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A surgical patient's transfusion survival guide: long-overdue advice on how to avoid the risk of "potluck" blood should the need for a transfusion arise.

Long-overdue advice on how to avoid the risk of "potluck" blood should the need for a transfusion arise.

Monty Kobey of San Diwas transfused with HIV-infected blood in 1984. Officials at both the Alvarado Hospital Medical Center and the San Diego Blood Bank, according to Kobey and his wife, knew he received contaminated blood in early 1987, but didn't tell him until it was too late. Two days after Kobey was hospitalized for a "mysterious brain infection," and six months after Alvarado Hospital was aware of the tainted blood, Kobey was informed. The Kobeys believe that perhaps, had he known sooner, his state of confusion and mental disability could have been diagnosed earlier and treated before irreversible complications set in. Adding to the tragedy is their knowledge that if transfusion alternatives had been used, his whole ordeal might have been avoided. The banked blood he received was probably unnecessary. Monty Kobey and his wife are suing Alvarado Hospital Medical Center and the San Diego Blood Bank.

Tragically, Kobey's story is one that should never have to be told. Yet, his is not the only such case. Unsuspecting patients are still unnecessarily receiving homologous banked-blood transfusions throughout the nation.

The purpose of this article is to help you protect yourself from getting an HIV infection by avoiding unnecessary transfusions and knowing the right kind of transfusion to get if you must have one.

Protection begins with knowledge about the alternatives.

Although most people who receive AIDS-infected blood become infected, blood banks have been slow to notify those who might be infected and even slower to take their partners into consideration.

Fear of stimulating litigation encourages blood banks to avoid notifying those who may have been infected. One source, who insisted on remaining anonymous, said"They are going to die soon anyway. If we wait long enough, they won't be able to sue us. Why create problems?"

According to the July 27, 1988, issue of AIDS Policy and Law, the Oklahoma Blood Institute and a doctor at St, Anthony Hospital in Oklahoma City are being sued by a woman who allegedly received HIV-infected blood in 1986. The suit Spiegel v. Fisher alleges that the plaintiff was infected from a transfusion received during heart surgery. As anticipated, the worst fears of the blood-banking industry are coming true. In 1987, the patient was notified during a lookback program. This knowledge enabled her to initiate the suit. In addition, this is the first case on record claiming that failure to use Intraoperative Autologous Transfusion (IAT) is a factor in litigation.

Some responsible institutions are performing lookback programs and coping responsibly with the consequences. The majority are not, leaving thousands of transfusion recipients and their sexual partners in the dark about their infections.

One woman had sex with her husband only five times after his transfusion, but she still became infected.

However, as a result of litigation, the neglect of sexual partners of transfusion recipients who are infected or at risk may soon come to an end.

A Denver jury recently ordered infectious disease specialist Donald Kerns, M.D., to pay Suzie Quintana $70,000 in damages "for failure to describe precautions Quintana could take to prevent exposing her husband to infection." (American Medical News, June 17, 1988.) She was a transfusion recipient.

Meanwhile, blood banks say hospitals should take the responsibility of notifying the sexual partners of transfusion recipients. Hospitals want physicians to do it. Physicians point to public health authorities. And some public health authorities oppose laws requiring contact tracing.

Therefore, you need to take it upon yourself to get tested if you have any doubt at all. The reason: should you be infected, time is of the essence in starting a program to protect your immune system and prevent the onset of AIDS-related symptoms-and you also want to protect your partner.

Recycling Your Own Blood (IAT)

The best way to avoid transfusionborne infection is simply to receive your own blood. Dr. Lester Sauvage, of the Hope International Heart Research Institution in Seattle, states emphatically that not using autologous blood (the patient's own blood) when using it is feasible could subject a physician to litigation.

That's why Intraoperative Autologous Transfusion (IAT) is recommended, It is a method of recycling your own blood during surgery. Blood lost during the operation, instead of being discarded, is processed through an automated machine, washed, filtered, and returned to the patient within three to five minutes.

This procedure can be used for all operations except those that involve malignancy, infection, or open bowel surgery. However, too often, banked blood is used when IAT would be better, Some blood bankers claim IAT is expensive and Labor intensive, but this is not true. It is costeffective if two or more units are needed and actually saves money if more than three units are transfused.

