMedGoogle ScholarCrossref
    83.
    Toy P, Hoag MS, Lamberson HV. Higher non-A, non-B hepatitis surrogate marker rates in designated donor units [abstract].  Transfusion. 1988;28:(suppl)  17SGoogle Scholar
    84.
    Davis M, Sofer M, Gomez-Marin O, Bruck D, Soloway MS. The use of cell salvage during radical retropubic prostatectomy: does it influence cancer recurrence?  BJU Int. 2003;91(6):474-47612656896PubMedGoogle ScholarCrossref
    85.
    Liang TB, Li DL, Liang L,  et al.  Intraoperative blood salvage during liver transplantation in patients with hepatocellular carcinoma: efficiency of leukocyte depletion filters in the removal of tumor cells.  Transplantation. 2008;85(6):863-86918360269PubMedGoogle ScholarCrossref
    86.
     Suitability of donor. 21 CFR §640.3
    87.
    AABB.  Standards for Blood Banks and Transfusion Services. 27th ed. Bethesda, MD: AABB; 2011
    88.
    Eder AF. Allogeneic and autologous blood donor selection. In: Roback JD, Combs MR, Grossman BJ, Hillyer CD, eds. Technical Manual. 16th ed. Bethesda, MD: AABB; 2008:137-181
    89.
    Goodnough LT. Alternatives to allogeneic transfusion in patients with surgical anemia. In: Mintz PD, ed. Transfusion Therapy: Clinical Principles and Practice. 3rd ed. Bethesda, MD: AABB Press; 2011:699-720
    ×