Letters to the Editor

Autologous transfusion: our goals To the Editor:

On measuring the success of an autologous blood donation program, Kruskall’s goal was stated as being “...to maximize the use of autologous blood by patients undergoing such pro- cedures and the efficiency with which the techniques are em- ployed,” and reference was made to a table of eight surgical or obstetrical procedures.’ Success is the fulfillment of goals set in advance. But the goals must be right. With all due respect to Kruskall, I consider her goal myopic and very narrow in scope. In a democratic society where the balance between man and the state is tipped toward the individual, the right of the patient should take precedence. Implicit in Kruskall’s goal is that we will not coerce patients to donate in order to maximize the use of autologous blood. A corollary should be that we will not deprive patients of the right to donate blood for au- tologous use, even if they have a statistically low chance of using it. The expectations of the patients should be the center of our goal. In general, the public does not have a clear per- ception of statistics; rather, individuals react to their emotions. Two actual incidents are representative. First, a patient was admitted through the emergency room for possible surgery. The physician ordered a transfusion, which used homologous blood. A daughter came to visit the patient and, on seeing the blood transfusion in process, removed the needle from the patient’s arm. Despite all the counseling we could provide, the family insisted on untested directed donation. Second, a hem- atologist, a faculty member of an internationally respected medical school, was scheduled for elective disc operation. He knew, and was also told by the neurosurgeon, that the chances of blood transfusion were very remote, but still he wished to donate 2 units. In the first case, the statistics were not persua- sive, and in the second case, they were not pertinent. There are many paradoxical views in the practice of transfusion med- icine. Blood donation is a relatively harmless procedure, and we encourage millions of people to donate. Yet when it comes to our patients, we try to impose statistics and policies on them.

Therefore, we have set the following goals for autologous donation:

1. Do no harm. 2. Inform and educate patients and physicians to the full

extent of our knowledge, 3. Provide the service and ensure easy accessibility for all

patients who may require a blood transfusion. 4. Let the patients decide for themselves. We may try to convince or persuade some patients, and we

may even end by maximizing autologous blood utilization, but still it is the patient who decides. It is my experience that with an autologous program established around these goals, ac- ceptance by the patients and physicians has been excellent.2 In conclusion, I believe that our goals should provide comfort and assurance to our patients that, barring economic con- straints, “all will be done that can be done.”

ALI DANESHVAR, MD, MAS Atlantic City Medical Center

1925 Pacific Avenue Atlantic City, NJ 08401

References 1 . Kruskall MS. On measuring thc success of an autologous blood

donation program (cditorial). Transfusion 1991;31:481-2.

2. Daneshvar A. Autologous transfusion: the treatment of choice. Md Med J 1986;36:473-82.

Don’t forget the SOPCAB! To the Editor:

In an editorial’ on measuring the success of an autologous blood donation program, Kruskall stated that these programs should be efficient, enrolling only appropriate patients who have a reasonable likelihood of using the blood donated. In an earlier editorial,2 Silvergleid enumerated his concerns for the appropriate indications for autologous blood donation and sug- gested the possibility of using the maximum surgical blood order schedule (MSBOS)3 as a guideline. We agree with the statements of both authors, but we were dismayed that neither mentioned the development of a model to assist in the for- mulation of an autologous blood collection schedule that ad- dresses this very need.

Our group described, in an earlier article in this j o ~ r n a l , ~ a proposal that we termed a “schedule of optimal preoperative collection of autologous blood,” or SOPCAB. The SOPCAB is intended to serve as a tool for judging the appropriateness of preoperative blood donation and the number of units that it would be reasonable to collect for any surgical procedure in a given institution. Like the MSBOS, the SOPCAB should be used by surgeons and transfusion medicine specialists as a general guideline for arriving at decisions regarding the man- agement of patients scheduled for elective surgery. Unlike the MSBOS, the SOPCAB provides consideration of postoperative as well as intraoperative requirements for autologous blood for each surgical procedure. If the MSBOS is used for such cal- culations, it will often fall short of providing sufficient blood for the patient’s perioperative blood needs, because postoper- ative requirements are not addressed.

It is important to recognize that, just as the MSBOS allows for a certain number of “unnecessary” compatibility tests if most patients are to be protected by ensuring the timely avail- ability of blood, the SOPCAB must allow a certain degree of “overcollection” if we are to provide the majority of patients with autologous blood only. We are in complete agreement with both Kruskall and Silvergleid that guidelines for preop- erative autologous collections are a necessity, and we believe it important to stress that decisions should be based on the number of units required to protect a given percentage of pa- tients from allogeneic blood exposure for a particular surgical procedure, rather than primarily on the fraction of units that may be “wasted.”

FREDERICK B. AXELROD, MD American Blood Institute

11500 Olympic Boulevard Suite 150

Los Angeles, CA 90064 SAMUEL H. PEPKOWITZ, MD

DENNIS GOLDFINGER, MD Cedars-Sinai Medical Center

Los Angeles, CA

References 1. Kruskall MS. On measuring the success of an autologous blood

donation program (editorial). Transfusion 1991;31:481-2.