Because IAT machines are not available in all hospitals, businesses have sprung up to meet this need.

PSICOR, one of the IAT services expanding nationally, is currently available in many cities. If your hospital does not have IAT equipment, PSICOR supplies the equipment and the personnel to any hospital or doctor that requests it, 24 hours a day. PSICOR light-heartedly calls itself th"Federal Express of IAT."

Plasmapheresis

For procedures that involve massive blood loss, IAT may not eliminate all need for blood bank products. Heart surgery, for example, may require 40 to 50 units of blood.

Amazingly enough, IAT can keep recirculating blood until it has recycled that many units. However, in the process, you lose platelets and clotting factors essential for stopping the bleeding after surgery.

As a result, at the end of surgery, your doctor might order a "six pack" of platelets from the blood bank. But there is a way to avoid even this small amount of foreign blood product: another machine can draw off some of your own platelet-rich plasma just before surgery begins while you are undergoing anesthesia. This plateletrich plasma, full of fresh clotting factors, is saved until the end of the operation. During surgery, IAT is used. When the surgeon is closing, he gives you back your own plasma. You begin clotting and the bleeding dries up nicely.

"It's cost-effective because the patients are at a lower risk for getting AIDS and other blood-borne infections, and because they won't stay in the hospital as long and will be generally healthier because they used their own blood," says Bob Garvie, vice president of Haemonetics Corporation, which manufactures plasmapheresis equipment as well as the Cell Saver, an IAT device. Most 'insurance companies cover both IAT and plasmapheresis.

Pre-donation: Banking Your Own Blood

Wayne Tombaugh sued Irwin Memorial Blood Bank and Kaiser Permanente Medical Center in San Francisco after he got AIDS through a transfusion. Tombaugh, a member of the San Francisco Chamber of Commerce, was well aware of AIDS. Months before August 1984, when he was to have surgery for an aneurism, he volunteered to pre-donate his own blood. However, the doctors assured him that blood transfusions would not be necessary. Blood was used, and unfortunately it was infected with the AIDS virus. Tombaugh learned that he had AIDS in December 1986 and filed a lawsuit immediately, Even though he was put on a respirator and could not speak, his daughter recalls his anger. "He clenched his fist and shook it like he was saying, 'Get the --.'"

If he had insisted on predonating, in spite of his doctor's reassurances, and requested IAT and plasmapheresis, he might be alive and healthy today.

There is no truer statement than "Your own blood is the best blood." Several private enterprises have sprung up to meet the surging demand for banking one's own blood.

In San Diego, for example, Merus Personal Blood Banks has just begun a new service that enables people to pre-donate blood at their homes or offices. A registered nurse makes the personal calls with a portable bloodcollection unit so the patient isn't inconvenienced by trips to the blood bank. This service will be expanded nationwide by early 1989.

Just as ambitious in the convenience race is a program set up by Idant Division of the Daxor Corporation, of New York, the firm that boasts of opening the first autologous blood center in the United States. Pre-donated blood is stored frozen at a facility at Federal Express' Memphis, Tennessee, hub and shipped anywhere in the country in an average of six hours.

Idant has refined the blood-thawing process so that it takes only 45 minutes, according to Dr. Joseph Feldschuh, Daxor president.

Feldschuh, who launched the program because his own father died of complications resulting from infected blood, said a recent incident shows how valuable such a service could be:

The daughter of a vice president of a large corporation was injured in an automobile accident in Maryland. Although the father had not yet taken advantage of Idant's local pre-donation services for his own family, he had paid for his secretary to do so. The daughter had lost half the blood in her body, and doctors eventually made the decision to give her a transfusion. Before they did, however, the father checked his secretary's blood type and got permission to use her blood. "We gave the blood to a motorized courier, it was put on a shuttle flight to Washington, picked up by another courier, and taken to the hospital. That blood was out our door and in the patient's arm in three hours," Feldschuh says. Frozen blood units can be stored indefinitely, according to Feldschuh.

Directed Donations

Choosing your donor is an alternative to traditional banked blood if you have exhausted the possibility of using your own blood.

