A prospective randomized comparison of three blood conservation strategies for radical prostatectomy.

BACKGROUND: Preoperative autologous blood donation is a standard of care for elective surgical procedures requiring transfusion. The authors evaluated the efficacy of alternative blood-conservation strategies including preoperative recombinant human erythropoietin (rHuEPO) therapy and acute normovolemic hemodilution (ANH) in radical retropubic prostatectomy patients. METHODS: Seventy-nine patients were prospectively randomized to preoperative autologous donation (3 U autologous blood); rHuEPO plus ANH (preoperative subcutaneous administration of 600 U/kg rHuEPO at 21 and 14 days before surgery and 300 U/kg on day of surgery followed by ANH in the operating room); or ANH (blinded, placebo injections per the rHuEPO regimen listed previously). Transfusion outcomes, perioperative hematocrit levels, postoperative outcomes, and blood-conservation costs were compared among the three groups. RESULTS: Baseline hematocrit levels were similar in all groups (43%+/-2%). On the day of surgery hematocrit decreased to 34% +/-4% in the preoperative autologous donation group (P < 0.001), increased to 47%+/-2% in the rHuEPO plus ANH group (P < 0.001), and remained unchanged at 43%+/-2% in the ANH group. Allogeneic blood exposure was similar in all groups. The rHuEPO plus ANH group had significantly higher hematocrit levels compared with the other groups throughout the hospitalization (P < 0.001). Average transfusion costs were significantly lower for ANH ($194+/-$192) compared with preoperative autologous donation ($690+/-$128; P < 0.001) or rHuEPO plus ANH ($1,393+/-$204, P < 0.001). CONCLUSIONS: All three blood-conservation strategies resulted in similar allogeneic blood exposure rates, but ANH was the least costly technique. Preoperative rHuEPO plus ANH prevented postoperative anemia but resulted in the highest transfusion costs.     

A Prospective Randomized Comparison of Three Blood Conservation Strategies for Radical Prostatectomy

Background: Preoperative autologous blood donation is a standard of care for elective surgical procedures requiring transfusion. The authors evaluated the efficacy of alternative blood-conservation strategies including preoperative recombinant human erythropoietin (rHuEPO) therapy and acute normovolemic hemodilution (ANH) in radical retropubic prostatectomy patients.

Methods: Seventy-nine patients were prospectively randomized to preoperative autologous donation (3 U autologous blood); rHuEPO plus ANH (preoperative subcutaneous administration of 600 U/kg rHuEPO at 21 and 14 days before surgery and 300 U/kg on day of surgery followed by ANH in the operating room); or ANH (blinded, placebo injections per the rHuEPO regimen listed previously). Transfusion outcomes, perioperative hematocrit levels, postoperative outcomes, and blood-conservation costs were compared among the three groups.

Results: Baseline hematocrit levels were similar in all groups (43% +/- 2%). On the day of surgery hematocrit decreased to 34% +/- 4% in the preoperative autologous donation group (P < 0.001), increased to 47% +/- 2% in the rHuEPO plus ANH group (P < 0.001), and remained unchanged at 43% +/- 2% in the ANH group. Allogeneic blood exposure was similar in all groups. The rHuEPO plus ANH group had significantly higher hematocrit levels compared with the other groups throughout the hospitalization (P < 0.001). Average transfusion costs were significantly lower for ANH ($194 +/- $192) compared with preoperative autologous donation ($690 +/- $128; P < 0.001) or rHuEPO plus ANH ($1,393 +/- $204, P < 0.001).     

