The use of allogeneic blood in elective surgery is decreasing,
in part because of a diminished sensitivity of physicians to transfusion
triggers such as hemoglobin count, because of the need for cost
containment in those centers in which the use of allogeneic blood
represents a patient or hospital cost, and, finally, because of the
reluctance of patients to accept banked blood when alternatives
are available.
Autologous blood programs can provide part of the needed blood supply,
but patients may be ineligible for self-donation, facilities for
self-donation and storage may not be available, and clerical error
at any time between the point of collection and readministration
of autologous blood may lead to errors in transfusion.
The use of erythropoietin (epoetin alfa) to enhance preoperative red
blood-cell volume has proven to be an effective strategy1. The purpose
of this study by Feagan and colleagues was to determine whether
a modified dose of epoetin alfa would be effective in decreasing
the use of allogeneic blood in patients undergoing routine total
hip arthroplasty. The authors have shown that the modified dosing schedule
is effective, but, not surprisingly, it is not as effective as the
higher dose. The lower dose is cheaper but no less time-consuming
for the patients. Furthermore, the use of supplementary iron is
essential if epoetin alfa is to be effective.
The use of epoetin alfa appears to be both efficacious and safe under
the controlled conditions of this trial and others. In my opinion,
its use should be expanded, not only to decrease the use of allogeneic
blood transfusions in those patients who cannot or will not participate
in an autologous blood program, but also to increase hemoglobin levels
in patients whose levels might otherwise fall below the threshold
and disqualify them from participation in autologous programs. Finally,
epoetin alfa should be used to increase blood-cell volume in patients
participating in autologous programs to decrease the incidence of
preoperative anemia, a common outcome following autologous blood
transfusion.