Removal of methylene blue from plasma via an adsorbent filter.

OBJECTIVE: To evaluate adsorbent filtration of methylene blue (MB) and leukocytes from plasma. METHODS: Plasma (750 ml) from apheresis of 10 normal subjects was split into three aliquots: control (A), filtration (B) and MB addition (to 1 microM), phototreatment and filtration (C). Biochemical and coagulation tests were performed: units A and B were reinfused. RESULTS: Filtration reduced MB to undetectable (< 0.05 microM) levels and leukocytes by 3 log10. Biochemical analytes were unchanged. The partial thromboplastin time was prolonged with MB addition (11 +/- 13%) or filtration (26 +/- 12%, p < 0.05), but the effects were not additive. Autologous transfusion was well tolerated. CONCLUSION: Adsorbent filtration can reduce residual MB to undetectable levels and yields a component suitable for transfusion.

Cost-effectiveness of preoperative autologous blood donation for orthopedic and cardiac surgeries.

Decision analysis techniques can be used to determine objectively the health improvement benefit obtained from a medical intervention relative to the resources required for the intervention. Such calculations can help direct societal healthcare policies but may not be directly applicable to an individual patient. However, these analyses can still be used to indicate those situations in which an intervention is most beneficial and those in which its use may not be appropriate. Preoperative autologous blood donation (PABD), for example, may not be cost-effective if blood units are collected when they are not likely to be used or if such units are transfused solely because they are available. Furthermore, the risks associated with PABD may exceed those of the allogeneic transfusion that the patient seeks to avoid, particularly in patients with significant cardiac disease. In such settings, careful, objective analyses may help direct not only healthcare policy but also hemotherapy practice for individual patients.

Minimizing donor exposure in hemotherapy.

As with any medical therapy, transfusion has risks and complications that are inherent in its application. There are also many options in standard approaches and alternatives to allogeneic transfusion to be considered that allow hemotherapy to be tailored to the patient's needs, maximizing benefit while reducing risk. Transfusion of standard, allogeneic components selected at random and derived from an altruistic donation by a community volunteer donor continue to comprise the majority of transfusions. However, many steps can be taken to minimize allogeneic exposure and its consequences. Transfusing only when the benefits are clinically important and justify the risks is probably most important. Options abound for pharmacologic intervention, altering collection systems and using the donor as his or her own source of blood to further reduce allogeneic exposure.

Determinants of physician ordering of preoperative autologous donations.

Preoperative autologous donation (PAD) is frequently utilized to reduce infectious disease transmission risks, but it is an expensive form of hemotherapy that is not always closely matched with the needs of the patients. We compared the use of PAD in an academic medical center with patient needs and then investigated the efficacy of a simple intervention to promote targeting of PAD toward patients most likely to benefit from having PADs available. Over a 3-month period, surgeons whose patients received allogeneic components were asked to complete a questionnaire designed to identify reasons for not ordering PAD. PAD units were used in 14 (11%) of 124 cases, accounting for 6% of perioperative red cell use. The responses (46, 42% of the surveys sent) stated that PAD had not been ordered because of time constraints (39%), medical problems (26%), anemia (15%), and lack of expectation of blood use (24%). Chart review documented the presence of cited conditions in 88% of cases. Logistic and cost concerns were not evident. However, only 8% of the 176 PAD units collected in that period were transfused. Following dissemination of PAD ordering guidelines, this proportion rose to 52% without a reduction in the proportion of elective surgical cases utilizing autologous transfusion. This improvement in ordering practice was maintained over at least in 5-month period. Thus we were able to improve the efficiency of PAD application (reducing over-ordering) through a simple feedback to surgeons that assisted them in targeting PAD toward patients most likely to need transfusion.

Cost-effectiveness of preoperative autologous donation in coronary artery bypass grafting.

