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CMAJ
CMAJ - July 28, 1998JAMC - le 28 juillet 1998

Alternatives to blood transfusion are risky too

CMAJ 1998;159:137

See response from: J.M. Thomas
I would like to make 3 points in reply to Dr. J. Mervyn Thomas's letter "Blood transfusions: listen to the patient" (CMAJ 1998;158[5]:585) and his plea for increased use of alternatives to allogeneic blood.

It is true that patients are more aware now than they were a decade ago of the risks associated with allogeneic transfusion. However, are patients making realistic risk estimates, and are they also aware of the risks of the alternatives? Just as blood products will never be without risk, it is also unlikely that effective alternatives will ever be without risk. For example, autologous predonation is associated with bacterial infection1 and transfusion reactions because of laboratory error.2 Indeed, the frequency of these side effects may be higher than with allogeneic blood, because patients who predonate often receive more transfusions than those who do not.3 Concern remains about the risk of thrombosis associated with aprotinin4 and erythropoietin,5 and it must be remembered that relatively few patients have participated in trials of pharmacological agents. Because the frequency of severe side effects from allogeneic blood is now very low, studies of the alternatives must involve large numbers of patients to be sure that they are just as safe.

Unfortunately, the cost-effectiveness of many of the alternatives to allogeneic transfusion has not been well established. Indeed, most well-designed studies have found the cost-effectiveness of preoperative autologous donation and erythropoietin unattractive according to conventional criteria.6,7

Finally, I believe the term "bloodless surgery" can be misleading. It implies to patients that major surgery can always be achieved without blood transfusion.

Rather than providing patients with false expectations, we should be encouraging frank discussion of the benefits and risks of both allogeneic transfusion and its alternatives.

Andreas Laupacis, MD, MSc
Director
Clinical Epidemiology Unit
Ottawa Civic Hospital
Loeb Research Institute
Ottawa, Ont.
alaupacis@lri.ca

Dr. Laupacis chairs the International Study of Perioperative Transfusion, which receives nonrestricted research funds from Janssen-Ortho Inc.

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References
  1. Red blood cell transfusions contaminated with Yersinia enterocolitica United States, 1991­1996, and initiation of a national study to detect bacteria-associated transfusion reactions. MMWR 1997;46:553-5.
  2. Goldman M, Remy-Prince S, Trepanier A, Decary F. Autologous donation error rates in Canada. Transfusion 1997;37:523-7.
  3. Forgie MA, Wells PS, Laupacis A, Fergusson D, for the International Study of Perioperative Transfusion (ISPOT) Investigators. Preoperative autologous donation decreases allogeneic transfusion but increases exposure to all red blood cell transfusion. Arch Intern Med 1998;158:610-6.
  4. Laupacis A, Fergusson D, for the International Study of Perioperative Transfusion (ISPOT) Investigators. Drugs to minimize peri-operative blood loss in cardiac surgery — meta analyses using peri-operative blood transfusion as the outcome. Anesth Analg 1997;85:1258-67.
  5. D'Ambra MN, Gray RJ, Hillman R. Effect of recombinant human erythropoietin on transfusion risk in coronary bypass patients. Ann Thorac Surg 1997;64:1686-93.
  6. Etchason J, Petz L, Keeler E, Calhoun L, Kleinman S, Snider C, et al. The cost effectiveness of preoperative autologous blood donations. N Engl J Med 1995;332:719-24.
  7. Coyle D, Lee KM, Laupacis A, Fergusson D. Economic analysis of erythropoietin use in surgery. Ottawa: Canadian Coordinating Office for Health Technology Assessment; 1998.