Use of autologous blood in total hip replacement. A comprehensive program

We evaluated the effectiveness of a comprehensive program for the use of autologous blood in reduction of the need for transfusion of homologous blood in total hip replacement in a prospective study of a consecutive series of patients. Transfusion of homologous blood was minimized through transfusion of preoperatively deposited autologous blood, intraoperative and postoperative salvage of washed red blood cells, and use of the clinical condition of the patient as the sole criterion for transfusion of non-autologous blood, regardless of the hematocrit. The cases of 143 patients who had had 154 primary total hip replacements were studied. One hundred and forty-three procedures were done on patients who had not been prevented from donating blood for medical reasons, and 93 per cent of these 143 procedures were performed with the availability of one to five units of preoperatively deposited autologous blood. The patients predeposited an average of 2.6 units of blood for each procedure. Ninety-two per cent of the procedures for which autologous blood had been predeposited were performed without transfusion of homologous blood. In the entire group of patients, almost 90 per cent of the transfused blood was autologous blood. Intraoperative salvage of red blood cells was successful in 148 procedures, and salvage was continued in the recovery room for all of these patients. An average of 408 milliliters of red blood cells was saved and reinfused, and this was 28 per cent of the average total loss of blood (1435 milliliters) for this series of procedures.(ABSTRACT TRUNCATED AT 250 WORDS)     

Eliminating homologous blood transfusions during abdominal aortic aneurysm repair

In order to eliminate homologous blood transfusions during abdominal aortic aneurysm (AAA) repair, increased usage of autologous predonation and intraoperative salvage is required. To determine what quantity of predonated blood is necessary to completely avoid the use of homologous blood, we reviewed the transfusion histories of 100 consecutive patients undergoing elective AAA repairs. A total of 445 units of blood were transfused, and the number of units required was directly proportional to the size of the aneurysm. One hundred sixty-six units of blood (37%) were homologous, and 279 units (63%) were autologous. Of the autologous units, 255 (91%) were from intraoperative salvage and 24 (9%) were predonated. Stratification of transfusions by size revealed that for aneurysms less than or equal to 7 cm, 132 units of homologous and 21 units of predonated blood were transfused (1.55 units per patient and 0.25 units per patient, respectively). For aneurysms greater than 7 cm, 34 units of homologous and 3 units of predonated blood were used (2.3 units per patient and 0.2 units per patient, respectively). From these data, it is concluded that predonation before surgery of a minimum of 2 units for patients with smaller aneurysms and 3 units for patients with larger aneurysms, combined with intraoperative salvage, should eliminate the need for any homologous blood transfusions associated with elective AAA repair.     

Economic evaluation of a randomized clinical trial of haemodilution with cell salvage in aortic surgery

BACKGROUND: This study evaluated the costs of acute normovolaemic haemodilution (ANH) and intraoperative cell salvage (ICS) versus homologous blood transfusion in aortic surgery in a prospective multicentre randomized trial. METHODS: One hundred and forty-five patients were randomized either to standard transfusion practice (homologous) or to a combination of ANH and ICS (autologous). Costs for each inpatient admission were identified. Cell salvage costs were assigned on the assumption that 50 operations were done each year employing a trained cell salvage operator. The results were analysed statistically using bias-corrected bootstrap analysis. RESULTS: Patients who had transfusion of homologous blood received some 251 units and those having a homologous transfusion received 103 units (P = 0.008). There was no difference in morbidity, mortality and duration of hospital stay. Transfusion-related mean costs were similar at 340 UK pounds for patients having a homologous transfusion and 357 UK pounds for those receiving autologous blood (mean difference 17 UK pounds (95 per cent confidence interval [c.i.]--184 UK pounds to 174 UK pounds); P not significant). There was also no significant difference in mean overall costs: 5859 UK pounds for homologous and 5384 UK pounds for autologous transfusion (mean difference--475 UK pounds (95 per cent c.i.--2231 UK pounds to 1342 UK pounds)). Sensitivity analysis showed that costs remained similar for 20 and 150 operations per annum. Exclusion of a dedicated cell salvage operator reduced autologous transfusion costs but did not have a significant impact on overall cost. CONCLUSION: Autologous transfusion is cost neutral in aortic surgery even when surgical activity is low.     

