Saturday, June 16, 2007

Transfusions bring experts' blood to boil

Contrary to their benign image, blood transfusions are overused and often harm patients, expert say

REFUSE at your own risk: for years that's the message doctors have relayed to Jehovah's Witnesses and others who've declined blood transfusions.
But transfusions are not the wonder procedure of popular, or even medical profession, imagination. Mounting evidence shows they significantly increase the risk of post-operative complications - including infections, kidney failure, lung injury and death.

Yet instead of being saved as a last resort, they are still being performed when other safer options could be used instead.

In fact, more than 25 per cent of blood transfusions currently performed are unnecessary, according to a visiting US expert who spoke at the annual scientific meeting of the Australian and New Zealand College of Anaesthetists (ANZCA) two weeks ago.

Internationally renowned emergency medicine and anaesthiology professor Bruce Spiess told the conference that while blood transfusions have long been "believed to be helpful and a pillar of modern medicine'', there was now relatively little evidence to support such claims.

"Drug options are carefully tested and regulated through prospective, randomised double-blind testing, but blood transfusion stands apart,'' Spiess says. "It has never been safety or efficacy tested.''

It's a point that has been echoed by several Australian experts, including anaesthesists associate professor Larry McNicol and doctor Peter McCall at Austin Health in Melbourne.

"From the point of view of the risk of transmitting infections, blood transfusions are safer than they have ever been,'' McCall says.

"However, there is an ever-increasing body of research about adverse outcomes in association with them. Still there is a tendency to think that blood transfusions are mystical and lifesaving, and it is better to give them than to withhold them.''

The reasons not to make blood transfusion routine are becoming increasingly apparent: a person who has had a blood transfusion after surgery has up to four times the risk of wound infections. People who have blood transfusions during cancer surgery face up to twice the risk of the cancer recurring.

In his conference presentation, Spiess discussed Swedish research on cardiac patients that compared Jehovah's Witnesses who refused blood transfusions to patients with similar disease progression during open-heart surgery. The research found those who refused transfusions had noticeably better survival rates.

There are a few major reasons complications arise following transfusion. For one thing, immune response is impaired as the body responds to the blood as a foreign body, much in the same way it responds to a transplant, experts say. The properties of red blood cells also become altered when blood is stored, reducing their ability to distribute oxygen through the body.

Yet at least 25 per cent of transfusions that are done could be avoided, Spiess says.

A 2005-2006 audit of the use of fresh frozen plasma in hospitals in Tasmania and Victoria found that one-third of the transfusions performed were inappropriate under underguidelines issued by the National Health and Medical Research Council, says associate professor Larry McNicol, who also chairs the Better Safer Transfusion program run by the Victorian Government.

"Essentially these patients really perhaps didn't need it and there might not have been therapeutic benefits,'' McNicol says.

But there are still circumstances when blood transfusion is necessary, and the patient would probably die if they did not receive one, says University of Sydney professor James Isbister, a consultant on haemotology and blood transfusion who chairs the Red Cross advisory board.

Isbister says blood transfusion can be vital for patients undergoing major surgery after experiencing major trauma or shock when there is major bleeding that is difficult to control quickly. It can also be instrumental in managing hemophilia, where blood does not clot, as well as acute hemorrhages.

"A lot of major surgery would never have developed without the possibility for blood transfusion either - for instance, open heart surgery,'' Isbister says.

But many of the cases in the Better Safer Transfusion audit involved transfusions that could have been avoided. For example, it was once thought that blood transfusions should be performed any time a patient's hemoglobin level dipped below 10 grams of hemoglobin per decilitre of blood - but now guidelines in varying countries put that between 6 and 8g.

"It used to be that 10g was the acceptable minimum, but now we know that patients are at no detriment by a running a lower count and we can avoid these additional risks,'' McCall says.

"When the blood count is lower, the heart is able to beat more strongly - so it can actually pump more efficiently to distribute the blood better.''

The audit also uncovered a tendency for some doctors to use transfusions as a precaution in patients who were at risk of bleeding, but not yet bleeding - for example, they might have had abnormal test results. In those cases the guidelines recommend doctors wait until bleeding starts.

Other studies have also shown that the likelihood of receiving a transfusion during elective orthopaedic surgery or cardiac surgery can vary enormously between hospitals, despite there being little difference between the patients, Isbister says.

"There's huge variation between hospitals and surgeons depending on where you have your operation - in one hospital you can have an 80 per cent chance of being transfused, and in another hospital 10 per cent chance.''

"Most patients undergoing hip and knee surgery should only have a 10 to 20 per cent chance of needing a transfusion - but there's evidence it can be much higher.''

There are a number of ways to avoid transfusions, including drugs that minimise blood loss and others that stop clots from being dissolved, as well as anesthetic and surgical techniques to minimise blood loss.

"You don't always have to bring a person's blood pressure up to normal - you can keep it low and that minimises bleeding,'' he says.