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TRANSFUSION 1992-Vol. 32. No. 2 LETTERS TO THE EDITOR 191

2. Silvergleid AJ. Preoperative autologous donation: what have we learned? (editorial). Transfusion 1991;31:99-101.

3. Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976;16:380-7.

4. Axelrod FB, Pepkowitz SH, Goldfinger D. Establishment of a schedule of optimal preoperative collection of autologous blood. Transfusion 1989;29:677-80.

The above two letters were sent to Dr. Kruskall, who offered the following reply.

The schedule for autologous blood donations (SOPCAB) developed by Axelrod and colleagues1 is a useful approach for targeting the appropriate number of preoperative collections for given surgical procedures, and I am happy to support it in this letter. However, the purpose of my editorial* was to pro- pose that indications for the collection of autologous blood are limited. I intentionally skirted Axelrod’s article because their SOPCAB calculations, based on current transfusion practices at Cedars-Sinai Medical Center, suggest the use of autologous blood in situations that I consider questionable, such as trans- urethral prostate resections.

Daneshvar believes that patients should be able to choose to donate autologous blood whenever they wish. I disagree for both medical and economic reasons. As Daneshvar himself points out, the risks of transfusion-transmitted disease and the likelihood of a transfusion being needed are just two of the many aspects of transfusion therapy that are very difficult for patients without medical backgrounds to comprehend. There- fore, the decision to collect and use autologous blood should be one of the many made by a physician in the process of caring for a patient. Certainly patients should be educated about autologous blood usage techniques, just as they are about other aspects of their surgery. However, the donation of autologous blood is not a patient’s right, anymore than it would be, for example, his or her right to insist on antibiotics to treat a cold. Although I agree that the donation process is safe, the effort and costs entailed are substantial. Resources for medical care are finite; to conserve them, autologous blood usage tech- niques, like other medical procedures, should be used only for solid indications.

MARGOT S . KRUSKALL, MD Blood Bank

Beth Israel Hospital 330 Brookline Avenue

Boston, UA 02215

1.

2.

References Axclrod FB, Pepkowitz SH, Goldfinger D. Establishment of a schcdule of optimal preoperative collection of autologous blood. Transfusion 1989;29:677-80. Kruskall MS. On measuring the success of an autologous blood donation program (editorial). Transfusion 1991;31:481-2.

Yersinia and blood donation To the Editor:

In a recent issue of this journal, Grossman et al.’ suggested that asking blood donors about recent history of diarrhea or severe abdominal pain might intercept a majority of individuals infected with Yersiniu enterocolitica and thus prevent poten- tially fatal posttransfusion toxemia. According to those au- thors, this strategy would defer about 4 percent of potential donors, the vast majority of whom would represent no threat

to transfusion recipients. However, at a meeting earlier this year of the Food and Drug Administration’s Blood Products Advisory Committee, epidemiologists from the Centers for Disease Control said that although two-thirds of the blood do- nors implicated in an episode of transfusion-associated Yersinia toxemia had gastrointestinal illness before donation, most had mild or moderate rather than severe symptoms or diarrhea.

In an unpublished study, four members of the Council of Community Blood Centers questioned almost 6000 donors on more general symptomatology of gastrointestinal illness no more than 30 days before donation; 9.7 percent gave a positive re- sponse. While a deferral rate approaching 1 in 10 prospective donors would cause unacceptable blood shortages, such do- nation criteria might prevent two-thirds of such transfusion- associated reactions and deaths.

Fortunately, the incidence of fatal posttransfusion Yersinia toxemia appears to be extremely rare. Communications with staff of the Food and Drug Administration confirm there has been only one Yersinia-related fatality reported in the last 2 years. However, should the threat resurface, public health au- thorities might consider shortdating units of blood collected from individuals with a history of any gastrointestinal illness in the 30 days before donation. Almost all Yersinia-associated transfusion toxemias in the United States have occurred more than 26 days into the storage of red cells. If the situation requires some action, selective shortdating of blood collections could serve the dual purpose of protecting blood recipients while making otherwise acceptable donations available for transfusion.

LOUIS KATZ, MD Mississippi Valley Blood Services

3425 East Locust Street Davenport, LA 52803

JAMES L. MACPHERSON Council of Community Blood Services

Washington, DC THOMAS F. ZUCK, MD Hawvorih Blood Center University of Cincinnati

Cincinnati, OH

Reference 1. Grossman BJ, Kollins P, Lau PM, et al. Screening blood donors

for gastrointestinal illness: a strategy to eliminate carriers of Yer- siniu enterocoliticu. Transfusion 1991;31:500-1.

The above letter was sent to Dr. Grossman and colleagues, who elected not to publish a response.

Comparison of two approved enzyme immunoassays for the detection of antibodies to the hepatitis C virus in 5216

United States blood donors

To the Editor: Testing for antibody to the hepatitis C virus (anti-HCV) by

using licensed enzyme immunoassays (EIA-1) should reduce the risk of transfusion-associated HCV infections. The licensed first-generation anti-HCV EIA-1 tests appear to have good sen- sitivity and specificity, but confirmatory assays for differen- tiating true-positive from false-positive results are not yet approved by the United States (US) Food and Drug Admin- istration (FDA). This differentiation is especially important in low-risk US populations, such as healthy blood donors. Whereas