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• W1979442852 abstract "One of the few benefits of the epidemic of acquired immunodeficiency syndrome (AIDS) is the increased concern on the part of the lay and medical communities for the risks of posttransfusion disease. Fear of AIDS has resulted in various strategies on the part of patients and physicians to avoid blood transfusion or reduce donor exposure. This reaction has a degree of irony, inasmuch as transfusionists have had limited success after many years of cautioning physicians against inappropriate blood transfusion, principally because of posttransfusion hepatitis. Moreover, hepatitis remains a far more prevalent posttransfusion infection than AIDS. The messianic zeal with which some have championed predeposit autologous transfusion in this AIDS era is remarkable. The recent proliferation of publications and seminars on this subject not only has had a positive effect on many curricula vitae but also has resulted in the implication that it is a newly discovered technique; however, it has been advocated for many years.1Grant FC Autotransfusion.Ann Surg. 1921; 74: 253-254Google Scholar, 2Milles G Langston H Dalessandro W Experiences with autotransfusions.Surg Gynecol Obstet. 1962; 115: 689-694Google Scholar, 3Newman MM Hamstra R Block M Use of banked autologous blood in elective surgery.JAMA. 1971; 218: 861-863Crossref PubMed Scopus (52) Google Scholar, 4Brzica Jr, SM Pineda AA Taswell HF Autologous blood transfusion.Mayo Clin Proc. 1976; 51: 723-737PubMed Google Scholar Perhaps autologous donation of blood did not become more frequently used earlier because of the reluctance of clinicians and blood banks to undertake the somewhat cumbersome procedure necessary for its safe and successful implementation. Undoubtedly, predeposit autologous transfusion is the safest type of blood transfusion for elective surgical procedures because it precludes sensitization of the patient to blood group antigens and also avoids transmission of disease. It is not applicable in certain situations, as is noted in the proposal by Brecher and associates in this issue of the Proceedings (pages 903 to 905); however, usual blood donor requirements can be waived to expand its utilization. For example, my colleagues and I and other investigators have obtained blood preoperatively from young patients who are to have orthopedic procedures, the only limiting factor in this group of patients being the ability of the child to cooperate with the donation. Another strategy that has received attention as a result of the AIDS epidemic is so-called directed donation. As noted by Brecher and colleagues, this procedure is of dubious merit and probably is more important for the psychologic benefit of the patient and donors than for its medical value; however, the denigration of directed donation by blood banks has largely fallen on deaf ears. Although, in general, there is no evidence of increased safety resulting from this procedure, one possible exception may be donation of blood from parents for their young children. The suggestion of Brecher and co-workers to restrict donor exposure through collection of increased numbers of blood components from “directed donors” is an intriguing one. A severe limiting factor in this schema, however, is the inability to store platelet concentrates beyond 5 days. Thus, the blood must be collected in immediate proximity to the time of transfusion. Most hospital blood banks have limited facilities and staff for collection of blood and rely primarily on regional blood centers for their blood supply. The program described by Brecher and associates seemingly would be most successful if implemented by the hospital where the patient will undergo transfusion. Most likely, however, additional staff and space would be needed for such a service. Not only would nurses be required to collect the blood but also added personnel may be needed to schedule the various donors and to ensure that the collected units of platelets, plasma, and erythrocytes are transfused to the intended patient. Quite likely, the cost of the increased personnel would exceed the economic gain to the institution from the collected blood components, an unacceptable drawback in this time of containment of health-care expenses. Therefore, this system would be applicable primarily in a setting wherein a large blood donation service preexisted in a hospital and wherein current personnel have adequate time to expand their duties or could use these directed donor procedures to fill previously unscheduled time. As they have acknowledged, the frequency of blood donation used by Brecher and colleagues is in violation of the standards of the American Association of Blood Banks.5Holland PV Schmidt PJ Standards for Blood Banks and Transfusion Services. Twelfth edition. American Association of Blood Banks, Arlington, Virginia1987Google Scholar So-called directed donors must satisfy all blood donor requirements, and donation of erythrocytes is restricted to once every 8 weeks or five times per year. Although autologous donations may be made more frequently, this exception currently is inapplicable to directed donors. Their call for a reexamination of frequency of donation is fitting; yet this issue must be resolved on the basis of potential depletion of the donor's iron stores, especially because, as the authors have noted, there is no evidence of beneficial effect of directed donation. As mentioned, the platelet concentrates must be collected in immediate proximity to the operation. Because staffing limitations would likely preclude collection of the platelets on the weekend in either a regional or a hospital donor center, this restriction may have implications on the scheduling of operative procedures early in the week. Furthermore, rescheduling of operations must be curtailed, as delays might interfere with proper use of the collected platelet concentrates. Brecher and co-workers note that half of their collected parental apheresis platelets are not used for the intended recipient because of postponement or cancellation of operations or lack of need for the component. One must wonder about the reaction of the patient and of the “directed donor” to the unavailability of the donated component because of postponement or cancellation of the operation. The use of these components for other patients is appropriate; however, it raises a serious moral question about the somewhat implied coercive manner of collection of these blood products. Although the authors view this in a global sense as a benefit to their blood-recipient population, what of the patient for whom the original donations were intended? Finally, an important issue that must be addressed in association with the current advocacy of autologous donation and directed donation is the actual need of most patients for these services. In our institution, many of the patients who donate blood for their own subsequent transfusion, or who recruit directed donors, never require transfusion. Aside from these practical issues, one must admire the program described by Brecher and associates, in that it satisfies the transfusion requirements of many patients and reduces their exposure to a variety of donors. In addition, this approach is associated with obvious psychologic benefit not only for the patient but also for the patient's acquaintances. In summary, although this program provides a reasonable approach for reducing the donor exposure to patients, its implementation may not be cost-effective, it is unlikely to meet the needs of many of the intended patients, and, as described, it violates current guidelines of national accrediting organizations." @default.
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• W1979442852 title "Strategies for Blood Transfusion" @default.
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