Autologous blood transfusion with recombinant human erythropoietin in heart surgery--studies on the volume of preoperative donation and postoperative administration]

Recombinant human erythropoietin (rHuEPO) was administered to 42 elective heart surgery patients, and the volume of autologous blood donated within the preoperative short period and effects of improving anemia by postoperative rHuEPO administration were studied. rHuEPO (100 U/kg/day) and chondroitin sulfate-iron (40 mg/day) were given intravenously for preoperative 14 days, and each 400 ml of autologous blood was donated on the 14th and 4th day before operation. Reticulocytes increased significantly 3 days after administration (p less than 0.01). The hemoglobin level, 13.4 +/- 1.0 g/dl before the first donation, returned to 13.4 +/- 1.1 g/dl just before operation. 800 ml of autologous blood, needed for usual open heart surgery, may possibly have been donated within 14 days without making patients anemic by intravenous rHuEPO administration. For postoperative rHuEPO administration, the patients were divided into 3 groups: Group I (10 cases): given for 14 days, Group II (12 cases): for 7 days, Group III (20 cases): no administration. Reticulocytes decreased rapidly after termination of rHuEPO administration in each group, and on the 7th day after termination, they returned to the level before administration. The hemoglobin level in Group I was maintained after termination of rHuEPO, and was +2.2 +/- 1.1 g/dl on the 21st postoperative day compared with the level of 1st postoperative day. The hemoglobin level in Group II fell after termination and was +0.9 +/- 0.7 g/dl on the 21st day, this being comparable to the level of Group III. There were significant differences between Group I and II (p less than 0.05), and between Group I and III (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Safety and efficacy of blood donation prior to elective cardiac surgery in anemic patients.

OBJECTIVE: To determine the safety and effectiveness of blood donation in anemic patients, we harvested blood from cardiac patients with baseline hemoglobin levels below 11.0 g/dl. METHODS: Subjects were 118 patients who underwent elective cardiac surgery between January 1994 and October 1997. We assigned patients to 1 of 2 groups based on their entry hemoglobin level: an anemic group (hemoglobin < 11.0 g/dl, n = 20) and a nonanemic group (hemoglobin > or = 11.0 g/dl, n = 98). All patients received subcutaneous administration of recombinant human erythropoietin, and autologous blood was collected once a week for at least 3 weeks before the scheduled surgery date if the hemoglobin level exceeded 10.5 g/dl. RESULTS: No statistically significant differences were seen between the 2 groups in patient profiles or surgical data. The estimated hemoglobin increase did not differ significantly between groups at any time point. The total collected blood volume per patient was greater in the nonanemic group than in the anemic group (1098 +/- 224 ml vs. 712 +/- 334 ml), but the difference in volume was not statistically significant. The percentage of patients who received allogeneic blood did not differ significantly between groups. No side effects were associated with hemoglobin level prior to donation because the incidence of side effects was similar across hemoglobin levels. CONCLUSIONS: This study suggests that autologous blood donation reduces the need for allogeneic blood in patients with baseline hemoglobin levels below 11.0 g/dl.     

Präoperative Eigenblutspende in der Herzchirurgie

BACKGROUND: Preoperative autologous blood donation is an effective method to reduce allogeneic transfusion requirement. However, this method is only rarely utilized in cardiac surgery. Besides economic concerns one essential argument against predonation is the lack of sufficient time due to the short waiting lists. The aim of the present study was to investigate the efficacy of autologous predonation to reduce allogeneic blood transfusion in routine cardiac surgery on a center without longer preoperative waiting lists. PATIENTS AND METHODS: A total of 2,626 cardiac surgery patients were included. Primary endpoint of the study was the perioperative incidence of allogeneic packed cell transfusion. If time between diagnosis and admission to the hospital was >10 days, predonation was offered to the patients. Data were stratified for preoperative risk score. Logistic and linear regression analysis tested the influence of different variables on the incidence of allogeneic blood transfusion and the total amount of allogeneic blood. RESULTS: Of all patients 267 (11.2%) underwent predonation. The incidence of allogeneic packed cell transfusion was reduced from 53% to 19% by autologous predonation (p<0.001). The total amount of allogeneic blood transfused was significantly different between the groups (2.2+/-4.2 vs. 0.84+/-6.3 units; p<0.001). DISCUSSION: Autologous predonation in cardiac surgery was effective in reducing blood transfusions even in the absence of longer preoperative waiting times. It is a safe and effective method to minimize blood transfusion in cardiac surgery.     

