Transfusion Guidelines

To the Editor: Dr Golinko shares with us a wonderful story (Residents' Corner, July/August 2007), discussing Dr Dronsky's mentorship. But although such mentorship was admirable, I do quibble with some of the implications of Dr Dronsky's advice, which may well reflect the way they transfuse in Russia, but it is not at all clear that that is how we ought to do transfusions in the United States. Transfusion requires balancing risks and benefits of each component, as supported by evidence-based medicine. I do not know if all the components ordered in that case were required, but I have little doubt that even patients in the intensive care unit do not need to be transfused to a hematocrit level of 40%.¹

The take-home lesson of this experience is the importance of coming to the aid of those less experienced than you, rather than that every crisis requires all possible interventions, even when benefit is unproven.

Jed B. Gorlin, MD
Medical Director, Transfusion Service,
Hennepin County Medical Center, Minneapolis

1. Hebert PC, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med. 1999;340:409-417.

Bowel Prep Dosing

To the Editor: In "Acute Renal Failure with Bowel Preparation," (June 2007) Drs Battula and Fleisher describe an elderly patient's experience after taking 4 fl oz of an oral sodium phosphates solution. Although the authors discussed contraindications, they do not include appropriate dose or dose timing. The 4 fl oz given to this patient is more sodium phosphates solution than Fleet Laboratories recommends or has ever recommended. The authors also fail to indicate over what time period the 4 fl oz was ingested. Proper dosing and timing instructions are available at www.phospho-soda.com.

Furthermore, this patient presented with a dry mouth, suggesting inadequate hydration. Hydration is important in proper bowel preparation, regardless of the cathartic agent, as large amounts of fluid are excreted rectally during the bowel-cleansing process. Finally, the authors write, "Oral sodium phosphates solution contains 2.4 g of monobasic sodium phosphate and 0.9 g of dibasic sodium phosphate." Fleet's oral sodium phosphates products contain 2.4 g of monobasic sodium phosphate monohydrate and 0.9 g of dibasic sodium phosphate heptahydrate per 5 mL (see Physician's Desk Reference).

Michael Caswell
Director of Safety & Product Evaluation
C.B. Fleet Company, Lynchburg, Va

Drs Battula and Fleisher Reply: Mr Caswell is correct that Fleet's oral sodium phosphates solution comes only in dosing of 1.5 and 3 fl oz bottles. The 4 fl oz dose was recommended to this patient by our gastroenterologist, using combined bottles. However, our patient did not complete even the first 1.5 fl oz dose, because of adverse effects. We regret the wrong information cited in this case, where we mistakenly assumed, based on our notes, that the patient ingested the full 4 fl oz prescribed.