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Challenging the traditional transfusion; knowing the alternatives can save lives while providing peace of mind for patients facing high-blood-loss procedures.

A precedent-setting lawsuit recently awarded $3.9 million to a blood-transfusion AIDS victim. The judgment against the Blood Center of Southeastern Wisconsin will have a major impact on the blood-bank industry as a whole.

John Carroll, a 63-year-old man from Brookfield, Wisconsin, told a jury that he expected to die of AIDS within a year.

He received infected blood products through transfusion during heart surgery in April of 1985. The blood he received had not been screened or recalled after screening became required in March of 85.

The blood bank conformed to the letter of the law by testing new donor blood but didn't test its inventory, which it continued to distribute for transfusion. The infected blood donor had given blood repeatedly, once in March and again in November. Mr. Carroll and his wife did not learn of his infection until nine months after the operation. By that time his wife could have become infected too.

This expensive lesson-in money for the blood bank, and in loss of life for the Carrolls-sends a message to all blood bankers that carelessness, insensitivity, and delays will not be tolerated by the courts, or the people. It also highlights the need for more legislation to protect patients from unnecessary transfusions.

The blood-supply system within the United States and the international exchange of blood and blood products have been seriously challenged by the HIV (AIDS) epidemic. Many experts feel the blood industry was slow to respond to the HIV crisis. The Presidential Commission on the HIV Epidemic states in its final report, "The initial response of the nation's blood banking industry to the possibility of contamination of the nation's blood by a new infectious agent was unnecessarily slow."

Even if the blood industry had responded with lightning speed, it would still have been five or ten years too late. When a virus, such as HIV, takes an average of seven to nine years before symptoms appear, the medical community is not even aware of the disease in our presence until it has been traveling through blood for almost a decade. And when the problem finally becomes evident, the response is often delayed.

A recent example is HTLV-1, a cancer virus transmissible through transfusion. The process of getting HTLV-1 tests approved and in use at the blood banks took several years.

Last June the Presidential AIDS Commission recommended that all blood banking facilities should implement screening procedures for HTLV-1."

It is fair to say that HIV and its relatives will not be the last blood-borne viruses to challenge the health of the human species. With this knowledge in mind, we must develop a national blood strategy that fulfills three criteria:

1. minimizes the use of banked blood (homologous blood);

2. maximizes the use of a person's own blood (autologous blood);

3. improves our rapid-response capability when new blood-borne diseases are identified.

Mr. Carroll received blood products-clotting factors--from infected donor blood that could probably have been avoided altogether if a technique called plasmapheresis had been used. In this way he would not have had to depend on the conscientiousness of the blood bank or the quality of its blood products.

Plasmapheresis is a simple procedure performed in the operating room just before surgery begins. Some plasma-rich in platelets and other clotting factors-is withdrawn from a patient's own bloodstream by a special machine and is saved for later. During the operation, another machine is used to recycle the patient's own blood during surgery. Even if a great deal of blood is lost, it can be recycled, but often platelets and necessary clotting factors are washed away in the process. When the surgeon is ready to close, he need not use a "six pack" of someone else's platelets. Instead, he returns the patient's own platelet-rich plasma that was standing by during the operation. This way no foreign blood or blood product is necessary.

Knowledge of these alternatives to traditional transfusions can save lives while providing peace of mind for those facing heart surgery or other high-blood-loss procedures. These resources also provide comfort to the relatives and friends of older patients who need an operation.

However, it isn't only aging patients or accident victims who are vulnerable to transfusion-related AIDS.

A 22-year-old woman from Ventura, California, might be a healthy, happy mother today if she had known the right questions to ask her doctor a few years back. At 17, suffering from heavy menstrual bleeding, she went to her physician, who performed a dilation and curettage. Because she was slightly anemic from blood loss, she received two units of blood. At 19 and pregnant, the woman learned she was infected with the AIDS virus. She has since given birth. However, because it takes more than a year before the HIV test is reliable for newborns, the medical status of her baby is unknown. Now she is in the early stages of AIDS-related complex.

In 1989, such a patient would probably not have been transfused at all, because medical science is in transition from using transfusions liberally to minimizing their use. Yet unnecessary transfusions are still commonplace, and many physicians continue practicing the old way. This teenager had a common adolescent problem. She could have been anyone's young daughter.

Babies, children, and pregnant women are especially vulnerable to transfusion-related infections because they often can't predonate. Babies and children are usually too small. Pregnant women are frequently too anemic. Unless other methods of autologous blood use become routine, they will be forced to depend on homologous blood products.

Approximately 2 million unnecessary transfusions are given each year, to patients who receive two units of blood or less. They could have survived without receiving any blood at all. However, an important few will not survive because they received an infected transfusion.

To ensure that physicians discuss transfusions with patients before surgery, the Presidential Commission on the HIV Epidemic recommends: Informed consent for transfusion of blood or its components should include an explanation of the risks involved, including the possibility of HIV infection, and information about appropriate alternatives to homologous blood transfusion therapy.

"These specifically include pre-deposit autologous blood [your own blood], intraoperative autologous transfusion-known as IAT [recycling your own blood during surgery]hemodilution techniques, and postoperative collection, " the recommendation reads.