Nonanemic Patients Do Not Benefit from Autologous Blood Donation Before Total Hip Replacement

To avoid the potential risks of allogeneic transfusion during total hip arthroplasty (THA), the use of preoperative autologous blood donation (PABD) has been utilized. We performed a retrospective chart review of 283 patients undergoing THA that either donated 1 U of autologous blood (188 patients) or did not donate autologous blood before surgery (95 patients) in order to investigate the difference in postoperative transfusion rate (autologous and allogeneic), the incidence of allogeneic transfusion, and the difference in cost of each protocol. In addition, the study compared transfusion rates in patients with and without preoperative anemia (hemoglobin (Hb) ≤ 12.5 g/dL). At 0.75 transfusions per patient versus 0.22 transfusions per patient, the PABD patients had a significantly higher overall transfusion rate. PABD significantly reduced the need for allogeneic blood in anemic patients (Hb ≤ 12.5 g/dL) from 52.6% to 11.8%. PABD did not have the same affect in nonanemic patients (allogeneic transfusion rate 5.7% versus 4.0%). The study demonstrated that nonanemic patients undergoing THA do not benefit from PABD, but it is effective for anemic patients.     

Autologous blood donation in cardiac surgery: reduction of allogeneic blood transfusion and cost-effectiveness

OBJECTIVE: The purpose of this study was to assess transfusion requirements in patients undergoing cardiac surgery with and without autologous blood donation and to calculate the costs of predonation from the hospital perspective. DESIGN: Observational study. SETTING: Single university hospital. PARTICIPANTS: Four thousand three hundred twenty-five patients undergoing elective cardiac surgery with and without autologous blood donation. INTERVENTIONS: Eight hundred forty-nine patients (20%) underwent autologous blood donation, whereas 3,476 (80%) did not. Perioperative allogeneic blood transfusion was recorded as the primary endpoint. To avoid selection bias, patients were stratified according to their preoperative risk score. A decision model was derived from acquired data for the optimization of autologous blood donation. MEASUREMENTS AND MAIN RESULTS: Allogeneic blood transfusion rate was 13% in patients with predonation versus 48% without predonation (p < 0.05). This difference remained statistically significant even after risk stratification. The predonation of 1, 2, or 3 units reduced the probability of receiving allogeneic blood to 24%, 14%, and 9%, respectively. An efficient program of predonation within the department of anesthesiology allowed keeping the costs of predonation low. Decision-tree analysis revealed that predonation of 2 autologous units of blood saved the most allogeneic blood for the smallest increase in costs. Incremental cost for male patients predonating 2 units was dollars 33 (US), whereas for females predonation could be done at no extra cost in comparison to patients without predonation. CONCLUSION: Autologous blood donation significantly reduces allogeneic blood requirement in cardiac surgery. If adjusted for diagnosis and gender, autologous blood donation is a cost-effective alternative to reduce allogeneic blood consumption.     

Targeted Preoperative Autologous Blood Donation in Total Knee Arthroplasty Reduces the Need for Postoperative Transfusion

Background

Preoperative donation of autologous blood has been widely used to minimize the potential risk of allogeneic transfusions in total knee arthroplasty. A previous study from our center revealed that preoperative autologous donation reduces the allogeneic blood exposure for anemic patients but has no effect for non-anemic patients.

Questions/Purposes

The current study investigates the impact of a targeted blood donation protocol on overall transfusion rates and the incidence of allogeneic blood transfusions.

Methods

Prospectively, 372 patients undergoing 425 unilateral primary knee replacements were preoperatively screened by the Blood Preservation Center between 2009 and 2012. Anemic patients with a hemoglobin level less than 13.5 g/dL were advised to donate blood, while non-anemic patients did not donate.

Results

Non-anemic patients who did not donate blood required allogeneic blood transfusions in 5.9% of the patients. The overall rate of allogeneic transfusion was significantly lower for anemic patients who donated autologous blood (group A, 9%) than those who did not donate (group B, 33%; p?<?0.001). Donating autologous blood did increase the overall transfusion rate of anemic patients to 0.84 per patient in group A compared to 0.41 per patient in group B (p?<?0.001).

