To The Editor:
We greatly appreciated the article "Hemolytic Disease of the
Newborn Caused by Transfusion of a Husband's Directed Blood Donation.
A Case Report" (81-A: 1170-1172, Aug. 1999), by Kennedy et al. We
agree with the authors, and we wish to focus the attention of readers
on the controversy related to the indication for blood transfusion
in the case reported. We also wish to comment on some of the risks
of hemotherapy.
Recently, the Canadian Critical Care Trials Group suggested that
the use of a threshold for red-cell transfusion of as low as seventy
grams of hemoglobin per liter, combined with a maintenance of hemoglobin
concentrations in the range of seventy to ninety grams per liter,
was at least as effective as, and presumably superior to, a more
liberal transfusion strategy (threshold, 100 grams per liter; support
range, 100 to 120 grams per liter) in critically ill patients with
normovolemia4. Moreover, a recent
meta-analysis showed that patients who predonated autologous blood
were more likely to receive any transfusion1.
This latter finding is thought to be related to more liberal transfusion
practices and to lower preoperative hemoglobin levels in autologous donors.
(At the time of the preadmission testing for elective hip replacement,
the hemoglobin level of the patient described by Kennedy et al. was
reported to be ninety-three grams per liter.)
As an example of another hypothetical complication of blood transfusion,
we have reported hypercoagulability in patients having hip or knee
arthroplasties who received allogenic blood with a postoperative
packed-cell volume of less than 30 percent5.
In addition to age, type of operation, femoral fracture, and spinal
injury, blood transfusion was described by Geerts et al.2,3 as a risk factor for venous thromboembolic
disease in patients with major trauma.
Thus, a crude cost-benefit analysis of the above-mentioned studies
suggests that physicians should use a more limiting transfusion
policy.
Teodoro Iturbe, M.D.
Rosa Cornudella, M.D.
Alejandro Serrablo, M.D.
Martín Gutiè±²ez, M.D.
Corresponding author: Teodoro Iturbe, M.D.
Hematology Department, Coagulation Section
Zaragoza University Hospital
Avda. San Juan Bosco 15
50009-Zaragoza, Spain
M. S. Kennedy, R. O'Shaughnessy, R. C. Wasielewski, A.
Waheed, M. Hewitt, and D. Krugh reply:
We appreciate the comments of Drs. Iturbe, Cornudella, Serrablo,
and Gutiè±²ez. We agree that the trend is to use lower hemoglobin
levels as thresholds for transfusion. In addition, we agree that
patients who have donated autologous blood may be more likely to
receive a transfusion than those who have not donated. The findings
by Dr. Iturbe and colleagues of hypercoagulability in patients undergoing
hip and knee operations is of interest and concern. We look forward
to additional studies on this observation.
Melanie S. Kennedy, M.D.
Richard O'Shaughnessy, M.D.
Ray C. Wasielewski, M.D.
Abdul Waheed, M.S., M.T.
Martha Hewitt, M.T.
David Krugh, M.T.
Corresponding author: Melanie S. Kennedy, M.D.
125 Hamilton Hall, 1645 Neil Avenue
Columbus, Ohio 43210