The document summarizes the risks associated with surgical bleeding and blood transfusions. It discusses how bleeding can lead to hypovolemia and anemia, and the compensatory mechanisms the body employs. It then outlines the risks of transfusions, including transfusion reactions, infections transmitted through blood-borne pathogens, transfusion-related immune modulation that can increase infection risk and mortality, and the storage effects on red blood cells that are associated with increased morbidity and mortality. It notes that leukoreduction of blood products reduces some of these transfusion risks.

1. Surgical Bleeding and Transfusions: The Issues in 2004 Chief, Dept of Anesthesiology, Critical Care and Hyperbaric Medicine Englewood Hospital & Medical Center and Associate Clinical Professor, Mount Sinai School of Medicine Aryeh Shander, MD, FCCM, FCCP

3. Surgical Bleeding Vessel interruption Surgical repair Bleeding contained No need for further action Delay in repair Bleeding stops Surgical repair Clotting Factor consumption Impaired clotting Transfusion of blood products SIRS Transfusion related complications

6. MAC ROCIRCULATION MIC ROCIRCULATION PLASMA

7. Human Hemorrhage and Blood Pressure 25-30% bleed (n=6) Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81

8. Human Hemorrhage and Heart Rate 25-30% bleed (n=6) Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81

9. 25-30% bleed (n=6) p=0.002 Human Hemorrhage and Gastric Perfusion Hamilton-Davies C et al, Intensive Care Med 1997;23:276-81

11. “ Fluid” + Dobutamine / High Risk Surgery % Lobo et al, Crit Care Med 2000;28:3396-3404. * * p<0.05 *

13. Risks of Anemia

19. Risks of Blood Transfusions

26. Decline in HIV, HBV, and HCV Risks of Transmission Through Transfusion Adapted from Busch MP et al, JAMA 2003;289:959-62. Aubuchon JP, Transfusion 2004;44:1377-1383. Risk of Infection per Unit Transfused 1:100 1:1000 1:10,000 1:100,000 1:1,000,000 1:10,000,000 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 Year Revised Donor Deferral Criteria Non-A, Non-B Hepatitis Surrogate Testing HIV Antibody Screening HCV Antibody Screening p24 Antigen Testing HCV and HIV Nucleic Acid Testing HIV HCV HBV Clerical 1:12,000 Bacteria 1:2,000 TRALI 1:5,000

29. Risks of Allogeneic Blood ‘ TRIM’ Transfusion Related Immune Modulation

33. Mortality Rates Are Lower When Leukocyte - Reduced Blood Is Used Leukocyte reduction results in a significant reduction of mortality in patients undergoing cardiac surgery van de Watering LMG et al, Circulation 1998;97:562 – 568 Mortality Rate (%) 7.8% 3.3% n=914 Bc=306 Ff=305 Sc=303

37. Nosocomial Infection Rates in Critically Ill Patients N = 1,717 n = 416 n = 1,301 P < .05 Adjusted for severity of illness using MPM-0 scores, age, gender (Project IMPACT). Taylor RW et al, Crit Care Med 2002;30:2249-54. For each unit of PRBCs given, the odds of infection is increased by a factor of 1.5

38. Mortality Rates in Critically Ill Patients N = 1,717 n = 416 n = 1,301 P < .05 Taylor RW et al, Crit Care Med 2002;30:2249-54.

40. Univariate association rates of stroke and death in CABG with platelet transfusion Patients (%) STROKE DEATH Spiess BD et al, Transfusion 2004;44:1143-1148 N=1720/248 from 6 RCT for Aprotinin FDA approval