Conclusion

This investigation confirms that abandoning preoperative autologous blood donation for non-anemic patients does not increase allogeneic blood transfusion rates but significantly lowers overall transfusion rates.     

Does the Use of Erythropoietin Reduce the Risk of Exposure to Allogeneic Blood Transfusion in Cardiac Surgery? A Systematic Review and Meta‐Analysis

BACKGROUND: The use of blood conservation techniques is important in cardiac surgery as postoperative bleeding is common and allogeneic blood transfusion carries the risk of transfusion reactions and infection transmission. Erythropoietin with and without preoperative autologous blood donation is one of the modalities to avoid allogeneic blood transfusion. The objective of this review was to assess the effectiveness of erythropoietin in reducing the risk of exposure to allogeneic blood transfusion during or after cardiac surgery. METHODS: A meta-analysis of 11 identified randomized controlled trials, reporting comparisons between erythropoietin and control, was undertaken. The primary outcome was the number of patients exposed to allogeneic blood transfusion during or after cardiac surgery. RESULTS: Eleven studies, involving 708 patients, met the inclusion criteria for this review. In total, 471 patients were given erythropoietin, and 237 patients formed the control group. The administration of erythropoietin with and without preoperative autologous blood transfusion prior to cardiac surgery is associated with a significant risk reduction: RR = 0.28 (95% CI 0.18-0.44, P < 0.001) and RR = 0.53 (95% CI 0.32-0.88, P < 0.01), respectively. CONCLUSION: The administration of erythropoietin before cardiac surgery is associated with a significant reduction in the risk of exposure to allogeneic blood transfusion. Further studies are warranted to define the patients' subgroups that may benefit the most from EPO administration.     

Efficacy of preoperative autologous blood donation: analysis of blood loss and transfusion practice in total hip replacement

STUDY OBJECTIVE: To determine the frequency of allogeneic transfusion for total hip replacement (THR) surgery and to examine the efficacy of preoperative autologous blood donation (PABD) under specified, standardized blood transfusion guidelines. DESIGN: Prospective, nonrandomized study. SETTING: University medical center. PATIENTS: All ASA physical status I, II, III, and IV patients undergoing single, primary, THR surgery from April 1998 to March 1999. INTERVENTIONS: All patients received standardized transfusion and anticoagulation therapy. Demographic, blood loss, and transfusion data were collected and compared between all patients participating in PABD (donors) and patients not participating in PABD (nondonors). Overall allogeneic blood exposure was established. Since most anemic patients could not participate in PABD, allogeneic transfusion frequency was also examined in a subset of nonanemic patients (hemoglobin > or =12 g/dL) who were potentially able to participate in PABD. MEASUREMENTS AND MAIN RESULTS: n = 231 patients, 142 donors and 89 nondonors. Mean estimated blood volume (EBV) of donors was 4991 +/- 1042 mL versus nondonors 4631 +/- 1108 mL (p < 0. 01). ASA physical status I-II/III-IV among donors was 118/24 versus nondonors 61/28 (p < 0.01). Overall allogeneic blood exposure was 22% (51/231). Allogeneic transfusion frequency for all donors was 15% (22/142) versus nondonors 33% (29/89) (p < 0.05). Among nonanemic patients, donor versus nondonor EBV and ASA physical status I-II/III-IV were 5074 +/- 1019 mL versus 4743 +/- 1172 mL and 107/20 versus 48/15 (p = NS); allogeneic transfusion frequency reduced to 13% (16/127) versus 17% (11/63) (p = NS), respectively. CONCLUSIONS: Allogeneic blood exposure was >10% despite the use of PABD. The efficacy of PABD has been obscured by the fact that donors of autologous blood tend to be larger and healthier than nondonors. After exclusion of anemic patients, autologous donors and nondonors were clinically comparable and the difference in allogeneic blood exposure was not statistically significant. PABD offers only a modest, if any, benefit for THR surgery.     

