Comparative Analysis of Two Published Qualitative Research Papers on the Benefits of Autologous Blood Transfusion

Comparative Analysis of Two Published Qualitative Research Papers on the Benefits of Autologous Blood Transfusion in Elective Total Hip Replacement

Introduction
Autologous blood transfusion refers to the transfusion of blood which has been donated by the selfsame patient. Autologous transfusion is indicated for elective surgeries where ‘type and screen’ is not used, for members of religious sects which forbid use of blood products, and for individuals who have exceptionally rare blood groups or unusual antibodies and for whom compatible blood cannot be easily found (Adias et al, 2006).

Autologous transfusion can be carried out in three ways and these include perioperative cell salvage (PCS), autologous normovolaemic haemodilution (ANH) and predeposit autologous donation (PAD). In PCS, blood that has been lost either preoperatively or post operatively is collected and infused back into the patient. PAD involves the preoperative withdrawal of blood from the patient about a month before the surgery is conducted. The blood is withdrawn several times and stored for the upcoming surgical procedure. Finally, ANH is carried out preoperatively in the operating or anesthetic rooms for patients who are considered at risk of losing a lot of blood. ANH involves the removal of 1 to 1.5 liters of whole blood and replacement of this blood with colloid or crystalloid. The withdrawn blood is then replaced once the loss of blood is contained (Ozgönenel et al, 2007; Adias et al, 2006).

On the other hand, allogeneic blood transfer is more pervasive and involves the transfusion of blood which has been donated by a person other than the patient

Increasingly, more and more procedures are being conducted using autologous rather than homologous blood transfusion. Reports indicate that the avoidance rate of homologous blood transfusion now exceeds 90 percent (Yamamoto et al, 2004).

Total hip replacement is a procedure that involves the potential loss of a lot of blood and the choice of the transfusion method to be used is of critical importance (Pierson, Hernon & Farles, 2004). Whereas there are many documented studies which deal with the benefits of autologous blood transfixion, few recent studies address the benefits of autologous blood transfusion in elective total hip replacement (THR).

This review compares two qualitative research articles on the benefits of autologous blood transfusion in elective total hip replacement. The first paper is titled ‘Feasibility of pre-operative autologous blood donation in Indian patients with elective orthopedic surgery’. This paper was written Saluja et al and was published in the Indian Journal of Medical Research in November 2006. The other paper is titled ‘Autologous Blood Transfusion in Total Hip Arthroplasty’, was written by Yamamoto, Imakiire, Masaoka and Shinmura and was published in the Journal of orthopedic Surgery in 2004.

Feasibility of Pre-operative Autologous Blood Donation in Indian Patients with Elective Orthopedic Surgery by Saluja et al (2006)
This paper is based on a 15 month study carried out in India. The study sought to determine the feasibility of pre-operative autologous blood donation in Indian patients undergoing elective orthopedic surgery. The target population consisted of 144 individuals and stringent inclusion and exclusion criteria were applied in order to ensure that persons enrolled in the study were ideal in helping the researcher obtain the ultimate aim. The nature of this study was a prospective case-control study (Saluja et al, 2004).

In this study, the inclusion criteria included patients’ readiness to take part in the study, baseline hemoglobin levels exceeding 11g/dl or haematocrit volume greater than 34 percent, and attainment of the usual blood screening criteria. Patients who had diabetes mellitus that was managed using oral hypoglycemics and those with hypertension managed by a single drug were also eligible for the study. Exclusion criteria included type 1 diabetes, chronic liver or kidney conditions, acute heart disease, infections, and history of myocardial infarction and angina. In addition, individuals with uncontrolled high blood pressure as well as those with stenosis of the aorta were not eligible for participation (Saluja et al, 2004).

The sample size of the study consisted of 49 patients. The 49 patients were divided into 2 groups – the case group and the control group. The case group comprised of 22 subjects. This group was transfused preoperatively with autologous blood. On the other hand, the control group was made up of 27 subjects. This group was similar to the case-control group with respect to the sex, age, hemoglobin level and eligibility for preoperative blood donation. The only difference was that patients in this group had no desire to take part in the study (Saluja et al, 2004).

