Canadian Journal of Anaesthesia

, Volume 41, Supplement 1, pp R52–R69

Blood products: when to use them and how to avoid them

  • Jean-François Hardy
  • Sylvain Belisle
  • Danielle Robitaille
Refresher Course Outline — Saturday, June 18 Track II

Conclusion

Despite the complications associated with transfusions,HBP remains an essential therapeutic modality, without which many major surgical procedures would be impossible. Clinicians must realize that transfusion of HBP is the most frequent transplantation of living tissue between humans. Even if known infectious complications could be eliminated, transfusion ofHBP will never be a totally safe procedure. New transfusion-related complications, the magnitude of which is unknown, such as graft-vs-host disease in immunocompetent patients, have emerged recently. Other, as yet unidentified, pathogens will undoubtedly be transmitted by HBP in the future.

A number of strategies exist that can reduce, and sometimes abolish, the need forHBP. Unfortunately, some of these may remain unavailable to our patients because of financial constraints on the Canadian health care system. Nonetheless, physicians must always keep in mind that the first and foremost strategy to avoid transfusion ofHBP is their thorough understanding of the pathophysiological mechanisms involved in anaemia and coagulopathy, and their thoughtful adherence to published guidelines for the practice of transfusion.7,11–13,17

Du bon usage des dérivés du sang

Conclusion

Malgré les complications associées aux transfusions, les PSH demeurent essentiels et sans eux plusieurs interventions chirurgicales majeures seraient irréalisables. Les cliniciens doivent réaliser que les transfusions de PSH représentent les transplantations de tissus les plus fréquentes entre humains, et que même si on réussissait à éliminer complètement les complications infectieuses, les transfusions de PSH ne deviendront jamais complètement inoffensives. De nouvelles complications transfusionnelles comme la réaction du greffon contre l’hôte chez des patients immunocompétents ont fait récemment leur apparition. A l’avenir, d’autres pathogènes, non encore identifiés seront indubitablement transmis par les PHS.

Certaines stratégies peuvent diminuer et quelquefois abolir les besoins de PHS. Malheureusement, quelquesunes ne sont pas disponibles pour nos patients à cause des contraintes du système des soins de santé canadien. Toutefois, les médecins doivent toujours avoir à l’esprit que la première et la principale stratégie permettant d’éviter les PHS consiste en une bonne compréhension des mécanismes physiopathologiques impliqués dans l’anémie et les coagulopathies et leur adhérence inconditionnelle aux critères de la pratique transfusionnelle.7,11–13,17