Preoperative treatment with recombinant human erythropoietin or predeposit of autologous blood in women undergoing primary hip replacement

BACKGROUND: Controversy exists about the advantages of predeposit of autologous blood (PDAB), and whether more comfortable blood conservation regimens may yield comparable results. To test the hypothesis that preoperative treatment with recombinant human erythropoietin (rHuEPO) with or without acute concomitant normovolaemic haemodilution (ANHD) is as effective as PDAB in reducing allogeneic blood transfusions, we conducted a prospective randomised study in women undergoing primary hip replacement. METHODS: Sixty consecutive female patients scheduled for primary hip replacement and suitable for PDAB were randomly assigned to one of 3 groups. Group I (EPO) and II (ANHD) received 600 U/kg rHuEPO s.c. and 100 mg iron saccharate i.v. on day 14 and, if needed, on day 7 before surgery. Additionally, in group II acute normovolaemic haemodilution (ANHD) was implemented after induction of anaesthesia. In group III (PDAB) conventional PDAB up to 3 U, without volume replacement but with concomitant oral iron therapy, was performed starting 4 weeks before surgery. RESULTS: The blood conservation methods resulted in a comparable net gain of red cells in all 3 groups until the day of surgery. Because of the withdrawal of autologous blood, haemoglobin values before surgery were lower in the PDAB group than in the EPO and ANHD groups, and during surgery were lower in the PDAB and ANHD groups than in the rHuEPO-only group. Applying moderate ANHD in conjunction with preoperative rHuEPO treatment did not yield an incremental decrease in allogeneic transfusions. There was no difference between the groups in the number of patients who received allogeneic transfusions or in the total number of allogeneic units transfused. CONCLUSIONS: Withdrawal of autologous blood is associated with lower pre- and intraoperative haemoglobin levels when compared to preoperative augmentation of red cell mass using rHu-EPO. As a measure to reduce allogeneic transfusion requirements, preoperative treatment with rHuEPO may be as effective as standard predeposit of autologous blood in women undergoing primary hip replacement, but requires less preoperative time.     

Subcutaneous use of erythropoietin in heart surgery.

The effect of subcutaneous administration of recombinant human erythropoietin (rHuEPO) in ameliorating anemia resulting from autologous blood donation was compared with intravenous administration of rHuEPO. Forty patients undergoing coronary artery bypass procedures were divided into three groups. Group I (12 patients) received intravenous administration of rHuEPO (100 U.kg-1.day-1) and intravenous iron preparations for 14 days before operation; group II (14 patients) had subcutaneous administration of rHuEPO (600 U/kg) on preoperative days 14 and 7 and oral iron preparations for 14 days; and group III (14 patients) received oral iron preparations alone and served as the controls. Each patient predonated 800 mL of blood in the 2 weeks before operation. The reticulocyte count increased significantly in groups I and II (p less than 0.01), but little in group III. The hemoglobin level just before operation was higher in groups I (p less than 0.01) and II (p less than 0.05) compared with group III. Four patients (29%) in group III required homologous blood transfusion versus none in groups I and II (p less than 0.05). Subcutaneous administration of rHuEPO once a week was as effective as daily intravenous administration. Preoperative autologous blood donation can be performed over a short period on an outpatient basis with subcutaneous administration of rHuEPO.     

Preoperative autologous donation versus cell salvage in the avoidance of allogeneic transfusion in patients undergoing radical retropubic prostatectomy

