Blood and Blood Products Safety and Risk (1996) / Chapter Skim
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4: Risk Tolerance
4: Risk Tolerance
Pages 81-108
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From page 81... ...
IV Risk Tolerance
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From page 83... ...
Allogeneic blood is available for both elective and emergency surgery, which truly is an advantage of the use of allogeneic blood, because there is no burden on the patient. Use of autologous blood is not always an option.
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From page 84... ...
In Blundell's work there was a change in the scientific approach to the use of transfusion. For the first time, Blundell was transfusing patients to treat blood volume loss and red cell loss, not to correct mental illness.
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From page 85... ...
He looked at 243 cases of blood transfusion, and he again showed that two-thirds of these were successful in saving lives.56 Most of these were for postpartum hemorrhage and the bulk of this material was Blundell's. In 1883, nothing was known about ABO and Rh blood groups.
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From page 86... ...
As Bernheim said in his 1917 book Blood Transfusion, Hemorrhage, and the Anemias,s~ "Hundreds of people have been saved Dom premature death Tom hemorrhage." The literature contains many statements such as this, without any scientific basis for support such as a prospective or randomized trial. This was the perception of transfusion in general.
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From page 87... ...
At Cooper HospitalUniversity Medical Center in Camden, New Jersey, about 10 to IS percent of overall red cell recipients in 1994 were coronary artery bypass recipients. This is a 550-bed university tertiary-care hospital where about 300 to 400 coronary bypass procedures are done per year, so there is a significant number of patients who are transfused in conjunction with cardiac surgery.
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From page 88... ...
The primary reason we should use red cell transfusion now Is to improve oxygen delivery. All of the foregoing has been focused on life-saving interventions.
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From page 89... ...
A difference of only 1.8 percent may not seem like a lot, but if one considers the 2 to 3 percent mortality now viewed as acceptable in a quarter million coronary bypass patients, then this small difference represents both a large number of patients and a doubling of the operative risk. Jeffrey Carson and I have now studied 528 patients: 206 Jehovah's Witnesses, and 322 who are not, looking at mortality and hemoglobin levels.
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From page 90... ...
That means admitting a seriously injured patient every 5 hours throughout the year. In 1994, 26 percent of all red cells and components went to trauma patients; thus, the trauma patients are prime users of blood in the hospital.
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From page 91... ...
There is some evidence in studies of Jehovah's Witnesses associating increased morbidity and mortality with lower hemoglobin levels, and we are beginning to get evidence that transfusion can turn that around. There is evidence for red cell-related limits of cardiac compensation, and we are beginning to acquire more solid physiologic findings about those limits that will help us to determine in the future just what we can do and what the transfusion intervention will provide.
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From page 93... ...
markers, the apparent benign and nonprogressive course of non-A, non-B hepatitis, and the benefits of clotting factor concentrates as we knew them in the pre-AIDS era. Following the introduction of pooled plasma fractions in the late 1960s, a 30 percent incidence of acute hepatitis was reported in first-time recipients of Factor VIII concentrate.64 During the middle to late 1970s high rates of liver function abnormalities accompanied by very high rates of peripheral blood markers for HBV were reported in those patients who were repeatedly exposed to both cryoprecipitates and clotting factor concentrates.
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From page 94... ...
Those persons who received clotting factor concentrates during the 1970s and the 1980s, before the advent of viral inactivation procedures, were almost universally infected, and those who received repeated infusions of cryoprecipitate also had a high rate of infection. The vast majority of those who were infected remained chronically infected.
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From page 95... ...
The second is a youngster with severe Factor VIII deficiency who was treated with clotting factor concentrates Mom an early age as part of a home infusion program. He grew up with the philosophy, "When in doubt, treat to prevent irreparable joint damage and other complications from persistent bleeding into sonic tissues." His mother was taught to infuse him at home when he was about 5 years old, and as he approached adolescence he was taught to infuse himself at the first sign of any bleeding.
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From page 96... ...
More than one-half of these received treatment in home settings, compared with only one-tenth in 1970. With the transition to home care and early treatment with clotting factor concentrates, hospitalizations and visits to emergency rooms declined, and patients and their families experienced freedom from hospital dependency.
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From page 97... ...
These theoretical risks are not meant to scare patients, nor are they meant to deter them from using the products upon which they depend for their lives, their livelihoods, and their independence. We all know that many steps are incorporated into the process of manufacturing recombinant Factor VIII which should eliminate all known infectious agents that might contaminate the end product, but just how safe are clotting factor concentrates today?
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From page 98... ...
By 1990, a huge amount had been learned about this, and we are just now beginning to learn about the natural history of hepatitis C If you talk to many persons with hemophilia who received clotting factor concentrates during that era, you will find that it would have been intolerable to them to think about not having these products to provide them with the kind of life that was worthwhile for them.
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From page 99... ...
Lew Barker: I find this word "tolerate" a little bit strange. We tolerate graft-versus-host disease in people who have transplants.
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From page 101... ...
However, a related parasite, Leishmania donovani, has a parasitemic phase. While there is a case in the literature of a transmission by a blood transfusion, clearly this is not a major public health problem.
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From page 102... ...
We tolerate this particular risk of blood transfusion for most recipients receiving blood Mom unrelated donors. Does allogeneic blood transfusion alter the recipient's immune response?
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From page 103... ...
The work of Opelz and colleagues73 on graft survival in patients receiving cadaver kidneys demonstrates that those people who received blood transfusions had better organ graft survival, and there was also a dose response. This suggests that there was an immunosuppressive effect of allogeneic blood.
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From page 104... ...
Also, those who received autologous blood as a control in matched studies had fewer postoperative infections than those who received allogeneic blood.78 Is that also an immunosuppressive effect that we tolerate? Five prospective studies of postoperative infection also looked at allogeneic blood transfusion either without controls or with autologous blood as control, or compared allogeneic blood with allogeneic blood that had the white cells taken out of it.
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From page 105... ...
He used different concentrations of mononuclear cells from different healthy donors and found a dose response relationship showing that lymphocytes endogenously infected with HIV were stimulated by coculture with allogeneic mononuclear cells. If you separated out these cells and looked at granulocytes, monocytes, lymphocytes, or unfractionated mononuclear cells, you saw exactly the same kind of phenomenon, but if you took all the white cells out of the allogeneic blood by filtration or washing, or used plasma devoid of lymphocytes, you did not see this phenomenon.
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From page 106... ...
. Conceivably, we should be informing patients that this is a potential risk in blood transfusion.
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From page 107... ...
Other than the attractive alternative of trying to move totally away from allogeneic blood transfusions, I think once we understand jumping genes or whatever they are, there will be something else to concern ourselves with. These may be the problems of the next century associated with allogeneic blood transfusions.
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From page 108... ...
108 BLOOD AND BLOOD PRODUCTS: SAFETY AND RISK in that blood center. Subsequently, a third case occurred several months later, and it was from the same source.
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