All patients were placed under iron therapy pre and post operatively. In the period before the operation, blood was withdrawn from the patients following the procedure of Morse. The withdrawn blood was processed according to standard practices, subjected to the usual compulsory tests and infected blood disposed of. Triplicate copies of the patient ID were glued on the requisition form, the file of the patient and on the autologous units. Besides, different issue forms were allotted for allogeneic and autologous units and the former issued after the autologous units had been given out. These steps were taken to ensure that mistakes did not occur (Saluja et al, 2004).

            The researchers made a number of important observations pertaining to the benefits of autologous donation of blood. First, they found out that blood wastage in the case group was significantly lower when compared to wastage in the control group. In this respect, a mean volume of 733 ml was lost in the case group compared to a mean loss of 827 ml seen in the control group. The second benefit of autologous donation during THR was that the procedure lowers the length of hospital stays. Patients in the case group stayed in the hospital for an average of 32 days compared to the 40 days spent in the hospital by patients in the control group. Thirdly, autologous donation during THR leads to a significant decrease in the exposure to allogeneic blood. Fourth, no transfusion reactions were observed in members of the case group. This contrasted with the 4 patients in the control group who were seen to develop allergic and febrile non-hemolytic transfusion reactions (Saluja et al, 2004).

In conclusion it is noted that elective total hip replacement is associated with a number of benefits including reduced wastage of blood, reduced length of hospital stays and therefore lower costs and decreased exposure to allogeneic blood. These benefits are especially evident in settings where there is a detailed plan for preoperative autologous donation in place (Saluja et al, 2004).

Autologous Blood Transfusion in total Hip Arthroplasty by Yamamoto, Imakiire, Masaoka and Shinmura (2004)
This research article is based on a study conducted by Yamamoto, Imakiire, Masaoka and Shinmura (2004). The ten year study was carried out at Tokyo Medical University’s Department of Orthopedic Surgery and sought to ascertain whether it is possible to avoid using homologous blood transfusion during total hip replacement as well as to elucidate the benefits and disadvantages of autologous blood transfusion.

Subjects – the total number of subjects in the study was 253 patients. Out of this, 56 were male and 197 were female with an average age of 60.3 years (Yamamoto et al, 2004).

Unlike the study carried out by Saluja et al (2006), this particular investigation was a retrospective study. Even though this study was largely quantitative, the authors also employed qualitative techniques and give a detailed description of their experiences with autologous donation during THR. Like Saluja et al (2006), Yamamoto et al (2004) found out that preoperative autologous donation increased avoidance to allogeneic blood transfusion. The study demonstrated an overall avoidance rate of 72 percent. However, this rate was seen to vary widely depending on the underlying disease condition, age and sex of the patient, year of surgery and the type of surgical procedure one was being subjected to. The highest avoidance rate was 95 percent and this was witnessed in those patents who underwent a mixture of blood pooling and intra-operative recovery system. These findings are consistent with outcomes obtained by other researchers (Yamamoto et al, 2004).

Discussion
Despite the benefits associated with autologous donation during THR, Yamamoto et al (2006) mention a number of disadvantages associated with the procedure. These include the risk for preoperative anemia and the risk of infection by atmospheric bacteria. Even so, the authors do not report of a single case of bacterial infection in their institution during THR and discount the possibility of this happening if correct procedures are followed. Similarly, Saluja et al, (2006) report that autologous transfusion of blood is safer than allogeneic blood transfusion. As they report, the latter method is encumbered by a higher risk of transfusion transmitted infections (TTIs) especially in the developing countries.

Other researchers have also extensively discussed the risk of TTIs posed by allogeneic blood transfusion. Marcucci, Madjdpour and Spahn (2004) assert that less than 60 percent of blood transfused to patients in developing countries is screened for TTIs. Among the TTIs listed include viral diseases such as hepatitis C virus, HIV and hepatitis B virus HBV; parasitic and bacterial infections and prion infections such as Creutzfeldt-Jakob disease (vCJD). In more advanced nations however, the risk for TTIs is not a big issue. According to Saluja (2006 p. 506), only 1 in 900,000 patients transfused with allogeneic blood stands at the risk of contracting HIV in the developed countries. One out of every 1.6 million are at risk of getting HCV while 1 out of every 63,000 patients transfused with allogeneic blood is at risk of contracting HBV. Since these risks are virtually non-existent with the autologous donation, the latter method is deemed to be safer and therefore more beneficial.

