Autologous blood collection in anemic patients using low-dose erythropoietin therapy.

Autologous donation of blood for use during elective surgery is being recommended and used more frequently. Autologous donation and transfusion represent the safest way to handle elective surgical blood requirements because they eliminate the risk of transfusion-transmitted disease and alloimmunization, and significantly reduce the other risks associated with homologous transfusion. Many individuals, particularly women and the elderly, do not have sufficient initial hemoglobin concentration or hemopoietic reserve to effectively use autologous donation. Use of standard-dose recombinant human erythropoietin (rHuEPO) (600 units/kg) to mitigate these limitations is costly. The optimal dose, interval, and route of administration for rHuEPO therapy has yet to be perfected. This article describes a program using low-dose (< 100 units/kg) rHuEPO and also discusses the effectiveness, cost savings, and clinical indications for the use of low-dose rHuEPO.     

前蛙跳式自体预贮血在猪心脏体外循环手术模型中的应用

背景：同种异体输血在相同血型的人类中已经得到实现,但关于猪的血型类型及如何异体输血国内外无确切报道。 目的：探讨术前蛙跳式自体预贮血在猪心脏体外循环手术模型中应用的可行性。 方法：16只家猪随机区组法分为2组,自体预贮血组、同种异体输血组。另4头猪放血供同种异体输血组异体输血应用。两组猪均在体外循环下行心脏手术。自体预贮血组手术全程仅输自体血,同种异体输血组手术全程输注等量异体血。记录自体预贮血组放血前后的血红蛋白及血细胞压积,两组术前基础值、体外循环过程中、体外循环结束后及术后1 d的血红蛋白值。 结果与结论：20只实验猪全身血容量 (2500±428) mL;自体预贮血组第1次预计放血量为(501±86) mL,实际放血量为(493±93) mL;第2次预计放血量为(750± 128) mL,实际放血量为(719±98) mL。自体预贮血组猪采血前后血红蛋白计数及血细胞压积差异有显著性意义(P < 0.01)。自体预贮血组术后1 d时点血红蛋白数值明显高于同种异体输血组(P< 0.01),两组其余术前基础值、体外循环过程中、体外循环结束后时点血红蛋白数值差异无显著性意义(P > 0.05);与术前比较,两组术后1 d时点血红蛋白值显著低于术前基础值 (P < 0.01)。自体预贮血组存活率明显高于同种异体输血组(P < 0.01)。结果说明与同种异体输血相比,术前蛙跳式自体预贮血安全有效,术后猪成活率更高。     

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.     

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.     

人工全髋关节置换后自体血回输的安全及有效性评价

BACKGROUND: Autologous blood transfusion device has been widely used in the clinic, reduces allogeneic blood transfusion, and avoids the occurrence of blood transfusion complications, and effectively improves the patient’s blood safety, but the application of autologous blood transfusion after total hip arthroplasty has been seldom reported. OBJECTIVE: To discuss the safety and effectiveness of autologous blood transfusion after total hip arthroplasty. METHODS: 200 patients were treated by primary unilateral total hip arthroplasty from March 2013 to March 2015. They were randomly divided into two groups. 127 patients in the autologous blood transfusion group received  autologous blood transfusion by a drainage tube. 73 patients in the negative pressure drainage ball group received a negative pressure drainage tube. The standard for allogeneic blood transfusion after replacement was hemoglobin < 80 g/L. The changes in hemoglobin were compared before and 1 and 7 days after replacement between the two groups. Total drainage volume and allogeneic blood transfusion were compared within 6 hours after replacement between the two groups.  RESULTS AND CONCLUSION: There were no statistical differences in hemoglobin levels at 7 days before and after replacement, in drainage volume within 6 hours and the total drainage volume between the two groups (P > 0.05). Hemoglobin levels were significantly higher in the autologous blood transfusion group than in the negative pressure drainage ball group at 1 day after replacement (P < 0.05). In the autologous blood transfusion group, autologous blood transfusion volume was averagely 324.2 mL. Allogeneic blood transfusion volume was averagely 146.7 mL in 31 patients. No reaction was found after autologous blood transfusion. In the negative pressure drainage ball group, 49 patients received allogeneic blood transfusion (averagely 261 mL). The volume and proportion of allogeneic blood transfusion were significantly lower in the autologous blood transfusion group than in the negative pressure drainage ball group (P < 0.05). Among patients receiving allogeneic blood transfusion, seven patients affected pyrogenetic reaction during blood transfusion. These findings suggested that autologous blood transfusion is simple and effective, can effectively reduce the volume and reaction of allogeneic blood transfusion after total hip arthroplasty and avoid blood-borne diseases, with good prospects.        

