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Preoperative autologous blood donation in Europe

We read with interest the editorial in TRANSFUSION by Brecher and Goodnough1 about the rise and fall of preoperative autologous blood donation (PABD) in the US. We would like to add a European perspective and make certain comments regarding the use of PABD in elective orthopedic surgery (EOS). We agree that, in terms of blood saving, the benefits of PABD in EOS are often comparable to those of acute normovolemic hemodilution. However, many anesthesiologists do not use acute normovolemic hemodilution because it delays surgical procedures. In our experience, PABD is easily programmable. It may also reduce the incidence of deep vein thrombosis after EOS, such as total hip arthroplasty,2 although this effect of PABD should be investigated further. Autologous blood wastage is a serious problem, but wastage can be reduced by adjusting the number of units collected to each hospital’s transfusion experience or each surgical team’s or patient’s characteristics and not to general surgical blood-ordering schedules. This strategy, together with periodic audits of PABD use, should avoid over-collection, prevent excessively decreased postoperative Hcts, reduce administrative errors, and improve cost-effectiveness. Data from the Orthopaedic Surgery Transfusion Haemoglobin European Overview (OSTEO) study, a multinational survey conducted in Europe to assess current practices in blood management techniques in EOS, are promising as 90 percent of autologous units collected were transfused.3 If this trend applies also to the US experience, the data presented in Fig. 1 of the article by Brecher and Goodnough1 may well reflect an increase in the collection to transfusion ratio (0.55 in 1992-94 vs. 0.70 in 1997-99) due to improved patient selection, rather than a decline in interest in PABD. Moreover, the application of more restrictive transfusion criteria, with lower transfusion triggers, and the implementation of additional blood conservation methods (aprotinin, EPO, perioperative blood salvage, etc.) may also account for a relative decrease in PABD. Finally, we feel that the “pendulum movement” of PABD suggested by Brecher and Goodnough should not be applied universally. With respect to Europe concerns, although PABD is underused in most European Union (EU) countries, there are several reasons to believe that the use of PABD, as well as that of other blood-saving strategies, will rise in the near future. First, the progressively aging populations will reduce the number of volunteer donors, whereas there is increasing demand for blood to meet transfusion requirements of surgical procedures (e.g., orthopedic, cardiac, cancer). At the same time, travel to specific areas (e.g., UK, malarial areas), body piercing, and tattoos have also caused many young donors to be temporary or permanently deferred. Together, these factors may lead to a shortage of blood. Second, there is increasing migration from Africa and Latin America to EU countries, which may result in new infectious or parasitic diseases for which reliable screening methods are not yet available, possibly increasing the risk of blood-borne infections. Third, there is increasing evidence of a transfusion-related immunomodulatory effect of allogeneic blood. If there is at least a 10-percent higher rate of postoperative infection in transfused patients, with longer hospital stays, PABD could be highly cost-effective, especially in young people.4 Fourth, introduction of WBC-reduction by inline filtration after donation in most EU countries will increase transfusion costs more than 20 percent without clear benefit. If this added cost does not apply to autologous blood, the cost-effectiveness of autologous blood would be improved. Lastly, most EU countries have a National Health Service that covers medical care expenses, including transfusions, and also require, by law, that informed consent be obtained from each patient for each transfusion. Under these regulations, we must explain and offer PABD to all candidate patients, as in some states in the US. This requirement has been included in the Code of Ethics for Blood Donation and Transfusion by the ISBT and formally endorsed by the WHO; it is under review by the Council of Europe’s Expert Committee.5 For all these reasons, we believe that the pendulum is still swinging upward in Europe, and it could return up again in the US if nonclinical determinants of transfusion practice are further investigated and modified.6 Manuel Muñoz, MD International Multidisciplinary Autotransfusion Study Group (GIEMSA) University of Málaga School of Medicine 29071 Málaga, Spain e-mail: mmunoz@uma.es José A. Garcı́a-Erce, MD Department of Hematology and Transfusion Medicine “Miguel Servet” University Hospital Zaragoza, Spain