In surgery where there's a risk of major blood loss, doctors frequently use a technique called "red cells salvage'', which allows them to reuse the patient's own blood rather than transfusing someone else's. The patient's blood is collected in a machine where it is then washed in a saline solution before being given back to the patient.

But the battle to reduce unnecessary transfusions often begins before surgery.

"One of the ways to minimise transfusions is to prepare patients better before surgery - for example you can give them supplements to get their blood count up before surgery,'' McCall says.

To that end a 2005 South Australian audit found that 18 per cent of people who had been on waiting lists for elective surgery had anemia, which increases the chances of needing a transfusion. If the anemia had been better managed before surgery some of those patients could have avoided blood transfusions, according to Kathryn Robinson, medical adviser of South Australia's BloodSafe.

But for all the bad news, experts say that change is on the horizon. Various states are developing initiatives to help decrease unnecessary transfusions, and at a conference of federal and state health ministers in March the federal Government said it would fund two initiatives expected to improve the safety of the blood supply and improve outcomes for people who do ultimately need transfusions.

One of those initiatives is the universal testing of platelets, which carry particularly high risks of complications. Unlike other blood products, platelets can't be refrigerated, so they are susceptible to contamination by bacteria. International guidelines recommend all platelets be universally tested for the bacteria, but currently only about 5 per cent of the supply is tested, McNicol says.

At the same meeting the government announced that by 2010 all blood will be processed to remove white blood cells, known as leuko-reduced blood, which has been shown to dramatically reduce complications and is already in widespread use in Canada, New Zealand, Western Europe and elsewhere.

"There are three randomised controlled studies in heart surgery, where patients who were deemed appropriate to be transfused got either leuko-reduced blood or blood with white cells present,'' Spiess says.

"The death rate in those with leuko-reduced blood was roughly half that in those with blood with white cells,'' Speiss says. "In the patients that got no blood, there were no deaths at all.''


From Abscam On: The career and modus operandi of Rep. John P. Murtha


Johnstown, Pennsylvania's "Showcase for Commerce" started in 1991 as a small trade show for area businesses, but since then it has grown into one of the U.S. defense industry's most important events of the year. Many big names are represented -- Northrop Grumman, Raytheon, and Lockheed Martin all have booths within a few yards of each other -- but the star of the show is John P. Murtha, Johnstown's U.S. congressman, who attends every year and visits every exhibit booth. An entourage follows Murtha around the crowded arena, including a photographer, several senior staff members, and one assistant whose sole job appears to be gathering promotional materials and taking copious notes. At each booth, powerful defense-industry executives greet him with smiles and handshakes, eager to show him their latest prototypes and proposals.

The showcase is symbolic of Johnstown's transformation from a hard-hit former steel town into, as one contractor who attended this year's showcase put it, "the beating heart of the U.S. defense industry," or at least one of its major regional hubs. Murtha gets a hero's welcome at the showcase, not just because it was his idea, but also because his position as chairman or ranking member of the defense appropriations subcommittee for the past 18 years has a lot to do with the defense industry's interest in the region.

In turn, Murtha's patronage for his district has made him one of the most powerful members of the House of Representatives and a huge roadblock standing between the Democrats and the kind of meaningful ethics reform they promised during their 2006 "culture of corruption" campaign. The money he secures for Johnstown comes back to him in the form of campaign contributions, which ensure his reelection and provide him with surplus cash to give out to other members. Murtha has been reelected 16 times, giving him seniority in the House and the plum committee assignments that go with it. His chairmanship of the defense subcommittee gives him control over half of the earmarks in every defense appropriations bill, which buy him even more loyalty and influence in the House. On top of all that, Murtha has a strong relationship with Speaker Nancy Pelosi, dating back to when he helped get her a seat on the powerful Appropriations Committee. He is an integral part of the new Democratic majority -- and it cannot be the party of institutional reform as long as he is in power.

Evidence of that was on recent display when Murtha twice violated a new rule governing earmarks -- provisions lawmakers can attach to bills directing agencies to fund specific projects -- and got away with it when his party defeated a Republican's attempt to hold him accountable. During one of their sporadic attempts at ethics reform since taking over Congress, House Democrats passed a new rules package in January that included a measure forbidding members to condition earmarks for other members on how they vote. In early May, Rep. Mike Rogers, a Michigan Republican, offered a motion to remove a $23 million earmark for the National Drug Intelligence Center from the intelligence authorization bill on the grounds that several government agencies tasked with auditing the center have declared it to be an inefficient and duplicative waste of taxpayer money. The only problem with Rogers's attempt to cut the center's funding was that the center is in Johnstown, and the guy who sponsored the earmark was John Murtha.