Épargne transfusionnelle en chirurgie orthopédique

In addition to more restrictive “transfusion triggers”, presently available allogeneic blood conservation strategies in surgery include preoperative increase in red blood cells (RBC) mass, techniques or pharmaceutical agents that reduce blood loss, and perioperative blood salvage. Because of very important risk reduction in allogeneic blood, benefit/risk of preautologous blood donation (PAD) is quite questionable at this moment. Indeed, at this moment in France, we focus to avoid any transfusion (allogeneic and autologous blood). Therefore the most important techniques used are pharmacological: erythropoietin before surgery with a number of injections related to baseline Hb, and tranexamic acid during and after surgery. Cell saving is used only if bleeding is enough important like arthroplasty revisions. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics are determinant to settle a blood conservation strategy. The choice of a technique should take into account (a) the delay before surgery, (b) the anticipated blood loss for the procedure that varies among institutions, (c) the tolerable blood loss without transfusion for the patient, and (d) the efficacy of the blood conservation technique in the given setting. Nevertheless, at this moment in France, it is quite important to notice that the risk of delay or lack of transfusion induces much more deaths that the transfusion itself during or after anesthesia [Anesthesiology 105, 1087–97].     

Blood loss following knee replacement surgery,use it don't lose it

We prospectively studied the ability of the post-operative salvage and reinfusion of unwashed blood to reduce the allogeneic blood transfusion requirements of 339 patients undergoing various types of knee replacement procedures (unilateral, bilateral, revision and unicompartmental). For each type of procedure studied, the use of post-operative blood salvage and reinfusion significantly reduced the need for allogeneic blood transfusion (P<0.01). Knee replacement surgery performed with a bloodless field using a tourniquet is ideally suited to the use of post-operative blood salvage and reinfusion as a method of autologous blood transfusion and since this study has shown that large reductions in the use of allogeneic blood can be achieved by its use, we recommend that it be considered for all types of knee replacement surgery.     

Peri-operative use of EPO]

In moderately anaemic patients, Autologous Blood Donation is much less effective than Erythropo?etin (EPO) at constituting a pre-operative RBC reserve. Indeed, the ability to give blood is limited or even impossible for anaemic individuals. EPO lowers the risks associated with autologous and allogeneic transfusions, while improving probably the quality of life of the patients. EPO therapy is efficient, in moderate anaemic patients, to reduce allogeneic transfusion when iron supplementation is associated. All blood conservation techniques carry their own efficiency limits, constraints and risks that, in addition to institutional considerations and individual patient characteristics, are determinant to settle a blood conservation strategy. But to optimise benefit/cost/effectiveness of this technique, it is important to take into account the delay before surgery, the anticipated blood loss for the procedure that varies among institutions and the tolerable blood loss without transfusion for the patient. To reduce the cost, a strategy according to baseline haematocrit and to blood loss has to be adapted at each patient. Furthermore, when the delay between the first EPO injection and the surgical procedure is sufficient, the number of injections can be easily reduced to obtain the same Ht the day prior to surgery.     

Autologous transfusion: when best should not be the enemy of good enough...]

Autologous blood transfusion has been shown to decrease allogeneic transfusion in patients undergoing elective procedures, in adults as well as in children. However, its indication must be carefully discussed for each patient, since, on the one hand, viral risks associated with allogeneic blood are greatly reduced, while on the other hand, adverse events may occur in some patients with poor physical condition. An assessment of the ratio 'benefit-risk' has to be made for each patient.     

Does intraoperative transfusion during total knee arthroplasty reduce the need for transfusion after surgery?: A preliminary retrospective cohort study

ObjectivesAfter total knee arthroplasty (TKA), many patients experience anemia due to blood loss. To prevent postoperative anemia and allogeneic blood transfusion after TKA, we used prophylactic allogeneic or autologous blood transfusion intraoperatively. This study evaluated the effects of prophylactic transfusion during TKA.Materials and methodsThis retrospective cohort study included 579 patients receiving scheduled unilateral TKA. We allocated the patients into three groups, the prophylactic allogeneic transfusion (Group AL), prophylactic autologous transfusion (Group AT), and no prophylactic transfusion with intra-articular tranexamic acid administration (Group C) groups. After propensity score matching, we compared the rate of postoperative allogeneic blood transfusions until three days after TKA, postoperative hemoglobin and hematocrit levels until four days after TKA, and the side effects in each groups.ResultsThe postoperative allogeneic blood transfusion rates were statistically higher in group AL and AT than in group C (18.2% and, 18.9% vs 2.3%, respectively; P < 0.000). The postoperative hemoglobin and hematocrit levels were statistically lower in group Auto than in group C (P < 0.0001), but the levels in group AL were not different from those of group C (P = 0.493 vs. P = 0.384 respectively). In addition, the side effects were statistically higher in group AL and AT than in group C.ConclusionProphylactic intra-operative transfusions did not reduce the rates of allogeneic transfusions and produced more side effects and hypotension after surgery than intra-articular tranexamic acid administration with no prophylactic transfusion in patients undergoing TKAs.     