Concern about the safety of the allogeneic blood supply has made preoperative autologous blood donation (PAD) routine before major noncardiac operations. However, the costs and benefits of PAD in elective coronary artery bypass grafting (CABG) are not well established. We used decision analysis to (1) calculate the cost-effectiveness of PAD in CABG, expressed as cost per year of life saved, and (2) compare the health benefits of reducing allogeneic transfusions with the potential risks of autologous blood donation by patients with coronary artery disease. A prospective study of 18 institutions provided data on transfusion practice and blood product costs in CABG. On average, PAD in CABG costs $508,000 to $909,000 per quality-adjusted year of life saved, depending on the number of units donated. Preoperative autologous blood donation is more cost-effective (as low as $518,000 per year of life saved) when targeted to younger patients undergoing CABG at centers with high transfusion rates. The cost-effectiveness of PAD is strongly dependent on estimates of posttransfusion hepatitis incidence, but less so on plausible estimates of the current risk of human immunodeficiency virus transmission. Although the actual risk of PAD is uncertain, even a small fatality risk (> 1 per 101,000 donations) associated with blood donation by patients awaiting CABG negates all life expectancy benefits of PAD. At current costs, PAD by patients awaiting CABG is not cost-effective, producing small health benefits at high societal cost. For the individual patient, the risk of donating blood before CABG may well outweigh the benefits associated with fewer allogeneic transfusions.

The cost-effectiveness of preoperative autologous blood donation for total hip and knee replacement.

Although the frequency of preoperative autologous blood donation is increasing dramatically, the economic implications of its use remain largely unexplored. Decision analysis was used to calculate the cost-effectiveness of autologous blood donation for hip and knee replacement. Cost-effectiveness, expressed as cost per quality-adjusted year of life saved, was based on observed red cell use in 629 patients undergoing surgery at two tertiary-care centers. Autologous blood donation for bilateral and revision joint replacement cost $40,000 per quality-adjusted year of life saved at Center 1 and $241,000 at Center 2. Autologous blood donation for primary unilateral hip replacement cost $373,000 per quality-adjusted year of life saved at Center 1 and $740,000 at Center 2. Autologous blood donation was least cost-effective for primary unilateral knee replacement ($1,147,000/quality-adjusted year of life saved at Center 1 and $1,467,000/year at Center 2). Differences between autologous blood collections and transfusion requirements explained variations among procedures in the cost-effectiveness of autologous blood donation. Higher transfusion rates in autologous blood donors than in nondonors accounted for the poorer cost-effectiveness of autologous blood donation at Center 2 than at Center 1. Autologous blood donation is not as cost-effective as most accepted medical practices. Its cost-effectiveness can be improved substantially by the avoidance of overcollection and overtransfusion of autologous blood.

The safety of preoperative autologous blood donation in the nonhospital setting.

The increasing use of preoperative autologous donation (PAD) of blood has led to more frequent donation in settings outside of hospitals, despite concerns that persons making PADs may face increased risks of postdonation reaction. Analysis was conducted of 5660 PADs made at 25 different blood centers, to determine the risks of PAD in nonhospital settings and to search for predictors of severe reactions. Sixteen percent (886) of the donations studied were by persons who did not meet all usual homologous donor criteria. The most common variances were for cardiovascular disease, including the use of cardiac drugs (416 donors, 41% of those not meeting criteria), history of angina (204, 23%), and history of myocardial infarction (192, 22%). Donation by persons not meeting routine criteria was followed by a higher reaction rate than that by donors without any variance (4.3 vs. 2.7%; p less than 0.0001). An increased likelihood of reaction was associated with donor age less than 17 years, female gender, weight less than 110 pounds, and a history of reaction. Four reactions were graded as severe (transient ischemic attack, 1; angina, 3), and all occurred in donors not meeting all criteria (0.4% of 886 donations). A review of these donors' histories failed to identify distinguishing features from which their severe reactions could have been predicted. This study documents the infrequency of severe reactions after PADs by persons referred to a blood center for donation, even those not meeting routine homologous donor criteria, and quantitates the risk to these donors of a severe reaction.

Intraoperative autotransfusion: a community program.

The Southern Arizona Regional Blood Program of the American Red Cross in cooperation with Tucson hospitals conducted a pilot program of the provision of intraoperative autologous transfusion services. The service provided instruments, staff, and disposables to salvage and wash red cells shed during scheduled and emergency surgical procedures. The lower cost and other efficiencies of providing this service through a regional blood center suggest that it may be more appropriate to offer this service on a regional basis than exclusively within a hospital. Hospitals and regional blood centers should consider offering this advanced form of hemotherapy to their communities.

Whole body hyperthermia with a microwave regional boost: unexpected toxicity in the pig.

An animal model was used to investigate the potential for delivering a regional temperature boost using microwave energy after whole body hyperthermia had been induced in a pig using low density, radiant heat. Thermal profiles and an unexpected toxicity in the region of the microwave energy deposition, which included the heart and liver, are reported.