Reduction of blood transfusion rates in unilateral total knee arthroplasty by the introduction of a simple blood transfusion protocol

We prospectively studied blood transfusion practices within a single institution before and after the introduction of a blood transfusion protocol in consecutive patients undergoing unilateral total knee arthroplasty. Data were collected on 393 patients (group I) prior to and 295 patients (group II) after the introduction of the protocol. Following the introduction of the protocol, patients with preoperative haemoglobin of less than 11 g/dl were cross-matched prior to surgery. The criterion for postoperative transfusion was postoperative haemoglobin of less than 8.5 g/dl or a symptomatic patient with haemoglobin of greater than 8.5 g/dl. This change in practice reduced the transfusion rates from 31% in group I to 11.9% in group II. It reduced the non-utilisation of blood from 64 to 1%. There were no adverse outcomes related to the introduction of the protocol.     

Haemoglobin levels following unicompartmental knee arthroplasty: influence of transfusion practice and surgical approach

A retrospective review was undertaken of preoperative and day 3 postoperative haemoglobin (Hb) levels in all unicompartmental knee arthroplasty (UKA) procedures performed by a single surgeon. Sixty-six UKAs were performed using the same prosthesis through an open approach with patella eversion. This group was compared with 212 UKAs performed using a minimally invasive approach without patella eversion, with an implant and instrumentation specifically devised for this approach. Both groups were well matched for patient demographics, surgical and anaesthetic techniques, thromboprophylaxis, and postoperative regimes. All patients received transfusions with pre-donated blood, except the unilateral minimally invasive approach group. An analysis of covariance was undertaken to examine the influence of the surgical approach and whether surgery was unilateral or bilateral, taking into account preoperative Hb levels and units of blood transfused. The average fall in Hb following UKA, adjusted for other variables, was 2.73 g/dl with an open approach compared to 1.82 g/dl with a minimally invasive approach. This difference was significant (p=0.0044). The average postoperative Hb in the minimally invasive group was 12.05 g/dl (range, 8.8 to 15.8 g/dl). Patients undergoing unilateral minimally invasive UKA are unlikely to develop symptomatic anaemia and should not be required to predonate blood or undergo transfusion.     

Utilization patterns of frozen autologous red blood cells. Experience in a referral center and a community hospital

The risks of homologous blood transfusion have motivated some blood centers and private industry to consider providing long-term storage of frozen, autologous red blood cells as a service. The usefulness of this practice is unknown. We performed a retrospective analysis of frozen autologous red blood cell use in two hospitals. Records were available for 21- and 9-year intervals, respectively. A total of 104 autologous units were cryopreserved for 41 patients. Fifteen (37%) of 41 patients received one or more of their stored units of red blood cells. Twenty-two patients had autologous units frozen in anticipation of elective surgery; 11 (50%) of these 22 patients received some or all of their stored units. Sixteen patients had autologous units stored because of potential transfusion problems related to rare blood types or to the presence of multiple blood cell alloantibodies, and another 3 patients had units frozen simply at their personal request. Only 4 (21%) of these latter 19 patients who donated without a specific planned use eventually received their frozen autologous red blood cells. Long-term autologous frozen red blood cell storage can improve medical management of some patients with anticipated surgical procedures or unusual requirements for transfusion. However, our study suggests that most autologous units frozen without specific planned use will not be transfused.     