The blood-banking industry claims directed donations are not any better than banked blood. Although it is true that directed donations fail to offer the disease barrier provided by autologous transfusion, there can be advantages. For those who have spouses with the same blood type, using their blood is not much riskier than having sex with them.

On the Horizon

The promising new field of genetic engineering will soon have an impact that wasn't possible only a few years ago. Ortho Pharmaceutical is marketing in Europe and seeking U.S. approval for human recombinant erythropoietin, which accelerates the production of new blood cells.

Erythropoietin will be especially useful for those who want to pre-donate their own blood, but whose operations have fairly heavy transfusion requirements. Injected with erythropoietin, patients will be able to donate about twice the normal amount of blood in the weeks prior tosurgery.

Erythropoetin will also be valuable for surgical patients who are discharged slightly anemic because of the growing practice of avoiding transfusions whenever possible. The drug will get the patient's blood back to normal much more quickly.

"This is a breakthrough drug, an advance we feel is as important as the development of human insulin," says Dr. Kenneth Krantz, Ortho's clinical research director. "It's a replication of a naturally occurring hormone produced by the kidney, and it has minimal side effects."

Krantz adds, "For about the same cost as receiving homologous transfusions, you can take erythropoietin and make your own blood."

It is not only AIDS that justifies all this attention to the transfusion issue. In an estimated 10 percent of transfusions, some form of hepatitis is transmitted. One study even links a higher cancer recurrence rate to whole blood transfusions (Anaesthesiology News, October 1988). HTLV I is another infection transmissible by transfusion, and there will probably be new bloodborne viruses discovered in the future.

These are powerful incentives for improving the safety of donor blood -and avoiding transfusion by using the newest medical technology.

Summary of Resources

Intraoperative Autologous Transfusion (IAT)-IAT is a process in which a machine recycles your own blood during surgery, enabling you to avoid transfusions in most cases. It can be used for emergency as well as elective procedures.

Plasmapheresis-Plasmapheresis harvests platelets from your bloodstream just before surgery so that they can be returned to your body after the operation to give you the necessary clotting factors to stop bleeding. Used with IAT, it completely eliminates the need for donor transfusion in most cases.

Pre-donation-Pre-donating your blood before elective surgery is a good idea and should be done whenever possible, even when your doctor doesn't expect much blood loss. Approximately four units can be stored during the month preceding surgery.

Directed donationsChoosing your donor is an alternative to traditional banked blood if you have exhausted the possibility of using your own blood.

* If you have had surgery during the last ten years, ask your doctor if you received any transfusions or blood products. If you did, get tested for HIV and advise your sexual partners to get tested too.

* If you are going to have surgery, discuss transfusions and alternatives with your doctor in advance. Ask if the type of surgery you are about to have might require blood. If not, consider donating a pint or two for good measure, just in case of unexpected complications. If you don't need it, you have contributed to the general blood supply. Just be sure to let the blood bank know in advance that this is your intention, or they may discard your unused blood. If blood loss is common with the procedure-in bypass surgery, for example-predonate as much blood as possible.

* Always ask for Intraoperative Autologous Transfusion (IAT)-a process in which your own blood is recycled during surgery-if your operation qualifies. Plan for plasmapheresis if necessary (if your doctor thinks you might need platelets or additional clotting factors).

* Ask your physician to schedule your surgery at a hospital equipped for IAT and plasmapheresis during surgery.

* If the equipment is not available in any accessible hospitals, inquire about services provided by such companies as PSICOR and some branches of the Red Cross, which deliver and staff the equipment from outside.

* Consider freezing a supply of your own blood with one of the services that offer rapid national delivery, such as Idant.

* If IAT and plasmapheresis are not enough and you need additional blood, insist on local blood or blood from a low-risk area. Origin of blood (the lab where the blood was drawn) is printed on the label of the container. If you need several units, request they come from a single donor rather than different donors, to further reduce your risk.

* When choosing a surgeon or anticipating an operation from a family doctor, ask your physician how many transfusions he or she has given during the last one to two years. Don't hesitate to investigate. This is your life!

* When consulting with your physician, keep informed of advances in medical technology that you may be able to take advantage of when anticipating surgery.
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Author:Crenshaw, Theresa L.
Publication:Saturday Evening Post
Date:Mar 1, 1989
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