There are many methods for preventing allogeneic blood administration during radical retropubic prostatectomy, and many of these methods have been compared with each other, but no studies have compared preoperative autologous donation (PAD) and cell salvage (CS). In this study, we evaluated these two methods in patients undergoing radical retropubic prostatectomy. In a prospective cohort model, allogeneic exposure in patients from one surgeon who routinely had his patients donate blood before surgery was compared with that in patients from a different surgeon who predominantly used CS. Fifty patients were enrolled in the study: 26 in the PAD group and 24 in the CS group. No difference in allogeneic exposure was seen between the two groups. A significant difference was seen in the volume of red blood cells lost (891 +/- 298 mL versus 1134 +/- 358 mL in the PAD and CS groups, respectively). We conclude that PAD and CS are equivalent in their ability to avoid allogeneic transfusion. Larger surgical blood loss in the CS group would suggest that in a more rigorously designed study, CS might provide better allogeneic avoidance than PAD. IMPLICATIONS: In this prospective cohort study, cell salvage and preoperative autologous donation were compared with respect to their ability to avoid allogeneic transfusion. There was a suggestion that cell salvage might offer better allogeneic transfusion avoidance.     

Use of perflubron emulsion to decrease allogeneic blood transfusion in high-blood-loss non-cardiac surgery: results of a European phase 3 study

BACKGROUND: This single-blind randomized study in general surgery evaluated the efficacy of perflubron emulsion (PFC) as an artificial oxygen carrier being used to augment preoperative acute normovolemic hemodilution to reduce and avoid transfusion of both allogeneic erythrocytes and erythrocytes from preoperative autologous donation compared with standard of care. METHODS: Subjects (N = 492) with hemoglobin concentrations of 12-15 g/dl undergoing noncardiac surgical procedures with 20 ml/kg or greater expected blood loss were randomized into two groups. Control patients were transfused intraoperatively at a hemoglobin concentration less than 8.0 +/- 0.5 g/dl or at protocol-defined, physiologic triggers. PFC-treated patients first underwent acute normovolemic hemodilution to hemoglobin of 8.0 +/- 0.5 g/dl, followed by dosing with perflubron emulsion (1.8 g/kg). When hemoglobin reached less than 6.5 +/- 0.5 g/dl, an additional 0.9-g/kg dose was given. PFC patients were transfused at hemoglobin less than 5.5 +/- 0.5 g/dl or at predefined physiologic triggers. After surgery, hemoglobin was maintained at 8.5 +/- 0.5 g/dl or greater in all patients until discharge. Efficacy endpoints included the number of allogeneic and preoperative autologous donation units transfused and the percentage of subjects avoiding transfusion. RESULTS: Both groups had similar hemoglobin concentrations at screening (13.5 +/- 1.0 g/dl) and at discharge: 10.8 +/- 1.2 g/dl (PFC) and 11.1 +/- 1.3 g/dl (control). At 24 h, more patients in the PFC group avoided allogeneic and preoperative autologous donation erythrocyte transfusions (53% vs. 43%, < 0.05), and fewer erythrocytes were transfused (1.5 +/- 4.8 vs. 2.1 +/- 3.9 units; median, 0 vs. 1 unit; P = 0.013). By day of discharge, these differences were not significant in the intent-to-treat population, but overall there were less allogeneic and preoperative autologous donation erythrocyte transfusions in the PFC group (696 vs. 846 units). In the protocol-defined target population (n = 330 subjects with blood loss > or = 20 ml/kg), significantly greater avoidance of any erythrocyte transfusion was maintained through day of hospital discharge (26% vs. 16% in the PFC and control groups, respectively; P < 0.05), and there was also a significant reduction in the number of erythrocyte units transfused (3.4 +/- 2.9 vs. 4.9 +/- 2.4 units; median 2 vs. 4 units; P < 0.001). Adverse events rates were similar in the PFC (86%) and control (81%) groups; however, more serious adverse events were reported in the PFC group (32%) than in controls (21%; P < 0.05). Overall mortality was 3%, and the difference between groups (PFC, 4% vs. controls, 2%) was not statistically significant. CONCLUSIONS: Augmented acute normovolemic hemodilution with PFC reduces transfusion needs in patients undergoing noncardiac surgical procedures with blood loss 20 ml/kg or greater.     

