Autologous Transfusion - From Euphoria to Reason: Clinical Practice Based on Scientific Knowledge - Part I

Autologous transfusion has been claimed by supreme court sentence [1], and wanted by governmental health care officials [2]. Therefore, and before the background of an increasing limitation or even shortage in resources made available for health care, it is important to critically analyse, discuss and outweigh benefits and risks of autologous and allogeneic blood transfusion under different kinds of views:

The clinical impact of an immuno-modulation mediated by allogeneic blood transfusion is still open. In-line leucocyte filtration results in an improvement of the resulting blood product, and enables routine administration of autologous whole blood of high quality associated with an increase in storage time. The clinical relevance of activation of leucocytes by blood salvage and mechanical processing is not completely resolved and understood yet. Though mechanical processing of peri-operatively salvaged wound blood is routinely administered, its basic physical principles are not well known among users. The quality of autologous packed RBC obtained by mechanical processing of peri-operative blood-salvage is decisively influenced both by variation of the processing parameters and the “initial” reservoir haematocrit of the salvaged wound-/drainage blood. In patients with tumor surgery, the safety of the peri-operatively salvaged and mechanically processed blood with succeeding irradiation of the final blood product is still discussed controversially concerning both legal aspects and benefit for the patients. There is still a controversial discussion of, or even open questions on application of blood salvage and mechanical processing in special types of surgery or co-existing diseases. Clinical data in critically ill intensive care patients suggest that even in these patients the so-called “transfusion trigger” can be handled more variable and individually more differentiated than so far accustomed to. Therefore, knowledge of the compensatory mechanism is manadatory if tolerating peri-operative anaemia. What are the rational medical reasons for either a different or an identical “transfusion trigger” in allogeneic versus autologous blood transfusion? Lowering the “transfusion trigger” for red blood cells is associated with a decline of platelets and coagulation proteins, too, and causing the potential risk of dilution coagulopathy. Are coagulation-linked parameters the limiting point of acute normovolaemic heaemodilution? Pre- or peri-operatively applied drugs are administered to reduce the need for allogeneic blood supply. How effective and safe are they? BSE, nvCJD still represent “white spots” concerning safety of allogeneic blood transfusion. Haemoglobin-based oxygen carriers are (still/again) critically evaluated, and are still away from routine clinical administration. Considering the potential risk of an increased rate of postoperative bacterial infections associated with allogeneic blood transfusion urges a new economic balance of pre-operative autologous blood donation versus allogeneic blood supply by means of cost-effectiveness analysis.

This second international/interdisciplinary symposium on “Autologous Transfusion - From Euphoria to Reason: Clinical Practice Based on Scientific Knowledge” that was held in Nottwil, Switzerland on January 18 - 19, 2002 critically discussed the above named topics with respect to the actual scientific data and resulting “current clinical state of practice”. This meeting was not only for giving answers to open questions, but also to provoke new questions on “old topics”, and critically re-consider so-called established clinical routine practice.

By doing so, clinical application of autologous transfusion measures will consistently be based on science and continuously adopted to new scientific knowledge. This kind of patients' care is not only beneficial to the individual patient, and thus medically reasonable, but it is also economically rational while still ethical. “For many physicians it is difficult to comprehend that medical and economical ethics belong together. Only what we save today, can we spend for investments tomorrow, that will cause benefit in the future” (translated from German into English according to [3]). According to v. d. Schulenburg [4] “economical acts and thoughts are ethical acts when resulting in careful spending and less wastage of limited resources. It is only during times of shortages that true ethics become obvious” (translated from German into English according to [4]).

By the agreement of the editors of the below named scientific journals it is possible to publish the lectures presented on this international/interdisciplinary symposium both in German in “Anästhesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie” (Thieme Co., Stuttgart), and English in “Infusion Therapy and Transfusion Medicine” (Karger Co., Basel). The topic of autologous transfusion covers the interest both of anaesthesiologists and transfusion specialists. Therefore, this kind of publication in two different languages and journals was chosen by the guest-editors, in order to enable the presentation of the papers to the broad audience of two different medical specialities. As the articles appear in two different languages, they are not considered a “double-publication” on the corresponding topic. The organisers/guest-editors are very grateful both to the editors of these scientific journals for the opportunity to present the papers of this symposium and to the authors for their appreciated co-operation and contributions.

References

• 1 Bundesgerichtshof .BGH-Urteil vom 17. 12. 1991 - AZ: VI ZR 40/91. 
• 2 von Auer F. Autologous Transfusion - Pros and Cons from the Health Policy Perspective.  Infus Ther Transfus Med. 2002;  29 in press
• 3 von Eiff W. Sparen im Krankenhaus.  In: Westfälische Nachrichten, Münster 21.01.2000
• 4 von der Schulenburg J-M. Vorwort.  In: Ökonomie in der Medizin. Schulenburg v d JM (Hrsg). Stuttgart. ; Schattauer 1996

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