Large volume autologous plasma predonation and retransfusion in orthopedic surgical patients.

BACKGROUND: Intraoperative washed autologous transfusion of the scavenged blood can reduce the deterioration of anemia, even during the operation with a comparatively large blood loss. On the other hand, plasma level can not be collected by this system. The preoperative donation and perioperative retransfusion of autologous plasma may reduce the plasma dilution. PURPOSE: The influence of a large volume plasma predonation and perioperative retransfusion on the plasma protein level was investigated. METHODS: Thirteen patients (63.2 +/- 13.2 yr, 70.3 +/- 12.1 kg) were examined regarding their serum protein (SP), IgG, coagulation systems, colloid osmotic pressure (COP), blood cell count before, just after, 2 h after and 7 days after the donation of 900 ml plasma by plasmapheresis with a simultaneous volume replacement. Twenty surgical patients (52.8 +/- 17.3 yr, 72.6 +/- 16.6 kg, the mean predonated autologous plasma: 2100 ml) with intra- and postoperative retransfusion of autologous plasma were examined perioperatively for SP, IgG, coagulation systems and COP. These parameters were compared with that of the predonated plasma. RESULTS: All data including SP, coagulation and COP, with the exception of IgG, completely recovered within 7 days after preoperative plasmapheresis. Perioperatively, autologous washed blood transfusion system was used. The retransfused volume of autologous predonated plasma was 1740 ml on average. Although about 41 of blood on average was lost perioperatively, only one patient out of 20 patients had to be administered homologous red blood cell transfusion. The levels of most parameters, except for COP, constantly recovered in accordance with the autologous plasma transfusion. Differences in the patterns of improvement were also observed between the parameters. CONCLUSION: A 900 ml plasma predonation can therefore be safely performed with an interval of not less than a week between the last donation and the operation. Autologous plasma retransfusion is thus considered to improve the protein levels.     

Currently available blood saving methods in a patient at cardiac surgery under extracorporeal circulation

Different blood saving methods are analyzed in 2000 cardiac surgical patients undergoing coronary and vascular bypass surgery in 1993 to 2000. The basic blood saving methods are as follows: intraoperative autoreinfusion (normovolemic thermodilution), reinfusion of the patient's blood, preoperative autologous plasma donation in combination with aprotinine, aminocapronic acid, etc. An analysis revealed a decrease in homologous blood components intraoperatively. Red blood cell transfusion decreased from 100% in 1993 to 44% in 2000, fresh frozen plasma and platelet transfusions did from 98 to 39% and from 96 to 1%, respectively. Intraoperative homologous blood transfusion could be avoided in 70% of those undergone coronary bypass surgery.     

The Efficacy,Safety and Cost-Effectiveness of Intra-Operative Cell Salvage in High-Bleeding-Risk Cardiac Surgery with Cardiopulmonary Bypass: A Prospective Randomized and Controlled Trial

Objective: Intra-operative cell salvage (CS) was reported to be ineffective, safe and not cost-effective in low-bleeding-risk cardiac surgery with cardiopulmonary bypass (CPB), but studies in high-bleeding-risk cardiac surgery are limited. The objective of this study is to evaluate the efficacy, safety and cost-effectiveness of intra-operative CS in high-bleeding-risk cardiac surgery with CPB.Methods: One hundred and fifty patients were randomly assigned to either with intra-operative CS group (Group CS) or without intra-operative CS group (Group C). Study endpoints were defined as perioperative allogeneic red blood cell (RBC) transfusion, perioperative impairment of blood coagulative function, postoperative adverse events and costs of transfusion-related.Results: Both the proportion and quantity of perioperative allogeneic RBC transfusion were significantly lower in Group CS than that in Group C (p=0.0002, <0.0001, respectively). The incidence of residual heparin and total impairment of blood coagulative function in the 24 hours after surgery, the incidence of postoperative excessive bleeding, were significantly higher in Group CS than that in Group C (p=0.018, 0.042, 0.034, respectively). Cost of both allogeneic RBC transfusion and total allogeneic blood transfusion were significantly lower in Group CS than that in Group C (p<0.001, =0.002, respectively). Cost of total blood transfusion was significantly higher in Group CS than that in Group C (p =0.001).Conclusion: Intra-operative CS in high-bleeding-risk cardiac surgery with CPB is effective, generally safe, and cost-effective in developed countries but not in China.     

