Table your contaminated equipment during induction.

Weltert et al. included only patients undergoing off-pump cardiac surgery and thus cannot be used to address safety and efficacy for on-pump surgery. The study by Yoo et al. included only 74 patients (not much larger than our pilot trial) and seems to have not been properly blinded. Moreover, in that study transfusions were guided by the hemoglobin concentration, so it is hard to understand why the ESA group had a markedly lower intraoperative transfusion need than the control group (0.7 0.7 vs. 1.2 1.1 units/patient) when the two groups had very similar postinduction hemoglobin concentrations (11.6 1.2 g/dl vs. 11.5 1.4 g/dl) and reticulocyte counts (80 24 vs. 75 27 10/ l). Thus, these studies do not provide strong support for the use of ESAs in cardiac surgery with CPB. Finally, Dr. Faraoni et al. state that our results should be viewed with caution, with which we strongly agree because it was a pilot study. We specifically stated that “it would be inappropriate to modify clinical practice based on the results of this pilot study.” We did conclude that the intervention “reduces perioperative anemia and erythrocyte transfusions, and may reduce plasma iron levels,” and we stand by this conclusion because it is supported by the results. We also noted that “large multicenter trials adequately powered to determine if this intervention reduces postoperative acute kidney injury are warranted.” To that end, we have created a multidisciplinary research team at 20 institutions and have applied for peer-reviewed funding to conduct such a trial. Given that definitive safety and efficacy data are also lacking for alternative interventions aimed at reducing perioperative transfusions, such as but not limited to ESAs and acute normovolemic hemodilution, the only logical conclusion is that these interventions also should not be used outside of clinical trials that are properly designed to determine their overall risk-benefit profiles.