Recombinant human erythropoietin reduces allogeneic blood transfusion requirements in patients undergoing major orthopedic surgery

Blood loss is a significant problem encountered in patients undergoing total joint arthroplasty, and is considered to be one of the factors affecting the outcome of the operation. Traditionally these patients have been treated with blood transfusions. The introduction of recombinant human erythropoietin (rHuEpo) into clinical practice enabled assessment of its effectiveness to decrease the allogeneic blood transfusion requirement (BTR), thus avoiding or minimizing transfusion-related complications. Fifteen patients undergoing total hip replacement (THR, 10 patients) and total knee replacement (TKR, 5 patients) in our institute (from January-April 1997), were studied. After signing an informed consent they received daily s.c. rHuEpo (100 IU/kg for those with hemoglobin (Hb) > 13 g/dl, 300 IU/kg for Hb < 13) during the 10 days prior to surgery and the 4 days following the operation. Allogeneic red blood cell (RBC) transfusions were given as needed. Hb levels were measured on days -10, 0, +1.3 and 7 of the procedure and the BTR was recorded. The results were compared with those of previous patients operated on from January-December 1996. Patients who were eligible for the study but refused to participate served as controls. The mean Hb level in the study group prior to rHuEpo administration (day -10) was 13.41 g/dl, similar to those of the control group (13.47 g/dl on day 0). However, the mean Hb levels in the rHuEpo treated patients on days 0, 1, 3 and 7 were 14.37, 11.09, 10.99, and 11.2 g/dl, respectively. This way compared with the levels of 13.47 (p = 0.016), 9.88 (p = 0.024), 9.60 (p = 0.004) and 9.97 g/dl (p = 0.007) in the control patients. The difference between the rHuEpo treated patients and the control patients was more significant among the THR patients than among the TKR patients. Of the 10 rHuEpo-treated THR patients, only a single patient required one allogeneic blood unit, as compared with 23 units transfused to the 30 control patients. None of the rHuEpo-treated TKR patients required blood transfusion as opposed to 4 units needed by the 11 control patients. In total, only one allogeneic blood unit was required by the study group which way calculated to an average consumption of 0.066 blood unit per person, compared with 27 blood units used by the 41 controls, i.e. 0.66 blood units per person (p < 0.001). In the patients treated, rHuEpo was very well tolerated with no adverse effects.     

Rate of blood loss over 48 hours following total knee replacement

The purpose of this study was to determine the rate of blood loss after total knee arthroplasty and assess the efficacy of drains using autologous blood transfusion. A prospective study was undertaken of 100 consecutive patients undergoing routine total knee arthroplasty. The diagnosis was osteoarthritis in 85% of patients and rheumatoid arthritis in 12% of cases. The rate of blood loss was recorded hourly for the first 12 h, 4 hourly for the subsequent 12 h and 6 hourly for the following 24 h. Autologous blood was reinfused within 12 h of surgery according to the protocol. Eighty-four percent of the total blood drained, was collected in the first 12 h and 94% in the first 24 h. 69% of the total blood which was drained was reinfused. The mean preoperative haemoglobin was 13.18 gm/dl and 10.23 gm/dl on the 5th day. A mean volume of 70-80 ml of homologous blood was reinfused in addition to the autologous transfusion in 11 of the 100 cases. There were no cases of deep or superficial sepsis, nor any identifiable complications related to the autologous blood transfusion. This study suggests it is safe to remove the postoperative joint drain after the 12-h period.     

Experience with predeposition of autologous blood in elective orthopaedic and plastic surgery: the role of oral iron medication

The risk of transmission of transfusion-associated infections, mainly AIDS, led to the increased use of autologous transfusion by four methods: predeposition of autologous blood, haemodilution, intraoperative and postoperative blood salvage. We started a program of autologous predeposition at blood transfusion centre of Saint Andrews General Hospital of Patras in co-operation with orthopaedic and plastic surgery in 1992. To date, 617 autologous units have been collected from 257 patients undergoing various operations. Our protocol was as follows: the minimum Hb value before each donation was 12 g/dl, body weight over 50 kg, age 18-70 years and 8-10 day intervals between donations. The exclusion criteria were anaemia, evidence of blood loss, renal disease, chronic and acute inflammatory or malignant disorders, pregnancy and lactation. We chose 40 patients with haemoglobin values of 13-15 g/dl and ferritin levels > 50 ng/ml, who gave three autologous units. They were separated in two groups of twenty patients. Those in group 1 received 300 mg of elemental iron in three daily oral doses, while the others in group 2 received no iron medication. We studied haematologic variables, reticulocytes and ferritin levels in both groups before each autologous donation. We also studied the possible complications and their incidence in patients over 60 years old. According to our results, haematologic variables such as Hb, mean corpuscular Hb (MCH), mean corpuscular volume (MCV) and reticulocytes were not influenced by oral iron therapy. We observed a slight increase in MCV in both study groups which means the production of larger red blood cells. We also noticed a higher decrease of ferritin in patients with no iron therapy, but without a fall of ferritin levels under the normal values. We conclude that oral iron therapy in non-iron deficient patients undergoing a moderate program of three autologous units is not necessary. In addition, autologous blood donation is also feasible in patients over 60 years old without severe complications.     

