Efficacy and cost-effectiveness of autologous blood predeposit in patients undergoing radical prostatectomy procedures.

OBJECTIVES: To assess the efficacy and cost-effectiveness of preoperative autologous blood donation (PAD) in radical prostatectomy procedures. METHODS: A retrospective 3-year review was performed of transfusion outcomes in radical prostatectomy procedures. Cost, benefits, and cost-effectiveness were established using a previously published Markov decision analysis model. RESULTS: Three hundred eighty-four (97%) of 394 patients predonated 3.5 +/- 0.6 (mean +/- SD) autologous blood units. Of these, 2.1 +/- 1.2 units (60%) were retransfused. Forty-two (11%) of 394 patients also received allogeneic blood. Autologous blood donors received only 0.2 +/- 0.6 allogeneic blood units, compared with 1.4 +/- 1.4 (p < 0.05) units transfused to patients who did not predonate. The net costs of PAD ranged from $83 to $303 per procedure. The life-expectancy benefit of PAD ranged from 0.05 to 0.07 days. The overall cost-effectiveness of PAD was estimated to be $1,813,000 per quality adjusted life-year saved. However, PAD was significantly more cost-effective for 2 unit donations ($531,000 per quality adjusted life-year saved). CONCLUSIONS: We conclude that autologous blood donation is an effective blood conservation strategy in elective radical prostatectomy. However, the cost-effectiveness of this practice compares unfavorably with that reported for other medical interventions. Alternative and more cost-effective strategies to reduce the need for allogeneic blood in this setting must be developed.

Acute preoperative hemodilution in patients undergoing radical prostatectomy: a case study analysis of efficacy.

Despite published guideline and consensus conference recommendations, the role of acute preoperative hemodilution in elective surgery has not been defined. We performed a case study analysis of this technique in a large surgical program in order to estimate its degree of efficacy as practiced routinely, and to better define its role as a blood conservation strategy. Patients undergoing elective radical prostatectomy by one surgeon during a 3-yr period were analyzed retrospectively for blood loss, hematocrit levels, records of acute hemodilution, and transfusion outcomes. Patient blood volumes were determined by nomogram; final hematocrits after discrete blood volumes lost by surgery or by hemodilution were estimated. Sixteen (4.4%) of 410 total patients reviewed underwent hemodilution, representing 0 (0%), 4 (3%), and 12 (8%) of the 112, 146, and 152 patients undergoing surgery in years 1, 2, and 3, respectively. Median whole blood volume and mean red blood cell (RBC) volume removed by hemodilution was 1000 mL (range, 400-1500 mL) and 338 mL (range, 156-585 mL), respectively, representing 15% of patients' admission RBC volume. Net intraoperative RBC volume "saved" in losses by this technique was 95 mL (range, 25-204 mL), representing only 9.3% (range, 4%-17%) of total RBC volume lost during hospitalization. RBC volume removed by hemodilution constituted 34% (95-283 mL) of the total RBC volume transfused. We conclude that use of acute preoperative hemodilution remains in evolution and, as a single blood conservation intervention, contributes only modestly to blood conservation.

Vascular access for therapeutic plasma exchange.

Adequate venous access is an essential component of therapeutic plasma exchange (TPEX). The simplest kind of venous access is venipuncture of antecubital veins, but this technique may be limited by venous size or scarring following the procedure, requiring the placement of a specialized vascular access device (VAD). VADs provide reliable central venous access and may remain in place for several weeks or months, depending on the VAD and the venous site chosen. Their use, however, is potentially limited by the risk of complications. We discuss indications for insertion, choice of catheter and access site, and complications of VAD placement for TPEX.

The effect of an intraoperative treatment algorithm on physicians' transfusion practice in cardiac surgery.

BACKGROUND: Inappropriate transfusion in cardiac surgery may, in part, be due to empiric transfusion therapy instituted in the absence of timely laboratory data. Therefore, the effect of a transfusion decision algorithm based on intraoperative coagulation monitoring of physicians' transfusion practice and the transfusion outcome was evaluated. STUDY DESIGN AND METHODS: In a randomized, controlled trial, cardiac surgical patients determined to have microvascular bleeding at the cessation of cardiopulmonary bypass were assigned to algorithm (A) or standard (S) therapy. Group A was treated with plasma and platelet therapy according to a transfusion algorithm based on on-site coagulation data available within 4 minutes. For Group S, the use of laboratory-based data and the decision to transfuse blood components were at physician discretion. RESULTS: Sixty-six patients were entered into the study (Group A, n = 30; Group S, n = 36). Other than the fact that there were significantly more female patients in Group S than in Group A, no differences between cohorts in regard to perioperative risk factors for blood transfusion needs were identified. Therefore, gender was factored in as a covariate in the statistical analysis. Group A patients received fewer hemostatic blood component units (p = 0.008) and had fewer total donor exposures (p = 0.007) during the entire hospitalization period. Linear regression analysis of the differences in slopes in Groups A and S for the relationships between the red cell volume lost and the red cell volume transfused (p < 0.03), non-red cell units transfused (p < 0.0001), and total number of blood components transfused (p < 0.0001) demonstrated that physicians' transfusion practice was significantly altered by the use of a transfusion algorithm with on-site coagulation data, independent of surgical blood losses. CONCLUSION: The use of algorithms by transfusion decision makers can serve as an effective physician education intervention.

Integration of concurrent collection of plasma into a plateletpheresis program.