A decision aid for autologous pre-donation in cardiac surgery--a randomized trial

OBJECTIVES: The objective of this randomized, controlled study was to determine the usefulness of a decision aid on pre-donation of autologous blood before elective open heart surgery. METHODS: The decision aid (DA) group received a tape and booklet which described the options for peri-operative transfusion in detail. The no decision aid (NDA) group received information usually given to patients about autologous donation. RESULTS: A total of 120 patients were randomized. The DA group rated themselves better prepared for decision making and showed significant improvements in knowledge (p = 0.001) and realistic risk perceptions (p = 0.001). In both groups there was an increase in the proportion of patients choosing allogeneic blood between baseline and follow-up (p = 0.001). Patients in the DA group were significantly more satisfied with the amount of information they received, how they were treated and with the decision they made, than patients in the NDA group. CONCLUSION: The decision aid is useful in preparing patients for decision making. PRACTICE IMPLICATIONS: The next stage is to explore strategies to make it available to all appropriate patients.     

洗涤式自体血回输对心脏手术患者凝血和携氧功能的影响

目的:观察洗涤式自体血回输对心脏手术患者凝血功能和红细胞携氧功能相关指标的影响。方法:61例手术患者采用美国美敦力血液回输机进行洗涤式自体血回输,分别测定术前、术后当天、术后第1天、术后第7天血液凝固指标:血小板计数(PLT)、血浆凝血酶原时间(PT)、活化部分凝血活酶时间(APTT)、凝血酶时间(TT)、纤维蛋白原(FIB)、D-二聚体(D-D)和红细胞携氧功能相关指标:血氧分压(PaO2)、血氧饱和度(SaO2)、血酸碱度(pH)、红细胞计数(RBC)、血红蛋白含量(HGB)、红细胞压积(Hct)。结果:61例患者术中回收原血和"机血"共84912ml,平均每例患者回输浓缩红细胞465ml。与术前比较,术后当天和术后第1天凝血功能指标PLT、FIB显著降低(P<0.01),PT显著延长(P<0.05或P<0.01),术后当天D-D明显升高(P<0.05);携氧功能指标PaO2在术后当天和术后第1天显著升高(P<0.01),RBC、HGB、Hct均显著降低(P<0.01,P<0.05)。术后第7天所有异常指标均恢复至术前水平。结论:洗涤式自体血回输不影响血液凝固和携氧功能,可安全应用于心脏手术。     

Guidelines for the Treatment of Preoperative Anaemia with Epoetin

Recombinant human erythropoietin (epoetin) has been approved for use in patients undergoing autologous blood donation (ABD) in Japan, the European Union and Canada since 1993, 1994 and 1996 respectively, and for perisurgical adjuvant therapy without ABD in Canada and the US since 1996. Early clinical trials of epoetin therapy in the setting of ABD have provided important information with respect to clinical safety, dose and erythropoietic response. Later trials of perisurgical epoetin therapy without ABD provided data on efficacy (i.e. reduced allogeneic blood exposure) that led to approval of epoetin in this setting. However, the epoetin doses (300 U/kg subcutaneously x 14 days) used in these trials, and their subsequent inclusion in labelling for the use of this product, are costly to administer. A recent study has indicated that weekly administration of epoetin 600 U/kg over 4 weeks is just as effective but less costly than a daily regimen over 2 weeks. The most cost-effective regimen that has been shown to minimise allogeneic exposure is preoperative epoetin therapy with 600 U/kg/ week x 2 plus 300 U/kg on the day of surgery, coupled with acute normovolaemic haemodilution in patients undergoing radical retropubic prostatectomy. A similar regimen of epoetin therapy in patients undergoing coronary artery bypass grafting (2500 U/kg in divided doses over 2 weeks preoperatively) coupled with 'blood pooling', has also been described. 'Low dose' epoetin therapy coupled with acute normovolaemic haemodilution is cost-equivalent to the predonation of 3 autologous blood units, and may replace this strategy as a standard of care in the elective surgical setting.     

Surgical and anaesthetic management of anaemia: pros and cons of cell salvage devices

Autologous cell salvaged blood can be an effective way of minimising allogeneic blood transfusion in the elective and emergency surgical setting. The controlled use of such devices does require training and assessment of the operator's competence. There remains a reluctance to use in all surgical situations due to clinical objections about the likelihood of contamination of the blood by bacteria, malignant cells and fetal debris. A well led cell salvage service can ensure that quality assurance is achieved and provides a ready source of red cells for transfusion.     

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.