Efficiency of blood usage for elective surgery in the University Hospital Kuala Lumpur

Provision of quality care, service and blood products to patients while containing costs and the amount of blood used should be the aim of every blood bank. Therefore a prospective audit was carried out over three months to determine how efficiently blood was being used in elective surgery in the University Hospital, Kuala Lumpur. Every case with blood crossmatched was monitored to determine the amount transfused and the posttransfusion haemoglobin level. Overcrossmatching of varying degrees was noted in almost all surgical procedures and overtransfusion in 45.5% of patients transfused. The rate of case postponement was 18.1%. These indicate inefficient utilization of blood and other resources. The transfusion index (TI) and range of units transfused were calculated for each procedure. They can be used as indicators of blood requirement and potential severity of hemorrhage. Suggestions to improve efficiency of blood utilization include the introduction and ongoing monitoring of guidelines on crossmatching and transfusion based on the data obtained here, by the hospital blood transfusion committee; the "group, screen and hold" practice for surgical procedures with high crossmatch transfusion ratios, low transfusion indices and a small range of units transfused could also be adopted.     

Étude pilote des caractéristiques des patients transfusés et des produits sanguins labiles utilisés

The aim of this study was to describe blood recipients and blood components transfused during the first 24 hours in 13 French hospitals. We included all blood recipients who had not had any blood transfusion within the past six months. Recipients were screened for red cell alloantibodies, the alanine aminotransferase activity and specific viral markers (hepatitis B and C, Human Immunodeficiency Virus). Eligible patients represented 47% of the all transfused. Among the 371 patients included, 57% were males and 71% were transfused in a surgical unit. Alloantibodies, non specific and specific viral markers were detected in 3%, 19% and 2% respectively. Among the patients included, 42 received 172 autologous units. In total, 1056 allogeneic units (an average of 3 units per patient) were transfused; blood products were leucocyte-depleted (49%) or leucocyte-poor (20%) ; 54% of red cell units were matched for antigens Rh and Kell. Neoplasms were the most frequently reported disease for which patients were transfused. This study provides baseline blood transfusion information on recipients and blood utilization for a specific period in French hospitals. Following this study, a national study will allow the clarification of the characteristics, for instance the surgical procedures requiring transfusion.     

Autotransfusion with predeposit-haemodilution and perioperative blood salvage: 20 years of experience. Rizzoli Study Group on Orthopaedic Anesthesia.

BACKGROUND: Through a prospective study, we evaluated the efficacy of an integrated autotransfusion regimen comprised of predeposit-hemodiluition and intra and post-operative blood salvage in major orthopaedic surgery. METHODS: We examined the records of 2303 consecutive patients (1524 females and 779 males, mean age 62.7, standard deviation 11 years (range 16-90 yrs), pre-operative haemoglobin (Hb) concentration 13.5 (SD 1.4) (range 6.7-19.3) g/dl undergong total hip arthroplasty (THA 1582 patients), THA after the removal of internal fixation devices (RFD+THA, 25 patients), total knee arthroplasty (TKA, 347 patients), revision surgery of the hip (HR, cup+stem revision, 248 patients; cup revision 64 patients; stem revision 23 patients) and total knee revision (TKR 14 patients). We estimated that the number of predonations (MSBOS - maximum surgery blood order schedule) was 2 units for THA, TKA and TKR, and 3 units for partial or total hip revision and for total hip arthroplasty with fixation removal. RESULTS: It was possible to obtain the MSBOS in 2070 patients (89.8%). Homologous red blood cell (HRBC) transfusion were carried out in 184 patients (8%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower pre-operative Hb concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, a higher ASA rating and co-existing diseases such as coronary artery disease. CONCLUSIONS: Cooperation among anaesthesis, transfusionists and surgeons in the application of an integrated autotransfusion regimen enabled us to treat 92% of our patients with only autotransfusion.     