A simple mathematical approach to calculate blood loss in radical prostatectomy

INTRODUCTION: The aim of this study was to apply a simple mathematical approach to calculate blood loss in 126 patients undergoing radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Perioperative red blood cell loss (RBCL) was estimated by adding the difference in circulating red blood cells from before to after surgery to the allogeneic red blood cells transfused in the same period. RESULTS: Mean preoperative hematocrit was 45 +/- 4% and mean perioperative RBCL was 574 +/- 297 ml, corresponding to a mean equivalent whole blood loss (WBL) of 1,479 +/- 831 ml. Twenty of 126 patients (15.9%) received 42 units of allogeneic packed red blood cells (PRBC), for a mean of 2.1 +/- 1.2 U/patient. The transfusion rate was higher in patients with a preoperative hematocrit of 40% or less (45 vs. 13%, p = 0.014). CONCLUSIONS: Anatomical RRP is still associated with appreciable operative blood loss. Owing to the high preoperative hematocrit values, the allogeneic blood transfusion rate is low and the transfusion requirement of the majority of patients is limited to about 2 units of PRBC. Preoperative autologous blood augmentation strategies may not be routinely needed for patients with a basal hematocrit of >40%.     

Experience of predeposit autologous blood transfusion and medication of recombinant human erythropoietin in pediatric open heart surgery]

To avoid using the homologous blood, 11 children between the age of 5 and 15 years donated autologous blood of 10 ml/kg of body weight (upper limit 400 ml) once a week for two weeks prior to elective open heart surgery. Five of 11 children received erythropoietin (100 U/kg of body weight) intravenously three times a week for two weeks. Only one patient experienced a mild donor reaction but no adverse effects occurred in erythropoietin therapy. In all the patients cardiac operations were able to be completed without homologous blood transfusion. Patients treated with erythropoietin were not anemic despite of preoperative donation although without erythropoietin therapy patients were mildly anemic. Our experience documents safety and effectiveness of predeposit autologous blood transfusion and erythropoietin therapy in pediatrics.     

Effects of recombinant human erythropoietin on thrombosis and fibrinolysis in autologous transfusion for hip surgery

Recombinant human erythropoietin (rHuEPO) is effective in allowing autologous blood donation in patients unable to donate because of anemia. As adverse effects of rHuEPO might include activation of coagulation and possibly fibrinolysis, we investigated these possibilities in the context of autologous blood donation preceding hip surgery. Thirty-seven patients who donated 800 ml of autologous blood for elective hip surgery were randomly assigned to either a group of 20 receiving preoperative treatment with rHuEPO (erythropoietin beta), 6000 U i.v. twice weekly for 3 weeks, or an untreated control group of 17. A significant increase in platelet count was associated with autologous blood donation and intraoperative blood loss with or without rHuEPO. Coagulation and fibrinolysis were increased significantly by intraoperative blood loss in both groups, but not by rHuEPO. Coagulation and fibrinolysis were not activated by rHuEPO for elective hip surgery.     