Intraoperative autologous transfusion in revision total hip arthroplasty

The records of ninety-eight patients (100 hips) who had revision total hip arthroplasty were reviewed to evaluate the efficacy of intraoperative autologous transfusion in reducing homologous blood-transfusion requirements. In the fifty hips in the study group, a mean of 685 milliliters of autologous blood, or 47 per cent of the estimated loss of blood, was transfused intraoperatively. During the entire course of hospitalization, the mean of the total homologous blood-transfusion requirements was 795 milliliters in thirty-nine study-group patients, compared with 1160 milliliters in forty-six control-group patients who did not have autologous transfusion. This difference was statistically significant (p less than 0.029). Eleven patients in the study group and four patients in the control group did not receive homologous blood. Over-all, the use of intraoperative autologous transfusion was directly responsible for a 42 per cent reduction in the total amount of homologous blood that was transfused.     

Minimizing the use of homologous blood products during repair of abdominal aortic aneurysms

The recent threat of post-transfusion AIDS and increased awareness of blood-related hepatitis have compelled surgeons to minimize the use of homologous blood products during aortic aneurysm repair. Reducing or eliminating homologous blood transfusion can be achieved by aggressive attention to three aspects of patient care: (1) routine use of autologous transfusion; (2) careful surgical technique, emphasizing the minimum dissection needed to expose the aneurysm adequately; and (3) a higher threshold for use of any blood products. In a prospective study of 100 consecutive aortic reconstructions, 80 per cent of patients undergoing aneurysm repair received only their own blood during hospitalization. Routine intraoperative autologous red-cell salvage has also conserved the bank blood supply by reducing usage of homologous blood by 75 per cent. The key to minimizing homologous blood requirements for aneurysm repair has been the development of rapid cell-washing autotransfusion devices.     

Intraoperative autologous blood salvage with cardiac surgery: an analysis of five years' experience in more than 3,000 patients.

STUDY OBJECTIVE: To analyze intraoperative autologous salvage of shed mediastinal blood and subsequent transfusion in cardiac surgery. DESIGN: Retrospective statistical analysis. SETTING: University hospital. PATIENTS: Three thousand twenty two patients undergoing cardiac surgery from 1984 to 1988. INTERVENTIONS: A review of anesthesia and transfusion records of all patients who underwent intraoperative salvage of shed blood and autologous transfusion using the Sorenson Receptal Auto Transfusion System (ATS) with saline wash prior to reinfusion in cardiac surgery. MEASUREMENTS AND MAIN RESULTS: The salvaged blood volume ranged from 36 to 2,795 ml, with a mean of 321 +/- 222 ml (SD). Eighteen percent of patients did not receive any homologous blood products during their hospitalization. Patients who received only salvaged autologous transfusion were younger, had higher preoperative hemoglobin and hematocrit values, had a larger body surface area, and had shorter surgeries compared with patients who received only homologous blood or both autologous and homologous blood. More blood products were given to patients who received salvaged autologous blood compared with those who did not. Patients who underwent normovolemic hemodilution prior to extracorporeal circulation with subsequent reinfusion received significantly fewer blood products. Ten preoperative and four intraoperative variables significantly influenced the salvaged volume. Previous cardiac surgery was the most significant preoperative variable, and repair of ventricular septal defect produced by myocardial ischemia was the most significant intraoperative variable. CONCLUSION: Considering the average salvaged volume and its current autologous transfusion-related expense, autologous blood salvage is potentially an economic benefit. Perioperative blood conservation requires a considerable commitment from surgeons, anesthesiologists, perfusionists, and intensive care physicians to be effective.     

Intraoperative autologous blood transfusion for hemoperitoneum resulting from ectopic pregnancy or ovarian bleeding during laparoscopic surgery.

OBJECTIVE: Our purpose was to evaluate the efficacy and safety of intraoperative autologous blood transfusion during laparoscopic surgery for hemoperitoneum in benign gynecologic disease. METHODS: The Cell Saver, Haemo Lite 2, an intraoperative autologous blood salvage device, was used in laparoscopic surgery on 18 patients with ectopic pregnancies or ovarian bleeding who had a large hemoperitoneum with/without severe anemia and hypovolemic shock. RESULTS: The blood loss was 1186 +/- 789 mL, and the volume of reinfused processed blood was 661 +/- 405 mL in ectopic pregnancy cases. The blood loss was 716 +/- 219 mL, and the volume of reinfused processed blood was 496 +/- 138 mL in ovarian bleeding. Laparoscopic surgery was performed and homologous blood transfusion was not required in any patient. No adverse reactions or procedural difficulties associated with the autologous blood transfusions occurred. CONCLUSIONS: Intraoperative autologous blood transfusion enabled the performance of laparoscopic surgery for large hemoperitoneum caused by ectopic pregnancies or ovarian bleeding without a homologous blood transfusion.     

Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery

The efficacy of a program of transfusion of previously deposited autologous blood for patients undergoing total hip-replacement surgery was studied by comparing five different parameters for a group of fifty consecutive patients who deposited blood for autologous transfusion and a randomly chosen, closely matched control group of fifty patients who received only homologous blood. Sixty-two per cent of the patients in the group that deposited autologous blood did not receive additional homologous blood while in the hospital. The patients who deposited autologous blood had a mean preoperative hematocrit of 36 per cent, compared with 39 per cent for the control group, but the average postoperative hematocrits of the two groups did not differ (33 per cent). There was no significant difference in the average total loss of blood or need for replacement of blood between the groups. Transfusion-related complications developed in two patients in the control group. We concluded that previous deposit of autologous blood for transfusion is an effective method for reducing the need for transfusion of homologous blood and for avoiding the attendant complications of transfusion of homologous blood. This method of the replacement of blood should be considered for patients who are to undergo a major orthopaedic procedure on the hip.     

Autotransfusion in revision total hip arthroplasties using uncemented prostheses

During the period from March 1983 to April 1987, autotransfusion was used in 64 patients treated with cementless revision total hip arthroplasties. An average of 3.9 units of intraoperative blood was salvaged, using a semicontinuous system; 6.5 units were salvaged in patients requiring segmental grafting of the acetabulum and femur. Patients not requiring segmental grafting had only 2.1 units salvaged. The use of homologous banked blood in patients without stored autologous units available was almost three times that of patients with autologous blood. Autotransfusion in the form of autologous transfusions and intraoperative blood salvage accounted for 72% of the total blood requirements. The cell saver is most cost-effective in patients with femur and acetabular bone loss requiring segmental grafting. An autologous transfusion program is important in all patients in whom blood transfusions are expected.     

Efficacy of postoperative blood salvage following total hip arthroplasty in patients with and without deposited autologous units

BACKGROUND: Patients undergoing total hip replacement routinely receive perioperative blood transfusions, increasing their risk of blood-borne disease, isoimmunization, anaphylactic reaction, and hemolytic reaction. The purpose of this retrospective, case-control study was to evaluate the effect of postoperative blood salvage on the need for allogeneic transfusion following total hip replacement. METHODS: We reviewed the medical records of ninety consecutive patients who, during a twelve-month period, had undergone unilateral, elective total hip replacement that included use of a postoperative blood salvage device. For comparison, we reviewed the medical records of ninety consecutive patients who had undergone total hip replacement without postoperative blood salvage. Overall, 156 patients had complete medical records and were included in the study. RESULTS: Eight (10 percent) of the patients who had been treated with a drain and seventeen (23 percent) of the patients who had been treated without a drain received allogeneic transfusions. Of the nineteen patients who had not deposited autologous blood, all six without postoperative blood salvage required allogeneic transfusion. With control for other variables in the model, regression analysis showed a significantly increased risk of allogeneic transfusion among patients who had undergone total hip replacement without postoperative blood salvage (p = 0.0028) and without having predonated autologous units (p = 0.0001). CONCLUSIONS: Despite a limited sample size, the study results showed that postoperative blood salvage significantly reduced the risk of allogeneic transfusion among patients managed with total hip replacement, whether or not they had deposited autologous blood (p < 0.0001). With control for donated units, age, gender, preoperative hematocrit, intraoperative blood loss, and cementless technique, patients who were treated without postoperative blood salvage were approximately ten times more likely to require allogeneic transfusion than were patients who had a drain.     

Banked autologous blood in elective surgery

Homologous transfusion carries a 5 per cent risk of transfusion reaction, a 0.5 per cent risk of overt hepatitis, and a 0.05 per cent risk of hepatitis-associated death. Autologous transfusion eliminates all of these risks and serves as an additional supply of blood.Fifty patients donated blood preoperatively for possible later autologous transfusion. Twelve of these patients received autologous blood only, and two patients received 1 unit of autologous blood and 2 units of homologous blood. Although carried out only once in this study, if iron stores are adequate and the hemoglobin level is above 11 gm/100 ml, 2 units or more can be drawn preoperatively with equal safety. No adverse effects were noted in these patients.If one or more transfusions might be required during an elective surgical procedure, banked autologous blood is completely safe and should be utilized whenever possible. Recent changes in the regulations governing blood banks make this feasible, and good medical practice makes it desirable.     