Predictors of increased transfusion requirements and optimizing transfusional support in patients on Extracorporeal membrane oxygenation (ECMO)

ECMO has an established role in neonatal, paediatric and adult patients with cardiac and/or respiratory failure who failed to respond to conventional therapies. It provides temporary cardiopulmonary support until the recovery of the patients or the institution of definitive treatment. Patients undergoing ECMO, especially adults, have high requirements for all blood components. High transfusional needs have been associated with increased mortality in the adults. Neonatal patients generally have lower overall transfusion requirements than the adults. The significant transfusion requirements among ECMO patients is contributed by increased bleeding from the need for systemic anticoagulation to reduce circuit thrombosis, activation and consumption of platelets and clotting factors, and anaemia from haemodilution and haemolysis. The need to prime the ECMO circuit with red cells may also account for part of the neonatal transfusion requirements There can be wide inter-individual variations in the transfusion requirements of ECMO patients. Differences in pre-determined transfusion triggers may account for differences in blood utilization between centers. Central cannulation can be associated with higher cannulation bleeding rates and blood utilization than peripheral cannulation. In neonates, factors associated with increased daily platelet transfusions include the use of venoarterial ECMO and the presence of concomitant sepsis and meconium aspiration. Neonates with sepsis or congenital diaphragmatic hernia may have the highest overall platelet transfusions due to longer ECMO duration. Neonates with intracranial haemorrhage were observed to require more platelet transfusions. In our retrospective analyses of adult ECMO patients in a cardiothoracic surgical unit in Singapore, there were positive correlations of total red cell, platelet and FFP transfusions with ECMO duration which in turn increased in non-surgical or septic patients. On multivariate analyses, nadir haemoglobin of <7.5 g/dL associated with increased average daily red cell and FFP transfusions. Recent antiplatelet usage and maximum haemoblobin decline of >5.5 g/dl while on ECMO independently associated with increased average daily platelet transfusions. In addition, increased ECMO duration (which correlated negatively with nadir platelet count) was also independently associated with average daily transfusion of >3 platelet concentrate units. Bleeding was not an independent factor associated with any of the blood component utilization. Our findings suggest that the patients' haemoglobin levels and the perceived need to minimize coagulopathies among patients with significant anaemia and/or additional bleeding risks may have the greatest impact on clinicians' transfusion decisions in adult patients undergoing ECMO. Measures including the use of activated recombinant factor VII to reduce haemorrhage, and reduction in allogeneic blood transfusion with the use of an autotransfusion device during elective changes of ECMO systems have been reported to reduce transfusion requirements. Close collaboration between the transfusion service and the ECMO team is necessary to optimize the transfusion support of patients undergoing ECMO.     

Granulocyte enriched buffy coat transfusions in neutropenic patients

Twenty four courses of granulocyte enriched buffy coat transfusions were administered to 22 different infected neutropenic patients. Those patients who received an average of greater than or equal to 13 units per transfusion, which represented a mean of 1.02 X 10(10) granulocytes, had a survival rate of only 30% which was not significantly different from the 28.5% found among patients who received an average of less than or equal to 12 units per transfusion, which represented a mean of .63 X 10(10) granulocytes. In addition, no significant difference in survival rate was found between patients who received a course of greater than or equal to four transfusions and those who received a course of less than or equal to three transfusions. Finally, no significant difference in survival rate was found between patients with acute leukemia and those with other disorders or between patients with positive cultures and those whose cultures were negative. Given the poor clinical results associated with buffy coat transfusions, it is concluded that every effort should be made to recruit single leukapheresis donors for the support of infected neutropenic patients, rather than use granulocyte enriched buffy coats as they are presently produced.     

