Today's News

Saturday, February 15, 1997

Urges immediate use of autologous blood after surgery

The use of preoperatively autologous blood (PAB) for a transfusion after surgery to avoid transmission of disease has increased in recent years. However, there is debate on whether the transfusion should be performed immediately after surgery or only after the patient's hemoglobin level has fallen below a trigger point.

Proponents of the PAB liberal utilization argue that the use of the patient's own blood without the risk of transmissible diseases and transfusion reactions reduces the risk/benefit ratio in favor of earlier transfusion triggers, said Paul A. Lotke, MD, who presented scientific paper 265 Friday.

"Conversely, these same proponents concede that with any transfusion there is some risk, principally from clerical error and bacterial contamination," said Dr. Lotke, department of orthopaedic surgery, University of Pennsylvania School of Medicine, Philadelphia. Reports analyzing the cost-effectiveness of PAB, especially for some procedures with variable blood losses, indicate that PAB is expensive and may not be worth the costs of obtaining and storing PAB, he said.

Based on a study of patients undergoing total knee arthroplasty (TKA), Dr. Lotke recommended that PAB be utilized immediately, especially in the elderly, in the postoperative period for TKA patients. Sixty-five patients who had donated two units of blood received one unit in the recovery room and the second unit when they were returned to the nursing floor. A second group of 62 patients did not receive PAB transfusion unless their hemoglobin, measured the next morning, had fallen below a trigger point. Twenty-five patients who could not donate their blood were analyzed separately and included in the delayed transfusion group for nonsurgical complications.

The study found statistically fewer nonsurgical complications when autologous blood was transfused immediately in the postoperative period.

The delayed group had 16 complications including one patient who sustained a myocardial infarction and another who developed cardiac arrythmia. Seven patients had mental confusion; four, lethargy; and three, orthostatic hypotension. The immediate group had five complications, including two cases of confusion and orthostatic hypotension and one case of lethargy.

The average age of patients who sustained any nonsurgical complications was 74.2 years. Patients not having a nonsurgical complication had an average age of 67.4 years.

Acute anemia adversely effects cardiac function, Dr. Lotke said. "The risk of myocardial ischemia or infection for acutely lower hemoglobin levels in elderly patients with and/or under-diagnosed coronary disease is significant," he said.

In addition, although not statistically significant, Dr. Lotke said there is a tendency for patients who had the immediate transfusion to have less pain, feel better and progress more rapidly at physical therapy.

"The decision to transfuse in the postoperative period is a precise risk vs. benefit decision," Dr. Lotke said. "The risks of PAB are principally related to clerical errors and bacterial contamination. They are real, but their probability is low."

The availability of PAB is important to physicians because it may allow them to avoid the dilemma of delaying needed transfusions for the fear of disease transmission, Dr. Lotke said. Immediate utilization of PAB also avoids the decision of which patients are at risk from nonsurgical complications and which will fall below a reasonable trigger and be exposed to cardiac complications.