Möglichkeiten zur Einsparung von Fremdbluttransfusionen bei operativen Eingriffen

Alternative techniques to reduce the need for homologous blood transfusions are clinically available for several years. Actually a decision of our federal constitutional court (Bundesgerichtshof) outlined the medicolegal importance of autologous blood transfusion concepts. Pre-operative donation of red cells and/or plasma, acute normovolemic hemodilution, and intraoperative blood salvage and retransfusion will be discussed in terms of effectiveness, advantages, indications, and contraindications. In an emergency hemorrhage situation only the intraoperative blood salvage and retransfusion is available. The other autologous concepts are important in elective surgery.     

Blood conservation in spinal surgery. Review of current techniques.

The potential dangers of homologous blood transfusions are well known. Among the more serious complications of such therapy are hepatitis and acquired immune deficiency syndrome. As a result, blood conservation has become a topic of great interest to both physicians and patients. Numerous studies exist documenting the effectiveness of preoperative autologous blood donation, intraoperative autologous transfusion, hypotensive anesthesia, and postoperative blood salvage. Perioperative recombinant human erythropoietin is a promising new adjunct to these techniques. Careful surgical technique is crucial to the success of these complex modalities. In the absence of tumor, systemic infection, or gross wound contamination, these modalities should be considered when a spinal procedure is planned in which homologous blood may be required.     

Intraoperative autologous transfusion in children undergoing spinal surgery

An intraoperative autologous transfusion program was used in conjunction with preoperative phlebotomy in 25 children undergoing elective spinal surgery. Operative red blood cells, 10,000 ml, with an average hematocrit of 55%, as well as 7,300 ml of preoperative phlebotomy blood were returned to the patients. No complications were noted. The complete blood count on discharge was satisfactory, and the clotting parameters were unchanged. The results of this study show that intraoperative autologous transfusion with preoperative phlebotomy is safe, easy to perform, and cost-effective in children undergoing elective spinal surgery. The risks of homologous blood transfusions were eliminated.     

Intraoperative autologous transfusion in orthopaedic patients

The cases of 175 consecutive patients who had intraoperative autologous transfusion during revision total hip arthroplasty, an elective operation on the spine, repair of trauma to the spine, or open reduction of a fracture of the acetabulum were reviewed to evaluate the applicability of this technique in orthopaedic operations. A separate group of forty-one consecutive patients who had open reduction of a fracture of the acetabulum or the spine before the introduction of the autotransfuser was reviewed and compared with the group that had autotransfusion. An autologous blood predeposit program was used for twenty-five of fifty-two patients who had a procedure on the hip and for fifty-one of fifty-five patients who had an elective procedure on the spine. The mean rate of red blood-cell salvage using the autotransfuser was 60 per cent over-all. The mean transfusion requirements were significantly less (p less than 0.001) in all groups of patients in whom the autotransfuser was used. Use of the autotransfuser reduced the mean requirement for banked blood in patients who had a fracture of the acetabulum from 3.8 to 2.3 units per patient, and significantly reduced the mean need for banked blood in individuals who had trauma to the spine from 2.7 to 1.8 units per patient (p less than 0.01). The use of prebanked autologous blood further reduced the mean requirement for homologous blood from 2.4 to 0.8 unit per patient in those who had revision total hip arthroplasty (p less than 0.005), and from 3.6 to 0.4 unit per patient in those who had an elective procedure on the spine (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Autologous blood transfusion in patients with hepatocellular carcinoma undergoing hepatectomy

BACKGROUND: Homologous blood transfusion (HBT) has the risk of an immunosuppressive effect and may adversely affect the prognosis of patients with carcinomas. Autologous blood transfusion (ABT) has not yet become a standard procedure in gastroenteric cancer surgery. We investigated the usefulness and problems of ABT combined with the use of recombinant human erythropoietin (rh-EPO). METHODS: An evaluation of autologous blood transfusion (ABT) combined with recombinant human erythropoietin (rh-EPO) treatment was conducted in 46 patients with hepatocellular carcinoma undergoing hepatectomy. Preoperative autologous blood donation (ABD) was accomplished for 25 of the 46 patients. The preoperative changes in hemoglobin and hematocrit in relation to route of administration of erythropoietin were studied. In addition, intraoperative blood requirements and the postoperative complications for patients who predonated were compared with those of patients who underwent surgery without autologous predonation. RESULTS: The proportion of patients not requiring additional homologous blood transfusions (HBT) during operation was significantly higher in the ABD group than in the non-ABD group (88% versus 38%). The incidence of postoperative complications was significantly higher in patients receiving HBT than in nontransfused patients and in those receiving ABT. CONCLUSIONS: Preoperative autologous blood donation in combination with rh-EPO therapy markedly reduced the requirement for homologous blood transfusion during surgery in patients with hepatocellular carcinoma having hepatectomy.     