The issues in autologous transfusion

Autologous transfusion should be recognized by patients and physicians as an important measure to provide safer transfusion therapy. This should be suggested to patients in general good health (who are not obviously frail) who have no significant medical problems and no likelihood of severe reaction, who can take iron supplements, and who have at least a 10% chance of using blood during surgery or are having surgery in which the average use is one or more units. Such patients should receive iron supplementation beginning 1 week before the first autologous donation, and should donate one to five units on a weekly basis, but no more frequently than every 72 hours, with their last unit donated 72 hours before surgery. Elderly individuals may donate if the risk of donor reaction seems low. In children and adults, the amount of blood removed should be reduced in proportion to the blood volume if the individual does not meet the standard weight of 50 kg for a 450-mL donation. "Fail-safe" identification systems should be used; these will insure that the correct donor/patient receives the transfusion. Processing of the units is preferred but still optional. Use of these units as homologous units should not be done unless the donor has a hematocrit level acceptable to an autologous donor, meets all the criteria for recipient safety, the unit is processed and negative for all viral markers, and the donor has recently (eg, within 3 years) participated in the volunteer donor program. The unit should be transfused to the patient in situations in which homologous blood would be indicated. Safeguards to prevent volume overload are needed when the unit is stored as whole blood. Future research objectives should include the use of recombinant erythropoietin to prevent donation-induced anemia, delineation of medical conditions which should contraindicate the donation, and determination of the real costs involved in autologous transfusion. Education of the general public, patients, and physicians about the desirability of autologous transfusion should proceed. Third-party carriers also need to be educated about the cost implications and the need to pay for this activity. However, such education should also stress that autologous units will only cover planned, elective surgery and that major blood needs for emergency surgery, trauma, and chronic transfusion will still need to be met by homologous blood from altruistic community blood donors.     

Autologous Blood Transfusion: Evaluation of an Alternative Strategy in Reducing Exposure to Allogeneic Blood Transfusion

The perceived risk of transfusion-transmitted disease led to the rejuvenation of autologous blood transfusion (ABT). ABT, a process in which the blood donor and recipient are the same, is increasingly becoming an integral component of the elective surgical protocol in many institutions. Various methods of ABT are being utilized. These include: preoperative blood donation, in which the patient donates blood prior to surgery and the blood is stored for an expected need during or after surgery; acute normovolemic hemodilution, in which blood is collected immediately prior to surgery and replaced with cell free fluids and then returned to the patient upon need; intraoperative blood salvage in which blood is collected from the surgical field and is reinfused after being washed and finally, postoperative blood salvage in which collected shed blood from surgical drains is reinfused to the patient. Although ABT is known to reduce the risk of allogeneic blood transfusion, it is not risk free and should be evaluated in relation to the patient's clinical picture. The combination of various methods of ABT in addition to the proper utilization of blood may consequently lead to the elimination of patients' exposure to allogeneic blood transfusion in many surgical procedures.     

Preoperative autologous blood donation in 612 hospitals. A College of American Pathologists' Q-Probes study of quality issues in transfusion practice.