References

  1. 1.
    Beal RW. The rational use of blood. Aust N Z J Surg 1976; 46: 309–13.PubMedGoogle Scholar
  2. 2.
    Surgenor DM, Wallace EL, Hale SG, Gilpatrick MW. Changing patterns of blood transfusion in four sets of United States hospitals, 1980 to 1985. Transfusion 1988; 28: 513–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Crosby ET Perioperative haemotherapy: II. Risks and complications of blood transfusion. Can J Anaesth 1992; 39: 822–37.PubMedGoogle Scholar
  4. 4.
    Ellison N, Faust RJ. Complications of blood transfusion.In: Benumof JL, Saidman LJ. (Eds.). Anesthesia and Perioperative Complications. St. Louis: Mosby Year Book 1992; 507–19.Google Scholar
  5. 5.
    Crosby ET Perioperative haemotherapy: I. Indications for blood component transfusion. Can J Anaesth 1992; 39: 695–707.PubMedCrossRefGoogle Scholar
  6. 6.
    Irving GA. Perioperative blood and blood component therapy. Can J Anaesth 1992; 39: 1105–15.PubMedGoogle Scholar
  7. 7.
    The Canadian Red Cross Society Clinical Guide to Transfusion. 3rd ed. 1993.Google Scholar
  8. 8.
    Dodd RY. The risk of transfusion-transmitted infection (Editorial). N Engl J Med 1992; 327: 419–21.PubMedGoogle Scholar
  9. 9.
    Donahue JG, Murioz A, Ness PM, et al. The declining risk of post-transfusion hepatitis C virus infection. N Engl J Med 1992; 327: 369–73.PubMedGoogle Scholar
  10. 10.
    Nelson KE, Donahue JG, Munõz A, et al. Transmission of retroviruses from seronegative donors by transfusion during cardiac surgery. A multicenter study of HIV-1 and HTLV-I/II infections. Ann Intern Med 1992; 117: 554–9.PubMedGoogle Scholar
  11. 11.
    Consensus Conference: Perioperative red blood cell transfusion. JAMA 1988; 360: 2700–3.Google Scholar
  12. 12.
    Consensus Conference: Fresh frozen plasma. Indications and risks. JAMA 1985; 253: 551–3.CrossRefGoogle Scholar
  13. 13.
    Consensus Conference: Platelet transfusion therapy. JAMA 1987; 257: 1777–80.CrossRefGoogle Scholar
  14. 14.
    Shoemaker WC. A stitch in time saves lives (Editorial). Chest 1993; 103: 663–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Wilkerson DK, Rosen AL, Gould SA, Sehgal LR, Sehgal HL, Moss GS. Oxygen extraction ratio: a valid indicator of myocardial metabolism in anemia. J Surg Res 1987; 42: 629–34.PubMedGoogle Scholar
  16. 16.
    Welch HG, Meehan KR, Goodnough LT. Prudent strategies for elective red blood cell transfusion. Ann Intern Med 1992; 116: 393–402.PubMedGoogle Scholar
  17. 17.
    American Society of Anesthesiologists Committee on Transfusion Medicine. Questions and answers about transfusion practices. 2nd ed. 1992.Google Scholar
  18. 18.
    Weisel RD, Charlesworth DC, Mickleborough LL, et al. Limitations of blood conservation. J Thorac Cardiovasc Surg 1984; 88: 26–38.PubMedGoogle Scholar
  19. 19.
    Mathru M, Kleinman B, Blakeman B, Sullivan H, Kumar P, Dries DJ. Myocardial metabolism and adaptation during extreme hemodilution in humans after coronary revascularization. Crit Care Med 1992; 20: 1420–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Carson JL, Poses RM, Spence RK, Bonavita G. Severity of anaemia and operative mortality and morbidity. Lancet 1988; 1: 727–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Van Der Linden P, Gilbart E, Paques P, Simon S, Vincent JL. Influence of hematocrit on tissue O2 extraction capabilities during acute hemorrhage. Am J Physiol 1993; 264: H1942–7.PubMedGoogle Scholar
  22. 22.
    Izraeli S, Ben-Sira L, Harell D, Naor N, Ballin A, Davidson S. Lactic acid as a predictor for erythrocyte transfusion in healthy preterm infants with anemia of prematurity. J Pediatr 1993; 122: 629–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Escolar G, Garrido M, Mazzara R, Castillo R, Ordinas A. Experimental basis for the use of red cell transfusion in the management of anemic-thrombocytopenic patients. Transfusion 1988; 28: 406–11.PubMedCrossRefGoogle Scholar
  24. 24.
    Livio M, Benigni A, Remuzzi G, Coagulation abnormalities in uremia. Sem Nephrol 1985; 5: 82–90.Google Scholar
  25. 25.
    Mohr R, Martinowitz U, Lavee J, Amroch D, Ramot B, Goor DA. The hemostatic effect of transfusing fresh whole blood versus platelet concentrates after cardiac operations. J Thorac Cardiovasc Surg 1988; 96: 530–4.PubMedGoogle Scholar
  26. 26.
    Counts RB, Haisch C, Simon TL, Maxwell NG, Heimbach DM, Carrico CJ. Hemostasis in massively transfused trauma patients. Ann Surg 1979; 190: 91–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Reed RL 2nd,Ciavarella D, Heimbach DM, et al. Prophylactic platelet administration during massive transfusion. Ann Surg 1986; 203: 40–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Murray DJ, Olson J, Strauss R, Tinker JH. Coagulation changes during packed red cell replacement of major blood loss. Anesthesiology 1988; 69: 839–45.PubMedCrossRefGoogle Scholar
