AUTHORS' RESPONSE

We appreciate the comments to our article submitted by Ms Carroll. The article was not intended to be an exhaustive listing of all possible blood conservation strategies, so we did not include anesthesia techniques, surgical considerations or perfusion technologies such as autotransfusion in the review. Although cardiac surgery patients consume approximately 20% of US blood products1 and blood use within hospitals is generally highest in cardiac surgery departments,2 only a small number of active blood conservation programs in US hospitals are reported.3,4 We believe this lack of blood conservation efforts is not due to a lack of published information on the use of blood sparing "tools" such as autotransfusion techniques; rather, this lack of organized blood conservation efforts is due to the inherent difficulties implementing complex multidisciplinary change projects within a bureaucratic and compartmentalized healthcare system. Therefore, the primary emphasis of the article was to provide the organizational framework to effect such changes through the use of change champions, change agents, and employment of multidisciplinary teams. The function of these cross-functional teams is to study, implement, and monitor local blood conservation strategies. Most of the specific blood conservation strategies listed were those likely to directly involve critical care nurses.

With regards to the return of mediastinal shed blood as a mechanism to reduce allogeneic blood exposure, a word of caution is in order. The clinical efficacy and cost-effectiveness of this technique depends on the volume of postoperative shed blood available for reinfusion, the hematocrit of the fluid (which is usually only 10% to 20%), and local transfusion rates. Most important, if the decision is made to reinfuse this blood, it should first be washed using certified devices operated by properly trained personnel. Owing to high levels of plasma-free hemoglobin, inflammatory cytokines, and fibrin degradation products, direct reinfusion of wound shed blood can lead to complement activation, hypotension, febrile reactions, mediastinitis, multisystem organ failure, systemic inflammtory response syndrome, disseminated intravascular coagulation, and even death.5-8

Barbara L. Maglish Ehrman, MSN, RN, CNS

Clinical Nurse Specialist, St. Vincent Hospital and Health Services, and Adjunct Assistant Clinical Professor, Indiana University Graduate School of Adult Health Nursing, Indianapolis, Ind.

Holly A. Moore, BSN, RN

Professional Staff Nurse, St. Vincent Hospital and Health Services, Indianapolis, Ind.

References