We compared predeposit autologous blood utilization practices in 612 hospitals (where 107,559 autologous and 2,504,522 homologous units were transfused in all of 1989). Participating blood bankers prospectively followed up donors who presented for initial donation during an 11-week period in early 1990. They recorded the number of autologous donors whose blood was drawn (n = 22,276); units that were donated (n = 40,163), transfused (n = 23,988), crossed over (n = 937), and discarded (n = 15,443); and donors transfused with autologous blood only (n = 11,923) or donors who received homologous blood (n = 2002). Most donors (89.7%) avoided homologous blood, including donors (39.5%) who did not require transfusion. Units that were donated for low-risk surgery represented 23.1% of all units that were collected, and the rate of donation for these procedures was directly proportional to the percentage of donors who did not require transfusion and to the discard rate. We concluded that a major focus of quality improvement in autologous transfusion practice should be the reduction of donations for surgical procedures for which blood replacement is rarely needed.     

Required laboratory examination and blood transfusion therapy in massive hemorrhage during surgery

Massive hemorrhage during surgery often results from diluted coagulopathy due to loss of coagulation factors (e.g., fibrinogen), especially in cases of thoracic aortic aneurysm and liver transplantation. The most important issue in preventing massive hemorrhage during surgery is transfusion therapy for hemostasis. When massive hemorrhage occurred in cases of the above surgery, we measured the fibrinogen level in plasma, and administered cryoprecipitate or fibrinogen concentrate to the patient when the fibrinogen level was below 150 mg/dL. The hemostatic efficacy of this treatment was evaluated by counting volume of blood loss and number of transfusion units in comparison with cases of conventional treatment with fresh frozen plasma. We observed a rapid increase in plasma fibrinogen level and subsequent improvement in hemostasis after cryoprecipitate or fibrinogen concentrate was administered. The average blood loss decreased by 30% and the average number of transfusion units was reduced about 30 to 60% when those agents were given to patients with severe hypofibrinogenemia during surgery. The number of cases of early death due to massive hemorrhage during surgery decreased by 75% when cryoprecipitate or fibrinogen concentrate was used. Thus, in patients showing hypofibrinogenemia (i.e., <150 mg/dL) during surgery, administration of cryoprecipitate or fibrinogen concentrate should be effective in establishing hemostatsis, and therefore in reducing blood loss and number of transfusion units. This treatment should help to improve the prognosis of patients in surgery, and also to decrease the use of blood products.     

Acute hemolytic transfusion reactions due to multiple alloantibodies including anti-E, anti-c and anti-Jkb

We report a case of two consecutive episodes of acute hemolytic transfusion reactions (HTRs) due to multiple alloantibodies in a 34-yr-old man who suffered from avascular necrosis of left femoral head. He received five units of packed red blood cells (RBCs) during surgery. Then the transfusion of packed RBCs was required nine days after the surgery because of the unexplained drop in hemoglobin level. The transfusion of the first two units resulted in fever and brown-colored urine, but he received the transfusion of another packed RBCs the next day. He experienced even more severe symptoms during the transfusion of the first unit. We performed antibody screening test, and it showed positive results. Multiple alloantibodies including anti-E, anti-c and anti-Jkb were detected by antibody identification study. Acute HTRs due to multiple alloantibodies were diagnosed, and the supportive cares were done for 6 days. We suggest the antibody screening test should be included in the panel of pretransfusion tests for safer transfusion, and it is particularly mandatory for the patients with multiple transfusions, pregnant women, and preoperative patients.     

Defining the clinical need for rare red blood cells

Transfusion support of patients with antibodies against high frequency (HF) antigens or a combination of antibodies that is rare is challenging and requires multidisciplinary cooperation. The treating physician should decide if there is a definitive clinical need for red blood cell (RBC) transfusion for the specific patient. According to recent clinical trials RBC transfusion is usually not indicated if the patient is haemodynamically stable and the haemoglobin (Hb) is higher than 7 g/dl. Alternative strategies for patient support might be required if rare blood is unavailable or while awaiting rare RBC unit arrival from national or international sources.     

