To the Editor:—  We have read with great interest both the editorial by Spahn et al.  1and the article by Atzil et al.  2in the December issue of Anesthesiology. We fully agree with the argumentation, but we want to go further into this debate.

The very well designed animal study of Atzil et al.  2is very interesting, expressing the independent role of blood transfusion in cancer progression and, more precisely, the role of aged erythrocytes more than leukocytes. The editorial of Spahn et al.  1related to this article summarizes brilliantly the numerous disadvantages of homologous blood transfusion.

Red blood cell transfusion is a frequently performed activity in routine anesthetic practice. There are great differences between European countries: The number of blood products given to patients in 1,000 inhabitants is 40 in France, 89 in Denmark, and 73 in Germany.3,4Nevertheless, we should like to pinpoint the findings of the study by Lienhart et al.  published in this same journal.5This survey used the French death certificates national database to assess mortality related to anesthesia in France in 1999. The major finding of this survey was the reduction by a magnitude of 10 of the anesthesia-related mortality rate in France, as compared with a previous survey 20 yr ago. The analysis of the causes leading to the perioperative deaths was very enlightening. It was estimated from this survey that nearly 100 deaths occur perioperatively in France each year as a result of inadequate blood management. Surprisingly, more deaths partially related to delayed or absent blood transfusion were observed, and only a small proportion of complications occurred after an episode of transfusion. In many cases point-of-care monitoring of hemoglobin was not used to estimate blood loss, although it is likely that these inexpensive devices were already available in most hospitals at that time. Blood loss associated with delayed or absent blood transfusion caused not only intraoperative hypotension and hypovolemic shock, but also postoperative myocardial ischemia and infarction in patients with preexisting coronary artery disease. It seems impossible to know if the use of restrictive threshold for blood transfusion is responsible for this situation. After this nationwide study, the French Society of Anesthesia sent to its members key messages focusing on blood transfusion during the perioperative period: Quick diagnosis, threshold respect, and guideline implementation.6,7 

On one hand, a body of evidence is growing on short-term and long-term complications of homologous transfusion, but on the other hand, facts suggest that patients may die of mistreated perioperative anemia.

We wanted to emphasize this point after reading these articles, but of course “our own blood is still the best thing to have in our veins.”8 

*Percy Military Teaching Hospital, Clamart, France.

Spahn DR, Moch H, Hofmann A, Isbister JP: Patient blood management: The pragmatic solution for the problems with blood transfusions. Anesthesiology 2008; 109:951–3
Atzil S, Arad M, Glasner A, Abiri N, Avraham R, Greenfeld K, Rosenne E, Beilin B, Ben-Eliyahu S: Blood transfusion promotes cancer progression: A critical role for aged erythrocytes. Anesthesiology 2008; 109:989–97
Rouger P: Evolution of transfusion risks over a 15-year period (1987–2002). Ann Fr Anesth Reanim 2004; 23:1102–6
Rouger P: Transfusion medicine in Europe. Transfus Clin Biol 2004; 11:11–4
Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M, Jougla E: Survey of anesthesia-related mortality in France. Anesthesiology 2006; 105:1087–97
Auroy Y, Lienhart A, Pequignot F, Benhamou D: Complications related to blood transfusion in surgical patients: Data from the French national survey on anesthesia-related deaths. Transfusion 2007; 47(2 Suppl):184S–9S
Benhamou D, Lienhart A, Auroy Y, Pequignot F, Jougla E: Accidents by ABO incompatibility and other main complications related to blood transfusion in surgical patients: Data from the French national survey on anaesthesia-related deaths. Transfus Clin Biol 2005; 12:389–90
Frenzel T, Van Aken H, Westphal M: Our own blood is still the best thing to have in our veins. Curr Opin Anaesthesiol 2008; 21:657–63