  29. 29.
    Braunstein AH, Oberman HA. Transfusion of plasma components. Transfusion 1984; 24: 281–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Connelly CS, Panush RS. Should nonsteroidal antiinflammatory drugs be stopped before elective surgery? Arch Intern Med 1991; 151: 1963–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Bashein G, Nessly ML, Rice AL, Counts RB, Misbach GA. Preoperative aspirin therapy and reoperation for bleeding after coronary artery bypass surgery. Arch Intern Med 1991; 151: 89–93.PubMedCrossRefGoogle Scholar
  32. 32.
    Becker RC, Caputo R, Ball S, Corrao JM, Baker S, Gore JM. Hemorrhagic potential of combined diltiazem and recombinant tissue-type plasminogen activator administrator. Am Heart J 1993; 126: 11–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Kyo S, Omoto R, Hiroshima K, Eguchi S, Fujita T. Effect of human recombinant erythropoietin on reduction of homologous blood transfusion in open-heart surgery. A Japanese multicenter study. Circulation (Supplement) 1992; 86: II–413-8.Google Scholar
  34. 34.
    Konishi T, Ohbayashi T, Kaneko T, Ohki T, Saitou Y, Yagnmato Y. Preoperative use of erythropoietin for cardiovascular operations in anemia. Ann Thorac Surg 1993; 56: 101–3.PubMedGoogle Scholar
  35. 35.
    Nonoguchi H, Abe K, Komatsu F. Recombinant human erythropoietin for autologous blood donation (Letter). Lancet 1992; 339: 1483.PubMedCrossRefGoogle Scholar
  36. 36.
    Hisatomi K, Isomura T, Galli SJ, Yasunaga H, Hayashida N, Ohishi K. Augmentation of interleukin-2 production after cardiac operations in patients treated with erythropoietin. J Thorac Cardiovasc Surg 1992; 104: 278–83.PubMedGoogle Scholar
  37. 37.
    Goodnough LT, Shuck JM. Risks, options, and informed consent for blood transfusion in elective surgery. Am J Surg 1990; 159: 602–9.PubMedCrossRefGoogle Scholar
  38. 38.
    Carey JS, Cukingnan RA, Carson E. Transfusion therapy in cardiac surgery: impact of the Paul Gann Blood Safety Act in California. Am Surg 1991; 12: 830–5.Google Scholar
  39. 39.
    Kuitunen A, Hynynen M, Salmenperä, et al. Anaesthesia affects plasma concentrations of vasopressin, von Willebrand factor and coagulation factor VIII in cardiac surgical patients. Br J Anaesth 1993; 70: 173–80.PubMedCrossRefGoogle Scholar
  40. 40.
    Valeri CR, Khabbaz K, Khuri SF, et al. Effect of skin temperature on platelet function in patients undergoing extracorporeal bypass. J Thorac Cardiovasc Surg 1992; 104: 108–16.PubMedGoogle Scholar
  41. 41.
    Rohrer MJ, Natale AM. Effect of hypothermia on the coagulation cascade. Crit Care Med 1992; 20: 1402–52.PubMedCrossRefGoogle Scholar
  42. 42.
    Royston D High-dose aprotinin therapy: a review of the first five years’ experience. J Cardiothorac Vasc Anesth 1992; 6: 76–100.PubMedCrossRefGoogle Scholar
  43. 43.
    Hardy JF, Desroches J. Natural and synthetic antifibrinolytics in cardiac surgery. Can J Anaesth 1992; 39: 353–65.PubMedGoogle Scholar
  44. 44.
    Salzman EW, Weinstein MJ, Weintraub, et al. Treatment with desmopressin acetate to reduce blood loss after cardiac surgery. A double-blind randomized trial. N Engl J Med 1986; 314: 1402–6.PubMedGoogle Scholar
  45. 45.
    Mongan PD, Hosking MR The role of desmopressin acetate in patients undergoing coronary artery bypass surgery: a controlled clinical trial with thromboelastographic risk stratification. Anesthesiology 1992; 77: 38–46.PubMedCrossRefGoogle Scholar
  46. 46.
    Shiffrin JS, Glass DD. DDAVP administration for postbypass bleeding. Pro: desmopressin is of value in the treatment of post-cardiopulmonary bypass bleeding. J Cardiothorac Vasc Anesth 1991; 5: 285–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Hackman T, Naiman SC. Con: desmopressin is not of value in the treatment of post-cardiopulmonary bypass bleeding. J Cardiothorac Vasc Anesth 1991; 5: 290–3.CrossRefGoogle Scholar
  48. 48.
    Kobrinsky NL, Letts RM, Patel LR, et al. l-desamino-8-D-arginine vasopressin (desmopressin) decreases operative blood loss in patients having Harrington rod spinal fusion surgery. A randomized double-blinded, controlled trial. Ann Intern Med 1987; 107: 446–50.PubMedGoogle Scholar
  49. 49.
    Guay J, Reinberg C, Poitras B, et al. A trial of desmopressin to reduce blood loss in patients undergoing spinal fusion for idiopathic scoliosis. Anesth Analg 1992; 75: 405–10.PubMedCrossRefGoogle Scholar
  50. 50.
    Anonymous. Desmopressin and arterial thrombosis (Editorial). Lancet 1989; 938–9.Google Scholar
