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It is becomming time for all hospitals/transfusion services to think ahead----not only is the supply of even 'old' blood been in danger because of donations going down, new diseases, old diseases, things like TRALI, and worring about pandemics, terrorism, etc---if you wait long enough, hospitals will be forced into formal conservation, rather than moving toward them now. I, for one want the best my money can buy--not unreasonable to want that---why wouldn't I want the youngest blood for my hip replacement from the blood bank for my surgery? The situation could get to that point where patients demand the best--again, not unreasonable---but if surgeries and hospitals begin to use the best blood saving practices out there--the likelihood of the situations will be diminished. Go to sites like Society for Advancement of Blood Management (SABM). For the immediate question for cardiac surgery, the 'freshest' blood is their own with cell salvage, and most of your hospitals doing cardiac surgeries already have perfusion teams using cell savers. Meticulous hemostasis in surgery, using latest techniques and technology, cell salvage, etc, are all part of blood conservation. I know I am rambling now, but it was only a matter of time when yet something else will impact the blood supply. There are a handful of forward thinking formal blood conservation programs in hopsitals that do transplants and heart surgeries with little or no allogenic blood. We should all be thinking in that direction.

Although publication in the NEJM gives this article the veneer of credibility, there are a number of problems with this study. First, it is a retrospective study, so it does not have the power that a prospective randomized controlled trial would have (despite the authors' attempt to argue that their retrospective data was "prospectively" by clinicians carrying out patient care. Although the authors argue that the populations were matched, they simply were not. Here are the differences between the populations that by the authors own work are statistically significant: Statistically Significant Differences in the New Blood vs. Old Blood Populations Blood group (# of units/total # of units - %)53.1% of new blood units were type O, only 31.1% of old blood were type O56% of old blood were type A, 37.9% new blood type ABlood group (# of patients/total # of patients - %)50.9% new blood patients type O, only 30.4 percent old blood type O49.4 % old blood type A, 34.7% new blood type AHigher rate of abnormal left ventricular function in the old blood group (63.1 vs 57.9%Higher rate of mitral regurgitation for old blood (67.3 vs. 64.1%)Peripheral vascular disease higher in old blood patients (58.5 vs. 54.4%)Leukocyte reduction: significantly higher number of old blood patients receiving both leukoreduced and nonleukoreduced products (11.4 vs. 3.9)Larger body surface area in older blood patients #'s 3, 4 and 5 indicate a higher risk population than the "new blood" folks. The authors talk about ventilator time, but have made no adjustment for pre-existing lung function - these are elderly people - want to bet how many of those folks with peripheral vascular disease were/are smokers with less than optimal lung function? Take a look at Figure 1A. This is where "demonstrate" the two populations are the same with regard to # of units transfused. The scale on the Y axis is 0-30. Now look at figure 3 - the Kaplan Meier curve they use to show their "significant difference" between old and new blood folks. Looks like a big difference, right? Until you check out the scale, where the entire graph is a 15% spread (from 85-100%). So they've magnified a really small difference to make it seem big. Oh, and if you pull that same little trick on figure 1a, it shows the same "huge difference" in the two populations as they are claiming for fig 3. NEJM did a big disservice in printing this article in this form. The most this article does is support the need for a randomized controlled prospective trial. We are all aware the storage lesion exists, but none of us know its true impact on patient outcome in cardiac patients or any other. That said, it unfortunately was well publicized on a slow news day. "Old Blood Can Kill You" in our local rag - it almost made me bleed into my brain. Although some of you are struggling with your surgeons and clinicians, my greatest concern is what we will be hearing from patients and their families every time we transfuse them and they question how old the blood is. And should there be a bad outcome for any reason, well - welcome to litigation land, because surely it was the "bad old blood" that killed the 85 year-old 3 pack a day smoker with CHF, diabetes and metastatic cancer, right?