Transfusion-free Surgical Program Reduced Use Of Blood Products For All Liver Transplant Patients

Development of a transfusion-free surgical program for Jehovah's Witness patients undergoing liver transplantation also has helped reduce the overall use of blood products for non-Jehovah's Witnesses undergoing the procedure, according to a study in the September issue of Archives of Surgery, one of the JAMA/Archives journals.

"Orthotopic liver transplantation [in which a patient's diseased liver is removed and a donor liver transplanted into the same place] is typically associated with a large volume of blood loss, resulting in multiple transfusions and related complications," the authors describe in background information in the article. "Transfusion-free surgery is rapidly gaining much-needed attention primarily because of the concerns surrounding transmission of diseases such as human immunodeficiency virus, hepatitis C and other viral infections. Additionally, long-term shortage of blood products and a paucity of alternatives put the system under duress, resulting in cancellation or postponement of elective cases."

Nicolas Jabbour, M.D., from the INTEGRIS Baptist Medical Center, Oklahoma City, and colleagues analyzed the medical records of 365 adult and pediatric orthotopic liver transplants performed from January 1997 through December 2004 at the University of Southern California-University Hospital in Los Angeles. The investigators evaluated the impact of the initiation of a transfusion-free program for Jehovah's Witnesses undergoing liver transplantation on the overall use of blood products in non-Jehovah's Witnesses undergoing the procedure. The pediatric and Jehovah's Witness transplant recipients were eliminated from the study, leaving only adult non-Jehovah's Witness patients who either received a liver transplant from a deceased donor or a living donor (n=272). These patients were categorized into two groups based on the initiation of the Transfusion-Free Medicine and Surgery Program at USC (for Jehovah's Witnesses) in January 2000. Group 1 consisted of recipients who received the liver transplant before January 2000 and group 2 included all patients who underwent transplantation after January 2000.

"Recipients in group 1 underwent orthotopic liver transplants without intraoperative blood-saving or salvaging techniques, whereas all transplant recipients in group 2 underwent intraoperative cell salvage (ICS) and acute normovolemic hemodilution (ANH) whenever feasible," the authors report. "ANH indicates a therapeutic initiative that involves simultaneously removing the patient's blood and replacing it with nonblood products..."

"In comparing group 2 with group 1, the mean (average) MELD [model of end-stage liver disease] score was statistically significantly higher, whereas the mean number of intraoperative PRBC (packed red blood cells) and FFP (fresh frozen plasma) transfusions were significantly lower," the authors report. The MELD score describes the survival probability of a patient with end-stage liver disease, with higher scores indicating sicker patients. "The number of preoperative and postoperative PRBC, FFP and platelet transfusions between the two groups was not statistically different."

"The development of a transfusion-free surgical program for Jehovah's Witness patients has had a positive impact on reducing the overall blood use in non-Jehovah's Witness patients," the authors note. According to the authors, autotransfusion decreases some of the complications of transfusions, such as transmission of unknown pathogens, and also helps to preserve blood bank resources, which consequently reduces the overall procedure cost. "Surgeons are the leading consumers of blood products, and it is important that we are leaders in promoting transfusion-free techniques. In conclusion, we propose that the recognized need to minimize the use of blood products be elevated to the same level as antibiotic and deep venous thrombosis prophylaxis (prevention)."

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