Prior deposition of autologous blood in elective orthopaedic surgery

We retrospectively analyzed a program of prior deposit and storage of autologous blood that was used for patients who underwent elective orthopaedic procedures over a period of thirty-six months at the Walter Reed Army Medical Center. Of a total of 211 patients who underwent total joint replacement or spinal fusion during this period and who had sufficient records to be included in the study, a total of 159 patients enrolled in the program. The fifty-two patients who did not enroll in the study, twelve of whom were rejected because of medical problems, served as a control group. Since the preoperative hematocrit values for patients in the group that received autologous blood were similar to those for the control group, multiple preoperative phlebotomies in these patients, who had received supplemental iron, did not seem to have any deleterious effects. One hundred and thirteen (71 per cent) of the 159 patients who were enrolled in the program received only autologous blood. The remaining forty-six patients required homologous blood also, but 64 per cent of their transfusion needs were provided by autologous blood. The only reactions to the transfusions in the study were in four patients who received homologous blood. We think that a program of prior deposit and storage of autologous blood should be an option for patients who are to undergo elective orthopaedic surgery. Such a program is well tolerated by the patients and easily managed by the staff, and it was not difficult to implement at our tertiary referral hospital.     

自体血液回收在小儿特发性脊柱侧弯矫正术中的应用价值评估

目的：探讨血液回收在小儿特发性脊柱侧弯矫正术中的应用价值。方法：对各20例脊柱侧弯矩形主患者分别采用输自身回收血液和输异体库血的方法。而使患者术后HCT≥30，Hb≥10g/L，并观察输血时过敏反应的发生率。结果：采用血液回收组可以明显减少异体库血的需要量，而且可避免输异体血时发生的过敏反应，结论：血液回收在小儿脊柱侧弯矫形术中具有很高的应用价值。     

Autologous blood transfusion in revision hip arthroplasty. A prospective, controlled study of 30 patients.

In a prospective, randomized study of the efficacy and effects of autologous blood transfusion in revision hip arthroplasty, 30 patients were randomly allocated into two groups. The Control Group received homologous blood transfusion. The Study Group deposited 2-3 units of blood preoperatively, intraoperative blood salvage was used, and no homologous blood was transfused intraoperatively. There was a smaller postoperative blood loss in the Study Group. The preoperative hemoglobin values were lower in the Study Group, but one week postoperatively they were higher than in the Control Group. The decrease in the values of AT III and protein C was lower in the Study Group. The combination of preoperative blood donation and intraoperative blood salvage reduced blood loss and homologous blood transfusion in revision hip arthroplasty.     

Blood salvage in total hip and knee arthroplasty in a community hospital: a retrospective study

PURPOSES: To assess the results of postoperative and intra-operative blood salvage in patients undergoing total knee and hip arthroplasty, respectively, and to determine if both methods of blood salvage reduce allogeneic transfusion. METHODS: Of 229 patients who attempted blood salvage, 114 of 152 patients who underwent total knee arthroplasty received the salvaged blood postoperatively, 35 of 77 patients who underwent total hip arthroplasty received the salvaged blood intra-operatively. Various data were collected to assess whether certain factors resulted in autologous and/or allogeneic blood transfusions. RESULTS: Patients that received postoperative salvaged blood after total knee arthroplasty generally had higher postoperative levels of haemoglobin and haematocrit compared to those who did not. Patients with autologous blood transfusion following cemented knee surgery were less likely to require allogeneic blood transfusion. For hip arthroplasty patients, postoperative levels of haemoglobin and haematocrit were similar in both groups who received and did not receive salvaged blood. Lower preoperative haemoglobin and haematocrit levels correlated with a greater likelihood of autologous and/or allogeneic blood transfusion for both knee and hip arthroplasty patients. CONCLUSIONS: Although total knee arthroplasty patients who received salvaged blood had higher haemoglobin levels on the first postoperative day, the receipt of salvaged blood did not significantly reduce the incidence of allogeneic blood transfusion, because salvaged blood was a kind of blood loss. However, reinfusion of salvaged blood may reduce the number of units of allogeneic blood used. Given the short supply of allogeneic blood and its risks of transmitting disease, intra-operative and postoperative blood salvage carries clear advantages.