First, Murtha allegedly threatened Rep. Todd Tiahrt, a Kansas Republican and fellow member of the Appropriations Committee, for voting with Rogers. (Tiahrt, whose district houses a Boeing assembly plant with business before Murtha's subcommittee, declined to comment for this article and isn't discussing the incident.) Then Murtha went after Rogers: "I hope you don't have any earmarks in the defense appropriation bill because they are gone, and you will not get any earmarks now and forever," Murtha said. When Rogers told Murtha that this was not the way to handle their dispute, Murtha responded, "That's the way I do it."

Rogers says, "As a former FBI agent, and with about twelve years' experience in politics now, I can tell the difference between what is passionate, emotional, sometimes even angry political speech, versus what is certainly intended to be an act of intimidation." He says Murtha's threat clearly crossed that line. Yet when Rogers introduced a motion to reprimand Murtha for violating the new rule, all but two House Democrats voted to kill the resolution without a debate. "I wasn't surprised that [the Democrats] took the partisan position on [the resolution]," Rogers says, "but I was a little surprised that they didn't allow the debate . . . or at least refer it to the ethics committee on their own. They took neither option. They basically said, "We're not even going to talk about it.'"

Among Democrats voting to shield Murtha was Zack Space, the freshman Democrat who replaced scandal-plagued Ohio Republican Bob Ney and who has taken a prominent role as a spokesman for the Democrats' new lobbying-reform bill. A week before Murtha's run-in with Rogers, Space went on a C-SPAN program and said, "Members of Congress must know that if they break the rules, they will be caught and punished." Given that Space and a number of freshmen like him owe their seats to their party's rhetoric on the subject of GOP corruption, one might be surprised that not a single one of them voted to reprimand Murtha. But their actions make more sense in light of Representative Murtha's recent fundraising activities.

Last year Murtha formed a leadership political-action committee called Majority PAC, through which he contributed over $150,000 to other Democrats' campaigns. According to the Majority Accountability Project, a conservative-leaning watchdog group, this included nearly $50,000 to the campaigns of 19 freshmen, including Space. Even though leadership PACs became more popular in 2006 among all members of Congress, it turned out to be an especially advantageous time for Murtha to establish one. Just as a new crop of reform-minded Democrats looked like it was headed for Congress, Murtha added a new weapon to his arsenal of influence.

Considering Murtha's history of ethical transgressions, perhaps this showed some foresight on his part. Ever since his notorious involvement as an unindicted co-conspirator in the 1980 Abscam sting operation, Murtha has consistently opposed tougher ethics rules and has actually co-sponsored legislation to make it harder to investigate members of Congress. In 1998, he and Pennsylvania Republican Joe McDade (who was indicted but acquitted on bribery charges in the early 1990s) sponsored a bill to create a congressionally appointed review board with oversight into Justice Department investigations of lawmakers' activities. At the time, congressional watchdog groups called it the Corrupt Politicians' Protection Board. More recently, Murtha referred to the Democrats' latest attempts at ethics reform as "total crap."

All of these various aspects of Murtha's m.o. -- the earmarks, the campaign cash, and the network of personal connections -- were on display at this year's trade show in Johnstown. Take the story of Kuchera Industries, founded in 1985 just outside of Johnstown. Kuchera's executives paid little attention to their congressman until one of Murtha's former aides, Carmen Scialabba, approached CEO Bill Kuchera in 2001 about a non-profit Scialabba created to help disabled people find work. It must have seemed like the opportunity of a lifetime for the small manufacturing firm. The Washington Post reported last December that Kuchera subsequently joined the non-profit's board, started employing more disabled workers, and hired a lobbying firm chaired by a retired congressman -- Joe McDade.

FEC records show that Kuchera's top officials proceeded to donate more than $45,000 to Murtha and his PAC over the next three election cycles, and an analysis of Murtha's recent fundraising efforts shows an even more dramatic increase in Kuchera's contributions. In just the first three months of 2007, Kuchera's top executives have given Murtha and his PAC close to $20,000 -- nearly half the amount they contributed over the previous six years. Last year, according to a study done by Taxpayers for Common Sense, Murtha earmarked $1.3 million for Kuchera in the defense appropriations bill. This year, the day after Murtha stopped by all three companies' booths at the Johnstown showcase, Kuchera announced at a press conference that it had been awarded two new contracts, totaling $14 million, by Northrop Grumman and Raytheon -- both of which have substantial business before Murtha's subcommittee.

Murtha declined to be interviewed for this article, but in response to a question about his involvement in the deal, a spokesman for Murtha wrote, "Our staff works with community organizations and leaders to effectively market our region. The announcements made at the Showcase were a direct result of area businesses providing quality work coupled with superior responsiveness at a price that is frequently unmatched."

Of course, Murtha has never apologized for steering money into his district. But for the Democrats, he creates an uncomfortable political problem by demonstrating how powerless they are to challenge his way of doing business. It might be good politics to campaign against the other guy's network of campaign cash and influence, but apparently it's even better politics actually to have such a network. Just ask 17-term congressman Jack Murtha.

Mr. Spruiell is National Review Online's media reporter