We have reviewed our initial experience with a program of concurrent collection of plasma (CCP) during plateletpheresis, which was instituted to increase the number of units of fresh frozen plasma produced by our hospital-based donor service. Sixty percent of eligible donors (1,006 of 1,682) participated in CCP, and 21 donors subsequently dropped out of the program. Of these, only one of four first-time donors have returned, whereas the majority of established plateletpheresis donors (16 of 17) have continued to donate platelets. Additional plasma was collected at a minimum of 8-week intervals on the Fenwal CS-3000 Plus or COBE Spectra without a change in the requirements for donor testing or the collection procedure. The quality of these platelet products was compared to that of those donated without CCP. There was a small decrease in platelet yield for products with CCP on the CS-3000 Plus (mean yield 4.5 x 10(11) with CCP versus 4.9 x 10(11) without CCP, P < .01). No negative effects were seen on the percentage of products with a minimum yield of 3 x 10(11) platelets or on leukocyte contamination. In addition, there was no difference in the rate of adverse donor reactions. During a 12-month interval, CCP provided 34% (3,798 of 11,266 units) of all fresh frozen plasma for our hospital without additional staff or equipment. The results of this retrospective study suggest that CCP merits further evaluation.

Potential for transfusion-associated graft-versus-host disease due to apheresis platelets matched for HLA class I antigens.

Transfusion-associated graft-versus-host disease (TA-GVHD) has been reported in immunocompetent recipients of nonirradiated cellular blood components from donors who are homozygous for an HLA haplotype shared with the patient. In these cases, donor lymphocytes have no antigens foreign to the recipient, and this similarity in HLA antigens appears important for the development of TA-GVHD. Experience with 65 patients receiving apheresis platelets matched for class I HLA antigens was reviewed to determine the incidence of such a transfusion among HLA-matched, unrelated donor-recipient pairs. In 5 percent of transfusions (31/673), the patient received lymphocytes from a donor exhibiting no antigens foreign to the recipient, but the patient had additional HLA-A or -B antigens not present on donor lymphocytes. Twenty-three percent (n = 15) of patients received at least one such transfusion. In addition, most patients were immunosuppressed as a result of their underlying disease or therapy, which may decrease the degree of antigen matching required to initiate TA-GVHD. Until the pathogenesis of this disease is better understood, it is recommended that the transfusion of an HLA-matched cellular blood component be considered a risk factor for the development of TA-GVHD regardless of the patient's immune status, and that all such blood components be irradiated.

Development of alloanti-Jka in a patient with hemolytic anemia due to autoanti-Jkb.

Autoanti-Jkb and a transient autoanti-E were identified in a patient with autoimmune hemolytic anemia, and red blood cells negative for Jkb and E antigens were transfused. Twelve weeks after transfusion, the autoantibody appeared to have developed broad specificity. However, autoadsorption studies revealed that the broad reactivity was due to the development of alloanti-Jka in addition to the autoanti-Jkb. Distinguishing this combination of alloanti-Jka plus autoanti-Jkb from an autoantibody with broad specificity will be important in selecting Jka antigen-negative red cells for subsequent transfusions. This case emphasizes the importance of additional serologic testing to detect alloantibodies in patients with broadly reactive warm autoantibodies.

Analysis of venous access for therapeutic plasma exchange in patients with neurological disease.

We retrospectively analyzed our 2-year experience with venous access for 363 therapeutic plasma exchanges in 46 patients with neurological disease, including acute Guillain-Barré syndrome (N = 20), myasthenia gravis (N = 17), and chronic inflammatory demyelinating polyneuropathy (N = 9). Twenty-three patients (50%) completed the planned course of therapy using only peripheral venous access, and 28 central venous catheters were placed in the remaining 23 patients. Patients utilizing central venous access did not undergo a greater number of procedures, but they were more likely to have acute Guillain-Barré syndrome (P < 0.02) or to be hospitalized in a medical intensive care unit (P < 0.01). Three types of central catheters were used, and although our experience was predominantly with 1 type, differences were noted. Only 3% of procedures (3 of 96) done with a Quinton-Mahurkar catheter were associated with a catheter failure, compared to 27% (4 of 15, P < 0.01) with a Hickman catheter and 67% (2 of 3) with a triple-lumen catheter. Life-threatening complications occurred with 3 of 28 (11%) central catheters. To optimize the success of therapeutic plasma exchange using central access, it is critical that hemapheresis personnel advise each patient's primary physician regarding the type of central venous catheter required. Currently, we recommend use of a Quinton-Mahurkar or other dual-lumen hemodialysis catheter.

Gastric leiomyoblastoma (epithelioid leiomyoma) occurring in a child: a case report.

Leiomyoblastomas are rare smooth muscle tumors occurring most commonly in the gastrointestinal tract of adults. We report the unusual occurrence of a gastric leiomyoblastoma in a child who presented with refractory iron deficiency anemia. The tumor had a superficial erosion which was apparently the source of intermittent hemorrhage resulting in anemia. Epithelioid cells, spindled cells, and cells arranged in a perithelial pattern were seen by microscopy, characteristic of a leiomyoblastoma. Immunohistochemical staining demonstrated muscle actin, vimentin, desmin, and alpha-1-antichymotrypsin, and electron microscopy showed focal densities alternating with thin filaments. All of these features help to differentiate the tumor from an inflammatory pseudotumor. Leiomyoblastomas are associated with paragangliomas and pulmonary chondromas in children, but these were not present in this child. The prognosis of leiomyoblastomas may be related to tumor size, mitotic rate, and cellular characteristics.

Successful outcome of severe aplastic anemia following Epstein-Barr virus infection.

Severe aplastic anemia has been reported in children following Epstein-Barr virus (EBV) infection. The pathophysiology of disease is not known, but an immunologic mechanism is suspected because of the rapid response to steroids. A patient with severe aplastic anemia following EBV infection experienced bone marrow recovery after treatment with high-dose prednisone. After reviewing the literature it is concluded that steroid therapy is indicated in this select group of patients.