Yamamoto et al (2004) also corroborate findings by earlier researchers (Etchason et al, 1995; Popovsky, 1994; Rutherford & Kaplan, 1995) that the preoperative donation of autologous blood during THR is very expensive. This occurs because of the large amounts of pooled blood which end up being disposed of. Further to this, it is important to note that large amounts of blood are disposed of principally because the intra-operative bleeding volume is often overstated. When a lot of the blood is disposed of, it reduces the cost benefit to safety ratio. Another reason behind the disposal of large amounts of blood has to do with poor patient selection. Besides the cost benefit aspects, wastage of blood is another recurrent theme here and this is also reported by Saluja et al (2006). In their study, Saluja et al (2006 p.510) report that, in general, the overall wastage rate was 32.3 percent but cite instances where the wastage went up to 50 percent.

However, Saluja et al (2006) imply that autologous donation during THR is inherently cheaper especially in instances where the patients are enrolled in a predonation plan. This is a finding that resonates well with Adias et al (2006 p.115). In a review of autologous blood transfusion during THR, Adias et al (2006 p.115) compares the direct costs associated with the three different types of autologous transfusion versus the direct costs associated with allogeneic blood transfusion. According to their article, the cost per unit of allogeneic blood transfusion is $32.99. In contrast, the cost per unit for PAD, ANH and PCS is markedly lower at $ 9.83, $ 9.12 and $ 14.73.

In a review of studies comparing autologous transfusion to allogeneic transfusion, Adias et al, 2006 p.116 reports that majority of the studies found better prognostic outcomes for patients undergoing autologous blood transfusion than for patients undergoing allogeneic transfusion. Besides reducing the risk for contracting TTIs, autologous blood transfusion has also many other benefits. It is safer than allogeneic transfusion, does not require cross-matching and is not affected by the risk of isoimmunization due to foreign material (Martinez et al, 2007; Adias et al, 2006).

Different investigators have also determined the benefits offered by the different types of autologous blood transfusion. PAD lowers exposure to allogeneic blood and is devoid of the many drawbacks associated with allogeneic transfusion. Additionally, PAD also decreases the risk for thromboembolism, enhances the flow of blood in the small vessels and into tissues since the procedure is accompanied by a lower viscosity and haematocrit (Gonzalez-Porras et al, 2009). According to Adias et al (2006) however, there is a lot of wastage in PAD and patients are exposed a lot to transfusion. This particular finding ties in well with the outcomes obtained by Saluja et al (2006) and Yamammoto et al (2004).

Whereas Saluja et al (2006) and Yamamoto et al (2004) did not determine the specific benefits attributable to ANH with regard to THR, some researchers such as Adias et al, (2006 p.115) report that ANH can possibly endanger those patients who are at risk of myocardial infarction.  According to Yamammoto et al (2004), a combination of PAD and PCS is associated with more favorable prognostic outcomes, a case in point being the reduced exposure to allogeneic transfusion seen when this combination is employed. Even so, PCS has been implicated in multi-organ failure and coagulopathy. PSC has also been associated with several pathologies affecting the coagulation of blood. These pathologies include thrombocytopenia, high concentration of degraded fibrin products, hypofibrinogenaemia and longer partial thromboplastin and prothrombin times (Adias et al, 2006 p. 116).

As mentioned earlier, Yamamoto et al (2004) listed several drawbacks associated with autologous blood transfusion within the context of elective orthopedic surgery. Both studies by Adias et al (2006) and Yamamoto et al, (2004) do not find autologous blood transfusion to have severe effects on anemic patients. .Even so, Martinez et al, (2007) opine that autologous blood transfusion may be injurious to patients with anemia. As they assert such patients should be transfused with erythropoietin EPO instead of being subjected to autologous blood transfusion. Also, Martinez et al (2007) avers that postoperative blood salvage may be a more useful technique than autologous transfusion and need to be used more often in THR.