  51. 51.
    Mannucci PM, Lusher JM. Desmopressin and thrombosis (Letter). Lancet 1989; 675–6.Google Scholar
  52. 52.
    Karski JM, Teasdale SJ, Norman PH, Carroll JA, Weisel RD, Glynn MFX. Prevention of postbypass bleeding with tranexamic acid and E-aminocaproic acid. J Cardiothorac Vasc Anesth 1993; 7: 431–5.PubMedCrossRefGoogle Scholar
  53. 53.
    Yau TM, Carson S, Weisel RD, et al. The effect of warm heart surgery on postoperative bleeding. J Thorac Cardiovasc Surg 1992; 103: 1155–63.PubMedGoogle Scholar
  54. 54.
    Kang Y. Clinical use of synthetic antifibrinolytic agents during liver transplantation. Sem Thromb Hemost 1993; 19: 258–61.CrossRefGoogle Scholar
  55. 55.
    Sher G. Trasylol in the management of abruptio placentae with consumption coagulopathy and uterine inertia. J Reprod Med 1980; 25: 113–8.PubMedGoogle Scholar
  56. 56.
    Beck OJ, Oeckler R. Subarachnoid haemorrhage (Letter). BMJ 1982; 284: 1050.CrossRefGoogle Scholar
  57. 57.
    Thompson JF, Roath OS, Francis JL, Webster JHH, Chant ADB. Aprotinin in peripheral vascular surgery (Letter). Lancet 1990; 335: 911.PubMedCrossRefGoogle Scholar
  58. 58.
    Neuhaus P, Bechstein WO, Lefebre B, Blumhardt G, Slama K. Effects of aprotinin on intraoperative bleeding and fibrinolysis in liver transplantation (Letter). Lancet 1989; 924–5.Google Scholar
  59. 59.
    Grosse H, Lobbes W, Frambach M, von Broen O, Ringe B, Bartheis M. The use of high dose aprotinin in liver transplantation: the influence on fibrinolysis and blood loss. Thromb Res 1991; 63: 287–97.PubMedCrossRefGoogle Scholar
  60. 60.
    tDietrich W, Barankay A, Hähnel Ch, Richter JA. Highdose aprotinin in cardiac surgery: three years’ experience in 1,784 patients. J Cardiothorac Vasc Anesth 1992; 6: 324–7.CrossRefGoogle Scholar
  61. 61.
    Freeman JG, Turner GA.Venables CW, Latner AL. Serial use of aprotinin and incidence of allergic reactions. Curr Med Res Opin 1983; 8: 559–61.PubMedGoogle Scholar
  62. 62.
    Hardy JF, Belisle S. Aprotinin therapy for reoperative myocardial revascularization: an opposing view (Letter). Ann Thorac Surg 1993; 56: 198.PubMedCrossRefGoogle Scholar
  63. 63.
    Murkin JM, Shannon NA, Bourne RB, Rorabeck CH, Cruickshank M. Aprotinin does not increase the risk of venous thrombosis in patients undergoing revision total hip joint replacement surgery. Anesthesiology 1993; 79: A58.Google Scholar
  64. 64.
    Goodnough LT, Johnston MFM, Toy PTCY, and the Transfusion Medicine Academic Award Group The variability of transfusion practice in coronary artery bypass surgery. JAMA 1991; 265: 86–90.PubMedCrossRefGoogle Scholar
  65. 65.
    Myhre BA. To treat the patient or to treat the surgeon (Editorial). JAMA 1991; 265: 97–8.PubMedCrossRefGoogle Scholar
  66. 66.
    Johnson RG, Thurer RL, Kruskall MS, et al. Comparison of two transfusion strategies after elective operations for myocardial revascularization. J Thorac Cardiovasc Surg 1992; 104: 307–14.PubMedGoogle Scholar
  67. 67.
    Wasman J, Goodnough LT Autologous blood donation for elective surgery. Effect on physician transfusion behavior. JAMA 1987; 258: 3135–7.PubMedCrossRefGoogle Scholar
  68. 68.
    Côté DJ. L’hémodilution normovolémique. Can J Anaesth 1991; 38: 243–51.PubMedGoogle Scholar
  69. 69.
    Gross JB. Estimating allowable blood loss: corrected for dilution. Anesthesiology 1983; 58: 277–80.PubMedGoogle Scholar
  70. 70.
    Schönberger JPAM, Bredée JJ, Tjian D, Everts PAM, Wildevuur CRH. Intraoperative predonation contributes to blood saving. Ann Thorac Surg 1993; 56: 893–8.PubMedGoogle Scholar
  71. 71.
    Stehling L. Autotransfusion and hemodilution.In: Miller RD (Ed.). Anesthesia, 3rd ed., New York: Churchill Livingstone Inc., 1990; 1501–13.Google Scholar
  72. 72.
    ϕvrum E, Am Holen E, Abdelnoor M, ϕystese R. Conventional blood conservation techniques in 500 consecutive coronary artery bypass operations. Ann Thorac Surg 1991; 52: 500–5.Google Scholar
  73. 73.
    Thaler M, Shamiss A, Orgad S, et al. The role of blood from HLA-homozygous donors in fatal transfusionassociated graft-vs-host disease after open-heart surgery. N Engl J Med 1989; 321: 25–8.PubMedGoogle Scholar
  74. 74.
    Bell C. Fatal transfusion-associated graft-versus-host disease caused by blood from an unrelated donor in an immunocompetent patient. Transfusion 1993; 33: 785–6.PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1994

Authors and Affiliations

  • Jean-François Hardy
    • 1
  • Sylvain Belisle
    • 1
  • Danielle Robitaille
    • 1
  1. 1.Departments of AnaesthesiaHaematology of the Université de Montréal, Montreal Heart InstituteMontréal

Personalised recommendations