Factors affecting blood loss in total knee arthroplasty patients

The aim of the study was to identify the factors affecting major blood loss in patients undergoing total knee arthroplasty (TKA), in order to reduce blood loss and requirements for blood transfusion. This prospective randomized study included 80/184 patients treated by TKA at University Hospital of Traumatology, Zagreb, Croatia, from January 2005 till December 2007. The following parameters were analyzed: patient age, sex, body mass index (BMI), arterial blood pressure, preoperative hemoglobin level and hemoglobin level preceding blood transfusion, length of surgery, blood loss and volume of blood transfused. According to patient age, there were no differences in the length of surgery, blood loss volume, hemoglobin level before blood transfusion and use of blood transfusion. Older patients had lower hemoglobin level before blood transfusion and received greater volumes of blood transfusion, but the difference was not statistically significant. Male patients had a significantly higher preoperative hemoglobin level as compared to female patients (P = 0.012). The mean volume of blood loss and of transfused blood was larger in male than female patients, however, the difference did not reach statistical significance. According to BMI, there were no differences in the length of surgery, blood loss, volume of transfused blood and hemoglobin level before transfusion. Patients with a lower preoperative hemoglobin level did not lose more blood during and after surgery, but the requirement for blood transfusion was significantly higher (P = 0.014). Hypertensive patients had a statistically greater perioperative blood loss (P = 0.038), but did not receive more transfused blood (P = 0.494). Preoperative hemoglobin level was higher in patients with elevated arterial blood pressure than in those with normal blood pressure, but the difference was not statistically significant (P = 0.595). Hemoglobin level before blood transfusion was also higher in hypertensive patients than in those with normal blood pressure, but it was not statistically significant (P = 0.288). In patients with longer duration of surgery, blood loss and volume of blood transfused blood were statistically significantly greater (P = 0.003 and P = 0.015, respectively). Study results yielded a significant positive correlation between the length of surgery and the volume of blood loss (r = 0.282; P = 0.011) as well as between the length of surgery and the volume of blood transfused (r = 0.362; P = 0.001). A significant negative correlation was established between the preoperative hemoglobin level and application of blood transfusion (r = -0.250; P = 0.025). Patients with hypertension had a significantly larger blood loss volume as compared to patients with normal arterial pressure (P = 0.038) and received more blood transfusions than patients with normal blood pressure, but the difference was not statistically significant (P = 0.494). Age, sex and BMI had no statistically significant effect on blood loss volume and application of blood transfusion. Male patients had a significantly higher preoperative hemoglobin level (P=0.012), larger mean blood loss volume (P = 0.057) and received more blood transfusions than female patients, however, the difference did not reach statistical significance (P = 0.562). Based on study results, it is concluded that requirements for blood transfusion will be greater in patients with hypertension and lower preoperative hemoglobin level as well as in all cases with longer duration of surgery. To reduce the use of allogeneic blood transfusion, it is necessary to correct arterial blood pressure before surgery in hypertensive patients and also to magnify preoperative hemoglobin level if it is lower.     

Usefulness of low prime perfusion pediatric circuit in decreasing blood transfusion

We tested the efficiency of small prime volume in decreasing the blood requirement during pediatric cardiac surgery. This is a retrospective analysis of transfusion in 259 consecutive patients weighing <15 kg. We downsized the bypass circuit and avoided noncritical components to obtain a cardiopulmonary bypass prime volume, including a cardioplegia circuit of 140 ml for patients up to 6 kg, and of 170 ml for those weighing 6-15 kg. For intra- and postoperative care, transfusions were limited to 1 unit of packed red blood cells and 1 unit of fresh frozen plasma in 129 of the 134 patients weighing <6 kg. Seventy-six of 125 (61%) patients who were between 6 kg and 15 kg had bloodless surgery. None of the 259 patients had platelets infusion. In transfused cases, only eight patients (3%) needed more than two different donor products. In bloodless cases, hemoglobin values were 11.5 +/- 1.8 g/dl before, 9.4 +/- 1.7 g/dl during, and 10.5 +/- 1.8 g/dl after surgery. No adverse effects of this procedure were encountered. Small prime volume is efficient and safe in decreasing blood use in pediatric surgery.