The beneficial effects of autologous blood transfusion are also affected by some negative effects associated with the procedure including inconvenience of the procedure (Chun, Martin and Loper cited in Feagan et al 2004) and wastefulness. Autologous blood transfusion has also been implicated in the occurrence of phlebotomy-induced anemia and it is still not very clear on when non-anemic patients can predonate. (Adias et al, 2006; Billotte et al, 2002; Martinez et al, 2006; Yamamoto et al, 2004). According to Couvret (2004) and Martinez et al (2007) autologous blood transfusion is also expensive. Besides, it leads to a higher exposure to transfusion and may be associated with the risk of bacterial infections and clerical error. According to Martinez et al 2007, these risks far exceed the risk of TTIs posed by allogeneic transfusion. According to Adias et al, 2006, these 2 are the greatest impediments affecting the use of autologous blood. These drawbacks need to be weighed against the potential benefits and the possible outcomes offered by other transfusion methods.

While drawing attention to the benefits of autologous blood transfusion in THR, both Saluja et al (2006) and Yamamoto (2004) are agreed that allogeneic transfusion is far less beneficial a method than autologous blood transfusion. They concur that allogeneic blood transfusion cannot be carried out on many people the world over because the supply of donor blood is limited. This is a position that is well documented by other researchers.

According to Marcucci, Madjdpour and Spahn (2004) more than 80 percent of the world’s population is found in the developing nations. These developing nations have access to just 40 percent of the world’s blood supply and only 20 percent of safe blood (Saluja et al, 2006). Besides, this method of blood transfusion is fraught with immunological risks as it places patients at the risk of developing immunological complications. The immunological risks faced by patients undergoing allogeneic transfusion include the risk of hemolytic transfusion reactions. The method is also more costly compared to autologous blood transfusion.

According to Young et al (2004), another drawback associated with allogeneic transfusion is autoimmunization. Marcucci, Madjdpour and Spahn (2004) argue that allogeneic transfer places the recipients of the blood under the risk of immunosuppression and may also enhance the possibility of cancer recurrence. Yet another risk associated with allogeneic transfusion is that of acute lung injury (Goodnough, 2003). Corwin et al (2004) determined that patients subjected to allogeneic blood transfusion have higher morbidity and are more traumatized compared with patients undergoing autologous transfusion. Multiorgan failure and transient hypotension are some of the other risks which patients undergoing allogeneic transfusion have to face (Adias et al, 2006). Finally, allogeneic blood transfusion also predisposes patients to the risk of mistransfusion. As Marcucci, Madjdpour and Spahn (2004) declare, this occurs at the rate of 1 person in every 14, 000 when the procedure is used. Since autologous blood transfusion is largely free from the drawbacks associated with allogeneic blood transfusion, then its benefits are quite evident.

Both research articles, though exhaustive in their analysis of the particular research questions, were not concerned with a detailed description of the benefits associated with autologous blood transfusion in THR. Even so, the benefits associated with the procedure were apparent with the interpretation of the results. Both studies were not randomized and hence the representative ness of the selected subjects can be called into question. Whereas Saluja et al (2006) ensured that the validity of their study by ensuring triplicate copies of patient ID were stuck on different places, it is not clear if the study by Yamamoto et al (2004) had measures of validity.

Conclusion
This paper evaluated two research articles on the benefits of autologous blood transfusion in total hip replacement. The first article was written by Saluja et al (2006) while the second article was written by Yamamoto et al (2004). Both articles concur that the procedure is associated with a reduced exposure to allogeneic transfusion, lower risk of TTIs and reduced cost. They also find autologous transfusion to be safer. Even so, findings by Saluja et al (2006) suggest that the procedure is of more benefit if patients are enrolled in a detailed preoperative plan. Both articles concur also that the procedure is fraught with a lot of wastage. Yamamoto et al (2006) mentions a number of disadvantages associated with the procedure. These include the risk for preoperative anemia and the risk of infection by atmospheric bacteria..

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