Dr. Thomas Zuck, a professor of transfusion medicine and the director of the Hoxworth Blood Center, University of Cincinnati Medical Center, said the best strategy for reducing the risk of HIV infection through blood transfusions is "Don't give any transfusions that aren't absolutely necessary." In fact, 50 percent of the transfusions of banked blood can probably be avoided with proper techniques. One orthopedic surgeon in San Diego has not given banked blood for more than two years.

There are many reasons why banked blood should be avoided whenever possible. * The Food and Drug Administration, which regulates the blood-bank industry, recently uncovered safety problems in 12 percent of the nation's blood centers and hospitals. More than 190 of the 1,543 blood banks have violated regulations for handling blood. * Due to clerical error, the Red Cross Blood Bank in Nashville distributed 16 units of blood potentially infected with the AIDS virus. In addition, laboratory test records for at least 8,735 pints of blood drawn during March 1986 were "missing, lost or otherwise unavailable for inspection." (Nashville Banner, April 5, 1988.) * The Red Cross Blood Bank in Washington, D.C., recently had a similar mixup. Eighteen units of AIDS-infected blood were distributed for transfusion. (Washington News Observer [AP], March 19, 1988.) * A Denver blood bank, failing to follow standard procedure, distributed 22 units of blood that initially tested positive for the AIDS virus and hepatitis. (San Diego Union, September 1988.) * Blood shortages pressure blood banks to get more blood. Under pressure to collect more and more blood, blood banks may be more likely to accept borderline donors. The same principle applies to interpreting test results, which often depends on a subjective assessment. Questionable results might be read as negative.

One of the most important questions you can ask yourself today is: If I were to undergo surgery tomorrow, how much trust would I place in the blood transfused into my veins? Not nearly as much as you once would have, if you've been following reports that reveal the true risk of developing the HIV infection through blood transfusions.

Although testing of the blood supply provides an important measure of protection, there is a window period during which infected blood can slip through undetected. This period is of special significance when you learn that last year there were ads in Gay Scene magazine soliciting for New York City blood donors, or that the Irwin Memorial Blood Bank in San Francisco held blood drives in the Castro district-the heart of the gay community.

Even if you live in a low-risk area, the blood you receive may not be safe. Why? The National Blood Exchange, situated in the Irwin Memorial Blood Bank building in San Francisco, exports blood to all parts of the United States.

This exchange tracks blood surpluses and shortages to keep blood circulating throughout the nation. "Blood migration" is a common practice that patients and even some doctors don't know about.

The blood-banking industry claims that in spite of the window" problem in testing, the blood supply is safe because its first line of defense is "donor deferral," which means that high-risk individuals are discouraged from donating blood. Blood banks use questionnaires and depend upon the truthfulness of donors.

However, even the most truthful person does not usually know the sexual patterns of all former partners. In fact, just a few years ago it was considered bad sexual etiquette to discuss former relationships. Obviously, the reliability of the donor-deferral program "the first line of defense"-is brought into question by blood drives in homosexual communities and ads in gay magazines.

There is good news to report, however. Several excellent programs can serve as role models for the rest of the nation: * Dr. Charles Huggins, the director of blood transfusion services at Massachusetts General Hospital, checks the surgical schedule daily and assigns IAT transfusion to surgeries that can use it. * Dr. Gerald Giordano, the director of the Southern Arizona Regional Red Cross Blood Program, has pioneered a model program using IAT within the blood-banking industry. Relieving hospitals of the need to buy their own equipment, he supplies both the machines and the trained staff on a 24-hour basis. He has demonstrated that not only is it possible, but it can be economically viable for the Red Cross. * Dr. Lester Sauvage of the Hope Heart Institute in Seattle, Washington, uses IAT and plasmapheresis (withdrawal of blood and return of selected components) routinely for cardiothoracic surgery. Recently, Dr. Sauvage performed a triple bypass with aortic valve surgery on a 52year-old man. He required no banked blood. Plasmapheresis and IAT were more than adequate, and the patient is well today with no fear of AIDS. For Dr. Sauvage, this case is the general rule rather than the exception, and it previews a new standard of medicine. * Dr. Ronald Gilcher, the director of the Sylvan N. Goldman Center in Oklahoma City, recognized the threat from blood migration. He took a state that regularly imported blood from elsewhere and intensified local blood drives. Now he has a surplus in Oklahoma, and he can export low-risk blood to places that need it.

National Blood Safety Plan

In the age of AIDS, there are few readily available solutions. A rare exception to a less-than-optimistic picture is the prevention of transfusion-related

HIV infection.

If blood banks would stop holding drives in high-risk neighborhoods, and would prevent advertising in gay magazines, the blood supply could become almost as safe as some now claim it is.

If, instead of distributing high-risk blood throughout the nation, blood drives were intensified in low-risk areas, excesses could be shipped to high-risk areas.

If, instead of competing with intraoperative autologous transfusion services, the blood-bank industry promoted IAT enthusiastically, it could solve the problem of blood shortages.

If the blood bankers took advantage of all forms of autologous transfusion, including IAT and plasmapheresis, blood banks could be more selective in choosing donors. Banked blood would be safer.

Until there is a national blood strategy making these resources available to everyone, patients should take advantage of them, because they are available today.
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Author:Crenshaw, Theresa L.
Publication:Saturday Evening Post
Date:Apr 1, 1989
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