Recombinant erythropoietin in autologous blood donation

As a result of the AIDS crisis, public and physician pressure have increased the utilization of autologous blood products. Attitudes about homologous blood transfusion, however, have changed dramatically in recent years. A large segment of the population undergoing elective surgery is elderly and therefore has a significant incidence of cardiovascular disease and a slow response of the erythropoietic system when acute anemia occurs. However, preoperative autologous blood donation programs require 2-5 weeks to complete; the average yield is only 2.2 units per patient. As a consequence, autologous predonation is underused and homologous transfusion cannot be completely avoided in all patients. For several years recombinant human erythropoietin (rHuEPO) has been available and has been successfully used in the treatment of patients with renal anemia. This study evaluated the effect of r-HuEPO on patients with preoperative autologous blood collection. METHODS. Ten patients of both sexes scheduled for hip arthroplasty underwent a preoperative autologous program. During a period of 23 days prior to surgery autologous blood donation was performed with 7.5 ml/kg withdrawal on four occasions, the last one 5 days prior to surgery. Five patients were randomly treated with subcutaneous injections of rHuEPO (Erypo, Cilag GmbH, Sulzbach; Distributor: Fresenius AG, Oberursel, FRG) 200 IU/kg seven times, starting 3 days after the first blood withdrawal. All patients (n = 10) received oral iron therapy with iron sulphate 304 mg/die (= 100 mg iron/die). Patients with hypertension or recent myocardial infarction were excluded from the study. The hemoglobin level before donation had to be at least 11.0 g/dl. On each study day, a complete blood count and platelets, differential, and reticulocyte count were determined by standard methods as were transferrin, ferritin, and total iron-binding capacity. Blood loss and blood consumption during and after the operation were registered. The indication for blood transfusion (autologous/homologous) was based on hemoglobin values, which were not acceptable below 8.5 g/dl. RESULTS. No side effects of rHuEPO treatment were observed. Blood loss ranged from 650 to 1100 ml intraoperatively and 400 to 950 ml postoperatively with no differences between the groups. Patients with rHuEPO had no autologous red cell concentrates (aRCC) during the operation; two of them had two units of aRCC on the 2nd postoperative day. Two of the patients in the control group had intraoperative blood transfusions (2 and 3 units aRCC, respectively); all patients in this group were transfused postoperatively: 12 of the 20 units collected were utilized. At the onset of the operation the mean hemoglobin value in patients with rHuEPO was 13.5 +/- 0.4 g/dl compared to 11.3 +/- 0.3 g/dl in the controls. Reticulocytes increased significantly during the investigation period. On the 2nd, 3rd, and 4th days of autologous blood collection and before the onset of surgery, the number of reticulocytes was significantly greater in rHuEPO patients than in the controls. Further laboratory variables such as transferrin, ferritin, and total iron-binding capacity did not change significantly during the investigation period; there were no significant differences between the two groups. DISCUSSION. The results of the present study show that rHuEPO leads to an increase in reticulocytes with maintenance of hemoglobin levels during the phlebotomy program. As a consequence, patients with anemia and particular contraindications to homologous blood derivatives (irregular antibodies, Jehovah's Witnesses) may be able to undergo major surgery successfully. The possibility of shortening the intervals between phlebotomies would seem to be of major advantage; our data also suggest that an aggressive autologous blood collection program would increase yields over present programs. In our institute a minimum hemoglobin level of 11.5 g/dl is accepted for autologous donation.(ABSTRACT TRUNCATED AT 400 WORDS)     

Pr?operative An?mie in der Orthop?die

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels <?13?g/dl at preadmission testing. Preoperative anemia has been associated with increased mortality and morbidity after surgery, increased allogeneic blood transfusion therapy and increased rates of postoperative infection leading to a longer length of hospital stay. Because of the risks associated with allogeneic blood transfusions according to German law patients have to be offered the option of autologous transfusion if the risk associated with allogeneic blood transfusion is >?10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28?days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ???120?g/l, normal male????130?g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.     

Preoperative anemia in orthopedic surgery: clinical impact, diagnostics and treatment

In a national audit of elective orthopedic surgery conducted in the US, 30% of patients were found to have hemoglobin (Hgb) levels ?10%. However, one of these measures, the autologous blood donation, can exaggerate anemia and can increase the overall transfusion rates (allogeneic and autologous). As autologous procedures (autologous blood donation and cell salvage) are not always appropriate for anemic patients together with an expected shortage of blood and because preoperative anemia is associated with perioperative risks of blood transfusion, a standardized approach for the detection, evaluation and management of anemia in this setting was identified as an unmet medical need. A panel of multidisciplinary physicians was convened by the Society for Blood Management to develop a clinical care pathway for anemia management in elective surgery patients for whom blood transfusion is an option. In these guidelines elective surgery patients should have Hgb level determination at the latest 28?days before the scheduled surgical procedure. The patient target Hgb before elective surgery should be within the normal range (normal female ≥?120?g/l, normal male?≥?130?g/l). Laboratory testing should take place to further determine nutritional deficiencies, chronic renal insufficiency and/or chronic inflammatory diseases. Nutritional deficiencies should be treated and erythropoiesis-stimulating agent (ESA) therapy should be used for anemic patients in whom nutritional deficiencies have been ruled out and/or corrected.